Clinical Cardiology最新文献

Ventricular arrhythmias (VAs) following acute coronary syndrome (ACS) are strongly associated with hemodynamic instability and increased mortality, underscoring the importance of accurate prediction for implementing prophylactic strategies. Giubertoni and colleagues demonstrated that the PRAISE score effectively identifies high-risk patients for atrial fibrillation (AF) or VAs during hospitalization for ACS [1]. Nevertheless, several points warrant further consideration.

The authors employed clinical parameters required for calculating the PRAISE score [1], a tool originally developed using machine learning to predict 1-year adverse cardiovascular and bleeding events following ACS [2]. However, additional potential predictors are known to influence arrhythmogenesis. For example, hyperuricemia and chronic obstructive pulmonary disease have been implicated in the development of AF, while specific electrocardiographic and echocardiographic parameters are associated with ischemia-induced ventricular tachycardia [3-5]. Incorporating these established risk factors into a revised risk score may enhance its clinical utility.

Another critical consideration involves the hazard ratios of individual variables. Identifying modifiable risk factors provides actionable therapeutic targets to mitigate the incidence of AF and VAs post-ACS. For instance, anemia emerged as a significant predictor in the original PRAISE cohort, alongside age and left ventricular ejection fraction [2]. Notably, anemia is widely recognized as a contributor to the pathogenesis of AF and may represent a practical focus for intervention.

The clinical implications of these findings remain ambiguous [1]. Cardiac reverse remodeling often occurs within approximately 30 days following ACS. During this period, the use of wearable cardioverter-defibrillators may be appropriate, whereas implantable cardioverter-defibrillators are typically not recommended. A pertinent question arises: how can referencing the PRAISE score inform strategies to improve mid- and long-term clinical outcomes following ACS?

The authors have nothing to report.

The authors have nothing to report.

The authors declare no conflicts of interest.

The posterior lead can be estimated in the supine position using a specific electrocardiogram (ECG) algorithm. Makarawate and colleagues directly measured the posterior lead ECG in the prone position [1]. They demonstrated that a prolonged QTc interval in the prone position correlated with higher APACHE II scores in patients with COVID-19. Several concerns have been raised regarding their findings.

The QTc interval is strongly correlated with heart rate, as heart rate is a factor in the formula used to calculate the QTc interval. With a fixed QT interval, the QTc interval increases with an elevated heart rate. The authors observed an increase in heart rate in the prone position compared to the standard position [1]. Caution must be exercised in interpreting QTc interval in the prone position, because most of the evidence is constructed from QTc interval in the standard position.

The authors evaluated the impact of ECG findings obtained in the prone position in patients with COVID-19 [1]. However, some of these patients had acute coronary syndrome, which likely influenced the ECG patterns [2]. It would be more ideal to exclude such patients from the analysis to focus on the primary concern. Additionally, patients with atrial fibrillation were included. The QTc interval is generally overestimated during atrial fibrillation when calculated using the Bazett formula [3].

The authors identified a QTc interval cutoff of 460 ms to predict an APACHE II score > 12. A QTc interval exceeding 460 ms is typically indicative of long QT syndrome, which is commonly observed in patients with electrical disorders or myocardial injury. These individuals likely exhibit severe systemic conditions, explaining why they were treated in the prone position. The clinical utility of ECG measurements in the prone position remains unclear.

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Major bleeding, including intracranial hemorrhage (ICH), is a significant complication in patients with non-valvular atrial fibrillation (NVAF) undergoing treatment with oral anticoagulants (OACs). The authors proposed a novel risk score for predicting ICH in NVAF patients, incorporating variables such as age, sex, nonsmoking status, renal replacement therapy, and OAC use [1]. However, several critical concerns merit discussion.

The authors compared their proposed risk score with the established HAS-BLED score [1], a widely utilized tool for predicting not only ICH but also other major bleeding events classified as ≥ BARC 3b [2]. Unlike the novel score, the HAS-BLED score includes parameters such as hepatic dysfunction and the use of antiplatelet agents. Consequently, employing the HAS-BLED score as a comparator may not fully capture the nuances of the novel score's predictive capability for ICH specifically.

Patients with NVAF are susceptible to a range of complications, including thromboembolic events and heart failure. A noteworthy concern is the potential applicability of the novel risk score in predicting these broader complications. Furthermore, in the authors' study, only 6.7% of the cohort were treated with direct oral anticoagulants (DOACs) [1], which currently represent the predominant class of anticoagulants in clinical practice [3]. This limited representation raises questions about the generalizability of the score to patients receiving DOACs, warranting further validation.

Additionally, prior literature advises against the use of OACs in patients undergoing renal replacement therapy due to heightened bleeding risks [4]. Excluding such patients from the construction of risk scores may be more appropriate to ensure clinical relevance and applicability.

The authors have nothing to report.

The authors have nothing to report.

The authors declare no conflicts of interest.