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Influence of Epidemiologic and Clinical Trends on Risk Stratification and Net Clinical Benefit of Long-term Oral Anticoagulation for Nonvalvular Atrial Fibrillation 流行病学和临床趋势对长期口服抗凝治疗非瓣膜性房颤的风险分层和临床净获益的影响
Pub Date : 2018-12-01 DOI: 10.21925/mplsheartjournal-d-18-00016.1
R. Asinger, G. Shroff
The prevalence of atrial fibrillation without rheumatic valvular disease, nonvalvular atrial fibrillation (NVAF), increases with age and independently predicts future stroke and systemic embolism. Randomized controlled trials of long-term oral anticoagulation for NVAF since the 1980s report a 67% risk reduction in stroke and systemic embolism. Data from these trials are used in risk calculators to predict stroke and bleeding; clinicians use these calculators to determine individualized net clinical benefit of oral anticoagulation. Over the past three decades, NVAF stroke rates have declined independent of oral anticoagulation. Newer asymptomatic (subclinical) NVAF populations are being identified, and clinical practice has changed with increasingly older patients (with higher fall and bleeding risk) receiving oral anticoagulation. These trends suggest contemporary patients with NVAF may derive a lower net benefit from oral anticoagulation compared with those in the original randomized controlled trial. Methods that evaluate for and continuously monitor net clinical benefit of oral anticoagulation for contemporary NVAF are necessary.
无风湿性瓣膜病的房颤,即非瓣膜性房颤(NVAF)的患病率随着年龄的增长而增加,并独立预测未来的中风和全身栓塞。自20世纪80年代以来,长期口服抗凝治疗非瓣膜性房颤的随机对照试验报告称,卒中和全身栓塞的风险降低了67%。这些试验的数据被用于风险计算器来预测中风和出血;临床医生使用这些计算器来确定口服抗凝治疗的个体化临床净收益。在过去的三十年中,非瓣膜性房颤卒中发生率的下降与口服抗凝无关。新的无症状(亚临床)非瓣膜性房颤人群正在被发现,随着越来越多的老年患者(有更高的跌倒和出血风险)接受口服抗凝治疗,临床实践也发生了变化。这些趋势表明,与最初的随机对照试验相比,当代非瓣膜性房颤患者口服抗凝治疗的净获益可能较低。有必要对当代非瓣膜性房颤口服抗凝治疗的净临床效益进行评价和持续监测。
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引用次数: 0
Rationale and Design of an Evidence Based Tool to Guide Preoperative Evaluation and Management 指导术前评估和管理的循证工具的基本原理和设计
Pub Date : 2018-12-01 DOI: 10.21925/mplsheartjournal-d-18-00009.1
Alex R Campbell, David P. Ingham, Joshua J Mueller, T. Henry, S. Sharkey, M. K. Cummings
In the United States, over testing and over treatment are recognized as the cause of both excess cost and patient harm. Healthcare value (defined as “health outcomes achieved relative to the costs of care”) has become a focus to improve the quality and affordability of healthcare. Perioperative evaluation and management of the surgical patient represents a clear opportunity to improve healthcare value. Herein, we describe the rationale for and the development of a standardized clinical decision support tool that has been distributed to over 600 clinicians performing preoperative evaluations. All patients undergoing this evaluation will be tracked, with the intent to publish both healthcare cost and safety outcomes. The use of a perioperative decision support tool is a unique approach to value in healthcare.
在美国,过度检测和过度治疗被认为是造成成本过高和患者伤害的原因。医疗保健价值(定义为“相对于医疗费用实现的健康成果”)已成为提高医疗保健质量和可负担性的重点。围手术期患者的评估和管理是一个明显的机会,以提高医疗保健价值。在此,我们描述了标准化临床决策支持工具的基本原理和发展,该工具已分发给600多名临床医生进行术前评估。所有接受该评估的患者都将被跟踪,目的是公布医疗成本和安全性结果。围手术期决策支持工具的使用是实现医疗保健价值的独特方法。
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引用次数: 0
Udder Confusion: Are Dairy Foods Good for Us? 乳房困惑:乳制品对我们有好处吗?
Pub Date : 2018-12-01 DOI: 10.21925/MPLSHEARTJOURNAL-D-18-00013
C. Bowron
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引用次数: 0
Improving Value Through Heart Failure Care Coordination: The Allina Health Experience 通过心力衰竭护理协调提高价值:艾琳娜健康经验
Pub Date : 2018-12-01 DOI: 10.21925/MPLSHEARTJOURNAL-D-18-00011
S. Bradley, Pam Rush, K. Wolf, Amin Rahmatullah, Robin L. Braun, M. Samara, A. Bank, S. Bergeson, Wendy Gunderson, C. Strauss, Shaina Witt, M. Hutchinson, T. Tong, D. Mueller, P. Eckman, S. Kubo
Reducing readmission following heart failure is emerging as a target of quality initiatives in the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program. In response to higher readmission rates than desired following heart failure (HF) hospitalization, Allina Health hospital's cardiovascular subspecialty care developed an HF nurse care coordinator program to reduce readmissions. The nurse HF care coordinator serves as the bridge to help manage care following hospital discharge and ensure adherence to protocols developed by the HF management program. This effort was initially developed and implemented at Mercy and Unity Hospital and was associated with a 4.3% reduction in HF readmissions. Subsequent expansion of the HF nurse care coordinator program to United and Abbott Northwestern Hospitals was associated similar reductions in HF readmissions. Concurrently, all-cause mortality at 6 months post-discharge was also significantly lower following implementation of the program (mortality pre-HF care coordinator program 12.6% vs. post-HF care coordinator program 18.8%, P = .047) in propensity matched analysis. The findings of this effort suggest the potential for care coordination programs to improve the care and outcomes of patients with HF.
减少心力衰竭后的再入院正在成为医疗保险和医疗补助服务中心医院再入院减少计划的质量倡议的目标。为了应对心力衰竭(HF)住院后再入院率高于预期的情况,Allina Health医院的心血管亚专科护理制定了心力衰竭护士护理协调员计划,以减少再入院率。心衰护理协调员护士作为桥梁,帮助管理出院后的护理,并确保心衰管理计划制定的协议得到遵守。这项工作最初是在Mercy and Unity医院开发和实施的,与心衰再入院率降低4.3%有关。随后将心衰护理协调员项目扩展到联合医院和雅培西北医院,心衰再入院率也有类似的下降。同时,在倾向匹配分析中,实施该方案后出院后6个月的全因死亡率也显著降低(心衰前护理协调员方案死亡率12.6% vs心衰后护理协调员方案死亡率18.8%,P = 0.047)。这项工作的发现提示了护理协调方案的潜力,以改善心衰患者的护理和预后。
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引用次数: 0
Future Therapy for Low-Risk Patients With Severe Aortic Stenosis—A Provider Survey 低危重度主动脉狭窄患者的未来治疗——提供者调查
Pub Date : 2018-12-01 DOI: 10.21925/mplsheartjournal-D-18-00010
Aisha K. Ahmed, E. Brilakis, K. Mudy, B. Sun, P. Sorajja, M. Gössl
With the expansion of transcatheter aortic valve replacement in low-risk patients, we sought to explore current implanters' predictions on the future of this therapy by sending a survey to a sample of 8,261 healthcare professionals using Internet-based software. The survey contained six questions regarding physician specialty and experience, transcatheter aortic valve replacement age cutoff, optimal treatment for low-risk patients, transcatheter aortic valve replacement valve sequence, and transcatheter aortic valve replacement concerns. The majority, 29% percent, of all respondents felt that transcatheter aortic valve replacement will become the first-choice therapy for all patients, regardless of age and 70% felt that the optimal treatment would be transcatheter aortic valve replacement, with transcatheter aortic valve replacement valve-in-valve if the first valve degenerates. Regarding the sequence of transcatheter aortic valve replacement valves, 78% preferred the Edwards Sapien 3 valve (ES-3) as the first transcatheter aortic valve replacement valve followed by either a second ES-3 or Medtronic Evolut valve. Despite the high acceptance of transcatheter aortic valve replacement, many respondents (56%) felt that surgical aortic valve replacement might still remain the preferred treatment in low-risk patients due to an unknown durability of transcatheter aortic valve replacement valves. A majority of implanters see transcatheter aortic valve replacement followed by valve-in-valve transcatheter aortic valve replacement as the first-line therapy for low-risk patients with severe aortic stenosis, but long-term durability of transcatheter aortic valve replacement is an unanswered concern.
随着经导管主动脉瓣置换术在低风险患者中的应用范围的扩大,我们试图通过使用基于互联网的软件向8261名医疗保健专业人员发送调查样本,探索目前植入者对该疗法未来的预测。该调查包含六个问题,包括医生专业和经验、经导管主动脉瓣置换术的年龄截止、低危患者的最佳治疗、经导管主动脉瓣置换术的瓣膜顺序以及经导管主动脉瓣置换术的关注点。大多数(29%)的受访者认为经导管主动脉瓣置换术将成为所有患者的首选治疗方法,无论年龄如何,70%的受访者认为最佳治疗方法是经导管主动脉瓣置换术,如果第一个瓣膜退行性变,则进行经导管主动脉瓣置换术。关于经导管主动脉瓣置换瓣膜的顺序,78%的患者首选Edwards Sapien 3 (ES-3)瓣膜作为第一个经导管主动脉瓣置换瓣膜,其次是第二个ES-3或美敦力Evolut瓣膜。尽管经导管主动脉瓣置换术的接受度很高,但许多受访者(56%)认为,由于经导管主动脉瓣置换术的耐久性未知,手术主动脉瓣置换术可能仍然是低风险患者的首选治疗方法。大多数植入者将经导管主动脉瓣置换术和瓣中瓣经导管主动脉瓣置换术作为低危严重主动脉瓣狭窄患者的一线治疗,但经导管主动脉瓣置换术的长期持久性是一个未解决的问题。
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引用次数: 0
Systemic Thrombolytic Therapy for Stroke After Transcaval Transcatheter Aortic Valve Replacement 经颅主动脉瓣置换术后卒中的全身溶栓治疗
Pub Date : 2018-12-01 DOI: 10.21925/mplsheartjournal-d-18-00012.1
Steven Smedhammer, Matthew Glogoza, C. Dyke, T. Haldis
An 80-year-old male with aortic stenosis underwent transcatheter aortic valve replacement through a transcaval approach. The aorta was closed with an Amplatzer device without retroperitoneal leak or fistula. The patient developed a stroke three hours after the procedure and was treated with tissue plasminogen activator. Imaging after thrombolytic therapy revealed no aortic extravasation from the puncture site. To our knowledge, this demonstrates the first case in which thrombolytic therapy was used after transcaval access to the abdominal aorta for transcatheter aortic valve replacement and suggests that patients without leak after transcaval aortic closure, thrombolytic therapy is not contraindicated.
一例80岁男性主动脉瓣狭窄患者接受经导管主动脉瓣置换术。用Amplatzer装置关闭主动脉,无腹膜后漏或瘘。患者在手术后3小时发生中风,并接受组织型纤溶酶原激活剂治疗。溶栓治疗后影像学显示穿刺处无主动脉外渗。据我们所知,这是第一例经腹主动脉经导管主动脉瓣置换术后使用溶栓治疗的病例,表明经腹主动脉关闭后无泄漏的患者,溶栓治疗不是禁忌。
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引用次数: 0
Key Considerations For Integrating Sacubitril/Valsartan Into Chronic Heart Failure Management 将苏比利/缬沙坦纳入慢性心力衰竭治疗的关键考虑因素
Pub Date : 2018-12-01 DOI: 10.21925/mplsheartjournal-d-18-00014.1
M. Lillyblad
Heart failure with reduced ejection fraction remains a prevalent clinical syndrome associated with significant morbidity and mortality. Despite significant advances in heart failure with reduced ejection fraction pharmacotherapy, 5-year mortality remains 50%. Sacubitril/valsartan is a first-in-class angiotensin-receptor-neprilysin inhibitor, Food and Drug Administration–approved to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure with reduced ejection fraction. Sacubitril/valsartan is recognized as a significant therapeutic advancement and endorsed by national guidelines, yet adoption into clinical practice has lagged across the United States. Recommendations for use differ greatly between the Prospective Comparison of Angiotensin-Receptor-Neprilysin Inhibitor with Angiotensin-Converting-Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure clinical trial, international guidelines, and the Food and Drug Administration-approved labeling, which can lead to uncertainty with prescribing. It is essential to establish an evidence-based, pragmatic approach to patient selection and management of sacubitril-valsartan facilitate integration into clinical practice. This review summarizes the pharmacology of sacubitril/valsartan, its known benefits and risks, and important considerations for incorporating sacubitril/valsartan into chronic heart failure management.
心力衰竭伴射血分数降低仍然是一种常见的临床综合征,与显著的发病率和死亡率相关。尽管降低射血分数药物治疗在心力衰竭方面取得了重大进展,但5年死亡率仍为50%。Sacubitril/valsartan是一种一流的血管紧张素受体-neprilysin抑制剂,美国食品和药物管理局(fda)批准用于降低慢性心力衰竭患者射血分数降低的心血管死亡和心力衰竭住院风险。Sacubitril/缬沙坦被认为是一项重大的治疗进展,并得到了国家指南的认可,但在美国,临床实践的采用却滞后。使用血管紧张素受体- neprilysin抑制剂与血管紧张素转换酶抑制剂的前瞻性比较以确定心力衰竭临床试验中全球死亡率和发病率的影响,国际指南和食品和药物管理局批准的标签之间的建议存在很大差异,这可能导致处方的不确定性。建立一个以证据为基础的、实用的方法来选择和管理苏比替-缬沙坦,以促进其融入临床实践。本文综述了沙比里尔/缬沙坦的药理学,已知的益处和风险,以及将沙比里尔/缬沙坦纳入慢性心力衰竭治疗的重要注意事项。
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引用次数: 0
Health Status and Quality of Life of Patients Enrolled in a Specialized Refractory Angina Clinic 某专科难治性心绞痛门诊患者的健康状况和生活质量
Pub Date : 2018-12-01 DOI: 10.21925/MPLSHEARTJOURNAL-D-18-00008
N. M. Bennett, S. Rutten-Ramos, Theresa L. Arndt, R. Garberich, J. Traverse, A. Poulose, Patricia Mitchell, K. Storey, T. Henry
As the mortality of coronary artery disease improves and the population ages, an increasing number of patients with refractory angina are not candidates for percutaneous or surgical revascularization. We evaluated the impact of a dedicated refractory angina clinic on quality of life. In 76 patients who completed the Medical Outcomes Study 36-Item Short-Form Health Survey and Seattle Angina Questionnaire at baseline and 1 year, the Medical Outcomes Study results showed the proportion of patients who rated their health as “good” or “excellent” more than doubled from baseline to 1 year (15.8% vs. 42.2%; P < .001). Similarly, the Seattle Angina Questionnaire score was significantly improved at 1 year compared to baseline (P = .025), as were angina stability (P = 0.017) and angina frequency (P = .010). In conclusion, treatment in a dedicated clinic is associated with improved quality of life in patients with refractory angina.
随着冠状动脉疾病死亡率的提高和人口老龄化,越来越多的难治性心绞痛患者不适合经皮或手术血管重建术。我们评估了一个专门的难治性心绞痛诊所对生活质量的影响。76名患者在基线和1年完成了医疗结果研究36项简短健康调查和西雅图心绞痛问卷,医疗结果研究结果显示,从基线到1年,将自己的健康状况评为“良好”或“优秀”的患者比例增加了一倍以上(15.8%比42.2%;P < 0.001)。同样,与基线相比,西雅图心绞痛问卷评分在1年后显著改善(P = 0.025),心绞痛稳定性(P = 0.017)和心绞痛频率(P = 0.010)也是如此。总之,在专门的诊所治疗可以提高难治性心绞痛患者的生活质量。
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引用次数: 2
Genetic Arrhythmia Center: Caring for Patients and Families at Risk for Sudden Cardiac Death and Advancing the Understanding of Rare Cardiomyopathies and Channelopathies 遗传性心律失常中心:照顾有心源性猝死风险的患者和家属,提高对罕见心肌病和通道病的认识
Pub Date : 2018-12-01 DOI: 10.21925/mplsheartjournal-d-19-00022.1
M. Kunz, Sajya M. Singh, S. Casey, K. Storey, W. Katsiyiannis, Raed H. Abdelhadi, A. Berg, Mosi K. Bennett, J. Sengupta
Although rare in the general population, genetic arrhythmia syndromes have a significant public health impact due to their contribution to the incidence of sudden cardiac death, particularly in children and young adults. When sudden cardiac death occurs in the absence of ischemic heart disease, a genetic cardiac condition may be suspected and clinical and genetic screening of family members is recommended. The Genetic Arrhythmia Center at the Minneapolis Heart Institute collaborates with local partners in the Sudden Cardiac Arrest network to connect patients and their family members with interdisciplinary care for diagnosis and treatment of these conditions. The most common conditions seen in the Genetic Arrhythmia Center include arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction, long QT syndrome, and Brugada syndrome. In addition to providing clinical care and genetic testing and counseling services, the Genetic Arrhythmia Center is working to advance the scientific understanding of the clinical presentation and natural history of these rare conditions.
虽然遗传性心律失常综合征在一般人群中很少见,但由于其导致心源性猝死的发生率,特别是在儿童和年轻人中,对公共卫生产生了重大影响。在没有缺血性心脏病的情况下发生心源性猝死时,可能怀疑是遗传性心脏病,建议对家庭成员进行临床和遗传筛查。明尼阿波利斯心脏研究所的遗传心律失常中心与心脏骤停网络的当地合作伙伴合作,将患者及其家属与这些疾病的诊断和治疗的跨学科护理联系起来。遗传性心律失常中心最常见的疾病包括致心律失常性右室心肌病、左室不致密化、长QT综合征和Brugada综合征。除了提供临床护理、基因检测和咨询服务外,遗传心律失常中心还致力于促进对这些罕见疾病的临床表现和自然史的科学理解。
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引用次数: 0
When 1 + 1 = 3 当1 + 1 = 3
Pub Date : 2018-06-01 DOI: 10.21925/MPLSHEARTJOURNAL-D-18-00003
R. Hauser
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引用次数: 0
期刊
Journal of the Minneapolis Heart Institute Foundation
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