JRSM Cardiovascular Disease最新文献

Objective: The aim of this online clinical vignette-based survey study was to compare risk assessments by vascular surgeons, anaesthesiologists and interventional radiologists involved in treating patients with aortic aneurysms in the Netherlands with the NSQIP risk calculator outcomes.

Methods: Participants, recruited using purposive sampling, provided their estimation of the likelihood of postoperative complications and events following aortic surgery in five fictional cases. These cases were subsequently scored using the NSQIP calculator. The risk assessments were statistically analysed using the ANOVA and student t-test.

Results: All participating specialists i.e. twelve vascular surgeons, ten interventional radiologists and ten anaesthesiologists completed the survey. In the vast majority of outcomes and vignettes, no significant differences were found between various specialists, whereas significant differences were found between the NSQIP risk calculator outcomes and the combined risk assessments of the specialists. Overall, specialist risk assessments differ from the NSQIP, but neither particularly higher nor lower compared to the risk calculator.

Conclusions: Risk assessment by vascular surgeons, anaesthesiologists and interventional radiologists differs significantly with NSQIP risk calculator outcomes, within the framework of both endovascular and open aortic aneurysm repair. Based on these results, implementing the NSQIP risk calculator in preoperative workup could be of added value in both patient planning as well as adequately informing patients for obtaining consent.

Objectives: There is a high rate of false-positive arterial Thoracic Outlet Syndrome (ATOS) diagnoses due to limited research into the optimal use of ultrasound. To improve future diagnostic efficiency, we aimed to characterise the haemodynamic effects of different provocative positions and estimate the prevalence of compression in the healthy population.

Design: In this cross-sectional, observational study, the effect of varying degrees of arm abduction on discomfort levels and/or changes in subclavian artery Doppler waveform was analysed in the healthy population; the peak systolic velocity (PSV), systolic rise time (SRT), phasicity and extent of turbulence were recorded.

Setting: Department of the Vascular Studies, Royal Free Hospital.

Participants: 19 participants (11 females, 27.4 ± 5.2 years) were recruited for bilateral scans.

Main outcome measures: Seven positions were investigated; the primary outcome was an occlusion or monophasic waveform indicating significant compression and this was compared with the secondary outcome; any physiological discomfort.

Results: 28.9% experienced significant arterial compression in at least one position; 120° abduction was the position with the greatest level of abduction that did not result in significant waveform changes or symptoms. The PSV and SRT were difficult to accurately measure and bore no correlation to the level of compression.

Conclusion: Ultrasound testing in isolation would result in a false indication of TOS in almost 30% of our normal population. With further research, the 120° abduction position may have a lower false-positive rate. The PSV and SRT must be interpreted with caution due to their variability even within the healthy population.

Objectives: The right ventricular (RV) function is an important prognostic factor in acute and chronic heart failure (HF). Echocardiography is an essential imaging modality with established parameters for RV function which are useful and easy to perform. However, these fail to reflect global RV volumes due to reliability on one acoustic window. It is therefore attractive to calculate RV volumes and ejection fraction (RVEF/E) using an ellipsoid geometric model which has been validated against MRI in healthy adults but not in the HF patients.

Design: This is a retrospective analysis of a prospective cross-sectional study enrolling 418 consecutive patients with symptoms of HF according to a predefined study protocol. All patients underwent echocardiographic assessment of RV function using Tricuspid Annular Plane Systolic Excursion (TAPSE) and RV fractional area change (RVFAC) and RVEF/E.

Setting: Single centre study with multiple locations for acute in-patients including high dependency units.

Participants: Patients with acute or exacerbation of chronic HF older than 18 y.o.

Main outcome measures: Ability of RVEF/E to predict patient outcomes compared with two established parameters of RV function over two-year follow-up period. Primary outcome measure was all-cause mortality.

Results: RVEF/E is equal to TAPSE & RVFAC in predicting outcome (p ≤ 0.01 vs p ≤ 0.01) and provides additional benefit of RV volume estimation based on standard 2D echo measurements.

Conclusions: In this study we have shown that RVEF/E derived from ellipsoid model is not inferior to well established measures of RV function as a prognostic indicator of outcome in the acute HF.

Objectives: Following surgical creation of arterio-venous fistulae (AVF), the desired outward remodeling is often accompanied by the development of neointimal hyperplasia (NIH), which can stymie maturation and may lead to thrombosis and access failure. The aim of this study was to investigate the feasibility of using a non-invasive test, to detect and quantify the turbulent flow patterns believed to be associated with NIH development.

Design: This was a prospective, observational study. Ultrasound derived turbulence intensity ratios (USTIR) were calculated from spectral Doppler waveforms, recorded from newly formed AVF, and were compared with haemodynamic and structural changes observed during the initial maturation period.

Setting: Measurements were obtained by accredited Clinical Vascular Scientists, at the Royal Free Hospital, London.

Participants: Patients with newly created AVF were invited to participate in the study. A total of 30 patients were initially recruited with 19 participants completing the 10 week study protocol.

Outcome measures: The primary outcome measure was the development of NIH resulting in a haemodynamically significant lesion.The secondary outcome was successful maturation of the AVF at 10 weeks.

Results: Elevated USTIR in the efferent vein 2 weeks post surgery corresponded to the development of NIH formation (P = 0.02). A cut off of 6.39% predicted NIH development with a sensitivity of 87.5% and a specificity of 80%.

Conclusion: Analysis of Doppler waveforms can successfully identify deleterious flow patterns and predict inward luminal remodelling in maturing AVF. We propose a longitudinal follow up study to assess the viability of this technique as a surveillance tool.

Background: Stress from obstructive sleep apnoea (OSA) stimulates catecholamine release and consequently can exacerbate hypertension, even in the absence of a catecholamine-producing tumour (phaeochromocytoma). As such, a positive screening test for suspected phaeochromocytoma may be misleading. There exists only a handful case reports, and no controlled trials, how continuous positive airway pressure (CPAP) to treat OSA influences catecholamine levels. We examined changes to levels of urinary catecholamine and blood pressure in response to CPAP treatment.

Methods: We conducted a meta-analysis of data aggregated from published case reports of individual patient data up to April 2020. The quality of the reports was evaluated using the risk of bias in non-randomized studies of interventions (ROBINS-I) tool.

Results: A total of 13 cases (seven men and six women) from seven reports met our search criteria. Patients had mean age of 49.1 years (range = 36-62) and body mass index of 37.4 kg/m² (range = 27-56). Most had moderate to severe OSA with CPAP treatment. Nine cases had 24-hour urinary noradrenaline assessment before and after CPAP treatment. CPAP treatment led to a 21% reduction (104 nmol/24-hours, 95% credible interval =59 to 148) in 24-hour urinary noradrenaline to within reference ranges, and 25% reduction (from 131 to 100 mmHg) in mean arterial pressure. The risk of overall bias evaluated by the ROBINS-I tool was found to be low in the majority of reports.

Conclusions: Investigations of patients suspected of phaeochromocytoma, particularly obese individuals, should exclude OSA and treat this condition if present before performing screening tests to assess for catecholamine levels.

Background: Smoking and dyslipidaemia are known individual risk factors of coronary artery disease (CAD). The present study examined the combined risk of smoking and dyslipidaemia on coronary atherosclerosis.

Methods: Coronary artery calcium (CAC), measured by cardiac CT, was used to assess the extent of CAD, which was related to smoking and dyslipidaemia using logistic regression, adjusted for age, sex, hypertension, BMI and family history of ischaemic heart disease.

Results: Seventy-one patients (46 men, 25 women: median age of 53.7yrs; IQR = 47.0-59.5) were recruited. The mean log₁₀ CAC score in never-smokers without dyslipidaemia (reference group) was 0.37 (SD = 0.73), while the value in those with a history of smoking was 0.44 ± 0.48 (mean difference: 0.07, 95%CI:-0.67 to 0.81, p = 0.844), dyslipidaemia was 1.07 ± 1.08 (mean difference: 0.71, 95%CI: 0.24 to 1.17, p = 0.003), and both risk factors was 1.82 ± 0.64 (mean difference: 1.45, 95%CI:0.88 to 2.02, p < 0.001). For individuals in the reference group, the proportions with none, one and multiple vessel disease were 80.6%, 16.1% and 3.2%; for those with a history of smoking or with dyslipidaemia were 50.0%, 25.0% and 25.0%; and for those with both risk factors were 8.3%, 25.0% and 66.7%. Patients with a history of both risk factors had greater adjusted risks of having one- vessel disease - OR = 14.3 (95%CI = 2.1-98.2) or multiple vessel disease: OR = 51.8 (95%CI = 4.2-609.6).

Conclusions: Smoking and dyslipidaemia together are associated with high coronary artery calcification and CAD, independent of other major risk factors.

Covid-19 virus has been recognized to develop major cardiac complications. The indirect effect of the virus though, in terms of fear for hospital admissions, constitutes a greater threat. In this case we present a 69-year old male patient who suffered from a myocardial infarction that has not been given the proper attention due to the fear of in-hospital contact with covid patients. The result was the delayed revascularization and eventually the development of heart failure. This case presents the full range of covid-19 affection to the heart and raises the public awareness for not underestimating symptoms suggesting life-threatening conditions.

Objective: To investigate demographic disparities in prehospital cardiopulmonary resuscitation (CPR) initiation and successful outcomes of patients with out-of-hospital cardiac arrest (OHCA) treated by emergency medical services (EMS) providers.

Methods: We analyzed the National Emergency Medical Service Information Systems (NEMSIS) 2017 database, analyzing patient gender, age and race against CPR initiation and Return of Spontaneous Circulation (ROSC). The analysis was performed for a subset of patients who received bystander interventions (n = 3,362), then repeated for the whole cohort of patients (n = 5,833).

Results: Within the subgroup of patients that received CPR or AED application prior to the arrival of the paramedics, a logistic regression for CPR initiation rates as a function of race, gender and age reported the following adjusted odds ratios: African American (AA) to White 0.570 (95%CI [0.419, 0.775]), Hispanic to White 0.735 (95%CI [0.470, 1.150]); female to male 0.768 (95%CI [0.598, 0.986]); senior to adult 0.708 (95%CI [0.545, 0.920). Similarly, a logistic regression of ROSC as a function of race, gender and age reported the following adjusted odds ratios: AA to White 0.652 (95%CI [0.533, 0.797]) Hispanic to White 1.018 (95%CI [0.783, 1.323]); female to male 0.887 (95%CI [0.767, 1.025]); senior to adult 0.817 (95%CI [0.709, 0.940]). Similar trends existed in the entire cohort of patients.

Conclusions: These results suggest that there are discrepancies in patient care during cardiopulmonary arrest performed by EMS for OHCA, inviting further exploration of healthcare differences in the prehospital EMS approach to OHCA.

Background: Blood flow is a crucial measurement in the assessment of heart valve disease. Time-resolved flow using magnetic resonance imaging (4 D flow MRI) can provide a comprehensive assessment of heart valve hemodynamics but it relies in manual plane analysis. In this study, we aimed to demonstrate the feasibility of automate the detection and tracking of aortic and mitral valve planes to assess blood flow from 4 D flow MRI.

Methods: In this prospective study, a total of n = 106 subjects were enrolled: 19 patients with mitral disease, 65 aortic disease patients and 22 healthy controls. Machine learning was employed to detect aortic and mitral location and motion in a cine three-chamber plane and a perpendicular projection was co-registered to the 4 D flow MRI dataset to quantify flow volume, regurgitant fraction, and a peak velocity. Static and dynamic plane association and agreement were evaluated. Intra- and inter-observer, and scan-rescan reproducibility were also assessed.

Results: Aortic regurgitant fraction was elevated in aortic valve disease patients as compared with controls and mitral valve disease patients (p < 0.05). Similarly, mitral regurgitant fraction was higher in mitral valve patients (p < 0.05). Both aortic and mitral total flow were high in aortic patients. Static and dynamic were good (r > 0.6, p < 0.005) for aortic total flow and peak velocity, and mitral peak velocity and regurgitant fraction. All measurements showed good inter- and intra-observer, and scan-rescan reproducibility.

Conclusion: We demonstrated that aortic and mitral hemodynamics can efficiently be quantified from 4 D flow MRI using assisted valve detection with machine learning.

Bifurcation lesions are common and associated with higher risks of major cardiac events and restenosis after percutaneous coronary intervention (PCI). Treatment requires understanding of lesion characteristics, stent design and therapeutic options. We review the evidence for provisional vs 2-stent techniques. We conclude that provisional stenting is suitable for most bifurcation lesions. We detail situations where a 2-stent technique should be considered and the steps for performing each of the 2-step techniques. We review the importance of lesion preparation, intracoronary imaging, proximal optimization (POT) and kissing balloon inflation.