Critical Pathways in Cardiology最新文献

Background: ST-segment elevation myocardial infarction (STEMI) remains a leading cause of global mortality. Although overall incidence is declining, this trend is less evident among younger individuals, emphasizing the need to better understand modifiable risk factors and clinical outcomes in this population.

Objective: This study aimed to analyze the clinical profile and outcomes of young patients with STEMI undergoing primary percutaneous coronary intervention in a contemporary cohort.

Methodology: This prospective cohort study included patients aged ≥18 years with confirmed STEMI treated with primary percutaneous coronary intervention at a tertiary university hospital from March 2011 to January 2025. Patients were stratified into two groups: young (≤45 years) and older (>45 years). The primary outcome was inhospital mortality. A two-sided significance level of P < 0.05 was adopted.

Results: A total of 2050 patients were included; 191 (9.3%) were ≤45 years old (mean age: 39.9 years). Younger patients showed significantly lower inhospital mortality (4.2% vs. 12.1%; P = 0.001), shorter median length of stay (5 vs. 6 days; P = 0.001), and lower incidence of long-term major adverse cardiovascular and cerebrovascular events (15.2% vs. 24.7%; P = 0.003). They had a higher prevalence of active smoking (57.1% vs. 40.6%; P < 0.001), illicit drug use (18.3% vs. 10.0%; P < 0.001), HIV infection (4.7% vs. 2.2%; P = 0.003), and family history of coronary artery disease (24.2% vs. 12.4%; P < 0.001).

Conclusions: Young STEMI patients presented with fewer comorbidities and lower inhospital mortality, but a higher prevalence of behavioral risk factors. These findings highlight the need for targeted preventive strategies and early detection to improve long-term outcomes.

Approximately 20%-40% of patients that present for transcatheter aortic valve replacement with a balloon-expandable transcatheter heart valve (THV) fall into a borderline aortic annulus size (BAAS). There are potential benefits to overexpanding an undersized THV (OE-THV) in such cases that include reduced electrical disturbances and annular injury at the expense of increased paravalvular leak (PVL). We conducted a meta-analysis of data comparing conventional-sized versus OE-THV strategy for BAAS and reviewed the literature for balloon-expandable-THV in such cases. 9 nonrandomized studies that compared a conventional strategy to OE-THV in patients with BAAS were included in our study. Our findings suggest that there is no difference in mortality, stroke, mean gradient, or significant PVL. There was a trend towards fewer pacemakers in patients receiving an OE-THV. Borderline aortic annulus measurements are common in patients undergoing transcatheter aortic valve replacement and there appears to be equipoise between conventional sizing versus OE-THV. Future detailed studies are required to evaluate short- and long-term outcomes among strategies.

Background: Patients evaluated for transient ischemic attack (TIA) in the emergency department observation unit (EDOU) may be discharged with a long-term rhythm monitor to assess for atrial fibrillation (AF) and atrial flutter (AFL). We aimed to assess the diagnostic yield of long-term rhythm monitoring for diagnosing AF and AFL in an EDOU cohort of patients evaluated for TIA.

Methods: We conducted an observational cohort study, in which patients ≥18 years old who were evaluated in the EDOU TIA Protocol at an academic tertiary care center from July 1, 2021 to December 1, 2023 were accrued. This analysis included patients who received a long-term rhythm monitor (Zio Patch) at the time of EDOU discharge. Monitor results were reviewed for diagnoses of AF or AFL. Diagnostic yield, defined as the proportion receiving monitoring who had a new diagnosis of AF or AFL, was calculated with an exact 95% confidence interval (95% CI) and used to determine the number needed to test.

Results: Of the 523 EDOU TIA protocol patients, 59.7% (312/523) were female, 29.6% (155/523) were non-White, and the mean age was 65.9 ± 14.9 years. At discharge, 18.4% (96/523) received long-term rhythm monitoring, which identified AF in 5.2% (5/96) and AFL in 1.0% (1/96). However, 3 of these patients already had known AF/AFL. Thus, the yield for diagnosing new AF/AFL was 3.1% (3/96, 95% CI, 0.7%-8.9%), with a number needed to test of 32.

Conclusions: The diagnostic yield of long-term rhythm monitoring for diagnosing AF/AFL among discharged EDOU TIA protocol patients was low, suggesting it may be overprescribed in this population.

Background: The use of transcatheter edge-to-edge repair (TEER) for symptomatic mitral regurgitation is steadily increasing. However, the outcomes of TEER among patients with atrial fibrillation (AF), including readmission trends, remain unknown.

Methods: The Nationwide Readmissions Database was queried between 2016 and 2020 to identify TEER patients with and without AF. The 2 groups were then compared using propensity score matching and multivariate regression models. The outcomes included inhospital mortality, ` (AKI), heart failure (HF), acute stroke, myocardial infarction, postprocedure bleeding, and cardiac tamponade.

Results: A total of 39,867 TEER procedure recipients were included over the study period, of which, 24,729 (62%) had AF compared to 15,138 (38%) with no AF diagnosis. On adjusted analysis, the AF group had a higher rate of inpatient mortality, AKI, HF, and postprocedural bleeding. On the contrary, TEER with AF group had lower odds of myocardial infarction. The risk of stroke and cardiac tamponade was similar between the 2 groups. The median length of stay (LOS) at index hospitalization was longer in the AF cohort in comparison with those without [2 days (interquartile range: 5-1) vs. 1 day (interquartile range: 3-1)].

Conclusions: AF in TEER procedure recipients was associated with worse outcomes including a higher rate of inpatient mortality, AKI, and HF compared with the patients without AF. Readmission rates at 30, 90, and 180 days were similar between the 2 groups.

Background: Differentiating type 1 myocardial infarction (T1-MI) from type 2 MI (T2-MI) remains a diagnostic challenge, even with the availability of high-sensitivity cardiac troponin assays. This study explored whether N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), BNP, and their respective ratios to troponin could enhance the ability to distinguish between these MI subtypes.

Methods: As a High-Sensitivity Cardiac Troponin I Assays in the United States substudy, we examined data from 280 patients diagnosed with non-ST elevation MI (172 with T1-MI and 108 with T2-MI). We assessed NT-proBNP, BNP, high-sensitivity cardiac troponin I, and their ratios as potential discriminative biomarkers. Diagnostic accuracy was evaluated using receiver operating characteristic curves.

Results: NT-proBNP levels were markedly elevated in T2-MI patients compared with those with T1-MI (mean: 10,327 ± 12,923 vs. 4675 ± 11,740 ng/L; P = 0.006). Conversely, high-sensitivity cardiac troponin I concentrations were higher in T1-MI (1.4 ± 5.1 vs. 0.5 ± 1.1 ng/L; P = 0.030). Notably, the NT-proBNP-to-troponin ratio was more than 3 times greater in T2-MI cases (94,880 ± 152,648 vs. 24,209 ± 78,727; P = 0.007). NT-proBNP alone demonstrated fair discriminatory capacity [area under the receiver operating characteristic curve (AUC) 0.717, 95% confidence interval (CI): 0.578-0.856], closely matching the NT-proBNP-to-troponin ratio (AUC: 0.720, 95% CI: 0.566-0.873). In contrast, BNP and the BNP-to-troponin ratio offered lower diagnostic values. Mean BNP levels were 505.4 ± 576.6 ng/L for those with T2-MI and 437.1 ± 738.8 ng/L for patients with T1-MI. BNP-to-troponin ratio showed a poor discrimination for the 2 MI types (AUC: 0.660; 95% CI: 0.532-0.789).

Conclusions: Both NT-proBNP and its ratio to troponin show potential in differentiating T1-MI from T2-MI, reflecting distinct underlying pathophysiological processes. Given its comparable performance to the ratio, NT-proBNP alone may serve as a practical and cost-effective standalone marker. These findings support the hypothesis that incorporating NT-proBNP testing into routine clinical workflows may better inform the management of patients with suspected MI.

Background: There is uncertainty in the clinical utility of the HEART score, given its incorporation of an older generation of troponin assay. We sought to determine whether high-sensitivity troponin I (Hs-TnI) alone can effectively stratify cardiovascular risk in patients presenting to the emergency department with moderate or high HEART score by analyzing the management and outcomes of adults presenting to our emergency department with chest pain, moderate or high HEART score, and Hs-TnI below the 99th percentile.

Methods: For this population, we calculated the negative predictive value of Hs-TnI in ruling out a major adverse cardiac event (MACE; defined as myocardial infarction or death from a cardiovascular or unknown cause) at 30 days.

Results: The average HEART score was 5.1, and 1224 patients (92.0%) had a moderate HEART score (4-6) and 107 patients (8.0%) had a high HEART score (7+). The average age of patients was 59.0 years and 52.7% were women. The incidence of 30-day MACE was 0.2%. Overall, in this cohort of patients with moderate or high HEART score, Hs-TnI below the 99th percentile had a negative predictive value of 99.8% (95% confidence interval: 99.6%-100.0%) in ruling out MACE at 30 days.

Conclusion: Given the low event rate, a moderate or high HEART score should not be the sole determinant for admission when Hs-TnI is not elevated.

Background: While peripheral artery disease (PAD) is a recognized risk factor for other macrovascular diseases, including coronary artery disease, the impact of PAD severity in patients hospitalized for atrial fibrillation (AF) remains underexplored. Using a nationally representative cohort of patients admitted for AF, we examined clinical outcomes in those with different PAD severities and compared them to patients without PAD.

Methods: Data were obtained from the 2016 to 2022 Nationwide Readmissions Database to query all patients admitted for AF. Patients were categorized into 3 groups: No PAD (non-PAD), PAD, and critical limb ischemia (CLI). Multivariable regression models were constructed to adjust for patient and hospital-level factors and to examine the association between PAD severity and outcomes in patients admitted for AF.

Results: Out of 6,715,236 AF admissions, 4.5% had PAD, 0.3% had CLI, and the remaining were non-PAD. Following risk adjustment, in-hospital mortality was higher by 22% in PAD [adjusted odds ratio (aOR) 1.22, 95% confidence interval (CI), 1.07-1.39], and 264% in CLI (aOR, 3.64, 95% CI, 1.36-9.73), compared to non-PAD. Only PAD was linked with higher odds of acute ischemic stroke (aOR, 1.27, 95% CI, 1.12-1.44). However, the duration of hospital stay, hospitalization costs, and odds of nonhome discharge and 30-day nonelective readmissions were greater in patients with PAD and CLI compared to non-PAD patients.

Conclusion: Severe PAD was linked with significantly worse clinical outcomes, including higher in-hospital mortality, longer length of stay, incremental hospitalization costs, and higher 30-day nonelective readmission. These outcomes underscore the importance of early PAD management.

Purpose: To describe the experience and results of adopting evidence-based teaching strategies in a cardiovascular system course for undergraduate medical students.

Material and methods: Evidence-based methods for teaching undergraduate medical students were combined with feedback from students to inform and implement several changes to the course structure, content, and teaching methods.

Results and conclusions: The course was restructured with new learning objectives, "mini-tracks," 30-minute lectures, and purposeful repetition. Active learning (AL) was increased to 32 of 101 learning activities AL (31.7%). The overall approval rating for the course substantially increased after changes were made. Course directors should periodically review their learning activities for opportunities to adopt evidence-based educational techniques.

Background: Heart failure (HF) is a leading cause of hospitalization in the United States. The goal of this study was to evaluate contemporary population-level trends and demographic disparities in age-adjusted hospitalization rates for systolic heart failure (SHF) and diastolic heart failure (DHF).

Methods: We analyzed discharge data from the National Inpatient Sample database, years 2016 to 2020, for adults aged 20 and older. HF subtypes were identified using International Classification of Diseases, Tenth Revision codes. Age-adjusted hospitalization rates per 100,000 population were calculated and stratified by year, sex, and race.

Results: From 2016 to 2020, the age-adjusted DHF hospitalization rate increased from 219.4 [95% confidence interval (CI), 201.4-237.1] to 303.1 (95% CI, 277.7-328.5) per 100,000. SHF rates rose from 211.7 (95% CI, 194.7-228.7) to 262.6 (95% CI, 240.6-284.6). Hospitalizations for SHF were more common in men than women across all years; in 2020, the SHF hospitalization rate in men was 370.6 (95% CI, 323.8-417.4) compared to 171.9 (95% CI, 152.6-191.1) in women. Black patients consistently had the highest SHF and DHF hospitalization rates. In 2020, the DHF rate among Blacks was 418.3 (95% CI, 328.9-507.7) versus 284.8 (95% CI, 255.0-314.6) among Whites, and the SHF rate was 403.6 (317.3-478.8) versus 227.5 (95% CI, 203.7-251.3), respectively.

Conclusions: SHF and DHF age-adjusted hospitalization rates are rising significantly, with pronounced disparities by sex and race. Men and Black patients are disproportionately impacted.

Sustained ventricular tachycardia (VT) and fibrillation-related sudden cardiac death (SCD) account for nearly 450,000 deaths annually in the United States. Catheter ablation (CA) and antiarrhythmic drugs (AADs) are commonly used to manage VT recurrence; however, their comparative efficacy and safety remain uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing CA and AADs in patients with ischemic cardiomyopathy and implantable cardioverter-defibrillators (ICDs). PubMed, Embase, and Cochrane CENTRAL Library were searched up to February 15, 2025. Primary outcomes included all-cause mortality, cardiovascular mortality, VT storm, and appropriate ICD shock. Secondary outcomes included inappropriate ICD shock, appropriate antitachycardia pacing (ATP), heart failure hospitalization, stroke/transient ischemic attack (TIA), and myocardial infarction (MI). Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Three RCTs encompassing 587 patients (287 CA, 300 AADs) were included. No significant differences were found between CA and AADs in all-cause mortality (RR 0.88, 95% CI: 0.63-1.22; p=0.43), cardiovascular mortality (RR 1.23, 95% CI: 0.77-1.98; p=0.39), VT storm (RR 0.76, 95% CI: 0.39-1.46; p=0.41), or appropriate ICD shock (RR 0.87, 95% CI: 0.69-1.10; p=0.24). Secondary outcomes, including inappropriate ICD shock, ATP, heart failure hospitalization, stroke/TIA, and MI, were also comparable between the two groups. In this meta-analysis of RCTs, CA and AADs demonstrated comparable efficacy and safety in patients with VT. Larger high-quality trials are warranted to confirm these findings and further define the role of CA as a potential first-line therapy.