Critical Pathways in Cardiology最新文献

Background: Takotsubo Cardiomyopathy (TTC) is an acute heart condition in which physical or emotional stress causes left ventricular dysfunction. Psychiatric comorbidities have been linked to the precipitation of this condition, but large-scale data are limited. The goal of this study was to analyze the associations between TTC and various psychiatric conditions using nationally representative data.

Methods: A retrospective observational cohort study was conducted using the Nationwide Inpatient Sample (NIS) database from 2016-2022. ICD-10 code I51.81 was used to identify hospitalized patients ≥18 years with a primary diagnosis of TTC. In addition, ICD-10 codes were used to identify patients diagnosed with various psychiatric comorbidities.

Results: A total of 291,600 patients had a primary diagnosis of TTC. The mean age was 67.1 ± 14.26 years and 82.04% of the population was female. The following four psychiatric comorbidities were found to have significant associations with TTC: nicotine dependence (17.48% of patients; p<0.001; OR 1.08; 95% CI, 1.06-1.11), depressive disorders (19.20% of patients; p<0.001; OR 1.46; CI 95%, 1.43-1.49), anxiety (24.25% of patients; p<0.001; OR 1.83; CI 95%, 1.80-1.87), and PTSD (2.91% of patients; p<0.001; 1.25 OR; CI 95%, 1.18-1.31). No significant associations were found for dementia, alcohol related disorders, substance use other than tobacco and alcohol, manic disorders, or schizophrenia.

Conclusions: In this large, nationally representative sample, nicotine dependence, anxiety, depression, and PTSD were significantly associated with TTC. These findings highlight the importance of incorporating psychiatric health practices into the field of cardiology.

Early detection of cardiovascular disease and implementation of evidence-based treatments can reduce cardiovascular morbidity and mortality. Medical algorithms and decision-making tools provide a compelling option for screening, risk prediction, and treatment management. Such digital tools have the potential to aid both healthcare professionals and patients, providing support to decrease unwarranted diagnostic and treatment variability while guiding personalized care, with the overall objective of improving clinical outcomes. However, incorporating digital tools in healthcare settings is challenging, and evidence the required to support their adoption and understand the limitations can be lacking. A multinational panel of expert cardiologists and emergency physicians across North America, Europe, and Oceania gathered to deliberate on the current landscape of digital tools and medical algorithms, drawing on prior clinical experiences and knowledge of country-specific regulations. In this viewpoint, the evidence to support and guide the adoption of digital tools in cardiovascular clinical practice and the necessary components for successful integration into clinical workflows were discussed. Digital tools must be developed with the needs of the healthcare professionals, other relevant stakeholders (eg, administration personnel), and patients in mind to give them the best chance of widespread adoption. Academia, industry, and regulatory bodies should work together to cultivate and accelerate the implementation of digital tools in healthcare. The considerations discussed here may help decision makers to determine if a digital tool has the components necessary to integrate into the clinical workflow successfully.

Background: The long-term impact of super obesity [body mass index (BMI) ≥50 kg/m²] on outcomes after transcatheter aortic valve implantation (TAVI) is not well defined.

Methods: We used the 2015-2020 Nationwide Readmissions Database to identify TAVI procedures and compared patients with super obesity to those with BMI <50 kg/m². Propensity score-matched cohorts were constructed using clinical covariates. We evaluated net adverse cardiovascular events (NACE; composite of in-hospital mortality, stroke, and major bleeding), mortality, and complications during index admission and at 30 and 180 days. A prespecified subgroup analysis compared super-obese with normal-BMI patients.

Results: Among 184,199 TAVI procedures, 4669 patients (2369 super-obese, 2300 nonsuper-obese) were included in the matched cohort. Super-obese TAVI volume increased over time. At index admission, super-obesity was associated with higher odds of NACE [adjusted odds ratio (aOR), 1.57; 95% CI, 1.12-2.20], in-hospital mortality (aOR, 8.08; 95% CI, 3.19-20.48), and acute kidney injury (aOR, 1.48; 95% CI, 1.25-1.74), whereas stroke and major bleeding did not differ. At 30 days, only acute kidney injury remained higher in super-obese patients, and by 180 days, only permanent pacemaker implantation was increased (aOR, 2.55; 95% CI, 1.34-4.85). In subgroup analyses restricted to super-obese versus normal-BMI patients, super-obesity was associated with higher NACE and complications at index admission and 180 days.

Conclusions: Super-obese TAVI recipients have higher early risk and persistent excess risk for selected complications, indicating that extreme obesity defines a higher-risk TAVI phenotype despite broadly comparable longer-term outcomes versus patients with lower BMI.

Background: The ABCD2 score is a validated risk stratification tool used to quantify the risk of stroke within 48 hours among patients presenting with suspected transient ischemic attack (TIA). Limited data exist regarding its performance among patients in an emergency department observation unit (EDOU). The objective of this study was to determine the safety and efficacy of the ABCD2 score in a US EDOU cohort.

Methods: We conducted an observational cohort study using the Wake Forest Emergency Medicine TIA Registry. Patients ≥18 years old who were evaluated for possible TIA in the EDOU of Atrium Health Wake Forest Baptist from July 1, 2021 to December 1, 2023 were accrued. This analysis included patients without a persistent neurologic deficit, except for amaurosis fugax, vertigo, or paresthesias, as determined by the consulting neurologist and attending emergency physician. Patients were risk-stratified using the ABCD2 score as low- (0-3), moderate- (4-5), and high- (≥6) risk for short-term stroke. The primary safety outcome was index encounter stroke, as determined by the consulting neurologist and imaging. Efficacy was defined as the proportion of patients classified to the low-risk group. Negative predictive values and positive predictive values, and negative likelihood ratios and positive likelihood ratios for the ABCD2 score were calculated for index stroke and reported with 95% confidence intervals (CI).

Results: Of the 340 EDOU TIA patients, 55.9% (190/340) were female, 27.9% (95/340) were nonwhite, and the mean age was 67.1 ± 13.6 years. During the index visit, 21.8% (74/340) were diagnosed with acute stroke. The ABCD2 score classified 45.0% (153/340) as low-, 45.6% (155/340) as moderate-, and 9.4% (32/340) as high-risk. Of those identified as low-risk, 17.7% (27/153) had an index acute stroke. Negative predictive values and negative likelihood ratios of the ABCD2 score for index stroke were 63.5% (95% CI, 53.3-72.6) and 0.7 (95% CI, 0.5-1.1). Among patients classified as high-risk, 34.4% (11/32) had an index stroke, corresponding to a positive predictive value of 34.4% (95% CI, 20.9-50.9) and a positive likelihood ratio of 1.9 (95% CI, 1.0-3.7).

Conclusions: Although the ABCD2 score classified approximately half of patients as low-risk, nearly 20% of this group were diagnosed with an acute stroke during EDOU evaluation. These findings suggest that the ABCD2 score is not appropriate for ruling-out acute stroke among EDOU patients as it would lead to a high rate of missed strokes.

Background: Despite the clinical guidelines favoring medical therapy for stable angina, the optimal management of these patients remains unclear. Here, we compare medical management (MM) versus percutaneous coronary intervention (PCI) in patients with stable angina.

Methods: An extensive literature search was conducted using PubMed and Embase to identify randomized controlled trials of interest. Data were extracted and analyzed using a random-effects model to calculate pooled odds ratios (OR).

Results: Our meta-analysis of 28 randomized controlled trials included 9346 PCI patients and 9503 medically managed patients. The mean age was 62.5 ± 7.6 years in the PCI group and 62.8 ± 7.4 years in the other group. Men comprised 68% and 70% of the PCI and MM groups, respectively.Over a mean follow-up of 2.64 years, PCI was associated with a significantly lower incidence of myocardial infarction compared with MM (OR, 0.84; 95% CI, 0.74-0.96; P = 0.01). Although PCI showed trends toward lower odds of unplanned revascularizations and major adverse cardiovascular (CV) events, these differences were not statistically significant. There were no differences in outcomes of freedom from angina, unstable angina, nonfatal myocardial infarction, stroke, all-cause mortality, or CV death.

Conclusion: Advances in CV imaging and catheterization techniques have improved risk stratification and outcomes of PCI in stable angina. Further research is needed to identify clinical subgroups that benefit most from each treatment modality.

Sustained ventricular tachycardia (VT) and fibrillation-related sudden cardiac death 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 Cochrane Central Register of Controlled Trials (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, heart failure hospitalization, stroke/transient ischemic attack, and myocardial infarction. 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, antitachycardia pacing, heart failure hospitalization, stroke/transient ischemic attack, and myocardial infarction, were also comparable between the 2 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.

Guidelines recommend fasting before catheterization laboratory (cath lab) procedures. However, recent studies question the necessity of fasting, suggesting that fasting may not provide significant clinical benefits. This study aims to evaluate the existing evidence between outcomes for patients with fasting and nonfasting regimens. We conducted a comprehensive search for randomized controlled trials comparing fasting and nonfasting protocols before cath lab procedures. Outcomes included hypoglycemia, aspiration pneumonia, contrast nephropathy, all-cause mortality, and cardiovascular mortality. A random effects meta-analysis was performed to derive odds ratios (ORs) and 95% confidence intervals (CIs). The meta-analysis included 8 randomized controlled trials with a total of 3068 participants: 1544 in the fasting group and 1524 in the nonfasting group. Compared with fasting, nonfasting was not associated with significant differences in hypoglycemia (OR = 0.77, 95% CI, 0.44-1.34), aspiration pneumonia (OR = 1.33, 95% CI, 0.38-4.72), contrast nephropathy (OR = 1.82, 95% CI, 0.88-3.75), all-cause mortality (OR = 1.29, 95% CI, 0.51-3.28), or cardiovascular mortality (OR = 0.94, 95% CI, 0.22-4.05). Nonfasting regimens show no significant differences in safety outcomes compared with fasting, suggesting it may be implemented to improve patient experience without compromising safety. Larger trials are needed to confirm the safety of nonfasting regimens. Summary of outcomes (CEID, cardiac implantable electronic device; PCI, percutaneous coronary intervention; TAVR, transcatheter aortic valve replacement). The design features graphical elements sourced from Servier Medical Art, which are provided by Servier under the Creative Commons Attribution 4.0 unported license.

Background: Chronic total occlusion (CTO) lesions in coronary arteries present a significant challenge, often resulting in referrals for coronary artery bypass graft surgery. Successful percutaneous coronary intervention (PCI) for CTOs demands an accurate assessment of procedural potential.

Methods: This study aimed to compare the efficacy of different CTO scoring systems in predicting the PCI procedural success and the associated patient complications. It included patients with a CTO in at least one coronary artery who were scheduled for elective PCI based on objective evidence of ischemia. Experienced operators performed the PCI, recorded procedural variables, and assessed complications.

Results: Our findings indicated that the Japan CTO (J-CTO) score had the highest positive predictive value at 88.89%, closely followed by the CL CTO score at 88.79%, the CASTLE CTO score at 86.84%, and lastly, the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS) CTO score at 86.51%. All scores fell within an acceptable specificity range of 59.2% to 76.3%, while accuracy varied from 62.61% to 72.52%. We also estimated these values using the best Youden index, which was 0.362 for J-CTO, 0.355 for Euro CTO (CASTLE), 0.330 for CL CTO, and 0.283 for PROGRESS CTO, thus maximizing sensitivity and specificity at a particular point. The relation between CTO scores and complications showed comparable differences with no statistical significance and no correlation regarding the cutoff value.

Conclusions: This study shows that J-CTO and CASTLE provide slightly greater accuracy in predicting complex CTO PCI success compared to PROGRESS CTO and CL. However, the ostial location score did not demonstrate statistical significance in our patients.

Background: Limited data exist on the impact of body mass index (BMI) on the outcomes of admissions with acute pulmonary embolism (PE).

Methods: All adult (≥18 years) admissions with a primary diagnosis of PE were identified using the National Inpatient Sample (2016-2020) and categorized using BMI into underweight (<19.9 kg/m 2 ), normal (19.9-24.9 kg/m 2 ), and overweight/obese (>24.9 kg/m 2 ). Outcomes included in-hospital mortality, utilization of PE therapies, and resource utilization.

Results: Of 904,260 admissions, 1.8%, 70.4%, and 27.7% were underweight, normal, and overweight/obese, respectively. Underweight admissions were on average older (70.8 ± 0.2, 64.6 ± 0.05, 58.2 ± 0.07 years), male (56.7%, 49%, 58.3%) with higher comorbidity (Elixhauser Index 5.8 ± 0.03, 4 ± 0.06, 5.1 ± 0.09), from a lower socioeconomic status, and with Medicare insurance compared to normal and overweight/obese categories ( P < 0.001). The underweight cohort had higher rates of acute organ failure, bleeding complications, strokes, shock, and higher mechanical ventilation and hemodialysis use. In contrast to the underweight group, normal and overweight/obese groups had higher rates of mechanical thrombectomy (0.3%, 1.1%, 1.9%), systemic thrombolysis (1.5%, 2.6%, 4.2%), catheter directed therapy (0.9%, 3%, 5.8%), and surgical thrombectomy (0.0%, 0.1%, 0.2%) ( P < 0.001). Compared to the normal cohort (3.3%), the underweight cohort had higher [7.8%; odds ratio 1.85 (95% confidence interval 1.54-2.21)], whereas the overweight/obese cohort had lower [2.2%; odds ratio 0.47 (95% confidence interval 0.42-0.52)] in-hospital mortality (both P < 0.001). The underweight cohort had longer hospitalization stays, higher hospitalization costs, and were discharged home less frequently.

Conclusions: Compared to those with normal BMI, underweight status was associated with worse outcomes in those hospitalization with acute PE.

Radiofrequency catheter ablation (CA) has emerged as a therapeutic strategy for Brugada syndrome (BrS), particularly for patients with recurrent ventricular fibrillation (VF) and implantable cardioverter-defibrillator (ICD) shocks. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of CA compared with standard management. PubMed, Embase, and Scopus were searched from inception to August 2025 for randomized controlled trials and adjusted observational studies enrolling BrS patients undergoing CA versus ICD-only therapy, pharmacotherapy, or observation. Five studies (2 RCTs, 3 cohorts) comprising 510 patients (296 ablation; 214 control) were included. The primary outcome was ventricular arrhythmia recurrence; secondary outcomes were procedural complications and ICD-related complications. Pooled analysis demonstrated that CA significantly reduced ventricular arrhythmia recurrence (RR 0.20; 95% CI 0.05-0.75; P=0.02), with consistent benefit in randomized trials. No significant differences were observed in procedural complications (RR 0.81; 95% CI 0.32-2.01; P=0.65) or ICD-related complications (RR 1.16; 95% CI 0.49-2.78; P=0.73). Certainty of evidence ranged from moderate to very low based on GRADE. In conclusion, CA is an effective intervention for reducing recurrent ventricular arrhythmias in BrS without an increase in procedural or device-related adverse events. These findings support the expanding role of substrate-based ablation as a disease-modifying therapy in appropriately selected BrS patients.