Pub Date : 2024-09-01Epub Date: 2024-04-05DOI: 10.1097/HPC.0000000000000357
Somayyeh Barati, Mohammad Mehdi Mohammadpour, Mohammad Ali Sadrameli, Saeed Hosseini, Majid Maleki, Reza Golpira, Hooman Bakhshandeh, Majid Kyavar, Jamal Moosavi, Bahram Mohebbi, Azita H Talasaz, Stefano Barco, Frederikus A Klok, Parham Sadeghipour
Background: Regarding adjustments to warfarin dosage, numerous studies have shown that computerized methods are superior to those based on personal experience.
Objectives: To report the efficacy of a computer-based warfarin management system (WMS) in the Iranian population.
Methods: By utilizing the existing dosing algorithms and obtaining expert opinions, we developed a computer-based WMS at a large tertiary cardiovascular center. The time in therapeutic range and the number of international normalized ratio (INR) tests of clinic patients were compared before and after the implementation of WMS.
Results: Overall, 803 patients with 5407 INR tests were included in the before phase and 679 patients with 4189 INR tests in the after phase. The mean time in therapeutic range was 57.3% before and 59% after WMS implementation [mean difference, 1.64; 95% confidence interval (CI), -1.12-4.40]. In the before phase, the mean number of INR tests was 6.7, which dropped to 6.1 tests in the after phase (mean difference, -0.61; 95% CI, -0.97 to -0.24). Only 54.5% of the warfarin dosing prescriptions were consistent with the dosing recommendations of the WMS, and adherence to the WMS was poorest in the highest INR target range.
Conclusions: For the first time in Iran, we demonstrated that a computerized system was as effective as a traditional experience-based method to monitor INR in VKA-anticoagulated patients. Furthermore, it could reduce both the number of INR tests and that of visits.
{"title":"Applying a Computer-based Warfarin Management System at a Large Tertiary Cardiovascular Center in Iran.","authors":"Somayyeh Barati, Mohammad Mehdi Mohammadpour, Mohammad Ali Sadrameli, Saeed Hosseini, Majid Maleki, Reza Golpira, Hooman Bakhshandeh, Majid Kyavar, Jamal Moosavi, Bahram Mohebbi, Azita H Talasaz, Stefano Barco, Frederikus A Klok, Parham Sadeghipour","doi":"10.1097/HPC.0000000000000357","DOIUrl":"10.1097/HPC.0000000000000357","url":null,"abstract":"<p><strong>Background: </strong>Regarding adjustments to warfarin dosage, numerous studies have shown that computerized methods are superior to those based on personal experience.</p><p><strong>Objectives: </strong>To report the efficacy of a computer-based warfarin management system (WMS) in the Iranian population.</p><p><strong>Methods: </strong>By utilizing the existing dosing algorithms and obtaining expert opinions, we developed a computer-based WMS at a large tertiary cardiovascular center. The time in therapeutic range and the number of international normalized ratio (INR) tests of clinic patients were compared before and after the implementation of WMS.</p><p><strong>Results: </strong>Overall, 803 patients with 5407 INR tests were included in the before phase and 679 patients with 4189 INR tests in the after phase. The mean time in therapeutic range was 57.3% before and 59% after WMS implementation [mean difference, 1.64; 95% confidence interval (CI), -1.12-4.40]. In the before phase, the mean number of INR tests was 6.7, which dropped to 6.1 tests in the after phase (mean difference, -0.61; 95% CI, -0.97 to -0.24). Only 54.5% of the warfarin dosing prescriptions were consistent with the dosing recommendations of the WMS, and adherence to the WMS was poorest in the highest INR target range.</p><p><strong>Conclusions: </strong>For the first time in Iran, we demonstrated that a computerized system was as effective as a traditional experience-based method to monitor INR in VKA-anticoagulated patients. Furthermore, it could reduce both the number of INR tests and that of visits.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":"124-130"},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140855893","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Data on outcomes between unfractionated heparin and bivalirudin anticoagulation during percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) remains inconclusive. We aimed to systematically analyze PCI outcomes comparing unfractionated heparin and bivalirudin.
Methods: We systematically searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception in 1966 through January 2024 for studies evaluating PCI outcomes comparing unfractionated heparin and bivalirudin. Two investigators independently reviewed data. Conflicts were resolved through consensus. Random-effects meta-analyses were used.
Results: Ten prospective trials were identified that enrolled 42,253 individuals who presented with an acute coronary syndrome. Our analysis found that heparin when compared to bivalirudin was associated with an increased risk of trial-based definition of major bleeding (RR 1.68, 95% CI 1.29-2.20), non-access site complications (RR 4.6, 95% CI 1.75-12.09), TIMI major bleeding (RR 1.70, 95% CI 1.20-2.41), major bleeding risks (RR 1.87, 95% CI 1.49-2.36), cardiovascular disease death (RR 1.26, 95% CI 1.02-1.57), and thrombocytopenia (RR 1.67, 95% CI 1.07-2.62). There were no statistically significant differences between heparin and bivalirudin for all-cause mortality, MACE, stroke, reinfarction, target vessel revascularization, acute or stent thrombosis.
Conclusions: The present meta-analysis demonstrates bivalirudin reduces major bleeding when used for anticoagulation during PCI in patients with acute coronary syndromes and is not associated with an increased risk of stent thrombosis or MACE.
简介:有关急性冠状动脉综合征(ACS)经皮冠状动脉介入治疗(PCI)期间非分叶肝素和比伐卢定抗凝治疗效果的数据仍无定论。我们旨在系统分析比较非分叶肝素和比伐卢定的 PCI 结果:我们系统地检索了 Ovid MEDLINE、Ovid Embase、Ovid Cochrane 系统综述数据库、Scopus 和 Web of Science(从 1966 年数据库建立到 2024 年 1 月)中有关评估比较非分叶肝素和比伐卢定的 PCI 结果的研究。两名研究人员独立审查了数据。如有冲突,则通过协商一致的方式解决。采用随机效应荟萃分析:共确定了 10 项前瞻性试验,共纳入 42,253 名急性冠脉综合征患者。我们的分析发现,与比伐卢定相比,肝素与基于试验定义的大出血(RR 1.68,95% CI 1.29-2.20)、非入路部位并发症(RR 4.6,95% CI 1.75-12.09)、TIMI大出血(RR 1.70,95% CI 1.20-2.41)、大出血风险(RR 1.87,95% CI 1.49-2.36)、心血管疾病死亡(RR 1.26,95% CI 1.02-1.57)和血小板减少(RR 1.67,95% CI 1.07-2.62)。在全因死亡率、MACE、中风、再梗死、靶血管血运重建、急性血栓或支架血栓形成方面,肝素与双醋瑞定的差异无统计学意义:本荟萃分析表明,急性冠状动脉综合征患者在PCI期间使用比伐卢定进行抗凝时,可减少大出血,而且不会增加支架血栓形成或MACE的风险。
{"title":"Bivalirudin versus heparin in patients undergoing percutaneous coronary intervention in acute coronary syndromes.","authors":"Chayakrit Krittanawong, Tania Ahuja, Zhen Wang, Yusuf Kamran Qadeer, Errol Moras, Hafeez Ul Hassan Virk, Mahboob Alam, Hani Jneid, Samin Sharma","doi":"10.1097/HPC.0000000000000372","DOIUrl":"https://doi.org/10.1097/HPC.0000000000000372","url":null,"abstract":"<p><strong>Introduction: </strong>Data on outcomes between unfractionated heparin and bivalirudin anticoagulation during percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) remains inconclusive. We aimed to systematically analyze PCI outcomes comparing unfractionated heparin and bivalirudin.</p><p><strong>Methods: </strong>We systematically searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception in 1966 through January 2024 for studies evaluating PCI outcomes comparing unfractionated heparin and bivalirudin. Two investigators independently reviewed data. Conflicts were resolved through consensus. Random-effects meta-analyses were used.</p><p><strong>Results: </strong>Ten prospective trials were identified that enrolled 42,253 individuals who presented with an acute coronary syndrome. Our analysis found that heparin when compared to bivalirudin was associated with an increased risk of trial-based definition of major bleeding (RR 1.68, 95% CI 1.29-2.20), non-access site complications (RR 4.6, 95% CI 1.75-12.09), TIMI major bleeding (RR 1.70, 95% CI 1.20-2.41), major bleeding risks (RR 1.87, 95% CI 1.49-2.36), cardiovascular disease death (RR 1.26, 95% CI 1.02-1.57), and thrombocytopenia (RR 1.67, 95% CI 1.07-2.62). There were no statistically significant differences between heparin and bivalirudin for all-cause mortality, MACE, stroke, reinfarction, target vessel revascularization, acute or stent thrombosis.</p><p><strong>Conclusions: </strong>The present meta-analysis demonstrates bivalirudin reduces major bleeding when used for anticoagulation during PCI in patients with acute coronary syndromes and is not associated with an increased risk of stent thrombosis or MACE.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141972014","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background and objective: The HEART pathway serves as a tool for predicting major adverse cardiac events (MACE) among patients presenting with acute chest pain, aiding in early discharge of low-risk patients and reducing unnecessary cardiac investigations. This study aimed to evaluate physician-nurse reliability of the HEART pathway. Moreover investigates the efficacy of HEART pathway to predict 3-month MACE in patients with acute chest pain.
Method: We conducted a prospective study on 97 patients experiencing acute chest pain. A team of three professionals - a nurse, a cardiology resident, and a cardiology attending physician - performed risk stratification. We assessed inter-rater reliability among the raters as well as explored 3-month MACE outcomes.
Result: Excellent pairwise agreements were found between the raters. Overall agreement among raters was excellent, with an ICC of 0.84 (95% CI: 0.73 - 0.97). The HEART pathway score exhibited strong predictive power (AUC: 0.85) for 3-month MACE. At a cut-off score of 4, sensitivity, specificity, and negative predictive values were 87.5%, 58.9%, and 95.8%, respectively.
Conclusion: The HEART pathway score effectively predicts 3-month MACE in patients with acute non-traumatic chest pain. Moreover, the high agreement among the attending physician, the resident physician, and the nurse suggests that nurses could use this tool, potentially reducing the workload on physicians.
{"title":"Unlocking the Potential of the HEART Pathway: Predicting MACE and Facilitating Nurse-Physician Collaboration in Chest Pain Unit.","authors":"Zahra Behpour, Zahra Amirsardari, Haniye Aghakhani, Mohammadesmaeil Zanganehfar, Shiva Khaleghparast, Fidan Shabani, Hooman Bakhshandeh, Parham Sadeghipour","doi":"10.1097/HPC.0000000000000374","DOIUrl":"https://doi.org/10.1097/HPC.0000000000000374","url":null,"abstract":"<p><strong>Background and objective: </strong>The HEART pathway serves as a tool for predicting major adverse cardiac events (MACE) among patients presenting with acute chest pain, aiding in early discharge of low-risk patients and reducing unnecessary cardiac investigations. This study aimed to evaluate physician-nurse reliability of the HEART pathway. Moreover investigates the efficacy of HEART pathway to predict 3-month MACE in patients with acute chest pain.</p><p><strong>Method: </strong>We conducted a prospective study on 97 patients experiencing acute chest pain. A team of three professionals - a nurse, a cardiology resident, and a cardiology attending physician - performed risk stratification. We assessed inter-rater reliability among the raters as well as explored 3-month MACE outcomes.</p><p><strong>Result: </strong>Excellent pairwise agreements were found between the raters. Overall agreement among raters was excellent, with an ICC of 0.84 (95% CI: 0.73 - 0.97). The HEART pathway score exhibited strong predictive power (AUC: 0.85) for 3-month MACE. At a cut-off score of 4, sensitivity, specificity, and negative predictive values were 87.5%, 58.9%, and 95.8%, respectively.</p><p><strong>Conclusion: </strong>The HEART pathway score effectively predicts 3-month MACE in patients with acute non-traumatic chest pain. Moreover, the high agreement among the attending physician, the resident physician, and the nurse suggests that nurses could use this tool, potentially reducing the workload on physicians.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141749209","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-17DOI: 10.1097/HPC.0000000000000373
Mohammad Reza Movahed, Nishant Satapathy, Mehrtash Hashemzadeh
Introduction: Coronary perforation is one of the major complications of percutaneous coronary intervention (PCI). The goal of this study was to evaluate adverse outcomes and mortality in patients suffering from coronary perforation during PCI above the age of 30.
Methods: The National Inpatient Sample (NIS) database, years 2016-2020, was studied using ICD 10 codes. Patients suffering from perforation were compared to patients without perforation during PCI.
Results: PCI was performed in a weighted total of 10,059,269 patients. Coronary perforation occurred in 11,725 (0.12 %) of all PCI performed. The mortality rate of patients with perforations was very high in comparison to patients without perforations. (12.9% vs 2.5%, OR: 5.6, CI:5-6.3 p<0.001). Furthermore, patients with coronary perforations had much higher rates of urgent coronary bypass surgery, tamponade, cardiac arrest, and major cardiovascular outcomes. Mortality remained high and over 10% in the 5-year study period.
Conclusion: Using a large national inpatient database, all-cause inpatient mortality in patients with coronary perforation is very high (over 10%) with persistently high mortality rates over the years study suggesting that treatment of perforations needs further improvement.
{"title":"Coronary perforation occurring during percutaneous coronary intervention is associated with persistently high mortality and complication.","authors":"Mohammad Reza Movahed, Nishant Satapathy, Mehrtash Hashemzadeh","doi":"10.1097/HPC.0000000000000373","DOIUrl":"https://doi.org/10.1097/HPC.0000000000000373","url":null,"abstract":"<p><strong>Introduction: </strong>Coronary perforation is one of the major complications of percutaneous coronary intervention (PCI). The goal of this study was to evaluate adverse outcomes and mortality in patients suffering from coronary perforation during PCI above the age of 30.</p><p><strong>Methods: </strong>The National Inpatient Sample (NIS) database, years 2016-2020, was studied using ICD 10 codes. Patients suffering from perforation were compared to patients without perforation during PCI.</p><p><strong>Results: </strong>PCI was performed in a weighted total of 10,059,269 patients. Coronary perforation occurred in 11,725 (0.12 %) of all PCI performed. The mortality rate of patients with perforations was very high in comparison to patients without perforations. (12.9% vs 2.5%, OR: 5.6, CI:5-6.3 p<0.001). Furthermore, patients with coronary perforations had much higher rates of urgent coronary bypass surgery, tamponade, cardiac arrest, and major cardiovascular outcomes. Mortality remained high and over 10% in the 5-year study period.</p><p><strong>Conclusion: </strong>Using a large national inpatient database, all-cause inpatient mortality in patients with coronary perforation is very high (over 10%) with persistently high mortality rates over the years study suggesting that treatment of perforations needs further improvement.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141627941","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-05DOI: 10.1097/HPC.0000000000000370
George Hughes, Iyesatta Emeli, Matthew Wheatley, Abhinav Goyal, Janetta Bryksin, Timothy Moran, Matthew Keadey, Michael A Ross
Background: Use of high-sensitivity troponin (hs-cTn) might lead to an increase in hospital observation visits due to higher number of abnormal troponin levels.
Study objectives: To determine the impact of incorporating hs-cTn into a chest pain clinical decision protocol (CDP) on observation visits in a large academic health system.
Methods: This is a retrospective observational cohort study of all chest pain observation patients in four hospitals in an academic health system over 24 months. All hospitals used the Beckman Coulter Unicel Dxi instrument, and all shared the same emergency department (ED) chest pain protocol, which used the HEART pathway and serial troponins and directed ED dispositions to either an observation stay, ED discharge, or inpatient admission. Outcomes studied before and after introduction of a hs-cTn protocol included daily chest pain observation census, cost, observation hours, and inpatient admit rate. Census was reported as the daily chest pain observation census and as a proportion of all observation visits. Data was retrieved from a health system data warehouse and a cost accounting program.
Results: There were 6,712 chest pain observation visits over 24-months, with 4,087 visits before and 2,634 visits after the hs-cTn protocol implementation. Comparison groups were similar in terms of age, gender, and type of insurance. There were 10.59 (95% CI: 10.24 - 10.95) daily chest pain observation visits before and 7.66 (95% CI: 7.34 - 7.97) visits after implementation, with a 28% (95% CI: 35% - 20%) decrease in the total daily census. As a portion of all observation visits, there was a 22% drop in the proportion that were observed for chest pain. The daily number of chest pain patients requiring inpatient admission was unchanged. The daily total direct cost for chest pain observation decreased with an effective daily cost savings of $4,313 USD (95% CI: $1,534 - $6,998). The total daily number of chest pain observation bed hours also decreased by 41.5 hours (95% CI 13.4 - 96.4 hr).
Conclusion: Implementation of a hs-cTn chest pain protocol was associated with a significant decrease in the number and proportion of observation visits, a decrease in total daily cost and bed hours used, and no increase in inpatient admissions.
{"title":"The Impact of a High Sensitivity Troponin HEART Pathway Based Clinical Decision Protocol on Observation Visits.","authors":"George Hughes, Iyesatta Emeli, Matthew Wheatley, Abhinav Goyal, Janetta Bryksin, Timothy Moran, Matthew Keadey, Michael A Ross","doi":"10.1097/HPC.0000000000000370","DOIUrl":"https://doi.org/10.1097/HPC.0000000000000370","url":null,"abstract":"<p><strong>Background: </strong>Use of high-sensitivity troponin (hs-cTn) might lead to an increase in hospital observation visits due to higher number of abnormal troponin levels.</p><p><strong>Study objectives: </strong>To determine the impact of incorporating hs-cTn into a chest pain clinical decision protocol (CDP) on observation visits in a large academic health system.</p><p><strong>Methods: </strong>This is a retrospective observational cohort study of all chest pain observation patients in four hospitals in an academic health system over 24 months. All hospitals used the Beckman Coulter Unicel Dxi instrument, and all shared the same emergency department (ED) chest pain protocol, which used the HEART pathway and serial troponins and directed ED dispositions to either an observation stay, ED discharge, or inpatient admission. Outcomes studied before and after introduction of a hs-cTn protocol included daily chest pain observation census, cost, observation hours, and inpatient admit rate. Census was reported as the daily chest pain observation census and as a proportion of all observation visits. Data was retrieved from a health system data warehouse and a cost accounting program.</p><p><strong>Results: </strong>There were 6,712 chest pain observation visits over 24-months, with 4,087 visits before and 2,634 visits after the hs-cTn protocol implementation. Comparison groups were similar in terms of age, gender, and type of insurance. There were 10.59 (95% CI: 10.24 - 10.95) daily chest pain observation visits before and 7.66 (95% CI: 7.34 - 7.97) visits after implementation, with a 28% (95% CI: 35% - 20%) decrease in the total daily census. As a portion of all observation visits, there was a 22% drop in the proportion that were observed for chest pain. The daily number of chest pain patients requiring inpatient admission was unchanged. The daily total direct cost for chest pain observation decreased with an effective daily cost savings of $4,313 USD (95% CI: $1,534 - $6,998). The total daily number of chest pain observation bed hours also decreased by 41.5 hours (95% CI 13.4 - 96.4 hr).</p><p><strong>Conclusion: </strong>Implementation of a hs-cTn chest pain protocol was associated with a significant decrease in the number and proportion of observation visits, a decrease in total daily cost and bed hours used, and no increase in inpatient admissions.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141538752","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01DOI: 10.1097/HPC.0000000000000369
Sahil Zaveri, Mahmoud Alsaiqali, Howard Yu, Rafsan Ahmed, Ahmad Jallad, Adam S Budzikowski
Background: Atrioventricular node (AVN) radiofrequency (RF) ablation is a highly effective treatment of atrial tachyarrhythmias that are resistant to other management modalities. To date, there is limited research that compares the properties of different RF ablation catheters. The current study aims to compare the effectiveness of several types of RF catheters in AVN ablation.
Methods: 66 patients, with a mean age of 73.27 years, underwent AVN RF ablation. The catheters used were categorized as: un-irrigated (UI), externally-irrigated (EI), and contact force-sensing with 10-20 grams of force. EI catheters were divided into two different settings: low-power long-duration (LPLD) (30W, 45°C, and 60 sec) and high-power short-duration (HPSD) (50W, 43°C, and 12 sec). We compared the success rate of the different RF catheters using logistic regression and lesion times using linear regression.
Results: The distribution of the types of catheters used is: UI in 48%, LPLD in 16%, and HPSD in 36% of patients. All ablation procedures were successful, with no immediate post-procedure complications. HPSD had a significantly shorter lesion time than UI catheters by 403.42 sec [-631.67, -175.17].
Conclusion: UI catheters, LPLD, and HPSD were equally safe and effective in ablation procedures. The HPSD catheter had a significantly shorter lesion time and, thus, overall decreased procedure time.
{"title":"Low-Power Long-Duration Versus High-Power Short-Duration Radiofrequency Ablation of the Atrioventricular Node.","authors":"Sahil Zaveri, Mahmoud Alsaiqali, Howard Yu, Rafsan Ahmed, Ahmad Jallad, Adam S Budzikowski","doi":"10.1097/HPC.0000000000000369","DOIUrl":"https://doi.org/10.1097/HPC.0000000000000369","url":null,"abstract":"<p><strong>Background: </strong>Atrioventricular node (AVN) radiofrequency (RF) ablation is a highly effective treatment of atrial tachyarrhythmias that are resistant to other management modalities. To date, there is limited research that compares the properties of different RF ablation catheters. The current study aims to compare the effectiveness of several types of RF catheters in AVN ablation.</p><p><strong>Methods: </strong>66 patients, with a mean age of 73.27 years, underwent AVN RF ablation. The catheters used were categorized as: un-irrigated (UI), externally-irrigated (EI), and contact force-sensing with 10-20 grams of force. EI catheters were divided into two different settings: low-power long-duration (LPLD) (30W, 45°C, and 60 sec) and high-power short-duration (HPSD) (50W, 43°C, and 12 sec). We compared the success rate of the different RF catheters using logistic regression and lesion times using linear regression.</p><p><strong>Results: </strong>The distribution of the types of catheters used is: UI in 48%, LPLD in 16%, and HPSD in 36% of patients. All ablation procedures were successful, with no immediate post-procedure complications. HPSD had a significantly shorter lesion time than UI catheters by 403.42 sec [-631.67, -175.17].</p><p><strong>Conclusion: </strong>UI catheters, LPLD, and HPSD were equally safe and effective in ablation procedures. The HPSD catheter had a significantly shorter lesion time and, thus, overall decreased procedure time.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141581044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-21DOI: 10.1097/HPC.0000000000000368
Catarina Elias, Ana Neves, Rita Gouveia, Sérgio Madureira, Pedro Ribeirinho-Soares, Marta Soares-Carreira, Joana Pereira, Jorge Almeida, Patrícia Lourenço
Background: Patients with heart failure (HF) often have multiple cardiovascular risk factors (CVRF) and comorbidities (CMB). We evaluated the impact of additive CMB and CVRF in HF prognosis.
Methods: We retrospectively analyzed ambulatory patients with systolic dysfunction between January 2012 and May 2018. Follow-up: until January 2021. Endpoint: all-cause death. CVRF analyzed: Arterial hypertension, Diabetes mellitus and smoking. CMB evaluated: coronary artery disease, non-coronary atherosclerotic disease, respiratory disease, dementia, anemia, chronic kidney disease, inflammatory/autoimmune disease, active cancer and atrial fibrillation. Classification according to the number of CVRF and/or CMB: < 2 and ≥ 2. The independent prognostic impact of CVRF/CMB burden was assessed with multivariate Cox-regression.
Results: Most patients had ≥ 2 CMB (67.9%). Regarding CVRF, 14.9% presented none, 40.2% had one and 32.1% had two. During a median 49-month follow-up, 419 (49.1%) patients died. Mortality was higher among patients with ≥2 CVRF (56.1 vs 43.4% in those with <2) and in those with ≥2 CMB (57.7 vs 31.0%). While patients with one CMB had similar mortality than those with none. Patients with ≥2 CMB had higher long-term mortality risk: HR=2.47 (95% CI: 1.95-3.14). In patients with ≥2CVRF: HR of dying = 1.39 (1.14- 1.70). When taken together there was a clear survival disadvantage for patients with ≥ 2 CVRF/CMB - adjusted HR: 2.20 (1.45-3.34).
Conclusion: The presence of only 2 CVRF/CMB more than doubles the patients´ risk of dying. CVRF and CMB should be assessed as part of routine patient management.
{"title":"Even a low comorbidity burden predicts poor outcome in chronic heart failure.","authors":"Catarina Elias, Ana Neves, Rita Gouveia, Sérgio Madureira, Pedro Ribeirinho-Soares, Marta Soares-Carreira, Joana Pereira, Jorge Almeida, Patrícia Lourenço","doi":"10.1097/HPC.0000000000000368","DOIUrl":"https://doi.org/10.1097/HPC.0000000000000368","url":null,"abstract":"<p><strong>Background: </strong>Patients with heart failure (HF) often have multiple cardiovascular risk factors (CVRF) and comorbidities (CMB). We evaluated the impact of additive CMB and CVRF in HF prognosis.</p><p><strong>Methods: </strong>We retrospectively analyzed ambulatory patients with systolic dysfunction between January 2012 and May 2018. Follow-up: until January 2021. Endpoint: all-cause death. CVRF analyzed: Arterial hypertension, Diabetes mellitus and smoking. CMB evaluated: coronary artery disease, non-coronary atherosclerotic disease, respiratory disease, dementia, anemia, chronic kidney disease, inflammatory/autoimmune disease, active cancer and atrial fibrillation. Classification according to the number of CVRF and/or CMB: < 2 and ≥ 2. The independent prognostic impact of CVRF/CMB burden was assessed with multivariate Cox-regression.</p><p><strong>Results: </strong>Most patients had ≥ 2 CMB (67.9%). Regarding CVRF, 14.9% presented none, 40.2% had one and 32.1% had two. During a median 49-month follow-up, 419 (49.1%) patients died. Mortality was higher among patients with ≥2 CVRF (56.1 vs 43.4% in those with <2) and in those with ≥2 CMB (57.7 vs 31.0%). While patients with one CMB had similar mortality than those with none. Patients with ≥2 CMB had higher long-term mortality risk: HR=2.47 (95% CI: 1.95-3.14). In patients with ≥2CVRF: HR of dying = 1.39 (1.14- 1.70). When taken together there was a clear survival disadvantage for patients with ≥ 2 CVRF/CMB - adjusted HR: 2.20 (1.45-3.34).</p><p><strong>Conclusion: </strong>The presence of only 2 CVRF/CMB more than doubles the patients´ risk of dying. CVRF and CMB should be assessed as part of routine patient management.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-06-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141437629","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-06DOI: 10.1097/HPC.0000000000000365
Abida Hasan, Seyed M Zaidi, Sahil Zaveri, Nicholas Taklalsingh, Seyedeh L Zonnoor, Joseph Casillas-Gonzalez, Harshith Chandrakumar, Ashkan Tadayoni, Sara Sharif, Courtney Connelly, Aron Soleiman, Thiagarajan Sezhian, Karthik Sreedhara, Cindy L Tsui, Yelyzaveta Prysyazhnyuk, Diana Gruenstein, Adiell Melamed, Filip Oleszak, Rachel Axman, Daniel Beltre, Anan Kazi, Fahmida Patwari, Andrew Tsai, Michael Freilich, Anny Corominas, Kristaq Koci, Omar Siddique, Ryan Marder, Raphael Kirou, Isabel M McFarlane
Among White rheumatoid arthritis (RA) cohorts, heart failure with preserved ejection fraction (HFpEF) is the most prevalent type of heart failure (HF). We aimed to assess the type of HF affecting Black RA patients. 64 patients with RA-HF were compared to age-, sex-, and race-matched RA patients without HF. Left ventricular ejection fraction (LVEF), wall motion abnormalities, left ventricle (LV) mass, and wall thickness were reviewed. 87.3% were Black, 84.4% were women, with a mean age of 69.6 ± 1.38 (± SEM) and BMI (kg/m 2) 29.6 ± 1.07. RA-HF patients had higher rates of hypertension (HTN), chronic kidney disease, and atrial fibrillation. 66.7% had ≥3 cardiovascular risk factors compared to RA patients without HF. 2D-echocardiograms of RA-HF revealed that 62.3% had LVEF ≥50%, 37% had diastolic dysfunction, and 43.1% had wall motion abnormalities. LV mass and relative wall thickness measurements indicated LV eccentric remodeling. The odds ratio for HF was 4.7 (1.5-14.53 CI), p<0.01, among RA-HTN group and 3.5 (1.091-11.7 CI) p<0.01 among smokers. In our predominantly Black RA-HF patients, HFpEF was the most common type of HF. HTN was associated with the highest OR for HF. Eccentric hypertrophic remodeling, a known poor prognostic indicator for cardiovascular events, was found. Further studies are required to confirm our findings.
{"title":"Cardiovascular Risk Factors and Echocardiographic Findings in a Predominantly Black Population with Rheumatoid Arthritis and Heart Failure.","authors":"Abida Hasan, Seyed M Zaidi, Sahil Zaveri, Nicholas Taklalsingh, Seyedeh L Zonnoor, Joseph Casillas-Gonzalez, Harshith Chandrakumar, Ashkan Tadayoni, Sara Sharif, Courtney Connelly, Aron Soleiman, Thiagarajan Sezhian, Karthik Sreedhara, Cindy L Tsui, Yelyzaveta Prysyazhnyuk, Diana Gruenstein, Adiell Melamed, Filip Oleszak, Rachel Axman, Daniel Beltre, Anan Kazi, Fahmida Patwari, Andrew Tsai, Michael Freilich, Anny Corominas, Kristaq Koci, Omar Siddique, Ryan Marder, Raphael Kirou, Isabel M McFarlane","doi":"10.1097/HPC.0000000000000365","DOIUrl":"https://doi.org/10.1097/HPC.0000000000000365","url":null,"abstract":"<p><p>Among White rheumatoid arthritis (RA) cohorts, heart failure with preserved ejection fraction (HFpEF) is the most prevalent type of heart failure (HF). We aimed to assess the type of HF affecting Black RA patients. 64 patients with RA-HF were compared to age-, sex-, and race-matched RA patients without HF. Left ventricular ejection fraction (LVEF), wall motion abnormalities, left ventricle (LV) mass, and wall thickness were reviewed. 87.3% were Black, 84.4% were women, with a mean age of 69.6 ± 1.38 (± SEM) and BMI (kg/m 2) 29.6 ± 1.07. RA-HF patients had higher rates of hypertension (HTN), chronic kidney disease, and atrial fibrillation. 66.7% had ≥3 cardiovascular risk factors compared to RA patients without HF. 2D-echocardiograms of RA-HF revealed that 62.3% had LVEF ≥50%, 37% had diastolic dysfunction, and 43.1% had wall motion abnormalities. LV mass and relative wall thickness measurements indicated LV eccentric remodeling. The odds ratio for HF was 4.7 (1.5-14.53 CI), p<0.01, among RA-HTN group and 3.5 (1.091-11.7 CI) p<0.01 among smokers. In our predominantly Black RA-HF patients, HFpEF was the most common type of HF. HTN was associated with the highest OR for HF. Eccentric hypertrophic remodeling, a known poor prognostic indicator for cardiovascular events, was found. Further studies are required to confirm our findings.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-06-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141284968","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-01Epub Date: 2024-03-05DOI: 10.1097/HPC.0000000000000353
Rahul Rai, Payal Devi, Kapeel Kumar, Kainat Naeem, Hanesh Kumar, Kajal Kumari, Anish Kumar, Aman Kumar, Aqeel Muhammad, Muhammad Sohaib Khan, Ghulam Qadir, Shaheryar Ali, Mahveer Maheshwari, Mohammad Jawwad
Objective: To find out whether inclisiran sodium has different efficacy in heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH) patient groups.
Methods: We conducted the systematic review and meta-analysis of ORION clinical trials. PubMed, Embase, and Clinicaltrials.gov databases were searched for the relevant studies. Atheroscalerotic parameters considered for our objective were low-density lipoprotein cholesterol, total cholesterol, proprotein convertase subtilisin/kexin type 9 (PCSK9), apolipoprotein B, and nonhigh-density lipoprotein cholesterol. Primary outcomes were the percentage difference in atheroscalerotic parameters at follow-up relative to baseline values. Our study examined these primary outcomes to determine whether there is a statistically significant difference between the HeFH and HoFH groups. Risk of bias was assessed by the Cochrane risk of bias tool. Meta-analysis was performed when at least 2 studies reported on the same variable.
Results: Four ORION clinical trials provided the data related to the mean difference in the atheroscalerotic parameters at follow-up relative to baseline, of HeFH and HoFH patient populations, after administration of 300 mg inclisiran subcutaneously. We pooled together these mean differences for each group and applied a statistical test to analyze if the values were significantly different between the groups. The results of our study unveiled the significant difference in pooled mean differences in low-density lipoprotein cholesterol (HeFH: -48.62%; HoFH: -9.12%; P < 0.05), total cholesterol (HeFH: -30.31%; HoFH: -11.50%; P < 0.05), apolipoprotein (HeFH: -39.97%; HoFH: -14.68%; P < 0.05), and nonhigh-density lipoprotein (HeFH: -44.51%; HoFH: -12.22%; P < 0.05) between HeFH and HoFH groups. However, the difference in pooled mean difference in PCSK9 values (HeFH: -68.41%; HoFH: -56.25%; P = 0.2) between HeFH and HoFH groups was statistically insignificant. Studies were of high quality.
Conclusions: There was a significant difference in the reductions in atherosclerotic lipid parameters in heterozygous and homozygous populations after the administration of inclisiran except for PCSK9 parameter. Further studies are needed to support this conclusion.
{"title":"Efficacy of Inclisiran in Patients Having Familial Hypercholesterolemia: Heterozygous Compared to Homozygous Trait, a Systematic Review and Meta-analysis.","authors":"Rahul Rai, Payal Devi, Kapeel Kumar, Kainat Naeem, Hanesh Kumar, Kajal Kumari, Anish Kumar, Aman Kumar, Aqeel Muhammad, Muhammad Sohaib Khan, Ghulam Qadir, Shaheryar Ali, Mahveer Maheshwari, Mohammad Jawwad","doi":"10.1097/HPC.0000000000000353","DOIUrl":"10.1097/HPC.0000000000000353","url":null,"abstract":"<p><strong>Objective: </strong>To find out whether inclisiran sodium has different efficacy in heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH) patient groups.</p><p><strong>Methods: </strong>We conducted the systematic review and meta-analysis of ORION clinical trials. PubMed, Embase, and Clinicaltrials.gov databases were searched for the relevant studies. Atheroscalerotic parameters considered for our objective were low-density lipoprotein cholesterol, total cholesterol, proprotein convertase subtilisin/kexin type 9 (PCSK9), apolipoprotein B, and nonhigh-density lipoprotein cholesterol. Primary outcomes were the percentage difference in atheroscalerotic parameters at follow-up relative to baseline values. Our study examined these primary outcomes to determine whether there is a statistically significant difference between the HeFH and HoFH groups. Risk of bias was assessed by the Cochrane risk of bias tool. Meta-analysis was performed when at least 2 studies reported on the same variable.</p><p><strong>Results: </strong>Four ORION clinical trials provided the data related to the mean difference in the atheroscalerotic parameters at follow-up relative to baseline, of HeFH and HoFH patient populations, after administration of 300 mg inclisiran subcutaneously. We pooled together these mean differences for each group and applied a statistical test to analyze if the values were significantly different between the groups. The results of our study unveiled the significant difference in pooled mean differences in low-density lipoprotein cholesterol (HeFH: -48.62%; HoFH: -9.12%; P < 0.05), total cholesterol (HeFH: -30.31%; HoFH: -11.50%; P < 0.05), apolipoprotein (HeFH: -39.97%; HoFH: -14.68%; P < 0.05), and nonhigh-density lipoprotein (HeFH: -44.51%; HoFH: -12.22%; P < 0.05) between HeFH and HoFH groups. However, the difference in pooled mean difference in PCSK9 values (HeFH: -68.41%; HoFH: -56.25%; P = 0.2) between HeFH and HoFH groups was statistically insignificant. Studies were of high quality.</p><p><strong>Conclusions: </strong>There was a significant difference in the reductions in atherosclerotic lipid parameters in heterozygous and homozygous populations after the administration of inclisiran except for PCSK9 parameter. Further studies are needed to support this conclusion.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":"73-80"},"PeriodicalIF":0.0,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140040555","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-01Epub Date: 2024-02-21DOI: 10.1097/HPC.0000000000000351
Shaun G Goodman, Denis Roy, Charles V Pollack, Kori Leblanc, Kevin F Kwaku, Geoffrey D Barnes, Marc P Bonaca, Mellanie True Hills, Elena Campello, John Fanikos, Jean M Connors, Jeffrey I Weitz
The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.
全球心房颤动的发病率正在迅速上升,这在很大程度上是由于人口老龄化造成的。众所周知,心房颤动会使血栓栓塞性中风的风险增加五倍,但几十年来,管理得当的抗凝治疗可以大大降低这一风险,这一点已经显而易见。尽管药理学的进步(如从维生素 K 拮抗剂向直接口服抗凝剂的转变)提高了心房颤动患者长期口服抗凝治疗的安全性和便利性,但近期大量的观察数据表明,在人群中预防中风的效果并不理想。造成这种结果缺陷的原因是多方面的,包括抗凝药物处方不足(通常是由于处方者担心出血)、药物本身的局限性(药物间相互作用、肾功能不全时的生物蓄积性、半衰期短导致疗效消失等)以及患者因缺乏了解/教育、多药联用、害怕出血、健忘和社会经济障碍等因素而导致的依从性不佳。这种依从性通常不会报告给临床医生,从而进一步破坏了优化护理的努力。在 2023 年国际血栓与止血学会大会期间,一个由临床医生组成的多学科、跨专业小组召开会议,讨论了治疗中的这些差距、如何更容易地认识到这些差距,以及因子 XI 引导的抗凝剂在提高中风预防的安全性和有效性方面的潜力。要充分认识这一潜力,需要重新评估有关 "凝血级联 "的传统教学,并将导致(生理性)止血和(病理性)血栓形成的过程分离开来。本文对小组讨论进行了总结和介绍。
{"title":"Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics.","authors":"Shaun G Goodman, Denis Roy, Charles V Pollack, Kori Leblanc, Kevin F Kwaku, Geoffrey D Barnes, Marc P Bonaca, Mellanie True Hills, Elena Campello, John Fanikos, Jean M Connors, Jeffrey I Weitz","doi":"10.1097/HPC.0000000000000351","DOIUrl":"10.1097/HPC.0000000000000351","url":null,"abstract":"<p><p>The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the \"coagulation cascade\" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.</p>","PeriodicalId":35914,"journal":{"name":"Critical Pathways in Cardiology","volume":" ","pages":"47-57"},"PeriodicalIF":0.0,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11191052/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139933347","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}