Critical Pathways in Cardiology最新文献

Despite advances in percutaneous coronary procedures, in-stent restenosis remains a significant challenge. Although sirolimus- and paclitaxel-coated balloons are promising alternatives, but their comparative safety and efficacy remain uncertain. PubMed, Embase and Cochrane databases were searched using relevant keywords from inception until August 2025. A total of 11 studies (7 RCTs and 4 observational cohort studies) were included, comprising 3,633 participants overall. The primary outcomes assessed were target lesion revascularization (TLR) and target lesion failure (TLF). Meanwhile, the Secondary outcomes included stent thrombosis, all-cause mortality, myocardial infarction, major adverse cardiovascular events (MACE), survival, binary restenosis, and angiographic endpoints (acute gain, diameter stenosis, in-segment late lumen loss, in-lesion late lumen loss, and in-segment minimal lumen diameter). Interstudy heterogeneity was assessed using I2 and X2 statistics (I2>50%=significant heterogeneity). Interstudy heterogeneity was low for most outcomes, including all primary clinical endpoints, with moderate heterogeneity observed only for select angiographic measures (notably in-segment late lumen loss and diameter stenosis). Statistical calculations were performed using Review Manager 5.4.1, with a p-value of < 0.05 indicating statistical significance.This meta-analysis examined studies that compared paclitaxel-coated balloon (PCB) versus standard balloon (SCB) angioplasty. Regarding primary outcomes, there were no notable variations in target lesion failure (RR 1.08, 95% CI 0.90-1.29, p=0.36) or target lesion revascularization (RR 1.16, 95% CI 0.98-1.37, p=0.08). With all aggregated estimates being nonsignificant, secondary outcomes such as stent thrombosis, all-cause mortality, myocardial infarction, MACE, and survival were similar between groups. Angiographic endpoints revealed no discernible variations in late lumen loss (in-lesion and in-segment), acute gain, or diameter stenosis. Nonetheless, the SCB group's minimal lumen diameter was significantly smaller than that of the PCB group (MD -0.08 mm, 95% CI -0.14 to -0.01, p=0.02). In treating coronary ISR, sirolimus- and paclitaxel-coated balloons show similar overall safety and effectiveness; lesion-specific angiographic variations indicate that customized selection may improve patient outcomes.

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. 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. Our findings indicated that the J-CTO score had the highest positive predictive value (PPV) at 88.89%, closely followed by the CL CTO score at 88.79%, the CASTLE CTO score at 86.84%, and lastly, the 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 CASTLE CTO, 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 cut-off value. 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 ORA score did not demonstrate statistical significance in our patients.

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, 4,669 patients (2,369 super obese, 2,300 non-super 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: 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: 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: 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: 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.