Critical Pathways in Cardiology最新文献

Background: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is defined as myocardial infarction with <50% stenosis of coronary arteries. Atrial fibrillation (AF) is a common arrhythmia that may influence MINOCA outcomes.

Methods: We performed a retrospective analysis of the National Inpatient Sample (2016-2021), identifying MINOCA patients with and without AF using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Multivariable mixed-effects logistic regression and propensity score matching were applied to control for confounders and assess outcomes.

Results: Of 94,840 MINOCA patients, 28,270 (30%) had AF. AF was associated with higher in-hospital mortality (3.74% vs. 2.75%; P = 0.004), acute heart failure (38.33% vs. 34.97%; P < 0.001), sudden cardiac arrest (2.54% vs. 1.73%; P < 0.050), and cardiogenic shock (3.11% vs. 1.56%; P < 0.001). AF independently predicted in-hospital mortality [adjusted odds ratio (aOR), 1.3; 95% confidence interval (CI), 1.07-1.58; P < 0.001], heart failure (aOR, 1.48; 95% CI, 1.38-1.59; P < 0.001), cardiogenic shock (aOR, 1.85; 95% CI, 1.48-2.30; P < 0.001), and acute kidney injury (aOR, 1.15; 95% CI, 1.07-1.24; P < 0.001). There were no significant differences in percutaneous coronary intervention, mechanical circulatory support, or defibrillator use ( P > 0.050).

Conclusions: AF in MINOCA is associated with worse in-hospital outcomes, including mortality, sheart failure, acute kidney injury, and cardiogenic shock. AF may be a key prognostic marker in this population, warranting further research.

Background: Thirty-day performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology 0/1-hour (ESC 0/1-h) and "one-and-done" (hs-cTnT

Methods: A preplanned secondary analysis of a prospective multisite US cohort was conducted. Adults with chest pain were enrolled from 8 emergency departments (January 2017-September 2018). hs-cTnT measures (0- and 1-h) were used to classify patients by the ESC 0/1-h algorithm into rule-out, observation, and rule-in zones. Patients with 0-h measures

Results: Among 1462 patients with a mean age of 57.6 ± 12.9 years, 46.4% (678/1462) were female, and 14.0% (205/1462) had cardiac death or MI at 90 days. One-and-done strategy efficacy was 32.8% (479/1462), and NPV was 99.0% [95% confidence interval (CI), 97.6-99.7]. Adding the HEART score decreased efficacy to 20.1% (293/1462) and increased NPV to 99.7% (95% CI, 98.1-100). ESC 0/1-h efficacy was 57.8% (826/1430) and NPV was 98.3% (95% CI, 97.2-99.1). Combined with a HEART score, NPV increased to 99.3% (95% CI, 98.0-99.9), but efficacy decreased to 30.8% (95% CI, 28.3-33.2).

Conclusions: The one-and-done strategy and ESC 0/1-hour algorithm had modest rates of missed 90-day cardiac death or MI. Adding a HEART score improved safety but decreased efficacy.

Background: Chronic kidney disease (CKD) is a global health concern associated with an elevated risk of cardiovascular (CV) and all-cause mortality. The ankle-brachial index (ABI), a noninvasive diagnostic tool, is widely recognized for detecting peripheral arterial disease. This meta-analysis aims to assess whether abnormally low or high ABI values independently predict CV and all-cause mortality in CKD patients, including those on hemodialysis.

Methods: A systematic review and meta-analysis was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Cochrane, and Google Scholar databases through September 2024 to identify studies on abnormal ABI and mortality outcomes in CKD patients with or without hemodialysis. Data was analyzed with random-effects models, and subgroup analyses evaluated variations by patient characteristics, region, sample size, and follow-up duration.

Results: The analysis included 10 cohort studies comprising 13,378 participants. ABI values between 0.9 and 1.3 were defined as normal. Individuals with abnormally low ABI (<0.9) demonstrated a significantly higher incidence in CV mortality [hazard ratio (HR) = 2.23; confidence interval (CI), 1.75-2.83) and all-cause mortality (HR = 1.78; CI, 1.55-2.05). Those with high ABI ≥1.3 were associated with a 2.77-fold increase in CV mortality (HR = 2.77; CI, 1.74-4.41) and a 1.49 higher risk of all-cause mortality (HR = 1.49; CI, 1.09-2.02). Overall, abnormal ABI values were linked to a 1.74 higher risk of all-cause mortality (HR = 1.74; CI, 1.54-1.96) and a 2.34-fold increase in CV mortality (HR = 2.34; CI, 1.93-2.85). Subgroup analyses revealed higher mortality risks in hemodialysis patients compared with nondialysis CKD patients and in studies conducted in Asia.

Conclusions: Abnormal ABI values show a U-shaped relationship with mortality, serving as strong predictors of CV and all-cause mortality in CKD patients, particularly those on hemodialysis. Since CV and all-cause mortality are high in CKD patients, these findings suggest that ABI measurement is a useful screening technique to assist in prognosticating such patients. Further studies are warranted to validate these findings and to better understand the prognostic utility of ABI across different CKD stages, including both dialysis-dependent and nondialysis CKD patients.

Background: The pathophysiology of renal dysfunction requires population-based study. It is debatable in the literature whether cardiovascular metrics have an impact on cystatin C levels.

Methods: Using public-use biomarkers data of The National Longitudinal Study of Adolescent to Adult Health (Add Health) Wave 5 data, we tested, after adjusting for age (range: 32-42), anthropometrics (body mass index, waist circumference, and arm circumference), hemoglobin A1C, low-density lipoprotein, triglyceride, smoking, and sex, the association of 5 clinical cardiovascular measures (systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse pressure, and pulse rate) with cystatin C levels. Multiple linear regression analysis with a design-based approach was employed for data analysis after log-transformation of cystatin C levels.

Results: Our findings showed that there was no significant association between cystatin C levels and any of the previously mentioned cardiovascular parameters in this age group (P > 0.05). However, there was a significant association between cystatin C levels and age [exponentiated estimate (EE) (percent increase per unit) = 1.21; 95% confidence interval (CI) = 0.97-1.103, P < 0.0001], body mass index and waist circumference (EE = 0.702; 95% CI = 0.7-0.705, P < 0.0001), triglycerides level (EE = 0.02; 95% CI = 0.0199-0.0201, P = 0.01), smoking status [EE (compared with nonsmokers) = 8.98, 95% CI = 8.95-9.01, P < 0.0001], and female sex [EE (compared with males) = -5.92; 95% CI = -5.94 to -5.89, P < 0.0001].

Conclusions: Our findings clarify the impact of confounding factors, particularly age, on cystatin C levels. They also demonstrate how the significant correlation between cardiovascular parameters and cystatin C levels that were seen in earlier studies is largely affected by the age. Anthropometrics, age, lipid indices, and smoking should all be considered in clinical practice as possible reasons for increased cystatin C levels in otherwise healthy middle-aged individuals.

Introduction: Coronary angiography has been an established standard for over 6 decades for percutaneous coronary interventions (PCIs), but its role is limited to assessing vascular lumen and anterograde flow. In the 1980s, intravascular ultrasonography (IVUS) gained traction in interventional cardiology for its advantages over angiography. Despite its precise evaluation of plaque burden and vessel wall structure for optimizing stent implantation, the literature reports varying outcomes on the efficacy and safety of IVUS-guided angiography in patients presenting with acute coronary syndrome or coronary artery disease. To address this discrepancy, we conducted a comprehensive systematic review and meta-analysis to assess the efficacy and safety of utilizing IVUS versus angiography alone for PCI in these groups of patients.

Methods: We conducted a comprehensive systematic review and meta-analysis to assess the efficacy and safety of IVUS-guided angiography in these patients. Electronic databases were searched, and 25 studies were included. Inclusion criteria are given as follows: (1) patients aged >18 years, (2) patients with acute coronary syndrome or coronary artery disease undergoing IVUS-guided PCI or angiography-guided PCI, and (3) randomized controlled trials. Exclusion criteria comprised observational, nonrandomized studies, case reports, clinical spotlights, and review articles. Studied outcomes included all-cause mortality, cardiac death, myocardial infarction, target lesion revascularization (TLR), need for coronary artery bypass graft, and stent thrombosis (ST).

Results: Compared with angiography alone, IVUS-guided PCI demonstrated a significant reduction in cardiac death, TLR, and ST regardless of the follow-up period. No significant difference was observed between the 2 groups concerning all-cause mortality, and myocardial infarction regardless of the follow-up period, and the need for coronary artery bypass graft at 1-year follow-up.

Conclusions: Compared with angiography-guided PCI, IVUS-guided PCI is associated with a lower incidence of cardiac death, TLR, and ST.

Background: We have been pacing the right ventricular apex, creating an artificial left bundle branch block (LBBB) for more than 4 decades. We learned that some patients would develop dys-synchronization and hence heart failure due to QRS widening. If the lead is implanted in the left bundle area and a narrow QRS is achieved, those patients with LBBB will improve after implant, but those with non-LBBB morphologies might not benefit from QRS narrowing. However, there is not enough information regarding patients with narrow or wide QRS with different types of atrioventricular block that could also benefit from QRS narrowing.

Objectives: Demonstrate that a narrow-paced QRS is a significant determinant of mortality in patients receiving a permanent pacemaker despite the previous QRS morphology.

Patients and methods: We analyzed 204 patients from our pacemaker database. We attempted to implant the lead in the septal area. In our lab, we utilized standard lead electrodes. The criteria for appropriate implant were an electrogram with injury potential, an acceptable lead positioning in the right anterior oblique and left anterior oblique, and a ventricular bipolar threshold less or equal to 1.0 V @ 0.5 ms. QRS duration was assessed according to the global QRS method (from the earliest onset of the QRS in any of the 12 simultaneously recorded standard leads). A QRS interval of 135 ms was determined as a cutoff point using a receiver operator curve (mortality).

Results: The first implants were performed in March 2008 and ended in March 2024. A narrow QRS (<135 ms) was observed in 140 subjects (140/204, 68%). The primary endpoint (death from cardiovascular cause) was met in 10 (4.9%) patients. LBBB was present before implant in 29 patients and a QRS <135 ms was measured in 12/29 (41%). We did not observe more complications compared with the conventional technique. The survival curve using Kaplan-Meier analysis comparing the 2 groups was significantly different with a significant mortality reduction in the narrow QRS group.

Conclusions: A narrow-paced QRS is an independent variable associated with increased survival rates.

Background: Data are lacking to guide standardized management of coronary artery aneurysms (CAAs). We sought to analyze the available evidence in a quantitative manner.

Methods: An electronic search identified 431 case reports or case series on CAA, comprising 488 patients. Patient-level data were extracted. Subgroups of CAA with fistulous connections (CAAF) and CAA without fistulous connections (CAAO) were analyzed separately.

Results: Fistulous connection was present in 24.0% (117/488) of patients with CAA. Angina was a presenting symptom in 64.7% (301/465), with higher preponderance in the CAAO group [CAAO: 71.1% (249/350) versus CAAF: 45.2% (52/115); P < 0.01]. The median largest aneurysm diameter was higher in the CAAF group [CAAO: 3.0 (1.5-5.0) cm versus CAAF: 5.0 (3.0-7.0) cm; P < 0.01], and rupture was more frequently observed in the CAAF group [CAAO: 3.1% (11/353) versus CAAF: 13.8% (16/116); P < 0.01]. For any given diameter, CAAF had a higher risk of rupture compared with CAAO. Surgery was the most common management strategy, particularly in patients with CAAF [CAAO: 50.9% (189/371) versus CAAF: 75.2% (88/117); P < 0.01]. The Kaplan-Meier analysis showed a trend toward more favorable survival in CAAF. The hazard of mortality was associated with aneurysm diameter in both subsets but was higher in the CAAO group independent of surgical versus interventional management.

Conclusions: CAAF appears to have a higher risk of rupture but may be associated with better survival than CAAO. Management for patients with CAA differs based on the presence or absence of a fistula; however, both surgical and interventional modes of management result in similar survival.

Background: To further analyze the impacts, findings, and modalities of multiple cardiac screenings to answer the question, are multiple screens necessary and useful in youth?

Methods: Over 20 years, the Anthony Bates Foundation (ABF) has offered free and low-cost cardiac screenings to youth and their families nationwide. The volunteer force has provided blood pressure and ultrasound tests to participants throughout the 20 years. After year 7, electrocardiograms were added to the screening.

Results: Over the 20 years, ABF abnormal findings held steady between 10% and 13%, with potential life-threatening findings at 2.5%. The participants who have experienced multiple screening tests on average would repeat within 2.5 years and have abnormal findings at 31.84%, potential life-threatening at 11.43%, and total echocardiography-related abnormal findings at 16.82%. The variance between male and female attendance by age is also noted during the review of ABF repeat screened data. Male attendance was at 59.65% and female 40.35%. The abnormality rate of males for the first visit was 10.9% followed by the second visit of 18.80%. The abnormality rate of females for the first visit was 12.22% followed by the second visit of 17.09%. A detailed analysis of abnormal findings is presented in this article.

Conclusions: Cardiac screening involving multiple repeated screenings appears to be effective in detecting increasing numbers of abnormal findings that can be lifesaving.