Critical Pathways in Cardiology最新文献

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.

Background: Transcatheter aortic valve implantation (TAVI) has been established as the treatment of choice for severe aortic stenosis in high-risk patients as well as patients above 75 years old in all risk spectrums. Despite its worldwide adoption, implementation in lower-middle-income countries such as the Brazilian public health system (SUS, acronym in Portuguese) is incipient.

Objectives: This study aimed to evaluate TAVI exclusively within SUS patients.

Methods: This was a prospective cohort study in a public tertiary hospital in southern Brazil. All patients who underwent TAVI between 2018 and 2024 were included. The cohort was divided into 2 temporal periods: from July 2018 to December 2022 (n = 60) and January 2023 to October 2024 (n = 65). The clinical and procedural characteristics and in-hospital, as well as 1 year of outcomes, were evaluated according to Valve Academic Research Consortium-2 (VARC-2) criteria.

Results: During the study period, 125 patients underwent TAVI. The average age was 80 years (± 10), and 49.6% were male. The mean aortic valve area was 0.76 cm² and the mean gradient was 45 (±13) mm Hg. The mean STS predicted risk of mortality (STS-PROM) score was 4.6% (±3.6). Device success was achieved in 119 patients (95.2%). In-hospital mortality was 2 (1.6%). A new permanent pacemaker was required in 16 (12.8%). Demographic and clinical characteristics between the first and the second periods were similar.

Conclusions: The mortality and complications rate of TAVI performed within the scope of the Brazilian public health system were consistent with the clinical experience of other international registries.

Population-based studies of cardiovascular disease markers, such as high-sensitivity C-reactive protein (hs-CRP), are crucial. However, studies exploring the effect of metabolic indices on hs-CRP while controlling for confounding variables adequately in middle-aged adults are limited. Using Wave 5 public-use biomarkers data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), we examined the impact of various metabolic indices on hs-CRP in adults aged 32-42, controlling for eight allergic and infectious factors that may elevate hs-CRP levels. We used multiple linear regression analysis to determine which factors predict hs-CRP levels after the log transformation of the dependent variable. The total number of participants was N = 1839 (weighted N = 1,390,763), with a mean age of 38.1 (SD = 2.0) and 46.4% having obesity. Among the controlled variables, recent surgery was the only confounder to significantly predict increased hs-CRP levels [ P = 0.029; exponentiated estimate (EE) = 1.61; 95% confidence interval (Cl), 1.31-1.91]. Notably, current smoking and altered low-density lipoprotein levels did not show a significant association with hs-CRP levels ( P > 0.05). However, a significant increase in hs-CRP levels was observed in females compared with males ( P < 0.001; EE = 1.43; 95% Cl, 1.35-1.51). Similar findings were noted for diabetic HbA1c levels ( P = 0.001; EE = 1.6; 95% CI, 1.42-1.78), high waist circumference ( P = 0.015; EE = 1.25; 95% CI, 1.15-1.35), and stage 3 obesity ( P = 0.006; EE = 7.62; 95% CI, 2.86-12.38). Although not statistically significant, hs-CRP levels exhibited a gradual increase with rising body mass index after controlling for other variables. These findings will improve the clinical application of hs-CRP in predicting coronary artery disease, especially in younger adults.

Background: Atrial fibrillation (AF) is the most frequently recorded arrhythmia in clinical practice, and its appearance conditions high risk of morbidity and mortality. The role of the interatrial block (IAB) as a predictor pathway of the development of AF in the postoperative period of patients undergoing cardiac surgery has been studied scantly.

Methods: Partial IAB was defined as the P wave >120 ms and advanced IAB as the P wave >120 ms with biphasic morphology in inferior leads. The presurgical electrocardiography was analyzed, and the frequency of AF onset in the postoperative period was determined. A comparative analysis was performed between the patients who presented AF and those who did not.

Results: A total of 94 patients were included, with a mean age of 61 ± 16 years. Of the total number of patients, 42 (45%) presented some degree of IAB (partial 42.8% and advanced 57.1%). There was a significant relationship between patients with IAB and those who developed AF postcardiac surgery (21.3%; P < 0.01). The presence of IAB had an area under the curve of 0.75 (95% confidence interval, 0.66-0.85) and demonstrated a specificity of 69%, a sensitivity of 83%, and a negative predictive value of 92% for predicting AF development.

Conclusions: IAB has a relatively frequent incidence in patients undergoing cardiac surgery. There was a significant association between the presence of IAB and the development of AF in the postoperative period. Our findings establish for the first time that IAB has high specificity, sensitivity, and negative predictive value for predicting AF development postcardiac surgery.

The performance of nonphysician-led exercise stress testing with and without echocardiography has shown similar diagnostic utility and safety as physician-led models. While diagnostic accuracy and relative safety have been the focus of previous research, the current study aims to demonstrate efficiencies not previously reported, such as reduction in wait times for testing and improved service attendance. A nonphysician-led exercise stress echocardiography service was implemented on January 01, 2018; before this, all tests were performed under a physician-led model. Retrospective data was retrieved from both models (physician-led model from January 01, 2015 to December 31, 2017 and the nonphysician-led model from January 01, 2018 to December 31, 2023). Comparisons were made between the models regarding the number of tests performed, the average wait time to access testing, and the did not attend (DNA) rates. On average, 212 tests were performed in the physician-led model per year, with average wait times to access testing of 11.3 weeks and a DNA rate of 15.3%. In contrast, the nonphysician-led model performed on average 501 tests per year (135% increase) ( P < 0.001) with average wait times of 6 weeks (47% decrease) ( P < 0.01) and DNA rate of 4.8% (69% decrease). Despite the physician-led group displaying an overall higher cardiovascular disease risk, there were no adverse cardiovascular events at the time of testing in either model. Nonphysician-led exercise stress echocardiography remains as safe as physician-led models but demonstrates service improvements, including significant reductions in wait times and lower DNA rates.

Introduction: Peripheral artery disease (PAD) is a progressive, systemic atherosclerotic disease that is associated with an increased risk of coronary artery disease, cerebrovascular disease, and critical limb ischemia (CLI). CLI represents the most severe stage of PAD, characterized by progressive endothelial dysfunction and arterial narrowing. We hypothesized that the incidence of CLI and PAD would increase over the study period and that the rates of in-hospital mortality and major amputations among patients admitted with CLI would rise correspondingly.

Methods: We utilized the National Inpatient Sample database from 2016 to 2021 using the International Classification of Disease, Tenth Edition, Clinical Modification codes. Patients with primary or secondary diagnoses of PAD were initially selected, and subsequently hospitalization with CLI was appropriately identified. The Cochran Armitage test was used to describe the trend of outcomes across the years. All statistical analyses were conducted using the software Stata version 17.0.

Results: From 2016 to 2021, there were 2,930,639 admissions for CLI. Up to 65% of these patients were over the age of 60, and 35.8% of these patients were women. Most of these individuals were white (64.7%), followed by African Americans (15.8%) and Hispanics (12.6%). In-hospital mortality rates varied by revascularization method, with hybrid revascularization showing the highest rate at 2.6%, followed by endovascular revascularization at 1.8%, and surgical revascularization at 1.6%. Additionally, hospitalization costs were highest for patients undergoing hybrid revascularization ($46,257 ± $36,417), compared with endovascular ($36,924 ± $27,945) and surgical revascularization ($35,672 ± $27,127). Endovascular revascularization rates seemed to increase while surgical revascularization rates decreased during this time period.

Conclusions: PAD is a progressive, systemic atherosclerotic disease that is associated with an increased risk of coronary artery disease, cerebrovascular disease, and CLI. Our data showed that the rates of PAD and CLI hospitalizations have remained relatively stable from 2016 to 2021, but there seems to be a trend toward doing more revascularization via an endovascular approach as compared to a surgical approach.