Critical Pathways in Cardiology最新文献

Background: Ambulatory electrocardiogram (AECG) monitoring is an attractive method for objectively identifying atrial fibrillation (AF) symptoms by documenting simultaneous arrhythmia with symptomatic episodes. However, no study yet has evaluated this simultaneous symptom-rhythm correlation in patients with heart failure (HF). We aimed to measure the correlation between symptoms and atrial arrhythmia (ATAF) episodes among patients with HF and known AF using prolonged AECG monitoring.

Methods: We analyzed ATAF events and patient-triggered symptomatic events (PTSEs) on AECG monitors in adults with a history of AF and HF.

Results: Among 959 monitors, we identified a total of 26,634 events, including 15,787 ATAF events and 4950 PTSE. The mean age was 70 years, 48% were female, and 91% were Caucasian. Among 4950 PTSEs, only 1116 demonstrated ATAF (23%). PTSE showed a low correlation with ATAF, with a moderate inverse tetrachoric correlation of -0.62 (bootstrapped 95% confidence interval: -0.61 to -0.63). The mean heart rate (HR) of symptomatic ATAF events was 115 bpm (SD: 33), compared with asymptomatic ATAF (107 bpm, SD: 33, P < 0.001). The mean HR of all symptomatic events was 92 bpm (SD: 28) and of asymptomatic events was 99 bpm (SD: 30), P < 0.001.

Conclusions: Our study found that symptomatic events on AECG monitors poorly predict ATAF episodes, ATAF episodes are rarely noted as symptomatic, and poor HR control fails to fully explain AF symptoms in patients with known AF and HF. Our study encourages further research into other symptom assessments, such as patient-reported outcomes and a more comprehensive approach to AF treatment in HF rather than primarily symptom based.

Aortic dissection (AD) is a potentially fatal cardiovascular issue that needs to be diagnosed and treated very away. Although early detection is essential for bettering patient outcomes, there are substantial obstacles with the diagnostic techniques used today. Promising pathways for improving AD prognosis evaluation and early detection are presented by recent developments in serum biomarkers. The most recent research on serum biomarkers for AD is reviewed here, with an emphasis on the prognostic and diagnostic utility of these indicators. A number of biomarkers, including as matrix metalloproteinases, soluble elastin fragments, smooth muscle myosin heavy chain, and D-dimer, have been identified as putative markers of AD. These indicators are indicative of multiple pathophysiological mechanisms associated with AD, including inflammation, extracellular matrix remodeling, and vascular damage. Research has indicated that they are useful in differentiating AD from other acute cardiovascular diseases, facilitating prompt diagnosis and risk assessment.

Background: Patients with heart failure often have multiple cardiovascular risk factors (CVRFs) and comorbidities (CMBs). We evaluated the impact of additive CMB and CVRF on heart failure prognosis.

Methods: We retrospectively analyzed ambulatory patients with systolic dysfunction between January 2012 and May 2018. Follow-up was until January 2021. The endpoint was all-cause death. CVRF analyzed arterial hypertension, diabetes mellitus, and smoking. CMB evaluated coronary artery disease, noncoronary atherosclerotic disease, respiratory disease, dementia, anemia, chronic kidney disease, inflammatory/autoimmune disease, active cancer, and atrial fibrillation. Classification according to the number of CVRFs and/or CMBs is <2 and ≥2. The independent prognostic impact of CVRF/CMB burden was assessed with multivariate Cox regression.

Results: Most patients had ≥2 CMBs (67.9%). Regarding CVRF, 14.9% presented none, 40.2% had 1, and 32.1% had 2. During a median 49-month follow-up, 419 (49.1%) patients died. Mortality was higher among patients with ≥2 CVRFs (56.1 versus 43.4% in those with <2) and in those with ≥2 CMBs (57.7 versus 31.0%). While patients with 1 CMB had similar mortality than those with none. Patients with ≥2 CMBs had higher long-term mortality risk: hazard ratio (HR), 2.47 (95% CI, 1.95-3.14). In patients with ≥2CVRFs, the HR of dying is 1.39 (95% CI, 1.14-1.70). When taken together, there was a clear survival disadvantage for patients with ≥2 CVRFs/CMBs-adjusted HR, 2.20 (95% CI, 1.45-3.34).

Conclusions: The presence of only 2 CVRFs/CMBs more than doubles the patients´ risk of dying. CVRF and CMB should be assessed as part of routine patient management.

Population-based studies of cardiovascular disease markers, such as 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 data from the National Longitudinal Study of Adolescent 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 log transformation of the dependent variable. The total number of participants was N = 1839 (weighted N = 1390763), 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% Cl: [1.31-1.91]). Notably, current smoking and altered LDL or TG 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 to 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%CL: [1.42-1.78]), high waist circumference (P = 0.015, EE = 1.25; 95%CL: [1.15-1.35]), and grade 3 obesity (P = 0.006, EE = 7.62; 95%CL: [2.86-12.38]). Although not statistically significant, hs-CRP levels exhibited a gradual increase with rising BMI after controlling for other variables. These findings will improve the clinical application of hs-CRP in predicting coronary artery disease, especially in younger adults.

Introduction: Peripheral arterial disease (PAD) is a progressive, systemic atherosclerotic disease that is associated with an increased risk of coronary artery disease (CAD), cerebrovascular disease (CVD), 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 (NIS) database from year 2016 to 2021 using the ICD-10-CM codes. Patients with a primary or secondary diagnoses of PAD were initially selected and subsequently hospitalization with CLI were appropriately identified. 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 2016-2021, there were 2,930,639 admissions for critical limb ischemia. 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 to 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.

Conclusion: PAD is a progressive, systemic atherosclerotic disease that is associated with an increased risk of CAD, CVD, and CLI. Our data showed that the rates of PAD and CLI hospitalizations has remained relatively stable from 2016-2021, but there seems to be a trend towards doing more revascularization via an endovascular approach as compared to a surgical approach.

Background: The occurrence of transient myocardial ischemia (TMI) is an important pathology in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), yet studies are scarce regarding when TMI occurs during hospitalization, particularly in relation to invasive coronary angiography (ICA). This study examined: (1) TMI before or after ICA; (2) patient characteristics and ischemic burden by TMI group (before or after ICA); and (3) major in-hospital complications (transfer to critical care, death) and length of stay by TMI group (before or after ICA).

Methods: Secondary data analysis in hospitalized NSTE-ACS patients with TMI event(s) identified from 12-lead electrocardiographic Holter. Patient records were reviewed to assess ischemic burden [TMI time (min) ÷ hours recording duration], outcomes, and TMI timing, before or after ICA.

Results: In 38 patients, 3 (8%) had TMI before and after ICA. Of the remaining 35 patients (92%), TMI occurred before ICA (16; 46%), and after ICA (9; 26%), and 10 (28%) did not have ICA. Patient characteristics, untoward outcomes, and TMI duration (minutes) did not differ by group. Ischemic burden was higher in patients with TMI after ICA (7.29 ± 8.82 min/h) compared to before ICA (2.54 ± 2.11 min/h), P = 0.039. Hospital length of stay by TMI group was 113 ± 113 (before), 226 ± 244 (after), and 85 ± 65 hours (no ICA); P = 0.172.

Conclusions: Almost half of the sample had TMI before ICA; one-third had TMI but did not have ICA. Patients with TMI after an ICA had a higher ischemic burden. Future studies with larger sample sizes are needed to investigate further the short- and long-term clinical significance of TMI among NSTE-ACS patients.

Spontaneous coronary artery dissection (SCAD) can be treated conservatively. However, some SCAD patients can develop cardiogenic shock (CS). We evaluated the outcomes of SCAD-related CS using data from a national population-based cohort study from January 1, 2016, to December 30, 2019. In our study of 32,640 patients with SCAD, about 10.6% of patients presented with CS. We found that SCAD patients with CS had higher mortality and greater complications including use of mechanical circulatory devices, arrhythmias, respiratory support, and acute heart failure compared to those without CS. When comparing CS due to SCAD with that due to coronary artery disease, we found that although mortality rates were similar, those with CS due to SCAD were associated with higher risk of use of mechanical circulatory support, major bleeding, blood transfusion, and respiratory failure.

Background: The prevalence of hypertrophic cardiomyopathy (HCM) can be silent and can present with sudden death as the first manifestation of this disease. The goal of this study was to evaluate any association between reported physical symptoms with the presence of suspected HCM.

Method: The Anthony Bates Foundation has been performing screening echocardiography across the United States for prevention of sudden death since 2001. A total of 4120 subjects between the ages of 4 and 79 underwent echocardiographic screening. We evaluated any association between various symptoms and suspected HCM defined as any left ventricular wall thickness³ ≥15 mm.

Results: The total prevalence of suspected HCM in the entire study population was 1.1%. The presence of physical symptoms was not associated with HCM (chest pain in 4.3% of participants with HCM vs. 9.9% of the control, P = 0.19, palpitation in 4.3% of participants with HCM vs. 7.3% of the control, P = 0.41, shortness of breath in 6.4% of participant with HCM vs. 11.7% of the control, P = 0.26, lightheadedness in 4.3% of participant with HCM vs. 13.1% of the control, P = 0.07, ankle swelling in 2.1% of participant with HCM vs. 4.0% of the control, P = 0.52, dizziness in 8.5% of participant with HCM vs. 12.2% of the control, P = 0.44).

Conclusions: Echocardiographic presence of suspected HCM is not associated with a higher prevalence of physical symptoms in the participants undergoing screening echocardiography.

Introduction: Brigham and Women's Hospital historically used titratable weight-based heparin nomograms with as needed boluses managed by extracorporeal membrane oxygenation specialists to achieve a predetermined goal-activated partial thromboplastin time (aPTT). Due to concern amongst providers that as needed boluses may lead to supratherapeutic aPTT's and subsequent bleeding, new nomograms without as needed boluses were implemented. The purpose of this retrospective observational analysis is to provide a comparison in safety and efficacy between the heparin nomograms with as needed boluses and the new nomograms without boluses.

Methods: Adult patients who were cannulated on extracorporeal membrane oxygenation and initiated on an approved heparin bolus nomogram (January 1, 2018-December 31, 2019) or an approved heparin no-bolus nomogram (October 20, 2020-March 31, 2021) were screened for inclusion. The major endpoint evaluated was the percentage of supratherapeutic aPTTs, defined as an aPTT above the upper limit of the specified nomogram goal, within the first 72 hours.

Results: A total of 23 patients were included in the bolus nomogram cohort and 9 patients in the no-bolus nomogram cohort. Within the first 72 hours of initiation, there were 11.5% supratherapeutic aPTTs in the bolus group and 5.1% in the no-bolus group ( P = 0.101). Overall there was 1 bleeding event in the no-bolus group (11.1%) and 7 in the bolus group (30.4%) ( P = 0.26). There were no thromboembolic events in either group.

Conclusions: Overall, there was no difference found in the percentage of supratherapeutic aPTTs within the first 72 hours of heparin initiation between the bolus and no-bolus nomograms.

Background: Cardiac arrest remains a critical condition with high mortality and catastrophic neurological impact. Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as an adjunct in cardiopulmonary resuscitation modalities. However, survival with good neurological outcomes remains a major concern. This study aims to explore our early experience with ECPR and identify the factors associated with survival in patients presenting with refractory cardiac arrest.

Methods: This is a retrospective cohort study analyzing 6-year data from a tertiary center, the country reference for ECPR. This study was conducted at a national center of ECPR. Participants of this study were adult patients who experienced witnessed refractory cardiopulmonary arrest and were supported by ECPR. ECPR was performed for eligible patients as per the local service protocols.

Results: Data from 87 patients were analyzed; of this cohort, 62/87 patients presented with in-hospital cardiac arrest (IHCA) and 25/87 presented with out-of-hospital cardiac arrest (OHCA). Overall survival to decannulation and hospital discharge rates were 26.4% and 25.3%, respectively. Among survivors (n = 22), 19 presented with IHCA (30.6%), while only 3 survivors presented with OHCA (12%). A total of 15/87 (17%) patients were alive at 6-month follow-up. All survivors had good neurological function assessed as Cerebral Performance Category 1 or 2. Multivariate logistic regression to predict survival to hospital discharge showed that IHCA was the only independent predictor (odds ratio: 5.8, P = 0.042); however, this positive association disappeared after adjusting for the first left ventricular ejection fraction after resuscitation.

Conclusions: In this study, the use of ECPR for IHCA was associated with a higher survival to discharge compared to OHCA. This study demonstrated a comparable survival rate to other established centers, particularly for IHCA. Neurological outcomes were comparable in both IHCA and OHCA survivors. However, large multicenter studies are warranted for better understanding and improving the outcomes.