Critical Pathways in Cardiology最新文献

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.

Purpose: To describe the experience and results of adopting evidence-based teaching strategies in a cardiovascular system course for undergraduate medical students.

Material and methods: Evidence-based methods for teaching undergraduate medical students were combined with feedback from students to inform and implement several changes to the course structure, content, and teaching methods.

Results and conclusions: The course was restructured with new learning objectives, "mini-tracks," 30-minute lectures, and purposeful repetition. Active learning (AL) was increased to 32 of 101 learning activities AL (31.7%). The overall approval rating for the course substantially increased after changes were made. Course directors should periodically review their learning activities for opportunities to adopt evidence-based educational techniques.

Background: Heart failure (HF) is a leading cause of hospitalization in the United States. The goal of this study was to evaluate contemporary population-level trends and demographic disparities in age-adjusted hospitalization rates for systolic heart failure (SHF) and diastolic heart failure (DHF).

Methods: We analyzed discharge data from the National Inpatient Sample database, years 2016 to 2020, for adults aged 20 and older. HF subtypes were identified using International Classification of Diseases, Tenth Revision codes. Age-adjusted hospitalization rates per 100,000 population were calculated and stratified by year, sex, and race.

Results: From 2016 to 2020, the age-adjusted DHF hospitalization rate increased from 219.4 [95% confidence interval (CI), 201.4-237.1] to 303.1 (95% CI, 277.7-328.5) per 100,000. SHF rates rose from 211.7 (95% CI, 194.7-228.7) to 262.6 (95% CI, 240.6-284.6). Hospitalizations for SHF were more common in men than women across all years; in 2020, the SHF hospitalization rate in men was 370.6 (95% CI, 323.8-417.4) compared to 171.9 (95% CI, 152.6-191.1) in women. Black patients consistently had the highest SHF and DHF hospitalization rates. In 2020, the DHF rate among Blacks was 418.3 (95% CI, 328.9-507.7) versus 284.8 (95% CI, 255.0-314.6) among Whites, and the SHF rate was 403.6 (317.3-478.8) versus 227.5 (95% CI, 203.7-251.3), respectively.

Conclusions: SHF and DHF age-adjusted hospitalization rates are rising significantly, with pronounced disparities by sex and race. Men and Black patients are disproportionately impacted.

Hyperuricemia, characterized by elevated serum uric acid levels, has been linked to cardiovascular diseases such as hypertension, atrial fibrillation, chronic kidney disease, heart failure, metabolic syndrome, and coronary artery disease. This relationship, however, is complex; while some studies indicate a strong association, others suggest that it may be influenced by confounding factors. The rising global prevalence of hyperuricemia underscores the necessity for a deeper understanding of its cardiovascular implications. Hyperuricemia results from an imbalance in uric acid production and excretion, driven by dietary factors, obesity, insulin resistance, and other conditions. Elevated uric acid levels contribute to cardiovascular risk through mechanisms such as inflammation, oxidative stress, endothelial dysfunction, and activation of the renin-angiotensin-aldosterone system. This review highlights the importance of ongoing research to clarify hyperuricemia's role in cardiovascular disease and suggests that urate-lowering therapies, such as xanthine oxidase inhibitors, may confer cardiovascular benefits; however, evidence remains conflicting. The Cardiovascular Safety of Febuxostat and Allopurinol in Patients with Gout and Cardiovascular Morbidities (CARES) trial indicated an increased risk of cardiovascular and all-cause mortality with febuxostat compared with allopurinol, raising safety concerns. In contrast, the Febuxostat versus Allopurinol Streamlined Trial (FAST) demonstrated that febuxostat was noninferior to allopurinol, with even lower all-cause mortality. These opposing findings emphasize the complexity of treatment decisions and the need for individualized management strategies for hyperuricemia. Clinical decisions should consider individual patient risks and characteristics. Ultimately, this comprehensive analysis aims to enhance prevention and management strategies for cardiovascular diseases related to hyperuricemia. The overview includes discussions on major studies such as the Framingham Heart Study, CARES, FAST, PRIZE, and FREED trials, examining their results. It explores whether hyperuricemia is a causal factor versus an associated risk factor and whether it serves as a marker or mediator of disease. Additionally, the review addresses novel biomarkers and predictive models, the management of hyperuricemia in the context of cardiovascular risk, the role of urate-lowering therapies in cardiovascular disease, variability in guidelines and recommendations, and the impact of hyperuricemia in special populations such as those with diabetes and chronic kidney disease. The cardiovascular risk associated with hyperuricemia across various demographics is also discussed. Furthermore, the review suggests that existing risk scores might be modified to include uric acid levels in patients with hyperuricemia.

Chest discomfort before severe chest pain represents a clinical ischemia marker and indicates live myocardium in jeopardy and often precedes cardiac arrest or acute myocardial infarction (MI). The intermittent or stuttering symptoms that precede MI are referred to as "prodromal symptoms." These symptoms have been shown to correlate with cyclic ST changes and repeated episodes of spontaneous reperfusion and occlusion, occurring during a period of hours or days before the acute ischemia precedes to death or heart damage. These symptoms of premonitory angina have been associated with improved outcomes due to ischemic preconditioning or opening of collateral vascular channels around the area of ischemia. Acute prevention of an MI through prodromal symptoms recognition represents the opportunity for significantly reducing heart attack deaths. The early heart attack care program puts emphasis on prodromal symptom recognition and allows a shift in time backward to prevent the ischemic process from proceeding to MI. This strategy has been shown to pick up 15% of the patients with ischemia in the low probability group and to reduce inappropriate admissions to the hospital, as well as to reduce the number of patients with missed MIs being sent home from the emergency department.

Background: Hyperlipidemia (HLD) is a major contributor to atherosclerotic cardiovascular disease (ASCVD). Nearly 30% of emergency department (ED) patients with chest pain have undiagnosed and/or unmanaged HLD, putting them at an increased risk of ASCVD. Although safe and effective HLD treatments exist, the ED traditionally focuses on acute care and does not offer preventive cardiovascular care services. This represents a large, missed opportunity to improve cardiovascular health for the millions of Americans evaluated in the ED each year who are not receiving appropriate preventive care in the outpatient setting. The goals of this study are to determine the efficacy of novel ED-initiated preventive care on lowering cholesterol while also informing our understanding of patient adherence and implementation determinants of ED-initiated preventive cardiovascular care.

Methods: We will use a randomized, controlled, parallel-group trial of 130 ED patients being evaluated for acute coronary syndrome at a single site. Participants will be 40-75 years old with prior ASCVD, known diabetes, or 10-year ASCVD risk ≥7.5% who are not already receiving guideline-directed outpatient preventive care. Patients will be randomized with equal probability to EMERALD (Emergency Medicine Cardiovascular Risk Assessment for Lipid Disorders) or usual care. Patients in the EMERALD arm will be started on a statin and referred for a 30-day follow-up with cardiology or primary care, depending on the 10-year ASCVD risk level. Usual care arm patients will not be prescribed a statin in the ED and will be asked to follow up with a primary care provider. The primary outcome will be a percent change in low-density lipoprotein cholesterol at 30 days. Secondary outcomes include percent change in low-density lipoprotein cholesterol at 180 days and nonhigh-density lipoprotein cholesterol at 30- and 180 days, the proportion of EMERALD patients who pick up their statin, and the proportion of patients who attend 30-day outpatient follow-up. We will also use mixed methods and semistructured interviews to identify patient adherence facilitators and barriers and implementation determinants for Emergency Medicine providers.

Discussion: This is the first study to evaluate a novel, protocolized ED-initiated preventive cardiovascular care approach for HLD. If successful, the EMERALD intervention may be able to improve the cardiovascular health for at-risk patients and serve as a use case for other modifiable cardiovascular disease risk factors, such as diabetes, hypertension, tobacco use, and obesity. This single-site study will inform a planned multisite trial.

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.