Critical Pathways in Cardiology最新文献

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 (ACS) 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 30-day follow-up with cardiology or primary care, depending on 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 percent change in low-density lipoprotein cholesterol (LDL-C) at 30-days. Secondary outcomes include percent change in LDL-C at 180-days and non-high-density lipoprotein cholesterol (non-HDL-C) 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 semi-structured interviews to identify patient adherence facilitators and barriers as well as 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.

Introduction: Coronary perforation is one of the major complications of percutaneous coronary intervention (PCI). The goal of this study was to evaluate adverse outcomes and mortality in patients suffering from coronary perforation during PCI above the age of 30.

Methods: The National Inpatient Sample database, years 2016-2020, was studied using International Classification of Diseases, Tenth Revision codes. Patients suffering from perforation were compared with patients without perforation during PCI.

Results: PCI was performed in a weighted total of 10,059,269 patients. Coronary perforation occurred in 11,725 (0.12%) of all PCI performed. The mortality rate of patients with perforations was very high in comparison to patients without perforations. (12.9% vs. 2.5%, odds ratio, 5.6; CI, 5-6.3; P < 0.001). Furthermore, patients with coronary perforations had much higher rates of urgent coronary bypass surgery, tamponade, cardiac arrest, and major cardiovascular outcomes. Mortality remained high and over 10% in the 5-year study period.

Conclusions: Using a large national inpatient database, all-cause inpatient mortality in patients with coronary perforation is very high (over 10%), with persistently high mortality rates over the years, suggesting that treatment of perforations needs further improvement.

Background: Patients with long coronary lesions undergoing primary percutaneous coronary intervention (pPCI) have higher rates of adverse clinical events. Both stent length and stent overlap are associated with worse outcomes; however, data comparing very long stent (VLS) to overlapping stents (OSs) are limited, particularly during pPCI. This study aimed to compare the impact of a single VLS versus ≥2 OSs on clinical outcomes in a multicenter registry of patients undergoing pPCI.

Methods: This study included patients with ST-segment elevation myocardial infarction (STEMI) who underwent pPCI using a single VLS (≥38 mm) or ≥2 OS (total stent length, ≥38 mm) in the culprit lesion. After propensity score matching based on tortuosity, calcification, Killip class, culprit lesion length ≥40 mm, and culprit vessel, the final cohort for analysis was selected. The primary endpoint was a combination of mortality and target lesion failure (reinfarction, stent thrombosis, or new revascularization) at 2 years.

Results: Among 647 consecutive STEMI patients who underwent pPCI between March 2016 and September 2022, 353 received VLS and 294 received OSs. After propensity score matching, 264 patients remained (132 in each group). The occurrence of the primary outcome (VLS: 12.9 vs. OS: 15.9%; P = 0.86), all-cause mortality (VLS: 7.6 vs. OS: 9.8%; P = 0.51), and target lesion failure (VLS: 8.3 vs. OS: 6.8, P = 0.64) were similar between the 2 groups.

Conclusions: In this cohort of real-world patients with STEMI undergoing pPCI, we found no significant difference in outcomes between VLS and OSs. Both strategies are reasonable treatment options for STEMI patients.

Background: Use of high-sensitivity troponin (hs-cTn) might lead to an increase in hospital observation visits due to a higher number of abnormal troponin levels.

Study objectives: To determine the impact of incorporating hs-cTn into a chest pain clinical decision protocol (CDP) on observation visits in a large academic health system.

Methods: This is a retrospective observational cohort study of all chest pain observation patients in 4 hospitals in an academic health system over 24 months. All hospitals used the Beckman Coulter Unicel Dxi instrument, and all shared the same emergency department (ED) chest pain protocol, which used the HEART pathway and serial troponins and directed ED dispositions to either an observation stay, ED discharge, or inpatient admission. Outcomes studied before and after the introduction of an hs-cTn protocol included daily chest pain observation census, cost, observation hours, and inpatient admit rate. Census was reported as the daily chest pain observation census and as a proportion of all observation visits. Data were retrieved from a health system data warehouse and a cost accounting program.

Results: There were 6712 chest pain observation visits over 24 months, with 4087 visits before and 2634 visits after the hs-cTn protocol implementation. Comparison groups were similar in terms of age, gender, and type of insurance. There were 10.59 (95% CI, 10.24-10.95) daily chest pain observation visits before and 7.66 (95% CI, 7.34-7.97) visits after implementation, with a 28% (95% CI, 35%-20%) decrease in the total daily census. As a portion of all observation visits, there was a 22% drop in the proportion that were observed for chest pain. The daily number of chest pain patients requiring inpatient admission was unchanged. The daily total direct cost for chest pain observation decreased with an effective daily cost savings of $4313 USD (95% CI, $1534-$6998). The total daily number of chest pain observation bed hours also decreased by 41.5 hours (95% CI, 13.4-96.4 hours).

Conclusions: Implementation of a hs-cTn chest pain protocol was associated with a significant decrease in the number and proportion of observation visits, a decrease in total daily cost and bed hours used, and no increase in inpatient admissions.

Background and objective: The HEART pathway serves as a tool for predicting major adverse cardiac events (MACE) among patients presenting with acute chest pain, aiding in the early discharge of low-risk patients and reducing unnecessary cardiac investigations. This study aimed to evaluate physician-nurse reliability of the HEART pathway and investigate the efficacy of HEART pathway to predict 3-month MACE in patients with acute chest pain.

Methods: We conducted a prospective study on 97 patients experiencing acute chest pain. A team of 3 professionals, a nurse, a cardiology resident, and a cardiology attending physician, performed risk stratification. We assessed interrater reliability among the raters as well as explored 3-month MACE outcomes.

Results: Excellent pairwise agreements were found between the raters. Overall agreement among raters was excellent, with an intraclass correlation coefficient of 0.84 (95% confidence interval: 0.73-0.97). The HEART pathway score exhibited strong predictive power (area under curve: 0.85) for 3-month MACE. At a cutoff score of 4, sensitivity, specificity, and negative predictive values were 87.5%, 58.9%, and 95.8%, respectively.

Conclusions: The HEART pathway score effectively predicts 3-month MACE in patients with acute nontraumatic chest pain. Moreover, the high agreement among the attending physician, the resident physician, and the nurse suggests that nurses could use this tool, potentially reducing the workload on physicians.

Introduction: Embolic protection devices (EPDs) are catheter-based devices that can be used to capture atherosclerotic remnants released during percutaneous coronary intervention (PCI). We aim to study the efficacy and safety of EPDs in PCIs without saphenous vein grafts (SVGs) in ST-segment-elevation myocardial infarction (MI).

Methods: Three electronic databases of MEDLINE, Web of Science, and Embase were searched from inception to April 10, 2024, to identify relevant randomized controlled trials that compared outcomes of patients subjected to EPD during PCI with a control group where EPDs were not utilized. The primary outcome was 30-day all-cause mortality. Secondary outcomes were major adverse cardiovascular and cerebrovascular events at 30 days, post-PCI thrombolysis in MI grade 3 flow attainment, ST-segment resolution at 90 minutes post-procedure, and postprocedure angiographically detectable signs of distal embolization. The effect estimates of outcomes were assessed using risk ratio (RR) with a 95% confidence interval (CI). Random-effects meta-analysis was conducted using the restricted maximum likelihood method, given that the interstudy variance was inevitable.

Results: We included 3 randomized controlled trials enrolling 741 patients (age, 61.6 ± 12.15 years; 22% females) undergoing PCI without SVG lesions. As opposed to the control group, the use of EPD did not yield a significant effect on all-cause mortality [RR, 0.76 (95% CI, 0.31-1.86); I 2 = 0%], major adverse cardiovascular and cerebrovascular events [RR, 0.66 (95% CI, 0.34-1.27); I 2 = 0%], post-PCI thrombolysis in MI 3 flow [RR, 1.18 (95% CI, 0.86-1.62); I 2 = 77%], and ST-segment resolution at 90 minutes post-procedure [RR, 1.05 (95% CI, 0.90-1.22); I 2 = 0%]. However, EPD significantly decreased angiographically detectable signs of distal embolization [RR, 0.60 (95% CI, 0.36-0.99); I 2 = 0%].

Conclusions: EPD significantly reduced angiographically detectable signs of distal embolization in PCI without SVG lesions in ST-segment-elevation MI though there were no clinical signs of improved flow or mortality. Further trials are necessary to thoroughly evaluate the potential benefits and requirements of EPD usage in such procedures.

Introduction: Data on outcomes between unfractionated heparin and bivalirudin anticoagulation during percutaneous coronary intervention (PCI) in acute coronary syndromes remain inconclusive. We aimed to systematically analyze PCI outcomes by comparing unfractionated heparin and bivalirudin.

Methods: We systematically searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception in 1966 through January 2024 for studies evaluating PCI outcomes comparing unfractionated heparin and bivalirudin. Two investigators independently reviewed the data. Conflicts were resolved through consensus. Random-effects meta-analyses were used.

Results: A total of 10 prospective trials were identified that enrolled 42,253 individuals who presented with an acute coronary syndrome. Our analysis found that heparin when compared to bivalirudin was associated with an increased risk of trial-based definition of major bleeding [relative risk (RR): 1.68, 95% confidence interval (CI): 1.29-2.20], nonaccess site complications (RR: 4.6, 95% CI: 1.75-12.09), thrombolysis in myocardial infarction major bleeding (RR: 1.70, 95% CI: 1.20-2.41), major bleeding risks (RR: 1.87, 95% CI: 1.49-2.36), cardiovascular disease death (RR: 1.26, 95% CI: 1.02-1.57), and thrombocytopenia (RR: 1.67, 95% CI: 1.07-2.62). There were no statistically significant differences between heparin and bivalirudin for all-cause mortality, major adverse cardiovascular event, stroke, reinfarction, target vessel revascularization, and acute or stent thrombosis.

Conclusions: The present meta-analysis demonstrates bivalirudin reduces major bleeding when used for anticoagulation during PCI in patients with acute coronary syndromes and is not associated with an increased risk of stent thrombosis or major adverse cardiovascular event.

Novel contrast-induced acute kidney injury (CI-AKI) biomarkers are needed to detect earlier and with greater precision the pathophysiological changes in the renal medulla associated with kidney damage. We prospectively assessed the kinetics of urine oxygen tension (PO 2 ) in control healthy individuals and its prognostic ability for CI-AKI in patients undergoing percutaneous coronary intervention (PCI). We enrolled 202 consecutive patients (78% men, mean age 66 ± 10 years) treated with elective or urgent PCI. PO 2 was measured using a point-of-care (POC) standard blood gas analyzer at 3 time points (baseline, post-within 3 hours-PCI, and at 24 hours post-PCI) in urine samples. CI-AKI was defined as an increase of ≥25% or ≥0.5 mg/dl in pre-PCI serum creatinine at 48 hours post-PCI. Between baseline and post-PCI measurements, patients without CI-AKI showed a decrease of -37 (36) mm Hg in PO 2 urine levels, whereas patients with CI-AKI showed a decrease of only -23 (38) mm Hg. ( P = 0.014). Using receiver operating characteristic curve analysis, percentage change in urine PO 2 immediately after PCI relative to baseline levels significantly predicted CI-AKI (area under the curve 0.804; 95% confidence interval, 0.717-0.892). A significant drop in urine PO 2 appears as a normal response of the kidney medulla to an acute insult (contrast media) immediately post-PCI with recovery to baseline levels 24 hours later. The absence or attenuation of this drop in urine PO 2 could predict CI-AKI earlier and more precisely.

Background and purpose: Clevidipine is a parenteral dihydropyridine calcium channel blocker that received Food and Drug Administration approval in 2008 for the reduction of blood pressure (BP) when oral therapy is not feasible or not desirable. Soon after approval, our institution incorporated clevidipine into protocols for the management of hypertension among acute stroke patients, based on the drug's rapid onset of action and straightforward titration to goal. A subsequent retrospective review of its use in otherwise alteplase-eligible ischemic stroke patients with BP greater than 185/110 mm Hg (n = 32, in 2014) revealed that clevidipine in that setting demonstrated the shortest median time to BP control, the shortest median door-to-alteplase administration time, and the lowest administered volume of any parenteral antihypertensive used. As a result, clinical protocols in our institution were modified to make clevidipine first-line antihypertensive in both ischemic and hemorrhagic acute stroke. In this study, we report our institution's experience with clevidipine in acute stroke, comprising the largest such report to date.

Methods: We conducted a retrospective chart review of all acute stroke patients who received clevidipine in the emergency department (ED) or intensive care unit (ICU) (n = 295) for the management of clinically significant hypertension between January 1, 2015, and December 31, 2017. Metrics analyzed included target (goal) BP for thrombolysis eligibility among patients intended for lytic therapy according to stroke management guidelines in effect at the time of care.

Results: The median time for initial parenteral antihypertensive dose to goal (DTG) BP for all ischemic stroke patients (both those intended for and those not intended for lytic therapy) with complete data (n = 71 of 204) was 15 minutes; median time for door-to-IV-alteplase administration for ischemic stroke patients with complete data (n = 14 of 34 treated patients) was 59 minutes. The median time for initial parenteral antihypertensive DTG BP for all hemorrhagic stroke patients with complete data (n = 33 of 91 treated patients) was 39 minutes.

Conclusions: We conclude that the salutary findings of the initial small study are valid across a larger patient sample of all acute stroke types. Based on these data, clevidipine is shown to be safe, consistent, and effective in the treatment of acute hypertension in ischemic and hemorrhagic stroke events, and is a reasonable first-line treatment option for acute hypertension in this setting.

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 (BMI), waist circumference, and arm circumference), HbA1C, Low-Density Lipoprotein (LDL), triglyceride, smoking, and sex, the association of five 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% CI=[0.97, 1.103], P < 0.0001), BMI 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 to nonsmokers)=8.98, 95% CI=[8.95, 9.01], P < 0.0001), and female sex (EE (compared to males)= -5.92; 95% CI=[-5.94, -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 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.