Critical Pathways in Cardiology最新文献

Background: Several studies have been conducted over the years to find an effective and safe therapeutic agent to treat hypercholesterolemia. Inclisiran is a novel drug being studied for its efficacy and safety in reducing low-density lipoprotein cholesterol levels in patients to reduce the risk of cardiovascular diseases. No previous study was done to review the trials for the serious adverse events of this drug. The primary objective of this research is to investigate the incidence of serious adverse events of this drug.

Design: A systematic review and meta-analysis of clinical trials is performed.

Methods: A systematic search of PubMed, Embase, and ClinicalTrials.gov, from their inception till July 3, 2023, was performed for ORION trials, studying the efficacy and safety of inclisiran. The random-effects model was used in the meta-analysis to provide a pooled proportion of serious adverse events. The risk of bias in each study was assessed by the Cochrane Risk of Bias Tool.

Results: From 319 studies searched from the databases, only 8 relevant articles remained after a detailed evaluation. These studies, having a total of 4981 patients, were involved in the analysis, with a pooled estimate showing a nonsignificant incidence of serious adverse events. Each adverse event was studied individually, and product issues and endocrine disorders had the highest odds ratio among them. All included studies were classified as moderate quality.

Conclusion: Following systematic review and meta-analysis, we found no significant differences in any serious adverse events following the administration of inclisiran. However, larger ongoing trials will provide additional data to evaluate the safety profile of this agent.

Background: Idiopathic thrombocytopenic purpura (ITP) is characterized by a low platelet count. This may lead to an increased risk of hemorrhagic stroke but a lower rate of nonhemorrhagic stroke. The goal of this study was to evaluate the association between ITP and both hemorrhagic and nonhemorrhagic strokes using a large database.

Methods: We used the Nationwide Inpatient Sample (NIS) database to analyze the occurrence of hemorrhagic and nonhemorrhagic stroke in patients with and without a diagnosis of ITP from 2005 to 2014.

Results: Univariate analysis revealed a higher incidence of hemorrhagic stroke in patients with ITP in the year studied. (for example, in 2005: OR, 1.75; 95% CI, 1.57-1.94; P < 0.001; 2014: OR, 2.19; 95% CI, 2.03-2.36; P < 0.001). After adjusting for age, gender, race, and hypertension, hemorrhagic stroke remained significantly associated with ITP (in 2005: OR, 1.85; 95% CI, 1.49-1.89; P < 0.001; 2014: OR, 2.01; 95% CI, 1.86-2.18; P < 0.001) for all the years studied. Nonhemorrhagic stroke occurred at a lower rate in patients with ITP in most years (2006: OR, 0.91; 95% CI, 0.85-0.97; P = 0.004; 2014: OR, 0.88; 95% CI, 0.83-0.93; P < 0.001). Multivariate analysis confirmed a higher rate of nonhemorrhagic stroke in ITP patients.

Conclusion: Our analysis showed that there was a higher rate of hemorrhagic stroke but a lower rate of ischemic stroke in ITP patients, suggesting an important role of platelets in the occurrence of stroke.

Background: Early detection and follow-up of abdominal aortic aneurysm (AAA) are important and can be lifesaving. The goal of this study was to evaluate if routine abdominal aorta screenings during echocardiograms can be helpful in detecting asymptomatic abdominal aortic aneurysm.

Methods: We retrospective studied consecutive patients who were sent for outpatient routine echocardiograms for various clinical reasons in 2015-2017 until we reached a total of 1000 patients. Starting from the subcostal and then proceeding to the abdomen, a long-axis screening of the abdominal aorta was attempted on all of the patients after the echocardiogram was completed. No patient preparation was given. Imaging began from the subcostal view and proceeded caudally with images obtained every 1-2 cm. Measurement of the aortic diameter was performed from the longitudinal plane using the leading-edge-to-leading-edge method.

Results: The age range was 33-96 years with a median age of 72.4. A total of 273 (27.3%) patients did not have an appropriate window to evaluate AAA. Among the remaining 727 screenings, 18 (2.4%) had dilatation of abdominal aorta or AAA. The dilatation and aneurysms ranged between 2.5 and 4.5 cm in size. Abnormal aortic diameters were as follows: 5 (27.7%) were between 2.5 and 2.9 cm, 6 (33.3%) between 3 and 3.4 cm, 1 (5.5%) between 3.5 and 3.9, 5 (27.7%) between 4.0 and 4.4 cm, and 1 (5.5%) between 4.5 and 4.9 cm.

Conclusions: Performing routine abdominal aortic examinations during routine echocardiographic exams can detect a significant amount of abdominal aortic aneurysm which can be lifesaving. We suggest adding abdominal aortic assessment to routine echocardiographic examination.

Introduction: The prevalence of arterial hypertension (HTA) was continuously increased with a low percentage of pressure control blood pressure among treated patients. Therapeutic education (TE) was one of the inventive methods in the management of high blood pressure (HBP) worldwide. The objective was to assess the impact of TE on the control and management of HBP.

Methods: This was a quasi-experimental study consisting of an intervention, a pretest, and a post-test evaluation. This study was conducted in the external consultation service of cardiology CHU HEDI CHAKER of Sfax during over a period of 4 months (November 2021-March 2022).

Results: In total, 35 of the patients (50%) were women with a sex ratio of 1. The mean age was 63.33 ± 8.91 years. We noted a statistically significant decrease on both systolic and diastolic blood pressure blood pressure values after TE among educated patients (135.3 ± 9.77 vs. 141.9 ± 10.9; P  = 0.010) and (75 [70-80] vs. 80 [75-80]; P  = 0.002), respectively. We found a significantly good knowledge about HBP definition (Odds ratio [OR] = 3.4; P  = 0.022), HBP symptoms (OR = 9.1; P  < 0.001), and HBP complications (OR = 12.3; P  < 0.001) among educated patients. A significant association was noted between educated patients and low daily salt consumption after TE (OR = 2.7; P  = 0.048). Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation Educated patients had significantly more adequate auto-control devise use (OR = 1.01; P  = 0.028). Moreover, the respect of therapeutic compliance was statistically more important among educated patients (OR = 3.7; P  = 0.028).

Conclusions: Our results showed that the TE training session is an operative intervention to improve HBP management. Thus, integrating TE therapy in daily care should be continuous and should be exhaustive to all cardiovascular and all chronic diseases.

Introduction: The etiological assessment after an acute unprovoked pulmonary embolism (PE) represents an essential step in the overall management of the patient, with the aim of adapting the duration and type of anticoagulant to be used, avoiding recurrence and thus improving overall morbidity and mortality, but this is not such a simple question to answer.

Purpose: The main objective of this work is to know the benefit of a limited etiology strategy versus an extensive strategy after a first episode of acute non-provoked PE, first on all-cause mortality, and then the superiority of one strategy over another on the diagnosis of cancer at 1 year in patients admitted to a cardiac intensive care unit.

Methods: This is a single-center, retrospective study from 2014 to 2021, which includes all patients, admitted to a cardiac intensive care unit for a first episode, at high or high intermediate risk of mortality at day 30. The included patients were divided into 2 groups: those who received a limited cancer screening strategy, and those who received, in addition to the latter, an injected cerebral and cervical-thoracic-abdominal scan, and the determination of tumor markers. All data were extracted from the medical hospital files.

Results: In total, we included 130 patients. The mean age of our patients was 87.19 (SD = 6.1), with a female predominance with a percentage of 55.4%. Eighty-seven patients benefited from an extensive cancer screening strategy, versus 43 patients who benefited from a limited strategy. First, for mortality at 1 year, 27 deaths were found between the 2 groups but without significant difference (hazard ratio; 0.53; P = 0.16), and for the mean duration from embolic episode to death, there was a mean of 20 weeks for the limited strategy group and 24 weeks for the extensive strategy group, with a nonsignificant difference ( P = 0.106). For the diagnosis of cancer at 1 year, 28 patients were diagnosed with cancer: 13 patients in the limited strategy group versus 15 in the extensive strategy group, with no significant difference (hazard ratio, 1.983; P = 0.082). The mean time to diagnosis was 22 weeks in the limited strategy group and 20 weeks in the extensive strategy, with no significant difference ( P = 0.729).

Conclusion: To date, no scientific evidence has been established for the extensive versus the limited strategy, therefore, a minimal etiological workup is also effective in the detection of cancer after unprovoked PE.

Background: Patients with hypertrophic cardiomyopathy (HCM) usually have abnormal electrocardiograms consistent with left ventricular hypertrophy (LVH). The goal of this study was to evaluate the prevalence of abnormal ECG findings (LVH, T wave inversion, left bundle branch block, and left atrial enlargement) in participants with suspected HCM detected during screening echocardiography.

Method: The Anthony Bates Foundation has been performing screening echocardiography across the United States for the prevention of sudden death since 2001. A total of 682 subjects between the ages of 8 and 71 underwent echocardiographic screening together with ECG documentation. We evaluated the prevalence of abnormal ECG in participants with suspected HCM defined as any left ventricular wall thickness ≥15 mm.

Results: The prevalence of LVH and T wave inversion were higher in HCM subjects as expected [HCM occurred in 23.5% (4/17) vs. 5.6% (37/665), P = 0.002, T wave inversion occurred in 17.6% (3/17) vs. 4.1% (27/664), P = 0.007]. However, despite adding these 2 common ECG abnormalities in this population, the presence of detected abnormal ECG remained less than 25% (23.5% of HCM subjects had LVH or T wave inversion on ECG vs. 8.7% of control, P = 0.036). Left bundle branch block or abnormal left atrium on ECG were not found in any participants with suspected HCM.

Conclusions: The prevalence of abnormal ECG in the participants with suspected HCM detected during screening echocardiography is less than 25%. This suggests that ECG alone is not a sensitive marker for the detection of HCM.

Background: Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool.

Methods: We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway.

Results: Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE.

Conclusion: Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.

The systemic amyloidoses are a broad spectrum of diseases that result from misfolding of proteins that aggregate into amyloid fibrils. In cardiac amyloidosis, amyloid fibrils accumulate in the interstitial space between cardiac myocytes causing cellular injury and impairing compliance. Current data suggest that cardiac amyloidosis is more common than previously thought. Advances in cardiac imaging, diagnostic strategies, and therapies have improved the recognition and treatment of cardiac amyloidosis. A position statement for the diagnosis and treatment of cardiac amyloidosis has been published in 2021 by the European Society of Cardiology and an expert consensus decision pathway was published in 2023 by the American College of Cardiology. These are excellent documents but quite lengthy and complex. For this reason, our team developed a novel and simple pathway to help health care providers diagnose and treat patients with cardiac amyloidosis. Our pathway starts with a section titled "suspicion" in which we provide simple clues or "red flags" that are associated with the cardiac amyloidosis phenotype. It is followed by a section titled "diagnosis," where we present in a simplified 2 × 2 format the laboratory and imaging tests that must be performed for an accurate diagnosis. In the section titled "treatment," we describe the 4 pillars in the management of patients with cardiac amyloidosis, which includes the following: heart failure treatments, management of arrhythmias, treatment of significant aortic stenosis, and appropriate selection of disease modifying therapies. Our algorithm ends with our simplified recommendation for follow-up.

Background: Left ventricular (LV) ejection fraction (LVEF) is not a sensitive marker of LV systolic function in a subset of patients with preserved EF. The relation between LV pump function and global longitudinal strain (GLS) has not been elucidated well in patients with objectively preserved EF and no apparent heart failure (HF). We aimed to detect whether LV GLS can discover impaired LV pump function [presented as low stroke volume index (SVI) and low cardiac output (COP)] in patients with objectively preserved EF and no apparent clinical HF and its practice utility.

Methods: In total, 100 participants with LVEF of ≥50% were studied for demographic and echocardiographic data, including LVEF, stroke volume, SVI, COP, LV longitudinal strain assessments, apical 4-, 3-, and 2-chamber views averaged for GLS, and were classified into 2 groups: group 1: normal GLS (more negative than -18%) and group 2: low GLS (less negative than -18%).

Results: Reduced LV GLS was associated with lower SVI (35.6 ± 13.6 vs. 43.8 ± 12.7 mL/m 2 ; P = 0.01), lesser COP (5.4 ± 1.9 vs. 6.5 ± 2.1 l/min; P = 0.02), GLS had strong positive correlations with SVI ( r = 0.75; P < 0.001), and COP ( r = 0.66; P < 0.001). LV GLS at a cutoff value less negative than -15% is a strong predictor of SVI ≤35 mL/m 2 (76% sensitivity and 79% specificity) and at a cutoff value less negative than -13.5% it is a strong predictor of COP ≤4 L/min (76% sensitivity and 73% specificity). LV GLS was the best independent predictor of low SVI (<35 mL/m 2 ) and low COP (<4 L/min).

Conclusion: Impaired LV strain is associated with lower LV pump function, presented as lower COP and lower SVI in patients with preserved EF even in the absence of clinical HF. It is of great importance to incorporate GLS in the routine evaluation of LV function hand-by-hand with the noninvasive assessment of LV stroke volume and COP that can replace GLS on evaluation of LV pump function in old machines with no GLS modalities, for early pick-up of patients with impaired LV pump function before apparent HF.