Critical Pathways in Cardiology最新文献

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.

Introduction: Cystatin C (CysC) is a known prognostic marker in cardiovascular diseases and its role in acute heart failure (HF) has been documented.

Methods: We prospectively recruited HF patients followed in a HF clinic. Inclusion criteria: HF diagnosed ≥6 months, optimized evidence-based therapy, and ejection fraction <40% (Heart Failure with reduced ejection fraction). Exclusion criteria: renal replacement therapy and hospitalizations or therapeutic adjustments in the previous 2 months. A venous blood sample and 24-hour urine were collected. Follow-up: 5 years; endpoint: all-cause mortality. CysC was measured and creatinine clearance (CrCl) was calculated using 24-hour urine creatinine excretion. A Receiver operating characteristic curve was used to assess association of CysC with 5-year mortality. The prognostic role of CysC was determined using Cox-regression analysis. The multivariate model included CrCl (24-hour urine).

Results: We evaluated 215 chronic stable Heart Failure with reduced ejection fraction patients. Mean age was 68 years, 72.1% were male. Median CysC = 1.15 mg/L, creatinine = 1.20 mg/dL, and CrCl = 63.6 mL/min. During follow-up, 103 (47.9%) patients died. The area under the curve for CysC in predicting mortality was 0.77 (0.70-0.83). Best cut-off value for death prediction = 1.00 mg/L with a sensitivity = 83.5%, specificity = 56.2%, positive predictive value = 63.7%, and negative predictive value = 78.7%. Multivariate-adjusted (age-, B-type natriuretic peptide-, evidence-based therapy, New York Heart Association class, and CrCl) 5-year mortality Hazard ratio = 2.40 (95% Confidence interval, 1.25-4.61), P value = 0.008 when CysC ≥1.00 mg/L.

Conclusions: Patients with CysC <1.00 mg/L have almost 80% probability of being alive at 5 years; If CysC ≥1.00 mg/L, there is almost 2.5-fold higher death risk independently of B-type natriuretic peptide and CrCl.

Background: Regarding adjustments to warfarin dosage, numerous studies have shown that computerized methods are superior to those based on personal experience.

Objectives: To report the efficacy of a computer-based warfarin management system (WMS) in the Iranian population.

Methods: By utilizing the existing dosing algorithms and obtaining expert opinions, we developed a computer-based WMS at a large tertiary cardiovascular center. The time in therapeutic range and the number of international normalized ratio (INR) tests of clinic patients were compared before and after the implementation of WMS.

Results: Overall, 803 patients with 5407 INR tests were included in the before phase and 679 patients with 4189 INR tests in the after phase. The mean time in therapeutic range was 57.3% before and 59% after WMS implementation [mean difference, 1.64; 95% confidence interval (CI), -1.12-4.40]. In the before phase, the mean number of INR tests was 6.7, which dropped to 6.1 tests in the after phase (mean difference, -0.61; 95% CI, -0.97 to -0.24). Only 54.5% of the warfarin dosing prescriptions were consistent with the dosing recommendations of the WMS, and adherence to the WMS was poorest in the highest INR target range.

Conclusions: For the first time in Iran, we demonstrated that a computerized system was as effective as a traditional experience-based method to monitor INR in VKA-anticoagulated patients. Furthermore, it could reduce both the number of INR tests and that of visits.

Objective: To find out whether inclisiran sodium has different efficacy in heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH) patient groups.

Methods: We conducted the systematic review and meta-analysis of ORION clinical trials. PubMed, Embase, and Clinicaltrials.gov databases were searched for the relevant studies. Atheroscalerotic parameters considered for our objective were low-density lipoprotein cholesterol, total cholesterol, proprotein convertase subtilisin/kexin type 9 (PCSK9), apolipoprotein B, and nonhigh-density lipoprotein cholesterol. Primary outcomes were the percentage difference in atheroscalerotic parameters at follow-up relative to baseline values. Our study examined these primary outcomes to determine whether there is a statistically significant difference between the HeFH and HoFH groups. Risk of bias was assessed by the Cochrane risk of bias tool. Meta-analysis was performed when at least 2 studies reported on the same variable.

Results: Four ORION clinical trials provided the data related to the mean difference in the atheroscalerotic parameters at follow-up relative to baseline, of HeFH and HoFH patient populations, after administration of 300 mg inclisiran subcutaneously. We pooled together these mean differences for each group and applied a statistical test to analyze if the values were significantly different between the groups. The results of our study unveiled the significant difference in pooled mean differences in low-density lipoprotein cholesterol (HeFH: -48.62%; HoFH: -9.12%; P < 0.05), total cholesterol (HeFH: -30.31%; HoFH: -11.50%; P < 0.05), apolipoprotein (HeFH: -39.97%; HoFH: -14.68%; P < 0.05), and nonhigh-density lipoprotein (HeFH: -44.51%; HoFH: -12.22%; P < 0.05) between HeFH and HoFH groups. However, the difference in pooled mean difference in PCSK9 values (HeFH: -68.41%; HoFH: -56.25%; P = 0.2) between HeFH and HoFH groups was statistically insignificant. Studies were of high quality.

Conclusions: There was a significant difference in the reductions in atherosclerotic lipid parameters in heterozygous and homozygous populations after the administration of inclisiran except for PCSK9 parameter. Further studies are needed to support this conclusion.

The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.

Background: The burden of modifiable risk factors in young Egyptian adults presenting with first acute myocardial infarction (AMI), sex differences, sex-age interplay, and its relationship with demographic, angiographic characteristics, and type of AMI is a good topic for discussion.

Methods: The study enrolled 165 young (≤45 years old) consecutive, eligible patients diagnosed with first AMI (ST-elevation myocardial infarction, non-ST-elevation myocardial infarction), for their demographic, angiographic, echocardiographic, and laboratory investigations and gender differences.

Results: Our population were 29-45 years old and 12.1% were females, most of whom had ST-elevation myocardial infarction; obesity in females and smoking in males were the most prevalent; and the younger the age of females presenting with AMI the more aggressive underlying risk factors and the more reduction in left ventricular ejection fraction. Most of the female culprit lesions were thrombotic and the severity of atherosclerotic culprit lesions correlated positively with blood pressure.

Conclusions: The age paradox in young females (regarding left ventricular ejection fraction and the traditional risk factors) and the thrombotic nature of the culprit lesion mandate early intensive 1-year and 2-year preventive strategies against coronary heart disease (CHD) with special concern for obesity as the main trigger early in life with proper control of blood pressure. In males, smoking cessation programs are the main target to ameliorate the progress of CHD hand in hand with the other 1-year and 2-year preventive strategies of CHD.