Critical Pathways in Cardiology最新文献

The emergence of thrombectomy for large vessel occlusions has increased the importance of accurate prehospital identification and triage of acute ischemic stroke (AIS). Despite available clinical scores, prehospital identification is suboptimal. Our objective was to improve the sensitivity of prehospital AIS identification by combining dispatch information with paramedic impression. We performed a retrospective cohort review of emergency medical services and hospital records of all patients for whom a stroke alert was activated in 1 urban, academic emergency department from January 1, 2018, to December 31, 2019. Using admission diagnosis of acute stroke as outcome, we calculated the sensitivity and specificity of dispatch and paramedic impression in identifying AIS and large vessel occlusion. We identified factors that, when included together, would improve the sensitivity of prehospital AIS identification. Two-hundred twenty-six stroke alerts were activated by emergency department physicians after transport by Indianapolis emergency medical services. Forty-four percent (99/226) were female, median age was 58 years (interquartile range, 50-67 years), and median National Institutes of Health Stroke Scale was 6 (interquartile range, 2-12). Paramedics demonstrated superior sensitivity (59% vs. 48%) but inferior specificity (56% vs. 73%) for detection of stroke as compared with dispatch. A strategy incorporating dispatch code of stroke, or paramedic impression of altered mental status or weakness in addition to stroke, would be 84% sensitive and 27% specific for identification of stroke. To optimize rapid and sensitive stroke detection, prehospital systems should consider inclusion of patients with dispatch code of stroke and provider impression of altered mental status or generalized weakness.

Background: Remote cardiac monitoring and screening have already become an integral telemedicine component. The wide usage of several different wireless electrocardiography (ECG) devices warrants a validation study on their accuracy and reliability.

Methods: Totally, 300 inpatients with the Nabz Hooshmand-1 handheld ECG device and the GE MAC 1200 ECG system (as the reference) were studied to check the accuracy of the devices in 1 and 6-limb lead performance. Simultaneous 10-second resting ECGs were assessed for the most common ECG parameters in lead I. Afterward, 6-lead ECGs (limb leads), were performed immediately and studied for their morphologies.

Results: Of the 300 patients, 297 had acceptable ECG quality in both devices for simultaneous lead I ECGs. The ECGs were inspected on-screen by a cardiologist for their rhythms, rates, axes, numbers, morphologies of premature atrial and ventricular beats, morphologies and amplitudes of PQRST waves, P-wave durations, QRS-wave durations, P-R intervals, and QT intervals. No significant differences were detected between the devices, and no major abnormalities were missed. Six-limb lead ECGs were obtained in 284 patients, of whom 281 had acceptable quality in ECGs by both devices. The morphology matching evaluation of the ECGs demonstrated an overall 98% compatibility rate, with the highest compatibility in lead I and the lowest in lead augmented vector foot.

Conclusions: The diagnosis of critical pathological rhythms, including atrial fibrillation and high-grade atrioventricular node block, was not missed by the Nabz Hooshmand-1 and GE MAC 1200 ECG devices. Accordingly, rhythm detection as the primary purpose of handheld ECG devices was highly accurate. Both devices had acceptable sensitivity to diagnose long P-R and long and short QT intervals. Although the modern technology of smartphones and the physical inability for the 6-limb mode might cause old patients difficulty in utilizing such devices, their use for screening and follow-up is safe.

Introduction: Atrial fibrillation (AF) recurrence after a successful external electrical cardioversion (ECV) is common. Assessing an individual's risk of AF recurrence is a critical part of the treatment plan. We aimed to develop a prognostic prediction score to predict AF recurrence in AF patients who underwent successful ECV.

Methods: A retrospective cohort study that included AF patients who underwent successful ECV was conducted with a primary outcome of AF recurrence at 6 months. Logistic regression analysis was done to identify variables, and a prognostic prediction score was created and internally validated.

Results: Four prognostic predictors were identified, including the type of AF, persistent AF (1 point) and long-standing persistent AF (4 points), previous cardioversion (1 point), stroke/transient ischemic attack (3 points), and left atrial volume index ≥40 mL/m 2 (6 points). The total score of 14 was further divided into 3 risk groups; low-risk (0-2 points), moderate-risk (3-7 points), and high-risk (8-14 points). The positive likelihood ratio for a moderate-risk patient was 2.08 (95% CI, 1.64-2.63) and for a high-risk patient was 7.90 (95% CI, 2.48-25.17). The score showed good discrimination power with the c-statistic of 0.74 (95% CI, 0.69-0.79).

Conclusions: A simple prognostic prediction score for AF recurrence after successful ECV was created with a promising internally validated discrimination power. An external assessment of its usefulness as a tool to identify patients with low, moderate, and high risk for AF recurrence is warranted.

Background: The location of the wire sensor to measure fractional flow reserve (FFR) and diastolic pressure ratio (dPR) has not been systematically studied. Therefore, we hypothesize that the coronary physiological measurements will vary with the location of the sensor.

Methods: Fifty-four patients were screened, and 30 consecutive patients were enrolled. The OptoWire 2 or 3 generation fiberoptic pressure wire was used to assess whole cycle pressure distal/pressure aorta, dPR, and FFR. Our primary goal is to test if those measurements vary with the wire sensor placed at 10 mm (proximal), 35-45 mm (mid), and greater than or equal to 60-70 mm (distal) distal to the target lesion, respectively. We used a multilevel linear regression approach.

Results: Of 30 patients enrolled, 23 (76.6%) were males, mean age was 64.7 years (± 11.0 years), and mean stenosis was 61.6% (±13.4%). Adjusting for age, gender, and severity of stenosis, results showed that for all 3 measures (whole cycle pressure distal/pressure aorta, dPR, and FFR), pressure decreased in a linear fashion the further the sensor was from the target lesion ( P < 0.001). Further, pairwise comparisons of the measurements at adjacent locations similarly showed significant declines in pressure ( P < 0.001).

Conclusions: This is the first study to demonstrate that the location of the pressure wire can impact the results of both resting and hyperemic pressures, which can cause a false-negative result. This is especially important where the values are near the cutoff.

Introduction: With the current high burden on the healthcare system and limited resources, the efficient utilization of facilities is of utmost importance. We sought to present the practice guideline used at a high prevalence tertiary cardiology center and compare its safety and efficacy performance with the single high-sensitivity cardiac troponin T strategy, conventional and modified HEART score.

Methods: In this prospective cohort study, consecutive patients presenting to the emergency department with chest pain or an angina equivalent were recruited. The primary endpoints consisted of major adverse cardiac events at index visits and 30-day follow-up. Patients were managed according to the practice guideline, and sensitivity and negative predictive values were compared.

Results: Of the total 1548 patients, the mean age was 50.4 ± 15.7 years. Ninety-nine (10.9%) patients were admitted at the index visit, and 89 patients were consequently diagnosed with acute coronary symptoms. Six (0.007%) patients experienced major adverse cardiac events within the 30-day follow-up among discharged patients. Among 911 patients with at least 1 troponin, using single high-sensitivity cardiac troponin T, HEART score, and modified HEART score would have further admitted 805, 450, and 609 patients, respectively. The negative predictive value for all 4 algorithms did not significantly differ (99.2% vs. 100% vs. 99.3% vs. 99.6%, respectively).

Conclusions: The Tehran Herat Center protocol was a relatively safe protocol with high efficacy. Despite the high safety of the other diagnostic pathways, the high volume of patients needing additional evaluation could impose a high burden on the health care system.

Background: Distal trans-radial access (dTRA) is a novel technique of arterial cannulation in coronary interventions. The comparative efficacy of dTRA and conventional trans-radial access (TRA) in attenuating peri-procedural complications is unknown.

Methods: Embase and PubMed/MEDLINE were searched from their inception until June 25, 2022, for randomized clinical trials. Outcomes included were radial artery occlusion (RAO), radial artery spasm, hemostasis time, access time, unsuccessful cannulation, crossover rate, and early discharge after trans-radial stenting of coronary arteries (EASY) type I-III hematomas. Statistical analysis was conducted using the random effects model to derive risk ratios (RRs) and mean differences (MDs) with their corresponding 95% confidence intervals (CIs).

Results: A total of 6 randomized clinical trials comprising 3240 patients were included. Subjects were predominantly male (73%) and had a mean age of 66 years. The dTRA group had a lower risk of RAO [RR 0.43 (95% CI, 0.26-0.69); P = 0.0005; I 2 = 0%] and had a shorter hemostasis time [MD -22.85 min (95% CI, -39.06 to -6.65); P = 0.006; I 2 = 99%]. The dTRA group had a higher crossover rate [RR 3.04 (95% CI, 1.88-4.91); P = 0.00001; I 2 = 56%] and a longer access time [MD 0.68 min (95% CI, 0.17-1.18); P = 0.009; I 2 = 99%]. The TRA group had a lower rate of unsuccessful cannulation [RR 0.81 (95% CI, 0.70-0.95); P = 0.01; I 2 = 92%]. There was no significant difference between the groups for radial artery spasm and EASY type I-III hematomas.

Conclusion: dTRA is a safe alternative to conventional TRA for coronary interventions with a lower risk of RAO. Future trials are required to further compare both approaches.

Objective: To determine if health-related quality of life (HRQoL) improvement after cardiac resynchronization therapy (CRT) correlates with improved left-ventricular ejection fraction (EF).

Background: CRT was reported to improve EF and HRQoL in clinical trials of heart failure with reduced EF (HFrEF). It is unknown if improvements in HRQoL reflect EF response to CRT.

Methods: We included HFrEF patients who underwent CRT and had both pre- and post-CRT HRQoL assessment. EF response was categorized as absent (0% change or decrease), modest (0%-19% increase), or significant ( > 20% increase). We examined the associations between EF response and generic (PROMIS) and HF-specific (KCCQ-12) HRQoL.

Results: The group included 115 patients with mean age of 65 years and baseline EF of 31%; 39% were female (n = 45). Nineteen percent (n = 22) had significant, 57% (n = 66) modest, and 23% (n = 27) absent EF responses. AF burden across significant (8.9%), modest (4.8%), and absent EF responders (1.4%) was similar ( P = 0.20). Significant improvements in KCCQ-12 (43.4-57.5, P = 0.003), current health visual analog scale (49.1-55.9, P = 0.042), PROMIS fatigue (58.9-55.1, P = 0.026), and PROMIS satisfaction (42.7-46.4, P = 0.020) resulted following CRT across all groups. There was no association between significant EF improvement and HRQoL by KCCQ-12 (nonresponse, 44.4%; modest response, 33.3%; and significant response, 22.2%) at 1 year ( P = 0.52 across all groups).

Conclusion: CRT was associated with a modest to significant EF response in a majority of patients. However, EF response did not significantly correlate with generic or HF-specific HRQoL measures. Further investigations are warranted into determinants of improved HRQoL following CRT.

Cardiac rehabilitation following transcatheter aortic valve replacement (TAVR) is associated with improved outcomes; however, it remains relatively underutilized in this patient population. As part of a quality improvement initiative, we sought to increase the rate of cardiac rehabilitation referral after TAVR at our institution. We designed and implemented a multidisciplinary program that included education of cardiothoracic surgery providers discharging post-TAVR patients on the benefits of cardiac rehabilitation with participation of cardiac rehabilitation personnel during discharge rounds with the surgical team. The study period was defined as 12 months prior to and 6 months following the implementation of the education program. Overall referral rates increased from 5% to 56% ( P < 0.0001), and referrals placed before hospital discharge increased from 0.8% to 53% ( P < 0.0001) over the study period. In conclusion, a combination of education regarding the benefits of cardiac rehabilitation and cardiac rehabilitation personnel participation in discharge rounds significantly increased referral to cardiac rehabilitation after TAVR.