American Journal of Cardiology最新文献

Aortic dissection is the most common of the acute aortic syndromes. Acute aortic dissection remains a highly morbid and potentially lethal condition despite contemporary advances in medical and surgical care. Type B aortic dissection (TBAD) is classified as uncomplicated, uncomplicated with high-risk features, and complicated. The role of thoracic endovascular aortic repair (TEVAR) in uncomplicated TBAD remains uncertain and is the topic of ongoing clinical trials. In most complicated cases, TEVAR is effective at restoring visceral and extremity blood flow. TEVAR has also been shown to arrest hemorrhage in the setting of thoracic aortic rupture. TEVAR has been demonstrated to induce satisfactory remodeling in the covered segment of the thoracic aorta, but progressive enlargement of the visceral aorta has led to a variety of techniques designed to promote remodeling in the uncovered aortic segment. There is a need to better define high-risk features so that treatment can be tailored to specific clinical conditions.

Cardiac complications are the leading cause of morbidity and mortality in recipients of liver transplant (LT). Previous guidelines recommended stress testing to exclude coronary artery disease (CAD), although recent guidelines recommend coronary computed tomography angiography (CCTA). We aimed to assess the prevalence and predictors of CAD on CCTA and compare CCTA with stress testing in consecutive adult candidates for LT who underwent CAD noninvasive assessment between 2020 and 2023. Patients who underwent a stress test between January and December 2020 formed the stress cohort, and patients who underwent CCTA between January 2021 and September 2023 formed the CCTA cohort. There were 141 patients in the stress test cohort and 269 patients in the CCTA cohort. Stress test results were nondiagnostic or inconclusive in 18 patients (12.8%) whereas CCTA was nondiagnostic in 6 patients (2.2%). In patients evaluated with CCTA, mean coronary artery calcium (CAC) score was 332 ± 716 AU, with moderate or greater (>50%) stenosis in 33 patients (12.3%). New CAD was diagnosed in 158 patients (58.7%) using CCTA and in 5 patients (3.5%) using stress tests. Clinically actionable CAD (coronary artery calcium >100) on CCTA was present in 96 patients (35.7%). The number of CAD risk factors was associated with the presence of CAD on CCTA. In conclusion, there was a great burden of CAD, mainly nonobstructive, in a large cohort of candidates for LT who underwent CAD testing over a 4-year period. The current recommended risk-based evaluation of candidates for LT using CCTA as a first-line test was feasible and effective. Diagnosis of clinically actionable CAD on CCTA provides a vast opportunity for optimizing cardiac care in candidates for and recipients of LT.

Although there are established high-risk features in acute type B aortic dissection (TBAD), its management is variable. This study characterizes complicated, uncomplicated, and high-risk TBAD in addition to their management and outcomes to gain insight into the actual significance of these high-risk features and the reality of real-world practice in managing TBAD. A retrospective review of 62 patients was conducted. Patient demographics, management, and outcomes were characterized and evaluated with Pearson's χ² test, Fisher's exact test, or analysis of variance. Of the 32 high-risk TBADs, 66% (n = 21) received endovascular repair, 31% (n = 10) were medically managed, and 3% (n = 1) received hybrid (open and endovascular) repair. Refractory hypertension and pain (52%, n = 11) were the most common high-risk features in patients with high-risk TBAD who received endovascular repair. A maximum aortic diameter of >40 mm (67%, n = 6) was the most common high-risk feature in patients who received medical management. The most prevalent high-risk feature for all treatment groups in the high-risk TBADs was an aortic diameter of >40 mm (n = 16; 50%). Adverse postoperative outcomes were highest in the high-risk and complicated groups with endoleak as the most common adverse outcome (high-risk 12.9%, complicated 13.6%). Of the 62 patients, 47% (n = 26) had follow-up since their admission with an average follow-up time of 69 ± 166 days. The significance of high-risk features in the management of high-risk TBAD remains unclear. This single-center experience with managing acute TBAD reveals the reality of inadequate follow-up that may be specific to this disease process. This highlights a need to direct more efforts to assess long-term outcomes after treatment.

Frailty status is linked with a poorer clinical outcome, and patients with frailty are often less revascularized, even with percutaneous coronary intervention (PCI). We therefore sought to assess the impact of frailty on the clinical outcome of older patients with non-ST elevation acute myocardial infarction (NSTEMI) who underwent PCI. We prospectively enrolled 141 consecutive older patients (>75 years) admitted for NSTEMI; 104 patients underwent PCI (35 with frailty, 69 without frailty), and 37 were not revascularized (22 with frailty, 15 without). Patients with frailty were older, less frequently male, more affected by dementia and severe left ventricular dysfunction, and less treated with PCI; patients treated with PCI were younger and less affected by dementia. Thirty-day mortality rates were proportionally higher, from 3% in patients without frailty treated with PCI, to 7% in patients without frailty not treated with PCI, 17% in patients with frailty treated with PCI, and 48% in patients with frailty not treated with PCI (p <0.05). Similarly, 6-month mortality rates were proportionally higher (12%, 29%, 37%, and 71%). At multivariable analysis, frail status was associated to a sixfold increased risk of mortality at 30 days; at 6 months, frail status was associated to a 3.4-fold risk of death (p <0.01), but PCI was also associated to a lower risk of mortality (odds ratio 0.2, p <0.01). In an observational study in older patients with NSTEMI, frail status is associated to a poorer outcome, whereas PCI is associated to a better long-term outcome. A careful selection of patient suitable for revascularization by PCI may be useful in improving outcomes of older patients with frailty with NSTEMI.