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IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-03-03 DOI: 10.1016/S0002-8703(25)00064-X

引用次数: 0

Emergency department visits and hospitalizations after a diagnosis of angina with no obstructive coronary artery disease (ANOCA).

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-03-01 DOI: 10.1016/j.ahj.2025.02.021

Shubh Patel, Marinda Fung, Shuvam Prasai, Sonia Butalia, Todd J Anderson

Background: Angina with no obstructive coronary artery disease (ANOCA) presents diagnostic and treatment challenges, significantly burdening healthcare resources. This study assessed emergency department (ED) visits and hospitalizations and factors associated with these outcomes following ANOCA and stable angina (SA) with obstructive coronary artery disease (CAD) diagnoses.

Methods: A retrospective cohort of individuals who had their first invasive cardiac catheterization for chest pain in Alberta from 2002 to 2017 was extracted retrospectively from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Incidence rates (IRs) were calculated for ED visits and hospitalizations, while factors associated with these outcomes were analyzed using Cox models.

Results: Our analysis included 28,881 individuals (ANOCA, 36%). Two-year postcatheterization IRs of ED visits were 100.3-119.3 per 1,000 person-years for ANOCA and increased over time (unstandardized beta coefficient [b] = 2.19 per biennium [95% CI 0.83-3.55]; P = .008); for SA with obstructive CAD the IRs were 209.3-240.2 per 1,000 person-years and remained stable (b = -1.83 per biennium [95% CI -5.73 to 1.70]; P = .25). IRs of hospitalizations were 12.4-25.8 per 1,000 person-years and stable for ANOCA (b = -0.93 per biennium [95% CI -2.49 to 0.64]; P = .20); for SA with obstructive CAD, they were 106.4-171.4 per 1,000 person-years and decreased over time (b = -9.02 per biennium [95% CI -13.27 to -4.77; P = .002). A previous history of heart failure was most associated with ED visits (HR = 1.74 [95% CI 1.41-2.14]; P < .001) and hospitalizations (HR = 2.40 [95% CI 1.82-3.18]; P < .001) for ANOCA.

Conclusions: ED visits for ANOCA have risen over time while hospitalizations remain stable, indicating a growing burden despite generally lower rates than SA with obstructive CAD. These findings underscore the need for more effective management strategies to address the significant morbidity and resource utilization in ANOCA.

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引用次数: 0

Clinical outcomes of direct oral anticoagulant versus warfarin after transcatheter aortic valve replacement: From the STS/ACC TVT registry

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-26 DOI: 10.1016/j.ahj.2025.02.019

Tomo Ando MD , Tamim Nazif MD , Alexandros Briasoulis MD, PhD , Luis Afonso MD , Amanda Stebbins PhD , Guillaume Marquis-Gravel MD , Andrzei S. Kosinski PhD , Martin Leon MD , Sreekanth Vemulapalli MD

Background

Transcatheter aortic valve replacement (TAVR) recipients frequently have an indication for long-term oral anticoagulation, including atrial fibrillation or systemic thromboembolic disease. It remains unclear if there are differences in safety and effectiveness between direct oral anticoagulants (DOAC) and warfarin in this patient population.

Methods

Clinical outcomes were compared between TAVR recipients receiving DOACs or warfarin using data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) registry linked with Centers for Medicare & Medicaid Services claims data. The analysis included patients from the TVT registry who underwent successful TAVR and were discharged on either a DOAC or warfarin between January 2013 and May 2018. The primary outcome was any bleeding requiring hospitalization from discharge to 1 year. Secondary outcomes included all-cause mortality and stroke from discharge to 1 year. Multivariable Cox proportional hazards regression models were used to compare these outcomes between the 2 groups.

Results

A total of 29,142 patients underwent TAVR and were discharged on oral anticoagulation, among whom 10,973 (37.7%) were discharged on a DOAC. The use of DOACs increased throughout the study period and exceed the use of warfarin by the final year (2018). The cumulative incidence of bleeding requiring hospitalization at 1 year (11.8% vs 15.2%, P < .001) and all-cause mortality (15.5% vs 17.5%, P < .001) was significantly lower in DOAC group while stroke (2.47% vs 2.39%, P = .64) was not statistically different between groups. In an adjusted model, the use of a DOAC as opposed to warfarin was associated with a significantly lower risk of bleeding requiring hospitalization (adjusted hazard ratio 0.49, 95% confidence interval 0.43-0.56), all-cause mortality (adjusted hazard ratio 0.61, 95% confidence interval 0.57-0.66), and stroke (adjusted hazard ratio 0.86, 95% confidence interval 0.81-0.92) (all P < .001).

Conclusions

In this analysis of TAVR recipients discharged on oral anticoagulation in a large U.S. registry, the use of a DOAC rather than warfarin was associated with a lower risk of bleeding requiring hospitalization, all-cause mortality, and stroke from discharge to 1 year. Future randomized studies will be necessary to establish the optimal choice of anticoagulant in TAVR patients.

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引用次数: 0

High-risk features and probability of ischemic and bleeding events after percutaneous coronary intervention. 高风险特征与经皮冠状动脉介入治疗后发生缺血和出血事件的概率。

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-26 DOI: 10.1016/j.ahj.2025.02.018

Johann Auer, Gudrun Lamm

引用次数: 0

Genotype-guided de-escalation and abbreviation of dual antiplatelet therapy in patients with myocardial infarction and high bleeding risk: Design and rationale of the investigator-initiated, multicenter, randomized, controlled trial, DAN-DAPT

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-26 DOI: 10.1016/j.ahj.2025.02.020

Mia Ravn Jacobsen MD , Reza Jabbari MD, PhD , Erik Lerkevang Grove MD, PhD , Michael Mæng MD, PhD, DMSC , Karsten Veien MD , Mikkel Hougaard MD, PhD , Philip Freeman MB, BS, PhD , Henning Kelbæk MD, DMSC , Mette Gitz Charlot MD, PhD , Thomas Engstrøm MD, PhD, DMSC , Rikke Sørensen MD, PhD

Rationale

Approximately one-third of patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) are at high risk of bleeding side-effects when on dual antiplatelet therapy (DAPT). High bleeding risk is often accompanied by high ischemic risk, thus challenging the choice of P2Y₁₂ inhibitor and duration of DAPT. The optimal DAPT strategy for these patients remains debated, and it is unknown whether genotype-guided DAPT de-escalation to clopidogrel and aspirin, with or without abbreviation of DAPT to 3 months, is noninferior in terms of net adverse clinical events (NACE) and superior in reducing bleeding side-effects compared with standard DAPT for 6 months.

Design

The DAN-DAPT trial is an investigator-initiated, open-label, multicenter, multiarm, randomized controlled trial conducted at all Danish hospitals performing PCI. From 2022 to 2029, we planned to randomize 2,700 patients with MI and high bleeding risk in a 1:1:1 ratio to 1 of 3 groups: CYP2C19-genotyping and 6 months DAPT (experimental group 1), CYP2C19-genotyping and 3 months DAPT (experimental group 2), and 6 months DAPT with prasugrel (or ticagrelor) and aspirin (control group). The coprimary outcomes are NACE defined as the composite of all-cause mortality, recurrent MI, definite stent thrombosis, stroke, and BARC type 3-5 bleeding (Bleeding Academic Research Consortium), and major and minor bleedings defined as the composite of BARC type 2-5 bleedings at 1 year.

Conclusion

DAN-DAPT trial is an open-label, multicenter, randomized controlled trial comparing genotype-guided DAPT de-escalation to clopidogrel - with or without DAPT abbreviation to 3 months - and standard DAPT for 6 months after PCI in high bleeding risk patients with MI. As of March 2025, 36% of the planned 2,700 patients have been enrolled in the study.

Trial Registration

ClincialTrials.gov (NCT05262803) and EU number (2022-500125-32-00).

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引用次数: 0

Rationale and design of the women's ischemia syndrome evaluation mechanisms of coronary microvascular dysfunction leading to preheart failure with preserved ejection fraction (WISE Pre-HFPEF)

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-24 DOI: 10.1016/j.ahj.2025.02.017

Tatsunori Takahashi MD , Janet Wei MD , Ana C. Iribarren MD , Martha Gulati MD MS , Galen Cook-Wiens MS , Michael D. Nelson PhD , Behzad Sharif PhD , Eileen M. Handberg PhD , R. David Anderson MD , John Petersen MD , Daniel S. Berman MD , Carl J. Pepine MD , C. Noel Bairey Merz MD

Background

There is increasing recognition that the pathophysiology of coronary microvascular dysfunction (CMD) plays a pivotal role in the development of heart failure with preserved ejection fraction (HFpEF). However, the mechanisms underlying this role are not known.

Study design and methods

The Women's Ischemia Syndrome Evaluation Mechanisms of Coronary Microvascular Dysfunction Leading to Pre-Heart Failure With Preserved Ejection Fraction (WISE Pre-HFpEF) is a prospective cohort study enrolling 180 women and men undergoing clinically indicated invasive coronary angiography for suspected ischemia with no obstructive coronary artery disease. The study aims to investigate (1) CMD-related ischemia contribution to myocellular damage and impaired left ventricular (LV) relaxation as determined invasively by ultra-high sensitivity cardiac troponin I (u-hs-cTnI) measurements in the coronary sinus/great cardiac vein and LV pressure-volume loops, respectively, during provocative stress testing with isometric handgrip, and (2) CMD-related ischemic myocellular damage contribution to LV diastolic dysfunction progression as assessed using cardiac magnetic resonance imaging obtained at enrollment and 1-2 years later, along with prospectively repeated ambulatory u-hs-cTnI measurements.

Conclusions

The WISE pre-HFpEF study is designed to investigate whether ischemic myocardial damage secondary to CMD contributes to the progression of LV diastolic dysfunction. The findings from this study will provide new understanding of the role of CMD in HFpEF development as well as the potential benefits of CMD-directed therapies for the prevention and treatment of HFpEF.

Trial registration

ClilicalTrial.gov, NCT03876223

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引用次数: 0

Re-engineering the clinical approach to suspected cardiac chest pain assessment in the emergency department by expediting research evidence to practice using artficial intelligence. (RAPIDx AI) - a cluster randomised study design.

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-22 DOI: 10.1016/j.ahj.2025.02.016

Ehsan Khan, Kristina Lambrakis, Tom Briffa, Louise A Cullen, Jonathon Karnon, Cynthia Papendick, Stephen Quinn, Phil Tideman, Anton Van Den Hengel, Johan Verjans, Derek P Chew

Background: Clinical work-up for suspected cardiac chest pain is resource intensive. Despite expectations, high-sensitivity cardiac troponin assays have not made decision making easier. The impact of recently validated rapid triage protocols including the 0-hour/1-hour hs-cTn protocols on care and outcomes may be limited by the heterogeneity in interpretation of troponin profiles by clinicians. We have developed machine learning (ML) models which digitally phenotype myocardial injury and infarction with a high predictive performance and provide accurate risk assessment among patients presenting to EDs with suspected cardiac symptoms. The use of these models may support clinical decision-making and allow the synthesis of an evidence base particularly in non-T1MI patients however prospective validation is required.

Objective: We propose that integrating validated real-time artificial intelligence (AI) methods into clinical care may better support clinical decision-making and establish the foundation for a self-learning health system.

Design: This prospective, multi-centre, open-label, cluster-randomised clinical trial within blinded endpoint adjudication across 12 hospitals (n=20,000) will randomise sites to the clinical decision-support tool or continue current standard of care. The clinical decision support tool will utilise ML models to provide objective patient-specific diagnostic probabilities (i.e. likelihood for Type 1 myocardial infarction [MI] versus Type 2 MI/Acute Myocardial Injury versus Chronic Myocardial Injury etc.) and prognostic assessments. The primary outcome is the composite of cardiovascular mortality, new or recurrent MI and unplanned hospital re-admission at 12 months post index presentation.

Summary: Supporting clinicians with a decision support tool that utilises AI has the potential to provide better diagnostic and prognostic assessment thereby improving clinical efficiency and establish a self-learning health system continually improving risk assessment, quality and safety.

Trial registration: ANZCTR, Registration Number: ACTRN12620001319965, https://www.anzctr.org.au/.

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引用次数: 0

Effects of carvedilol on the prevention of cardiotoxicity induced by anthracyclines: Design and rationale of the CARDIOTOX trial

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-22 DOI: 10.1016/j.ahj.2025.02.014

Isabela Bispo Santos da Silva Costa MD, PhD , Remo H.M. Furtado MD, PhD , Luciano F. Drager MD, PhD , Pedro Gabriel Melo de Barros e Silva MD, PhD , Marcelo Dantas Tavares de Melo MD, PHD , Paula Araruna MD , Bruno C. Bacchiega MD , Sanderson Cauduro MD , Edilson Walter MD , Guilherme Loureiro Fialho MD, PhD , Odilson Silvestre MD, PhD, MPH , Lucas P. Damiani PhD , Lilian M. Barbosa MSc, MBA , Mariane Nascimento Luz Bsc , Ana Cecilia Alcantara Silva Bsc , Renata Rodrigues de Mattos MBA , Roberta Saretta MD , Marilia Harumi H.S. Rehder MD, PhD , Ludhmila Abrahao Hajjar MD, PhD , Teresa Lopes-Fernandez MD , Roberto Kalil Filho MD, PhD

Background

Patients with cancer undergoing chemotherapy with an anthracycline-based regimen are at increased risk of cardiotoxicity, predisposing to heart failure, arrhythmias and death. Whether carvedilol may confer benefit to prevent anthracycline-induced cardiotoxicity remains to be determined.

Design

CARDIOTOX is a double-blind, placebo controlled randomized clinical trial that plan to enroll 1,018 patients across 25 study sites in Brazil. Patients with active cancer scheduled to undergo an anthracycline-based chemotherapy regimen are eligible. Patients with prior HF or cardiomyopathy are excluded. Patients are randomized in 1:1 ratio to carvedilol (starting dose 6.25mg BID up titrated to 25mg BID or maximum tolerated dose) or placebo, stratified by site and use of renin-angiotensin blockers at baseline. Study drug is administered through the duration of chemotherapy and up to 30 days after the last dose of anthracycline. Patients are scheduled to undergo echocardiographic evaluations at baseline and at 3, 6, and 12 months. The study primary endpoint is the composite of new left ventricle ejection fraction (LVEF) reduction by at least 10% leading to an LVEF <50%, cardiovascular death, myocardial infarction, urgent care visit or hospitalization for heart failure, or clinically significant arrhythmias at 12 months. Echocardiographic images will be analyzed by a central core lab, clinical outcomes will be adjudicated, and safety endpoints include serious adverse events and adverse events of special interest (symptomatic bradycardia, hypotension, syncope and bronchospasm).

Summary

The CARDIOTOX trial is the largest trial to date analyzing the potential role of beta-blockers as prophylactic therapy to prevent cardiotoxicity induced by anthracyclines.

Trial Registration

Effects of Carvedilol on Cardiotoxicity in Cancer Patients Submitted to Anthracycline Therapy (CardioTox). ClinicalTrials.gov ID NCT04939883. https://clinicaltrials.gov/study/NCT04939883

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引用次数: 0

Reminders embedded in PCI reports to optimize discharge diabetes mellitus care (REMIND-DM): Rationale, design, and baseline characteristics

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-21 DOI: 10.1016/j.ahj.2025.01.020

Safia Chatur MD , Milan Seth MS , Mary Casey MPA , Michael P Thompson PhD, MPH , M. Imran Qureshi MD , Vishal Gupta MD , Mansoor Qureshi MD , Bashar Samman MD , Annemarie Forest MS, MPH , Hitinder S Gurm MD , Devraj Sukul MD, MSc , Muthiah Vaduganathan MD MPH

Background

Despite the robust clinical evidence base supporting their role for high-risk patients with type 2 diabetes (T2DM) and concomitant cardiovascular disease, prescription of sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) remains suboptimal. Clinical encounters occurring in the period post angiography may present a key opportunity to improve implementation in high-risk patients with T2DM.

Methods

Reminders EMbedded IN PCI Reports to Optimize Discharge Diabetes Mellitus Care (REMIND-DM) is a pragmatic, prospective, cluster randomized quality improvement study in patients with type 2 diabetes undergoing angiography and was run as a quality improvement initiative. Following a 6 month “baseline period”, REMIND-DM randomized 23 participating percutaneous coronary intervention (PCI) sites (caring for 7,045 patients over the study period) within the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) quality improvement collaborative to either usual care or a quality improvement intervention consisting of a templated PCI report “reminder” of medication eligibility linked to a decision support tool. Sites were followed for a 6 month “evaluation period.” The primary outcome is the new prescription of SGLT2 inhibitor or GLP-1RA among eligible patients at discharge after PCI. To examine the effectiveness of the intervention, primary analyses will be conducted using a difference-in-difference design examining changes in new cardioprotective therapy prescription from baseline to the evaluation periods in both arms.

Conclusions

The REMIND-DM implementation trial has enrolled a large, high-risk population of patients with T2DM and will determine the effectiveness of a low touch QI intervention within BMC2 implemented in the post-PCI period to improve timely prescription of risk lowering therapies in high-risk patients with T2DM.

{"title":"Reminders embedded in PCI reports to optimize discharge diabetes mellitus care (REMIND-DM): Rationale, design, and baseline characteristics","authors":"Safia Chatur MD , Milan Seth MS , Mary Casey MPA , Michael P Thompson PhD, MPH , M. Imran Qureshi MD , Vishal Gupta MD , Mansoor Qureshi MD , Bashar Samman MD , Annemarie Forest MS, MPH , Hitinder S Gurm MD , Devraj Sukul MD, MSc , Muthiah Vaduganathan MD MPH","doi":"10.1016/j.ahj.2025.01.020","DOIUrl":"10.1016/j.ahj.2025.01.020","url":null,"abstract":"<div><h3>Background</h3><div>Despite the robust clinical evidence base supporting their role for high-risk patients with type 2 diabetes (T2DM) and concomitant cardiovascular disease, prescription of sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) remains suboptimal. Clinical encounters occurring in the period post angiography may present a key opportunity to improve implementation in high-risk patients with T2DM.</div></div><div><h3>Methods</h3><div><em>R</em>eminders <em>EM</em>bedded <em>IN</em> PCI Reports to Optimize Discharge <em>D</em>iabetes <em>M</em>ellitus Care (REMIND-DM) is a pragmatic, prospective, cluster randomized quality improvement study in patients with type 2 diabetes undergoing angiography and was run as a quality improvement initiative. Following a 6 month “baseline period”, REMIND-DM randomized 23 participating percutaneous coronary intervention (PCI) sites (caring for 7,045 patients over the study period) within the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) quality improvement collaborative to either usual care or a quality improvement intervention consisting of a templated PCI report “reminder” of medication eligibility linked to a decision support tool. Sites were followed for a 6 month “evaluation period.” The primary outcome is the new prescription of SGLT2 inhibitor or GLP-1RA among eligible patients at discharge after PCI. To examine the effectiveness of the intervention, primary analyses will be conducted using a difference-in-difference design examining changes in new cardioprotective therapy prescription from baseline to the evaluation periods in both arms.</div></div><div><h3>Conclusions</h3><div>The REMIND-DM implementation trial has enrolled a large, high-risk population of patients with T2DM and will determine the effectiveness of a low touch QI intervention within BMC2 implemented in the post-PCI period to improve timely prescription of risk lowering therapies in high-risk patients with T2DM.</div></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":"285 ","pages":"Pages 12-20"},"PeriodicalIF":3.7,"publicationDate":"2025-02-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143482116","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Information for Readers

IF 3.7 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

American heart journal

Pub Date : 2025-02-21 DOI: 10.1016/S0002-8703(25)00051-1

引用次数: 0