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Barry AR, Helisaz H, Safari A, Loewen P. Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers After Coronary Artery Bypass Graft Surgery: A Population-Based Cohort Study. J Am Heart Assoc 2024:e035215. [PMID: 38842283 DOI: 10.1161/jaha.124.035215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/02/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The effect of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) on major adverse cardiovascular events (MACE) in patients who undergo coronary artery bypass graft surgery is equivocal. This retrospective, population-based cohort study evaluated effect of exposure to an ACEI/ARB on MACE using linked administrative databases that included all cardiac revascularization procedures, hospitalizations, and prescriptions for the population of British Columbia, Canada. METHODS AND RESULTS All adults who underwent coronary artery bypass graft surgery between 2002 and 2020 were eligible. The primary outcome was time to MACE, defined as a composite of all-cause death, myocardial infarction, and ischemic stroke using Cox proportional hazards models with inverse probability treatment weighting. Included were 15 439 patients and 6191 (40%) were prescribed an ACEI/ARB. Mean age was 66 years, 83% were men, and 16% had heart failure (HF). Median exposure time was 40 months. Over the 5-year follow-up, 1623 MACE occurred. Impact of exposure was different for patients with and without HF (P <0.0001 for interaction). After probability-weighting and adjustment for relevant covariates, exposure to ACEI/ARBs was associated with a lower hazard of MACE in patients with HF at 1 year (hazard ratio, 0.13 [95% CI, 0.09-0.19]) and 5 years (hazard ratio, 0.36 [95% CI, 0.30-0.44]). In patients without HF, ACEI/ARBs had a lower hazard of MACE at 1 year (hazard ratio, 0.35 [95% CI, 0.27-0.46]) and 5 years (hazard ratio, 0.66 [95% CI, 0.58-0.76]). CONCLUSIONS In this population-based study, ACEI/ARBs were associated with a lower hazard of MACE in a cohort of patients post-coronary artery bypass graft surgery irrespective of HF status.
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Affiliation(s)
- Arden R Barry
- Faculty of Pharmaceutical Sciences The University of British Columbia Vancouver British Columbia Canada
- Jim Pattison Outpatient Care and Surgery Centre Lower Mainland Pharmacy Services Surrey British Columbia Canada
| | - Hamed Helisaz
- GranTAZ Consulting Vancouver British Columbia Canada
- Faculty of Applied Science The University of British Columbia Vancouver British Columbia Canada
| | - Abdollah Safari
- GranTAZ Consulting Vancouver British Columbia Canada
- School of Mathematics, Statistics and Computer Science, College of Science University of Tehran Tehran Iran
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences The University of British Columbia Vancouver British Columbia Canada
- Centre for Cardiovascular Innovation The University of British Columbia Vancouver British Columbia Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences The University of British Columbia Vancouver British Columbia Canada
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Settelmeier S, Steven S, Post F, Ahrens I, Giannitsis E, Breuckmann F. New categorization of chest pain: noncardiac is in, atypical is out! Herz 2024; 49:181-184. [PMID: 38427126 DOI: 10.1007/s00059-024-05240-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/02/2024]
Abstract
Chest pain poses a diagnostic challenge in the emergency department and requires a thorough clinical assessment. The traditional distinction between "atypical" and "typical" chest pain carries the risk of not addressing nonischemic clinical pictures. The newly conceived subdivision into cardiac, possibly cardiac, and (probably) noncardiac causes of the presenting symptom complex addresses a much more interdisciplinary approach to a symptom-oriented diagnostic algorithm. The diagnostic structures of the chest pain units in Germany do not currently reflect this. An adaptation should therefore be considered.
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Affiliation(s)
- Stephan Settelmeier
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Sebastian Steven
- Med. Klinik III-Department for Cardiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Felix Post
- Internal Medicine, General and interventional Cardiology, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany
| | - Ingo Ahrens
- Krankenhaus der Augustinerinnen, Department for Cardiology and Intensive Care Medicine, Jakobstr. 27-31, 50678, Köln, Germany
| | - Evangelos Giannitsis
- Department for Internal Medicine III, Cardiology, Vascular Medicine and Pneumology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Frank Breuckmann
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Hufelandstr. 55, 45147, Essen, Germany.
- Cardiology, Pneumology, Neurology and Intensive Care Medicine, Klinik Kitzinger Land, Keltenstr. 67, 97318, Kitzingen, Germany.
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Law TM, Wohlfarth KM. Comparison of Heart Rates in Patients Initiated on Ticagrelor Versus Other P2Y12 Inhibitors After an Inferior ST Elevation Myocardial Infarction (STEMI). Ann Pharmacother 2024:10600280241255111. [PMID: 38816988 DOI: 10.1177/10600280241255111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND P2Y12 inhibitors have differing associations of bradyarrhythmias. Ticagrelor has been shown to increase adenosine plasma concentrations leading to increases in bradyarrhythmias. While clopidogrel and prasugrel have not been shown to have any association with bradyarrhythmias. OBJECTIVE The objective of this study was to determine heart rates after ticagrelor initiation compared to clopidogrel/prasugrel in inferior ST Elevation Myocardial Infarction (STEMI) patients. METHODS This was a retrospective, multicenter study conducted at 3 primary percutaneous coronary intervention (PCI) centers between January 1, 2017 and September 30, 2022. Adult patients were included if they were diagnosed with an inferior STEMI to the right coronary artery (RCA) and treated with PCI followed by an oral P2Y12 inhibitor. The primary outcome was heart rate at 48 hours or discharge, whichever first, after administration of ticagrelor compared to clopidogrel/prasugrel. RESULTS This study reviewed 331 patients, 172 in the ticagrelor group and 159 in the clopidogrel/prasugrel group. There were no statistical differences between groups regarding the primary outcome, with a median heart rate of 76 beats per minute (bpm) [67-85] in the ticagrelor group versus 73 bpm [66-84] in the clopidogrel/prasugrel group (P = 0.238). No differences were observed between groups regarding any secondary outcomes. CONCLUSION AND RELEVANCE There were similar heart rates between ticagrelor and clopidogrel/prasugrel. There were also similarities in the ability to tolerate beta-blocker therapy after initiation of a P2Y12 inhibitor. The results of this study suggest that in inferior STEMIs when using ticagrelor as the P2Y12 inhibitor, there are not increased clinical manifestations of bradycardia.
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Affiliation(s)
- Taylor M Law
- Department of Pharmacy, The University of Tennessee Medical Center, Knoxville, TN, USA
| | - Kevin M Wohlfarth
- Department of Pharmacy, ProMedica Toledo Hospital and Russell J. Ebeid Children's Hospital, Toledo, OH, USA
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Liu J, Peer SB, Sheth SS, Loor G. Restoration of Epicardial Blood Flow After Left Ventricular Unloading With the Impella CP Heart Pump in a Patient With STEMI Treated With Surgical Revascularization. Tex Heart Inst J 2024; 51:e238322. [PMID: 38805372 PMCID: PMC11134273 DOI: 10.14503/thij-23-8322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Left main occlusion presenting as ST-segment elevation myocardial infarction is an exceedingly morbid condition. This article reports a case of cardiac arrest in a patient after a treadmill stress test. Coronary angiography revealed 100% occlusion of the left main coronary artery. Left ventricular unloading with the Impella CP heart pump (ABIOMED/Johnson & Johnson MedTech) was used, after which epicardial blood flow was restored without angioplasty. The patient underwent surgical revascularization. Despite a prolonged revascularization time, there was no evidence of severe myocardial injury postoperatively.
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Affiliation(s)
- Jason Liu
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Syed B. Peer
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Samar S. Sheth
- Department of Cardiology, Baylor St Luke's Medical Center, Houston, Texas
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Kayser LE, Spolsdoff DE, Vakkalanka JP, Hoefer TJ, Walker CA, Georgakakos PK. Assessing Efficiency in a Static-Based 911 Ambulance Service: An Analysis of Operational Performance Metrics. PREHOSP EMERG CARE 2024:1-8. [PMID: 38805385 DOI: 10.1080/10903127.2024.2360672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/28/2024] [Indexed: 05/30/2024]
Abstract
Objectives: This study sought to evaluate performance indicators to assist a static-based 911 agency in defining its response efficiency.Methods: Initial assessment of three metrics - unit hour utilization (UHU), fractile response intervals, and level 0 frequency (occurrence when no ambulances are available to respond)- suggested the agency's response over its four coverage zones was inefficient, so an operational change was implemented: an ambulance was relocated from one service area to another to improve the overall response productivity. A two-year retrospective analysis was performed to determine the impact ambulance relocation had on the three targeted measurements.Results: The operational change resulted in a statistically significant change in unit hour utilization, a non-significant increase in fractile response intervals, and a statistically significant reduction in level 0 frequency from pre- to post-operational change times.Conclusions: These findings suggest a way to evaluate the efficiency of static-based ambulance deployment and potentially identify strategies for redeployment.
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Affiliation(s)
- Luke E Kayser
- Johnson County Ambulance Service, 808 S Dubuque St, Iowa City, IA 52240
| | - Devin E Spolsdoff
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242
- Department of Epidemiology, University of Iowa College of Public Health, 145 N Riverside Dr, Iowa City, IA 52242
| | - Talon J Hoefer
- Johnson County Ambulance Service, 808 S Dubuque St, Iowa City, IA 52240
| | - Curtis A Walker
- Johnson County Ambulance Service, 808 S Dubuque St, Iowa City, IA 52240
| | - Peter K Georgakakos
- Johnson County Ambulance Service, 808 S Dubuque St, Iowa City, IA 52240
- Department of Emergency Medicine, Division of EMS, University of Iowa Carver College of Medicine, 200 Hawkins Dr, Iowa City, IA 52242
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Liu C, Zhang H, Yang L, Chen L, Zu C, Wang F, Dai Y, Zhao H. Knowledge and attitude toward postoperative antithrombotic management and prevention in patients with coronary revascularization: a cross-sectional study. Front Cardiovasc Med 2024; 11:1388164. [PMID: 38826816 PMCID: PMC11140389 DOI: 10.3389/fcvm.2024.1388164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/08/2024] [Indexed: 06/04/2024] Open
Abstract
Background This study aimed to explore the knowledge and attitude (KA) toward postoperative antithrombotic management and prevention among coronary artery disease (CAD) patients who underwent coronary revascularization. Methods This cross-sectional study enrolled CAD outpatients and inpatients between May and December 2023 at Kailuan Medical Group at Tangshan. Basic demographic characteristics and KA scores were collected through a self-made questionnaire. Results This study included 523 valid questionnaires. The mean knowledge and attitude scores were 13.20 ± 6.20 (range: 0-26) and 43.68 ± 6.01 (range: 21-50), respectively, indicating poor knowledge and favorable attitude. Multivariable logistic regression analysis showed that junior high school education (OR = 2.160, P = 0.035), high school or technical school education (OR = 2.356, P = 0.039), and monthly average income >5,000 RMB (OR = 3.407, P = 0.002) were independently associated with knowledge. Knowledge (OR = 1.095, P = 0.002), BMI ≥ 24.0 kg/m2 (OR = 0.372, P = 0.011), junior high school (OR = 3.699, P = 0.002), high school or technical school (OR = 2.903, P = 0.028), high associate degree or above education (OR = 6.068, P = 0.014), monthly average income 3,000-5,000 RMB (OR = 0.296, P = 0.005), monthly average income > 5,000 RMB (OR = 0.225, P = 0.021), with hypertension (OR = 0.333, P = 0.003), blood tests every 2-3 weeks (OR = 10.811, P = 0.011), blood tests every month (OR = 4.221, P = 0.024), and blood tests every 2-3 months (OR = 3.342, P = 0.033) were independently associated with attitude. Conclusion CAD patients who underwent coronary revascularization had poor knowledge but favorable attitudes toward postoperative antithrombotic management and prevention. The study underscores the need for targeted education, especially for individuals with lower education and income levels, ultimately improving patient compliance and cardiovascular outcomes.
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Affiliation(s)
- Chunlu Liu
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Haijun Zhang
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Liming Yang
- Department of Cardiology, Tangshan Gongren Hospital, Tangshan, China
| | - Lihua Chen
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Changhao Zu
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Fangfang Wang
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Yunjia Dai
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Haiyan Zhao
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
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Clay S, Blankenship JC. Left Ventricular Thrombus After Myocardial Infarction: Opinions and Equipoise. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07572-2. [PMID: 38709455 DOI: 10.1007/s10557-024-07572-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Shannon Clay
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - James C Blankenship
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
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Zheng X, Wu H, Zhang M, Yao B. Clinical significance of R-wave amplitude in lead V 1 and inferobasal myocardial infarction in patients with inferior wall myocardial infarction. Ann Noninvasive Electrocardiol 2024; 29:e13114. [PMID: 38563240 PMCID: PMC10985631 DOI: 10.1111/anec.13114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 02/10/2024] [Accepted: 03/24/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE To assess electrocardiogram (ECG) for risk stratification in inferior ST-elevation myocardial infarction (STEMI) patients within 24 h. METHODS Three hundred thirty-four patients were divided into four ECG-based groups: Group A: R V1 <0.3 mV with ST-segment elevation (ST↑) V7-V9, Group B: R V1 <0.3 mV without ST↑ V7-V9, Group C: R V1 ≥0.3 mV with ST↑ V7-V9, and Group D: R V1 ≥0.3 mV without ST↑ V7-V9. RESULTS Group A demonstrated the longest QRS duration, followed by Groups B, C, and D. ECG signs for right ventricle (RV) infarction were more common in Groups A and B (p < .01). ST elevation in V6, indicative of left ventricle (LV) lateral injury, was more higher in Group C than in Group A, while the ∑ST↑ V3R + V4R + V5R, representing RV infarction, showed the opposite trend (p < .05). The estimated LV infarct size from ECG was similar between Groups A and C, yet Group A had higher creatine kinase MB isoform (CK-MB; p < .05). Cardiac troponin I (cTNI) was higher in Groups A and C than in B and D (p < .05 and p = .16, respectively). NT-proBNP decreased across groups (p = .20), with the highest left ventricular ejection fraction (LVEF) observed in Group D (p < .05). Group A notably demonstrated more cardiac dysfunction within 4 h post-onset. CONCLUSIONS For inferior STEMI patients, concurrent R V1 <0.3 mV with ST↑ V7-V9 suggests prolonged ventricular activation and notable myocardial damage. RV infarction's dominance over LV lateral injury might explain these observations.
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Affiliation(s)
- Xiao‐Bin Zheng
- Department of CardiologyShanxi Cardiovascular HospitalTaiyuanChina
| | - Hai‐Yan Wu
- Department of CardiologyShanxi Cardiovascular HospitalTaiyuanChina
| | - Ming Zhang
- Department of CardiologyShanxi Cardiovascular HospitalTaiyuanChina
| | - Bing‐Qi Yao
- Department of CardiologyShanxi Cardiovascular HospitalTaiyuanChina
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Feldman M, Bahaidarah F, Rahimi M, Howaidi S, Turner L, Verbeek PR, Cantor W, Cheskes S, Drennan I, Gilmartin K. Safety and Adverse Events During Primary Care Paramedic Interfacility Transfer of Stable STEMI Patients. PREHOSP EMERG CARE 2024:1-6. [PMID: 38619868 DOI: 10.1080/10903127.2024.2342569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/17/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Current guidelines recommend that patients presenting with ST-elevation myocardial infarction (STEMI) to hospitals not capable of performing primary percutaneous coronary intervention (PCI) be transferred to a PCI-capable hospital if reperfusion can be accomplished within 120 min. Most STEMI patients are accompanied by an advanced care paramedic (ACP, equivalent to EMT-P), nurse, or physician who can manage complications should they arise. In our region, stable STEMI patients are transported by primary care paramedics (PCPs, similar scope of practice to advanced EMT) in cases where a nurse, physician, or ACP paramedic is not available. Our goal was to describe adverse events and need for advanced interventions among initially stable STEMI patients during interfacility transfer by PCPs. METHODS We reviewed ambulance and hospital records of initially stable STEMI patients (as determined by first set of vital signs documented by paramedics) transferred to a PCI-capable hospital by PCPs between March 1, 2014, and December 31, 2019. We identified whether pre-determined adverse clinical events occurred during the transport as well as the potential need for advanced care interventions not within the PCP scope of practice. Adverse events upon arrival in the PCI lab were also identified. RESULTS Of 346 STEMI patients transferred, 179 met inclusion criteria. The mean age of included patients was 61 years (SD 12.1) and 74.9% (134/179) were male. Median transport interval was 36 min (IQR 3.0). During transport, 47/179 (26.0%) patients experienced pre-defined adverse events; for 16/47 (34%), one or more adverse events was major. Three patients met criteria for ACP interventions. One patient suffered a cardiac arrest and was promptly resuscitated with defibrillation by the PCPs. CONCLUSIONS We found PCP-interfacility transport of initially stable STEMI patients was safe and associated with a moderate proportion of adverse events, the majority of which did not require an advanced care intervention. These findings may help decision-making to avoid delays transferring stable patients to PCI-capable centers.
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Affiliation(s)
- Michael Feldman
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- County of Simcoe Paramedic Services, Midhurst, Ontario, Canada
- Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Fahad Bahaidarah
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mahbod Rahimi
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sara Howaidi
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Linda Turner
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - P Richard Verbeek
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Warren Cantor
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Sheldon Cheskes
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Ian Drennan
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Feng S, Wang S, Tang J, Zhu X. Ultrasound Combined With Continuous Microbubble Injection to Enhance Catheter-Directed Thrombolysis in Vitro and in Vivo. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:741-749. [PMID: 38158852 DOI: 10.1002/jum.16400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 11/23/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To investigate the influence of microbubble perfusion mode on catheter-directed thrombolysis (CDT), we evaluated the effect of two different types of microbubble perfusion modes (continuous injection versus bolus injection) on the thrombolytic efficacy of CDT in vitro and further assessed the effect of continuous microbubble injection on CDT in vivo. METHODS In an in vitro experimental setup, 50 fresh bovine whole blood clots were randomized into five groups: ultrasound and continuous microbubble injection-enhanced CDT (US + cMB + CDT), ultrasound and bolus microbubble injection-enhanced CDT (US + bMB + CDT), US + CDT, US + cMB, and CDT. In a porcine femoral vein thrombosis model, 16 completely obstructive thrombi were randomly assigned to the CDT group and the US + cMB + CDT group, respectively. Thrombolysis rate, vascular recanalization rate, hematoxylin-eosin, and immunofluorescence staining were used to evaluate the thrombolytic effect in vitro and in vivo. RESULTS In vitro, US + cMB + CDT group resulted in a significantly higher thrombolysis rate compared with the other four groups (P < .05). Meanwhile, this group also demonstrated a looser clot structure and more disrupted fibrin structures. In vivo, US + cMB + CDT contributed to a significantly higher vascular recanalization rate compared with CDT (87.50% versus 25.00%, P < .05). CONCLUSIONS US + cMB + CDT was more effective than US + bMB + CDT in thrombolysis, and ultrasound combined with continuous microbubble injection could enhance the thrombolytic efficacy of CDT.
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Affiliation(s)
- Shuang Feng
- Department of Ultrasound, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Shan Wang
- Department of Ultrasound, Huizhou Central People's Hospital, Huizhou, China
| | - Jiawei Tang
- Department of Ultrasound, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Xiansheng Zhu
- Department of Ultrasound, General Hospital of Southern Theatre Command, Guangzhou, China
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Al-Abdouh A, Mhanna M, Jabri A, Madanat L, Alhuneafat L, Mostafa MR, Kundu A, Gupta V. Bivalirudin versus unfractionated heparin in patients with myocardial infarction undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:52-61. [PMID: 37872022 DOI: 10.1016/j.carrev.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Bivalirudin is an alternative accepted therapy to unfractionated heparin for patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). We aimed in this meta-analysis to compare bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. METHODS We have screened PubMed/MEDLINE, Cochrane Library, and ClinicalTrials.gov (inception through January 8th, 2023) for randomized controlled trials (RCTs) evaluating bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. The DerSimonian and Laird method was used for estimation of tau2 to calculate the risk ratio (RR) and 95 % confidence interval (CI). RESULTS Ten RCTs with a total of 40,069 participants were included in our analysis. Bivalirudin as compared with unfractionated heparin was associated with significant decrease in major bleeding (RR 0.64 [0.52 to 0.79]; p < 0.01; I2 = 69 %) and cardiovascular mortality (RR 0.79 [0.67 to 0.92]; p < 0.01; I2 = 0 %). There was no significant difference between bivalirudin and unfractionated heparin groups in terms of major adverse cardiovascular events (RR 1.02 [0.91 to 1.14]; p = 0.73; I2 = 52 %), all-cause mortality (RR 0.89 [0.77 to 1.04]; p = 0.15; I2 = 23 %), MI (RR 1.02 [0.87 to 1.19]; p = 0.80; I2 = 36 %), stent thrombosis (RR 1.12 [0.52 to 2.40]; p = 0.77; I2 = 82 %), or stroke (RR 0.97 [0.73 to 1.29]; p = 0.85; I2 = 0 %). CONCLUSION Our meta-analysis suggests that bivalirudin compared with unfractionated heparin in patients with MI undergoing PCI was associated with lower rates of major bleeding and cardiovascular mortality without a significant difference in major adverse cardiovascular events, all-cause mortality, MI, stroke, or stent thrombosis.
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Affiliation(s)
| | - Mohammed Mhanna
- Department of Cardiovascular Medicine, University of Iowa, IA, USA
| | - Ahmad Jabri
- Department of Cardiology, Case Western University (Metrohealth), Cleveland, OH, USA
| | - Luai Madanat
- Department of Medicine, Beaumont Hospital, Detroid, MI, USA
| | - Laith Alhuneafat
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Amartya Kundu
- Division of Cardiology (Gill Kentucky), University of Kentucky, Lexington, KY, USA
| | - Vedant Gupta
- Division of Cardiology (Gill Kentucky), University of Kentucky, Lexington, KY, USA
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Gonzalez-Del-Hoyo M, Mas-Llado C, Blaya-Peña L, Siquier-Padilla J, Coughlan JJ, Peral V, Rossello X. Type of evidence supporting ACC/AHA and ESC clinical practice guidelines for acute coronary syndrome. Clin Res Cardiol 2024; 113:546-560. [PMID: 37436514 DOI: 10.1007/s00392-023-02262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/29/2023] [Indexed: 07/13/2023]
Abstract
AIM The aim of clinical practice guidelines for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) is to assist healthcare professionals in clinical decision-making. We evaluated the type of studies supporting these guidelines and their recommendations. METHODS All references and recommendations in the 2013 and 2014 ACC/AHA and 2017 and 2020 (ESC clinical guidelines for STEMI and NSTE-ACS were reviewed. References were classified into meta-analyses, randomised, non-randomised, and other types (e.g., position papers, reviews). Recommendations were classified according to class and their level of evidence (LOE). RESULTS We retrieved 2128 non-duplicated references: 8.4% were meta-analyses, 26.2% randomised studies, 44.7% non-randomised studies, and 20.7% 'other' papers. Meta-analyses were based on randomised data in 78% of cases and used individual-patient data in 20.2%. Compared to non-randomised studies, randomised studies were more frequently multicentre (85.5% vs. 65.5%) and international (58.2% vs. 28.5%). The type of studies supporting recommendations varied as per the LOE of the recommendation. For LOE-A recommendations, the breakdown of supporting recommendations was: 18.5% meta-analyses, 56.6% randomised studies, 16.6% non-randomised studies and 8.3% 'other' papers; for LOE-B this breakdown was 9%, 39.8%, 38.2%, and 12.9%; and for LOE-C; 4.6%, 19.3%, 30.3%, and 45.9%. CONCLUSIONS The references supporting the ACC/AHA and ESC guidelines on STEMI and NSTE-ACS consisted of non-randomised studies in ~ 45% of cases, with less than a third of the references consisting of meta-analyses and randomised studies. The type of studies supporting guideline recommendations varied widely by the LOE of the recommendation.
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Affiliation(s)
- Maribel Gonzalez-Del-Hoyo
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
| | - Caterina Mas-Llado
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Cardiology Department, Hospital de Manacor, Manacor, Spain
- Faculty of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Laura Blaya-Peña
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
| | | | - J J Coughlan
- Deutsches Herzzentrum München und Technische Universität München, Munich, Germany
- Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland
| | - Vicente Peral
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
- Faculty of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain
| | - Xavier Rossello
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain.
- Faculty of Medicine, Universitat de les Illes Balears (UIB), Palma, Spain.
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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13
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Rashid A, Purra S, Kakroo SA, Hafeez I, Lone AA, Rather H. Clinical, Demographic, and Angiographic Profiles of Amarnath Pilgrims Presenting With Acute Coronary Syndrome. Cureus 2024; 16:e58820. [PMID: 38784341 PMCID: PMC11113088 DOI: 10.7759/cureus.58820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION The challenges posed by high altitude are particularly significant in terms of cardiovascular health. There are currently no data available on acute coronary syndrome (ACS) among Amarnath pilgrims. The objective of this study was to investigate the clinical and angiographic profiles of ACS among Amarnath pilgrims, focusing on demographic characteristics, risk factors, types of ACS, clinical presentation, angiographic findings, and in-hospital outcomes. By examining these aspects, we aimed to provide insights into the unique challenges faced by pilgrims during their spiritual journey and to identify potential strategies for improving the prevention and management of ACS in this population. Methods: This was a hospital-based, prospective, observational study that included patients who had participated in the pilgrimage and presented with ACS between 2022 and 2023. Results: Sixty patients were recruited for the study, with a mean age of 51.19 ± 11.17 years. Of these, 43 (71.7%) were male. Risk factors identified in the study included hypertension in 35 (58.3%), smoking in 23 (38.3%), diabetes mellitus in 18 (30%), and dyslipidemia in 25 (41.6%) patients. ST-elevation myocardial infarction (STEMI) was present in 46 (76.66%) patients, Anterior wall myocardial infarction (AWMI) occurred in 29 (48.3%), inferior wall myocardial infarction (IWMI) in 15 (25%), and high lateral wall myocardial infarction (HLWMI) in two (3.3%) patients. Of the 60 patients, 19 (31.6%) were in Killip class I, 16 (26.6%) were in class II, and 25 (41.6%) were in classes III or IV. The average time from the onset of symptoms to hospitalization was 7.6 ± 3.1 hours, significantly higher in those with Killip class III or IV (9.3 ± 3.6 vs. 5.4 ± 2.7 hours, p = 0.01). There were nine (15%) in-hospital deaths, and in the multivariate analysis, advanced Killip class (p = 0.04) and delays in hospitalization of more than six hours (p = 0.03) were found to be significant predictors of mortality. CONCLUSION In conclusion, 40% of patients presented in the advanced Killip class, and 15% experienced in-hospital mortality. The average time from the onset of symptoms to hospitalization was significantly higher for those categorized in the advanced Killip classes. Our study highlights a significant association between advanced Killip class, delay in hospitalization, and in-hospital mortality among Amarnath pilgrims with ACS, underscoring the importance of timely intervention. It is recommended that appropriate measures be taken to improve patient outcomes in these cases.
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Affiliation(s)
- Aamir Rashid
- Department of Cardiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Sameer Purra
- Department of Cardiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Shahood A Kakroo
- Department of Cardiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Imran Hafeez
- Department of Cardiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Ajaz A Lone
- Department of Cardiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Hilal Rather
- Department of Cardiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
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14
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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15
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Jeong JH, Kook H, Lee SH, Joo HJ, Park JH, Hong SJ, Kim M, Park S, Jung JS, Yang JH, Gwon H, Ahn C, Jang WJ, Kim H, Bae J, Kwon SU, Lee WS, Jeong J, Park S, Lim S, Lee J, Lee J, Yu CW. Prediction of In-Hospital Mortality for Ischemic Cardiogenic Shock Requiring Venoarterial Extracorporeal Membrane Oxygenation. J Am Heart Assoc 2024; 13:e032701. [PMID: 38362865 PMCID: PMC11010074 DOI: 10.1161/jaha.123.032701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/17/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Clinical outcome of ischemic cardiogenic shock (CS) requiring extracorporeal membrane oxygenation is highly variable, necessitating appropriate assessment of prognosis. However, a systemic predictive model estimating the mortality of refractory ischemic CS is lacking. The PRECISE (Prediction of In-Hospital Mortality for Patients With Refractory Ischemic Cardiogenic Shock Requiring Veno-Arterial Extracorporeal Membrane Oxygenation Support) score was developed to predict the prognosis of refractory ischemic CS due to acute myocardial infarction. METHODS AND RESULTS Data were obtained from the multicenter CS registry RESCUE (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock) that consists of 322 patients with acute myocardial infarction complicated by refractory ischemic CS requiring extracorporeal membrane oxygenation support. Fifteen parameters were selected to assess in-hospital mortality. The developed model was validated internally and externally using an independent external cohort (n=138). Among 322 patients, 138 (42.9%) survived postdischarge. Fifteen predictors were included for model development: age, diastolic blood pressure, hypertension, chronic kidney disease, peak lactic acid, serum creatinine, lowest left ventricular ejection fraction, vasoactive inotropic score, shock to extracorporeal membrane oxygenation insertion time, extracorporeal cardiopulmonary resuscitation, use of intra-aortic balloon pump, continuous renal replacement therapy, mechanical ventilator, successful coronary revascularization, and staged percutaneous coronary intervention. The PRECISE score yielded a high area under the receiver-operating characteristic curve (0.894 [95% CI, 0.860-0.927]). External validation and calibration resulted in competent sensitivity (area under the receiver-operating characteristic curve, 0.895 [95% CI, 0.853-0.930]). CONCLUSIONS The PRECISE score demonstrated high predictive performance and directly translates into the expected in-hospital mortality rate. The PRECISE score may be used to support clinical decision-making in ischemic CS (www.theprecisescore.com). REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02985008.
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Affiliation(s)
- Joo Hee Jeong
- Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea University College of MedicineSeoulKorea
| | - Hyungdon Kook
- Division of Cardiology, Department of Internal Medicine, College of MedicineHanyang UniversitySeoulKorea
| | - Seung Hun Lee
- Department of Internal MedicineKorea University Graduate SchoolSeoulKorea
| | - Hyung Joon Joo
- Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea University College of MedicineSeoulKorea
| | - Jae Hyoung Park
- Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea University College of MedicineSeoulKorea
| | - Soon Jun Hong
- Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea University College of MedicineSeoulKorea
| | - Mi‐Na Kim
- Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea University College of MedicineSeoulKorea
| | - Seong‐Mi Park
- Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea University College of MedicineSeoulKorea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular SurgeryAnam Hospital, Korea University College of MedicineSeoulKorea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of MedicineHeart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of MedicineSeoulKorea
| | - Hyeon‐Cheol Gwon
- Division of Cardiology, Department of MedicineHeart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of MedicineSeoulKorea
| | - Chul‐Min Ahn
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Woo Jin Jang
- Department of CardiologyEwha Woman’s University Seoul Hospital, Ehwa Woman’s University School of MedicineSeoulKorea
| | - Hyun‐Joong Kim
- Division of Cardiology, Department of MedicineKonkuk University Medical CenterSeoulKorea
| | - Jang‐Whan Bae
- Department of Internal MedicineChungbuk National University College of MedicineCheongjuKorea
| | - Sung Uk Kwon
- Division of Cardiology, Department of Internal Medicine, Ilsan Paik HospitalInje University College of MedicineGoyangKorea
| | - Wang Soo Lee
- Division of Cardiology, Department of MedicineChung‐Ang University HospitalSeoulKorea
| | - Jin‐Ok Jeong
- Division of Cardiology, Department of Internal MedicineChungnam National University HospitalDaejeonKorea
| | - Sang‐Don Park
- Division of Cardiology, Department of MedicineInha University HospitalIncheonKorea
| | - Seong‐Hoon Lim
- Division of Cardiovascular Medicine, Department of Internal MedicineDankook University Hospital, Dankook University College of MedicineCheonanKorea
| | - Jiyoon Lee
- Department of Biostatistics, College of MedicineKorea UniversitySeoulKorea
| | - Juneyoung Lee
- Department of Biostatistics, College of MedicineKorea UniversitySeoulKorea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Anam HospitalKorea University College of MedicineSeoulKorea
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16
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Tona F, Civieri G, Vadori M, Masiero G, Iop L, Marra MP, Perin V, Cuciz E, Cecere A, Bernava G, Tansella D, Naumova N, Grewal S, Cozzi E, Iliceto S. Association of Angiotensin II Receptor Type 1 and Endothelin-1 Receptor Type A Agonistic Autoantibodies With Adverse Remodeling and Cardiovascular Events After Acute Myocardial Infarction. J Am Heart Assoc 2024; 13:e032672. [PMID: 38348777 PMCID: PMC11010093 DOI: 10.1161/jaha.123.032672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/27/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND The left ventricular remodeling (LVR) process has limited the effectiveness of therapies after myocardial infarction. The relationship between autoantibodies activating AT1R-AAs (angiotensin II receptor type 1-AAs) and ETAR-AAs (autoantibodies activating endothelin-1 receptor type A) with myocardial infarction has been described. Among patients with ST-segment-elevation myocardial infarction, we investigated the relationship between these autoantibodies with LVR and subsequent major adverse cardiac events. METHODS AND RESULTS In this prospective observational study, we included 131 patients with ST-segment-elevation myocardial infarction (61±11 years of age, 112 men) treated with primary percutaneous coronary intervention. Within 48 hours of admission, 2-dimensional transthoracic echocardiography was performed, and blood samples were obtained. The seropositive threshold for AT1R-AAs and ETAR-AAs was >10 U/mL. Patients were followed up at 6 months, when repeat transthoracic echocardiography was performed. The primary end points were LVR, defined as a 20% increase in left ventricular end-diastolic volume index, and major adverse cardiac event occurrence at follow-up, defined as cardiac death, nonfatal re-myocardial infarction, and hospitalization for heart failure. Forty-one (31%) patients experienced LVR. The prevalence of AT1R-AAs and ETAR-AAs seropositivity was higher in patients with versus without LVR (39% versus 11%, P<0.001 and 37% versus 12%, P=0.001, respectively). In multivariable analysis, AT1R-AAs seropositivity was significantly associated with LVR (odds ratio [OR], 4.66; P=0.002) and represented a risk factor for subsequent major adverse cardiac events (OR, 19.6; P=0.002). CONCLUSIONS AT1R-AAs and ETAR-AAs are associated with LVR in patients with ST-segment-elevation myocardial infarction. AT1R-AAs are also significantly associated with recurrent major adverse cardiac events. These initial observations may set the stage for a better pathophysiological understanding of the mechanisms contributing to LVR and ST-segment-elevation myocardial infarction prognosis.
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Affiliation(s)
- Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Giovanni Civieri
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Marta Vadori
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Laura Iop
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Valentina Perin
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Elisa Cuciz
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Annagrazia Cecere
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Giacomo Bernava
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Donatella Tansella
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Nataliia Naumova
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | | | - Emanuele Cozzi
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences, and Public HealthUniversity of PaduaPaduaItaly
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17
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Bai YB, Zhao F, Wu ZH, Shi GN, Jiang N. Left ventricular thrombosis caused cerebral embolism during venoarterial extracorporeal membrane oxygenation support: A case report. World J Clin Cases 2024; 12:973-979. [PMID: 38414596 PMCID: PMC10895634 DOI: 10.12998/wjcc.v12.i5.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/13/2023] [Accepted: 01/18/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Venoarterial (VA) extracorporeal membrane oxygenation (ECMO), an effective short-term circulatory support method for refractory cardiogenic shock, is widely applied. However, retrospective analyses have shown that VA-ECMO-assisted cases were associated with a relatively high mortality rate of approximately 60%. Embolization in important organs caused by complications of left ventricular thrombosis (LVT) during VA-ECMO is also an important reason. Although the incidence of LVT during VA-ECMO is not high, the consequences of embolization are disastrous. CASE SUMMARY A 37-year-old female patient was admitted to hospital because of fever for 4 d and palpitations for 3 d. After excluding the diagnosis of coronary heart disease, we established a diagnosis of "clinically explosive myocarditis". The patient still had unstable hemodynamics after drug treatment supported by VA-ECMO, with heparin for anticoagulation. On day 4 of ECMO support, a left ventricular thrombus attached to the papillary muscle root of the mitral valve was found by transthoracic echocardiography. Left ventricular decompression was performed and ECMO was successfully removed, but the patient eventually died of multiple cerebral embolism. CONCLUSION LVT with high mobility during VA-ECMO may cause embolism in important organs. Therefore, a "wait and see" strategy should be avoided.
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Affiliation(s)
- Yao-Bang Bai
- Intensive Care Unit, Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Feng Zhao
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Zhen-Hua Wu
- Intensive Care Unit, Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Guo-Ning Shi
- Intensive Care Unit, Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
| | - Nan Jiang
- Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300222, China
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18
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Jonik S, Kageyama S, Ninomiya K, Onuma Y, Kochman J, Grabowski M, Serruys PW, Mazurek T. Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention. Sci Rep 2024; 14:3218. [PMID: 38332036 PMCID: PMC10853195 DOI: 10.1038/s41598-024-53905-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 02/06/2024] [Indexed: 02/10/2024] Open
Abstract
The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)-356 patients or percutaneous coronary intervention (PCI)-679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.
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Affiliation(s)
- Szymon Jonik
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str, 01-267, Warsaw, Poland.
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland, University Road Galway, Galway, H91 TK33, Ireland
| | - Kai Ninomiya
- Department of Cardiology, National University of Ireland, University Road Galway, Galway, H91 TK33, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, University Road Galway, Galway, H91 TK33, Ireland
| | - Janusz Kochman
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str, 01-267, Warsaw, Poland
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str, 01-267, Warsaw, Poland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, University Road Galway, Galway, H91 TK33, Ireland
| | - Tomasz Mazurek
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str, 01-267, Warsaw, Poland
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19
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Song Y, Li H, Zhang X, Wang L, Xu HY, Lu ZC, Wang XG, Liu B. Individualized anti-thrombotic therapy for acute myocardial infarction complicated with left ventricular thrombus: A case report. World J Clin Cases 2024; 12:835-841. [PMID: 38322693 PMCID: PMC10841139 DOI: 10.12998/wjcc.v12.i4.835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Presently, there is no established standard anti-blood clot therapy for patients facing acute myocardial infarction (AMI) complicated by left ventricular thrombus (LVT). While vitamin K antagonists are the preferred choice for oral blood thinning, determining the best course of blood-thinning medication remains challenging. It is unclear if non-vitamin K antagonist oral blood thinners have different effectiveness in treating LVT. This study significantly contributes to the medical community. CASE SUMMARY The blood-thinning treatment of a patient with AMI and LVT was analyzed. Triple blood-thinning therapy included daily enteric-coated aspirin tablets at 0.1 g, daily clopidogrel hydrogen sulfate at 75 mg, and dabigatran etexilate at 110 mg twice daily. After 15 d, the patient's LVT did not decrease but instead increased. Clinical pharmacists comprehensively analyzed the cases from the perspective of the patient's disease status and drug interaction. The drug regimen was reformulated for the patient, replacing dabigatran etexilate with warfarin, and was administered for six months. The clinical pharmacist provided the patient with professional and standardized pharmaceutical services. The patient's condition was discharged after meeting the international normalized ratio value (2-3) criteria. The patient fully complied with the follow-up, and the time in the therapeutic range was 78.57%, with no serious adverse effects during pharmaceutical monitoring. CONCLUSION Warfarin proves to be an effective drug for patients with AMI complicated by LVT, and its blood-thinning course lasts for six months.
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Affiliation(s)
- Yan Song
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Hua Li
- Department of Cardiology, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Xia Zhang
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Lei Wang
- Department of Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Hong-Yan Xu
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Zhi-Chao Lu
- Department of Clinical Pharmacy, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Xiao-Gang Wang
- Department of Imaging, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
| | - Bo Liu
- Department of Pulmonary and Critical Care Medicine, Department of Clinical Microbiology, Zibo City Key Laboratory of Respiratory Infection and Clinical Microbiology, Zibo City Engineering Technology Research Center of Etiology Molecular Diagnosis, Zibo Municipal Hospital, Zibo 255400, Shandong Province, China
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20
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Li S, Wang X, Jin A, Liu G, Gu H, Li H, Campbell BCV, Fisher M, Yang Y, Wei Y, Wang J, Wang Y, Zhao X, Liu L, Li Z, Meng X, Wang Y. Safety and Efficacy of Reteplase Versus Alteplase for Acute Ischemic Stroke: A Phase 2 Randomized Controlled Trial. Stroke 2024; 55:366-375. [PMID: 38152962 DOI: 10.1161/strokeaha.123.045193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Reteplase is a more affordable new-generation thrombolytic with a prolonged half-life. We aimed to determine the safety dose range of reteplase for patients with acute ischemic stroke within 4.5 hours of onset. METHODS This is a multicenter, prospective, randomized controlled, open-label, blinded-end point phase 2 clinical trial. Patients with acute ischemic stroke aged between 18 and 80 years who were eligible for standard intravenous thrombolysis were enrolled from 17 centers in China and randomly assigned (1:1:1) to receive intravenous reteplase 12+12 mg, intravenous reteplase 18+18 mg, or intravenous alteplase 0.9 mg/kg. The primary safety outcome was symptomatic intracranial hemorrhage (SITS definition) within 36 hours. The primary efficacy outcome was the proportion of patients with the National Institutes of Health Stroke Scale score of no more than 1 or a decrease of at least 4 points from the baseline at 14 days after thrombolysis. RESULTS Between August 2019 and May 2021, 180 patients were randomly assigned to reteplase 12+12 mg (n=61), reteplase 18+18 mg (n=67), or alteplase (n=52). Four patients did not receive the study agent. Symptomatic intracranial hemorrhage occurred in 3 of 60 (5.0%) in the reteplase 12+12 mg group, 1 of 66 (1.5%) in the reteplase 18+18 mg group, and 1 of 50 (2.0%) in the alteplase group (P=0.53). The primary efficacy outcome in the modified intention-to-treat population occurred in 45 of 60 (75.0%) in the reteplase 12+12 mg group (odds ratio, 0.85 [95% CI, 0.35-2.06]), 48 of 66 (72.7%) in the reteplase 18+18 mg group (odds ratio, 0.75 [95% CI, 0.32-1.78]), and 39 of 50 (78.0%) in alteplase group. CONCLUSIONS Reteplase was well tolerated in patients with acute ischemic stroke within 4.5 hours of onset in China with a similar efficacy profile to alteplase. The efficacy and appropriate dosage of reteplase for patients with acute ischemic stroke need prospective validation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04028518.
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Affiliation(s)
- Shuya Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xuechun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Aoming Jin
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Gaifen Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hongqiu Gu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Hao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, VIC, Australia (B.C.V.C.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China (Y.Y.)
| | - Yan Wei
- Department of Neurology, Halison International Peace Hospital of Hengshui City, China (Y.W.)
| | - Junhai Wang
- Department of Neurology, Sinopharm Tongmei General Hospital, Datong, China (J.W.)
| | - Yilong Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xingquan Zhao
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Liping Liu
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Zixiao Li
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Xia Meng
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
| | - Yongjun Wang
- Department of Neurology and Department of Clinical Trial Center, Beijing Tiantan Hospital, Capital Medical University, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing, China (S.L., X.W., A.J., G.L., H.G., H.L., Yilong Wang, X.Z., L.L., Z.L., X.M., Yongjun Wang)
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21
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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22
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Al Said S, Kaier K, Sumaya W, Alsaid D, Duerschmied D, Storey RF, Gibson CM, Westermann D, Alabed S. Non-vitamin-K-antagonist oral anticoagulants (NOACs) after acute myocardial infarction: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD014678. [PMID: 38264795 PMCID: PMC10806408 DOI: 10.1002/14651858.cd014678.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND Balancing the risk of bleeding and thrombosis after acute myocardial infarction (AMI) is challenging, and the optimal antithrombotic therapy remains uncertain. The potential of non-vitamin K antagonist oral anticoagulants (NOACs) to prevent ischaemic cardiovascular events is promising, but the evidence remains limited. OBJECTIVES To evaluate the efficacy and safety of non-vitamin-K-antagonist oral anticoagulants (NOACs) in addition to background antiplatelet therapy, compared with placebo, antiplatelet therapy, or both, after acute myocardial infarction (AMI) in people without an indication for anticoagulation (i.e. atrial fibrillation or venous thromboembolism). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science, and two clinical trial registers in September 2022 with no language restrictions. We checked the reference lists of included studies for any additional trials. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) that evaluated NOACs plus antiplatelet therapy versus placebo, antiplatelet therapy, or both, in people without an indication for anticoagulation after an AMI. DATA COLLECTION AND ANALYSIS Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects pairwise analyses using Review Manager Web, and network meta-analysis using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons and allow ranking of treatments on a continuous 0-to-1 scale. MAIN RESULTS We identified seven eligible RCTs, including an ongoing trial that we could not include in the analysis. Of the six RCTs involving 33,039 participants, three RCTs compared rivaroxaban with placebo, two RCTs compared apixaban with placebo, and one RCT compared dabigatran with placebo. All participants in the six RCTs received concomitant antiplatelet therapy. The available evidence suggests that rivaroxaban compared with placebo reduces the rate of all-cause mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.69 to 0.98; number needed to treat for an additional beneficial outcome (NNTB) 250; 3 studies, 21,870 participants; high certainty) and probably reduces cardiovascular mortality (RR 0.83, 95% CI 0.69 to 1.01; NNTB 250; 3 studies, 21,870 participants; moderate certainty). There is probably little or no difference between apixaban and placebo in all-cause mortality (RR 1.09, 95% CI 0.88 to 1.35; number needed to treat for an additional harmful outcome (NNTH) 334; 2 studies, 8638 participants; moderate certainty) and cardiovascular mortality (RR 0.99, 95% CI 0.77 to 1.27; number needed to treat not applicable; 2 studies, 8638 participants; moderate certainty). Dabigatran may reduce the rate of all-cause mortality compared with placebo (RR 0.57, 95% CI 0.31 to 1.06; NNTB 63; 1 study, 1861 participants; low certainty). Dabigatran compared with placebo may have little or no effect on cardiovascular mortality, although the point estimate suggests benefit (RR 0.72, 95% CI 0.34 to 1.52; NNTB 143; 1 study, 1861 participants; low certainty). Two of the investigated NOACs were associated with an increased risk of major bleeding compared to placebo: apixaban (RR 2.41, 95% CI 1.44 to 4.06; NNTH 143; 2 studies, 8544 participants; high certainty) and rivaroxaban (RR 3.31, 95% CI 1.12 to 9.77; NNTH 125; 3 studies, 21,870 participants; high certainty). There may be little or no difference between dabigatran and placebo in the risk of major bleeding (RR 1.74, 95% CI 0.22 to 14.12; NNTH 500; 1 study, 1861 participants; low certainty). The results of the network meta-analysis were inconclusive between the different NOACs at all individual doses for all primary outcomes. However, low-certainty evidence suggests that apixaban (combined dose) may be less effective than rivaroxaban and dabigatran for preventing all-cause mortality after AMI in people without an indication for anticoagulation. AUTHORS' CONCLUSIONS Compared with placebo, rivaroxaban reduces all-cause mortality and probably reduces cardiovascular mortality after AMI in people without an indication for anticoagulation. Dabigatran may reduce the rate of all-cause mortality and may have little or no effect on cardiovascular mortality. There is probably no meaningful difference in the rate of all-cause mortality and cardiovascular mortality between apixaban and placebo. Moreover, we found no meaningful benefit in efficacy outcomes for specific therapy doses of any investigated NOACs following AMI in people without an indication for anticoagulation. Evidence from the included studies suggests that rivaroxaban and apixaban increase the risk of major bleeding compared with placebo. There may be little or no difference between dabigatran and placebo in the risk of major bleeding. Network meta-analysis did not show any superiority of one NOAC over another for our prespecified primary outcomes. Although the evidence suggests that NOACs reduce mortality, the effect size or impact is small; moreover, NOACs may increase major bleeding. Head-to-head trials, comparing NOACs against each other, are required to provide more solid evidence.
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Affiliation(s)
- Samer Al Said
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Wael Sumaya
- Department of Medicine, Faculty of Medicine, Dalhousie University, QE II Health Sciences Centre, Halifax Infirmary, Halifax, Canada
| | - Dima Alsaid
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany, Mannheim, Germany
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - C Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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23
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Stopyra JP, Snavely AC, Ashburn NP, Supples MW, Brown WM, Miller CD, Mahler SA. Rural EMS STEMI Patients - Why the Delay to PCI? PREHOSP EMERG CARE 2024:1-8. [PMID: 38235978 DOI: 10.1080/10903127.2024.2305967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND The objective of this study is to identify patient and EMS agency factors associated with timely reperfusion of patients with ST-elevation myocardial infarction (STEMI). METHODS We conducted a cohort study of adult patients (≥18 years old) with STEMI activations from 2016 to 2020. Data was obtained from a regional STEMI registry, which included eight rural county EMS agencies and three North Carolina percutaneous coronary intervention (PCI) centers. On each patient, prehospital and in-hospital time intervals were abstracted. The primary outcome was the ability to achieve the 90-minute EMS FMC to PCI time goal (yes vs. no). We used generalized estimating equations accounting for within-agency clustering to evaluate the association between patient and agency factors and meeting first medical contact (FMC) to PCI time goal while accounting for clustering within the agency. RESULTS Among 365 rural STEMI patients 30.1% were female (110/365) with a mean age of 62.5 ± 12.7 years. PCI was performed within the time goal in 60.5% (221/365) of encounters. The FMC to PCI time goal was met in 45.5% (50/110) of women vs 69.8% (178/255) of men (p < 0.001). The median PCI center activation time was 12 min (IQR 7-19) in the group that received PCI within the time goal compared to 21 min (IQR 10-37) in the cohort that did not. After adjusting for loaded mileage and other clinical variables (e.g., pulse rate, hypertension etc.), the male sex was associated with an improved chance of meeting the goal of FMC to PCI (aOR: 2.94; 95% CI 2.11-4.10) compared to the female sex. CONCLUSION Nearly 40% of rural STEMI patients transported by EMS failed to receive FMC to PCI within 90 min. Women were less likely than men to receive reperfusion within the time goal, which represents an important health care disparity.
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Affiliation(s)
- Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - W Mark Brown
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Chadwick D Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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24
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Fardman A, Massalha E, Natanzon SS, Brodov Y, Goitein O, Chernomordik F, Herscovici R, Grupper A, Kuperstein R, Mazin I, Matetzky S, Beigel R. Clinical predictors of left ventricular thrombus after myocardial infarction as detected by magnetic resonance imaging. Front Cardiovasc Med 2024; 10:1275390. [PMID: 38292454 PMCID: PMC10824980 DOI: 10.3389/fcvm.2023.1275390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/29/2023] [Indexed: 02/01/2024] Open
Abstract
Background The diagnosis of a left ventricular (LV) thrombus in patients with ST-segment elevation myocardial infarction (STEMI) remains challenging. The aim of the current study is to characterize clinical predictors for LV thrombus formation, as detected by cardiac magnetic resonance imaging (CMRI). Methods We retrospectively evaluated 337 consecutive STEMI patients. All patients underwent transthoracic echocardiography (TTE) and CMRI during their index hospitalization. We developed a novel risk stratification model (ThrombScore) to identify patients at risk of developing an LV thrombus. Results CMRI revealed the presence of LV thrombus in 34 patients (10%), of whom 33 (97%) had experienced an anterior wall myocardial infarction (MI), and the majority (77%) had at least mildly reduced left ventricular ejection fraction (LVEF < 45%). The sensitivity for thrombus formation of the first and second TTE was 5.9% and 59%, respectively. Multivariate logistic regression model revealed that elevated C-reactive protein levels, lack of ST-segment elevation (STe) resolution, elevated creatine phosphokinase levels, and STe in anterior ECG leads are robust independent predictors for developing an LV thrombus. These variables were incorporated to construct the ThrombScore: a simple six-point risk model. The odds ratio for developing thrombus per one-point increase in the score was 3.2 (95% CI 2.1-5.01; p < 0.001). The discrimination analysis of the model revealed a c-statistic of 0.86 for thrombus development. The model identified three distinct categories (I, II, and III) with corresponding thrombus incidences of 0%, 1.6%, and 27.6%, respectively. Conclusion ThrombScore is a simple and practical clinical model for risk stratification of thrombus formation in patients with STEMI.
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Affiliation(s)
- Alexander Fardman
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eias Massalha
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | - Yafim Brodov
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Orly Goitein
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Fernando Chernomordik
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Romana Herscovici
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Avishay Grupper
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Rafael Kuperstein
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Israel Mazin
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Roy Beigel
- The Cardiovascular Division, Sheba Medical Center, Tel-Hashomer, Affiliated to The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Komaki S, Matsuura Y, Tanaka H, Moribayashi K, Yamamura Y, Kurogi K, Ideguchi T, Yamamoto N, Nakai M, Tsuruda T, Kaikita K. Nitroglycerin use and adverse clinical outcomes in elderly patients with acute coronary syndrome. Open Heart 2024; 11:e002494. [PMID: 38216173 PMCID: PMC10806511 DOI: 10.1136/openhrt-2023-002494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/27/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE The primary care for acute coronary syndrome (ACS) includes the administration of nitroglycerin (GTN). This study aimed to investigate the association between the use of GTN before percutaneous coronary intervention (PCI) for ACS and clinical outcomes. METHODS Nine-hundred and forty-seven patients who underwent PCI for ACS were examined and classified into two groups: those who were treated with GTN before PCI (GTN group) and those who were not (non-GTN group). The incidence of major adverse cardiovascular events (MACE), which consist of all-cause mortality, non-fatal myocardial infarction, stroke and rehospitalisation for heart failure at 1 year, was compared between the two groups. RESULTS This study identified 289 patients with ACS who used GTN preceding PCI. Pre-PCI systolic blood pressure was significantly lower in the GTN group than in the non-GTN group (median (IQR); 132.0 (110.0-143.5) mm Hg vs 134.0 (112.0-157.0) mm Hg, respectively, p=0.03). Multivariate Cox regression analysis indicated that GTN use preceding PCI showed an independent association with the incidence of MACE (HR 1.57; 95% CI 1.09-2.28; p=0.016). Overall, the incidence of MACE 1 year after PCI for ACS was significantly higher in the GTN group than in the non-GTN group (log-rank test, p=0.024); however, this trend was consistently found in elderly patients aged ≥75 years (p=0.002) but not in non-elderly patients aged <75 years (p=0.773). CONCLUSIONS GTN use preceding PCI for ACS is associated with lower blood pressure and adverse clinical outcomes in elderly patients.
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Affiliation(s)
- Soichi Komaki
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Cardiovascular Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hiroki Tanaka
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kohei Moribayashi
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yoshimasa Yamamura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kazumasa Kurogi
- Department of Cardiovascular Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Takeshi Ideguchi
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Nobuyasu Yamamoto
- Department of Cardiovascular Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Michikazu Nakai
- Clinical Research Support Center, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshihiro Tsuruda
- Department of Hemo-Vascular Advanced Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Alsagaff MY, Revianto O, Sembiring YE, Ilman MI, Intan RE. Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report. J Med Case Rep 2024; 18:8. [PMID: 38184640 PMCID: PMC10771645 DOI: 10.1186/s13256-023-04284-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 11/24/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND The current guidelines have discouraged the routine use of intra-aortic balloon pump (IABP) in cardiogenic shock complicating acute coronary syndrome (ACS). Since then, the trend of IABP utilization in ACS has been declining. Nevertheless, the guidelines still preserve the recommendation of IABP use in hemodynamic instability or cardiogenic shock caused by post myocardial infarction (MI) ventricular septal rupture (VSR). CASE PRESENTATION A 46-years-old diabetic Southeast Asian female was referred from a peripheral facility with intractable heart failure despite treatment with vasoactive agents and diuretics for five days. The ECG suggested a recent anteroseptal myocardial infarction with normal high-sensitivity troponin-I value. The echocardiography detected a regional wall motion abnormality and a 10 mm wide ventricular septal defect. Invasive coronary angiography revealed a severe two-vessel coronary artery disease. We planned a delayed surgical strategy with preoperative optimization using IABP as a bridge to surgery. IABP implantation followed by significant hemodynamic improvement and rapid resolution of heart failure without any inotrope support. Afterwards, coronary artery bypass grafting (CABG) and VSR surgical repair were performed. We safely removed IABP on the third postoperative day with proper weaning and minimal vasoactive support. CONCLUSION We report a case where IABP still provided benefits for a patient with intractable heart failure caused by undetermined onset MI complicated by VSR. The use of IABP in such a case is in accordance with the recommendation of the current guidelines. Several studies showed that IABP use during preoperative optimization in the case of post-MI VSR was associated with survival benefits.
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Affiliation(s)
- Mochamad Yusuf Alsagaff
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia.
| | - Oky Revianto
- Department of Cardiovascular Thoracic Surgery, Faculty of Medicine, Airlangga University-RSUD Dr. Soetomo General Hospital Surabaya, Surabaya, East Java, 60286, Indonesia
| | - Yan Efrata Sembiring
- Department of Cardiovascular Thoracic Surgery, Faculty of Medicine, Airlangga University-RSUD Dr. Soetomo General Hospital Surabaya, Surabaya, East Java, 60286, Indonesia
| | - Muhammad Insani Ilman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia
| | - Ryan Enast Intan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia
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Rodríguez-Ramos MA, Santos-Medina M, Dueñas-Herrera A, Prohías Martínez JA, Rivas-Estany E. A collaborative approach to develop indicators for quality of care for ST segment Elevation Myocardial Infarction in networks without coronary intervention: A position paper. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:91-100. [PMID: 37599539 DOI: 10.3233/jrs-220057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Data about performance measures (PM) in patients with ST segment Elevation Myocardial Infarction (STEMI) in low- and middle-income countries is really scarce. One of the reasons is the lack of appropriate measures for these scenarios where coronary intervention is not the standard treatment. OBJECTIVE This study aimed to develop a set of PM and quality markers for patients with STEMI in these countries. METHODS Two investigators systematically reviewed existing guidelines and scientific literature to identify potential PM by referring to documents searched through PubMed from 2010 through 2019, using terms "Myocardial Infarction", "STEMI", "quality indicator", and "performance measure". A modified Delphi technique, involving multidisciplinary panel interview, was used. A 15-member multidisciplinary expert panel individually rated each potential indicator on a scale of 1 (lowest) to 5 (highest) during three rounds. All indicators that received a median score ≥4.5, in final round without significant disagreement were included as PM. RESULTS Through the consensus-building process, 84 potential indicators were found, of which 10 were proposed as performance measures and 2 as quality metrics, as follows: Pre-Hospital Electrocardiogram; Patients with reperfusion therapy; Pre-hospital Reperfusion; Ischemic time less than 120 minutes; System delay time less than 90 minutes; In-hospital Mortality; Complete in-hospital Treatment; Complete in-hospital Treatment in patients with Heart Failure; 30 day-Re-admissions; 30 day-mortality; Patients with in-hospital stress test performed; and, Patients included in rehabilitation programs. CONCLUSION This document provides the official set of PM of attention in ST segment Elevation Myocardial Infarction of the Cuban Society of Cardiology and Cuban National Group of Cardiology.
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Affiliation(s)
| | | | - Alfredo Dueñas-Herrera
- Department of Preventive Cardiology, Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
| | | | - Eduardo Rivas-Estany
- Department of Preventive Cardiology, Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
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Bhat KG, Pillai RKJ, Lodhi H, Guleria VS, Abbot AK, Gupta L, Rastogi G, Sharma A, Mohammed Z, Sharma V. Pharmacogenomic evaluation of CYP2C19 alleles linking low clopidogrel response and the risk of acute coronary syndrome in Indians. J Gene Med 2024; 26:e3634. [PMID: 37985132 DOI: 10.1002/jgm.3634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/03/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Clopidogrel is an antiplatelet drug widely prescribed to prevent atherothrombotic events in coronary artery disease patients. However, there is evidence to suggest that the effectiveness of clopidogrel varies owing to genetic diversity in CYP2C19. This heterogeneity in South Asians, who are also known to have high risk of cardiac events than other population groups, highlights the importance of investigating CYP2C19 variants to estimate the risk proportion in the groups. METHODS Given the high prevalence and genetic heterogeneity, the population-based case control was conducted in a cohort of 1191 subjects comprising 645 acute coronary syndrome (ACS) cases (unstable angina, ST-elevation myocardial infarction, and non-ST-elevation myocardial infarction) and 546 healthy controls of South Asian Indian origin. The metabolization status of CYP2C19 was assessed using *2, *3 and *17 variants in the stated cohorts to determine the prevalence of metabolization and its association with phenotypes. RESULTS The results suggest a possible genetic association between studied CYP2C19 polymorphisms and ACS, since there was a higher proportion of intermediate and poor metabolizers present in the studied cohorts. The association analyses revealed that the *2 allele of CYP2C19 confers a significant risk for ACS, while the *17 allele provides protection. CONCLUSIONS These findings contribute to the understanding of CYP2C19 genetic variants and their impact on clopidogrel response in South Asian Indians. Additionally, they underline the significance of assessing CYP2C19 variations in patients receiving clopidogrel therapy in order to improve therapeutic outcomes.
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Affiliation(s)
| | | | - Heemanshu Lodhi
- Department of Cardiology, Army Hospital, Research and Referral, New Delhi, India
| | - Vivek Singh Guleria
- Department of Cardiology, Army Hospital, Research and Referral, New Delhi, India
| | - Anil Kumar Abbot
- Department of Cardiology, Army Hospital, Research and Referral, New Delhi, India
| | - Love Gupta
- NMC Genetics India Pvt. Ltd, Gurugram, Haryana, India
| | | | - Anuka Sharma
- NMC Genetics India Pvt. Ltd, Gurugram, Haryana, India
| | | | - Varun Sharma
- NMC Genetics India Pvt. Ltd, Gurugram, Haryana, India
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Sheikhy A, Fallahzadeh A, Jameie M, Aein A, Masoudkabir F, Maghsoudi M, Tajdini M, Salarifar M, Jenab Y, Pourhosseini H, Mehrani M, Alidoosti M, Vasheghani-Farahani A, Hosseini K. In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis. Front Cardiovasc Med 2023; 10:1235667. [PMID: 38173819 PMCID: PMC10761535 DOI: 10.3389/fcvm.2023.1235667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
Aim A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established. Methods This retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions. Results Approximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99-12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91-2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92-6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women. Conclusions Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality.
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Affiliation(s)
- Ali Sheikhy
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aida Fallahzadeh
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mana Jameie
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Afsaneh Aein
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Masoudkabir
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Milad Maghsoudi
- Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masih Tajdini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Salarifar
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Yaser Jenab
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Pourhosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mehrani
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Alidoosti
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Vasheghani-Farahani
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Suzuki K, Niida T, Yuki H, Kinoshita D, Fujimoto D, Lee H, McNulty I, Takano M, Nakamura S, Kakuta T, Mizuno K, Jang I. Coronary Plaque Characteristics and Underlying Mechanism of Acute Coronary Syndromes in Different Age Groups of Patients With Diabetes. J Am Heart Assoc 2023; 12:e031474. [PMID: 38014673 PMCID: PMC10727321 DOI: 10.1161/jaha.123.031474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/17/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND High cardiovascular mortality has been reported in young patients with diabetes. However, the underlying pathology in different age groups of patients with diabetes has not been studied. METHODS AND RESULTS The aim of this study was to investigate the plaque characteristics and underlying pathology of acute coronary syndrome in different age groups of patients with or without diabetes in a large cohort. Patients who presented with acute coronary syndrome and underwent preintervention optical coherence tomography imaging were included. Culprit plaque was classified as plaque rupture, plaque erosion, or calcified plaque and stratified into 5 age groups. Plaque characteristics including features of vulnerability were examined by optical coherence tomography. Among 1394 patients, 482 (34.6%) had diabetes. Patients with diabetes, compared with patients without diabetes, had a higher prevalence of lipid-rich plaque (71.2% versus 64.8%, P=0.016), macrophage (72.0% versus 62.6%, P<0.001), and cholesterol crystal (27.6% versus 19.7%, P<0.001). Both diabetes and nondiabetes groups showed a decreasing trend in plaque erosion with age (patients with diabetes, P=0.020; patients without diabetes, P<0.001). Patients without diabetes showed an increasing trend with age in plaque rupture (P=0.004) and lipid-rich plaque (P=0.018), whereas patients with diabetes had a high prevalence of these vulnerable features at an early age that remained high across age groups. CONCLUSIONS Patients without diabetes showed an increasing trend with age in plaque rupture and lipid-rich plaque, whereas patients with diabetes had a high prevalence of these vulnerable features at an early age. These results suggest that atherosclerotic vascular changes with increased vulnerability start at a younger age in patients with diabetes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT04523194, NCT03479723. URL: https://www.umin.ac.jp/ctr/. Unique identifier: UMIN000041692.
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Affiliation(s)
- Keishi Suzuki
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Takayuki Niida
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Haruhito Yuki
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Daisuke Kinoshita
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Daichi Fujimoto
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Hang Lee
- Biostatistics CenterMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Iris McNulty
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Masamichi Takano
- Cardiovascular CenterNippon Medical School Chiba Hokusoh HospitalInzai, ChibaJapan
| | - Sunao Nakamura
- Interventional Cardiology UnitNew Tokyo HospitalChibaJapan
| | - Tsunekazu Kakuta
- Department of CardiologyTsuchiura Kyodo General Hospital, TsuchiuraIbarakiJapan
| | | | - Ik‐Kyung Jang
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
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Nishimoto Y, Inohara T, Kohsaka S, Sakakura K, Kawai T, Kikuchi A, Watanabe T, Yamada T, Fukunami M, Yamaji K, Ishii H, Amano T, Kozuma K. Changing Trends in Mechanical Circulatory Support Use and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Acute Coronary Syndrome Complicated With Cardiogenic Shock: Insights From a Nationwide Registry in Japan. J Am Heart Assoc 2023; 12:e031838. [PMID: 38038195 PMCID: PMC10727314 DOI: 10.1161/jaha.123.031838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Temporal trends in the management of acute coronary syndrome complicated with cardiogenic shock after the revision of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella require further investigation, because their impact remains uncertain. METHODS AND RESULTS Using the Japanese Percutaneous Coronary Intervention (J-PCI) registry database from 2019 to 2021, we identified 12 171 patients undergoing percutaneous coronary intervention for acute coronary syndrome complicated with cardiogenic shock under mechanical circulatory support. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella, and (3) venoarterial extracorporeal membrane oxygenation (VA-ECMO); the VA-ECMO group was further stratified into (3a) VA-ECMO alone, (3b) VA-ECMO in combination with IABP, and (3c) VA-ECMO in combination with Impella. The quarterly prevalence and outcomes were reported. The use of IABP alone decreased significantly from 63.5% in the first quarter of 2019 to 58.3% in the fourth quarter of 2021 (P for trend=0.01). Among 4245 patients requiring VA-ECMO, the use of VA-ECMO in combination with IABP decreased significantly from 78.7% to 67.3%, whereas the use of VA-ECMO in combination with Impella increased significantly from 4.2% to 17.0% (P for trend <0.001 for both). After adjusting for the confounders, the risk difference in the fourth quarter of 2021 relative to the first quarter of 2019 for in-hospital mortality was not significant (adjusted odds ratio, 0.84 [95% CI, 0.69-1.01]). CONCLUSIONS Our study revealed substantial changes in the use of different mechanical circulatory support modalities in acute coronary syndrome complicated with cardiogenic shock, but they did not significantly improve the outcomes.
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Affiliation(s)
- Yuji Nishimoto
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | - Taku Inohara
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Shun Kohsaka
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Tsutomu Kawai
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | - Atsushi Kikuchi
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | | | - Takahisa Yamada
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | | | | | - Hideki Ishii
- Department of Cardiovascular MedicineGunma University Graduate School of MedicineMaebashiJapan
| | - Tetsuya Amano
- Department of CardiologyAichi Medical UniversityNagakuteJapan
| | - Ken Kozuma
- Department of CardiologyTeikyo University HospitalTokyoJapan
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Jang H, Cho BR, Jang DK, Kim DS. Feasibility and safety values of activated clotting time-guided systemic heparinization in coil embolization for unruptured intracranial aneurysms. Acta Neurochir (Wien) 2023; 165:3743-3757. [PMID: 37982897 DOI: 10.1007/s00701-023-05869-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/22/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE This study aimed to evaluate the feasibility and safety values of activated clotting time (ACT)-guided systemic heparinization in reducing periprocedural thrombosis and bleeding complications during coil embolization of unruptured intracranial aneurysms. METHODS A total of 228 procedures performed on 213 patients between 2016 and 2021 were included in the retrospective analysis. The target ACT was set at 250 s. Logistic regression was performed to assess predictors for the occurrence of thrombosis and bleeding. Receiver operating characteristic (ROC) analyses were employed to determine the optimal cut-off values for ACT, heparinization, and procedure time. RESULTS Most (85.1%) of procedures were stent-assisted embolization. The mean baseline ACT was 128.8 ± 45.7 s. The mean ACT at 20 min after the initial intravenous heparin loading of 78.2 ± 18.8 IU/kg was 185 ± 46.4 s. The mean peak ACT was 255.6 ± 63.8 s with 51.3% (117 cases) achieving the target ACT level. Peak ACT was associated with symptomatic thrombosis (OR per second, 1.008; 95% CI, 1.000-1.016; P = 0.035) (cut-off value, 275 s; area under ROC (AUROC), 0.7624). Total administered heparin dose per body weight was negatively associated with symptomatic thrombosis (OR per IU/kg, 0.972; 95% CI, 0.949-0995; P = 0.018) (cut-off value, 294 IU/kg; AUROC, 0.7426) but positively associated with significant bleeding (OR, 1.008 per IU/kg; 95% CI, 1.005-1.012; P <0 .001) (cut-off value, 242 IU/kg; AUROC, 0.7391). Procedure time was significantly associated with symptomatic thrombosis (OR per minute, 1.05; 95% CI, 1.017-1.084; P value = 0.002) (cut-off value, 158 min; area under ROC, 0.8338). CONCLUSION This study demonstrated that ACT-guided systemic heparinization was feasible to achieve the target ACT value and proposes probable safety thresholds to prevent periprocedural complications through reducing procedure time during coil embolization of unruptured intracranial aneurysms in the stent era.
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Affiliation(s)
- Hyuk Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
| | - Byung-Rae Cho
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
| | - Dong-Kyu Jang
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea.
| | - Dong-Sub Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
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Nader G, Yavari M, Timilsina A, Rayamajhi S. A Case of Successful Direct Oral Anticoagulant Use for the Treatment of Warfarin-Induced Vasculitis in a Patient With Left Ventricular Thrombus. Cureus 2023; 15:e50885. [PMID: 38249209 PMCID: PMC10799545 DOI: 10.7759/cureus.50885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Cutaneous small vessel leukocytoclastic vasculitis (LCV) is isolated to the dependent areas of the skin. LCV can be induced by pharmaceutical drugs, and management requires abrupt discontinuation of the offending drug. Warfarin is a rare medication to cause LCV, with sparse literature to date. Here, we present a case of warfarin-induced LCV, complicated by a patient's comorbid left ventricular thrombus, and successful treatment with discontinuation of warfarin and replacement with a direct oral anticoagulant (apixaban).
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Affiliation(s)
- Georgette Nader
- Internal Medicine, Michigan State University College of Human Medicine, East Lansing, USA
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
| | - Majid Yavari
- Internal Medicine, Michigan State University College of Human Medicine, East Lansing, USA
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
| | - Anisha Timilsina
- Internal Medicine, Michigan State University College of Human Medicine, East Lansing, USA
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
| | - Sumugdha Rayamajhi
- Internal Medicine, Michigan State University College of Human Medicine, East Lansing, USA
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
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Lopez J, Mark J, Duarte GJ, Shaban M, Sosa F, Mishra R, Jain S, Tran A, Khizar A, Karpel D, Acosta G, Rodriguez-Guerra M. Role of genetic polymorphisms in clopidogrel response variability: a systematic review. Open Heart 2023; 10:e002436. [PMID: 37963685 PMCID: PMC10649851 DOI: 10.1136/openhrt-2023-002436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/31/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Clopidogrel is a P2Y12 inhibitor that has become a mainstay treatment following percutaneous intervention with drug-eluting stent placement to decrease restenosis and its potential complications, including sudden cardiac death and ischaemic strokes in patients with significant vascular disease. AREAS COVERED As a prodrug, the metabolism and efficacy of clopidogrel are contingent on the presence of wild-type CYP450 (CYP2C19) alleles. Genetic polymorphisms and variants are well known to impair its ability to prevent major adverse cardiovascular events in these patients, with inadequate response rates as high as 30% in previous publications. Patterns of allelic frequencies are expected to exhibit similarities between individuals of the same ancestry, ethnic group or geographic region. Accordingly, we seek to further elucidate worldwide prevalence rates for genetic polymorphisms in the CYP2C19-dependent metabolism of clopidogrel and review the potential of personalised CYP2C19 genotyping in clinical practice to mitigate this high treatment resistance and its associated burden on patients. EXPERTS' COMMENTARY Our findings support the consideration of genotyping before initiation of therapy to guide adequate dosage or substitutions of other P2Y12 inhibitors to promote personalised, precision medicine and to prevent adverse events when these therapies may inevitably fail in patients with variants of the CYP450 (CYP2C19) system.
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Affiliation(s)
- Jose Lopez
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, Lantana, Florida, USA
| | - Justin Mark
- Department of Internal Medicine, University of Miami Miller School of Medicine, Fort Lauderdale, Florida, USA
| | - Gustavo J Duarte
- Division of Cardiology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mohammed Shaban
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Franklin Sosa
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rishabh Mishra
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Swati Jain
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - An Tran
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Asma Khizar
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel Karpel
- Department of Internal Medicine, HCA Florida Aventura Hospital and Medical Center, Aventura, Florida, USA
| | - Giancarlo Acosta
- Division of Cardiology, Georgia Heart Institute, Gainesville, Florida, USA
| | - Miguel Rodriguez-Guerra
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
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Hasan N, Jauregui W, Zubair M, Pushparajan VK, Carson BJ, Attaluri DM, Dixon D, Jaisinghani A, Chuecos A, Ravichandran D. Adverse Drug Effect Profiles of Gp2b/3a Inhibitors: A Comparative Review of the Last Two Decades. Cureus 2023; 15:e49332. [PMID: 38143693 PMCID: PMC10748847 DOI: 10.7759/cureus.49332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
ST-Elevation Myocardial Infarction and non-ST Elevation Myocardial Infarction belong to the acute coronary syndrome group of diseases. These conditions are characterized by the complete or partial blockage of one or several coronary arteries, resulting in myocardial injury or necrosis. Various medications are used in their treatment, with the most recent addition being Glycoprotein IIb/IIIa inhibitors. They work by hindering the activity of glycoprotein IIb/IIIa receptors, which, in turn, prevents the clumping of platelets. Some of the GpIIb/IIIa inhibitors available in this category include abciximab, tirofiban, eptifibatide, roxifiban, and orbofiban. With this comprehensive literature review, we aimed to explore the potential adverse effects of these medications and compare the three in terms of their side effects profile. We searched through PubMed and Google Scholar and pinpointed 13 articles aligned with our inclusion criteria: six articles utilized eptifibatide, four were related to abciximab, and three used tirofiban. In 85% of the cases, a severe drop in platelet count, reaching as low as 1000/μL, was reported. Additionally, several other side effects were noted: one case documented multiple bruising spots appearing around the patient's body, two cases reported diffuse alveolar hemorrhage, and one case described a cardiac tamponade resulting from hemorrhagic pericarditis. Our study highlights the crucial significance of keeping a watchful eye on and comprehending the potential drawbacks linked to these medications in cardiovascular treatment. The necessity of researching these medications and their side effects is also evident, as this will significantly enhance the quality of treatment provided.
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Affiliation(s)
- Naziha Hasan
- Emergency Department, Derriford Hospital, Plymouth, GBR
| | - Walter Jauregui
- General Medicine, Universidad Nacional Autónoma de Honduras, Tegucigalpa, HND
| | - Mahrukh Zubair
- General Medicine, Mohi-ud-Din Islamic Medical College, Azad Jammu Kashmir, PAK
| | | | - Bryan J Carson
- Emergency Medicine, Northern Health and Social Care Trust, Coleraine, GBR
| | | | - Diny Dixon
- General Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, IND
| | | | - Andres Chuecos
- General Medicine, La Universidad de los Andes, Mérida, VEN
| | - Deepika Ravichandran
- General Medicine, American University of Antigua College of Medicine, St John's, ATG
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Stopyra JP, Snavely AC, Ashburn NP, Supples MW, Miller CD, Mahler SA. Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST-elevation myocardial infarction. Acad Emerg Med 2023; 30:1101-1109. [PMID: 37567785 PMCID: PMC10830062 DOI: 10.1111/acem.14787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/24/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients. METHODS We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death. RESULTS Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%). CONCLUSIONS Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min.
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Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael W. Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Chadwick D. Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Hu T, Yu WP, Zou HX, Chai ZH, Le SY, Hu FJ, Wang YC, Huang H, Lai SQ, Liu JC. Role of dysregulated ferroptosis‑related genes in cardiomyocyte ischemia‑reperfusion injury: Experimental verification and bioinformatics analysis. Exp Ther Med 2023; 26:534. [PMID: 37869642 PMCID: PMC10587876 DOI: 10.3892/etm.2023.12233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/09/2023] [Indexed: 10/24/2023] Open
Abstract
Acute myocardial infarction is a life-threatening condition with high mortality and complication rates. Although myocardial reperfusion can preserve ischemic myocardial tissue, it frequently exacerbates tissue injury, a phenomenon known as ischemia-reperfusion injury (IRI). However, the underlying pathological mechanisms of IRI remain to be completely understood. Ferroptosis is a novel type of regulated cell death that is associated with various pathological conditions, including angiocardiopathy. The purpose of this article was to elucidate the possible mechanistic role of ferroptosis in IRI through bioinformatics analysis and experimental validation. Healthy and IRI heart samples were screened for differentially expressed ferroptosis-related genes and functional enrichment analysis was performed to determine the potential crosstalk and pathways involved. A protein-protein interaction network was established for IRI, and 10 hub genes that regulate ferroptosis, including HIF1A, EGFR, HMOX1, and ATF3 were identified. In vitro, an anoxia/reoxygenation (A/R) injury model was established using H9c2 cardiomyoblasts to validate the bioinformatics analysis results, and extensive ferroptosis was detected. A total of 4 key hub genes and 3 key miRNAs were also validated. It was found that IRI was related to the aberrant infiltration of immune cells and the small-molecule drugs that may protect against IRI by preventing ferroptosis were identified. These results provide novel insights into the role of ferroptosis in IRI, which can help identify novel therapeutic targets.
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Affiliation(s)
- Tie Hu
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Wen-Peng Yu
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Hua-Xi Zou
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Zhi-Hao Chai
- Institute of Cardiovascular Surgical Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Shu-Yu Le
- Institute of Cardiovascular Surgical Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Fa-Jia Hu
- Institute of Cardiovascular Surgical Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Yi-Cheng Wang
- Institute of Cardiovascular Surgical Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Huang Huang
- Institute of Cardiovascular Surgical Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Song-Qing Lai
- Institute of Cardiovascular Surgical Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Ji-Chun Liu
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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Custodio-Sánchez P, Miranda-Noé D, López-Rojas LM, Paredes Paucar CP, Yábar Galindo WG, Rojas De La Cuba P, Martos Salcedo JO, Chacón-Diaz M. [Proposal for initial management of uncomplicated ST elevation myocardial infarction in centers without percutaneous coronary intervention capacity in Peru]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2023; 4:164-183. [PMID: 38298415 PMCID: PMC10824752 DOI: 10.47487/apcyccv.v4i4.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/18/2023] [Indexed: 02/02/2024]
Abstract
ST-segment elevation myocardial infarction (STEMI) is a clinical entity whose adequate treatment will depend on its prompt recognition, accurate diagnosis, and management in reperfusion networks. The first contact with these patients is generally done in centers without reperfusion capacity, attended by non-cardiologist doctors, and in centers far from hospitals with greater resolution capacity, something that is well known in our country. This manuscript proposes a strategy for the diagnosis and treatment of STEMI in centers without percutaneous coronary intervention capacity of the public health system in Peru, emphasizing not losing sight of electrocardiographic patterns compatible with coronary artery occlusion, adequate fibrinolysis and management of its complications, the treatment of infarction in special populations and highlighting the importance of the pharmacoinvasive strategy as the main form of reperfusion treatment in our country.
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Affiliation(s)
- Piero Custodio-Sánchez
- Unidad de Cardiología Intervencionista, Hospital Nacional Almanzor Aguinaga Asenjo, Chiclayo, Perú.Unidad de Cardiología IntervencionistaHospital Nacional Almanzor Aguinaga AsenjoChiclayoPerú
| | - David Miranda-Noé
- Servicio de Cardiología Clínica. Instituto Nacional Cardiovascular INCOR, Lima, Perú.Servicio de Cardiología ClínicaInstituto Nacional Cardiovascular INCORLimaPerú
| | - L. Marco López-Rojas
- Hospital Nacional Hipólito Unanue, Lima, Perú.Hospital Nacional Hipólito UnanueLimaPerú
| | - Cynthia Paola Paredes Paucar
- Unidad de insuficiencia cardiaca, Hospital Germans Trias i Pujol, Barcelona, España.Unidad de insuficiencia cardiacaHospital Germans Trias i PujolBarcelonaEspaña
| | - W. Germán Yábar Galindo
- Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú.Hospital Nacional Guillermo Almenara IrigoyenLimaPerú
| | - Paol Rojas De La Cuba
- Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú.Hospital Nacional Guillermo Almenara IrigoyenLimaPerú
| | - Jorge Orlando Martos Salcedo
- Servicio de Cardiología. Hospital Regional Docente de Cajamarca, Cajamarca, Perú.Servicio de CardiologíaHospital Regional Docente de CajamarcaCajamarcaPerú
| | - Manuel Chacón-Diaz
- Unidad Cardiovascular. Clínica Delgado AUNA, Lima, Perú.Unidad CardiovascularClínica Delgado AUNALimaPerú
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Daniels E, Lamb GC, Beckius A. Reducing inappropriate oxygen use in hospitalized medicine patients. Hosp Pract (1995) 2023; 51:205-210. [PMID: 37496308 DOI: 10.1080/21548331.2023.2241341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 03/21/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Evidence suggests inappropriate oxygenation may be harmful to patients. To improve oxygen use in our hospital, we initiated a quality improvement project with a goal to reduce the percentage of inappropriate utilization of oxygen by 50% within a year. METHODS Nasal cannula (NC) oxygen use data for medicine inpatients was abstracted weekly for chart review. A multidisciplinary team developed a guideline for use. Initiation of NC O2 with a baseline SPO2 > 92% was deemed inappropriate and 3+ consecutive SPO2 > 96% was defined as over-supplementation. Formal interventions included an oxygen use guideline, updated EMR order, unit-specific feedback, and magnetic placards. Progress was tracked by control charts. RESULTS Baseline data revealed 40% of patients were inappropriately placed on oxygen and 55% of patients had one instance of excessive supplementation. Only half of all improper uses of oxygen had charted medical reasoning, and 30% had a corresponding order. Instances of proper oxygen use had orders 48% of the time. Run charts revealed inappropriate initiation was significantly reduced to 27.1% (p < 0.0001) and excessive oxygenation decreased significantly to 34.4% (p < 0.0001) following interventions with no effect on other variables. CONCLUSIONS Our interventions significantly decreased improper oxygen initiation and excessive supplementation.
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Affiliation(s)
| | - Geoffrey C Lamb
- Section of Hospital Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anna Beckius
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Roh JW, Bae S, Johnson TW, Heo SJ, Kim Y, Cho DK, Kim JS, Kim BK, Choi D, Hong MK, Jang Y, Jeong MH. Impact of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction and Chronic Kidney Disease. Circ J 2023; 87:1339-1346. [PMID: 37258223 DOI: 10.1253/circj.cj-23-0189] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND In the setting of acute myocardial infarction (AMI), there are no data regarding the benefits of intravascular ultrasound (IVUS) for chronic kidney disease (CKD) patients.Methods and Results: This study used data from the Korea Acute Myocardial Infarction Registry, a large, multicenter prospective cohort. We evaluated 1,759 patients with AMI and CKD, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, and patients were classified into 2 groups: with and without IVUS. The primary outcome was target lesion failure (TLF) at 3 years. The hazard ratio (HR) of TLF according to eGFR was also analyzed. A total of 1,759 patients with AMI and CKD who underwent IVUS-guided PCI (19.2%) had a significantly lower risk of TLF at 3 years (8.9% vs. 15.3%; HR 0.55; 95% confidence interval [CI]: 0.38 to 0.81; P=0.002) than those who underwent angiography-guided PCI, regardless of their eGFR and the presence of end-stage renal disease (ESRD). The results were consistent after confounder adjustment and inversed probability weighting. CONCLUSIONS In patients with CKD and AMI who underwent PCI with 2nd-generation DES implantation, the use of IVUS guidance was associated with a significant reduction in 3-year TLF and showed consistently favorable outcomes regardless of eGFR and ESRD.
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Affiliation(s)
- Ji Woong Roh
- Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital
| | - SungA Bae
- Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital
| | | | - Seok-Jae Heo
- Division of Biostatistics, Department of Biomedical Systems Informatics, Yonsei University College of Medicine
| | - Yongcheol Kim
- Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital
| | - Deok-Kyu Cho
- Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital
| | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei University Health System
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University Health System
| | - Donghoon Choi
- Severance Cardiovascular Hospital, Yonsei University Health System
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University Health System
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Centre, CHA University
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Kamin Mukaz D, Cushman M. Percutaneous Coronary Intervention in Acute Myocardial Infarction: Community Wealth Matters. J Am Heart Assoc 2023; 12:e031415. [PMID: 37646210 PMCID: PMC10547354 DOI: 10.1161/jaha.123.031415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Debora Kamin Mukaz
- Department of MedicineLarner College of Medicine, University of VermontBurlingtonVTUSA
| | - Mary Cushman
- Department of MedicineLarner College of Medicine, University of VermontBurlingtonVTUSA
- Department of Pathology and Laboratory MedicineLarner College of Medicine, University of VermontBurlingtonVTUSA
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Xiao SY, Goldschlager N, Durstenfeld MS. Chest Pain, Bundle Branch Block, and Wide Complex Tachycardia: Is Three a Company or Crowd? Circulation 2023; 148:845-847. [PMID: 37669354 DOI: 10.1161/circulationaha.123.066197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Affiliation(s)
- Sophia Y Xiao
- Department of Medicine, University of California, San Francisco; and Division of Cardiology, Zuckerberg San Francisco General Hospital, CA
| | - Nora Goldschlager
- Department of Medicine, University of California, San Francisco; and Division of Cardiology, Zuckerberg San Francisco General Hospital, CA
| | - Matthew S Durstenfeld
- Department of Medicine, University of California, San Francisco; and Division of Cardiology, Zuckerberg San Francisco General Hospital, CA
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Zhang K, Jiang Y, Zeng H, Zhu H. Application and risk prediction of thrombolytic therapy in cardio-cerebrovascular diseases: a review. Thromb J 2023; 21:90. [PMID: 37667349 PMCID: PMC10476453 DOI: 10.1186/s12959-023-00532-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/18/2023] [Indexed: 09/06/2023] Open
Abstract
Cardiocerebrovascular diseases (CVDs) are the leading cause of death worldwide, consuming huge healthcare budget. For CVD patients, the prompt assessment and appropriate administration is the crux to save life and improve prognosis. Thrombolytic therapy, as a non-invasive approach to achieve recanalization, is the basic component of CVD treatment. Still, there are risks that limits its application. The objective of this review is to give an introduction on the utilization of thrombolytic therapy in cardiocerebrovascular blockage diseases, including coronary heart disease and ischemic stroke, and to review the development in risk assessment of thrombolytic therapy, comparing the performance of traditional scales and novel artificial intelligence-based risk assessment models.
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Affiliation(s)
- Kexin Zhang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Yao Jiang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Hesong Zeng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Hongling Zhu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Oqab Z, Kunadian V, Wood DA, Storey RF, Rao SV, Mehran R, Pinilla-Echeverri N, Mani T, Boone RH, Kassam S, Bossard M, Mansour S, Ball W, Sibbald M, Valettas N, Moreno R, Steg PG, Cairns JA, Mehta SR. Complete Revascularization Versus Culprit-Lesion-Only PCI in STEMI Patients With Diabetes and Multivessel Coronary Artery Disease: Results From the COMPLETE Trial. Circ Cardiovasc Interv 2023; 16:e012867. [PMID: 37725677 DOI: 10.1161/circinterventions.122.012867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 07/31/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND In the COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI), a strategy of complete revascularization reduced the risk of major cardiovascular events compared with culprit-lesion-only percutaneous coronary intervention in patients presenting with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Patients with diabetes have a worse prognosis following STEMI. We evaluated the consistency of the effects of complete revascularization in patients with and without diabetes. METHODS The COMPLETE trial randomized a strategy of complete revascularization, consisting of angiography-guided percutaneous coronary intervention of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only percutaneous coronary intervention (guideline-directed medical therapy alone). In prespecified analyses, treatment effects were determined in patients with and without diabetes on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Interaction P values were calculated to evaluate whether there was a differential treatment effect in patients with and without diabetes. RESULTS Of the 4041 patients enrolled in the COMPLETE trial, 787 patients (19.5%) had diabetes. The median HbA1c (glycated hemoglobin) was 7.7% in the diabetes group and 5.7% in the nondiabetes group. Complete revascularization consistently reduced the first coprimary outcome in patients with diabetes (hazard ratio, 0.87 [95% CI, 0.59-1.29]) and without diabetes (hazard ratio, 0.70 [95% CI, 0.55-0.90]), with no evidence of a differential treatment effect (interaction P=0.36). Similarly, for the second coprimary outcome, no differential treatment effect (interaction P=0.27) of complete revascularization was found in patients with diabetes (hazard ratio, 0.61 [95% CI, 0.43-0.87]) and without diabetes (hazard ratio, 0.48 [95% CI, 0.39-0.60]). CONCLUSIONS Among patients presenting with STEMI and multivessel disease, the benefit of complete revascularization over a culprit-lesion-only percutaneous coronary intervention strategy was consistent regardless of the presence or absence of diabetes.
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Affiliation(s)
- Zardasht Oqab
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Dalhousie University, Nova Scotia, Halifax, Canada (Z.O.)
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom (V.K.)
| | - David A Wood
- Centre for Cardiovascular Innovation, UBC Division of Cardiology, St Paul's and Vancouver General Hospital, Canada (D.A.W., R.H.B., J.A.C.)
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Sunil V Rao
- NYU Langone Health System, New York (S.V.R.)
| | - Roxana Mehran
- Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Thenmozhi Mani
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Robert H Boone
- Centre for Cardiovascular Innovation, UBC Division of Cardiology, St Paul's and Vancouver General Hospital, Canada (D.A.W., R.H.B., J.A.C.)
| | - Saleem Kassam
- Scarborough Health Network Centenary, Toronto, Ontario, Canada (S.K.)
| | | | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (S.M.)
| | - Warren Ball
- Peterborough Regional Health Centre, Toronto, Ontario, Canada (W.B.)
| | - Matthew Sibbald
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Nicholas Valettas
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Raul Moreno
- University Hospital La Paz, Madrid, Spain (R.M.)
| | | | - John A Cairns
- Centre for Cardiovascular Innovation, UBC Division of Cardiology, St Paul's and Vancouver General Hospital, Canada (D.A.W., R.H.B., J.A.C.)
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
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Holzer M, Poole JE, Lascarrou JB, Fujise K, Nichol G. A Commentary on the Effect of Targeted Temperature Management in Patients Resuscitated from Cardiac Arrest. Ther Hypothermia Temp Manag 2023; 13:102-111. [PMID: 36378270 PMCID: PMC10625468 DOI: 10.1089/ther.2022.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplete, especially since there was no significant difference in primary outcome between hypothermia versus normothermia in the recently reported TTM2 trial. We critically appraise trials of IH/TTM versus normothermia to characterize reasons for the lack of treatment effect, based on a previously published framework for what to consider when the primary outcome fails. We found a strong biologic rationale and external clinical evidence that IH treatment is beneficial. Recent TTM trials mainly included unselected patients with a high rate of bystander cardiopulmonary resuscitation. The treatment was not applied as intended, which led to a large delay in achievement of target temperature. While receiving intensive care, sedative drugs were likely used that might have led to increased neurologic damage as were antiplatelet drugs that could be associated with increased acute stent thrombosis in hypothermic patients. It is reasonable to still use or evaluate IH treatment in patients who are comatose after CA as there are multiple plausible reasons why IH compared to normothermia did not significantly improve neurologic outcome in the TTM trials.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeanne E. Poole
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | | | - Ken Fujise
- Harborview Medical Center, Heart Institute, University of Washington, Seattle, Washington, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, Washington, USA
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46
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Sbrollini A, Ter Haar CC, Leoni C, Morettini M, Burattini L, Swenne CA. Advanced repeated structuring and learning procedure to detect acute myocardial ischemia in serial 12-lead ECGs. Physiol Meas 2023; 44:084003. [PMID: 37376978 DOI: 10.1088/1361-6579/ace241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 06/27/2023] [Indexed: 06/29/2023]
Abstract
Objectives. Acute myocardial ischemia in the setting of acute coronary syndrome (ACS) may lead to myocardial infarction. Therefore, timely decisions, already in the pre-hospital phase, are crucial to preserving cardiac function as much as possible. Serial electrocardiography, a comparison of the acute electrocardiogram with a previously recorded (reference) ECG of the same patient, aids in identifying ischemia-induced electrocardiographic changes by correcting for interindividual ECG variability. Recently, the combination of deep learning and serial electrocardiography provided promising results in detecting emerging cardiac diseases; thus, the aim of our current study is the application of our novel Advanced Repeated Structuring and Learning Procedure (AdvRS&LP), specifically designed for acute myocardial ischemia detection in the pre-hospital phase by using serial ECG features.Approach. Data belong to the SUBTRACT study, which includes 1425 ECG pairs, 194 (14%) ACS patients, and 1035 (73%) controls. Each ECG pair was characterized by 28 serial features that, with sex and age, constituted the inputs of the AdvRS&LP, an automatic constructive procedure for creating supervised neural networks (NN). We created 100 NNs to compensate for statistical fluctuations due to random data divisions of a limited dataset. We compared the performance of the obtained NNs to a logistic regression (LR) procedure and the Glasgow program (Uni-G) in terms of area-under-the-curve (AUC) of the receiver-operating-characteristic curve, sensitivity (SE), and specificity (SP).Main Results. NNs (median AUC = 83%, median SE = 77%, and median SP = 89%) presented a statistically (Pvalue lower than 0.05) higher testing performance than those presented by LR (median AUC = 80%, median SE = 67%, and median SP = 81%) and by the Uni-G algorithm (median SE = 72% and median SP = 82%).Significance. In conclusion, the positive results underscore the value of serial ECG comparison in ischemia detection, and NNs created by AdvRS&LP seem to be reliable tools in terms of generalization and clinical applicability.
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Affiliation(s)
- Agnese Sbrollini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - C Cato Ter Haar
- Cardiology Department, Leiden University Medical Center, Leiden, the Netherlands
- Cardiology Department, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Chiara Leoni
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Micaela Morettini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Laura Burattini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Cees A Swenne
- Cardiology Department, Leiden University Medical Center, Leiden, the Netherlands
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Dalia T, Pothuru S, Chan WC, Mehta H, Goyal A, Farhoud H, Boda I, Malhotra A, Vidic A, Rali AS, Hanff TC, Gupta K, Fang JC, Shah Z. Trends and Outcomes of Cardiogenic Shock in Patients With End-Stage Renal Disease: Insights From USRDS Database. Circ Heart Fail 2023; 16:e010462. [PMID: 37503601 DOI: 10.1161/circheartfailure.122.010462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND There is a paucity of data regarding epidemiology, temporal trends, and outcomes of patients with cardiogenic shock (CS) and end-stage renal disease (chronic kidney disease stage V on hemodialysis). METHODS This is a retrospective cohort study using the United States Renal Data System database from January 1, 2006 to December 31, 2019. We analyzed trends of CS, percutaneous mechanical support (intraaortic balloon pump, percutaneous ventricular assist device [Impella and Tandemheart], and extracorporeal membrane oxygenation) utilization, index mortality, 30-day mortality, and 1-year all-cause mortality in end-stage renal disease patients. RESULTS A total of 43 825 end-stage renal disease patients were hospitalized with CS (median age, 67.8 years [IQR, 59.4-75.8] and 59.1% men). From 2006 to 2019, the incidence of CS increased from 275 to 578 per 100 000 patients (Ptrend<0.001). The index mortality rate declined from 54.1% in 2006 to 40.8% in 2019 (Ptrend=0.44), and the 1-year all-cause mortality decreased from 63% in 2006 to 61.8% in 2018 (Ptrend=0.73), but neither trend was statistically significant. There was a significantly decreased utilization of intra-aortic balloon pumps from 17 832 to 7992 (Ptrend<0.001), increased utilization of percutaneous ventricular assist device from 137 to 5201 (Ptrend<0.001) and increase in extracorporeal membrane oxygenation use from 69 to 904 per 100 000 patients (Ptrend<0.001). After adjusting for covariates, there was no significant difference in index mortality between CS patients requiring percutaneous mechanical support versus those not requiring percutaneous mechanical support (odds ratio, 0.97 [CI, 0.91-1.02]; P=0.22). On multivariable regression analysis, older age, peripheral vascular disease, diabetes, and time on dialysis were independent predictors of higher index mortality. CONCLUSIONS The incidence of CS in end-stage renal disease patients has doubled without significant change in the trend of index mortality despite the use of percutaneous mechanical support.
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Affiliation(s)
- Tarun Dalia
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Suveenkrishna Pothuru
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Wan-Chi Chan
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Harsh Mehta
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Amandeep Goyal
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Hassan Farhoud
- Medical Student, Class of 2023, University of Kansas Medical Center (H.F.)
| | - Ilham Boda
- Department of Internal Medicine, University of Kansas Health System (I.B., A.M.)
| | - Anureet Malhotra
- Department of Internal Medicine, University of Kansas Health System (I.B., A.M.)
| | - Andrija Vidic
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (A.S.R.)
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City (T.C.H., J.C.F.)
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City (T.C.H., J.C.F.)
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Health System (T.D., S.P., W.-C.C., H.M., A.G., A.V., K.G., Z.S.)
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Osho A, Fernandes MF, Poudel R, de Lemos J, Hong H, Zhao J, Li S, Thomas K, Kikuchi DS, Zegre-Hemsey J, Ibrahim N, Shah NS, Hollowell L, Tamis-Holland J, Granger CB, Cohen M, Henry T, Jacobs AK, Jollis JG, Yancy CW, Goyal A. Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry. Circulation 2023; 148:229-240. [PMID: 37459415 DOI: 10.1161/circulationaha.123.065512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. METHODS We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence. RESULTS Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]). CONCLUSIONS Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.
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Affiliation(s)
- Asishana Osho
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston (A.O.)
| | | | - Ram Poudel
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - James de Lemos
- University of Texas Southwestern Medical Center, Dallas (J.d.L.)
| | - Haoyun Hong
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Juan Zhao
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Shen Li
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Kathie Thomas
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Daniel S Kikuchi
- Osler Medical Residency, Johns Hopkins Hospital, Baltimore, MD (D.S.K.)
| | | | - Nasrien Ibrahim
- Harvard T.H. Chan School of Public Health, Boston, MA (N.I.)
| | - Nilay S Shah
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Lori Hollowell
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | | | | | | | - Timothy Henry
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | | | - James G Jollis
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | - Clyde W Yancy
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Abhinav Goyal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.G.)
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Wu C, Gao X, Li L, Jing Q, Li W, Xu H, Zhang W, Li S, Zhao Y, Wang Y, Li W, Wu Y, Hu F, Jin C, Qiao S, Yang J, Yang Y. Role of ST-Segment Resolution Alone and in Combination With TIMI Flow After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2023:e029670. [PMID: 37449560 PMCID: PMC10382099 DOI: 10.1161/jaha.123.029670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
Background To evaluate the role of ST-segment resolution (STR) alone and in combination with Thrombolysis in Myocardial Infarction (TIMI) flow in reperfusion evaluation after primary percutaneous coronary intervention (PPCI) for ST-segment-elevation myocardial infarction by investigating the long-term prognostic impact. Methods and Results From January 2013 through September 2014, we studied 5966 patients with ST-segment-elevation myocardial infarction enrolled in the CAMI (China Acute Myocardial Infarction) registry with available data of STR evaluated at 120 minutes after PPCI. Successful STR included STR ≥50% and complete STR (ST-segment back to the equipotential line). After PPCI, the TIMI flow was assessed. The primary outcome was 2-year all-cause mortality. STR < 50%, STR ≥50%, and complete STR occurred in 20.6%, 64.3%, and 15.1% of patients, respectively. By multivariable analysis, STR ≥50% (5.6%; adjusted hazard ratio [HR], 0.45 [95% CI, 0.36-0.56]) and complete STR (5.1%; adjusted HR, 0.48 [95% CI, 0.34-0.67]) were significantly associated with lower 2-year mortality than STR <50% (11.7%). Successful STR was an independent predictor of 2-year mortality across the spectrum of clinical variables. After combining TIMI flow with STR, different 2-year mortality was observed in subgroups, with the lowest in successful STR and TIMI 3 flow, intermediate when either of these measures was reduced, and highest when both were abnormal. Conclusions Post-PPCI STR is a robust long-term prognosticator for ST-segment-elevation myocardial infarction, whereas the integrated analysis of STR plus TIMI flow yields incremental prognostic information beyond either measure alone, supporting it as a convenient and reliable surrogate end point for defining successful PPCI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01874691.
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Affiliation(s)
- Chao Wu
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Xiaojin Gao
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Ling Li
- Medical Research and Biometrics Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Quanmin Jing
- Department of Cardiology General Hospital of Shenyang Military Region Shenyang China
| | - Weimin Li
- Department of Cardiology The First Affiliated Hospital of Harbin Medical University Harbin China
| | - Haiyan Xu
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Wenbo Zhang
- Department of Epidemiology University Medical Center Groningen Groningen the Netherlands
| | - Sidong Li
- Division of Life Sciences and Medicine University of Science and Technology of China Hefei China
| | - Yanyan Zhao
- Medical Research and Biometrics Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Wei Li
- Medical Research and Biometrics Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Yongjian Wu
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Fenghuan Hu
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Chen Jin
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Shubin Qiao
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Jingang Yang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
| | - Yuejin Yang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, State Key Laboratory of Cardiovascular Disease National Center for Cardiovascular Diseases Beijing China
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Savage ML, Hay K, Vollbon W, Doan T, Murdoch DJ, Hammett C, Poulter R, Walters DL, Denman R, Ranasinghe I, Raffel OC. Prehospital Activation of the Cardiac Catheterization Laboratory in ST-Segment-Elevation Myocardial Infarction for Primary Percutaneous Coronary Intervention. J Am Heart Assoc 2023:e029346. [PMID: 37449585 PMCID: PMC10382081 DOI: 10.1161/jaha.122.029346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
Background Prehospital activation of the cardiac catheter laboratory is associated with significant improvements in ST-segment-elevation myocardial infarction (STEMI) performance measures. However, there are equivocal data, particularly within Australia, regarding its influence on mortality. We assessed the association of prehospital activation on performance measures and mortality in patients with STEMI treated with primary percutaneous coronary intervention from the Queensland Cardiac Outcomes Registry (QCOR). Methods and Results Consecutive ambulance-transported patients with STEMI treated with primary percutaneous coronary intervention were analyzed from January 1, 2017 to December 31, 2020 from the QCOR. The total and direct effects of prehospital activation on the primary outcomes (30-day and 1-year cardiovascular mortality) were estimated using logistic regression analyses. Secondary outcomes were STEMI performance measures. Among 2498 patients (mean age: 62.2±12.4 years; 79.2% male), 73% underwent prehospital activation. Median door-to-balloon time (34 minutes [26-46] versus 86 minutes [68-113]; P<0.001), first-electrocardiograph-to-balloon time (83.5 minutes [72-98] versus 109 minutes [81-139]; P<0.001), and proportion of patients meeting STEMI targets (door-to-balloon <60 minutes 90% versus 16%; P<0.001), electrocardiograph-to-balloon time <90 minutes (62% versus 33%; P<0.001) were significantly improved with prehospital activation. Prehospital activation was associated with significantly lower 30-day (1.6% versus 6.6%; P<0.001) and 1-year cardiovascular mortality (2.9% versus 9.5%; P<0.001). After adjustment, no prehospital activation was strongly associated with increased 30-day (odds ratio [OR], 3.6 [95% CI, 2.2-6.0], P<0.001) and 1-year cardiovascular mortality (OR, 3.0 [95% CI, 2.0-4.6]; P<0.001). Conclusions Prehospital activation of cardiac catheterization laboratory for primary percutaneous coronary intervention was associated with significantly shorter time to reperfusion, achievement of STEMI performance measures, and lower 30-day and 1-year cardiovascular mortality.
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Affiliation(s)
- Michael L Savage
- Cardiology Department The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine, Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Karen Hay
- School of Clinical Medicine, Faculty of Medicine University of Queensland Brisbane Queensland Australia
- QIMR Berghofer Medical Research Institute Brisbane Queensland Australia
| | - William Vollbon
- Queensland Cardiac Outcomes Registry Brisbane Queensland Australia
| | - Tan Doan
- Queensland Ambulance Service Brisbane Queensland Australia
| | - Dale J Murdoch
- Cardiology Department The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine, Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Christopher Hammett
- Cardiology Department The Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Rohan Poulter
- Queensland Cardiac Outcomes Registry Brisbane Queensland Australia
- Cardiology Department Sunshine Coast University Hospital Brisbane Queensland Australia
| | - Darren L Walters
- Cardiology Department The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine, Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Russell Denman
- Cardiology Department The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine, Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Isuru Ranasinghe
- Cardiology Department The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine, Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Owen Christopher Raffel
- Cardiology Department The Prince Charles Hospital Brisbane Queensland Australia
- School of Clinical Medicine, Faculty of Medicine University of Queensland Brisbane Queensland Australia
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