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The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly infectious, carries significant morbidity and mortality, and has rapidly resulted in strained health care system and hospital resources. In addition to patient-related care concerns in infected individuals, focus must also relate to diminishing community spread, protection of staff, case selection, and concentration of resources. The current document based on available data and consensus opinion addresses appropriate catheterization laboratory preparedness for treating these patients, including procedure-room readiness to minimize external contamination, safe donning and doffing of personal protective equipment (PPE) to eliminate risk to staff, and staffing algorithms to minimize exposure and maximize team availability. Case selection and management of both emergent and urgent procedures are discussed in detail, including procedures that may be safely deferred or performed bedside.
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Cateterismo Cardíaco/estatística & dados numéricos , Angiografia Coronária/estatística & dados numéricos , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto/normas , COVID-19 , Cateterismo Cardíaco/normas , Cardiologia , Angiografia Coronária/métodos , Infecções por Coronavirus/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Laboratórios Hospitalares , Liderança , Masculino , Mentores , Pandemias/estatística & dados numéricos , Equipamento de Proteção Individual/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Sociedades Médicas , Análise de Sobrevida , Estados UnidosRESUMO
Objectives. Using composite endpoints and/or only first events in clinical research result in information loss and alternative statistical methods which incorporate recurrent event data exist. We compared information-loss under traditional analyses to alternative models. Design. We conducted a retrospective analysis of patients who underwent percutaneous coronary intervention (Jan2010-Dec2014) and constructed Cox models for a composite endpoint (readmission/death), a shared frailty model for recurrent events, and a joint frailty (JF) model to simultaneously account for recurrent and terminal events and evaluated the impact of heart failure (HF) on the outcome. Results. Among 4901 patients, 2047(41.8%) experienced a readmission or death within 1 year. Of those with recurrent events, 60% had ≥1 readmission and 6% had >4; a total of 121(2.5%) patients died during follow-up. The presence of HF conferred an adjusted Hazard ratio (HR) of 1.32 (95% CI: 1.18-1.47, p < .001) for the risk of composite endpoint (Cox model), 1.44 (95% CI: 1.36-1.52, p < .001) in the frailty model, and 1.34 (95% CI:1.22-1.46, p < .001) in the JF model. However, HF was not associated with death (HR 0.87, 95% CI: 0.52-1.48, p = .61) in the JF model. Conclusions. Using a composite endpoint and/or only the first event yields substantial loss of information, as many individuals endure >1 event. JF models reduce bias by simultaneously providing event-specific HRs for recurrent and terminal events.
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Readmissão do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/mortalidade , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
The present-day cardiac catheterization laboratory (CCL) is home to varied practitioners who perform both diagnostic, interventional, and complex invasive procedures. Invasive, non-interventional cardiologists are performing a significant proportion of the work as the CCL environment has evolved. This not only includes those who perform diagnostic-only cardiac catheterization but also heart failure specialists who may be involved in hemodynamic assessment and in mechanical circulatory support and pulmonary hypertension specialists and transplant cardiologists. As such, the training background of those who work in the CCL is varied. While most quality metrics in the CCL are directed towards evaluation of patients who undergo traditional interventional procedures, there has not been a focus upon providing these invasive, noninterventional cardiologists, hospital/CCL administrators, and CCL directors a platform for quality metrics. This document focuses on benchmarking quality for the invasive, noninterventional practice, providing this physician community with guidance towards a patient-centered approach to care, and offering tools to the invasive, noninterventionalists to help their professional growth. This consensus statement aims to establish a foundation upon which the invasive, noninterventional cardiologists can thrive in the CCL environment and work collaboratively with their interventional colleagues while ensuring that the highest quality of care is being delivered to all patients.
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Benchmarking/normas , Cateterismo Cardíaco/normas , Cardiologistas/normas , Prestação Integrada de Cuidados de Saúde/normas , Padrões de Prática Médica/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Cateterismo Cardíaco/efeitos adversos , Cardiologistas/educação , Certificação/normas , Competência Clínica/normas , Consenso , Educação de Pós-Graduação em Medicina/normas , Humanos , Especialização/normasRESUMO
AIM: There is a variable cardiovascular risk reduction attributable to aspirin because of individual differences in the suppression of thromboxane A2 and its downstream metabolite 11-dehydro-thromboxane B2 (11dhTxB2 ). The aim of this study is to evaluate the optimal cut point of urinary 11dhTxB2 for the risk of mortality in aspirin-treated coronary artery disease (CAD) patients. METHODS AND RESULTS: This was a prospective cohort study including stable CAD patients who visited the Baylor Heart and Vascular Hospital in Dallas or the Texas Heart Hospital Baylor Plano, TX between 2010 and 2013. The outcome of all-cause mortality was ascertained from chart review and automated sources. The 449 patients included in this analysis had a mean age of 66.1 ± 10.1 years. 67 (14.9%) patients died within 5 years; 56 (87.5%) of the 64 patients with known cause of death suffered a cardiovascular related mortality. Baseline ln(urinary 11dhTxB2 /creatinine) ranged between 5.8 and 11.1 (median = 7.2) with the higher concentrations among those who died (median: 7.6) than those who survived (median = 7.2, P < 0.001). Using baseline ln(11dhTxB2 ) to predict all-cause mortality, the area under the curve was 0.70 (95% CI: 0.64-0.76). The optimal cut point was found to be ln(7.38) = 1597.8 pg/mg, which had the following decision statistics: sensitivity = 0.67, specificity = 0.62, positive predictive value = 0.24, negative predictive value = 0.92, and accuracy = 0.63. CONCLUSION: Our data indicate the optimal cut point for urine 11dhTxB2 is 1597.8 (pg/mg) for the risk prediction of mortality over five years in stable patients with CAD patients treated with aspirin.
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Aspirina/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Tromboxano B2/análogos & derivados , Idoso , Idoso de 80 Anos ou mais , Aspirina/urina , Biomarcadores/urina , Causas de Morte , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/urina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/urina , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Texas , Tromboxano B2/urina , Fatores de Tempo , Resultado do Tratamento , UrináliseRESUMO
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndromes and sudden cardiac death. The epidemiology, pathogenesis, and optimal approaches to diagnosis and management are poorly understood. Additionally, SCAD as a syndrome is commonly under-recognized and its prognosis is not well studied. Guidelines on management of SCAD have not yet been established. We present three cases of SCAD that varied in their clinical presentation and describe the different management strategies utilized. This is followed by a review of the clinical features, epidemiology, prognosis, and potential treatment strategies for patients presenting with SCAD.
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Fármacos Cardiovasculares/uso terapêutico , Ponte de Artéria Coronária , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/terapia , Intervenção Coronária Percutânea , Doenças Vasculares/congênito , Adulto , Angiografia Coronária , Anomalias dos Vasos Coronários/epidemiologia , Stents Farmacológicos , Eletrocardiografia , Feminino , Humanos , Masculino , Intervenção Coronária Percutânea/instrumentação , Fatores de Risco , Resultado do Tratamento , Ultrassonografia de Intervenção , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/epidemiologia , Doenças Vasculares/terapia , Adulto JovemRESUMO
BACKGROUND: Cardiac troponins are often found to be elevated in patients with renal dysfunction, even in the absence of acute myocardial injury. The objective of this report was to characterize the scaled troponin values and proportion of adjudicated acute myocardial infarction (AMI) among patients with and without renal dysfunction. METHODS: The data was from a multicenter prospective study including patients presenting to the emergency department with symptoms of AMI. Troponin measurements were standardized across various assays by calculating the observed results as multiples of the assay-specific 99th percentile upper limit of normal. Patients with an estimated glomerular filtration rate (eGFR; calculated by the Chronic Kidney Disease Epidemiology Collaboration formula) <60 mL/min/1.73 m2 were considered to have renal dysfunction. RESULTS: Of 430 included patients, 249 (58%) were male and 181 (42%) were female, with a mean age of 55.9 ± 12.3 and 57.3 ± 12.8 years, respectively. Eighty-seven (20.2%) had renal dysfunction. The proportions of patients with at least one scaled troponin value above the 99th percentile cut-off point among patients with and without renal dysfunction were 40 (45.9%) and 81 (23.6%) respectively (p < 0.001). The proportions of patients with an adjudicated diagnosis of AMI among those with and without renal dysfunction were 20.7 and 18.7%, respectively (p = 0.67). Using scaled troponins, by the second test there was >5X and by the third test >15X separation in the excursion of troponin among those with AMI compared to those without. CONCLUSIONS: One or more elevated troponin values are common in those with renal dysfunction. Scaled troponins for eGFR groups were similar, indicating that the use of this interpretative technique is applicable in discerning AMI for those with and without renal dysfunction.
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Taxa de Filtração Glomerular , Rim/fisiopatologia , Infarto do Miocárdio/sangue , Troponina I/sangue , Troponina T/sangue , Adulto , Idoso , Biomarcadores/sangue , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Cardiac computed tomography angiography (CCTA) has become the gold standard for noninvasive anatomic assessment of the coronary arteries. With high positive predictive value and even higher negative predictive value, CCTA allows for rapid determination of the presence or absence of coronary plaque and triage of patients' need for further invasive evaluation and treatment. From an interventional cardiologist's perspective, CCTA (more so than stress testing) is helpful in determining the need for invasive therapy. In conjunction with functional assessments, the anatomic evaluation from CCTA mirrors the anatomical assessment of a coronary angiogram more than any other noninvasive assessment. This allows for catheter selection, percutaneous coronary intervention preplanning, as well as additional decision making before the patient has entered the catheterization laboratory. This manuscript explores some of the more recent developments in noninvasive coronary angiography and discusses the use and utility of CCTA from an interventional cardiologist's perspective.
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BACKGROUND: Dual anti-platelet therapy including clopidogrel or prasugrel is standard of care for patients receiving stents. Prasugrel has quicker onset so it can be loaded later than clopidogrel with greater efficacy. However, prasugrel is much more expensive than clopidogrel. OBJECTIVES: To describe the incidence of 30-day death from cardiovascular causes, myocardial infarction, unstable angina requiring intervention, and minor and major bleeding in patients loaded with 60 mg of prasugrel prior to percutaneous coronary intervention (PCI) and then continued on 75 mg of clopidogrel daily after the procedure. METHODS: We reviewed sequential medical records of 102 patients (Mean age: 67.8, male 68.6%, smokers: 22.6%, BMI: 29.5%, hypertension: 90.2%, DM: 33.3%, average ejection fraction: 49.7%) who underwent PCI (3.9% STEMI, 12.7% NSTEMI, 35.3% unstable angina and 48.1% electively) at Baylor University Medical Center between October 2009 and December 2011 who were loaded with prasugrel 60 mg prior to procedure, and then continued on 75 mg clopidogrel daily. RESULTS: None of the patients died or experienced a myocardial infarction (MI) within 30 days of the procedure. Three patients experienced unstable angina requiring intervention but none had in-stent thrombosis or restenosis on repeat angiography. None of the patients experienced a major bleeding event. One patient developed a gastrointestinal bleed which did not require blood transfusion and the bleeding it resolved on discontinuation of the clopidogrel. CONCLUSION: In this retrospective pilot study, a strategy of loading patients needing PCI with prasugrel 60 mg immediately prior to coronary intervention, then continuation of anti-platelet therapy with 75 mg clopidogrel daily was safe and effective.
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Intervenção Coronária Percutânea , Piperazinas/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Tiofenos/uso terapêutico , Ticlopidina/análogos & derivados , Idoso , Clopidogrel , Feminino , Humanos , Masculino , Projetos Piloto , Cuidados Pós-Operatórios , Cloridrato de Prasugrel , Cuidados Pré-Operatórios , Estudos Retrospectivos , Ticlopidina/uso terapêuticoRESUMO
A 79-year-old woman underwent transesophageal echocardiography to evaluate the severity of her mitral regurgitation prior to urgent bypass. Evaluation of the right-sided chambers was notable for a mass in the right atrial appendage (RAA). Surgical excision and pathologic examination proved this to be a thrombus. This is the first reported case of a RAA thrombus in a patient with normal sinus rhythm and normal right ventricular (RV) function. It illustrates that complete transesophageal studies may sometimes demonstrate incidental findings, and that right atrial thrombus can (rarely) be found in patients in sinus rhythm with normal RV function.
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Apêndice Atrial/diagnóstico por imagem , Ecocardiografia/métodos , Cardiopatias/diagnóstico por imagem , Trombose/diagnóstico por imagem , Idoso , Feminino , Humanos , Achados Incidentais , Função Ventricular DireitaRESUMO
Percutaneous transluminal angioplasty and stent placement for renovascular hypertension is a recognized albeit seldom used therapy. We present a case of severe renovascular hypertension, due to renal artery atherosclerosis, treated successfully with stent placement via the radial artery access approach.
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We present a case report of a 37-year-old male who presented to the emergency department with altered mental status and electrocardiographic changes suggestive of an ST-elevation myocardial infarction (STEMI). He was ultimately diagnosed with extreme hyperthermia, secondary to drug use, which was managed promptly with supportive measures resulting in a successful outcome. This case highlights the importance of considering drug-induced hyperthermia as a potential cause of altered mental status and EKG changes in patients, especially in those with a history of drug abuse.
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Following a traumatic coronary artery dissection and subsequent myocardial infarction from a nonpenetrating strike to the chest by an airborne metal pipe, a 33-year-old male police officer completed 12 weeks of high-intensity, symptom-limited cardiac rehabilitation in order to return to active duty. Physiological and perceptual responses to exercise were used to progress the patient through high-intensity activities that challenged the musculoskeletal and cardiorespiratory systems while simulating real work activities. In addition to substantial improvements in functional capacity (8.6 to 10.3 METS) and left ventricular ejection fraction (20% to 45%), the patient was able to fully return to work as an active-duty police officer.
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OBJECTIVES: The aim of this trial was to test whether the potassium ferrate hemostatic patch (PFHP) as an adjunct to the TR Band (TRB) facilitated an early deflation protocol. BACKGROUND: Shorter TRB compression times may reduce the rate of radial artery occlusion (RAO) and reduce observation time after transradial access. METHODS: A total of 443 patients were randomized to the TRB or PFHP + TRB, with complete TRB deflation attempted 60 minutes postprocedure. The primary outcome was the time to successful full deflation of the TRB without bleeding, with secondary outcomes of time to discharge and complications including hematoma, RAO, or bleeding requiring intervention beyond TRB reinflation. RESULTS: Time to complete TRB deflation was 66 ± 14 minutes with the PFHP vs 113 ± 56 minutes for the TRB alone (P < 0.001). Minor rebleeding requiring TRB reinflation was much more frequent without the PFHP (0% vs 67.7%; P < 0.001) with 2.3 ± 1.3 additional reinflation and deflation attempts needed for hemostasis. Hematomas developed in 4.0% of the PFHP group and 6.8% of the TRB group (P = 0.20). RAO was rare (<1%), although 41% of patients received <5,000 U heparin. Among percutaneous coronary intervention patients, time to TRB deflation (68 ± 15 minutes vs 138 ± 62 minutes; P < 0.001) and composite complications (10.0% vs 24.2%; P = 0.04) were reduced with the PFHP. CONCLUSIONS: Compared with the TRB alone, the PFHP facilitated early 60-minute TRB deflation following transradial catheterization, with a numeric reduction in vascular complications. RAO occurs rarely with early deflation regardless of heparin dose. (Comparing TR Band to StatSeal in Conjunction With TR Band II [StatSeal II]; NCT04046952).
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Arteriopatias Oclusivas , Cateterismo Periférico , Hemostáticos , Arteriopatias Oclusivas/etiologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Periférico/efeitos adversos , Hemostasia , Técnicas Hemostáticas , Hemostáticos/efeitos adversos , Heparina/efeitos adversos , Humanos , Compostos de Ferro , Compostos de Potássio , Artéria Radial/diagnóstico por imagem , Fator de Transcrição STAT2 , Resultado do TratamentoRESUMO
We report a case of a 24 year old woman with an aneurysmal patent ductus arteriosus (PDA) that was percutaneously closed using an Amplatzer Vascular Plug II. This is the first report of the successful use of an Amplatzer Vascular Plug II for a PDA, and suggests the feasibility and safety of its utilization in select cases.
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Aneurisma/terapia , Cateterismo Cardíaco , Permeabilidade do Canal Arterial/terapia , Aneurisma/complicações , Aneurisma/diagnóstico por imagem , Cateterismo Cardíaco/instrumentação , Permeabilidade do Canal Arterial/complicações , Permeabilidade do Canal Arterial/diagnóstico por imagem , Feminino , Humanos , Desenho de Prótese , Dispositivo para Oclusão Septal , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemAssuntos
Cardiologia/educação , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/prevenção & controle , Currículo , Medicina Nuclear/educação , Tomografia Computadorizada de Emissão , Avaliação Educacional/métodos , Humanos , Modelos Educacionais , Ensino/métodos , Estados UnidosRESUMO
A 78-year-old man presented with a left main stenosis as the culprit lesion in an acute myocardial infarction. He had no significant narrowing in any other coronary territory. This case describes findings in an isolated left main myocardial infarction and discusses appropriate treatment strategies.
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Described herein are 2 adults with right coronary artery aneurysms measuring ≥4.0 cm in maximal diameter. Each aneurysm contained huge intra-aneurysm thrombus and each coronary artery contained atherosclerotic plaques diffusely. Each aneurysm was resected without complication and each patient has resumed preoperative level of activities without limitations.
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Aneurisma Coronário/patologia , Aneurisma Coronário/cirurgia , Aneurisma Coronário/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/diagnóstico por imagem , Placa Aterosclerótica/patologia , Placa Aterosclerótica/cirurgia , Tomografia Computadorizada por Raios XRESUMO
Objective: The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods: We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results: There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions: This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.