The Modified Risk of Paradoxical Embolism Score Is Associated with Patent Foramen Ovale in Patients with Ischemic Stroke: A Nationwide US Analysis.

BACKGROUND: The Risk of Paradoxical Embolism (RoPE) score was developed to identify stroke-related patent foramen ovale (PFO) in patients with cryptogenic stroke. METHODS: We conducted a retrospective analysis of the 2016 to 2020 National Inpatient Sample to determine the performance of the modified RoPE score in identifying the presence of a PFO in patients with acute ischemic stroke (AIS). RESULTS: A total of 3,338,805 hospital admissions for AIS were analysed and 3.0% had PFO. Patients with PFO were younger compared to those without a PFO (median 63 years vs. 71 years, p < 0.001) and fewer were female (46.1% vs. 49.7%, p < 0.001). The patients with PFO had greater mean modified RoPE scores (4.0 vs. 3.3, p < 0.001). The area under the curve for the RoPE score in predicting PFOs was 0.625 (95%CI 0.620-0.629). The best diagnostic power of the RoPE score was achieved with a cut-off point of ≥4 where the sensitivity was 55% and the specificity was 64.2%. A cut-off point of ≥5 increased the specificity (83.1%) at the expense of sensitivity (35.8%). The strongest predictor of PFOs was deep vein thrombosis (OR 3.97, 95%CI 3.76-4.20). CONCLUSIONS: The modified RoPE score had modest predictive value in identifying patients with PFO among patients admitted with AIS.

The Molecular Mechanisms and Therapeutic Targets of Atherosclerosis: From Basic Research to Interventional Cardiology.

The goal of this Special Issue was to collect original pieces as well as state-of-the-art review articles from scientists and research groups with specific interests in atherosclerosis research [...].

Impact of COVID-19 Pandemic on Cardiovascular Healthcare in Croatia: A Comprehensive Nationwide Survey.

The impact of the COVID-19 pandemic on cardiovascular healthcare in Croatia remains largely unexplored. This study aimed to compare the utilization and provision of cardiovascular services during the pre-pandemic (2017-2019) and pandemic (2020-2021) periods, leveraging nationwide data from the Croatian Health Insurance Fund, which covers 95% of all insurance claims in the country. Our findings reveal that while the use of coronary angiographies decreased during the pandemic, there was a notable increase in the utilization of advanced heart failure treatment modalities and percutaneous coronary interventions, particularly in the context of acute myocardial infarction. Additionally, transcatheter aortic valve implantations saw a significant rise during the pandemic period. Furthermore, laboratory diagnostic testing for troponin and natriuretic peptides experienced a marked increase, while the utilization of most other cardiovascular services remained stable or showed only minor declines compared to the pre-pandemic era. These observations suggest that the Croatian cardiovascular healthcare system displayed resilience during the COVID-19 pandemic, successfully maintaining and even expanding access to various diagnostic and interventional procedures despite facing widespread societal and logistical challenges.

A Refractory Electrical Storm after Acute Myocardial Infarction: The Role of Temporary Ventricular Overdrive Pacing as a Bridge to ICD Implantation.

An electrical storm (ES) is defined as the presence of at least three episodes of sustained ventricular tachycardia or ventricular fibrillation within 24 h. This patient had a previously known arterial hypertension, type II diabetes mellitus, and chronic kidney disease and has presented to the Emergency Department (ED) with symptoms of retrosternal chest pain lasting for several hours prior. The initial 12-lead electrocardiogram revealed ST segment elevation in the anterior leads (V1-V6). Emergent coronary angiography revealed an acute occlusion of the proximal left anterior descending artery (pLAD) and percutaneous coronary intervention was performed with successful implantation of one drug-eluting stent in the pLAD. On day 8 of hospitalization, the patient developed a refractory ES for which he received 50 DC shocks and did not respond to multiple lines of antiarrhythmic medications. Due to a failure of medical therapy, we decided to implant a temporary pacemaker and initiate ventricular overdrive pacing (VOP) that was successful in terminating ES. Following electrical stabilization, the patient underwent a successful ICD implantation. This case demonstrates that VOP can contribute to hemodynamic and electrical stabilization of a patient that suffers from refractory ES and this treatment modality might serve as a temporary bridge to ICD implantation.

The influence of the initial clinical presentation of upper tract urothelial carcinoma on histopathological tumor features.

PURPOSE: To investigate the influence of the initial clinical presentation (symptomatic vs. asymptomatic) on histopathological tumor features in patients with upper tract urothelial carcinoma (UTUC). METHODS: We conducted a single-center, cross-sectional, and retrospective study that enrolled 72 adults with primary UTUC who underwent radical nephroureterectomy at our institution over a period of 4 years (April 2019-April 2023). RESULTS: Symptomatic patients exhibited significantly higher frequencies of high-grade UTUC (73.6% vs. 36.8%, p = 0.006), ≥ T2 stage UTUC (60.4% vs. 26.3%, p = 0.007), and larger tumor sizes (median 5 vs. 4 cm, p = 0.015) compared to asymptomatic patients. Multiple regression analyses demonstrated significant associations between symptomatic presentation and the presence of high-grade UTUC (OR 6.35, 95% CI 1.81-22.27, p = 0.004), ≥ T2 stage UTUC (OR 5.98, 95% CI 1.62-22.08, p = 0.007), and larger tumor size (B 3.14, 95% CI 0.62-5.66, p = 0.015). A subset of patients with hematuria was separately analyzed to assess the influence of hematuria severity (gross vs. microscopic) on UTUC characteristics. Patients with gross hematuria exhibited significantly higher frequencies of high-grade UTUC (72.9% vs. 33.3%, p = 0.048) and ≥ T2 stage UTUC (58.3% vs. 22.2%, p = 0.001). Multiple regression analyses showed significant associations between gross hematuria and the presence of high-grade UTUC (OR 6.34, 95% CI 1.15-34.95, p = 0.034) and ≥ T2 stage UTUC (OR 6.54, 95% CI 1.11-38.93, p = 0.039). CONCLUSION: Initial symptomatic presentation was independently associated with adverse histopathological UTUC characteristics, potentially attributed to earlier detection of UTUC in asymptomatic patients, before the onset of symptoms.

Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients.

In patients with AF, the presence of left atrial/left atrial appendage (LA/LAA) thrombus is related to an increased risk of thromboembolic events. Anticoagulation therapy, either with vitamin K antagonists or novel oral anticoagulants (NOACs) is therefore mandatory in AF with LA/LAA thrombus in order to lower the risk of stroke or other systemic embolic events. Despite the efficacy of these treatments, some patients will have persistent LAA thrombus remaining or may have contraindications to oral anticoagulation. Currently, little is known about the occurrence, risk factors and resolution rate of LA/LAA thrombus in patients who are already under optimal chronic oral anticoagulation, including vitamin K antagonists or NOACs. The common action in clinical practice in this scenario is switching from one to another anticoagulant drug exhibiting a different mechanism of action. Repeated cardiac imaging is then advised within several weeks to visually verify thrombus dissolution. Finally, there is a substantial scarcity of data on the role and optimal use of NOACs after LAA occlusion. The aim of this review is to critically evaluate data and provide up-to-date information on the best antithrombotic strategies in this challenging clinical scenario.

The impact of antithrombotic therapy on the time of detection of bladder cancer.

Introduction: The aim of this article was to investigate the impact of chronic antithrombotic therapy (AT) use on the time of detection of bladder cancer, assuming that patients taking AT experience episodes of macroscopic hematuria earlier, and therefore have a more favorable histopathological grade and stage, as well as a smaller number and size of tumors compared to patients not taking AT. Material and methods: A retrospective, cross-sectional study was conducted, including 247 patients who underwent bladder cancer surgery for the first time at our institution during the three-year period (2019-2021) and who experienced macroscopic hematuria. Results: A lower frequency of high-grade bladder cancer (40.6% vs 60.1%, P = 0.006), T2 stage (7.2% vs 20.2%, P = 0.014), and a lower frequency of tumors larger than 3.5 cm (29% vs 57.9%, P <0.001) were found in patients using AT compared to patients not using them. The patients using AT had a smaller mean tumor size (2.98 vs 4.51 cm, P <0.001). A multivariable regression analysis, adjusted for age, sex, and number of comorbidities, showed a lower probability of having a high-grade cancer (OR 0.393, 95% CI 0.195-0.792, P = 0.009), T2 stage (OR 0.276, 95% CI 0.090-0.849, P = 0.025), and tumors larger than 3.5 cm (OR 0.261, 95% CI 0.125-0.542, P <0.001) in patients using AT. Conclusions: More favorable histopathological grades, stages, and smaller tumor sizes were found in patients with bladder cancer who experienced macroscopic hematuria and were using AT compared to patients not taking AT.

Blood Coagulation Disorders in Heart Failure: From Basic Science to Clinical Perspectives.

Heart failure (HF) is a clinical syndrome that is divided into 3 subtypes based on the left ventricular ejection fraction. Every subtype has specific clinical characteristics and concomitant diseases, substantially increasing risk of thromboembolic complications, such as stroke, peripheral embolism and pulmonary embolism. Despite the annual prevalence of 1% and devastating clinical consequences, thromboembolic complications are not typically recognized as the leading problem in patients with HF, representing an underappreciated clinical challenge. Although the currently available data do not support routine anticoagulation in patients with HF and sinus rhythm, initial reports suggest that such strategy might be beneficial in a subset of patients at especially high thromboembolic risk. Considering the existing evidence gap, we aimed to review the currently available data regarding coagulation disorders in acute and chronic HF based on the insight from preclinical and clinical studies, to summarize the evidence regarding anticoagulation in HF in special-case scenarios and to outline future research directions so as to establish the optimal patient-tailored strategies for antiplatelet and anticoagulant therapy in HF. In summary, we highlight the top 10 pearls in the management of patients with HF and no other specific indications for oral anticoagulation therapy. Further studies are urgently needed to shed light on the pathophysiological role of platelet activation in HF and to evaluate whether antiplatelet or antithrombotic therapy could be beneficial in patients with HF. LAY SUMMARY: Heart failure (HF) is a clinical syndrome divided into 3 subtypes on the basis of the left ventricular systolic function. Every subtype has specific clinical characteristics and concomitant diseases, substantially increasing the risk of thromboembolic complications, such as stroke, peripheral embolism and pulmonary embolism. Despite the annual prevalence of 1% and devastating clinical consequences, thromboembolic complications are not typically recognized as the leading problem in patients with HF, representing an underappreciated clinical challenge. Although the currently available data do not support routine anticoagulation in patients with HF and no atrial arrhythmia, initial reports suggest that such a strategy might be beneficial in a subset of patients at especially high risk of thrombotic complications. Considering the existing evidence gap, we aimed to review the currently available data regarding coagulation problems in stable and unstable patients with HF based on the insight from preclinical and clinical studies, to summarize the evidence regarding anticoagulation in HF in specific patient groups and to outline future research directions to establish the optimal strategies for antiplatelet and anticoagulant therapy in HF, tailored to the needs of an individual patient. In summary, we highlight the top 10 pearls in the management of patients with HF and no other specific indications for oral anticoagulation therapy.

Emergency transvenous temporary pacing during rotational atherectomy.

Background: Rotational atherectomy (RA) during percutaneous coronary intervention may cause transient bradycardia or a higher-degree heart block. Traditionally, some operators use prophylactic transvenous pacing wire (TPW) to avoid haemodynamic complications associated with bradycardia. Objective: We sought to establish the frequency of bail-out need for emergency TPW insertion in patients undergoing RA that have received no upfront TPW insertion. Methods: We performed a single-centre retrospective study of all patients undergoing RA between October 2009 and October 2022. Patient characteristics, procedural variables, and in-hospital complications were registered. Results: A total of 331 patients who underwent RA procedure were analysed. No patients underwent prophylactic TPW insertion. The mean age was 73.3 ± 9.1 years, 71.6% (n = 237) were male, while nearly half of the patients were diabetic [N = 158 (47.7%)]. The right coronary artery was the most common target for RA (40.8%), followed by the left anterior descending (34.1%), left circumflex (14.8%), and left main stem artery (10.3%). Altogether 20 (6%) patients required intraprocedural atropine therapy. Emergency TPW insertion was needed in one (0.3%) patient only. Eight (2.4%) patients died, although only one (0.3%) was adjudicated as being possibly related to RA-induced bradycardia. Five patients (1.5%) had ventricular fibrillation arrest, while nine (2.7%) required cardiopulmonary resuscitation. Six (1.8%) procedures were complicated by coronary perforation, two (0.6%) were complicated by tamponade, while 17 (5.1%) patients experienced vascular access complications. Conclusions: Bail-out transvenous temporary pacing is very rarely required during RA. A standby temporary pacing strategy seems reasonable and may avoid unnecessary TPW complications compared with routine use.

Data Collection Theory in Healthcare Research: The Minimum Dataset in Quantitative Studies.

There is considerable interest in data analytics because of its value in informing decisions in healthcare. Data variables can be derived from routinely collected records or from primary studies. The level of detail for individual variables in quantitative studies is often disregarded. In this work, we aim to present the concept of a minimum dataset for any variable. The most basic level of data collection is the value of a variable. In addition, there may be an indicator of severity and a measure of duration or how long the value has been present. The time course defines how the values for a variable fluctuated over time. The validity or accuracy of the values for a variable is also important to avoid spurious findings. Finally, there may be additional modifiers which drastically change the impact of a variable. In conclusion, the minimum dataset is a framework which can be used for the purposes of study design and appraisal of studies. Not all data requires full consideration of the minimum dataset framework for each variable, but the framework may be important if more detailed results are desired.

The Impact of Concomitant Diagnosis of Viral Infections on in-Hospital Mortality in Patients Hospitalized with a Diagnosis of Heart Failure in the United States: Insights from the National Inpatient Sample.

The impact of viral infections on patients admitted with a diagnosis of heart failure is not well understood. We conducted a retrospective cohort study using data from the National Inpatient Sample in the United States to evaluate the proportion of admissions with a diagnosis of heart failure and viral infections, and we explored how viral infections had impact on in-hospital mortality and length of stay. There were a total of 20,713,539 admission records with a diagnosis of heart failure included in the analysis and 3.8% had a concomitant diagnosis of viral infection. The mean length of stay was 20.1 ± 26.9 days, 12.9 ± 13.6 days, 12.1 ± 13.8 days, and 5.1 ± 6.5 days for records with a diagnosis of cytomegalovirus, viral meningitis/encephalitis, herpes simplex infection, and no viral infection, respectively. The most common diagnoses of viral infections were influenza (n = 240,260) and chronic viral hepatitis (n = 194,400), and the highest rates of mortality were observed for records with a diagnosis of cytomegalovirus (13.2%), acute viral hepatitis (12.5%), and viral meningitis/encephalitis (11.1%). The viral infections significantly associated with increased odds of mortality were cytomegalovirus infection (OR 1.84 95% CI 1.57-2.16), acute hepatitis (OR 1.29 95% CI 1.15-1.45), and HIV (OR 1.22 95% CI 1.11-1.34). In conclusion, viral infections are co-diagnosis in 3.8% of patient records with heart failure and detection of some viruses may be important as they increase mortality and may prolong length of stay in hospital.

Feasibility and safety of catheter-directed thrombolysis via superficial cubital vein for the treatment of acute massive and submassive pulmonary embolism.

INTRODUCTION: Proximal venous approaches (femoral or jugular) for catheter-directed thrombolysis (CDT) of acute pulmonary embolism (PE) dominate in clinical practice. AIM: We investigated the feasibility and safety of CDT in acute PE by using the superficial cubital venous approach. MATERIAL AND METHODS: All patients with acute PE received intravenous unfractionated heparin plus CDT. CDT included mechanical thrombus fragmentation and the local application of adjuvant thrombolytic therapy through the pigtail catheter - alteplase administered as 2.5 mg bolus in each main branch of the pulmonary artery plus adjuvant 25 mg for 12 h in the more severely affected branch of the pulmonary artery. RESULTS: Twenty-seven consecutive patients presenting with acute massive (high risk) PE (n = 10) or submassive (intermediate risk) PE (n = 17) were enrolled in the study. The mean age of the enrolled cohort was 60.6 (14.1) years and most patients were female (n = 14, 52%). The procedural success of CDT application through the cubital vein was achieved in all patients. After the procedure, the systolic pulmonary artery pressure decreased from 61.4 (18.3) to 35.8 (12.3) mm Hg (p < 0.001) while the mean pulmonary artery pressure decreased from 35.7 (10.8) to 21.1 (6.5) mm Hg (p < 0.001). Similarly, the mean arterial pressure increased from 81.9 (12.8) to 89.0 (10.3) mm Hg (p = 0.031). Miller angiographic obstruction score and Miller index decreased significantly after the CDT intervention (p < 0.001). There were no deaths, major bleeding events, or hemorrhagic strokes. CONCLUSIONS: CDT by using the cubital approach is a simple, safe, and feasible treatment option for PE. This approach was associated with significant improvement in hemodynamic parameters without fatal outcomes or major periprocedural complications.