RESUMO
We analyzed data from 4 nationwide prospective registries of consecutive patients with acute coronary syndromes (ACS) admitted to the Italian Intensive Cardiac Care Unit network between 2005 and 2014. Out of 26 315 patients with ACS enrolled, 13 073 (49.7%) presented a diagnosis of non-ST elevation (NSTE)-ACS and had creatinine levels available at hospital admission: 1207 (9.2%) had severe chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <30), 3803 (29.1%) mild to moderate CKD (eGFR 31-59), and 8063 (61.7%) no CKD (eGFR > 60 mL/min/1.73 m2). Patients with severe CKD had worse clinical characteristics compared with those with mild-moderate or no kidney dysfunction, including all the key predictors of mortality (P < .0001) which became worse over time (all P < .0001). Over the decade of observation, a significant increase in percutaneous coronary intervention rates was observed in patients without CKD (P for trend = .0001), but not in those with any level of CKD. After corrections for significant mortality predictors, severe CKD (odds ratio, OR: 5.49; 95% CI: 3.24-9.29; P < .0001) and mild-moderate CKD (OR: 2.33; 95% CI: 1.52-3.59; P < .0001) remained strongly associated with higher in-hospital mortality. The clinical characteristics of patients with NSTE-ACS and CKD remain challenging and their mortality rate is still higher compared with patients without CKD.
Assuntos
Síndrome Coronariana Aguda , Ponte de Artéria Coronária/mortalidade , Mortalidade Hospitalar , Infarto do Miocárdio sem Supradesnível do Segmento ST , Intervenção Coronária Percutânea/mortalidade , Insuficiência Renal Crônica/mortalidade , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/tendências , Feminino , Mortalidade Hospitalar/tendências , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/tendências , Sistema de Registros , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The availability of bare metal stents (BMS) followed by drug-eluting stents of first- (DES1) and second-generation (DES2) progressively increased the rate of the percutaneous revascularizations [percutaneous coronary intervention (PCI)] with unknown impact on the long-term outcome of real-world patients with established coronary artery disease. We sought to investigate treatments applied in patients with coronary artery disease in BMS, DES1 and DES2 eras and their 5-year outcome. METHODS: A total of 3099 consecutive patients with at least one coronary stenosis more than 50% observed in 2002 (BMS era), 2005 (DES1 era) and 2011(DES2 era) were enrolled at 13 hospitals in Veneto region, Italy. RESULTS: Moving from BMS to DES1 and DES2 eras patients became significantly older, had more comorbidities and received more frequently statins, betablockers, renin-angiotensin modulators and antiplatelets (Pâ<â0.0001 for all). The PCI/conservative therapy ratio increased from 1.9 to 2.2 and 2.3, the PCI/coronary artery by-pass surgery ratio from 3.6 to 4.0 and 5.1. The crude 5-year survival was 84.9, 83.4 and 81.4% (Pâ=â0.20) and survival free of myocardial infarction, stroke or further revascularizations was 62.1, 60.2 and 60.1% (Pâ=â0.68), with cardiovascular mortality accounting for 60.9, 55.6 and 43.4% of deaths. At multivariable analysis cardiovascular mortality was significantly lower in patients enrolled in 2011 vs. 2002 (hazard ratioâ=â0.712, 95% confidence interval 0.508-0.998, Pâ=â0.048). CONCLUSION: From BMS to DES1 and DES2 eras progressive worsening of patients characteristics, improvement of medical treatment standards and increase in PCI/conservative therapy and PCI/coronary artery by-pass surgery ratios were observed. Five-year outcomes remained similar in the three cohorts, but in the DES2 era cardiovascular mortality was reduced.
Assuntos
Doença da Artéria Coronariana/terapia , Estenose Coronária/terapia , Intervenção Coronária Percutânea/instrumentação , Stents , Idoso , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Bases de Dados Factuais , Stents Farmacológicos , Feminino , Humanos , Itália , Masculino , Metais , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Desenho de Prótese , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: Our study was intended to examine time trends of management and mortality of acute coronary syndrome patients with associated diabetes mellitus. METHODS: We analyzed data from 5 nationwide registries established between 2001 and 2014, including consecutive acute coronary syndrome patients admitted to the Italian Intensive Cardiac Care Units. RESULTS: Of 28,225 participants, 8521 (30.2%) had diabetes: as compared with patients without diabetes, they were older and had significantly higher rates of prior myocardial infarction and comorbidities (all P < .0001). Prevalence of diabetes and comorbidities increased over time (P for trend < .0001). Cardiogenic shock rates were higher in patients with diabetes, as compared with those without diabetes (7.8% vs 2.8%, P < .0001), and decreased significantly over time only in patients without diabetes (P = .007). Revascularization rates increased over time in patients both with and without diabetes (both P for trend < .0001), although with persistingly lower rates in patients with diabetes. All-cause in-hospital mortality was higher in patients with diabetes (5.4 vs 2.5%, respectively, P < .0001) and decreased more consistently in patients without diabetes (P for trend = .007 and < .0001, respectively). At multivariable analysis, diabetes remains an independent predictor of both cardiogenic shock (odds ratio 2.03; 95% confidence interval, 1.77-2.32; P < .0001) and mortality (odds ratio 1.95; 95% confidence interval, 1.69-2.26; P < .0001). CONCLUSIONS: Despite significant mortality reductions observed over 15 years in acute coronary syndromes, patients with diabetes continue to show threefold higher rates of cardiogenic shock and lower revascularization rates as compared with patients without diabetes. These findings may explain the persistingly higher mortality of patients with diabetes and acute coronary syndromes.
Assuntos
Síndrome Coronariana Aguda/mortalidade , Complicações do Diabetes/mortalidade , Sistema de Registros , Choque Cardiogênico/epidemiologia , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Complicações do Diabetes/etiologia , Complicações do Diabetes/terapia , Feminino , Mortalidade Hospitalar , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica , Choque Cardiogênico/etiologiaRESUMO
AIMS: Although the benefits of percutaneous coronary interventions (PCIs) in patients with stable chronic ischemic heart disease (SIHD) are controversial, a large number of PCIs are currently performed in SIHD patients, frequently after coronary angiography (ad-hoc procedures), without the use of fractional flow reserve (FFR) to identify patients most likely to benefit from PCI. METHODS: Assessment of regional variations in PCI for SIHD performed in Italy in 2017 and correlation of the regional number of PCI per million inhabitants with the use of FFR were performed using the data reported in the registry of the Italian Society of Interventional Cardiology (SICI-GISE) registry for the year 2017. RESULTS: PCI for SIHD accounted for 44.5% of all PCI performed in Italy with large variations among the Italian regions. There was a significant and inverse relationship between the use of FFR and the PCI number per million inhabitants performed for SIHD in the various Italian regions (Pâ=â0.01). In the Veneto region, where local authorities mandated Heart Team reports to select the most appropriate treatment choice in multivessel disease patients, the rate of ad-hoc procedures was significantly lower than the national average. CONCLUSION: PCI for SIHD patients represent almost half of all procedures currently performed in Italy with regional variations inversely related to physiologic guidance use. The mandatory assessment by the Heart Team to select the most appropriate treatment choice in multivessel disease patients is associated with a significantly lower number of ad-hoc procedures.
Assuntos
Disparidades em Assistência à Saúde/tendências , Isquemia Miocárdica/terapia , Intervenção Coronária Percutânea/tendências , Padrões de Prática Médica/tendências , Tomada de Decisão Clínica , Humanos , Itália/epidemiologia , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/epidemiologia , Seleção de Pacientes , Sistema de Registros , Fatores de TempoRESUMO
OBJECTIVE: Patients with non ST-segment elevation acute coronary syndromes (NSTE-ACS) and peripheral arterial disease (PAD) present a worse prognosis compared to those without PAD. We sought to describe contemporary trends of in-hospital management and outcome of patients admitted for NSTE-ACS with associated PAD. METHODS: We analyzed data from 6 Italian nationwide registries, conducted between 2001 and 2014, including consecutive NSTE-ACS patients. RESULTS: Out of 15,867 patients with NSTE-ACS enrolled in the 6 registries, 2226 (14.0%) had a history of PAD. As compared to non-PAD patients, those with PAD had significantly more risk factors and comorbidities (all pâ¯<â¯0.0001) that increased over time. Patients with PAD underwent less frequently coronary angiography (72.0% vs 79.2%, pâ¯<â¯0.0001) and percutaneous coronary intervention (PCI, 42.9% vs 51.8%, pâ¯<â¯0.0001), compared to patients without PAD. Over the years, a progressive and similar increase occurred in the rates of invasive procedures both in patients with and without PAD (both p for trend <0.0001). The crude in-hospital mortality rate did not significantly change over time (p for trendâ¯=â¯0.83). However, as compared to 2001, the risk of death was significantly lower in all other studies performed at different times, after adjustment for multiple comorbidities.. At multivariable analysis, PAD on admission was an independent predictor of in-hospital mortality [odds ratio (OR): 1.75; 95% confidence intervals (CI): 1.35-2.27; pâ¯<â¯0.0001]. CONCLUSIONS: Over the 14â¯years of observation, patients with PAD and NSTE-ACS exhibited worsening baseline characteristics and a progressive increase in invasive procedures. Whereas crude in-hospital mortality did not change over time, we observed a significant reduction in comorbidity-adjusted mortality, as compared to 2001.
Assuntos
Síndrome Coronariana Aguda/mortalidade , Angiografia Coronária/tendências , Mortalidade Hospitalar/tendências , Intervenção Coronária Percutânea/tendências , Doença Arterial Periférica/complicações , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/cirurgia , Idoso , Idoso de 80 Anos ou mais , Eletrocardiografia , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Sistema de Registros , Medição de Risco , Fatores de RiscoRESUMO
OBJECTIVES: The objective of this study was to investigate mid-term clinical outcomes of patients treated with 'full-plastic jacket' (FPJ) everolimus-eluting Absorb bioresorbable vascular scaffold (BRS) implantation. BACKGROUND: FPJ with BRS may represent an interesting option for patient with diffuse coronary artery disease (CAD), but data on the clinical impact of FPJ using the Absorb BRS are scant. METHODS: FPJ was defined as the implantation of >56â¯mm of overlapping BRS in at least one vessel. We compared outcomes of patients receiving Absorb FPJ vs. non-FPJ within the multicenter prospective RAI Registry. RESULTS: Out of 1505 consecutive patients enrolled in the RAI registry, 1384 were eligible for this analysis. Of these, 143 (10.3%) were treated with BRS FPJ. At a median follow-up of 649â¯days, no differences were observed between FPJ and non-FPJ groups in terms of the device-oriented composite endpoint (DoCE) (5.6% vs. 4.4%, pâ¯=â¯0.675) or the patient-related composite endpoint (PoCE) (20.9% vs. 15.9%, pâ¯=â¯0.149). Patients receiving FPJ had higher rates of target vessel repeat revascularization (TVR) (11.2% vs. 6.3%, pâ¯=â¯0.042). In the FPJ group, there was no cardiac death and only one (very late) stent thrombosis (ST) (0.7%). CONCLUSIONS: Mid-term outcomes of a FPJ PCI strategy in the setting of diffuse CAD did not show a significant increase in composite device- and patient-related events, with rates of cardiac death and ST comparable to non-FPJ Absorb BRS implantation. However, these findings are hypothesis generating and requiring further validation.
Assuntos
Implantes Absorvíveis , Prótese Vascular/tendências , Doença da Artéria Coronariana/terapia , Stents Farmacológicos/tendências , Everolimo/administração & dosagem , Sistema de Registros , Implantes Absorvíveis/tendências , Idoso , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Alicerces Teciduais/tendências , Resultado do TratamentoRESUMO
We aimed to investigate whether the expression of the OPG/RANK/RANKL triad in peripheral blood mononuclear cells (PBMC) and circulating levels of markers of ectopic mineralization (OPG, FGF-23, PPi) are modified in patients with calcific aortic valve disease (CAVD). We found that patients affected by CAVD (n = 50) had significantly higher circulating levels of OPG as compared to control individuals (p = 0.003). No differences between the two groups were found in FGF-23 and PPi levels. RANKL expression was higher in the PBMC from CAVD patients (p = 0.018) and was directly correlated with the amount of valve calcification (p = 0.032). In vitro studies showed that treatment of valve interstitial cells (VIC) with RANKL plus phosphate was followed by increase in matrix mineralization (p = 0.001). In conclusion, RANKL expression is increased in PBMC of patients with CAVD, is directly correlated with the degree of valve calcification, and promotes pro-calcific differentiation of VIC.
Assuntos
Estenose da Valva Aórtica/genética , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Calcinose/genética , Regulação da Expressão Gênica , Leucócitos Mononucleares/metabolismo , Ligante RANK/genética , RNA/genética , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/metabolismo , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/metabolismo , Biomarcadores/metabolismo , Calcinose/diagnóstico , Calcinose/metabolismo , Células Cultivadas , Feminino , Fator de Crescimento de Fibroblastos 23 , Humanos , Masculino , Ligante RANK/biossíntese , Reação em Cadeia da Polimerase em Tempo Real , Tomografia Computadorizada por Raios XRESUMO
Background: The effectiveness of remote monitoring (RM) in the management of the elderly after hospitalisation for heart failure (HF) is uncertain. Methods and results: Randomized trial (2:1 design) comparing RM with usual care (UC) in patients >65â¯years old, hospitalised in the previous 3â¯months for HF with left ventricular ejection fraction <40% or >40% plus BNPâ¯>â¯400 (or NT-proBNP >1500); the primary end-point (PE) was the combined 12-month incidence of death by any cause or at least one hospital readmission for HF. Overall, 229 and 110 pts were enrolled in the RM and UC group, respectively; in the intention-to-treat analysis, the PE was reached in 101 (44.1%) and 51 (46.4%) patients in the RM and UC group respectively (pâ¯=â¯0.78), with no difference in mortality (24.0% vs 21.8%, pâ¯=â¯0.097) or in the proportion of patients with at least one rehospitalisation for HF (34.5% vs 39.1%, pâ¯=â¯0.48). Quality of life, secondary end-point measured by SF36v2 scores, was significantly improved in the RM group, both in physical (2.63 score difference, pâ¯<â¯0.0001) and mental (1.69 score difference, pâ¯=â¯0.04) components. In the on-treatment analysis comparing 190 patients that ultimately received RM with the 149 remaining patients, the primary end-point was reached in 40.0% vs 51.0% (pâ¯=â¯0.055), respectively. Conclusion: In the intention-to-treat analysis, during the 12-month follow up of elderly patients hospitalised for HF, remote monitoring had no impact on the primary end-point but it significantly improved patients' quality of life. In the on-treatment analysis a trend for improving the PE was observed in the RM group.
Assuntos
Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Hospitalização/tendências , Monitorização Ambulatorial/tendências , Telemedicina/tendências , Idoso , Idoso de 80 Anos ou mais , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Insuficiência Cardíaca/terapia , Humanos , Masculino , Monitorização Ambulatorial/métodos , Consulta Remota/métodos , Consulta Remota/tendências , Telemedicina/métodos , Resultado do TratamentoRESUMO
Aim Chronic ischaemic cardiovascular disease (CICD) remains a leading cause of morbidity and mortality worldwide. The CICD Pilot Registry enrolled 2420 patients across 10 European Society of Cardiology countries prospectively to describe characteristics, management strategies and clinical outcomes in this setting. We report here the six-month outcomes. Methods and results From the overall population, 2203 patients were analysed at six months. Fifty-eight patients (2.6%) died after inclusion; 522 patients (23.7%) experienced all-cause hospitalisation or death. The rate of prescription of angiotensin-converting enzyme inhibitors, beta-blockers and aspirin was mildly decreased at six months (all P < 0.02). Patients who experienced all-cause hospitalisation or death were older, more often had a history of non-ST-segment elevation myocardial infarction, of chronic kidney disease, peripheral revascularisation and/or chronic obstructive pulmonary disease than those without events. Independent predictors of all-cause mortality/hospitalisation were age (hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.07-1.27) per 10 years, and a history of previous peripheral revascularisation (HR 1.45, 95% CI 1.03-2.03), chronic kidney disease (HR 1.31, 95% CI 1.0-1.68) or chronic obstructive pulmonary disease (HR 1.42, 95% CI 1.06-1.91, all P < 0.05). We observed a higher rate of events in eastern, western and northern countries compared to southern countries and in cohort 1. Conclusion In this contemporary European registry of CICD patients, the rate of severe clinical outcomes at six months was high and was influenced by age, heart rate and comorbidities. The medical management of this condition remains suboptimal, emphasising the need for larger registries with long-term follow-up. Ad-hoc programmes aimed at implementing guidelines adherence and follow-up procedures are necessary, in order to improve quality of care and patient outcomes.
Assuntos
Cardiologia , Gerenciamento Clínico , Isquemia Miocárdica/terapia , Sistema de Registros , Sociedades Médicas , Idoso , Doença Crônica , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Hospitalização/tendências , Humanos , Masculino , Morbidade/tendências , Isquemia Miocárdica/epidemiologia , Projetos Piloto , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida/tendências , Fatores de TempoRESUMO
OBJECTIVES: To compare clinical outcomes of patients treated with overlapping versus non-overlapping Absorb BVS. BACKGROUND: Limited data are available on the clinical impact of stent overlap with the Absorb BVS bioresorbable stent. METHODS: We compared outcomes of patients receiving overlapping or non-overlapping Absorb BVS in the multicenter prospective RAI Registry. RESULTS: Out of 1,505 consecutive patients treated with Absorb BVS, 1,384 were eligible for this analysis. Of these, 377 (27%) were in the overlap group, and 1,007 (73%) in the non-overlap group. The most frequent overlap configuration was the marker-to-marker type (48%), followed by marker-over-marker (46%) and marker-inside-marker (6%) types. Patients of the overlap group had higher prevalence of multivessel disease and higher SYNTAX score, and required more frequently the use of intravascular imaging. At a median follow-up of 368 days, no difference was observed between overlap and non-overlap groups in terms of a device-related composite endpoint (cardiac death, TV-MI, ID-TLR) (5.8% vs. 4.1%, P = 0.20) or of a patient-related composite endpoint (any death, any MI, any revascularization) (15.4% vs. 12.5%, P = 0.18). Cardiac death (1.0% vs. 1.3%, P = 0.54), MI (4.5% vs. 3.6%, P = 0.51), TVR (4.5% vs. 3.6%, P = 0.51) and stent thrombosis (1.1 vs. 1.5%, P = 1.00) were also comparable between groups. When assessing outcomes of the overlap population according to overlap configurations used, no difference was observed in terms of the device- or patient-related composite endpoints. CONCLUSIONS: Outcomes of patients with or without overlapping BVS were comparable at mid-term follow-up despite higher angiographic complexity of the overlap subset. © 2017 Wiley Periodicals, Inc.
Assuntos
Implantes Absorvíveis , Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Everolimo/administração & dosagem , Isquemia Miocárdica/cirurgia , Intervenção Coronária Percutânea/instrumentação , Idoso , Fármacos Cardiovasculares/efeitos adversos , Angiografia Coronária , Everolimo/efeitos adversos , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Estudos Prospectivos , Desenho de Prótese , Recidiva , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Tomografia de Coerência Óptica , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
NSTE-ACS patients are a heterogeneous population, with different clinical features and prognosis. A large proportion of them is medically managed, without any revascularization. In the EYSHOT and FAST-MI registries such patients were 40% and 35%, respectively. These patients are at higher risk of adverse cardiovascular events and have a worse prognosis compared with those receiving revascularization. Medically managed NSTE-ACS patients consist of different subgroups: those not undergoing coronary angiography, those without significant coronary artery disease, and those with coronary stenoses not referred to revascularization. Patients with NSTE-ACS for whom a conservative strategy without coronary angiogram is planned must be very carefully selected. In patients with comorbidities, frailty, or advanced age, a careful balance between benefits and risks is needed to choice the management strategy (perform or not coronary angiography and/or revascularization), as evidence-based medicine data are lacking in the setting of frailty and comorbidities. In this decisional process, it should be also taken into consideration the role of coronary anatomy in risk stratification and treatment guidance. NSTE-ACS patients managed without revascularization less frequently receive guideline-recommended pharmacological treatment. Dual antiplatelet therapy (DAPT) is recommended for 12months also in medically managed patients, after careful balancing of ischemic and bleeding risk. In these patients it is mandatory to optimize pharmacological treatment, including antiplatelet therapy, to improve outcome. In NSTE-ACS medically managed, the proportion of patients discharged with DAPT should be increased in comparison with current practice, and the use of ticagrelor in place of clopidogrel should be considered in selected patients.
Assuntos
Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/terapia , Tratamento Conservador/métodos , Revascularização Miocárdica , Vigilância da População , Angiografia Coronária/métodos , Gerenciamento Clínico , Humanos , Inibidores da Agregação Plaquetária/administração & dosagem , Fatores de Risco , Resultado do TratamentoRESUMO
The regurgitation of the native aortic valve in patient with previous David operation may represent a clinical challenge because the morbidity and mortality risk of re-operation is not negligible. Here we describe the case of a patient suffering from late severe aortic regurgitation, many years after David operation, efficaciously treated with transfemoral transcatheter aortic valve implantation. To the best of our knowledge, this is the first description of such treatment in a patient with aortic regurgitation and previous David operation.
Assuntos
Aneurisma Aórtico/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Cateterismo Periférico/métodos , Artéria Femoral , Substituição da Valva Aórtica Transcateter/métodos , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Cateterismo Periférico/efeitos adversos , Ecocardiografia Doppler em Cores , Artéria Femoral/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Reimplante , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
The purpose of cardiopulmonary resuscitation after sudden cardiac arrest is to restore minimal blood flow to provide oxygen to the brain and other vital organs. Chest compressions and external defibrillation are the first line for circulatory support. Although early defibrillation is the main factor influencing survival, cardiopulmonary resuscitation must be characterized by high-quality external chest compressions. Unfortunately, the performance of manual chest compressions decreases during time and in hostile conditions. For these reasons, mechanical devices for chest compression are able to support rescuers during cardiopulmonary resuscitation. Commonly used mechanical chest compression devices in Europe include LUCAS and Autopulse. Routine utilization of mechanical chest compression devices cannot be recommended because randomized controlled trials, such as LINC and PARAMEDIC for LUCAS and CIRC for Autopulse, have not demonstrated their superiority compared with manual chest compressions. The aim of this review is to analyze recent data regarding utilization of mechanical chest compression devices, and to clarify advantages and limitations.
Assuntos
Reanimação Cardiopulmonar/instrumentação , Parada Cardíaca/terapia , Desenho de Equipamento , Hospitalização , Humanos , Parada Cardíaca Extra-Hospitalar/terapiaRESUMO
Stable coronary artery disease (CAD) is a clinical entity of great epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions. Stable CAD encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity, and diet. Adherence to therapy as an emerging risk factor is also discussed.
RESUMO
When performing epicardial ablation of ventricular tachycardia (VT), caution must be taken not to damage the coronary arteries. We report a case in which a new, nonfluoroscopic technique for incorporating an accurate, real-time reconstruction of the main coronary vessels into a three-dimensional electroanatomic map was used for epicardial VT ablation.
Assuntos
Ablação por Cateter/métodos , Angiografia Coronária/métodos , Vasos Coronários/diagnóstico por imagem , Mapeamento Epicárdico/métodos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/cirurgia , Idoso , Feminino , Fluoroscopia , Humanos , Técnica de Subtração , Cirurgia Assistida por Computador/métodos , Resultado do TratamentoRESUMO
OBJECTIVES: In an in vitro model, the authors tested the hypotheses that: 1) lesion dimensions correlate with lesion size index (LSI); and 2) LSI could predict lesion dimensions better than power, contact force (CF), and force-time integral (FTI). BACKGROUND: When performing radiofrequency (RF) catheter ablation for cardiac arrhythmias, reliable predictors of lesion quality are lacking. The LSI is a multiparametric index incorporating time, power, CF, and impedance recorded during ablation. METHODS: RF lesions were created on porcine myocardial slabs by using an open-tip irrigated catheter capable of real-time monitoring of catheter-tissue CF. Initially, 3 power settings of 20, 25, and 30 W were used with a fixed CF of 10 g. A fixed power of 20 W was then set with a CF of 20 and 30 g, thereby yielding a total of 5 ablation groups. In each group, LSI values of 5, 6, 7, and 8 were targeted. Sixty RF lesions were created by using 20 ablation protocols (3 lesions for each protocol). RESULTS: Lesion width and depth were not correlated with power or CF, but the results significantly correlated with FTI (p < 0.01) and LSI (p < 0.0001). Four steam pops occurred with power set at 30 W; no pops were noted with 20 or 25 W even when high LSI values were targeted. CONCLUSIONS: In this in vitro model, FTI and LSI predicted RF lesion dimensions, whereas power and CF did not. The LSI predictive value was higher than that of FTI. Steam pops occurred only using high ablation power levels, regardless of the targeted LSI.
Assuntos
Ablação por Cateter/métodos , Ventrículos do Coração/patologia , Ventrículos do Coração/cirurgia , Irrigação Terapêutica/métodos , Animais , Arritmias Cardíacas/cirurgia , Desenho de Equipamento , Técnicas In Vitro , Modelos Animais , Vapor , SuínosRESUMO
BACKGROUND: Age- and sex-specific differences exist in the treatment and outcome of ST-elevation myocardial infarction (STEMI). We sought to describe age- and sex-matched contemporary trends of in-hospital management and outcome of patients with STEMI. METHODS AND RESULTS: We analyzed data from 5 Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive patients with STEMI. All the analyses were age- and sex-matched, considering 4 age classes: <55, 55 to 64, 65 to 74, and ≥75 years. A total of 13 235 patients were classified as having STEMI (72.1% men and 27.9% women). A progressive shift from thrombolysis to primary percutaneous coronary intervention occurred over time, with a concomitant increase in overall reperfusion rates (P for trend <0.0001), which was consistent across sex and age classes. The crude rates of in-hospital death were 3.2% in men and 8.4% in women (P<0.0001), with a significant increase over age classes for both sexes and a significant decrease over time for both sexes (all P for trend <0.01). On multivariable analysis, age (odds ratio 1.09, 95% CI 1.07-1.10, P<0.0001) and female sex (odds ratio 1.44, 95% CI 1.07-1.93, P=0.009) were found to be significantly associated with in-hospital mortality after adjustment for other risk factors, but no significant interaction between these 2 variables was observed (P for interaction=0.61). CONCLUSIONS: Despite a nationwide shift from thrombolytic therapy to primary percutaneous coronary intervention for STEMI affecting both sexes and all ages, women continue to experience higher in-hospital mortality than men, irrespective of age.
Assuntos
Intervenção Coronária Percutânea/métodos , Sistema de Registros , Medição de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Terapia Trombolítica/métodos , Fatores Etários , Idoso , Eletrocardiografia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores Sexuais , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
Non-ST-elevation acute coronary syndromes (NSTE-ACS) represent one of the most common clinical presentations of ischemic heart disease. Patients with NSTE-ACS are a heterogeneous population, with different clinical features and prognosis. A significant proportion of this population is medically managed, without any revascularization. In the Italian EYESHOT and French FAST-MI registries, patients managed with a conservative strategy were 40% and 35%, respectively. NSTE-ACS patients not undergoing coronary revascularization are at higher risk of adverse cardiovascular events and have a worse prognosis, including short- and long-term mortality, compared with those receiving revascularization. Patients with NSTE-ACS medically managed consist of three different subgroups: those not undergoing coronary angiography, those receiving coronary angiography and without significant coronary artery disease, and those with significant coronary artery disease at angiography but not receiving revascularization. Patients presenting with NSTE-ACS for whom a conservative strategy without coronary angiography is planned should be selected very carefully and coronary angiography should not be denied because of the lack of on-site cath-lab facilities. In addition, advanced age alone, in the absence of severe comorbidities or frailty, should not be considered as a reason for denying coronary angiography and, in general, optimal treatment. Given that evidence-based data are lacking, a careful balance between benefits and risks is needed in the decision to perform or not coronary angiography and/or revascularization in patients with important comorbidities, or frailty, or advanced age. In this decisional process, it should be also taken into consideration the role of coronary anatomy in risk stratification and treatment guidance.NSTE-ACS patients managed without revascularization less frequently receive guideline-recommended pharmacological treatment. Dual antiplatelet therapy is recommended for 12 months also in medically managed patients, after careful balance of ischemic and bleeding risk. Indeed, in this group of patients it is mandatory to optimize pharmacological treatment, including antiplatelet therapy, in order to improve clinical outcome. In NSTE-ACS not undergoing revascularization, the proportion of patients discharged with dual antiplatelet therapy should be increased in comparison to current clinical practice, and the use of ticagrelor instead of clopidogrel should be considered in selected patients.
Assuntos
Síndrome Coronariana Aguda/terapia , Isquemia Miocárdica/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Síndrome Coronariana Aguda/fisiopatologia , Angiografia Coronária/métodos , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Humanos , Isquemia Miocárdica/fisiopatologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Inibidores da Agregação Plaquetária/uso terapêutico , Medição de Risco , Fatores de RiscoRESUMO
Stable coronary artery disease is of epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions.Stable coronary artery disease encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow-charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity and diet. Adherence to therapy as an emerging risk factor is also discussed.