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Background: Coronary artery disease (CAD) is a common finding in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). However, the impact on prognosis of chronic total occlusions (CTOs), a drastic expression of CAD, remains unclear. Methods and results: We retrospectively reviewed 1,487 consecutive TAVR cases performed at a single tertiary care medical center. Pre-TAVR angiograms were analyzed for the presence of a CTO. At the time of TAVR, 11.2% (n = 167) patients had a CTO. There was no significant association between the presence of a CTO and in-hospital or 30-day mortality. There was also no difference in long-term survival. LV ejection fraction and mean aortic gradients were lower in the CTO group. Conclusions: Our analysis suggests that concomitant CTO lesions in patients undergoing TAVR differ in their risk profile and clinical findings to patients without CTO. CTO lesion per se were not associated with increased mortality, nevertheless CTOs which supply non-viable myocardium in TAVR population were associated with increased risk of death. Additional research is needed to evaluate the prognostic significance of CTO lesions in TAVR patients.
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ST-elevation myocardial infarction (STEMI) is a life-threatening emergency that can result in cardiac structural complications without timely revascularization. A retrospective study from the National Inpatient Sample included all patients with a diagnosis of STEMI between 2016 and 2020. Primary outcomes of interest were in-hospital mortality, length of stay (LoS), and healthcare costs for patients with and without structural complications. There were 994,300 hospital admissions included in the analysis (median age 64 years and 32.2% female). Structural complications occurred in 0.78% of patients. There was a three-fold increase in patients with cardiogenic shock (41.6% vs. 13.6%) and in-hospital mortality (30.6% vs. 10.7%) in the group with structural complications. The median LoS was longer (5 days vs. 3 days), and the median cost was significantly greater (USD 32,436 vs. USD 20,241) for patients with structural complications. After adjustments, in-hospital mortality was significantly greater for patients with structural complications (OR 1.99, 95% CI 1.73-2.30), and both LoS and costs were greater. There was a significant increase in mortality with ruptured cardiac wall (OR 9.16, 95% CI 5.91-14.20), hemopericardium (OR 3.20, 95% CI 1.91-5.35), and ventricular septal rupture (OR 2.57, 95% CI 1.98-3.35) compared with those with no complication. In conclusion, structural complications in STEMI patients are rare but potentially catastrophic events.
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Heart failure with preserved ejection fraction (HFpEF) is associated with multiple cardiovascular and noncardiovascular comorbidities and risk factors which increase the risk of thrombotic complications, such as atrial fibrillation, chronic kidney disease, arterial hypertension and type 2 diabetes mellitus. Subsequently, thromboembolic risk stratification in this population poses a great challenge. Since date from the large randomized clinical trials mostly include both patients with truly preserved EF, and those with heart failure with mildly reduced ejection fraction, there is an unmet need to characterize the patients with truly preserved EF. Considering the significant evidence gap in this area, we sought to describe the coagulation disorders and thrombotic complications in patients with HFpEF and discuss the specific thromboembolic risk factors in patients with HFpEF, with the goal to tailor risk stratification to an individual patient.
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Transtornos da Coagulação Sanguínea , Diabetes Mellitus Tipo 2 , Insuficiência Cardíaca , Tromboembolia , Trombose , Humanos , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/tratamento farmacológico , Volume Sistólico , Diabetes Mellitus Tipo 2/epidemiologia , Comorbidade , Trombose/epidemiologia , Trombose/etiologia , Transtornos da Coagulação Sanguínea/epidemiologia , PrognósticoRESUMO
BACKGROUND: It is unclear how COVID-19 pandemic affected care and outcomes among patients who are diagnosed with ST-elevation myocardial infarction (STEMI) in the USA. METHODS: We analyzed the data from National Inpatient Sample from 2016 to 2020 and assessed the impact of COVID-19 infection and the COVID-19 pandemic (year 2020) on in-hospital mortality, length of stay (LOS) and hospitalization costs.P. RESULTS: There were 1 050 905 hospitalizations with STEMI, and there was an 8.2% reduction in admissions in 2020. Patients with COVID-19 versus those without had significantly greater in-hospital mortality (45.2% vs. 10.7%; P < 0.001). In 2020, 3.0% of hospitalizations had a diagnosis of COVID-19, and the mortality was 11.5% compared to 10.7% for patients admitted in 2016-2019 period. There was a significantly increased mortality (OR 6.25, 95% CI 5.42-7.21, P < 0.001), LOS (coefficient 3.47, 95% CI 3.10-3.84, P < 0.001) and cost (coefficient 10.69, 95% CI 8.4-12.55, P < 0.001) with COVID-19 infection compared with no infection. There was a borderline difference in mortality (OR 1.04, 95% CI 1.00- 1.09, P = 0.050) but LOS (coefficient -0.21, 95% CI-0.28 to -0.14, P < 0.001) and costs (3.14, 95% CI 2.79 to 3.49, P < 0.001) were reduced in 2020 compared to 2016-2019 period. CONCLUSIONS: In conclusion, in patients hospitalized with STEMI, COVID-19 infection was associated with increased mortality, LOS, and cost but during the pandemic year of 2020 there was a small trend for increased mortality for patients with a diagnosis of STEMI.
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COVID-19 , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Estados Unidos/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Pacientes Internados , Pandemias , Tempo de Internação , Mortalidade HospitalarRESUMO
BACKGROUND: Ticagrelor improves clinical outcomes in patients with acute coronary syndrome compared with clopidogrel. Ticagrelor also inhibits cell uptake of adenosine and has been associated with cardioprotective effects in animal models. We sought to investigate the potential cardioprotective effects of ticagrelor, as compared with clopidogrel, in stable patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS: This was a Prospective Randomized Open Blinded End-points (PROBE) trial enrolling stable patients with coronary artery disease (CAD) requiring fractional flow reserve (FFR)-guided PCI of intermediate epicardial coronary lesions. ST-segment elevation at intracoronary (IC)-ECG during a two-step sequential coronary balloon inflations in the reference vessel during PCI was used as an indirect marker of cardioprotection induced by ischemic preconditioning. The primary endpoint of the study was the comparison of the delta (Δ) (difference) ST-segment elevation measured by intracoronary-ECG during two-step sequential coronary balloon inflations. RESULTS: Fifty-three patients were randomized to either clopidogrel or ticagrelor. The study was stopped earlier because the primary endpoint was met at a pre-specified interim analysis. ΔST-segment elevation was significantly higher in ticagrelor as compared to clopidogrel arms (p<0.0001). Ticagrelor was associated with lower angina score during coronary balloon inflations. There was no difference in coronary microvascular resistance between groups. Adenosine serum concentrations were increased in patients treated with ticagrelor as compared to those treated with clopidogrel. CONCLUSIONS: Ticagrelor enhances the cardioprotective effects of ischemic preconditioning compared with clopidogrel in stable patients with CAD undergoing PCI. Further studies are warranted to fully elucidate the mechanisms through which ticagrelor may exert cardioprotective effects in humans. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique Identifier: NCT02701140.
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Despite the efforts to deliver the best evidence-based care, in-hospital death is an inevitable event among some patients hospitalized in cardiology departments. We conducted a retrospective evaluation of mortality events from inpatient admissions to the cardiology department between 2010 and 2019. Data were collected from morbidity and mortality meeting presentations that evaluated comorbidities, medical history, treatments, and causes of death for the overall cohort and according to age group and sex. There were 1182 registered deaths. The most common causes of death among patients were acute myocardial infarction (AMI, 53.0%), heart failure (HF, 11.7%), cardiac arrest (CA, 6.6%), HF with complication/defined cardiomyopathy (6.3%), and sepsis (4.4%). We observed a decline in deaths from AMI from 61.9% in 2010 to 46.7% in 2019, while there was a clear increase in deaths from HF (11.1% in 2010 to 25.9% in 2019). Compared to patients ≥65 years, younger patients were more likely to have died from CA (15.7% vs. 4.3%, p < 0.001) and other cardiac reasons (3.0% vs. 0.4%, p < 0.001). The majority of deaths were due to AMI, HF, and CA. We observed a significant declining trend in the proportion of deaths due to AMI in recent years, with an increase in deaths due to HF.
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BACKGROUND: The association of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on myocardial function, as reflected in myocardial work (MyW) parameters, in patients with ischemic cardiomyopathy and heart failure (HF) is unknown. METHODS: We analyzed data from 68 patients who were hospitalized with chronic HF due to ischemic cardiomyopathy and stratified them according to the mode of revascularization. All patients underwent a 2D speckle tracking echocardiography exam performed by the same expert sonographer and had complete MyW data including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). RESULTS: The mean age of patients was 70 ± 10 years and 86.8% were men. The mean left ventricular ejection fraction (LVEF) in overall cohort was 31.6 ± 9.5%. Both subgroups did not significantly differ in terms of baseline LVEF, comorbidities, and pharmacotherapy. Compared with those who received PCI, patients revascularized with CABG had significantly greater GWI (821 vs. 555 mmHg%, p = 0.002), GCW (1101 vs. 794 mmHg%, p = 0.001), GWE (78 vs. 72.6%, p = 0.025), and global longitudinal strain (-8.7 vs. -6.7%, p = 0.004). Both patient subgroups did not significantly differ with respect to GWW (273 vs. 245 mmHg%, p = 0.410 for CABG and PCI, respectively) and survival during the median follow-up of 18 months (log-rank p = 0.813). CONCLUSION: Patients with HF and ischemic cardiomyopathy revascularized with CABG had greater myocardial work performance when compared with those revascularized with PCI. This might suggest a higher degree of functional myocardial revascularization associated with the CABG procedure.
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This study investigated the impact of the initial clinical presentation of bladder cancer on tumor characteristics. A cross-sectional, retrospective study was performed, and it involved 515 patients who underwent transurethral bladder cancer resection at the University Hospital Center Split between April 2019 and April 2023, excluding recurrent cases. The association between symptomatic versus asymptomatic presentation and bladder cancer characteristics was analyzed. A subgroup analysis compared tumor characteristics between patients with gross and microscopic hematuria. Multiple regression analyses revealed a significant association between symptomatic presentation and the detection of high-grade bladder cancer (OR 3.43, 95% CI 2.22-5.29, p < 0.001), concomitant CIS (OR 3.41, 95% CI 1.31-8.88, p = 0.012), T2 stage bladder cancer (OR 5.79, 95% CI 2.45-13.71, p < 0.001), a higher number of tumors (IRR 1.24, 95% CI 1.07-1.45, p = 0.005), and larger tumor size (B 1.68, 95% CI 1.19-2.18, p < 0.001). In the subgroup analysis, gross hematuria was associated with the detection of high-grade bladder cancer (OR 2.07, 95% CI 1.12-3.84, p = 0.020), T2 stage bladder cancer (OR 6.03, 95% CI 1.42-25.49, p = 0.015), and larger tumor size (B 1.8, 95% CI 0.99-2.6, p < 0.001). The identified associations between symptomatic presentation and unfavorable bladder cancer characteristics, likely attributed to early detection in asymptomatic cases, underscore the importance of additional research in the development of bladder cancer screening strategies.
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Falso Aneurisma , Cardiomiopatia de Takotsubo , Humanos , Cardiomiopatia de Takotsubo/complicações , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Falso Aneurisma/complicações , Falso Aneurisma/diagnóstico por imagem , Ecocardiografia , EletrocardiografiaRESUMO
BACKGROUND: Coronary artery aneurysms (CAA) are uncommon, often incidental findings in patients with acute coronary syndrome (ACS) that represent a management challenge due to as there is a paucity of literature in this area. METHODS: We analyzed the National Inpatient Sample database from 2016 to 2020 by including all patients with the admission diagnosis of the ACS who underwent percutaneous coronary intervention (PCI). We sought to evaluate the association of CAA with other relevant systemic conditions and determine the impact of CAA on in-hospital outcomes. RESULTS: Among 1,733,655 hospital admission with ACS who underwent PCI, 2675 had CAA. There was a 2-fold increase in odds of CAA if the patient had coronary artery dissection (OR 2.05 95%CI 1.12-3.75, p = 0.020) or extracoronary aneurysm (OR 2.47 95%CI 1.46-4.16, p = 0.001) and a 3-fold increase in odds if they had a systematic inflammatory disorder (OR 3.24 95%CI 2.08-5.07, p < 0.001). CAA was not associated with increased odds of mortality (OR 1.22 95%CI 0.76-1.95, p = 0.42), bleeding (OR 1.29 95%CI 0.86-1.95, p = 0.22), acute stroke (OR 0.91 95%CI 0.40-2.07, p = 0.83), major adverse cardiac and cerebrovascular events (OR 1.08 95%CI 0.72-1.61, p = 0.71) or cardiac complications (OR 0.85 95%CI 0.49-1.47, p = 0.55). However, it was significantly associated with increased odds of vascular complications (OR 2.17 95%CI 1.47-3.19, p < 0.001). CONCLUSIONS: For patients with ACS who undergo PCI, the presence of CAA is associated with greater odds of vascular complications but after adjustments there was no difference in mortality or other complications. In this population, CAA is more prevalent in patients with coronary dissection, extracoronary aneurysms and systemic inflammatory disorders.
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Síndrome Coronariana Aguda , Aneurisma Coronário , Intervenção Coronária Percutânea , Humanos , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/terapia , Síndrome Coronariana Aguda/complicações , Intervenção Coronária Percutânea/efeitos adversos , Vasos Coronários , Resultado do Tratamento , Aneurisma Coronário/diagnóstico por imagem , Aneurisma Coronário/epidemiologia , Aneurisma Coronário/terapia , HospitaisRESUMO
Primarily a consequence of sedentary lifestyle, atherosclerosis has already reached pandemic proportions, and with every year the burden of it is only increasing. As low-density lipoprotein cholesterol (LDL-C) represents a crucial factor in atherosclerosis formation and progression, stringent lipid-lowering therapy could conceivably be the key to preventing the unfavorable outcomes that arise as a consequence of atherosclerosis. The use of statins in lipid-lowering is often burdened by adverse events or is insufficient to prevent cardiovascular events as a monotherapy. Therefore, in the present review, the authors aimed to discuss the underlying mechanisms of dyslipidemia and associated atherosclerotic cardiovascular disease (ASCVD) and preclinical and clinical trials of novel therapeutic approaches to its treatment, some of which are still in the early stages of development. Apart from novel therapies, a novel change in perspective is needed. Specifically, the critical objective in the future management of ASCVD is to embrace emerging evidence in the field of atherosclerosis, because clinicians are often burden by common practice and personal experience, both of which have so far been shown to be futile in the setting of atherosclerosis.
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Anticolesterolemiantes , Aterosclerose , Doenças Cardiovasculares , Dislipidemias , Inibidores de Hidroximetilglutaril-CoA Redutases , Humanos , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/prevenção & controle , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , LDL-Colesterol , Dislipidemias/tratamento farmacológico , Aterosclerose/complicações , Anticolesterolemiantes/efeitos adversosRESUMO
Left ventricular thrombus (LVT) is a recognized complication of acute myocardial infarction (AMI) which can cause significant morbidity and mortality from systemic embolism. We conducted a systematic review and meta-analysis of factors that have been shown in studies to be independently predictive of LVT post-AMI. A total of 23 studies met the inclusion criteria with 1 047 785 patients. The proportion of patients with LVT ranged from 0.2% in the nationwide study in the USA to 36.1% in the cohort of patients with LV aneurysm. Pooled results from nine studies suggest that greater values for left ventricular ejection fraction is associated with reduced odds of LVT formation [odds ratio (OR) 0.90; 95% confidence interval (CI), 0.86-0.93; I2 = 76%]. Left ventricular aneurysm was a significant predictor of LVT formation (OR 6.07; 95% CI, 2.27-16.19; I2 = 91%; seven studies) and anterior location of MI was also a significant predictor (OR 7.72; 95% CI, 2.41-24.74; I2 = 69%; four studies). Three studies suggest that there was an increase in odds of LVT formation with greater values of C-reactive protein (OR 2.06; 95% CI, 1.07-3.97; I2 = 89%; three studies). The use of glycoprotein IIb/IIIa inhibitors (OR 2.52; 95% CI, 1.55-4.10; I2 = 0%; two studies) and greater SYNTAX score (OR 1.21; 95% CI, 1.08-1.36; I2 = 46%; two studies) were associated with LVT. In conclusion, patients with reduced ejection fraction, AMI and with left ventricular aneurysm are at risk of LVT formation and careful imaging evaluation should be performed to identify LVT in these patients to prevent stroke or peripheral embolism.
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Embolia , Infarto do Miocárdio , Trombose , Humanos , Volume Sistólico , Função Ventricular Esquerda , Infarto do Miocárdio/complicações , Trombose/etiologia , Trombose/complicações , Embolia/complicaçõesRESUMO
Left ventricular thrombus (LVT) is a recognized complication of acute myocardial infarction which is associated with stroke. There has yet to be a published systematic review that focuses on outcomes for patients with LVT. We conducted a systematic review on treatments, adverse events and thrombus resolution in patients with LVT. Meta-analysis and numerical pooling were used to evaluate the difference in outcomes based on treatment and the presence or absence of LVT. A total of 39 studies were included (5475 patients with LVT and 356 589 patients with no LVT). The use of direct oral anticoagulants (DOACs) was associated with reduced mortality [RR, 0.66; 95% confidence interval (CI), 0.45-0.97; I2 = 9%] and bleeding (RR, 0.64; 95% CI, 0.48-0.85; I2 = 0%) compared to warfarin but there was a nonsignificant reduction in stroke/embolic events (RR, 0.95; 95% CI, 0.76-1.19; I2 = 3%). For patients with any treatment, the rate of stroke/embolic events, bleeding and mortality at follow-up of up to 12 months was 6.4, 3.7 and 7.9%, respectively. Pooled results from six studies that evaluated resolution at 6 months suggest that 80% of LVT were resolved. Apixaban was associated with the highest rate of (93.3%) whereas warfarin exhibited the lowest rate of resolution 73.1%. LVT is best managed with DOAC compared to warfarin therapy. An individualized approach to antithrombotic therapy is warranted as there appears to be no duration of therapy that clearly results in the resolution of all cases of LVT so follow-up imaging after discontinuation of anticoagulant is needed.
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Embolia , Acidente Vascular Cerebral , Trombose , Humanos , Varfarina , Anticoagulantes/efeitos adversos , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Hemorragia/induzido quimicamente , Acidente Vascular Cerebral/tratamento farmacológico , Embolia/complicaçõesRESUMO
BACKGROUND: Coronary artery aneurysms (CAA) are infrequent findings among patients undergoing coronary angiography and may be associated with systemic diseases. METHODS: We analyzed the National Inpatient Sample database from 2016 to 2020 by including all patients with the admission diagnosis of the chronic coronary syndrome (CCS). We sought to determine the impact of CAA on in-hospital outcomes encompassing all-cause death, bleeding, cardiovascular complications, and stroke. Secondly, we examined the association of CAA with other relevant systemic conditions. RESULTS: The presence of CAA was associated with a 3-fold increase in the odds of cardiovascular complications (OR 3.1, 95 % CI 2.9-3.8), however, it was associated with reduced odds of stroke (OR 0.7, 95 % CI 0.6-0.9). There was no significant impact on all-cause death and overall bleeding complications, although there appeared to be a reduction in the odds of gastrointestinal (GI) bleeding associated with CAA (OR 0.6, 95 % CI 0.4-0.8). Patients with CAA vs. those without CAA had a significantly greater prevalence of extracoronary arterial aneurysms (7.9 % vs. 1.4 %), systemic inflammatory disorders (6.5 % vs. 1.1 %), connective tissue disease (1.6 % vs. 0.6 %), coronary artery dissection (1.3 % vs. 0.1 %), bicuspid aortic valve (0.8 % vs. 0.2 %), and extracoronary arterial dissection (0.3 % vs. 0.1 %). In the multivariable regression, systemic inflammatory disorders, extracoronary aneurysms, coronary artery dissection, and connective tissue diseases were independent predictors of CAA. CONCLUSIONS: CAA in patients with CCS is associated with greater odds of cardiovascular complications during hospitalization. These patients also had a substantially greater prevalence of extracardiac vascular and systemic abnormalities.
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Aneurisma Coronário , Cardiopatias , Síndrome de Linfonodos Mucocutâneos , Acidente Vascular Cerebral , Humanos , Aneurisma Coronário/diagnóstico por imagem , Aneurisma Coronário/epidemiologia , Vasos Coronários , Estudos Retrospectivos , Síndrome , Hospitais , Síndrome de Linfonodos Mucocutâneos/complicaçõesRESUMO
The autonomic nervous system is crucial in initiating and maintaining atrial fibrillation (AF). Catestatin is a multipurpose peptide that regulates cardiovascular systems and reduces harmful, excessive activity of the sympathetic nervous system by blocking the release of catecholamines. We aimed to determine whether serum catestatin concentrations are associated with AF severity, duration indices, and various clinical and laboratory indicators in these individuals to better define the clinical value of catestatin in patients with AF. The present single center study enrolled 73 participants with AF and 72 healthy age-matched controls. Serum catestatin concentrations were markedly higher in AF patients than controls (14.11 (10.21-26.02) ng/mL vs. 10.93 (5.70-20.01) ng/mL, p = 0.013). Furthermore, patients with a more severe form of AF had significantly higher serum catestatin (17.56 (12.80-40.35) vs. 10.98 (8.38-20.91) ng/mL, p = 0.001). Patients with higher CHA2DS2-VASc scores (17.58 (11.89-37.87) vs. 13.02 (8.47-22.75) ng/mL, p = 0.034) and higher NT-proBNP levels (17.58 (IQR 13.91-34.62) vs. 13.23 (IQR 9.04-22.61), p = 0.036) had significantly higher serum catestatin concentrations. Finally, AF duration correlated negatively with serum catestatin levels (r = -0.348, p = 0.003). The results of the present study implicate the promising role of catestatin in the intricate pathophysiology of AF, which should be explored in future research.
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Background: The influence of different viral infections in patients with myocarditis is unknown. Myocarditis is an inflammatory disease of heart muscle that is commonly caused by viruses. The impact of different viral infections in patients with myocarditis is unknown. Methods: We conducted a retrospective cohort study using data between 2016-2020 in the National Inpatient Sample in the USA to evaluate admissions with myocarditis and concomitant viral infection. The outcomes of in-hospital mortality, length of stay (LoS), and cost, among patients hospitalized for myocarditis was evaluated. Results: A total of 27,050 hospital admissions for myocarditis were included and 6750 (25.0%) had a co-diagnosis of viral infection. Patients with myocarditis and viral infection had significantly higher mortality compared to those without viral infection (23.6% vs. 4.4%, p < 0.001). Viral infection was associated with increased in-hospital mortality (odds ratio (OR) 2.03, 95% CI 1.51 to 2.73, p < 0.001), greater median LoS (7 vs. 3 days, p < 0.001) and median hospitalization cost ($21,445 vs. $11,596, p < 0.001), compared to patients without viral infection. The rate of death was greatest for patients with a diagnosis of coronavirus disease 2019 (COVID-19), viral pneumonia and herpes zoster, respiratory syncytial virus, chronic hepatitis, and influenza which was 36.0%, 34.3%, 27.3%, 21.4%, 20.0%, and 14.5%, respectively. Conclusions: In conclusion, the diagnosis of viral infection is present in one in four patients hospitalized with myocarditis and is correlated with greater mortality, LoS, and in-hospital cost.