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OBJECTIVES: To review the effectiveness of manual thrombectomy (MT) in a series of patients with ST-elevation myocardial infarction (STEMI) exclusively presenting with TIMI 0-1 flow undergoing percutaneous coronary intervention (PCI), in accordance to the angiographically estimated area at risk (AAR). Second, to assess major in-hospital clinical events, emphasizing neurological outcomes. BACKGROUND: The routine utilization of MT in STEMI is not recommended. However, in recent trials, a significant proportion of patients had neither large thrombus burden nor a totally occluded coronary segment, neutralizing the expected benefits of MT. In addition, the efficiency of MT to remove thrombus has rarely been addressed. Finally, MT diminished distal embolization, which has been related to mortality. RESULTS: In 850 consecutive STEMI-patients, MT was utilized in 525 (62%) and it was considered efficient (TIMI 2-3 flow after MT) in 445 (85%). We found a significant interaction between the AAR and the effectiveness of MT to reduce infarct size (P-interaction = 0.014). In patients having AAR ≥ 28% (n = 184), efficient MT conferred lesser infarct size compared to inefficient MT (Ln-transformed peak CK): 7.87 ± 0.86 versus 8.36 ± 0.41 IU/L, P = 0.005, with no impact for AAR <28%. Clinical outcomes including stroke between MT and PCI-only groups were not different. CONCLUSION: In comparison with the group where MT was inefficient, efficient MT may modestly reduce final infarct size without a significant clinical benefit. In comparison with PCI-only, no difference was found regarding stroke. © 2017 Wiley Periodicals, Inc.
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Circulación Coronaria , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/terapia , Trombectomía/métodos , Anciano , Angiografía Coronaria , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/fisiopatología , Accidente Cerebrovascular/etiología , Trombectomía/efectos adversos , Trombectomía/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
ST-elevation myocardial infarction (STEMI) survivors have a heightened risk of developing heart failure (HF). The magnitude of this risk with the advent of primary percutaneous coronary intervention is less characterized. We aimed to examine the incidence and predictors of incident HF and all-cause mortality in a contemporary STEMI cohort. We performed a retrospective analysis of 700 consecutive patients with STEMI treated with primary percutaneous coronary intervention at a tertiary hospital. The primary outcome was the occurrence of HF during follow-up. HF was defined by HF hospitalization or the presence of congestion that led to de novo prescription or up-titration of diuretics in the outpatient clinic. The secondary outcome was defined by the occurrence of HF or all-cause mortality. During a median follow-up period of 43.6 months, HF events occurred in 110 patients (15.7%), 34 (4.8%) managed as outpatient and 76 (10.9%) requiring hospitalization. Left ventricular ejection fraction (LVEF) <50% was present in 76% of those who developed HF. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01 to 1.06), diabetes (HR 1.85, 95% CI 1.12 to 3.05), door-to-balloon time (HR 1.002, 95% CI 1.000 to 1.003), Killip-Kimball class ≥II (HR 2.24, 95% CI 1.32 to 3.80) and LVEF <50% (HR 1.71, 95% CI 1.01 to 2.92) were independent predictors. All-cause mortality incidence was 8.7%. HF was independently associated with a threefold increased risk of dying (HR 3.52, 95% CI 1.85 to 6.69, p <0.001). In conclusion, a substantial proportion of contemporary patients with STEMI develop HF, which triplicates the risk of dying. Older age, diabetes and LVEF <50% independently predicted the development of HF and all-cause death.
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Insuficiencia Cardíaca/epidemiología , Mortalidad , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/cirugía , Factores de Edad , Anciano , Anciano de 80 o más Años , Diabetes Mellitus/epidemiología , Femenino , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/fisiopatología , Volumen SistólicoRESUMEN
INTRODUCTION: Reports of cardiovascular complications related to the COVID-19 infection have been frequent. METHODS: Narrative review for relevant articles on the topic. The classic cardiovascular risk factors, like age, obesity, diabetes, and hypertension are associated with adverse outcomes in COVID-19 patients. Cardiovascular complications can have a diverse clinical presentation including silent myocardial injury, acute coronary syndromes, thromboembolism, cardiac arrhythmias, and heart failure. There are multiple mechanisms of cardiac injury that are not mutually exclusive. The approach to diagnosis and management should be carried out according to usual practice, while considering the particularities of COVID-19 infection. CONCLUSION: The interaction between SARS-CoV-2 and the heart is complex and is manifested in multiple ways. Regardless of the clinical presentation, cardiac complications convey a worse prognosis. Patients should be actively monitored and treated accordingly.
Introdução: As complicações cardiovasculares associadas a infeção por COVID-19 têm sido frequentemente reportadas. Métodos: Revisão da literatura sobre os artigos relevantes neste tópico. Os fatores de risco cardiovasculares clássicos como idade, obesidade, diabetes e hipertensão foram associados a um risco maior de evolução desfavorável. As complicações cardiovasculares podem ter uma apresentação clínica variável incluindo lesão miocárdica, síndrome coronário agudo, trombo-embolismo, arritmias e insuficiência cardíaca. Estão descritos múltiplos mecanismos de lesão cardíaca os quais não são mutualmente exclusivos. A abordagem diagnóstica e terapêutica deve seguir a prática comum tendo, no entanto, em consideração as particularidades da infeção por COVID-19. Conclusão: A interação entre a infeção por COVID-19 e o coração é complexa e manifesta-se de várias formas. Independentemente da apresentação clínica, as complicações cardíacas conferem um prognostico desfavorável pelo que devem ser monitorizadas ativamente e tratadas de forma apropriada.
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Síndrome Coronario Agudo , COVID-19 , Diabetes Mellitus , Insuficiencia Cardíaca , Síndrome Coronario Agudo/etiología , Humanos , SARS-CoV-2RESUMEN
BACKGROUND: Concurrent evidence about cardiogenic shock (CS) characteristics, treatment and outcome does not represent a global spectrum of patients and is therefore limited. The aim of this study was to investigate these regional differences. METHODS: To investigate regional differences in presentation characteristics, treatments and outcomes of patients treated with all types of cardiogenic shock (CS) in a single calendar year on a multi-national level. Consecutive patients from 19 tertiary care hospitals in 13 countries with CS who were treated between January 1, 2018 and December 31, 2018 were enrolled in this study. RESULTS: In total, 699 cardiogenic shock patients were included in this study. Of these patients, 440 patients (63%) were treated in European hospitals and 259 (37%) were treated in Non-European hospitals. Female patients (P<0.01) and patients with a previous myocardial infarction (P=0.02) were more likely to present at Non-European hospitals; whereas older patients (P=0.01) and patients with cardiogenic shock due to acute heart failure (P<0.01) were more likely to present at European hospitals. Vasopressor use was more likely in Non-European hospitals (P=0.04), whereas use of mechanical circulatory support (MCS) was more likely in European hospitals (P<0.01). Despite adjustment for relevant confounders, 30-day in-hospital mortality risk was comparably high in CS patients treated in European vs. Non-European hospitals (hazard ratio 1.08, 95% CI 0.84-1.39, P=0.56). CONCLUSION: Despite marked heterogeneity in characteristics and treatment of CS patients, including fewer use of MCS but more frequent use of vasopressors in Non-European hospitals, 30-day in-hospital mortality did not differ between regions.
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Corazón Auxiliar , Choque Cardiogénico , Femenino , Mortalidad Hospitalaria , Humanos , Sistema de Registros , Factores de Riesgo , Choque Cardiogénico/terapia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Aims: Women's participation is steadily growing in medical schools, but they are still not sufficiently represented in cardiology, particularly in cardiology leadership positions. We present the contemporary distribution of women leaders in cardiology departments in the World Health Organization European region. Methods and results: Between August and December 2020, we applied purposive sampling to collect data and analyse gender distribution of heads of cardiology department in university/third level hospitals in 23 countries: Austria, Azerbaijan, Belgium, Bosnia-Herzegovina, Croatia, France, Germany, Greece, Italy, North Macedonia, Morocco, Poland, Portugal, Russia, Serbia, Slovakia, Slovenia, Spain, Switzerland, Tunisia, Turkey, Ukraine, and the UK. Age, cardiology subspecialty, and number of scientific publications were recorded for a subgroup of cardiology leaders for whom data were available. A total of 849 cardiology departments were analysed. Women leaders were only 30% (254/849) and were younger than their men counterpart (â 52.2 ± 7.7 years old vs. â 58.1 ± 7.6 years old, P = 0.00001). Most women leaders were non-interventional experts (â 82% vs. â 46%, P < 0.00001) and had significantly fewer scientific publications than men {â 16 [interquartile range (IQR) 2-41] publications vs. â 44 (IQR 9-175) publications, P < 0.00001}. Conclusion: Across the World Health Organization European region, there is a significant gender disparity in cardiology leadership positions. Fostering a diverse and inclusive workplace is a priority to achieve the full potential and leverage the full talents of both women and men.
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BACKGROUND: Mediastinal paragangliomas (PGs) are rare and particularly challenging neuroendocrine tumours. Clinical presentation is heterogeneous and tumour resection can be challenging due to bleeding and the risk of catecholamine surges in functional tumours. CASE SUMMARY: A 36-year-old man with multiple cardiovascular risk factors was admitted with subacute heart failure. Investigations revealed a large non-metastatic functional mediastinal PG irrigated mainly by a left circumflex coronary anomalous feeder branch. The surgical risk was deemed very high due to patient comorbidities, tumour vascularization, and close relation to major thoracic structures. A multidisciplinary team decided to perform embolization of the anomalous coronary branch followed by peptide-receptor radionuclide therapy with 177-LuDOTATE aiming to decrease tumour size and perioperative risk. Follow-up studies showed a reduction in tumour vascularization, size, and hormonal production. DISCUSSION: The innovative strategy of combining embolization of the anomalous feeder branch with radionuclide therapy proved to be a promising approach.
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BACKGROUND: The benefits of exercise-based cardiac rehabilitation (EBCR) programs in post-acute myocardial infarction (AMI) patients have been demonstrated. Our aim was to assess the impact of EBCR in ≥ 70-years-old vs. younger post-AMI patients. METHODS: We retrospectively evaluated patients who underwent a supervised EBCR protocol, twice a week during 6-12 weeks. We evaluated changes in several outcomes based on pre- and post-CRP assessments. RESULTS: Of a total of 1607 patients, 333 (21%) were ≥ 70-years-old. After the EBCR, an overall improvement on functional capacity, daily physical activity, lipid profile, body mass index, glycated hemoglobin (HbA1c), N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and C-reactive protein was observed in both younger and older patients (P < 0.05). Older patients showed a smaller benefit on the increment of daily physical activity and lipid profile improvement, but a larger reduction in NT-pro-BNP. In the multivariate analysis, only improvements on daily physical activity and HbA1c were dependent on age. CONCLUSION: As their younger counterparts, older patients, significantly improved functional capacity, metabolic parameters and level of daily physical activity after EBCR.
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INTRODUCTION: Recovered Out-of-Hospital Cardiac Arrest (rOHCA) population is heterogenous. Few studies focused on outcomes in the rOHCA subgroup with proven significant coronary artery disease (SigCAD). We aimed to characterize this subgroup and study the determinants of in-hospital mortality. METHODS: Retrospective study of consecutive rOHCA patients submitted to coronary angiography. Only patients with SigCAD were included. RESULTS: 60 patients were studied, 85% were male, mean age was 62.6 ± 12.1 years. In-hospital mortality rate was 43.3%. Patients with diabetes and history of stroke were less likely to survive. Significant univariate predictors of in-hospital mortality were further analysed separately, according to whether they were present at hospital admission or developed during hospital evolution. At hospital admission, initial non-shockable rhythm, low-flow time>12min, pH<7.25mmol/L and lactates >4.75mmol/L were the most relevant predictors and therefore included in a score tested by Kaplan-Meyer. Patients who had 0/4 criteria had 100% chance of survival till hospital discharge, 1/4 had 77%, 2/4 had 50%, 3/4 had 25%. Patients with all 4 criteria had 0% survival. During in-hospital evolution, a pH<7.35 at 24h, lactates>2mmol/L at 24h, anoxic brain injury and persistent hemodynamic instability proved significant. Patients who had 0/4 of these in-hospital criteria had 100% chance of survival till hospital discharge, 1/4 had 94%, 2/4 had 47%, 3/4 had 25%. Patients with all 4 criteria had 0% survival. Contrarily, CAD severity and ventricular dysfunction didn't significantly correlate to the outcome. CONCLUSION: Classic prehospital variables retain their value in predicting mortality in the specific group of OHCA with SigCAD. In-hospital evolution variables proved to add value in mortality prediction. Combining these simple variables in risk scores might help refining prognostic prediction in these patients's subset.
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BACKGROUND: Right ventriculo-arterial coupling (RV-PA) can be estimated by echocardiography using the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) and it has prognostic value in the general heart failure (HF) population. We aimed to study the clinical correlates and prognostic value of RV-PA in HF patients undergoing cardiac resynchronization therapy (CRT). METHODS: We retrospectively studied 70 HF patients undergoing CRT implantation. RESULTS: RV-PA coupling was estimated by TAPSE/PASP ratio using baseline echocardiography. Non-response to CRT was defined as improvement of left ventricular ejection fraction < 5% in a follow-up echo 6-12 months after CRT. Those with lower TAPSE/PASP ratios (worse RV-PA coupling) had higher NT-proBNP concentrations and increased E/e' ratio. TAPSE/PASP ratio and PASP, but not TAPSE, predicted nonresponse to CRT with TAPSE/PASP ratio showing the best discriminative ability with a sensitivity of 76% and specificity of 71%. Among these parameters, PASP independently predicted all-cause mortality. CONCLUSIONS: RV-PA coupling estimated by TAPSE/PASP ratio was associated with established prognostic markers in HF. It numerically outperformed PASP and TAPSE in predicting the response to CRT. Our data suggest that this simple and widely available echocardiographic parameter conveys significant pathophysiological and prognostic meaning in HF patients undergoing CRT.
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AIM: Remote ischemic conditioning may reduce acute kidney injury (AKI) in patients undergoing a coronary intervention. As preinfarct angina (PIA) might act as a preconditioning stimulus in patients with ST-elevation myocardial infarction (STEMI), we aimed to study whether PIA reduces AKI in accordance to pre-existing chronic kidney disease. PATIENTS AND METHODS: We conducted a retrospective study including 891 consecutive STEMI patients who underwent primary coronary intervention from January 2008 to March 2016. AKI was determined on the basis of KDIGO criteria. The impact of PIA was evaluated in three groups according to the baseline glomerular filtration rate: less than 45 ml/min/1.73 m (group 1, n = 89), 45-59 ml/min/1.73 m (group 2, n = 117), and greater than or equal to 60 ml/min/1.73 m (group 3, n = 642). Univariate and multivariate predictors for AKI were determined. RESULTS: AKI developed in 13.8% of patients (n = 117) and was more prevalent in patients with worse baseline renal function (35% in group 1; 22% in group 2; and 9% in group 3, P < 0.01). The prevalence of PIA was similar across groups (28-34%, P = 0.2). Only in group 1 did patients with PIA have a significantly lower rate of AKI than patients without PIA (19 vs. 42%, P = 0.033). In multivariate analysis, the absence of PIA in group 1 patients conferred an almost three-fold risk of developing AKI (odds ratio = 2.92, P = 0.009), whereas no differences were found for the other groups. Age, total ischemic time, and intra-aortic balloon pump utilization were also related independently to AKI. CONCLUSION: In our series, STEMI patients with at least stage 3B chronic kidney disease had a three-fold risk of developing AKI in the absence of PIA. These findings suggest that patients with worse renal function may be more susceptible to the renoprotective effect of myocardial ischemic preconditioning.
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Lesión Renal Aguda/epidemiología , Angina de Pecho/terapia , Tasa de Filtración Glomerular , Riñón/fisiopatología , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/efectos adversos , Insuficiencia Renal Crónica/epidemiología , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/fisiopatología , Anciano , Anciano de 80 o más Años , Angina de Pecho/diagnóstico , Angina de Pecho/epidemiología , Angina de Pecho/fisiopatología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Infarto del Miocardio/fisiopatología , Portugal/epidemiología , Prevalencia , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/fisiopatología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Aneurisma Falso , Aneurisma Roto , Aneurisma Cardíaco , Pericarditis , Humanos , Aneurisma Falso/complicaciones , Aneurisma Falso/diagnóstico por imagen , Aneurisma Roto/complicaciones , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugía , Pericarditis/complicaciones , Pericarditis/diagnóstico por imagen , Aneurisma Cardíaco/complicaciones , Aneurisma Cardíaco/diagnóstico por imagenRESUMEN
INTRODUCTION: ST-elevation myocardial infarction (STEMI) is a medical emergency that benefits from rapid access to specialized care. The objective of this study was to describe developments in patient transport via the pre-hospital emergency medical system (EMS) and its impact on clinical outcomes. METHODS: We retrospectively studied STEMI patients who underwent primary percutaneous coronary intervention between January 2008 and July 2015. Patients were divided according to type of admission. Total ischemic time (TIT), door-to-balloon time (DBT) and in-hospital and one-year clinical outcomes were assessed for each group. RESULTS: A total of 764 patients were included, of whom 33.5% were transported by the EMS and 45.8% by their own means, 13.7% were transferred from another institution and 6.9% were transported by non-EMS ambulance. There was a trend for more frequent recourse to the EMS over the eight-year period. There was a higher percentage of patients with prior myocardial infarction and Killip class III/IV in the EMS group compared to the non-EMS group. Significant differences were seen between groups in reperfusion times, EMS patients having the shortest TIT and DBT (195 vs. 286 min, p<0.001 and 61 vs. 90 min, p<0.001, respectively), but no significant difference in event rates was observed. Patients presenting to the hospital early had higher rates of effective reperfusion and lower in-hospital mortality (6.9% vs. 33.9%, p<0.001). CONCLUSIONS: Recourse to the EMS significantly reduced ischemic times. Although this improvement was not directly associated with significant differences in event rates, it was associated with higher rates of effective reperfusion that were reflected in lower in-hospital mortality.
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Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/cirugía , Servicios Médicos de Urgencia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Transporte de Pacientes , Resultado del TratamientoAsunto(s)
Fístula Arterio-Arterial/diagnóstico , Enfermedades Asintomáticas , Atletas , Anomalías de los Vasos Coronarios/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Arteria Pulmonar/anomalías , Fístula Arterio-Arterial/congénito , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Diagnóstico Diferencial , Ecocardiografía , Humanos , Masculino , Arteria Pulmonar/diagnóstico por imagen , Adulto JovenAsunto(s)
Neuropatías Amiloides Familiares/diagnóstico por imagen , Ascitis Quilosa/diagnóstico por imagen , Insuficiencia Cardíaca/diagnóstico por imagen , Multimorbilidad , Anciano , Neuropatías Amiloides Familiares/genética , Neuropatías Amiloides Familiares/terapia , Ascitis Quilosa/genética , Ascitis Quilosa/terapia , Terapia Combinada , Ecocardiografía/métodos , Enfermedades Endémicas , Insuficiencia Cardíaca/genética , Insuficiencia Cardíaca/terapia , Humanos , Masculino , Tomografía de Emisión de Positrones/métodos , Pronóstico , Enfermedades Raras , Medición de Riesgo , España , Tomografía Computarizada por Rayos X/métodosRESUMEN
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