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BACKGROUND: Cognitive function and cardiovascular disease (CVD) have a bidirectional relationship, but studies on the impact of CVD subtypes and aging spectrum have been scarce. METHODS: We assessed older adults aged ≥60 years from the 2011 to 2012 and 2013 to 2014 cycles of the National Health and Nutrition Examination Survey who had coronary heart disease, angina, prior myocardial infarction, congestive heart failure, or prior stroke. We compared CERAD-IR, CERAD-DR, Animal Fluency test, and DSST scores to assess cognitive performance in older adults with and without CVD. RESULTS: We included 3,131 older adults, representing 55,479,673 older adults at the national level. Older adults with CVD had lower CERAD-IR (mean difference 1.8, 95% CI 1.4-2.1, P < .001), CERAD-DR (mean difference 0.8, 95% CI 0.6-1.0, P < .001), Animal Fluency test (mean difference 2.1, 95% CI 1.6-2.6, P < .001), and DSST (mean difference 9.5, 95% CI 8.0-10.9, P < .001) scores compared with those without CVD. After adjustment, no difference in CERAD-IR, CERAD-DR, and Animal Fluency test scores was observed, but DSST scores were lower in older adults with CVD (adjusted mean difference 2.9, 95% CI 1.1-4.7, P = .001). Across CVD subtypes, individuals with congestive heart failure had lower performance on the DSST score. The oldest-old cohort of patients ≥80 years old with CVD had lower performance than those without CVD on both the DSST and Animal Fluency test. CONCLUSION: Older adults with CVD had lower cognitive performance as measured than those free of CVD, driven by pronounced differences among those with CHF and those ≥80 years old with CVD.
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Doenças Cardiovasculares , Cognição , Inquéritos Nutricionais , Humanos , Idoso , Masculino , Feminino , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/psicologia , Pessoa de Meia-Idade , Cognição/fisiologia , Estados Unidos/epidemiologia , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Disfunção Cognitiva/diagnóstico , Idoso de 80 Anos ou mais , Fatores de RiscoRESUMO
PURPOSE OF REVIEW: Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies. RECENT FINDINGS: The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.
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LDL-Colesterol , Humanos , Idoso , LDL-Colesterol/sangue , LDL-Colesterol/efeitos dos fármacos , Medição de Risco/métodos , Doenças Cardiovasculares/prevenção & controle , Prevenção Secundária/métodos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Prevenção Primária/métodos , Anticolesterolemiantes/uso terapêutico , Aterosclerose/prevenção & controleRESUMO
BACKGROUND: Peripheral arterial disease (PAD) is commonly associated with coronary artery disease, and echocardiography is frequently performed before lower extremity revascularization (LER). However, the incidence of various echocardiographic findings in patients with PAD and their impact on the outcomes of LER has not been well studied. Reduced ejection fraction (EF) ≤ 40% is associated with increased major adverse limb events (MALE) after LER. METHODS: The electronic medical records of patients undergoing LER in a single center were reviewed. Patients were divided based on the presence or absence of reduced EF. Patient, transthoracic echocardiogram, procedural characteristics, and outcomes were compared between the 2 groups. RESULTS: A total of 1,114 patients (N = 131, 11.8% with reduced EF) underwent LER between 2013 and 2019. Patients with reduced EF were more likely to be male and have a history of coronary artery disease and heart failure. Furthermore, they were more likely to have diastolic dysfunction with moderate to severe mitral and tricuspid valve regurgitation. Patients with reduced EF were more likely to undergo LER for chronic limb-threatening ischemia, and to be treated with endovascular procedures. Perioperatively, patients with reduced EF were more likely to develop myocardial infarction. Lastly, the 2 groups had no difference in overall MALE or major amputation. However, on Kaplan-Meier curves, MALE-free survival was significantly lower for patients with reduced EF. Regression analysis demonstrated that indication and not EF was associated with MALE and MALE-free survival. CONCLUSIONS: Reduced EF is associated with decreased MALE-free survival for patients with PAD undergoing LER.
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Doença da Artéria Coronariana , Procedimentos Endovasculares , Doença Arterial Periférica , Humanos , Masculino , Feminino , Volume Sistólico , Doença da Artéria Coronariana/cirurgia , Resultado do Tratamento , Salvamento de Membro , Fatores de Risco , Procedimentos Endovasculares/efeitos adversos , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Estudos RetrospectivosRESUMO
PURPOSE: To report a case of a patient with May-Thurner syndrome who underwent endovenous stenting and was found to have pulsating arterial compression on the venous stent. REPORT: A 74-year-old man presented with 18 months of progressive right thigh and calf edema. After an extensive work-up, the patient underwent a venogram with intravascular ultrasound (IVUS), revealing compression of the right iliac vein by the external iliac artery and psoas muscle. Following stent deployment, fluoroscopy revealed extrinsic compression by an artery, but IVUS confirmed sufficient stent expansion. On follow-up, there was a significant resolution of right limb edema, and adjacent arterial pulsation/compression was deemed non-significant. CONCLUSION: The choice of venous stents is essential to prevent collapse from extrinsic compression, such as that from an adjacent artery. CLINICAL IMPACT: Carefully choosing venous stents is essential to ensure stent patency in the face of external compression.
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INTRODUCTION: Infra-popliteal peripheral arterial disease (IPPAD) poses challenges due to high restenosis and occlusion rates. The BASIL-2 trial demonstrated the superiority of endovascular treatment compared with surgical bypass in patients with IPPAD. However, the association between different endovascular modalities and clinical outcomes has not been conclusive. HYPOTHESIS: Combining plain old balloon angioplasty (POBA) with atherectomy is associated with improved clinical outcomes compared with POBA alone. METHODS: Patients who underwent POBA vs POBA+atherectomy for IPPAD from the Vascular Quality Initiative database were identified. To mitigate potential selection bias, we employed propensity score matching (PSM) to balance the distribution of confounding variables for mortality identified on multivariable logistic regression. Subsequently, we compared patient characteristics and long-term outcomes between the 2 treatment groups. RESULTS: Among patients who underwent endovascular intervention for IPPAD, 19 979 individuals (80.8%) were treated with POBA alone, while 4747 (19.2%) were treated with both POBA+atherectomy after PSM. Propensity score matching ensured minimal differences in baseline characteristics, such as indication for lower extremity revascularization (LER) and history of LER. After PSM, patients receiving POBA+atherectomy experienced higher rates of technical success and lower perioperative complications, such as renal complications and hematoma, compared with POBA alone. During long-term follow-up, patients who underwent atherectomy had lower rates of major amputation and major adverse limb events (MALE) but slightly lower freedom from reintervention. Nonetheless, there were no differences in mortality. CONCLUSION: Combining POBA with atherectomy appears to be a safe approach in patients with IPPAD, with lower rates of long-term amputation and MALE at the cost of a higher risk of reintervention. CLINICAL IMPACT: The use of adjunctive atherectomy is associated with improved long-term outcomes in patients with infra-popliteal disease.
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Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Isquemia Crônica Crítica de Membro , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/terapia , Extremidade Inferior/irrigação sanguínea , Stents , Resultado do Tratamento , Isquemia/diagnóstico por imagem , Isquemia/cirurgiaRESUMO
A 79-year-old female with chronic kidney disease (CKD) and transthoracic aortic valve replacement presented with exertional dyspnea and was found to have hemolysis due to moderate paravalvular leak. Balloon dilatation resolved symptoms and anemia. Detecting hemolysis related to paravalvular leak is challenging due to CKD, possibly leading to bone marrow suppression.
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Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Insuficiência Renal Crônica , Substituição da Valva Aórtica Transcateter , Feminino , Humanos , Idoso , Substituição da Valva Aórtica Transcateter/efeitos adversos , Hemólise , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Resultado do Tratamento , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapiaRESUMO
As the population ages, the demographic of adults aged 75 years and older in the U.S. is projected to grow to 45 million by 2050. Hypercholesterolemia is directly linked to atherosclerotic cardiovascular disease (ASCVD), which remains the leading cause of death in older adults. However, primary prevention of ASCVD through lipid-lowering agents remains unclear among older adults owing to limited involvement of older adults in current trials, lack of dedicated trials, and evidence primarily derived from secondary and retrospective analyses. Therefore, this article aims to (1) review key updates from the latest guidelines on treatment of hypercholesterolemia in older adults, (2) highlight limitations of the current ASCVD risk scores in the geriatric population, (3) present outcomes from key studies on the use of lipid-lowering agents and associated side effects, including a brief review of novel agents such as bempedoic acid, although very few adults over age 75 were included in these trial, and (4) finally, highlight upcoming dedicated trials of statins in older adults for the primary prevention of important geriatric outcomes as well as ASCVD.
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Background: Previous studies conflict on whether seasonal variability exists in atrial fibrillation (AF) admissions, and contemporary studies are lacking. Methods: We identified admissions for AF or atrial flutter in the Midwest and Northeast regions of the US from the National Inpatient Database for 2016 to 2020, grouped them into the four seasons (spring, summer, fall, winter), and compared the number of admissions. Subgroup analyses were performed stratified to sex, age, race, AF alone, and geographical regions. Results: A total of 955,320 admissions for AF or atrial flutter occurred. The number of admissions was highest during winter (243,990, 25.5% of the total), followed by fall (239,250, 25.0% of the total), summer (236,910, 24.8% of the total), and spring (235,170, 24.6% of the total). The differences were statistically significant (P < 0.001). An increasing trend in the number of admissions was observed from March to February of the next year (P trend <0.001). Admissions were most common in the winter and least common in the spring in subgroups of both sexes, age ≥65 years, Whites, non-Whites, AF alone, Northeast region, and Midwest region. Conclusion: Contemporary analysis of a national database demonstrates seasonal variability in the number of admissions for AF, with a slight increase observed during the winter.
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Studies on the long-term differences in quality-of-life (QoL) metrics after treatment for stable ischemic heart disease (SIHD) in older adults with diabetes mellitus are lacking. Older patients (age ≥65 years) in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial were stratified into those who received intensive medical therapy (IMT) only versus revascularization (percutaneous coronary intervention [PCI] vs coronary artery bypass graft surgery [CABG]) with Optimal Medical Therapy (OMT). Self-health score, Duke activity status index (DASI), energy rating, and health distress rating at 5 years were compared using multivariable linear regression. A total of 929 older adults were included, of whom 469 (50.5%) underwent medical therapy alone, 302 (32.5%) underwent PCI, and 158 (17.0%) had CABG. Patients who underwent CABG were more likely to have proximal left anterior descending coronary artery disease, chronic total occlusion, and higher myocardial jeopardy index. At 5 years of follow-up, no differences in self-health score, DASI, energy rating, and health distress rating were observed between PCI and IMT. There are also no differences in the 4 QoL measures between CABG and IMT alone. However, the DASI was marginally higher with CABG but not statistically significant (mean difference 3.88, 95% confidence interval -0.10 to -7.86, p = 0.057). At 5 years of follow-up, no differences in QoL measures were observed between PCI and CABG with OMT versus OMT alone in older adult patients with diabetes mellitus and SIHD. Future blinded randomized trials are necessary to investigate the impact of SIHD treatment in the older adult population, considering the risks associated with multimorbidity, polypharmacy, frailty, and cognitive impairment.
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Ponte de Artéria Coronária , Diabetes Mellitus Tipo 2 , Isquemia Miocárdica , Intervenção Coronária Percutânea , Qualidade de Vida , Humanos , Masculino , Feminino , Idoso , Diabetes Mellitus Tipo 2/complicações , SeguimentosRESUMO
BACKGROUND: Complete revascularization with percutaneous coronary intervention improves outcomes compared with culprit revascularization following myocardial infarction (MI) with multivessel coronary artery disease. An all-cause mortality reduction has never been demonstrated. Debate also remains regarding the optimal timing of complete revascularization (immediate or staged), and method of evaluation of nonculprit lesions (physiology or angiography). OBJECTIVES: This study aims to perform an updated systematic review with frequentist and Bayesian network meta-analyses including the totality of randomized data investigating revascularization strategies in patients presenting with MI and multivessel coronary artery disease. METHODS: The primary comparison tested complete vs culprit revascularization. Timing and methods of achieving complete revascularization were assessed. The prespecified primary outcome was all-cause mortality. Outcomes were expressed as relative risk (RR) (95% CI). RESULTS: Twenty-four eligible trials randomized 16,371 patients (weighted mean follow-up: 26.4 months). Compared with culprit revascularization, complete revascularization reduced all-cause mortality in patients with any MI (RR: 0.85; 95% CI: 0.74-0.99; P = 0.04). Cardiovascular mortality, MI, major adverse cardiac events and repeat revascularization were also significantly reduced. In patients presenting with ST-segment elevation myocardial infarction, the point estimate for all-cause mortality with complete revascularization was RR: 0.91 (95% CI: 0.78-1.05; P = 0.18). Rates of stent thrombosis, major bleeding, and acute kidney injury were similar. Immediate complete revascularization ranked higher than staged complete revascularization for all endpoints. CONCLUSIONS: Complete revascularization following MI reduces all-cause mortality, cardiovascular mortality, MI, major adverse cardiac events, and repeat revascularization. There may be benefits to immediate complete revascularization, but additional head-to-head trials are needed.
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Infarto do Miocárdio , Metanálise em Rede , Intervenção Coronária Percutânea , Humanos , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio/cirurgia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapiaRESUMO
Medical therapy, including antianginal treatment, is the cornerstone in the management of stable ischemic heart disease (SIHD). However, it remains unclear whether combining antianginal agents provides benefits beyond monotherapy in terms of quality of life (QoL) and cardiovascular outcomes. We used data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, which compared cardiovascular and QoL outcomes in patients with SIHD and diabetes mellitus randomized to revascularization with intensive medical therapy or intensive medical therapy alone. We categorized patients into 3 groups: ≥2 versus 1 versus 0 antianginals. We compared patient characteristics, QoL metrics, and cardiovascular end points at baseline and at 5 years, creating a multivariable model to adjust for key clinical confounders. Of 2,368 patients, 348 patients (14.7%) were on 0 antianginals, 1,020 patients (43.1%) were on 1 antianginal, and 1,000 patients (42.2%) were on ≥2 antianginals at baseline. The most common antianginal class was ß blockers. At baseline, patients on 0 antianginals had better QoL metrics (self-health score, Duke activity status index, and energy rating) than patients on ≥2 antianginals. However, at the 1-year follow-up, patients taking only 1 antianginal showed greater QoL improvement than those taking 0 antianginal, without any incremental benefit in QoL metrics seen in patients taking ≥2 antianginal agents, even after adjusting for multiple covariates such as age, heart failure, diabetes control, and myocardial jeopardy index. Lastly, at the 5-year follow-up, after adjustment, there were no differences in all-cause mortality, major adverse cardiovascular events, or myocardial infarction between patients taking different numbers of antianginals. Adults on a single antianginal for SIHD and diabetes mellitus had similar or better improvements in QoL than those on 2 or more antianginal agents at 1 year of follow-up. These findings merit further research to better understand the impact of medical therapy intensity on QoL in patients with SIHD and associated co-morbidities.
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Fármacos Cardiovasculares , Diabetes Mellitus Tipo 2 , Isquemia Miocárdica , Adulto , Humanos , Qualidade de Vida , Ponte de Artéria Coronária , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Seguimentos , Resultado do Tratamento , Isquemia Miocárdica/complicações , Angioplastia , Fármacos Cardiovasculares/uso terapêuticoRESUMO
Frailty, a clinical syndrome of increased vulnerability, due to diminished cognitive, physical, and physiological reserves is a growing concern in the cardiac intensive care unit (CICU). It contributes to morbidity, mortality, and complications and often exerts a bidirectional association with cardiovascular disease. Although it predominately affects older adults, frailty can also be observed in younger patients <65 years of age, with approximately 30% of those admitted in CICU are frail. Acute cardiovascular illness can also impair physical and cognitive functioning among survivors and these survivors often suffer from frailty and functional declines post-CICU discharge. Patients with frailty in the CICU often have higher comorbidity burden, and they are less likely to receive optimal therapy for their acute cardiovascular conditions. Given the significance of this geriatric syndrome, this review will focus on assessment, clinical outcomes, and interventions, in an attempt to establish appropriate assessment, management, and resource utilization in frail patients during and after CICU admission.
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Fragilidade , Avaliação Geriátrica , Humanos , Fragilidade/epidemiologia , Fragilidade/complicações , Avaliação Geriátrica/métodos , Idoso , Unidades de Terapia Intensiva , Doenças Cardiovasculares/terapia , Doenças Cardiovasculares/epidemiologia , Unidades de Cuidados Coronarianos , Idoso FragilizadoRESUMO
As the older adult population expands, an increasing number of patients affected by geriatric syndromes are seen by cardiovascular clinicians. One such syndrome that has been associated with poor outcomes is cognitive frailty: the simultaneous presence of cognitive impairment, without evidence of dementia, and physical frailty, which results in decreased cognitive reserve. Driven by common pathophysiologic underpinnings (eg, inflammation and neurohormonal dysregulation), cardiovascular disease, cognitive impairment, and frailty also share the following risk factors: hypertension, diabetes, obesity, sedentary behavior, and tobacco use. Cardiovascular disease has been associated with the onset and progression of cognitive frailty, which may be reversible in early stages, making it essential for clinicians to diagnose the condition in a timely manner and prescribe appropriate interventions. Additional research is required to elucidate the mechanisms underlying the development of cognitive frailty, establish preventive and therapeutic strategies to address the needs of older patients with cardiovascular disease at risk for cognitive frailty, and ultimately facilitate targeted intervention studies.
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Doenças Cardiovasculares , Disfunção Cognitiva , Diabetes Mellitus , Fragilidade , Humanos , Idoso , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/epidemiologia , Cognição/fisiologia , Avaliação Geriátrica/métodosRESUMO
BACKGROUND: In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA. METHODS: We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24â h, 24-72â h, 72-120â h, and >120â h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost. RESULTS: A total of 147â 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120â h and at >120â h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24â h from admission. In addition to these differences, CABG at >120â h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24â h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24â h. CONCLUSION: CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.
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Ponte de Artéria Coronária , Mortalidade Hospitalar , Tempo de Internação , Infarto do Miocárdio sem Supradesnível do Segmento ST , Tempo para o Tratamento , Humanos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/economia , Ponte de Artéria Coronária/estatística & dados numéricos , Feminino , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Estados Unidos/epidemiologia , Idoso , Pessoa de Meia-Idade , Tempo para o Tratamento/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Custos Hospitalares , Fatores de Tempo , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Pregnancy in patients with pulmonary hypertension (PH) is associated with a heightened risk of medical complications including right heart failure, pulmonary edema, and arrhythmias. Our study investigated the association between PH and these complications during delivery. METHODS AND RESULTS: The National Inpatient Sample was used to identify delivery hospitalizations from 2011 to 2020. Multivariable logistic regression was performed to study the association of PH with the primary outcomes of in-hospital medical and obstetric complications. A total of 37 482 207 delivery hospitalizations in women ≥18 years of age were identified, of which 9593 patients had PH. Pregnant patients with PH had higher incidence of complications during delivery including preeclampsia/eclampsia, arrhythmias, and pulmonary edema among others, compared with those without PH. Pregnant patients with PH also had a higher incidence of in-hospital mortality compared with those without PH (0.51% versus 0.007%). In propensity-matched analyses, PH was still significantly associated with a higher risk of in-hospital mortality (odds ratio [OR], 5.02 [95% CI, 1.82-13.90]; P=0.001), pulmonary edema (OR, 9.11 [95% CI, 6.34-13.10]; P<0.001), peripartum cardiomyopathy (OR, 1.85 [95% CI, 1.37-2.50]; P<0.001), venous thromboembolism (OR, 12.60 [95% CI, 6.04-26.10]; P<0.001), cardiac arrhythmias (OR, 6.11 [95% CI, 4.97-7.53]; P<0.001), acute kidney injury (OR, 3.72 [95% CI, 2.86-4.84]; P<0.001), preeclampsia/eclampsia (OR, 2.24 [95% CI, 1.95-2.58]; P<0.001), and acute coronary syndrome (OR, 2.01 [95% CI, 1.06-3.80]; P=0.03), compared with pregnant patients without PH. CONCLUSIONS: Delivery hospitalizations in patients with PH are associated with a high risk of mortality, pulmonary edema, peripartum cardiomyopathy, venous thromboembolism, arrhythmias, acute kidney injury, preeclampsia/eclampsia, and acute coronary syndrome.
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Mortalidade Hospitalar , Hospitalização , Hipertensão Pulmonar , Complicações Cardiovasculares na Gravidez , Humanos , Feminino , Gravidez , Hipertensão Pulmonar/epidemiologia , Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/terapia , Adulto , Estados Unidos/epidemiologia , Hospitalização/estatística & dados numéricos , Hospitalização/tendências , Complicações Cardiovasculares na Gravidez/epidemiologia , Complicações Cardiovasculares na Gravidez/terapia , Mortalidade Hospitalar/tendências , Incidência , Adulto Jovem , Fatores de Risco , Estudos Retrospectivos , Parto Obstétrico/estatística & dados numéricos , Parto Obstétrico/efeitos adversos , Edema Pulmonar/epidemiologia , Edema Pulmonar/etiologia , Edema Pulmonar/mortalidade , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/terapia , Arritmias Cardíacas/mortalidade , Medição de RiscoRESUMO
Background: Cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) is associated with high morbidity and mortality. Frailty is a common comorbidity in patients with cardiovascular disease and is also associated with adverse outcomes. The impact of preexisting frailty at the time of CS diagnosis following AMI has not been studied. Objectives: The purpose of this study was to examine the prevalence of frailty in patients admitted with AMI complicated by CS (AMI-CS) hospitalizations and its associations with in-hospital outcomes. Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2020 and identified all hospitalizations for AMI-CS. We classified them into frail and nonfrail groups according to the hospital frailty risk score cut-off of 5 and compared in-hospital outcomes. Results: A total of 283,700 hospitalizations for AMI-CS were identified. Most (70.8%) occurred in the frail. Those with frailty had higher odds of in-hospital mortality (adjusted OR [aOR]: 2.17, 95% CI: 2.07 to 2.26, P < 0.001), do-not-resuscitate status, and discharge to a skilled nursing facility compared with those without frailty. They also had higher odds of in-hospital adverse events, including intracranial hemorrhage, gastrointestinal hemorrhage, acute kidney injury, and delirium. Importantly, AMI-CS hospitalizations in the frail had lower odds of coronary revascularization (aOR: 0.55, 95% CI: 0.53-0.58, P < 0.001) or mechanical circulatory support (aOR: 0.89, 95% CI: 0.85-0.93, P < 0.001). Lastly, hospitalizations for AMI-CS showed an overall increase from 53,210 in 2016 to 57,065 in 2020 (P trend <0.001), with this trend driven by a rise in the frail. Conclusions: A high proportion of hospitalizations for AMI-CS had concomitant frailty. Hospitalizations with AMI-CS and frailty had higher rates of in-hospital morbidity and mortality compared to those without frailty.
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The incidence of frailty and cardiovascular disease (CVD) increases as the population ages. There is a bidirectional relationship between frailty and CVD, and both conditions share several risk factors and underlying biological mechanisms. Frailty has been established as an independent prognostic marker in patients with CVD. Moreover, its presence significantly influences both primary and secondary prevention strategies for adults with CVD while also posing a barrier to the inclusion of these patients in pivotal clinical trials and advanced cardiac interventions. This review discusses the current knowledge base on the relationship between frailty and CVD, how managing CVD risk factors can modify frailty, the influence of frailty on CVD management, and future directions for frailty detection and modification in patients with CVD.
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Doenças Cardiovasculares , Fragilidade , Humanos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Fragilidade/epidemiologia , Fragilidade/complicações , Fragilidade/diagnóstico , Idoso , Fatores de Risco , Idoso Fragilizado , Prognóstico , Medição de Risco , Avaliação Geriátrica/métodos , Fatores de Risco de Doenças Cardíacas , IncidênciaRESUMO
Importance: The optimal duration of dual antiplatelet therapy (DAPT) for older adults after percutaneous coronary intervention (PCI) is uncertain because they are simultaneously at higher risk for both ischemic and bleeding events. Objective: To investigate the association of abbreviated DAPT with adverse clinical events among older adults after PCI. Data Sources: The Cochrane Library, Google Scholar, Embase, MEDLINE, PubMed, Scopus, and Web of Science were searched from inception to August 9, 2023. Study Selection: Randomized clinical trials comparing any 2 of 1, 3, 6, and 12 months of DAPT were included if they reported results for adults aged 65 years or older or 75 years or older. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was used to abstract data and assess data quality. Risk ratios for each duration of DAPT were calculated with alternation of the reference group. Main Outcomes and Measures: The primary outcome of interest was net adverse clinical events (NACE). Secondary outcomes were major adverse cardiovascular events (MACE) and bleeding. Results: In 14 randomized clinical trials comprising 19â¯102 older adults, no differences were observed in the risks of NACE or MACE for 1, 3, 6, and 12 months of DAPT. However, 3 months of DAPT was associated with a lower risk of bleeding compared with 6 months of DAPT (relative risk [RR], 0.50 [95% CI, 0.29-0.84]) and 12 months of DAPT (RR, 0.57 [95% CI, 0.45-0.71]) among older adults. One month of DAPT was also associated with a lower risk of bleeding compared with 6 months of DAPT (RR, 0.68 [95% CI, 0.54-0.86]). Conclusions and Relevance: In this systematic review and meta-analysis of different durations of DAPT for older adults after PCI, an abbreviated DAPT duration was associated with a lower risk of bleeding without any concomitant increase in the risk of MACE or NACE despite the concern for higher-risk coronary anatomy and comorbidities among older adults. This study, which represents the first network meta-analysis of this shortened treatment for older adults, suggests that clinicians may consider abbreviating DAPT for older adults.
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Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária , Humanos , Idoso , Inibidores da Agregação Plaquetária/uso terapêutico , Metanálise em Rede , Coração , Confiabilidade dos DadosRESUMO
(1) Background: Cardiogenic shock (CS) is associated with high morbidity and mortality. Frailty and cardiovascular diseases are intertwined, commonly sharing risk factors and exhibiting bidirectional relationships. The relationship of frailty and non-acute myocardial infarction with cardiogenic shock (non-AMI-CS) is poorly described. (2) Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2020 and identified all hospitalizations for non-AMI-CS. We classified them into frail and non-frail groups according to the hospital frailty risk score cut-off of 5 and compared in-hospital outcomes. (3) Results: A total of 503,780 hospitalizations for non-AMI-CS were identified. Most hospitalizations involved frail adults (80.0%). Those with frailty had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 2.11, 95% confidence interval [CI] 2.03-2.20, p < 0.001), do-not-resuscitate status, and discharge to a skilled nursing facility compared with those without frailty. They also had higher odds of in-hospital adverse events, such as acute kidney injury, delirium, and longer length of stay. Importantly, non-AMI-CS hospitalizations in the frail group had lower use of mechanical circulatory support but not rates of cardiac transplantation. (4) Conclusions: Frailty is highly prevalent among non-AMI-CS hospitalizations. Those accompanied by frailty are often associated with increased rates of morbidity and mortality compared to those without frailty.