RESUMO
BACKGROUND: Patient-reported Outcome (PRO) measures may be used as the basis for out-patient follow-up instead of fixed appointments. The patients attend follow-up from home by filling in questionnaires developed for that specific aim and patient group (telePRO). The questionnaires are handled in real time by a specific algorithm, which assigns an outcome color reflecting clinical need. The specific questionnaires and algorithms (named solutions) are constructed in a consensus process with clinicians. We aimed to describe AmbuFlex' telePRO solutions and the algorithm outcomes and variation between patient groups, and to discuss possible applications and challenges. METHODS: TelePRO solutions with more than 100 processed questionnaires were included in the analysis. Data were retrieved together with data from national registers. Characteristics of patients, questionnaires and outcomes were tabulated for each solution. Graphs were constructed depicting the overall and within-patient distribution of algorithm outcomes for each solution. RESULTS: From 2011 to 2021, 29 specific telePRO solutions were implemented within 24 different ICD-10 groups. A total of 42,015 patients were referred and answered 171,268 questionnaires. An existing applicable instrument with cut-off values was available for four solutions, whereas items were selected or developed ad hoc for the other solutions. Mean age ranged from 10.7 (Pain in children) to 73.3 years (chronic kidney disease). Mortality among referred patients varied between 0 (obesity, asthma, endometriosis and pain in children) and 528 per 1000 patient years (Lung cancer). There was substantial variation in algorithm outcome across patient groups while different solutions within the same patient group varied little. DISCUSSION: TelePRO can be applied in diseases where PRO can reflect clinical status and needs. Questionnaires and algorithms should be adapted for the specific patient groups and clinical aims. When PRO is used as replacement for clinical contact, special carefulness should be observed with respect to patient safety.
Assuntos
Neoplasias Pulmonares , Qualidade de Vida , Feminino , Criança , Humanos , Qualidade de Vida/psicologia , Medidas de Resultados Relatados pelo Paciente , Pacientes Ambulatoriais , AlgoritmosRESUMO
BACKGROUND: To investigate if acute pulmonary vasodilation by sildenafil improves right ventricular function in patients with acute intermediate-high risk pulmonary embolism (PE). METHODS: Single center, explorative trial. Patients with PE were randomized to a single oral dose of sildenafil 50 mg (n = 10) or placebo (n = 10) as add-on to conventional therapy. The time from hospital admission to study inclusion was 2.3 ± 0.7 days. Right ventricular function was evaluated immediately before and shortly after (0.5-1.5 h) randomization by right heart catheterization (RHC), trans-thoracic echocardiography (TTE), and cardiac magnetic resonance (CMR). The primary efficacy endpoint was cardiac index measured by CMR. RESULTS: Patients had acute intermediate-high risk PE verified by computed tomography pulmonary angiography, systolic blood pressure of 135 ± 18 (mean ± SD) mmHg, increased right ventricular/left ventricular ratio 1.1 ± 0.09 and increased troponin T 167 ± 144 ng/L. Sildenafil treatment did not improve cardiac index compared to baseline (0.02 ± 0.36 l/min/m2, p = 0.89) and neither did placebo (0.00 ± 0.34 l/min/m2, p = 0.97). Sildenafil lowered mean arterial blood pressure (- 19 ± 10 mmHg, p < 0.001) which was not observed in the placebo group (0 ± 9 mmHg, p = 0.97). CONCLUSION: A single oral dose of sildenafil 50 mg did not improve cardiac index but lowered systemic blood pressure in patients with acute intermediate-high risk PE. The time from PE to intervention, a small patient sample size and low pulmonary vascular resistance are limitations of this study that should be considered when interpreting the results. TRIAL REGISTRATION: The trial was retrospectively registered at www.clinicaltrials.gov (NCT04283240) February 2nd 2020, https://clinicaltrials.gov/ct2/show/NCT04283240?term=NCT04283240&draw=2&rank=1 .
Assuntos
Pressão Arterial/efeitos dos fármacos , Ventrículos do Coração/efeitos dos fármacos , Embolia Pulmonar/tratamento farmacológico , Citrato de Sildenafila/uso terapêutico , Vasodilatação/efeitos dos fármacos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Citrato de Sildenafila/farmacologia , Resultado do Tratamento , Resistência Vascular/efeitos dos fármacosRESUMO
BACKGROUND: Premature atrial complexes (PACs) meet increased attention as a potential intermediary between sinus rhythm and atrial fibrillation (AF). Patients with even high numbers of PACs do not fulfill current guidelines for oral anticoagulation treatment though an associated stroke risk is suspected. OBJECTIVE: We aimed to determine whether a high number of PACs or runs of AF less than 30 seconds in 2-day continuous electrocardiogram (ECG) recording was associated with risk of recurrent ischemic stroke/transient ischemic attack (TIA) or death in a large cohort of patients with acute ischemic stroke or TIA and no prior AF. METHODS: We performed 48 hours continuous ECG recording within 1 week after ischemic stroke/TIA. PACs were reported as mean number of PACs per hour. Patients were followed in Danish Stroke Registry, Danish Civil Registration System, and Danish National Patient Registry. Cox Regression analysis was used to calculate hazard ratios. RESULTS: We included 1507 patients with TIA (40%) or ischemic stroke (60%), of which 98.7% had mild to moderate strokes. Mean age was 72.9 (7.8) years, 43.4% were females. Follow-up was 2.3 (1.3) years. Hazard ratio for recurrent stroke/TIA or death did not differ between quartiles of PAC burden, nor did any of the 2 components of this composite endpoint. Nonsustained AF less than 30 seconds was not associated with higher risk of recurrent stroke/TIA or death. CONCLUSIONS: In a large cohort of patients with recent ischemic stroke or TIA, burden of PACs or nonsustained AF less than 30 seconds were not associated to higher risk of recurrent stroke/TIA or death.
Assuntos
Fibrilação Atrial/mortalidade , Complexos Atriais Prematuros/mortalidade , Isquemia Encefálica/mortalidade , Ataque Isquêmico Transitório/mortalidade , Acidente Vascular Cerebral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Complexos Atriais Prematuros/diagnóstico , Complexos Atriais Prematuros/fisiopatologia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Dinamarca/epidemiologia , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Prognóstico , Estudos Prospectivos , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de TempoRESUMO
Atrial fibrillation (AF) is the most common cardiac cause of ischemic stroke and transient ischemic attack (IS/TIA). AIM: To compare the diagnostic value of seven-day external loop recording (ELR) and two-day Holter recording for detecting AF after IS/TIA. METHODS: 191 IS/TIA patients without AF history. Endpoint was AF >30s. We started two-day Holter recording and seven-day ELR simultaneously. RESULTS: Seven-day ELR and two-day Holter recording detected the same three AF patients. ELR detected another six patients with AF adjudicated by cardiologists, four detections after Holter (3 vs. 7, p=0.125) and two false-positive detections during Holter. Seven-day ELR automatically classified 50/191 patients (26%) with AF, but only 7/50 (14%) were confirmed as AF by cardiologists. CONCLUSION: Seven-day ELR did not detect significantly more patients with AF than two-day Holter recording. 86% of patients with ELR-classified AF were false positives, indicating a poor performance of the automatic AF detection algorithm used.
Assuntos
Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Eletrocardiografia Ambulatorial/métodos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Idoso , Causalidade , Comorbidade , Dinamarca/epidemiologia , Eletrocardiografia Ambulatorial/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
OBJECTIVES: Guidelines recommend initiating primary prevention with statins to those at highest cardiovascular risk. We assessed the gender-specific implementation and effectiveness of this risk-guided approach. METHODS: We identified 1399 consecutive patients without known cardiovascular disease or diabetes hospitalized with a first myocardial infarction (MI) in Denmark. Statin use before MI was assessed, and cardiovascular risk was calculated using SCORE (Systematic COronary Risk Evaluation). RESULTS: Among patients with first MI, 36% were women. Compared with men, they were older (mean 72 vs. 65years) but had a lower estimated risk (median 3.4% vs. 6.7%, SCORE high-risk model in the statin-naïve patients). Statin therapy had been initiated in 12% of women and 10% of men prior to MI. After adding 1.5mmol/L to the total cholesterol concentration of those already on statins, the estimated pre-treatment risk was much lower in women than men (median 3.8% vs. 9.2%, SCORE high-risk model), and only 29% of women would have passed the risk-based treatment threshold defined by the European guidelines (SCORE ≥5%). Estimated risk and statin use correlated directly in men but not in women. Only ~5% of first MI are prevented by the current use of statins in people without diabetes. CONCLUSION: In people destined for a first MI, statin therapy is uncommon and prevents few events. Lower-risk women receive as much statins as higher risk men. This gender disparity and inefficient targeting of statins to those at highest risk indicate that risk scoring is not widely used in routine clinical practice in Denmark.
Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Infarto do Miocárdio/prevenção & controle , Idoso , Dinamarca , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevenção Primária , Medição de Risco , Fatores SexuaisRESUMO
BACKGROUND: Preinvasive risk stratification is recommended in patients suspected of coronary artery disease (CAD). Stress echocardiography (SE), myocardial perfusion scintigraphy (MPS), and exercise test are the dominant methods of choice. Vasodilator SE is fast and induces only minor increase in heart rate. The diagnostic value of the absolute stress-rest difference in endocardial global longitudinal strain (ΔeGLS) and wall motion (ΔWMI) from adenosine SE was compared to summed stress score (SSS) from MPS and Duke treadmill score (DTS) from exercise test, using quantitative invasive coronary angiography (ICA) as the reference. METHODS AND RESULTS: A total of 128 patients (69% male, 62.7 (8.8) years) underwent adenosine SE, MPS, exercise test, and ICA. Forty-five patients (35%) had CAD. All stress outcomes differed significantly (P<.001) between patients with and without CAD: ΔeGLS: -1.3 (3.6)% vs -5.0 (3.3)%; WMI: 1.20 (0.34) vs 1.06 (0.13); SSS: 12.5 (8.2) vs 1.7 (3.6); and DTS: -3.4 (9.0) vs 3.9 (5.5). The cutoff values yielding the best sensitivity/specificity/accuracy were as follows: ΔeGLS: -2.3% or ΔWMI: 0 (69%/84%/79%), SSS: 4 (82%/94%/90%), and DTS: 1 (73%/78%/77%). The sensitivity of ΔeGLS + ΔWMI was similar to SSS (P=.11) and DTS (P=.59). The specificity of ΔeGLS + ΔWMI was inferior to SSS (P=.03) and similar to DTS (P=.28). CONCLUSION: Alterations in eGLS and wall motion during adenosine SE were closely associated with the presence of CAD and the combined sensitivity similar to that of MPS. If nuclear medical facilities are unavailable or radiation issues important, vasodilator ΔeGLS could be an acceptable alternative for patients unable to exercise.
Assuntos
Doença da Artéria Coronariana/diagnóstico , Ecocardiografia sob Estresse/métodos , Eletrocardiografia/métodos , Teste de Esforço/métodos , Imagem de Perfusão do Miocárdio/métodos , Cintilografia/métodos , Adenosina , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Compostos Radiofarmacêuticos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Tecnécio Tc 99m Sestamibi , VasodilatadoresRESUMO
UNLABELLED: Enhanced external counterpulsation (EECP) is a new therapy offered to patients with refractory angina pectoris (AP). PURPOSE: To assess the effect of EECP on AP, quality of life (QoL) and exercise capacity in a design starting with a control period to avoid the influence of regression-towards-the-mean. METHODS: Patients were examined two months before EECP, just before, just after, and three and 12 months after EECP. EECP was given for 1 h 5 days a week in 7 weeks. Three sets of pneumatic cuffs were mounted on the lower extremities and inflated sequentially in diastole to 260 mm Hg. RESULTS: 50 patients were included (male 72%, mean age: 62.5 years). Mean daily AP attacks were reduced during EECP from 2.7 to 0.9 (p < 0.005) and the Canadian Cardiovascular Society classification was reduced by at least 1 class in 82% just after EECP, 79% 3 months and 76% 12 months after EECP (p < 0.0002). Generic (SF36) and disease-specific QoL (Seattle AP questionnaire) improved just after, 3 and 12 months after compared with that before EECP. There was a significant improvement in exercise capacity and exercise-induced chest pain just after, three and 12 months after EECP (p < 0.02). No change was detected during the control period. CONCLUSIONS: EECP improves generic and disease-specific QoL, angina intensity and exercise capacity in at least 12 months.
Assuntos
Angina Pectoris/terapia , Contrapulsação , Tolerância ao Exercício , Qualidade de Vida , Idoso , Angina Pectoris/diagnóstico , Angina Pectoris/fisiopatologia , Angina Pectoris/psicologia , Teste de Esforço , Feminino , História Antiga , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recuperação de Função Fisiológica , Inquéritos e Questionários , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Learning and coping education strategies (LC) was implemented to enhance patient attendance in the cardiac rehabilitation programme. This study assessed the cost-utility of LC compared to standard education (standard) as part of a rehabilitation programme for patients with ischemic heart disease and heart failure. METHODS: The study was conducted alongside a randomised controlled trial with 825 patients who were allocated to LC or standard rehabilitation and followed for 5 months. The LC approach was identical to the standard approach in terms of physical training and education, but with the addition of individual interviews and weekly team evaluations by professionals. A societal cost perspective including the cost of intervention, health care, informal time and productivity loss was applied. Cost was based on a micro-costing approach for the intervention and national administrative registries for other cost categories. Quality adjusted life years (QALY) were based on SF-6D measurements at baseline, after intervention and follow-up using British preference weights. Multiple imputation was used to handle non-response on the SF-6D. Conventional cost effectiveness methodology was employed to estimate the net benefit of the LC and to illustrate cost effectiveness acceptability curves. The statistical analysis was based on means and bootstrapped standard errors. RESULTS: An additional cost of DKK 6,043 (95% CI -5,697; 17,783) and a QALY gain of 0.005 (95% CI -0.001; 0.012) was estimated for LC. However, better utility scores in both arms were due to higher utility while receiving the intervention than better health after the intervention. The probability that LC would be cost-effective did not exceed 29% for any threshold values of willingness to pay per QALY. The alternative scenario analysis was restricted to a health care perspective and showed that the probability of cost-effectiveness increased to 62% over the threshold values. DISCUSSION: The LC was unlikely to be cost-effective within 5 months of follow-up from a societal perspective, but longer-term follow-up should be evaluated before a definite conclusion is drawn. CONCLUSION: Future research should assess the LC strategies' long-term efficacy and cost-utility. TRIAL REGISTRATION: NCT01668394.
Assuntos
Insuficiência Cardíaca/reabilitação , Isquemia Miocárdica/reabilitação , Cooperação do Paciente/estatística & dados numéricos , Adaptação Psicológica , Idoso , Análise Custo-Benefício , Dinamarca/epidemiologia , Feminino , Seguimentos , Humanos , Aprendizagem , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente/psicologia , Educação de Pacientes como Assunto , Avaliação de Programas e Projetos de Saúde , Anos de Vida Ajustados por Qualidade de VidaRESUMO
BACKGROUND: Due to improved treatments and ageing population, many countries now report increasing prevalence in rates of ischemic heart disease and heart failure. Cardiac rehabilitation has potential to reduce morbidity and mortality, but not all patients complete. In light of favourable effects of cardiac rehabilitation it is important to develop patient education methods which can enhance adherence to this effective program. The LC-REHAB study aims to compare the effect of a new patient education strategy in cardiac rehabilitation called 'learning and coping' to that of standard care. Further, this paper aims to describe the theoretical basis and details of this intervention. METHODS/DESIGN: Open parallel randomised controlled trial conducted in three hospital units in Denmark among patients recently discharged with ischemic heart disease or heart failure. Patients are allocated to either the intervention group with learning and coping strategies incorporated into standard care in cardiac rehabilitation or the control group who receive the usual cardiac rehabilitation program. Learning and coping consists of two individual clarifying interviews, participation of experienced patients as educators together with health professionals and theory based, situated and inductive teaching. Usual care in cardiac rehabilitation is characterised by a structured deductive teaching style with use of identical pre-written slides in all hospital units. In both groups, cardiac rehabilitation consists of training three times a week and education once a week over eight weeks. The primary outcomes are adherence to cardiac rehabilitation, morbidity and mortality, while secondary outcomes are quality of life (SF-12, Health education impact questionnaire and Major Depression Inventory) and lifestyle and risk factors (Body Mass Index, waist circumference, blood pressure, exercise work capacity, lipid profile and DXA-scan). Data collection occurs four times; at baseline, at immediate completion of cardiac rehabilitation, and at three months and three years after the finished program. DISCUSSION: It is expected that learning and coping incorporated in cardiac rehabilitation will improve adherence in cardiac rehabilitation and may decrease morbidity and mortality. By describing learning and coping strategies the study aims to provide knowledge that can contribute to an increased transparency in patient education in cardiac rehabilitation. TRIAL REGISTRATION: Identifier NCT01668394.
Assuntos
Adaptação Psicológica , Insuficiência Cardíaca/reabilitação , Aprendizagem , Isquemia Miocárdica/reabilitação , Educação de Pacientes como Assunto/métodos , Terapia Comportamental/métodos , Dinamarca , Humanos , Estilo de Vida , Motivação , Cooperação do Paciente , Qualidade de Vida , Fatores de RiscoRESUMO
OBJECTIVE: 2D strain analysis based on speckle tracking (EchoPAC, GE) allows semi-automatic quantification of myocardial deformation. Microbubble contrast (MBC) alters the speckle pattern, but the impact of MBC on speckle tracking has not been thoroughly studied. We investigated whether 2D strain analysis performed on contrast-enhanced recordings obtained with a normal mechanical index (MI) was possible, and evaluated if and how strain measurements and speckle tracking were affected by MBC. METHODS AND RESULTS: Twenty-nine patients with normal echocardiograms were consecutively included and divided into two groups dependent on image quality (19 with high (HIQ) and 10 with low image quality (LIQ)). Before, during, three and seven minutes after MBC infusion (SonoVue, Bracco), the three standard apical loops were recorded (MI = 1.0) and analysed twice on two different days. Mean and regional (basal, mid-ventricular and apical) leftventricular peak systolic strain were calculated at each time point. No significant changes over time were detected in mean or regional strain. Reproducibility worsened during and three minutes after MBC infusion and was generally poorer in the LIQ group. Tracking was impaired during MBC for the HIQ group, but improved throughout the examination for the LIQ group. CONCLUSIONS: First, it was possible to quantify 2D strain from recordings obtained during or shortly after MBC infusion. Secondly, 2D strain measures were unaffected by the presence of MBC, and, thirdly, the reproducibility and the performance of the tracking algorithm were impaired when high intensities of MBC were present in the circulation.
Assuntos
Angina Estável , Ecocardiografia/métodos , Microbolhas , Idoso , Algoritmos , Angina Estável/diagnóstico , Angina Estável/fisiopatologia , Feminino , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Reprodutibilidade dos Testes , Volume Sistólico , Fatores de Tempo , Função Ventricular EsquerdaRESUMO
Enhanced external counterpulsation (EECP) is a non-invasive therapy offered to patients with refractory angina pectoris. Previous studies have demonstrated that its clinical effect depends on the diastolic/systolic augmentation ratio (D/S ratio). We hypothesized that the D/S ratio is associated with arterial stiffness measured as pulse wave velocity (PWV) and brachial pulse pressure (PP). Twenty patients with known refractory angina (17 men, 3 women; mean age 64 years) were included and underwent one hour of EECP treatment (Vasomedical Inc., Westbury, NY, USA). Three sets of cuffs were applied around the lower extremities. Gated by electrocardiography (ECG), air was inflated in diastole at a pressure of 260 mmHg and deflated at the start of systole. The D/S ratio was monitored with finger plethysmography. Carotid-femoral pulse wave velocity (PWV) was measured with mechanotransducers (Complior SP, Artech Medical, France). PWV and brachial BP were measured at baseline before EECP. The mean (SD) BP was 140 (23.5)/77 (9.9) mmHg, PP 62.8 (18.3) mmHg and PWV 10.8 (4.4) m/s. EECP treatment increased the D/S ratio during a one-hour session compared with baseline (1.30 (0.11) vs. 0.56 (0.04) P < 0.001), and the D/S ratio at 45 min. was significantly correlated with PWV (r = 0.49, P < 0.05) and PP (r = 0.58, P < 0.05). We demonstrated that the diastolic augmentation (D/S ratio) during EECP treatment depends on arterial stiffness. The results suggest that arterial compliance has a crucial influence on the effect of EECP and that large-artery stiffness may reduce the effect of EECP.
Assuntos
Artérias/fisiologia , Contrapulsação , Complacência (Medida de Distensibilidade) , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: Enhanced external counterpulsation (EECP) is a non-invasive therapy with long-term anti-anginal effects offered to patients with refractory angina pectoris. The purpose of the present study was to investigate the effect of EECP on myocardial contractility measured as global longitudinal strain (GLS) during EECP treatment. DESIGN: Patients with known refractory angina were enrolled by invitation and underwent 1 h of EECP treatment. Two-dimensional echocardiography and Doppler echocardiography were performed before and during EECP treatment with 15-minute intervals. The peak diastolic/systolic blood pressure ratio (D/S ratio) was monitored with finger pletysmography. GLS was assessed offline with speckle-tracking software (EchoPAC GE Healthcare USA). RESULTS: Twenty patients were included (mean age 65.0 ± 8.2; 85% males). During EECP treatment, the systolic function of the left ventricle (LV) expressed in terms of an increasing GLS (-17.9 vs. -16.2% p < 0.05) and a rising cardiac output (5.5 vs. 4.6 l/min p < 0.05) were improved. D/S ratio during the EECP procedure was inversely correlated to LV filling pressure (E/Em ratio r = - 0.5 p = 0.035). CONCLUSIONS: In conclusion, we demonstrated that EECP improved left ventricular GLS and systolic function in an acute setting. Future studies must explore whether these immediate hemodynamic changes are associated to the clinical effect of EECP treatment.
Assuntos
Angina Pectoris/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Contrapulsação , Ecocardiografia/instrumentação , Hemodinâmica , Contração Miocárdica/fisiologia , Função Ventricular Esquerda , Idoso , Análise de Variância , Angina Pectoris/patologia , Débito Cardíaco , Doença da Artéria Coronariana/patologia , Ecocardiografia/métodos , Feminino , Humanos , Modelos Lineares , Masculino , Estatística como Assunto , Fatores de TempoRESUMO
A 57-year-old woman suffering from severe Prinzmetal's angina was treated with a 7-week course of enhanced external counterpulsation (EECP). After completing EECP the angina intensity was reduced from CCS class IV to class I, quality of life was increased and medication was significantly reduced. The number of hospitalisations due to chest pain was reduced from 81 in the two years before EECP to 2 in the two years after EECP. To our knowledge, this is the first report demonstrating the effect of EECP on Printzmetal's angina.
Assuntos
Angina Pectoris Variante/terapia , Contrapulsação/métodos , Qualidade de Vida , Angina Pectoris Variante/diagnóstico , Feminino , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
AIM: The aim of this study was to assess risk factors for bleeding complications after elective coronary angiography (CA). METHODS AND RESULTS: We consecutively included 1,000 patients scheduled for elective diagnostic CA using the femoral approach. A bleeding complication was defined as formation of a hematoma >/=5 cm, severely oozing or pulsating bleeding through the skin, development of a pseudoaneurysm, or a bleeding demanding blood transfusion. We found a bleeding complication in 88 patients. In the multivariate analysis, only female gender and systolic blood pressure were associated with a bleeding complication. CONCLUSION: We conclude that systolic blood pressure and female gender are independent predictors of bleeding complications and that a high systolic blood pressure should be reduced before elective CA.
Assuntos
Angiografia Coronária/efeitos adversos , Artéria Femoral/cirurgia , Hemorragia/epidemiologia , Idoso , Pressão Sanguínea , Angiografia Coronária/métodos , Dinamarca/epidemiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Hemorragia/etiologia , Hospitais , Humanos , Hipertensão/complicações , Hipertensão/prevenção & controle , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de RiscoRESUMO
BACKGROUND: Detection of atrial fibrillation (AF) in patients who had ischaemic stroke and transient ischaemic attack (IS/TIA) is recommended. We aimed to compare external loop recording (ELR) against simultaneous continuous ECG recording for AF detection in patients who had acute IS/TIA and determine sensitivity, specificity and positive predictive value of AF detection using ELR. We hypothesised ELR to detect 15% fewer patients with AF than continuous ECG recording. METHODS: In this prospective cohort study, we included 1412 patients who had acute IS/TIA without prior AF. Monitoring was 48 hours. Primary outcome was AF >30 s. Cardiologist verified AF in continuous ECG was gold standard. RESULTS: In continuous ECG, 38 (2.7%) patients had AF. ELR automatically categorised 219/1412 patients (15.5%) with AF, including 32/38 (85%) patients with AF in continuous ECG. After cardiologist adjudication of ELR recordings, AF was diagnosed in 57/219 patients, of which 32 (56%) had AF in continuous ECG. For adjudicated AF detection by ELR, sensitivity was 84%, 95% CI (69% to 94%), specificity was 98%, 95% CI (97% to 99%) and positive predictive value was 56%, 95% CI (42% to 69%). CONCLUSION: Automatic AF detection with ELR results in an AF diagnosis in more than five patients without AF for each patient with AF as verified in continuous ECG. For adjudicated AF detection by ELR, sensitivity was confirmed to 84% and specificity 98%. Automatic ELR as investigated in this study may be considered to rule out AF, but it is not suitable as a single monitoring device for AF screening in patients early after stroke. TRIAL REGISTRATION NUMBER: NCT02155907.
Assuntos
Fibrilação Atrial/diagnóstico , Isquemia Encefálica/complicações , Eletrocardiografia Ambulatorial , Frequência Cardíaca , Ataque Isquêmico Transitório/complicações , Acidente Vascular Cerebral/complicações , Telemetria , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/fisiopatologia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Eletrocardiografia Ambulatorial/instrumentação , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Telemetria/instrumentação , Fatores de Tempo , Dispositivos Eletrônicos VestíveisRESUMO
The aim of the study was to examine whether moving during a 2-hour observation period in bed after coronary angiography was associated with a higher incidence of bleeding complications compared to a standard regimen, where the patients were told not to move. In both regimens a 4.5 kg sandbag 25 x 12 x 12 cm was placed over the puncture site along the inguinal ligament for the first hour. The sandbag prevented the patients from turning over, but did not prevent bending in the hip and knee. We consecutively included 1,000 patients scheduled for elective diagnostic coronary angiography using the femoral approach. The in-hospital incidence of hematoma > or =5 cm was 7%. No statistical difference was detected between the two regimens regarding the incidence of bleeding or hematoma formation. The patients preferred the alternative regimen and fewer patients in the alternative regimen had back pain as well as pain from the puncture site. We conclude that patients should not be told to lie still during the observation period after coronary angiography.
Assuntos
Repouso em Cama , Angiografia Coronária/efeitos adversos , Artéria Femoral , Hematoma/etiologia , Movimento , Postura , Idoso , Feminino , Hematoma/prevenção & controle , Humanos , Incidência , Masculino , Inquéritos e Questionários , Fatores de TempoRESUMO
Speckle tracking global longitudinal strain (GLS) from dobutamine stress echocardiography (SE) predicts coronary artery disease (CAD). The diagnostic value of GLS from vasodilator SE and the additional value of layer-specific speckle tracking analysis are unclear. We explored the usefulness of layer-specific GLS and non-layer-specific strain (automated functional imaging, AFI) from adenosine SE. The included 132 patients (67% male, 62.6 (9.0) years), of which 46 (35%) had CAD defined as ≥1 stenosis ≥70% (≥50% in the left main), underwent adenosine SE and invasive coronary angiography. Resting AFI and layer-specific GLS were similar in patients with or without CAD (p > 0.05). The stress-rest difference (Δvalue = stress-value - rest-value) in patients with CAD was less pronounced compared to patients without proved CAD (Δendocardial GLS: -1.2 (3.5)% vs. -5.0 (3.2)%; Δmidventricular GLS: -0.95 (3.0)% vs. -4.2 (2.7)%; Δepicardial GLS: -0.7 (2.5)% vs. -3.4 (2.3)%; ΔAFI: -0.8 (2.9)% vs. -3.6 (3.1)%, p < 0.00001 for all comparisons). The diagnostic value of the three layer-specific GLS values and AFI were statistically similar (p = 0.19). The four Δvalues provided independent predictive value to the risk assessment given by gender, age, wall motion and ΔEF (p = 0.002, AFI and p < 0.0001, layer-specific GLS). The accuracies were acceptable (71-80%) with modest sensitivities (54-65%) and high specificities (80-91%). The deformation response to vasodilator infusion was associated with the presence of CAD. Endocardial, midventricular and epicardial GLS and AFI from adenosine SE had similar diagnostic values. The specificities were high, but the modest sensitivities are a limitation to the clinical application.
Assuntos
Adenosina/administração & dosagem , Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse/métodos , Contração Miocárdica , Vasodilatadores/administração & dosagem , Função Ventricular Esquerda , Idoso , Área Sob a Curva , Angiografia Coronária , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Volume SistólicoRESUMO
BACKGROUND: A large angle between the QRS vector and the T-wave vector (QRS-T angle) in electrocardiograms (ECGs) has recently been introduced as a marker of poor prognosis. The prognostic value in diabetes is unknown. We assessed the long-term predictive power of the frontal plane QRS-T angle in the diabetic population. METHODS: In 1992-93, the diabetic population of the municipality of Horsens, Denmark, was delineated by the prescription method, and an age- and gender-stratified sample of 240 diabetic persons was randomly selected. In 2015, 12-lead ECGs taken in 1993-94 were analyzed. Vital statistics were obtained from the Danish Civil Registration System and data regarding hospitalizations taken from The National Patient Registry in July 2015. RESULTS: In total, 178 people agreed to participate (74%) in the study, with the mean (sd) age being 58.9 (10.2) years and 56% being male. The total observation time was 21.5 (0.18) years, during which time 122 (69%) persons died, 32 (18%) suffered a myocardial infarction (MI) and 126 (71%) reached the composite endpoint of non-fatal MI or all-cause death. In Cox regression multivariate analysis a QRS-T angle above 90° was found to be an independent predictor of all-cause death (HR=2.2 (95% CI: 1.3-3.8)), MI (HR=2.95 (95% CI: 1.1-7.7)) and MI or all-cause death (HR=2.0 (95% CI: 1.2-3.5)) (all p<0.05), when adjusting for the effects of co-variates (gender, age, length of diabetes, BMI, total cholesterol, diabetes type, hemoglobin A1c, smoking, hypertension and previous MI). CONCLUSION: A large QRS-T angle is a strong, independent long-term predictor of all-cause mortality, MI and MI or all-cause death in the diabetic population.
Assuntos
Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Angiopatias Diabéticas/diagnóstico , Cardiomiopatias Diabéticas/diagnóstico , Infarto do Miocárdio/diagnóstico , Idoso , Estudos de Coortes , Dinamarca/epidemiologia , Diabetes Mellitus Tipo 1/mortalidade , Diabetes Mellitus Tipo 2/mortalidade , Angiopatias Diabéticas/epidemiologia , Angiopatias Diabéticas/mortalidade , Cardiomiopatias Diabéticas/epidemiologia , Cardiomiopatias Diabéticas/mortalidade , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Sistema de Registros , Fatores de Risco , Análise de SobrevidaRESUMO
BACKGROUND: Despite proven benefits of cardiac rehabilitation (CR), adherence to CR remains suboptimal. This trial aimed to assess the impact of the patient education 'Learning and Coping Strategies' (LC) on patient adherence to an eight-week CR program. METHODS: 825 patients with ischaemic heart disease or heart failure were open label randomised to either the LC arm (LC plus CR) or the control arm (CR alone) across three hospital units in Denmark. Both arms received same amount of training and education hours. LC consisted of individual clarifying interviews, participation of experienced patients as co-educators, situational, reflective and inductive teaching. The control arm received structured deductive teaching. The primary outcomes were patient adherence to at least 75% of the exercise training or education sessions. We tested for subgroup effects on the primary outcomes using interaction terms. The primary outcomes were compared across arms using logistic regression. RESULTS: More patients in the LC arm adhered to at least 75% of the exercise training sessions than control (80% versus 73%, adjusted odds ratio (OR):1.48; 95% CI:1.07 to 2.05, P=0.018) and 75% of education sessions (79% versus 70%, adjusted OR:1.61, 1.17 to 2.22, P=0.003). Some evidence of larger effects of LC on adherence was seen for patients with heart failure, low education and household income. CONCLUSIONS: Addition of LC strategies improved adherence in rehabilitation both in terms of exercise training and education. Patients with heart failure, low levels of education and household income appear to benefit most from this adherence promoting intervention. TRIAL REGISTRATION: www.clinicaltrials.gov identifier NCT01668394.
Assuntos
Adaptação Psicológica , Reabilitação Cardíaca , Educação/métodos , Terapia por Exercício/métodos , Insuficiência Cardíaca , Isquemia Miocárdica , Educação de Pacientes como Assunto/métodos , Qualidade de Vida , Idoso , Reabilitação Cardíaca/métodos , Reabilitação Cardíaca/psicologia , Feminino , Insuficiência Cardíaca/psicologia , Insuficiência Cardíaca/reabilitação , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/psicologia , Isquemia Miocárdica/reabilitação , Cooperação do Paciente , Ensino , Resultado do TratamentoRESUMO
OBJECTIVE: Patients with normal stress perfusion have an excellent prognosis. Prospective studies on the diagnostic accuracy of stress-only scans with contemporary, independent examinations as gold standards are lacking. PATIENTS AND METHODS: A total of 109 patients with typical angina and no previous coronary artery disease underwent a 2-day stress (exercise)/rest, gated, and attenuation-corrected (AC), 99m-technetium-sestamibi perfusion study, followed by invasive coronary angiography. The stress datasets were evaluated twice by four physicians with two different training levels (expert and novice): familiar and unfamiliar with AC. The two experts also made a consensus reading of the integrated stress-rest datasets. The consensus reading and quantitative data from the invasive coronary angiography were applied as reference methods. RESULTS: The sensitivity/specificity were 0.92-1.00/0.73-0.90 (reference: expert consensus reading), 0.93-0.96/0.63-0.82 (reference: ≥1 stenosis>70%), and 0.75-0.88/0.70-0.88 (reference: ≥1 stenosis>50%). The four readers showed a high and fairly equal sensitivity independent of their familiarity with AC. The expert familiar with AC had the highest specificity independent of the reference method. The intraobserver and interobserver agreements on the stress-only readings were good (readers without AC experience) to excellent (readers with AC experience). CONCLUSION: AC stress-only images yielded a high sensitivity independent of the training level and experience with AC of the nuclear physician, whereas the specificity correlated positively with both. Interobserver and intraobserver agreements tended to be the best for physicians with AC experience.