RESUMO
BACKGROUND: For endovascular treatment of below-the-knee (BTK) peripheral artery disease (PAD), independently adjudicated real-world outcomes comparing non-stent (balloon angioplasty or PTA and adjunctive treatment) with or without a concomitant ipsilateral femoropopliteal (FP) artery intervention are scarce. METHODS: 1060 patients from the multicenter XLPAD Registry between 2006-2021 with non-stent based BTK PAD intervention are included. PRIMARY OUTCOME: 1-year incidence of major adverse limb events (MALE), a composite of all-cause death, any amputation, or clinically driven repeat revascularization. RESULTS: 566 patients underwent BTK and 494 BTKâ¯+â¯FP interventions; 72% men, with mean age 68.4 ± 10.9 years. Diabetes mellitus is more prevalent in BTK only group (76.5% vs. 69%, p=0.006). Mean Rutherford class 4.2 ± 1.18; chronic limb threatening ischemia is more frequent in the BTK group (55.3% vs. 49%, p=0.040). Moderate to severe calcification is higher in BTKâ¯+â¯FP (21.2% vs. 27.1%, p=0.024), so is lesion length (110.6 ± 77.3 vs. 135.4 ± 86.3 mm; p<0.001). Nearly, 81% lesions are treated with PTA. DCB (1.6% vs 14%, p<0.001) and atherectomy (38% vs. 58.5%; p<0.001) use is greater in BTKâ¯+â¯FP. Procedural success is higher in BTKâ¯+â¯FP group (86% vs. 91%, p=0.009), with amputation being the most common complication at 3.3% ≤30 days. One-year MALE (21.2% vs. 22.3%, p=0.675) and mortality (4.6% vs. 3.4%; p=0.3) are similar across BTK and BTKâ¯+â¯FP groups. CONCLUSION: Non-stent treatment for BTK PAD with concomitant FP intervention leads to high procedural success and similar rates of 1-year MALE compared with isolated BTK intervention. CONDENSED ABSTRACT: The vast majority of below-the-knee (BTK) peripheral artery disease (PAD) interventions are performed with balloon angioplasty. Presence of inflow femoropopliteal (FP) PAD in patients undergoing BTK interventions can affect the outcome of the procedure. This report explores the immediate procedural success and major adverse limb events at 1 year following balloon angioplasty treatment for isolated BTK and in those undergoing an additional FP PAD intervention.
RESUMO
Cardiovascular disease (CVD), the world's leading cause of death, exhibits notable epidemiological, clinical, and pathophysiological differences between sexes. Many such differences can be linked back to cardiovascular sexual dimorphism, yet sex-specific in vitro models are still not the norm. A lack of sex reporting and apparent male bias raises the question of whether in vitro CVD models faithfully recapitulate the biology of intended treatment recipients. To ensure equitable treatment for the overlooked female patient population, sex as a biological variable (SABV) inclusion must become commonplace in CVD preclinical research. Here, we discuss the role of sex in CVD and underlying cardiovascular (patho)physiology. We review shortcomings in current SABV practices, describe the relevance of sex, and highlight emerging strategies for SABV inclusion in three major in vitro model types: primary cell, stem cell, and three-dimensional models. Last, we identify key barriers to inclusive design and suggest techniques for overcoming them.
Assuntos
Doenças Cardiovasculares , Caracteres Sexuais , Humanos , Doenças Cardiovasculares/patologia , Feminino , Masculino , Animais , Fatores Sexuais , Modelos BiológicosAssuntos
COVID-19 , Doença Arterial Periférica , Humanos , Pandemias , SARS-CoV-2 , Procedimentos Cirúrgicos VascularesRESUMO
Morbidity and mortality associated with COVID-19 has increased exponentially, and patients with cardiovascular (CV) disease are at risk for poor outcomes. Several lines of evidence suggest a potential role for CV therapies in COVID-19 treatment. Characteristics of clinical trials of CV therapies related to COVID-19 registered on ClinicalTrials.gov have not been described. METHODS: ClinicalTrials.gov was queried on August 7, 2020 for COVID-19 related trials. Studies evaluating established CV drugs, other fibrinolytics (defibrotide), and extracorporeal membrane oxygenation were included. Studies evaluating anti-microbial, convalescent plasma, non-colchicine anti-inflammatory, and other therapies were excluded. Trial characteristics were tabulated from study-specific entries. RESULTS: A total of 2,935 studies related to COVID-19 were registered as of August 7, 2020. Of these, 1,645 were interventional studies, and the final analytic cohort consisted of 114 studies evaluating 10 CV therapeutic categories. Antithrombotics (32.5%; n = 37) were most commonly evaluated, followed by pulmonary vasodilators (14.0%; n = 16), renin-angiotensin-aldosterone system-related therapies (12.3%; n = 14), and colchicine (8.8%; n = 10). Trials evaluating multiple CV therapy categories and CV therapies in combination with non-CV therapies encompassed 4.4% (n = 5) and 9.6% (n = 11) of studies, respectively. Most studies were designed for randomized allocation (87.7%; n = 100), enrollment of less than 1000 participants (86.8%; n = 99), single site implementation (55.3%; n = 63), and had a primary outcome of mortality or a composite including mortality (56.1%; n = 64). Most study populations consisted of patients hospitalized with COVID-19 (81.6%; n = 93). At the time of database query, 28.9% (n = 33) of studies were not yet recruiting and the majority were estimated to be completed after December 2020 (67.8%; n = 78). Most lead sponsors were located in North America (43.9%; n = 50) or Europe (36.0%; n = 41). CONCLUSIONS: A minority (7%) of clinical trials related to COVID-19 registered on ClinicalTrials.gov plan to evaluate CV therapies. Of CV therapy studies, most were planned to be single center, enroll less than 1000 inpatients, sponsored by European or North American academic institutions, and estimated to complete after December 2020. Collectively, these findings underscore the need for a network of sites with a platform protocol for rapid evaluation of multiple therapies and generalizability to inform clinical care and health policy for COVID-19 moving forward.
Assuntos
Tratamento Farmacológico da COVID-19 , Doenças Cardiovasculares/tratamento farmacológico , Ensaios Clínicos como Assunto/estatística & dados numéricos , National Library of Medicine (U.S.) , Sistema de Registros/estatística & dados numéricos , SARS-CoV-2 , COVID-19/complicações , COVID-19/mortalidade , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/mortalidade , Colchicina/uso terapêutico , Terapia Combinada/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Fibrinolíticos/uso terapêutico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipoglicemiantes/uso terapêutico , Participação do Paciente/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Sistema Renina-Angiotensina , Resultado do Tratamento , Estados Unidos , Vasodilatadores/uso terapêuticoRESUMO
BACKGROUND: A meta-analysis of trials in endovascular therapy suggested an increased mortality associated with treatment exposure to paclitaxel. Multiple publications and corrections of prior data were performed, and the United States Food and Drug Administration has issued multiple advisories regarding paclitaxel use. We analyzed how this controversy impacted device purchasing and related utilization patterns in the period immediately following publication of the meta-analysis. METHODS AND RESULTS: Ascension Healthcare System purchase data over a 14-month period were synthesized across centers for both paclitaxel and non-paclitaxel devices. A fixed-effects regression model and a binary regression model with facility-level controls were used to compare purchasing patterns before and after the meta-analysis. Purchase volumes of each paclitaxel device fell. Pooled purchase volumes of all paclitaxel devices decreased from a 14-month peak of 631 devices in October 2018 to a 14-month nadir of 359 devices in February 2019. An F-test comparing the pooled-month specific fixed effects for the months before vs after the publication of the meta-analysis has an F-statistic of 11.64, suggesting that average purchasing levels in the two periods are statistically different (P<.001). Utilization of non-paclitaxel devices did not decline. CONCLUSIONS: Purchase volumes of paclitaxel devices decreased immediately during the months following publication of the related meta-analysis. Total Ascension-wide paclitaxel device purchase volume in February 2019 demonstrated a 43.1% reduction from peak monthly purchase volume during the assessed period and a 32.5% reduction compared with November 2019, the last month preceding publication of the meta-analysis.
Assuntos
Stents Farmacológicos , Procedimentos Endovasculares , Oclusão de Enxerto Vascular , Efeitos Adversos de Longa Duração , Paclitaxel , Doença Arterial Periférica/cirurgia , Vigilância de Produtos Comercializados , Antineoplásicos Fitogênicos/economia , Antineoplásicos Fitogênicos/farmacologia , Materiais Revestidos Biocompatíveis/farmacologia , Qualidade de Produtos para o Consumidor , Stents Farmacológicos/efeitos adversos , Stents Farmacológicos/economia , Stents Farmacológicos/estatística & dados numéricos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/mortalidade , Humanos , Efeitos Adversos de Longa Duração/etiologia , Efeitos Adversos de Longa Duração/mortalidade , Metanálise como Assunto , Neointima/prevenção & controle , Paclitaxel/economia , Paclitaxel/farmacologia , Vigilância de Produtos Comercializados/economia , Vigilância de Produtos Comercializados/métodosRESUMO
See Article by Arruda-Olson et al.
Assuntos
Sistemas de Apoio a Decisões Clínicas , Doença Arterial Periférica , Registros Eletrônicos de Saúde , Humanos , PrognósticoRESUMO
Percutaneous coronary intervention (PCI) has matured rapidly to tackle increasingly complex coronary disease. Operators must be aware of the incidence of the basic risks involved with coronary angiography and PCI to appropriately inform patients and obtain procedural consent. Even before a wire enters a coronary artery, specific risks, including vascular access complications, renal injury, allergic reaction, and radiation injury, are constantly present. With initiation of PCI, new risks to the coronary circulation arise. A fundamental knowledge of the presentation of these complications and expert ability to emergently manage them are of the utmost importance to the successful completion of PCI.
Assuntos
Angiografia Coronária/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Humanos , Incidência , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologiaRESUMO
Pulmonary embolism (PE) is a complex diagnosis that encompasses a wide range of clinical presentations. Often patients who present with PE have complicated medical histories which can make their management challenging. Many novel therapeutic strategies and tools are emerging to improve the care and outcomes of patients with PE. Pulmonary embolism response teams (PERTs) are developing at multiple centers to improve the decision making, efficiency and orchestration of these clinical strategies. Concordantly with development of PERT programs is the design and implementation of systems to allow for numerous specialists to convene and discuss complex PE patients in real time. The mechanisms to engage a multidisciplinary approach are proving to be an invaluable resource in the decision making processes and treatment of high risk PE patients. Ultimately, other multi-disciplinary teams may adopt these methods to better address their clinical needs.
RESUMO
Cerebral angiography is an invasive procedure utilized without supporting guidelines in preoperative evaluations of infective endocarditis (IE). It is used to identify mycotic intracranial aneurysm, which is suspected to increase the risk of intracranial bleeding during cardiac surgery. Our objectives were to: (1) assess the utility of cerebral angiography by determining which subset of IE patients benefit from its performance; and (2) identify clinical and noninvasive screening tests that can preclude the need for invasive cerebral angiography. Retrospective analysis was performed of all patients treated surgically for IE from 7/2007 to 1/2012 and discharged with medical treatment for IE from 7/2007 to 7/2009 presenting to a large academic center. Of the 151 patients who underwent cerebral angiography, mycotic aneurysm was identified in seven (prevalence=4.6%; 95% CI 2.3-9.3%). Five had viridans group streptococci as the causative IE microorganism (p=0.0017). Noninvasive imaging and particularly absence of intracranial bleed on magnetic resonance imaging conveys a negative predictive value (NPV) of 0.977 (95% CI 0.879-0.996). Absence of a focal neurologic deficit or altered mental status convey a NPV of 0.990 (95% CI 0.945-0.998) and 0.944 (95% CI 0.883-0.974), respectively. Clinical suspicion for mycotic aneurysm and thus utilization of cerebral angiography is likely necessary only in the setting of acute neurologic deficits and when noninvasive imaging demonstrates acute intracranial bleed. A novel association between viridans group streptococci and intracranial mycotic aneurysm is demonstrated.
Assuntos
Angiografia Cerebral , Endocardite/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Infectado/diagnóstico , Angiografia Cerebral/métodos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Estudos RetrospectivosRESUMO
In-hospital sudden cardiac arrest and resuscitation is distinct from out-of-hospital sudden cardiac arrest (OOHSCA) and warrants specific attention. Sudden cardiac arrest (SCA) is a manifestation of an underlying process rather than a disease itself. The complex, multiorgan system dysfunction common among the inpatient population can precipitate SCA by both similar and very different mechanisms than OOHSCA. The diagnostic and treatment algorithms of SCA remain largely the same between the inpatient and outpatient arenas. The application of complex diagnostic and therapeutic interventions is permissible, but such tools must not interrupt or delay the important basics of cardiac arrest management in the inpatient setting, including adequate chest compressions and timely defibrillation when appropriate.
Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca/terapia , Reanimação Cardiopulmonar/métodos , Parada Cardíaca/epidemiologia , Parada Cardíaca/etiologia , Humanos , Pacientes Internados , Avaliação de Resultados em Cuidados de Saúde , Estados Unidos/epidemiologiaRESUMO
Recognition and appropriate treatment of ventricular fibrillation or pulseless ventricular tachycardia is an essential skill for healthcare providers. Appropriate defibrillation can improve survival and benefit patient outcome. Similarly, increased public access to automatic electronic defibrillators has been shown to improve out-of-hospital survival for cardiac arrest. When combined with high-quality cardiopulmonary resuscitation, electrical therapies are an important aspect of resuscitation in the patient with cardiac arrest. This article focuses on the use of electrical therapies, including defibrillation, cardiac pacing, and automated external defibrillators, in cardiac arrest.
Assuntos
Estimulação Cardíaca Artificial/métodos , Reanimação Cardiopulmonar/métodos , Cardioversão Elétrica/métodos , Parada Cardíaca/terapia , Desfibriladores , Cardioversão Elétrica/história , História do Século XVIII , História do Século XIX , História do Século XX , HumanosRESUMO
Precordial percussion is a technique by which a manual force is applied repeatedly to the chest of a patient experiencing an unstable bradycardic or asystolic rhythm. The force is used not to defibrillate the myocardium as is the case with the "precordial thump" in pulseless ventricular tachycardia/ventricular fibrillation but rather to initiate a current through the myocardium in the form of an essentially mechanically paced beat. In this review, we discuss the physiology and utility of precordial percussion, or precordial thump, in the emergency setting as a very temporary bridge to more effective and permanent pacing techniques.