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1.
Catheter Cardiovasc Interv ; 100(3): 295-303, 2022 09.
Artículo en Inglés | MEDLINE | ID: mdl-35766040

RESUMEN

OBJECTIVES: We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL-A) in ST-segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation. BACKGROUND: The incremental benefit of prehospital electrocardiogram (PH-ECG) transmission on the diagnostic accuracy and appropriateness of CCL-A has been examined in a small number of studies with conflicting results. METHODS: We identified consecutive PH-ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL-A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL-A rate. Secondary outcomes included rates of false-positive CCL-A, inappropriate CCL-A, and inappropriate CCL nonactivation. RESULTS: Among 1088 PH-ECG transmissions, there were 565 (52%) CCL-As and 523 (48%) CCL nonactivations. The appropriate CCL-A rate was 97% (550 of 565 CCL-As), of which 4.9% (n = 27) were false-positive. The inappropriate CCL-A rate was 2.7% (15 of 565 CCL-As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST-segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST-segment elevation (n = 20, 4.0%), and others. CONCLUSIONS: PH-ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false-positive CCL-As, whereas using UGA alone would have almost doubled CCL-As. The benefits of cardiologist consultation were identifying "masquerading" STEMI and avoiding unnecessary CCL-As.


Asunto(s)
Cardiólogos , Servicios Médicos de Urgencia , Infarto del Miocardio con Elevación del ST , Bloqueo de Rama , Computadores , Electrocardiografía , Servicios Médicos de Urgencia/métodos , Humanos , Derivación y Consulta , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento
2.
Intern Med J ; 49(5): 671-676, 2019 05.
Artículo en Inglés | MEDLINE | ID: mdl-31083805

RESUMEN

There is a distinctive Venetian carnival mask with sinister overtones and historical significance to physicians because it belongs to the 'Doctor of the Plague'. The costume features a beaked white mask, black hat and waxed gown. This was worn by mediaeval Plague Doctors as protection according to the Miasma Theory of disease propagation. The plague (or Black Death), ravaged Europe over several centuries with each pandemic leaving millions of people dead. The cause of the contagion was not known, nor was there a cure, which added to the widespread desperation and fear. Venice was a major seaport, and each visitation of the plague (beginning in 1348) devastated the local population. In response, Venetians were among the first to establish the principles of quarantine and 'Lazarets' which we still use today. Plague outbreaks have occurred in Australia, notably in Sydney (1900-1925), and continue to flare up in poorer communities, most recently in Madagascar (2017). Antibiotics are the mainstay of treatment, but there are concerns regarding the emergence of resistant pathogenic strains of Yersinia pestis, and their potential use in bio-terrorism.


Asunto(s)
Pandemias/historia , Médicos/historia , Peste/historia , Historia del Siglo XV , Historia del Siglo XVI , Historia del Siglo XVII , Historia del Siglo XVIII , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Historia Antigua , Historia Medieval , Humanos , Italia/epidemiología , Peste/epidemiología , Peste/terapia
3.
Heart Lung Circ ; 28(3): 370-378, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-29459218

RESUMEN

BACKGROUND: Immediate cardiac catheterisation (CC) is recommended in ST-elevation myocardial infarction (STEMI) following sudden cardiac arrest (SCA). Guidelines advise urgent CC for SCA patients without-STEMI, at clinician discretion. We examined the clinical and angiographic factors predicting mortality in SCA patients having CC. METHODS: Consecutive SCA patients having CC at Liverpool Hospital, Sydney (January 2011-September 2015) were retrospectively analysed. Patient data were retrieved from hospital records, and angiographic SYNTAX scores (SS) were quantified online. Independent predictors of mortality were derived using multivariate logistic analysis. RESULTS: The study cohort comprised 104 SCA patients; mean age 61±12years, and 79% male. Immediate CC (<2hours post-SCA) was performed in 35% overall. Compared to the without-STEMI subgroup, STEMI patients had more ventricular fibrillation (91 vs 50%; p<0.0001), and higher mean peak serum high-sensitivity troponin-T (8.25±14.7 vs 1.97±6.13 ug/L; p=0.006); in the context of higher median SS (18 vs 6.5; p=0.002) and target-lesion SS (tSS, 10 vs 0; p<0.001). Percutaneous coronary intervention (PCI; 75 vs 23%; p<0.0001) and target vessel revascularisation (11 vs 0%; p=0.005) were more frequent for STEMI. All-cause mortality was 39%, at 1.3±1.5years follow-up. Independent mortality predictors were: delayed CC (HR 4.08), serum lactate >7mmol/L (HR 3.47), and tSS (HR 1.05). CONCLUSIONS: Elevated serum lactate, tSS, and delayed CC, were predictive of longer-term mortality in SCA patients having CC. Late CC in patients without-STEMI suggest scope for improvement in real-world systems of care. Closer scrutiny of target lesion complexity may aid prognostication in SCA survivors.


Asunto(s)
Cateterismo Cardíaco/efectos adversos , Angiografía Coronaria/métodos , Muerte Súbita Cardíaca/etiología , Sistema de Registros , Infarto del Miocardio con Elevación del ST/diagnóstico , Muerte Súbita Cardíaca/epidemiología , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Nueva Gales del Sur/epidemiología , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/cirugía , Tasa de Supervivencia/tendencias , Factores de Tiempo
4.
Catheter Cardiovasc Interv ; 89(3): 375-382, 2017 Feb 15.
Artículo en Inglés | MEDLINE | ID: mdl-27113534

RESUMEN

OBJECTIVES: The aims of this study were to evaluate clinical outcomes following PCI using SeQuent Please paclitaxel-coated balloons (PCB) of ISR and denovo lesions (DNL), in all-comer patients at Liverpool Hospital, Sydney, Australia. BACKGROUND: There have been promising results for PCI using drug-coated balloons; however, long-term data for clinical outcomes are lacking. METHODS: Baseline patient demographics, PCI procedural details, and clinical outcomes were collected. The primary endpoint was the incidence of MACE, a composite of cardiac death, myocardial infarction (MI), and clinical-driven target lesion restenosis (TLR). The median follow-up for clinical events was 1.3 [0.6-1.9] years. RESULTS: A total of 188 lesions (n = 147 patients) were treated with PCB, comprising 118 (63%) ISR lesions and 70 (38%) DNL. Patient mean age was 67 ± 11years, 79% were male, and 54% had type 2 diabetes mellitus (DM). MACE was recorded in 17 patients (12%), with cardiac death confirmed in 1 patient (0.7%). MACE was significantly lower for DNL than ISR (1% vs. 15%, P = 0.03), and PCB had favourable TLR for DNL. Cox regression demonstrated that DM (HR 7.17, 0.92-55.6, P = 0.05) and prior CABG (HR 3.22, 1.17-8.83, P = 0.02) were independent predictors of MACE for ISR lesions. CONCLUSIONS: MACE rates were acceptable, with overall low incidence of cardiac death, MI, and TLR, for PCB treatment of ISR and DNL. Independent predictors of poor outcome in the ISR group were DM and prior CABG. The particularly low MACE for the DNL group supports direct PCB as a viable stent-sparing PCI strategy in challenging patients and lesion subsets. © 2016 Wiley Periodicals, Inc.


Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Catéteres Cardíacos , Fármacos Cardiovasculares/administración & dosificación , Materiales Biocompatibles Revestidos , Reestenosis Coronaria/terapia , Paclitaxel/administración & dosificación , Intervención Coronaria Percutánea/instrumentación , Stents , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/mortalidad , Fármacos Cardiovasculares/efectos adversos , Distribución de Chi-Cuadrado , Angiografía Coronaria , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Reestenosis Coronaria/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Nueva Gales del Sur , Paclitaxel/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Modelos de Riesgos Proporcionales , Sistema de Registros , Retratamiento , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento
5.
J Interv Cardiol ; 28(2): 157-63, 2015 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-25884899

RESUMEN

OBJECTIVES: To investigate the correlation between "target-lesion" SYNTAX score (tSS) and radiation dose (RD) and examine the predictive value of tSS and other variables on RD from percutaneous coronary intervention (PCI). BACKGROUND: The complexity of PCI influences procedural RD. The novel tSS was utilized to quantify targeted-PCI complexity. METHODS: We studied 420 consecutive patients who had PCI in our hospital. Two investigators independently measured tSS using the SYNTAX scoring algorithm. Patients were divided into three BMI (kg/m(2) ) subgroups: <25 (normal), 25-30 (overweight), and >30 (obese); and tSS tertiles: <5.5 (simple), 5.5-9 (moderate), and >9 (complex). RESULTS: Obese patients were significantly younger and likely to have diabetes mellitus (DM). tSS positively correlated with RD for both genders, with median RD significantly higher in males (P < 0.0001). tSS correlated with RD in all three BMI subgroups (all P < 0.0001). Multivariate linear regression showed RD can be predicted by the formula: RD = -898 + 18 tSS + 49 BMI + 142 DM + 207 male. CONCLUSIONS: We report that tSS is a quantitative index of "target-lesion" PCI complexity, which is easy to measure with good reproducibility. tSS significantly and independently correlates with RD, although the strength of the association is less than for other predictors of RD (gender, diabetes, and BMI). tSS may be used to determine the RD from PCI and enhance patient risk-stratification when formulating a PCI strategy.


Asunto(s)
Infarto del Miocardio/terapia , Intervención Coronaria Percutánea , Dosis de Radiación , Anciano , Índice de Masa Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Resultado del Tratamiento
6.
Am Heart J ; 165(4): 591-9, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-23537977

RESUMEN

BACKGROUND: During percutaneous coronary intervention (PCI) performed in the emergent setting of ST-segment elevation myocardial infarction (STEMI), uncertainty about patients' ability to comply with 12 months dual antiplatelet therapy after drug-eluting stenting is common, and thus, selective bare-metal stent (BMS) deployment could be an attractive strategy if this achieved low target vessel revascularization (TVR) rates in large infarct-related arteries (IRAs) (≥3.5 mm). METHODS AND RESULTS: To evaluate this hypothesis, among 1,282 patients with STEMI who underwent PCI during their initial hospitalization, we studied 1,059 patients (83%) who received BMS, of whom 512 (48%) had large IRAs ≥3.5 mm in diameter, 333 (31%) had IRAs 3 to 3.49 mm, and 214 (20%) had IRAs <3 mm. At 1 year, TVR rate in patients with BMS was 5.8% (2.2% with large BMS [≥3.5 mm], 9.2% with BMS 3-3.49 mm [intermediate], and 9.0% with BMS <3.0 mm [small], P < .001). The rates of death/reinfarction among patients with large BMS compared with intermediate BMS or small BMS were lower (6.6% vs 11.7% vs 9.0%, P = .042). Among patients who received BMS, the independent predictors of TVR at 1 year were the following: vessel diameter <3.5 mm (odds ratio [OR] 4.39 [95% CI 2.24-8.60], P < .001), proximal left anterior descending coronary artery lesions (OR 1.89 [95% CI 1.08-3.31], P = .027), hypertension (OR 2.01 [95% CI 1.17-3.438], P = .011), and prior PCI (OR 3.46 [95% CI 1.21-9.85], P = .02). The predictors of death/myocardial infarction at 1 year were pre-PCI cardiogenic shock (OR 8.16 [95% CI 4.16-16.01], P < .001), age ≥65 years (OR 2.63 [95% CI 1.58-4.39], P < .001), left anterior descending coronary artery culprit lesions (OR 1.95 [95% CI 1.19-3.21], P = .008), female gender (OR 1.93 [95% CI 1.12-3.32], P = .019), and American College of Cardiology/American Heart Association lesion classes B2 and C (OR 2.17 [95% CI 1.10-4.27], P = .026). CONCLUSION: Bare-metal stent deployment in STEMI patients with IRAs ≥3.5 mm was associated with low rates of TVR. Their use in this setting warrants comparison with second-generation drug-eluting stenting deployment in future randomized clinical trials.


Asunto(s)
Infarto del Miocardio/terapia , Stents , Anciano , Angiografía Coronaria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Pronóstico , Recurrencia , Medición de Riesgo , Resultado del Tratamiento
7.
Am J Cardiol ; 201: 16-24, 2023 08 15.
Artículo en Inglés | MEDLINE | ID: mdl-37348152

RESUMEN

Peripheral endothelial dysfunction is an independent predictor of adverse long-term prognosis after acute coronary syndrome. Data are lacking on the effects of oral P2Y12-inhibitors on peripheral endothelial function in non-ST-elevation acute coronary syndrome (NSTEACS). Furthermore, the relation between peripheral endothelial function and invasive indexes of coronary microvascular function in NSTEACS is unclear. Between March 2018 and July 2020, hospitalized patients with NSTEACS were randomized (1:1) to ticagrelor or clopidogrel. Peripheral endothelial function was assessed with brachial artery flow-mediated vasodilation (FMD). Invasive indexes of coronary microvascular function were obtained using an intracoronary pressure-temperature sensor-tipped wire. In 70 patients included, mean age was 58.6 years, 78.6% (n = 55) were male and 20% (n = 14) had diabetes mellitus. Compared with clopidogrel, ticagrelor significantly improved FMD (14.2 ± 5.4% vs 8.9 ± 5.3%, p <0.001) after a median treatment time of 41.2 hours. The FMD was significantly correlated with the index of microcirculatory resistance (IMR) measured in the infarct-related artery (r = -0.38, p = 0.001), with a stronger correlation found in those who did not have percutaneous coronary intervention (r = -0.52, p = 0.03). Using receiver operating characteristic curve analysis, an FMD of 8.2% identified an IMR of >34 as the threshold, with 77.6% sensitivity and 52.4% specificity. In patients who did not have a percutaneous coronary intervention, an FMD of 11.49% identified an IMR of >34 with 84.6% sensitivity and 80% specificity. In conclusion, ticagrelor significantly improved peripheral endothelial function compared with clopidogrel in patients with NSTEACS. There was a significant correlation between brachial artery FMD and IMR of the infarct-related artery.


Asunto(s)
Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Humanos , Masculino , Persona de Mediana Edad , Femenino , Ticagrelor/uso terapéutico , Clopidogrel/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/etiología , Microcirculación , Infarto/inducido químicamente , Intervención Coronaria Percutánea/efectos adversos , Resultado del Tratamiento
8.
Circ Cardiovasc Interv ; 15(4): e011419, 2022 04.
Artículo en Inglés | MEDLINE | ID: mdl-35369712

RESUMEN

BACKGROUND: Coronary microvascular dysfunction after acute coronary syndrome is an important predictor of long-term prognosis. Data is lacking on the effects of oral P2Y12-inhibitors on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome. The aim of this study was to compare the acute effects of ticagrelor versus clopidogrel pretreatment on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome patients. METHODS: Hospitalized non-ST-segment-elevation acute coronary syndrome patients were randomized (1:1) to ticagrelor or clopidogrel. The index of microcirculatory resistance, coronary flow reserve, and resistive reserve ratio were obtained using an intracoronary pressure-temperature sensor-tipped wire. RESULTS: In total, 128 patients were randomized between March 2018 and July 2020. Mean age 59.2±11.8 years, 84% were male, mean Global Registry of Acute Coronary Events score was 93.7±24.5. Intracoronary physiological measurements were obtained in 118 patients (60 ticagrelor, 58 clopidogrel). In the infarct-related artery, the ticagrelor group had lower baseline index of microcirculatory resistance (22.0 [13.0-34.9] versus 27.7 [19.3-29.8]; P=0.02) and higher baseline resistive reserve ratio (3.0 [2.3-4.4] versus 2.4 [1.7-3.4]; P=0.01) compared with the clopidogrel group. A total of 88 patients underwent percutaneous coronary intervention (PCI; 45 ticagrelor, 43 clopidogrel). The ticagrelor group had lower post-PCI index of microcirculatory resistance (22.0 [15.0-29.0] versus 27.0 [18.5-47.5]; P=0.02) and higher post-PCI resistive reserve ratio (3.0 [1.8-3.8] versus 1.8 [1.5-3.4]; P=0.006) compared with the clopidogrel group. The coronary flow reserve was not significantly different between the 2 groups at baseline or post-PCI. No between-group differences were seen in any of the indices in the non-infarct-related artery. CONCLUSIONS: In non-ST-segment-elevation acute coronary syndrome patients, ticagrelor significantly improved coronary microvascular function before and after PCI compared with clopidogrel. REGISTRATION: URL: https://www.anzctr.org.au; Unique identifier: ACTRN12618001610224.


Asunto(s)
Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/tratamiento farmacológico , Anciano , Clopidogrel/efectos adversos , Femenino , Humanos , Masculino , Microcirculación , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Ticagrelor/efectos adversos , Factores de Tiempo , Resultado del Tratamiento
9.
J Am Heart Assoc ; 11(13): e025602, 2022 07 05.
Artículo en Inglés | MEDLINE | ID: mdl-35766276

RESUMEN

Background Patients with suspected ST-segment-elevation myocardial infarction (STEMI) and cardiac catheterization laboratory nonactivation (CCL-NA) or cancellation have reportedly similar crude and higher adjusted risks of death compared with those with CCL activation, though reasons for these poor outcomes are not clear. We determined late clinical outcomes among patients with prehospital ECG STEMI criteria who had CCL-NA compared with those who had CCL activation. Methods and Results We identified consecutive prehospital ECG transmissions between June 2, 2010 to October 6, 2016. Diagnoses according to the Fourth Universal Definition of myocardial infarction (MI), particularly rates of myocardial injury, were adjudicated. The primary outcome was all-cause death. Secondary outcomes included cardiovascular death/MI/stroke and noncardiovascular death. To explore competing risks, cause-specific hazard ratios (HRs) were obtained. Among 1033 included ECG transmissions, there were 569 (55%) CCL activations and 464 (45%) CCL-NAs (1.8% were inappropriate CCL-NAs). In the CCL activation group, adjudicated index diagnoses included MI (n=534, 94%, of which 99.6% were STEMI and 0.4% non-STEMI), acute myocardial injury (n=15, 2.6%), and chronic myocardial injury (n=6, 1.1%). In the CCL-NA group, diagnoses included MI (n=173, 37%, of which 61% were non-STEMI and 39% STEMI), chronic myocardial injury (n=107, 23%), and acute myocardial injury (n=47, 10%). At 2 years, the risk of all-cause death was higher in patients who had CCL-NA compared with CCL activation (23% versus 7.9%, adjusted risk ratio, 1.58, 95% CI, 1.24-2.00), primarily because of an excess in noncardiovascular deaths (adjusted HR, 3.56, 95% CI, 2.07-6.13). There was no significant difference in the adjusted risk for cardiovascular death/MI/stroke between the 2 groups (HR, 1.23, 95% CI, 0.87-1.73). Conclusions CCL-NA was not primarily attributable to missed STEMI, but attributable to "masquerading" with high rates of non-STEMI and myocardial injury. These patients had worse late outcomes than patients who had CCL activation, mainly because of higher rates of noncardiovascular deaths.


Asunto(s)
Servicios Médicos de Urgencia , Infarto del Miocardio , Infarto del Miocardio con Elevación del ST , Accidente Cerebrovascular , Cateterismo Cardíaco , Electrocardiografía , Servicios Médicos de Urgencia/métodos , Humanos , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/terapia , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia
10.
Catheter Cardiovasc Interv ; 78(5): 755-63, 2011 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-21780278

RESUMEN

OBJECTIVES: The goal was to compare stent sizing by coronary computed tomographic angiography (CCTA) with that deployed in an experienced setting based upon conventional coronary angiography (CA). BACKGROUND: Stent sizing is currently performed by visual estimation, with infrequent guidance by intravascular ultrasound. CCTA permits quantitative determination of stent length (Stent L) and diameter (Stent D). METHODS: Projected L (CTA-Stent L) and D (CTA-Stent D) were determined from CCTA obtained in 248 patients with 352 lesions undergoing percutaneous coronary intervention within 4 months of the CCTA, and were compared to the Stent-L and Stent-D of the actually deployed stents. The effects of lesion modification and calcified plaque were also evaluated. RESULTS: There were significant correlations between CTA-Stent L and Stent L (r = 0.656, P < 0.0001) and between CTA-Stent D and Stent D (r = 0.40, P < 0.001). Median predicted CTA-Stent L was slightly longer (20 mm vs. 18 mm, P < 0.0001) and predicted CTA-Stent D was slightly smaller (3.0 mm vs. 3.2 mm, P < 0.0001) than Stent-L and Stent-D, respectively. The differences were unchanged in stents with lesion modification by pre-dilation or intracoronary nitroglycerin. CTA Stent-L and CTA Stent-D increased significantly with increasing calcium (P < 0.0001 and P = 0.019, respectively). CONCLUSIONS: (1) There are significant correlations between CCTA and CA based stent sizing in an experienced setting. (2) CCTA projects slightly longer and slightly smaller diameter stents than those deployed during PCI irrespective of lesion modification; the small differences are unlikely to have clinical significance. (3) CCTA may offer a noninvasive alternative to intravascular ultrasound for stent planning.


Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Stents , Tomografía Computarizada por Rayos X , Anciano , Análisis de Varianza , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ciudad de Nueva York , Valor Predictivo de las Pruebas , Diseño de Prótesis , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/terapia
11.
Catheter Cardiovasc Interv ; 75(3): 420-6, 2010 Feb 15.
Artículo en Inglés | MEDLINE | ID: mdl-20091813

RESUMEN

OBJECTIVES: The purpose of this study was to examine the outcome of carotid stenting using bivalirudin and the influence of vascular closure devices (VCD) on the incidence and severity of peri-procedural hypotension. BACKGROUND: Bivalirudin, a short-acting direct thrombin inhibitor, has been shown to be an effective anticoagulant in coronary interventions, with less risk of bleeding compared with heparin. Routine use of VCD has become the standard of care, facilitating patient ambulation after percutaneous carotid and coronary interventions. The combined use of these two therapies (bivalirudin and VCD) may improve outcomes in carotid interventions where prolonged patient immobilization may exacerbate hypotension following stenting. METHODS: A total of 514 patients underwent 536 carotid stenting procedures in the 3-year period from September 2004 to September 2007. All patients received adjunctive bivalirudin, with and without VCD. This cohort was analyzed for peri-procedural and 30-day clinical outcomes and length of hospitalization. RESULTS: Thirty-day stroke and death rate was 1.7%. A total of 83 patients (15.4%) experienced intra- or post-procedural hypotension (systolic BP < 80 mm Hg). There were four (0.7%) major bleeding complications requiring transfusion, and length of stay was delayed more than 24 hr in five patients (0.93%), all of whom were in the manual compression group. CONCLUSIONS: This was a negative study, with no significant difference on prolonged hypotensive events in patients with vascular closure device and bivalirudin, compared with those with manual compression and bivalirudin. Vascular closure devices were safe and effective with a low incidence of complications. In carotid artery stenting, bivalirudin is safe with low incidence of major bleeding and acceptable 30-day adverse event rates (stroke and death).


Asunto(s)
Anticoagulantes/uso terapéutico , Estenosis Carotídea/terapia , Técnicas Hemostáticas/instrumentación , Fragmentos de Péptidos/uso terapéutico , Anciano , Anciano de 80 o más Años , Terapia Combinada , Femenino , Técnicas Hemostáticas/efectos adversos , Hirudinas , Humanos , Hipotensión/etiología , Masculino , Persona de Mediana Edad , Proteínas Recombinantes/uso terapéutico , Stents , Resultado del Tratamiento
12.
Am J Cardiol ; 128: 120-126, 2020 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-32650905

RESUMEN

Women and patients with incomplete revascularization (IR) have a worse prognosis after ST elevation myocardial infarction (STEMI). However, the extent to which IR affects outcomes for women with STEMI compared with men is not well characterized. Thus, we examined late outcomes of 589 consecutive STEMI patients who received percutaneous coronary intervention and assessed SYNTAX scores (SS), both at baseline and after all procedures (residual SS). A residual SS >8 defined IR. The primary end point was cardiac death or myocardial infarction (MI), with median follow-up of 3.6 years [interquartile range [IQR] 2.6 to 4.7]. Women (n = 123) had lower baseline SSs 15.0 [IQR 9 to 20], than men (n = 466), 16.0 [IQR 9 to 20; p = 0.02. After all planned procedures, the residual SS was 5.0 [IQR 0 to 9] in women and 5.0 (IQR 1 to 11] in men, p = 0.37. Cardiac death or MI occurred in (97/589) patients (16%), 24% (30/123) in women and 14% (67/466) in men (hazard ratio [HR] 1.75; 95% confidence intervals [CI] 1.14 to 2.69; p = 0.01). In patients with residual SYNTAX score (rSS) >8 cardiac death or MI occurred in 43% (15/35) of women and 23% 36/158 men (HR 2.14; 95% CI 1.17 to 3.91; p = 0.01). In patients with rSS = 0 to 8 cardiac death or MI occurred in 17% (15/88) of women and 10% of men (31/308) (HR 1.68; 95% CI 0.91 to 3.12; p = 0.10; interaction p value 0.58). Multivariate analysis found women were 1.77 times more likely than men to experience cardiac death or MI (95% CI 1.13 to 2.77; p = 0.01). In conclusion, we found despite a lower burden of disease at presentation and no difference in rates of IR between men and women, outcome differences were substantial. Women with rSS >8 were twice as likely as men with the same rSS to experience cardiac death or MI post-STEMI. Differences remained significant postrisk adjustment.


Asunto(s)
Cardiopatías/mortalidad , Infarto del Miocardio/epidemiología , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST/terapia , Terapia Trombolítica , Antagonistas Adrenérgicos beta/uso terapéutico , Anciano , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antitrombinas/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/uso terapéutico , Modelos de Riesgos Proporcionales , Recurrencia , Factores Sexuales , Stents , Resultado del Tratamiento
13.
Int J Cardiovasc Imaging ; 36(5): 865-872, 2020 May.
Artículo en Inglés | MEDLINE | ID: mdl-32052225

RESUMEN

Right atrial (RA) and right ventricular (RV) parameters assessed by traditional echocardiography lack sensitivity to identify pulmonary embolism (PE). We sought to determine if alterations in RV free wall longitudinal strain (FWS) would be present in PE patients and improve evaluation. This retrospective study comprised of 84 consecutive PE patients from 2 centres, with adequate transthoracic echocardiography (TTE) images for RV FWS analysis. PE patients were compared to 66 healthy controls. Compared to controls, PE patients had increased RV parasternal long-axis diameter (RVPLAX) (33.4 ± 5.8 mm vs 39.9 ± 4.1 mm) and RA area (17.4 ± 5.6 cm2 vs 14.5 ± 3.1 cm2) (p < 0.001 for both). RV function was reduced in PE patients (RV fractional area change 31.1 ± 13.2% vs 41.7 ± 9.1%, TAPSE 17.0 ± 4.5 vs 21.3 ± 2.2 mm; p < 0.001 for both). RV FWS was reduced in PE patients (-14.4 ± 7.2% vs - 26.0 ± 4.4%, p < 0.001). RV FWS was the best discriminator for PE (AUC 0.912). In comparative multiple logistic regression models for PE, the model which included traditional measures of RV size and function and RV FWS, produced a powerful classifier (AUC 0.966, SE 0.013) with significantly better performance (p < 0.022) than the model without RV FWS (AUC 0.921, SE 0.024). RV FWS is a discriminator of PE patients; addition of RV FWS to existing parameters of RV size and function, significantly improves sensitivity and specificity for diagnosis of PE, and may play a role in diagnosis and guiding therapy. Validation in other PE groups is required to confirm these observations and its prognostic value needs evaluation.


Asunto(s)
Ecocardiografía Doppler , Ventrículos Cardíacos/diagnóstico por imagen , Contracción Miocárdica , Embolia Pulmonar/diagnóstico por imagen , Disfunción Ventricular Derecha/diagnóstico por imagen , Función Ventricular Derecha , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Femenino , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Nueva Gales del Sur , Valor Predictivo de las Pruebas , Embolia Pulmonar/complicaciones , Embolia Pulmonar/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Disfunción Ventricular Derecha/etiología , Disfunción Ventricular Derecha/fisiopatología
14.
J Saudi Heart Assoc ; 31(4): 151-160, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31296977

RESUMEN

OBJECTIVES: The primary aim was to investigate the efficacy and safety of dual antiplatelet therapy (DAPT) using ticagrelor (T-DAPT) versus clopidogrel (C-DAPT) in a real-world ST-elevation myocardial infarction (STEMI) population. METHODS: We retrospectively analyzed 655 consecutive patients having primary percutaneous coronary intervention (PCI) for STEMI at Liverpool Hospital, Sydney, Australia (from January 2013 to April 2016). Medical and procedural therapies were at clinician discretion. Patient data were retrieved from hospital records and primary clinicians. RESULTS: T-DAPT (65%) was used more frequently, and in patients with lower mean CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) score, than C-DAPT (24.6 vs. 32.2; p < 0.0001, respectively). All-cause mortality was 9.0% at 2.7 years follow-up, with fewer deaths for T-DAPT (4.5% vs. 17.2%; p < 0.0001). T-DAPT incurred less BARC (Bleeding Academic Research Consortium) 3-5 major bleeding (5.0% vs. 12.4%; p < 0.0001). Multivariate regression showed that C-DAPT, GRACE (Global Registry of Acute Cardiac Events) score, and renal insufficiency were independently associated with mortality. Intra-aortic balloon pump (IABP) and GRACE score independently predicted BARC 3-5 bleeding. Early DAPT discontinuation (1.7%) and ticagrelor intolerance (7.6%) was rare. Switching DAPT regimen was infrequent (21.7%) and mostly attributed to clinician preference (73.2%). Independent determinants of C-DAPT selection were older age, diabetes, prior PCI, IABP, and higher CRUSADE score. CONCLUSION: Ticagrelor was preferred in low bleeding risk patients, which may have contributed to less BARC 3-5 bleeding and lower mortality for T-DAPT. Thus, bleeding mitigation is a clinical priority when selecting DAPT for PCI-treated STEMI patients. Continuation of initial DAPT regimen was typical, but early switching from clopidogrel to ticagrelor shows willingness to optimize DAPT. Patients with very low CRUSADE scores (<21.5) may be appropriate for switching to a potent P2Y12 inhibitor.

15.
Am J Cardiol ; 124(2): 285-291, 2019 07 15.
Artículo en Inglés | MEDLINE | ID: mdl-31101322

RESUMEN

Pulmonary embolism (PE) is associated with a high mortality; whether echocardiographic evaluation at presentation predicts long-term adverse outcomes is of importance. We sought to determine if a composite of routinely obtained echocardiographic parameters could determine long-term adverse events in PE patients. Right ventricular (RV) size and function and right atrial (RA) size were retrospectively evaluated in 233 consecutive PE patients with an inpatient echocardiogram, and compared with 70 healthy controls; mortality at 3 years was confirmed. PE patients had increased RV size (RV parasternal long-axis diameter [RVPLAX] and RV end-diastolic volume [p < 0.001 for both]) and RA area (p < 0.001). RV function was reduced in PE patients (RV fractional area change and RV ejection fraction [p <0.001 for both]). Peak tricuspid regurgitation (TR) velocity was higher in the PE group. At follow-up (3.0 ± 2.1 years), 61 patients died; multivariable analysis demonstrated RVPLAX diameter >37 mm (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.3 to 4.2; p = 0.005), RA area >20 cm2 (HR 2.0, 95% CI 1.1 to 3.5; p = 0.016), and TR velocity >2.9 ms-1 (HR 1.9, 95% CI 1.1 to 3.4; p = 0.021), were independent echocardiographic predictors of mortality. Patients with all 3 "risk markers" had ∼17-fold increased mortality compared with those with no "risk markers" (HR 16.9, 95% CI 6.1 to 47.2; p < 0.001). In conclusion, a composite of routinely collected echocardiographic parameters, namely an enlarged RA and RV (RVPLAX diameter), and TR velocity, were independent predictors of mortality in PE patients, with an exponential increase in mortality when all 3 parameters were significantly altered. Prospective validation is required to confirm these preliminary observations.


Asunto(s)
Ecocardiografía , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos
17.
Eur Heart J Qual Care Clin Outcomes ; 2(3): 164-171, 2016 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-29474609

RESUMEN

AIMS: To determine if high sensitivity troponin T (hs-TnT) measurements performed during the 'plateau phase' of troponin release (≥48 h) following ST-segment elevation myocardial infarction (STEMI) can predict major adverse cardiovascular endpoints (MACE), and to evaluate its prognostic value compared with cardiac magnetic resonance imaging (CMRI) parameters. METHODS AND RESULTS: We prospectively recruited 201 first presentation STEMI patients. Serial hs-TnT levels were measured at admission, peak (highest), 24, 48 and 72 h. CMRI and transthoracic echocardiography were performed (4 days median) post-STEMI, evaluating infarct scar characteristics and left ventricular ejection fraction (LVEF). Associations were determined between hs-TnT levels and CMRI parameters early after STEMI with MACE (comprising mortality, re-infarction, new or worsening of heart failure, cerebrovascular accident, and sustained ventricular arrhythmias) at medium-term follow-up. After 602 days (median), 33 (17%) patients had MACE. Upper tertile hs-TnT levels at 48 and 72 h were associated with MACE (Kaplan-Meier P = 0.002 and P = 0.012, respectively). Multivariate Cox analyses, incorporating diabetes, CMRI scar size, LVEF and hs-TnT levels (applied at a single hs-TnT time point) showed that 48 and 72 h hs-TnT levels were independent predictors for MACE (HR = 1.20, P = 0.002, and HR = 1.21, P = 0.035 respectively). CONCLUSION: Measurement of hs-TnT in the plateau phase after STEMI is an inexpensive method of prognostic risk assessment.

18.
Curr Med Res Opin ; 31(8): 1469-77, 2015 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-26086451

RESUMEN

OBJECTIVE: Ticagrelor is recommended in local and international guidelines as first-line therapy in combination with aspirin in patients presenting with acute coronary syndromes (ACS). The purpose of this article is to provide practical guidance regarding the use of ticagrelor in this setting. METHODS AND RESULTS: Ticagrelor, a direct-acting, reversible P2Y12 receptor antagonist, has a faster onset, and a more potent and predictable antiplatelet effect compared with clopidogrel. The authors recommend considering the use of ticagrelor in moderate-to-high risk ACS patients treated with an invasive approach and those managed non-invasively who have elevated troponin levels. Consistent with outcomes observed in the PLATO trial overall, ticagrelor was superior to clopidogrel treatment in patients with chronic kidney disease, a history of stroke or transient ischemic attack, the elderly, and patients requiring surgical revascularization. CONCLUSIONS: When switching from clopidogrel to ticagrelor, patients established on clopidogrel therapy can be switched directly without loading; patients not loaded with clopidogrel and not taking maintenance dose clopidogrel for at least 5 days should first be loaded with ticagrelor. Guidelines recommend discontinuing ticagrelor 5 days before surgery if antiplatelet effects are not desired and recommencing therapy as soon as safe following surgery. Ticagrelor should be avoided in individuals with a history of intracranial hemorrhage, moderate-to-severe hepatic impairment, high bleeding risk, within 24 hours of thrombolytic therapy, and in those treated with oral anticoagulants. Local, real-world experience suggests low bleeding rates with ticagrelor therapy. Dyspnoea is a common symptom in patients with ACS and is also a side-effect of ticagrelor therapy. Discontinuation of ticagrelor due to dyspnoea has been uncommon in clinical trials. However, local registry data suggest higher discontinuation rates (2-9%) related to dyspnoea in the real-world setting, indicating that clinicians may need to consider other potential causes of dyspnoea before discontinuing ticagrelor.


Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Adenosina/análogos & derivados , Inhibidores de Agregación Plaquetaria/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Adenosina/efectos adversos , Adenosina/uso terapéutico , Clopidogrel , Hemorragia/inducido químicamente , Humanos , Ticagrelor , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico
19.
Clin Ther ; 35(8): 1069-75, 2013 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-23973040

RESUMEN

BACKGROUND: Diabetes mellitus (DM) is a powerful independent risk factor for multivessel, diffuse coronary artery disease (CAD). The optimal coronary revascularization strategy in DM is not clearly defined, but past trials have suggested an advantage for coronary artery bypass grafting (CABG). Recently, the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial found patients randomized to CABG had lower rates of death and myocardial infarction (MI) compared with those randomized to percutaneous coronary intervention (PCI). OBJECTIVE: This article reviews the contemporary management of patients with DM presenting with acute coronary syndromes, particularly ST-elevation MI, in the post-FREEDOM era. METHODS: We undertook a comprehensive review of published literature addressing trials in this field performed to address current knowledge both in the pre- and post-FREEDOM era. RESULTS: The implications of FREEDOM for patients with acute coronary syndrome are that CABG provides a significant benefit, compared with PCI with drug-eluting stents, to patients with DM and multivessel coronary artery disease; and that patients similar to those enrolled in FREEDOM should receive CABG in preference to PCI. The relevance of FREEDOM's findings to the large proportion of patients who would not meet inclusion criteria-including patients with an acute coronary syndrome undergoing an early or emergent invasive strategy, remains uncertain. DISCUSSION: FREEDOM's outcomes have generated uncertainty regarding best practice once thrombolysis in myocardial infarction grade 3 flow is re-established in patients with DM and multivessel disease. Current interventional guidelines recommend optimally treating the culprit artery; however, decisions made at the time of revascularization influence future revascularization strategies, particularly stent choice and resultant P2Y12 receptor antagonist therapy. The preferred method for future revascularization may be questioned if the patient's residual coronary stenoses do not, post-PCI, meet the FREEDOM inclusion criteria, or where the left anterior descending artery is the infarct-related artery, and after left anterior descending artery PCI the patient would not receive an internal mammary graft. The management of residual disease and the preferred (further) revascularization strategy needs to be tested in an appropriately powered randomized trial. CONCLUSIONS: The optimal revascularization strategy in patients with acute coronary syndrome, diabetes, and multivessel disease, in particular those with ST elevation, is unclear, and not guided by level A (or B) evidence. Currently CABG is favored over PCI, and an individually tailored, collaborative approach, guided by a multidisciplinary heart team, should be employed.


Asunto(s)
Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/cirugía , Puente de Arteria Coronaria , Complicaciones de la Diabetes/cirugía , Síndrome Coronario Agudo/terapia , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/terapia , Complicaciones de la Diabetes/terapia , Humanos , Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea , Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema de Registros , Factores de Riesgo , Resultado del Tratamiento
20.
Int J Cardiol ; 167(4): 1276-81, 2013 Aug 20.
Artículo en Inglés | MEDLINE | ID: mdl-22560944

RESUMEN

There is little information on whether identification of multi-vessel disease (MVD) in patients with diabetic mellitus (DM) affects risk factor management. From 1125 consecutively screened patients between June 2006 and March 2010, we examined 227 diabetic patients with MVD on coronary angiography. Diabetic control and cholesterol levels were assessed by glycated haemoglobin (HbA1c) and total cholesterol (TC) respectively which were evaluated at baseline and at 1-year follow-up. Patients were grouped by age into <55(n=33), 55-65(n=75), 66-75(n=75) and >75(n=44). Target levels were defined as HbA1c<7% and TC<4.0 mmol/L. Patients <55 years had the highest HbA1c at 9.1[7.6-11.2]% with the lowest proportion of patients (n=3; 11.1%) within target at baseline, while 66-75 years had the best HbA1c at 7.1[6.4-7.8]% with the highest proportion (n=28, 45.2%) reaching target (p<0.0001). At 1-year, the poorest HbA1c control was again observed in the age <55 with fewer patients achieving target compared to the 66-75 age group (HbA1c: 8.5% vs 6.9%; % of patients at target: 20.7% vs 54.5%; p<0.0001). Furthermore, the group <55 years demonstrated the worst TC control at 1-year with a significant increase compared to the baseline TC (p=0.01). Patients with a lower body mass index (BMI) were likely to have an improvement in HbA1c and reach target (p=0.01). Paradoxically, patients who were current smokers demonstrated a beneficial effect on optimal TC control (29.2% vs 15.4%, p=0.027). In younger diabetic patients, risk factor modification at 1-year was poor despite identification of MVD. Developing an effective education and monitoring programme to improve glycaemic control in this high risk group should be a priority.


Asunto(s)
Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Diabetes Mellitus Tipo 1/diagnóstico por imagen , Diabetes Mellitus Tipo 2/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Enfermedad de la Arteria Coronaria/epidemiología , Estudios Transversales , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo
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