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1.
Circulation ; 147(11): 850-863, 2023 03 14.
Artigo em Inglês | MEDLINE | ID: mdl-36335531

RESUMO

BACKGROUND: Septal reduction therapy (SRT) in patients with intractable symptoms from obstructive hypertrophic cardiomyopathy (oHCM) is associated with variable morbidity and mortality. The VALOR-HCM trial (A Study to Evaluate Mavacamten in Adults with Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) examined the effect of mavacamten on the need for SRT through week 32 in oHCM. METHODS: A double-blind randomized placebo-controlled multicenter trial at 19 US sites included patients with oHCM on maximal tolerated medical therapy referred for SRT with left ventricular outflow tract gradient ≥50 mm Hg at rest or provocation (enrollment, July 2020-October 2021). The group initially randomized to mavacamten continued the drug for 32 weeks, and the placebo group crossed over to dose-blinded mavacamten from week 16 to week 32. Dose titrations were based on investigator-blinded echocardiographic assessment of left ventricular outflow tract gradient and left ventricular ejection fraction. The principal end point was the proportion of patients proceeding with SRT or remaining guideline eligible at 32 weeks in both treatment groups. RESULTS: From the 112 randomized patients with oHCM, 108 (mean age, 60.3 years; 50% men; 94% in New York Heart Association class III/IV) qualified for week 32 evaluation (56 in the original mavacamten group and 52 in the placebo cross-over group). After 32 weeks, 6 of 56 patients (10.7%) in the original mavacamten group and 7 of 52 patients (13.5%) in the placebo cross-over group met SRT guideline criteria or elected to undergo SRT. After 32 weeks, a sustained reduction in resting left ventricular outflow tract gradient (-33.0 mm Hg [95% CI, -41.1 to -24.9]) and Valsalva left ventricular outflow tract gradient (-43.0 mm Hg [95% CI, -52.1 to -33.9]) was observed in the original mavacamten group. A similar reduction in resting (-33.7 mm Hg [95% CI, -42.2 to -25.2]) and Valsalva (-52.9 mm Hg [95% CI, -63.2 to -42.6]) gradients was quantified in the cross-over group after 16 weeks of mavacamten. After 32 weeks, improvement by ≥1 New York Heart Association class was observed in 48 of 53 patients (90.6%) in the original mavacamten group and 35 of 50 patients (70%) after 16 weeks in the cross-over group. CONCLUSIONS: In severely symptomatic patients with oHCM, 32 weeks of mavacamten treatment showed sustained reduction in the proportion proceeding to SRT or remaining guideline eligible, with similar effects observed in patients who crossed over from placebo after 16 weeks. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04349072.


Assuntos
Cardiomiopatia Hipertrófica , Função Ventricular Esquerda , Adulto , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Volume Sistólico , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/tratamento farmacológico , Benzilaminas/farmacologia
2.
Artigo em Inglês | MEDLINE | ID: mdl-39357146

RESUMO

In a randomized double-blinded clinical trial of patients with ST segment elevation myocardial infarction (STEMI), goflikicept, an Interleukin-1 (IL-1) blocker, significantly reduced systemic inflammation, measured as the area-under-the-curve (AUC) for high-sensitivity C reactive protein (hsCRP) at 14 days. We report secondary analyses of biomarkers at 28 days, and cardiac function and clinical endpoints at 1 year. Patients received a single administration of goflikicept 80 mg (n=34), goflikicept 160 mg (n=34), or placebo (n=34). Both doses of goflikicept significantly reduced the AUC for hsCRP at 28 days compared with placebo, without statistically significant differences between the doses. There we no statistically significant differences between groups in the AUC for natriuretic peptides at 28 days. There were no significant differences between placebo, goflikicept 80 mg and 160 mg groups in deaths (2.9%, 2.9% and 0%), hospitalization for cardiovascular reasons (9.1%, 5.9%, and 0%), new-onset or progression of heart failure (9.1%, 5.9%, and 5.9%), and new or increased use of loop diuretics (24.2%, 14.7%, and 17.6%), nor in the number of patients with treatment emergent adverse events, with no treatment-related serious adverse events in any group. In conclusion, in patients with STEMI, IL-1 blockade with goflikicept 80 mg or 160 mg was well tolerated and associated with significant reduction of systemic inflammation. Further adequately powered studies are warranted to determine whether the reduction in systemic inflammation with goflikicept translates into a clinical benefit in patients with STEMI.

3.
Curr Cardiol Rep ; 26(7): 747-755, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38789693

RESUMO

PURPOSE OF REVIEW: Dysfunction and thrombosis of mechanical heart valves, although uncommon, represents a challenge that requires multidisciplinary expertise for diagnosis and management. The aim of this review is to summarize strengths and weaknesses of diagnostic methods and therapeutic strategies for this uncommon but potentially life-threatening pathology. RECENT FINDINGS: Expeditious diagnosis of mechanical valve thrombosis and exclusion of other diagnostic considerations, often with incorporation of multimodality imaging, can inform the best treatment strategy. Presentation of mechanical valve thrombosis can be asymptomatic or can include heart failure, life-threatening embolic events, or cardiogenic shock. Echocardiography, fluoroscopy and computed tomography are important in the evaluation of mechanical valve dysfunction. Therapeutic strategies for thrombosis include anticoagulation, systemic thrombolysis, and surgery. Choice of treatment depends on multiple factors including thrombus size, degree of valve dysfunction, clinical presentation, and available surgical expertise.


Assuntos
Próteses Valvulares Cardíacas , Trombose , Humanos , Trombose/etiologia , Trombose/diagnóstico por imagem , Trombose/terapia , Trombose/fisiopatologia , Terapia Trombolítica/métodos , Anticoagulantes/uso terapêutico , Ecocardiografia , Doenças das Valvas Cardíacas/terapia , Doenças das Valvas Cardíacas/fisiopatologia , Falha de Prótese , Tomografia Computadorizada por Raios X
4.
Curr Cardiol Rep ; 2024 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-39276266

RESUMO

PURPOSE OF REVIEW: To discuss the evolution in the approach to pericardial effusions and drainage from a historical perspective, the present state, and pathways for future innovative therapies. RECENT FINDINGS: Incorporation of advanced imaging tools has dramatically improved the safety profile of pericardial interventions. Outcome data allow for refined approaches to management of pericardial disease in special populations, such as pulmonary arterial hypertension. Consideration of intrapericardial interventions and pharmacotherapy represent novel and promising approaches to management of pericardial effusions moving forward. Although the impact of excess or rapidly accumulating pericardial fluid on hemodynamics has been recognized for centuries, the therapeutic approaches have only recently become more refined with the routine incorporation of such tools as echocardiography and fluoroscopy. The most utilized approaches for pericardiocentesis include the apical, subxiphoid, and parasternal, and the most favorable approach is that in which the pericardial fluid is closest to the body surface, where intervening vital structures are least likely to be damaged. With the notable exception of patients with pre-existing pulmonary hypertension, complete decompression of pericardial fluid with careful drain management reduces likelihood of pericardial effusion recurrence. In addition, percutaneous balloon pericardiotomies have been demonstrated to reduce recurrence in nonmalignant effusions.

5.
JAMA ; 332(13): 1090-1100, 2024 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-39235771

RESUMO

Importance: Pericarditis accounts for up to 5% of emergency department visits for nonischemic chest pain in North America and Western Europe. With appropriate treatment, 70% to 85% of these patients have a benign course. In acute pericarditis, the development of constrictive pericarditis (<0.5%) and pericardial tamponade (<3%) can be life-threatening. Observations: Acute pericarditis is diagnosed with presence of 2 or more of the following: sharp, pleuritic chest pain that worsens when supine (≈90%); new widespread electrocardiographic ST-segment elevation and PR depression (≈25%-50%); a new or increased pericardial effusion that is most often small (≈60%); or a pericardial friction rub (<30%). In North America and Western Europe, the most common causes of acute pericarditis are idiopathic or viral, followed by pericarditis after cardiac procedures or operations. Tuberculosis is the most common cause in endemic areas and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis. Treatment of acute idiopathic and pericarditis after cardiac procedures or operations involves use of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs), with doses tapered once chest pain has resolved and C-reactive protein level has normalized, typically over several weeks. These patients should receive a 3-month course of colchicine to relieve symptoms and reduce the risk of recurrence (37.5% vs 16.7%; absolute risk reduction, 20.8%). With a first recurrence of pericarditis, colchicine should be continued for at least 6 months. Corticosteroids are often used if pericarditis does not improve with NSAIDs and colchicine. In certain patients with multiple recurrences, which can occur for several years, interleukin 1 (IL-1) blockers have demonstrated efficacy and may be preferred to corticosteroids. Conclusions: Acute pericarditis is a common cause of nonischemic chest pain. Tuberculosis is the leading cause of pericarditis in endemic areas and is treated with antitubercular therapy. In North America and Western Europe, pericarditis is typically idiopathic, develops after a viral infection, or develops following cardiac procedures or surgery. Treatment with NSAIDs and colchicine leads to a favorable prognosis in most patients, although 15% to 30% of patients develop recurrence. Patients with multiple recurrent pericarditis can have a disease duration of several years or more, are often treated with corticosteroids, and IL-1 blockers may be used for selected patients as steroid-sparing therapy.


Assuntos
Dor no Peito , Colchicina , Pericardite , Humanos , Doença Aguda/epidemiologia , Doença Aguda/terapia , Anti-Inflamatórios não Esteroides/uso terapêutico , Antituberculosos/uso terapêutico , Dor no Peito/diagnóstico , Dor no Peito/tratamento farmacológico , Dor no Peito/epidemiologia , Dor no Peito/etiologia , Colchicina/uso terapêutico , Eletrocardiografia , Pericardite/diagnóstico , Pericardite/tratamento farmacológico , Pericardite/epidemiologia , Pericardite/etiologia , Medição de Risco , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Tuberculose/complicações , Tuberculose/tratamento farmacológico , Quimioterapia Combinada/métodos , Glucocorticoides/uso terapêutico
6.
J Cardiovasc Electrophysiol ; 34(3): 765-768, 2023 03.
Artigo em Inglês | MEDLINE | ID: mdl-36738138

RESUMO

Guidelines recommend using the CHA2DS2-VASc score to determine anticoagulation decisions in atrial fibrillation (AF) patients, including those who undergo pulmonary vein isolation (PVI), however this may not consistently occur in the real-world setting because of other clinical factors. We sought to evaluate the anticoagulation prescription rates patterns in AF patients 1 year PVI at our institution. Consecutive AF patients undergoing PVI in our prospective registry during 2014-2018 who were alive at 1-year post-PVI were studied. Anticoagulation prescription rates at this time-point were adjudicated, and correlated to CHA2DS2-VASc score, sex, and heart rhythm status at 1 year. Amongst 4596 patients undergoing PVI, mean age was 64.2 ± 10.0 years, 1328 (28.9%) were female, and based on CHA2DS2-VASc score anticoagulation was not indicated, can be considered and indicated in 872 (19.0%), 1183 (25.7%), and 2541 (55.3%) patients, respectively. At 1-year after PVI, 3504 (76.2%) patients were on anticoagulation, and 792 (17.2%) had recurrence of AF. Anticoagulation was continued in over half of AF patients without classic CHA2DS2-VASc indication particularly in those with AF recurrence and women, while they were mildly under-prescribed in those with indication, especially for those without AF recurrence and men. In a large real world cohort of patients after PVI, anticoagulation prescription is not solely depending on the CHA2DS2-VASc score and sex, but also heart rhythm status and other clinical or imaging factors.


Assuntos
Fibrilação Atrial , Ablação por Cateter , Veias Pulmonares , Masculino , Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Fibrilação Atrial/cirurgia , Veias Pulmonares/cirurgia , Medição de Risco/métodos , Coagulação Sanguínea , Ablação por Cateter/métodos , Recidiva , Resultado do Tratamento
7.
J Nucl Cardiol ; 30(2): 781-789, 2023 04.
Artigo em Inglês | MEDLINE | ID: mdl-35978070

RESUMO

BACKGROUND: The assessment of anomalous coronary arteries (AAOCA) remains controversial without an optimal stress modality for ischemia. We evaluated the value of PET-CT myocardial perfusion imaging in these patients and subsequent management. METHODS AND RESULTS: AAOCA patients (n = 82) undergoing PET-CT from 2015 to 2021 were retrospectively chart reviewed. Multivariable analyses performed to assess relevant clinical and imaging factors associated with ischemia on PET and AAOCA surgery. Key characteristics include mean age 45 ± 20 years, 30 (37%) female, 45 (55%) with chest pain, 19 (23%) anomalous left main coronary artery, 58 (71%) anomalous right coronary artery, 26 (32%) with objective ischemia on PET-CT, and 37 (45%) who underwent AAOCA surgery. Adverse outcomes over mean follow-up of 2.2 ± 1.8 years included one death and two myocardial infarctions. Anomalous left main was independently associated with ischemia on PET-CT, odds ratio (95% confidence intervals) 4.15 (1.31-13.1), P = .006. Chest pain and ischemia on PET-CT were independently associated with and provided incremental prognostic value for surgery, odds ratio 9.73 (2.78-34.0), P < .001 and 6.79 (1.99-23.2), P = .002, respectively. CONCLUSION: Ischemia on PET-CT occurred in a third of our cohort, identifying patients who may benefit from surgery. Larger studies are needed to evaluate the interplay between AAOCA, ischemia by PET and surgery.


Assuntos
Doença da Artéria Coronariana , Isquemia Miocárdica , Imagem de Perfusão do Miocárdio , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Masculino , Vasos Coronários , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos Retrospectivos , Imagem de Perfusão do Miocárdio/métodos , Isquemia Miocárdica/complicações , Isquemia , Dor no Peito , Tomografia por Emissão de Pósitrons/métodos , Doença da Artéria Coronariana/complicações , Angiografia Coronária
8.
Europace ; 25(9)2023 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-37721485

RESUMO

AIMS: Identifying patients with cardiac sarcoidosis (CS) who are at an increased risk of sudden cardiac death (SCD) poses a clinical challenge. We sought to identify the optimal cutoff for left ventricular ejection fraction (LVEF) in predicting ventricular arrhythmia (VA) and all-cause mortality and to identify clinical and imaging risk factors in patients with known CS. METHODS AND RESULTS: This retrospective cohort included 273 patients with well-established CS. The primary endpoint was a composite of VA and all-cause mortality. A modified receiver operating curve analysis was utilized to identify the optimal cutoff for LVEF in predicting the primary composite endpoint. Cox proportional hazard regression analysis was used to identify independent risk factors of the outcomes. At median follow-up of 7.9 years, the rate of the primary endpoint was 38% (83 VAs and 32 all-cause deaths). The 5-year overall survival rate was 97%. The optimal cutoff LVEF for the primary composite endpoint was 42% in the entire cohort and in subjects without a history of VA. Younger age, history of VA, lower LVEF, and any presence of scar by cardiac magnetic resonance (CMR) imaging and/or positron emission tomography (PET) were found to be independent risk factors for the primary endpoint and for VA, whereas lower LVEF, baseline NT-proBNP, and any presence of scar were independent risk factor of all-cause mortality. CONCLUSION: Among patients with CS, a mild reduction in LVEF of 42% was identified as the optimal cutoff for predicting VA and all-cause mortality. Prior VA and scar by CMR or PET are strong risk factors for future VA and all-cause mortality.


Assuntos
Miocardite , Sarcoidose , Humanos , Volume Sistólico , Função Ventricular Esquerda , Cicatriz , Estudos Retrospectivos , Sarcoidose/diagnóstico , Sarcoidose/diagnóstico por imagem , Medição de Risco
9.
Ann Vasc Surg ; 96: 166-175, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37169247

RESUMO

BACKGROUND: Cardiovascular complications are a major cause of morbidity and mortality in the postoperative period after major vascular surgery. Depending on the study population, up to 25% of patients have troponin elevation after noncardiac surgery, yet many do not meet the diagnosis of myocardial infarction (MI). Although outcomes of routine troponin elevation in patients undergoing mixed major vascular surgery have been evaluated, this has not been studied exclusively in elective, open abdominal aortic aneurysm repair (oAAA), especially regarding perioperative and overall mortality. METHODS: We conducted a single-center, retrospective review of routine troponin surveillance for consecutive, oAAA from 2014 to 2019. A total of 319 patients were identified and analyzed for management patterns and interventions. The cohort was stratified into groups for comparison based on those in whom troponin was routinely checked (RC) as part of a care strategy during the study period, not routinely checked (NRC), elevated troponin (ET) >0.001 ng/mL, and not elevated. The median follow-up was 21.5 ± 23.8 months. Groups were compared on demographic data, cardiac comorbidities, 30-day and 3-year outcomes for MI and death using two-sample t-tests, Wilcoxon rank sum tests, Pearson chi-square tests, and Fisher exact tests when appropriate. RESULTS: Troponin was measured in 83.7% (267/319) of patients who underwent elective oAAA repair. Routine troponin checks were obtained in 79.9% (255/319) of patients. ET was identified in 16.5% of those with RC (42/255) and 4.7% of those with NRC (3/64). Of patients with ET, 37.8% (17/45) had a cardiology consultation, 4.4% (2/45) had a percutaneous coronary intervention (PCI), and 4.4% (2/45) had another cardiac intervention. All 4 patients undergoing PCI or other cardiac intervention had received routine troponin checks. Patients with ET were older (71.2 vs. 68.6; P = 0.04), more likely to receive intraoperative blood products (P = 0.003), had longer operative times (P = 0.011), higher length of stay (9 vs. 7 days; P < 0.01), and higher 30-day MI rate (3 vs. 0; P = 0.04). They had neither longer aortic clamp times nor worse preoperative cardiac function, and the proximal clamp position during oAAA repair did not impact troponin detection. Additionally, 3-year overall mortality was increased in patients who had ET but there was not a significant difference in 3-year mortality between groups receiving routine troponin checks versus not. CONCLUSIONS: ET, identified after elective oAAA repair, was associated with a higher risk of 30-day MI and lower overall survival. However, it was not demonstrated that routine assessment of troponin levels postoperatively leads to decreased 3-year mortality in this setting.


Assuntos
Aneurisma da Aorta Abdominal , Infarto do Miocárdio , Intervenção Coronária Percutânea , Procedimentos de Cirurgia Plástica , Humanos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia
10.
J Card Fail ; 28(10): 1509-1518, 2022 10.
Artigo em Inglês | MEDLINE | ID: mdl-35843490

RESUMO

BACKGROUND: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized cause of heart failure. Given the expansion of noninvasive diagnosis with 99mTc-pyrophosphate (99mTc-PYP) scanning, and clinical use of the transthyretin stabilizer, tafamidis, we sought to examine the interplay of planar imaging heart-to-contralateral lung (H/CL) ratio, cardiac biomarkers, and survival probability in a contemporary cohort of patients referred for noninvasive evaluation of ATTR-CM. METHODS: This single-center retrospective cohort study included 351 consecutive patients who underwent a standardized imaging protocol with 99mTc-PYP scanning for the evaluation of ATTR-CM from January 1, 2018, to January 1, 2020. After the exclusion of light chain amyloidosis, patients were characterized as scan consistent with ATTR (+ATTR-CM) or scan not consistent with ATTR (-ATTR-CM) using current guidelines. Linear regression was used to examine the relationship between biomarkers and H/CL and univariate Cox proportional hazards models were used to assess the probability of transplant-free survival. RESULTS: We included 318 patients in the analysis (n = 86 patients +ATTR-CM; n = 232 patients -ATTR-CM). The median follow-up time was 20.1 months. During the study period, 67% of +ATTR-CM patients received tafamidis (median treatment duration, 17 months). The median H/CL ratio was 1.58 (interquartile range, 1.40-1.75). An H/CL ratio of more than 1.6 or less than 1.6 did not seem to have an impact on survival probability in +ATTR-CM patients (P = .30; hazard ratio, 0.65; 95% confidence interval, 0.31-1.41). Cardiac biomarkers were poorly correlated with H/CL (troponin T, R2 = 0.024; N-terminal pro-B-type natriuretic peptide, R2 =0.023). The Gillmore staging system predicted survival probability in +ATTR-CM as well as in the entire cohort referred for scanning. There was a trend toward longer survival among those who were -ATTR-CM compared with +ATTR-CM (P = .051; hazard ratio, 0.64; 95% confidence interval, 0.40-1.00). CONCLUSIONS: At a large referral center, the intensity of 99mTc-PYP uptake (H/CL ratio) has neither correlation with cardiac biomarker concentrations nor prognostic usefulness in an analysis of intermediate term outcomes in the early therapeutics era. The H/CL ratio has diagnostic value, but offers little prognostic value in patients with ATTR-CM. Established staging schema were predictive of survival in this contemporary cohort, re-emphasizing the importance of cardiac biomarkers and renal function in assessing disease severity and prognosis.


Assuntos
Neuropatias Amiloides Familiares , Cardiomiopatias , Insuficiência Cardíaca , Neuropatias Amiloides Familiares/diagnóstico por imagem , Neuropatias Amiloides Familiares/tratamento farmacológico , Cardiomiopatias/diagnóstico por imagem , Cardiomiopatias/tratamento farmacológico , Difosfatos , Humanos , Peptídeo Natriurético Encefálico , Pré-Albumina , Estudos Retrospectivos , Pirofosfato de Tecnécio Tc 99m , Troponina T
11.
J Nucl Cardiol ; 28(2): 536-542, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30877551

RESUMO

BACKGROUND: Assessing for coronary artery disease (CAD) in patients with left bundle branch block (LBBB) is difficult with noninvasive cardiac imaging. Few studies report the prevalence of LBBB associated septal-apical perfusion defects using regadenoson stress on Positron Electron Tomography (PET) imaging. METHODS AND RESULTS: We identified 101 consecutive patients with baseline LBBB, and without known CAD, who underwent rest-stress regadenoson PET. Investigators have the ability to prospectively identify studies, whose quality is limited by LBBB artifact. With the infusion of regadenoson, resting to peak stress heart rate rose from a median of 78 to 93 BPM. Despite this, LBBB perfusion artifacts were not identified in any studies. 10 individuals had both regadenoson SPECT and PET within 1 year. 3 of the 10 SPECT studies had LBBB artifacts, all of which were not seen on subsequent PET. 21 patients with PET had subsequent coronary angiography. Of these, 9 PETs were without significant inducible ischemia, and angiogram was without flow-limiting disease. 3 PETs identified inducible ischemia, but did not have flow-limiting disease on angiogram. 9 PETs identified inducible ischemia and had flow-limiting disease on angiogram. CONCLUSIONS: In patients with LBBB undergoing regadenoson PET stress imaging, artifactual septal perfusion defects are rare.


Assuntos
Bloqueio de Ramo/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Septos Cardíacos/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Tomografia por Emissão de Pósitrons/métodos , Purinas/farmacologia , Pirazóis/farmacologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada de Emissão de Fóton Único
12.
J Nucl Cardiol ; 28(5): 2190-2193, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33051803

RESUMO

The diagnosis of cardiac sarcoidosis (CS) is challenging. Recently, guidelines incorporated cardiac positron emission tomography (PET) with 18F-Fluorodeoxyglucose (F18-FDG) as a non-invasive diagnostic modality for the detection and follow-up of CS. However, this technique is dependent of patient dietary preparation to suppress physiological myocardial F18-FDG uptake. We present a case of possible CS which highlights a novel preparation protocol that facilitated appropriate myocardial suppression.


Assuntos
Fluordesoxiglucose F18/uso terapêutico , Tomografia por Emissão de Pósitrons/instrumentação , Sarcoidose/diagnóstico por imagem , Sarcoidose/dietoterapia , Adulto , Feminino , Humanos , Tomografia por Emissão de Pósitrons/métodos , Tomografia por Emissão de Pósitrons/estatística & dados numéricos , Compostos Radiofarmacêuticos/uso terapêutico , Sarcoidose/fisiopatologia
13.
J Nucl Cardiol ; 28(6): 2941-2948, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-32557148

RESUMO

BACKGROUND: With high-sensitivity troponin testing, approximately a third of patients presenting to emergency departments (EDs) with suspected acute coronary syndromes will have mildly abnormal values. However, data regarding rest-stress myocardial perfusion imaging (MPI) in these patients are limited. We hypothesize that stress testing is safe and that the yield for detecting myocardial ischemia is associated with risk stratification by the HEART score. METHODS AND RESULTS: We conducted a retrospective cohort study of consecutive patients referred for rest-stress MPI with mildly abnormal high-sensitivity troponin T (hs-cTn) values. Outcomes were adverse events related to stress MPI, defined as myocardial infarction or ventricular tachyarrhythmia, and the presence of ischemia, defined as a reversible perfusion defect. Among 213 patients, the median age was 67, most were male (61.5%, n = 131), and prior CAD was common (53.5%, n = 114). Myocardial ischemia was present in 13.6% (n = 29), and there were no adverse events attributable to stress MPI. A higher HEART score was associated with myocardial ischemia (Odds Ratio [OR] 1.50, 95% Confidence Interval [CI] 1.08 to 2.08, P = .002). CONCLUSION: Rest-stress MPI appears safe in patients with mildly abnormal hs-cTn values, and the yield for detecting ischemia is associated with the HEART score, though further validation studies are needed.


Assuntos
Teste de Esforço/métodos , Isquemia Miocárdica/sangue , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/fisiopatologia , Imagem de Perfusão do Miocárdio/métodos , Troponina/sangue , Idoso , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Descanso , Estudos Retrospectivos , Sensibilidade e Especificidade
14.
Europace ; 23(8): 1211-1218, 2021 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-33585883

RESUMO

AIMS: CHA2DS2-VASc score is widely utilized for risk stratification and guiding anticoagulation in patients with atrial fibrillation (AF). Cardiac computed tomography (CCT) routinely performed for pulmonary vein isolation (PVI) can also identify coronary artery calcifications (CAC). We evaluated the frequency and outcomes of incorporating CAC into the CHA2DS2-VASc score in AF patients undergoing PVI. METHODS AND RESULTS: Consecutive patients in a prospective PVI registry during 2014-18 having CCT within 1 year of PVI were studied. Reclassification of CHA2DS2-VASc score and associations between CAC as a binary variable detected on CCT with clinical characteristics, stroke as primary endpoint, death, myocardial infarction, and major adverse cardiovascular events (MACE) were analysed. Amongst 3604 AF patients, 2238 (62.1%) had CAC detected on CCT and was associated with most traditional cardiovascular risk factors. Coronary artery calcification was independently associated with all pre-specified endpoints adjusting for clinical parameters in multivariable analysis. Adjusting for CHA2DS2-VASc score, CAC was associated with stroke (hazards ratio 3.64, 95% confidence interval 1.25-10.6, P = 0.018), death (2.26, 1.29-3.98, P = 0.006), and MACE (2.08, 1.36-3.16, P = 0.001) during 2.8 ± 1.6-year follow-up. Incorporating CAC as a vascular disease parameter of CHA2DS2-VASc score, anticoagulation decision-making would be revised in 723 (20.1%) patients, including an additional 488 (13.5%) patients where anticoagulation would be now indicated. CONCLUSION: Coronary artery calcification is prevalent in AF patients undergoing PVI and independently associated stroke, death and MACE even when adjusted for traditional CHA2DS2-VASc score. Adding CAC as vascular component to the CHA2DS2-VASc score requires further research as it potentially modified the anticoagulation management in 20% of our AF cohort.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/diagnóstico por imagem , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Tomografia Computadorizada por Raios X
15.
Curr Cardiol Rep ; 23(9): 129, 2021 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-34342728

RESUMO

PURPOSE OF REVIEW: In coronavirus disease 2019 (COVID-19), myocardial injury occurs frequently in severe or critically ill hospitalized patients, yet myocarditis is much less common. In this context, revisiting the definition of myocarditis is appropriate with a specific focus on diagnostic and management considerations in patients infected with SARS-CoV-2. RECENT FINDINGS: Pathologic cardiac specimens from patients with COVID-19 suggest a mixed inflammatory response involving lymphocytes and macrophages, and importantly, cellular injury occurs predominantly at the level of pericytes and endothelial cells, less often involving direct myocyte necrosis. In COVID-19, the diagnosis of myocarditis has understandably been based predominantly on clinical criteria, and the number of patients with clinically suspected myocarditis who would meet diagnostic histological criteria is unclear. Echocardiography and cardiac magnetic resonance are important diagnostic tools, although the prognostic implications of abnormalities are still being defined. Importantly, SARS-CoV2 myocarditis should be diagnosed within an appropriate clinical context and should not be based on isolated imaging findings. Therapies in COVID-19 have focused on the major clinical manifestation of pneumonia, but the promotion of viral clearance early in the disease could prevent the development of myocarditis, and further study of immunosuppressive therapies once myocarditis has developed are indicated. A strict and uniform approach is needed to diagnose myocarditis due to SARS-CoV-2 to better understand the natural history of this disease and to facilitate evaluation of potential therapeutic interventions. A methodological approach will also better inform the incidence of COVID-19 associated myocarditis and potential long-term health effects.


Assuntos
COVID-19 , Miocardite , Células Endoteliais , Humanos , Incidência , Miocardite/diagnóstico , Miocardite/epidemiologia , Miocardite/terapia , Prognóstico , RNA Viral , SARS-CoV-2
16.
Curr Cardiol Rep ; 23(7): 90, 2021 06 03.
Artigo em Inglês | MEDLINE | ID: mdl-34081219

RESUMO

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID19) involves the heart, including pericardium. This article reviews the possible pathophysiological mechanisms in pericardial involvement in COVID19 and pericardial manifestations of COVID19. It also summarizes the patients with pericarditis secondary to COVID19 and outlines the contemporary treatment strategies in this patient population. RECENT FINDINGS: A high degree of suspicion is required to identify the pericardial involvement in COVID19 patients. It is proposed that an underlying hyperinflammatory reaction in COVID19 leads to pericardial inflammation. Acute pericarditis with or without myocardial involvement is diagnosed on clinical presentation, serum inflammatory markers, electrocardiogram, and echocardiogram. Multimodality imaging may also have an additional diagnostic value. Patients are usually managed medically, but some patients develop a life-threatening pericardial tamponade necessitating pericardial drainage. Pericardial involvement is an important clinical manifestation of COVID19 requiring a proper workup. Timely diagnosis and a specific management plan based on the presentation and concomitant organ involvement usually lead to a complete recovery.


Assuntos
COVID-19 , Tamponamento Cardíaco , Derrame Pericárdico , Pericardite , Tamponamento Cardíaco/diagnóstico por imagem , Tamponamento Cardíaco/etiologia , Humanos , Pericardite/diagnóstico por imagem , Pericardite/terapia , Pericárdio/diagnóstico por imagem , SARS-CoV-2
17.
Circulation ; 140(24): 1984-1994, 2019 12 10.
Artigo em Inglês | MEDLINE | ID: mdl-31690104

RESUMO

BACKGROUND: Prosthetic valve endocarditis (PVE) is a rare but critical mechanism of valve failure and death after transcatheter and surgical aortic valve replacement (TAVR, SAVR) warranting further analysis in modern aortic valve replacement experience. We characterize the incidence, risk factors, microbiological profile and outcomes of PVE from the PARTNER trials and registries (Placement of Aortic Transcatheter Valve). METHODS: We analyzed a pooled cohort of all patients in PARTNER 1 and PARTNER 2 trials and registries. Patients had severe aortic stenosis, were treated with TAVR or SAVR, and were analyzed with respect to development of PVE. PVE adjudication by a clinical events committee was based on modified Duke Criteria. The incidence, infection timing, organism, and association between PVE and all-cause mortality were analyzed. RESULTS: 8530 patients were included. PVE occurred in 107 cases (5.06 PVE events per 1000 person-years over a mean follow-up of 2.69±1.55 years [95% CI, 4.19-6.12]). The incidence of TAVR-PVE (5.21 PVE per 1000 person-years [95% CI, 4.26-6.38]) was not significantly different from SAVR-PVE (4.10 per 1000 person-years [95% CI, 2.33-7.22]; incident rate ratio, 1.27 [95% CI, 0.70-2.32]; P=0.44). Temporal risk of PVE was similar for TAVR and SAVR, even after adjusting for competing risk of death (hazard ratio, 1.15 [95% CI, 0.58-2.28]; P=0.69). Through multivariable analysis, PVE was associated with baseline cirrhosis (incident rate ratio, 2.86 [95% CI, 1.33-6.16]; P=0.007), pulmonary disease (incident rate ratio, 1.70 [95% CI, 1.16-2.48]; P=0.006), and renal insufficiency (incident rate ratio, 1.71 [95% CI, 1.03-2.83]; P=0.04). Timing of PVE was similar between TAVR and SAVR (<30 days: 4.2% vs 8.3%; 31 days to 1 year: 52.6% vs 66.7%; >1 year: 43.2% vs 25.0%; P=0.28). Staphylococcus occurred more commonly after SAVR (58.3% vs 28.4% in TAVR; P=0.04). PVE was strongly associated with all-cause mortality after endocarditis diagnosis (hazard ratio, 4.4 [95% CI, 3.42-5.72]; P<0.0001). CONCLUSIONS: The widespread adoption of TAVR and application to lower-risk patients makes understanding mechanisms of valve failure increasingly important. PVE is an established mechanism of prosthetic valve failure post-SAVR and TAVR with unclear differences between approaches. We herein demonstrate in the largest trials and registries of TAVR that PVE remains rare, but often fatal, in modern AVR experience and that there is no difference in incidence, predictors, or risk of PVE between TAVR and SAVR. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov. Unique identifiers: NCT00530894 (PARTNER 1), NCT01314313 (PARTNER 1IA), NCT02184442 (PARTNER 1IB), NCT03222141 (PII S3HR), NCT03222128 (PII S3i).


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Endocardite/cirurgia , Implante de Prótese de Valva Cardíaca , Idoso , Idoso de 80 Anos ou mais , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Fatores de Risco , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/métodos
19.
Eur Heart J ; 39(28): 2659-2667, 2018 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-29741615

RESUMO

Aims: In patients randomized to transcatheter or surgical aortic valve replacement (TAVR, SAVR), we sought to determine whether SAVR is associated with worsening right ventricular (RV) function and whether RV deterioration is associated with mortality. Methods and results: In 1376 patients from PARTNERIIA with paired baseline and 30-day core lab echocardiograms, worsening RV function was defined as decline by at least one grade from baseline to 30 days. Our primary outcome was all-cause mortality from 30 days to 2 years. Among 744 patients with TAVR, 62 (8.3%) had worsening RV function, compared with 156 of 632 patients with SAVR (24.7%) (P < 0.0001). In a multivariable model, SAVR [odds ratio (OR) 4.05, 95% confidence interval (CI) 2.55-6.44], a dilated RV (OR 2.38, 95% CI 1.37-4.14), and more than mild tricuspid regurgitation (TR) (OR 2.58, 95% CI 1.25-5.33) were associated with worsening RV function. There were 169 deaths, and patients with worsening RV function had higher all-cause mortality [hazard ratio (HR) 1.98, 95% CI 1.40-2.79]. This association remained robust after adjusting for clinical and echocardiographic variables. Among patients with worsening RV function, there was no mortality difference between TAVR and SAVR (HR 1.16, 95% CI 0.61-2.18). The development of moderate or severe RV dysfunction from baseline normal RV function conferred the worst prognosis (HR 2.87, 95% CI 1.40-5.89). Conclusion: After aortic valve replacement, worsening RV function is more common in patients with baseline RV dilation, more than mild TR, and in patients treated with SAVR. Worsening RV function and the magnitude of deterioration have important prognostic implications.


Assuntos
Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Complicações Pós-Operatórias/epidemiologia , Disfunção Ventricular Direita/epidemiologia , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/mortalidade , Prognóstico , Estudos Prospectivos , Substituição da Valva Aórtica Transcateter , Disfunção Ventricular Direita/mortalidade
20.
J Nucl Cardiol ; 25(5): 1601-1609, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-28224450

RESUMO

BACKGROUND: Coronary artery disease (CAD) accounts for more than half of all cardiovascular events. Stress testing remains the cornerstone for non-invasive assessment of patients with possible or known CAD. Clinical utilization reviews show that most patients presenting for evaluation of stable CAD by stress testing are categorized as low risk prior to the test. Attempts to enhance risk stratification of individuals who are sent for stress testing seem to be more in need today. The present study compares artificial neural networks (ANN)-based prediction models to the other risk models being used in practice (the Diamond-Forrester and the Morise models). METHODS: In our study, we prospectively recruited patients who were 19 years of age or older, and were being evaluated for coronary artery disease with imaging-based stress tests. For ANN, the network architecture employed a systematic method, where the number of neurons is changed incrementally, and bootstrapping was performed to evaluate the accuracy of the models. RESULTS: We prospectively enrolled 486 patients. The mean age of patients undergoing stress test was 55.2 ± 11.2 years, 35% were women, and 12% had a positive stress test for ischemic heart disease. When compared to Diamond-Forrester and Morise risk models, the ANN model for predicting ischemia provided higher discriminatory power (DP)(1.61), had a negative predictive value of 98%, Sensitivity 91% [81%-97%], Specificity 65% [60%-79%], positive predictive value 26%, and a potential 59% reduction of non-invasive imaging. CONCLUSION: The ANN models improved risk stratification when compared to the other risk scores (Diamond-Forrester and Morise) with a 98% negative predictive value and a significant potential reduction in non-invasive imaging tests.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Teste de Esforço/métodos , Redes Neurais de Computação , Medição de Risco/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos
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