RESUMO
OBJECTIVES: To develop a tool including exercise electrocardiography (ExECG) for patient-specific clinical likelihood estimation of patients with suspected obstructive coronary artery disease (CAD). METHODS: An ExECG-weighted clinical likelihood (ExECG-CL) model was developed in a training cohort of patients with suspected obstructive CAD undergoing ExECG. Next, the ExECG-CL model was applied in a CAD validation cohort undergoing ExECG and clinically driven invasive coronary angiography and a prognosis validation cohort and compared with the risk factor-weighted clinical likelihood (RF-CL) model for obstructive CAD discrimination and prognostication, respectively.In the CAD validation cohort, obstructive CAD was defined as >50% diameter stenosis on invasive coronary angiography. For prognosis, the endpoint was non-fatal myocardial infarction and death. RESULTS: The training cohort consisted of 1214 patients (mean age 57 years, 57% males). In the CAD (N=408; mean age 55 years, 53% males) and prognosis validation (N=3283; mean age 57 years, 57% males) cohorts, 11.8% patients had obstructive CAD and 4.4% met the endpoint. In the CAD validation cohort, discrimination of obstructive CAD was similar between the ExECG-CL and RF-CL models: area under the receiver-operating characteristic curves 83.1% (95% CIs 77.5% to 88.7%) versus 80.7% (95% CI 74.6% to 86.8%), p=0.14. In the ExECG-CL model, more patients had very low (≤5%) clinical likelihood of obstructive CAD compared with the RF-CL (42.2% vs 36.0%, p<0.01) where obstructive CAD prevalence and event risk remained low. CONCLUSIONS: ExECG incorporated into a clinical likelihood model improves reclassification of patients to a very low clinical likelihood group with very low prevalence of obstructive CAD and favourable prognosis.
Assuntos
Doença da Artéria Coronariana , Infarto do Miocárdio , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Teste de Esforço , Eletrocardiografia , Angiografia Coronária , Fatores de Risco , Medição de Risco , Valor Preditivo dos TestesAssuntos
Insuficiência Cardíaca/epidemiologia , Obesidade/complicações , Guias de Prática Clínica como Assunto/normas , Doença Aguda , Atenção à Saúde/economia , Atenção à Saúde/normas , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Mortalidade Hospitalar , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Hiponatremia/complicações , Hiponatremia/epidemiologia , Unidades de Terapia Intensiva/normas , Obesidade/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Readmissão do Paciente , Prognóstico , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Sistema de Registros , Fatores de Risco , Volume Sistólico/fisiologiaRESUMO
BACKGROUND: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). OBJECTIVES: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. METHODS: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. RESULTS: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). CONCLUSIONS: iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.
Assuntos
Estenose Coronária/complicações , Vasos Coronários/diagnóstico por imagem , Reserva Fracionada de Fluxo Miocárdico , Idoso , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização MiocárdicaAssuntos
Doenças Cardiovasculares/prevenção & controle , Meios de Comunicação , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Disseminação de Informação/métodos , Educação de Pacientes como Assunto , Recusa do Paciente ao Tratamento , Acesso à Informação , Doenças Cardiovasculares/mortalidade , Conflito de Interesses , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Marketing de Serviços de Saúde , Segurança do Paciente , Medição de Risco , Fatores de RiscoRESUMO
Worldwide, each year more than 7 million people experience myocardial infarction, in which one-year mortality rates are now in the range of 10%, but vary with patient characteristics. The consequences are even more dramatic: among patients who survive, 20% suffer a second cardiovascular event in the first year and approximately 50% of major coronary events occur in those with a previous hospital discharge diagnosis of ischaemic heart disease. The people behind these numbers spur this call for action. Prevention after myocardial infarction is crucial to reduce risk and suffering. Evidence-based interventions include optimal medical treatment with anti-platelets and statins, achievement of blood pressure, lipid and blood glucose targets, and appropriate lifestyle changes. The European Society of Cardiology and its constituent bodies are determined to embrace this challenge by developing a consensus document in which the existing gaps for secondary prevention strategies are reviewed. Effective interventions in relation to the patients, healthcare providers and healthcare systems are proposed and discussed. Finally, innovative strategies in hospital as well as in outpatient and long-term settings are endorsed.
Assuntos
Atenção à Saúde/organização & administração , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/prevenção & controle , Prevenção Secundária/normas , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/fisiologia , Reabilitação Cardíaca/métodos , Efeitos Psicossociais da Doença , Exercício Físico/fisiologia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Mortalidade/tendências , Infarto do Miocárdio/epidemiologia , Inibidores da Agregação Plaquetária/uso terapêutico , Fatores de Risco , Comportamento de Redução do Risco , Prevenção Secundária/métodosRESUMO
BACKGROUND: Cardiopulmonary exercise testing (CPET) gained importance in the prognostic assessment of especially patients with heart failure (HF). A meaningful prognostic parameter for early mortality in HF is exercise oscillatory ventilation (EOV). This abnormal respiratory pattern is recognized by hypo- and hyperventilation during CPET. Up until now, assessment of EOV is mainly done upon visual agreement or manual calculation. The purpose of this research was to automate the interpretation of EOV so this prognostic parameter could be readily investigated during CPET. METHODS AND RESULTS: Preliminary, four definitions describing the original characteristics of EOV, were selected and integrated in the "Ventilatory Oscillations during Exercise-tool" (VOdEX-tool), a graphical user interface that allows automate calculation of EOV. A Discrete Meyer Level 2 wavelet transformation appeared to be the optimal filter to apply on the collected breath-by-breath minute ventilation CPET data. Divers aspects of the definitions i.e. cycle length, amplitude, regularity and total duration of EOV were combined and calculated. The oscillations meeting the criteria were visualised. Filter methods and cut-off criteria were made adjustable for clinical application and research. The VOdEX-tool was connected to a database. CONCLUSIONS: The VOdEX-tool provides the possibility to calculate EOV automatically and to present the clinician an overview of the presence of EOV at a glance. The computerized analysis of EOV can be made readily available in clinical practice by integrating the tool in the manufactures existing CPET software. The VOdEX-tool enhances assessment of EOV and therefore contributes to the estimation of prognosis in especially patients with HF.
Assuntos
Teste de Esforço/métodos , Teste de Esforço/tendências , Desenvolvimento Industrial/tendências , Estudo de Prova de Conceito , Ventilação Pulmonar/fisiologia , Interface Usuário-Computador , HumanosAssuntos
Angina Pectoris/diagnóstico , Angina Pectoris/etiologia , Angiografia por Tomografia Computadorizada/métodos , Angiografia por Tomografia Computadorizada/normas , Angiografia Coronária/métodos , Angiografia Coronária/normas , Doença das Coronárias/diagnóstico , Análise Custo-Benefício , Ecocardiografia sob Estresse/normas , Eletrocardiografia/normas , Teste de Esforço/normas , Humanos , Isquemia Miocárdica/complicações , Revascularização Miocárdica/métodos , Fatores de Risco , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) remains a relatively frequent and life-limiting complication. However, the most prognostically discriminative (and therefore preferred) technique of AR evaluation after TAVI is not yet clearly defined. The aim of this study was to compare angiographic, echocardiographic and hemodynamic assessment of AR after TAVI in relation to one year outcome. METHODS AND RESULTS: In this single center prospective cohort study, angiography (AR grading), echocardiography (AR quantification using color Doppler flow mapping) and invasive hemodynamics (AR index) were assessed before and after TAVI. All patients were followed up to at least one year. A total of 111 consecutive (very) high-risk patients with severe, symptomatic aortic valve stenosis underwent TAVI. No concordant relation could be demonstrated between angiographic, echocardiographic and invasive assessment of AR after TAVI. AR index <25 post TAVI was significantly influenced by left ventricular posterior wall thickness (odds ratio: 1.276, p=0.030) and AR index pre TAVI (odds ratio: 0.948, p=0.019). Neither angiographic nor hemodynamic AR assessments were able to discriminate between good or significantly decreased one year survival. In contrast, color Doppler flow mapping of AR after TAVI was highly reproducible, and able to differentiate between good or significantly decreased one year survival (AR grades 0-I: one year survival 87% vs. AR grades II-III-IV: one year survival 68%, p=0.035). CONCLUSION: Echocardiography using color Doppler flow mapping is the preferred technique to assess prognostically relevant AR after TAVI.
Assuntos
Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/etiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Angiografia/métodos , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Estudos de Coortes , Ecocardiografia/métodos , Ecocardiografia Doppler em Cores , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/métodosRESUMO
PURPOSE: Peripheral blood (PB) admixture should be minimized during numerical and functional, as well as cytokinetic analysis of bone marrow (BM) aspirates for research purposes. Therefore, purity assessment of the BM aspirate should be performed in advance. We investigated whether bone matrix vesicle (BMV)-bound bone alkaline phosphatase (ALP) could serve as a marker for the purity of BM aspirates. RESULTS: Total ALP activity was significantly higher in BM serum (97 (176-124)U/L, median (range)) compared to PB serum (63 (52-73)U/L, p < 0.001). Agarose gel electrophoresis showed a unique bone ALP fraction in BM, which was absent in PB. Native polyacrylamide gel electrophoresis revealed the high molecular weight of this fraction, corresponding with membrane-bound ALP from bone matrix vesicles (BMV), as evidenced by electron microscopy. A serial PB admixture experiment of bone cylinder supernatant samples, rich in BMV-bound ALP, confirmed the sensitivity of this proposed quality assessment method. Furthermore, a BMV ALP fraction of ≥ 15% is suggested as cut-off value for minimal BM quality. Moreover, the BM purity declines rapidly with larger aspirated BM volumes. CONCLUSION: The exclusive presence of BMV-bound ALP in BM could serve as a novel marker to assess purity of BM aspirates.
Assuntos
Fosfatase Alcalina/análise , Biópsia por Agulha/normas , Transplante de Medula Óssea , Medula Óssea/fisiologia , Matriz Óssea/enzimologia , Idoso , Fosfatase Alcalina/classificação , Fosfatase Alcalina/metabolismo , Medula Óssea/ultraestrutura , Matriz Óssea/ultraestrutura , Procedimentos Cirúrgicos Cardíacos , Eletroforese em Gel de Poliacrilamida , Feminino , Humanos , Leucócitos Mononucleares/citologia , Leucócitos Mononucleares/enzimologia , Masculino , Microscopia Eletrônica , Pessoa de Meia-Idade , Ligação Proteica , Controle de Qualidade , Transplante AutólogoRESUMO
AIMS: The present observational case-control study assessed the cost-effectiveness of contemporary vascular closure devices (VCDs) for the prevention of vascular complications in an all-comers transfemoral percutaneous coronary intervention (PCI) population. METHODS AND RESULTS: A total of 8,292 consecutive PCI patients were enrolled from a single-centre prospective registry from January 2005 to December 2010. VCDs were available from July 2007 and, from that time point, VCDs were implanted in 1,780 of the 5,394 patients (33%). Vascular complications occurred in 221 (2.7%) patients. The use of VCDs was independently associated with a 53% risk reduction (OR 0.47, 95% CI: 0.3-0.7) in vascular complications (3.0% vs. 1.5%) and with a 65% risk reduction (IRR 0.37, 95% CI: 0.32-0.43) in the post-PCI length of hospital stay (LOS) (mean 2.8 vs. 1.5 days). Mainly due to the reduced LOS, the patients with VCDs accrued vascular direct medical costs (VCD, diagnosis and treatment of vascular complications, post-PCI LOS) that were on average 498 less than those accrued by the non-VCD patients. The cost-effectiveness was present across all vascular risk profiles. CONCLUSIONS: In this large, all-comers transfemoral PCI population, the use of VCDs was independently associated with a reduction in the rate of vascular complications and the post-PCI length of hospital stay and proved to be cost-saving across all vascular risk profiles.
Assuntos
Artéria Femoral , Hemorragia/economia , Hemorragia/prevenção & controle , Técnicas Hemostáticas/economia , Técnicas Hemostáticas/instrumentação , Custos Hospitalares , Intervenção Coronária Percutânea/economia , Dispositivos de Acesso Vascular/economia , Idoso , Bélgica , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , Redução de Custos , Análise Custo-Benefício , Feminino , Humanos , Tempo de Internação/economia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Punções , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Pulse wave velocity (PWV) of the arterial system is a very important parameter to evaluate cardiovascular health. Currently, however, there is no golden standard for PWV measurement. Digital image correlation (DIC) was used for full-field time-resolved assessment of displacement, velocity, acceleration, and strains of the skin in the neck directly above the common carotid artery. By assessing these parameters, propagation of the pulse wave could be tracked, leading to a new method for PWV detection based on DIC. The method was tested on five healthy subjects. As a means of validation, PWV was measured with ultrasound (US) as well. Measured PWV values were between 3.68 and 5.19 m/s as measured with DIC and between 5.14 and 6.58 m/s as measured with US, with a maximum absolute difference of 2.78 m/s between the two methods. DIC measurements of the neck region can serve as a test base for determining a robust strategy for PWV detection, they can serve as reference for three-dimensional fluid-structure interaction models, or they may even evolve into a screening method of their own. Moreover, full-field, time-resolved DIC can be adapted for other applications in biomechanics.
Assuntos
Processamento de Imagem Assistida por Computador/métodos , Microscopia/instrumentação , Análise de Onda de Pulso , Rigidez Vascular , Animais , Artérias/patologia , Automação , Materiais Biocompatíveis/química , Fenômenos Biomecânicos , Calibragem , Artéria Carótida Primitiva/patologia , Humanos , Imageamento Tridimensional , Luz , Microscopia/métodos , Movimento , Pressão , Pele/patologia , Processos Estocásticos , Propriedades de Superfície , UltrassonografiaRESUMO
AIMS: This study aimed to validate automatic intravascular optical coherence tomography (IVOCT) analysis for the evaluation of neointimal coverage in response to stent implantation. METHODS AND RESULTS: Fourteen stented segments in common iliac arteries, acquired from a total of seven adult male New Zealand White rabbits, were interrogated in vivo by IVOCT. Durable polymer everolimus-eluting stents (EES; Xience V, Abbott Vascular, Santa Clara, CA, USA) were used exclusively. Comparison with histology was made in a total of 63 pairs of images, where neointimal thickness over corresponding individual stent struts was assessed. A high correlation coefficient (R = 0.85, P < 0.001) was obtained by comparing automatic IVOCT analysis with histology. Moreover, Bland-Altman statistics showed good limits of agreement (LOAs) of ±45 µm, with an average difference of -10 µm. In addition, manual IVOCT assessment presented very similar results when compared with histology (R = 0.83, P < 0.001 and LOA = ±48 µm with an average difference of -8 µm). Therefore, a very high correlation value was found, comparing manual to automatic IVOCT measurements (R = 0.95, P < 0.001) together with good LOAs (±27 µm) and an average difference of -2 µm. CONCLUSION: The results of the study suggest that automatic IVOCT analysis is a reliable and accurate tool able to speed up current IVOCT analysis procedures. This would potentially allow for a better integration of IVOCT in clinical practice and clinical studies assessing vascular response to stent implantation in a large series of patients.
Assuntos
Stents Farmacológicos , Neointima/patologia , Tomografia de Coerência Óptica/métodos , Animais , Artéria Ilíaca/patologia , Processamento de Imagem Assistida por Computador , Masculino , Modelos Animais , CoelhosRESUMO
BACKGROUND: Two-dimensional transthoracic echocardiography (2DTTE) remains the first-line diagnostic imaging tool to assess primary mitral regurgitation although cardiovascular magnetic resonance (CMR) has proven to establish left ventricular function more accurately and might evaluate mitral regurgitation severity more reliably. We sought to compare routine evaluation of left ventricular function and mitral regurgitation severity by 2DTTE with assessment by CMR in moderate to severe primary mitral regurgitation without overt left ventricular dysfunction. METHODS: We prospectively included 38 patients (79% of male, age 57 ± 14 years) with at least moderate primary mitral regurgitation, a left ventricular ejection fraction ≥60% and a left ventricular end-systolic diameter ≤45 mm. Patients with evidence of coronary artery disease, arrhythmias or significant concomitant valvular disease were excluded. All patients were scheduled for 2DTTE and CMR. RESULTS: Left ventricular end-diastolic and end-systolic volumes were significantly underestimated by 2DTTE in comparison with CMR, although there was a strong correlation (Pearson r = 0.81, p < 0.00001 and r = 0.7, p < 0.00001, respectively). Measurement of the regurgitant orifice was similar between 2DTTE PISA method and planimetry by CMR (47 ± 24 vs. 42 ± 16 mm2, p = 0.12) with a strong correlation between both imaging techniques (Pearson r = 0.76, p < 0.0001). By contrast, assessment of the regurgitant volume by 2DTTE and by phase contrast velocity mapping by CMR showed poor agreement. CONCLUSIONS: In moderate to severe primary mitral regurgitation without overt left ventricular dysfunction, 2DTTE significantly underestimates left ventricular remodelling in comparison to CMR. Measurement of the regurgitant orifice with planimetry by CMR shows good agreement with the PISA method by 2DTTE and thus may be a valuable alternative to assess mitral regurgitation severity.
Assuntos
Ecocardiografia/métodos , Imagem Cinética por Ressonância Magnética/métodos , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico por imagem , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/etiologia , Bélgica , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: Considering the sizeable cost of transcatheter aortic valve implantation (TAVI) and conflicting cost-effectiveness studies, it is useful to gain more insight into the cost structure of the TAVI hospitalization. This study provides such a cost analysis and starts to evaluate options to soften the hospitalization cost burden in order to make TAVI economically more feasible. METHODS: Costs forTAVI hospitalization in the University Hospital of Antwerp were analysed uni- and bivariately. Graphical and numerical displays of the data are supplemented with the non-parametric Wilcoxon rank sum statistic and Spearman rank rho correlation. RESULTS: Overall, 47 percent of the cost could be attributed to the implanted valve and 21 percent was accounted for by the room costs. Further, costs seemed highly insensitive to pre-existing patient characteristics. Only patients with pulmonary hypertension were characterized with systematically higher costs (Wilcoxon rank sum P-value of 0.049). Complications related to TAVI had a significant upward impact on the costs and there was also evidence for a learning effect on total costs. CONCLUSIONS: In general the analyses showed that only limited options remain for cost reduction of the TAVI hospitalization cost. The most promising option is the reduction of the valve price. Avoidance of complications is hard to achieve given the current state of the art although this would significantly reduce overall costs.
Assuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco/economia , Implante de Prótese de Valva Cardíaca/economia , Preços Hospitalares/estatística & dados numéricos , Hospitalização/economia , Hospitais Universitários/economia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/economia , Bélgica , Análise Custo-Benefício , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos RetrospectivosRESUMO
The association of obesity with noncommunicable diseases, such as cardiovascular complications and diabetes, is considered a major threat to the management of health care worldwide. Epidemiological findings show that childhood obesity is rapidly rising in Western society, as well as in developing countries. This pandemic is not without consequences and can affect the risk of future cardiovascular disease in these children. Childhood obesity is associated with endothelial dysfunction, the first yet still reversible step towards atherosclerosis. Advanced research techniques have added further insight on how childhood obesity and associated comorbidities lead to endothelial dysfunction. Techniques used to measure endothelial function were further brought to perfection, and novel biomarkers, including endothelial progenitor cells, were discovered. The aim of this paper is to provide a critical overview on both in vivo as well as in vitro markers for endothelial integrity. Additionally, an in-depth description of the mechanisms that disrupt the delicate balance between endothelial damage and repair will be given. Finally, the effects of lifestyle interventions and pharmacotherapy on endothelial dysfunction will be reviewed.
Assuntos
Endotélio Vascular/fisiopatologia , Obesidade Infantil/fisiopatologia , Obesidade Infantil/terapia , Criança , Endotélio Vascular/patologia , Humanos , Obesidade Infantil/patologiaRESUMO
Stroke is a devastating complication after transcatheter aortic valve implantation (TAVI) and might partially be related to cardiac embolization. The aim of this single-center prospective study was to determine the incidence of intracardiac thrombi and left atrial spontaneous echo contrast (SEC), both known predictors of cardiac embolic stroke, in patients referred for potential TAVI. One hundred four consecutive patients with severe symptomatic aortic valve stenosis and at high or very high risk for surgery were included and underwent transesophageal echocardiography. In 11 patients (10.6%), intracardiac thrombi were detected, and 25 patients (24%) showed dense grade 2 SEC. Atrial fibrillation (p <0.0001), diastolic dysfunction (p = 0.0005), and atrial size (p = 0.0038) were related to the presence of intracardiac thrombus and/or dense SEC on multivariate analysis. In conclusion, the incidence of intracardiac thrombi and dense SEC in (very) high-risk patients with severe aortic valve stenosis referred for potential TAVI is high and can accurately be detected using transesophageal echocardiography. Systematic thromboembolic evaluation using transesophageal echocardiography is thus recommended in patients referred for TAVI.
Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Cateterismo Cardíaco , Ecocardiografia Transesofagiana/métodos , Próteses Valvulares Cardíacas , Medição de Risco/métodos , Tromboembolia/epidemiologia , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Bélgica/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Prognóstico , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Tromboembolia/diagnóstico por imagem , Tromboembolia/etiologiaAssuntos
Doenças Cardiovasculares/prevenção & controle , Adulto , Idoso , Anti-Hipertensivos/uso terapêutico , Biomarcadores , Pressão Sanguínea/fisiologia , Cardiologia , Fármacos Cardiovasculares/uso terapêutico , Doença Crônica/prevenção & controle , Atenção à Saúde , Diabetes Mellitus Tipo 2/prevenção & controle , Angiopatias Diabéticas/prevenção & controle , Diagnóstico por Imagem , Dieta , Combinação de Medicamentos , Diagnóstico Precoce , Registros Eletrônicos de Saúde , Medicina Baseada em Evidências , Exercício Físico/fisiologia , Feminino , Medicina Geral , Promoção da Saúde , Hospitalização , Humanos , Hipercolesterolemia/complicações , Hipercolesterolemia/prevenção & controle , Hipertensão/complicações , Hipertensão/prevenção & controle , Estilo de Vida , Lipídeos/sangue , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Papel do Profissional de Enfermagem , Obesidade/complicações , Obesidade/prevenção & controle , Seleção de Pacientes , Papel do Médico , Atenção Primária à Saúde/organização & administração , Prognóstico , Medição de Risco , Comportamento de Redução do Risco , Autocuidado , Fumar/efeitos adversos , Abandono do Hábito de Fumar/métodos , Prevenção do Hábito de Fumar , Fatores Socioeconômicos , Estresse Psicológico/complicações , Estresse Psicológico/prevenção & controleRESUMO
BACKGROUND: Circulating endothelial microparticles (EMP) reflect the condition of the endothelium and are of increasing interest in cardiovascular and inflammatory diseases. Recently, increased numbers of EMP following oral fat intake, possibly due to acute endothelial injury, have been reported. On the other hand, the direct interference of lipids with the detection of EMP has been suggested. This study aimed to investigate the effect of lipid-rich solutions, commonly administered in clinical practice, on the detection, both in vitro and in vivo, of EMP. METHODS: For the in vitro assessment, several lipid-rich solutions were added to whole blood of healthy subjects (nâ=â8) and patients with coronary heart disease (nâ=â5). EMP (CD31+/CD42b-) were detected in platelet poor plasma by flow cytometry. For the in vivo study, healthy volunteers were evaluated on 3 different study-days: baseline evaluation, following lipid infusion and after a NaCl infusion. EMP quantification, lipid measurements and peripheral arterial tonometry were performed on each day. RESULTS: Both in vitro addition and in vivo administration of lipids significantly decreased EMP (from 198.6 to 53.0 and from 272.6 to 90.6/µl PPP, respectively, pâ=â0.001 and pâ=â0.012). The EMP number correlated inversely with the concentration of triglycerides, both in vitro and in vivo (râ=â-0.707 and -0.589, p<0.001 and pâ=â0.021, respectively). The validity of EMP as a marker of endothelial function is supported by their inverse relationship with the reactive hyperemia index (râ=â-0.758, pâ=â0.011). This inverse relation was confounded by the intravenous administration of lipids. CONCLUSION: The confounding effect of high circulating levels of lipids, commonly found in patients that receive intravenous lipid-based solutions, should be taken into account when flow cytometry is used to quantify EMP.
Assuntos
Micropartículas Derivadas de Células/fisiologia , Endotélio Vascular/fisiologia , Lipídeos/sangue , Biomarcadores , Estudos de Casos e Controles , Doença da Artéria Coronariana/patologia , Citometria de Fluxo , Humanos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: B-type natriuretic peptide (BNP) is used as prognostic marker in acute coronary syndromes. It is unknown whether BNP reflects the amount of jeopardised myocardium in the initial phase of acute ST-elevation myocardial infarction (STEMI). METHODS: Patients admitted for percutaneous coronary intervention in the acute phase of STEMI were studied. Samples for BNP were taken at the time of coronary intervention and were correlated with the amount of jeopardised myocardium. This was defined on coronary angiography as the vascular region distal to the infarct-related lesion and was expressed by a vascular score. The extend of epicardial injury on ECG was evaluated by: summation of ST-segment elevation in the infarct-related leads, number of leads with > or = 1 mm ST-segment elevation and number of leads with > or = 1 mm ST-segment depression/elevation. RESULTS: A total of 113 patients (median age (25th, 75th percentile) 61 (54, 69)) were studied. Median BNP was 27 pg/ml (12, 62) and was assessed 225 min (150, 315) after onset of pain. There was no significant relation between BNP and vascular score (r=0.026, p=0.8). The only independent variable of BNP was time delay between onset of pain and sample collection. Stepwise regression identified the extent of ST-segment elevation as independent predictor of the vascular score. CONCLUSION: At initial presentation of STEMI, BNP measurement does not allow a correct prediction of jeopardised myocardium. In contrast, ST-segment analysis, in particularly the extent of ST-segment elevation, provides useful information about the extent of jeopardised myocardium.