Rates, predictors and the impact of cannabis misuse on in-hospital outcomes among patients undergoing percutaneous coronary intervention (from the National Inpatient Sample).

BACKGROUND: Whether cannabis use worsens outcomes in coronary heart disease is unknown and no previous study has evaluated the outcomes for patients who undergo percutaneous coronary intervention (PCI) according to cannabis use. METHODS: We analysed patients in the National Inpatient Sample between 2004 and 2014 who underwent PCI and evaluated rates, predictors and outcomes of patients according to cannabis misuse defined by cannabis abuse or dependence. RESULTS: A total of 7 306 012 patients were included and 32 765 cannabis misusers (0.4%). Cannabis misusers were younger (49.5 vs 64.6 years, P < .001) and were more likely to be male (82.7% vs 66.3%, P < .001). There was also a greater proportion of patients who were of black ethnicity in the cannabis misuse group (27.7% vs 7.9%, P < .001) and fewer elective admissions (7.8% vs 27.6%, P < .001). There was no difference in in-hospital mortality (OR 1.06 95% CI 0.80-1.40, P = .67), bleeding (OR 0.94 95% CI 0.77-1.15, P = .55) and stroke/transient ischaemic attack (OR 1.19 95% CI 0.98-1.45, P = .084) compared with non-cannabis misusers. Cannabis misusers had significantly lower odds of in-hospital vascular complications (OR 0.73 95% CI 0.58-0.90, P = .004). CONCLUSIONS: Our results suggest that cannabis misusers are more likely to be male, of black ethnicity and from the lowest quartile of income, but there was no evidence that cannabis misuse is associated with worse periprocedural outcomes following PCI when controlling for key proxies of health status.

Predictive value of atrial high-rate episodes for arterial stiffness and endothelial dysfunction in dual-chamber pacemaker patients.

BACKGROUND: Various pacing studies have demonstrated an association between right ventricular pacing (RVp) and atrial fibrillation (AF), even after preserving atrioventricular (AV) synchrony. We aimed to assess the interaction between arterial stiffness, endothelial function and atrial high-rate episodes (AHRE) in patients with dual-chamber pacemakers. METHODS: We studied 101 patients with dual-chamber pacemakers incorporated with sophisticated AF detection and therapy algorithms. Macrovascular endothelial dysfunction (ED) was measured by the relative change in aortic augmentation index (AIx), using carotid artery applanation tonometry in response to inhaled salbutamol and sublingual glyceryl trinitrate. Microvascular ED was measured by cutaneous laser Doppler flowmetry (LDF) in response to acetylcholine (Ach, endothelium dependent) and sodium nitroprusside (SNP, endothelium independent). Arterial stiffness was measured using carotid-femoral pulse wave velocity (PWVcf). 'Reservoir pressure' (Pr, MATLAB) describes the aortic 'cushioning' properties. RESULTS: Mean age of the cohort was 72.1 ± 10.8 years; men (n = 69) 68.3%. Of 101 dual-chamber pacemaker patients, 23.8% (n = 24) had AHRE detected on the baseline pacemaker interrogation. PP, PWVcf and Pr were significantly higher in patients with AHRE compared with those without AHRE. The change in AIx with salbutamol (∆% AIx Sal) and acetylcholine-induced changes in LDF (Δ%LDF Ach) were lower in patients with AHRE compared with those without AHRE. In patients with AHRE, significant correlations were observed between%Vp and Δ%LDF Ach (P = 0.03) as well as between PP and Δ%LDF Ach (P = 0.05). On multivariate analysis, PP, Pr, PWVcf and ∆% AIx Sal remained as independent predictors of AHRE. CONCLUSION: In patients with dual-chamber pacemakers, both higher arterial stiffness and greater endothelial dysfunction independently predicted AHRE, irrespective of the degree (or mode) of pacing. Arterial stiffness and endothelial dysfunction may potentially contribute to the perpetuation of atrial arrhythmias beyond the adverse effects of ventricular pacing alone.

Outcomes Following Percutaneous Coronary Intervention in Saphenous Vein Grafts With and Without Embolic Protection Devices.

OBJECTIVES: The aim of this study was to describe the early (inpatient and 30-day) and late (1-year) outcomes of percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs), with and without the use of embolic protection devices (EPD), in a large, contemporary, unselected national cohort from the database of the British Cardiovascular Intervention Society. BACKGROUND: There are limited, and discrepant, data on the clinical benefits of the adjunctive use of EPDs during PCI to SVGs in the contemporary era. METHODS: A longitudinal cohort of patients (2007 to 2014, n = 20,642) who underwent PCI to SVGs in the British Cardiovascular Intervention Society database was formed. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 2 groups: no EPD (PCI to SVGs without EPDs, n = 17,730) and EPD (PCI to SVGs with EPDs, n = 2,912). RESULTS: Patients in the EPD group were older, had more comorbidities, and had a higher prevalence of moderate to severe left ventricular systolic dysfunction. Mortality was lower in the EPD group during hospital admission (0.70% vs. 1.29%; p = 0.008) and at 30 days (1.44% vs. 2.01%; p = 0.04) but similar at 1 year (6.22% vs. 6.01%; p = 0.67). Following multivariate analyses, no significant difference in mortality was observed during index admission (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.42 to 1.19; p = 0.19), at 30 days (OR: 0.87; 95% CI: 0.60 to 1.25; p = 0.45), and at 1 year (OR: 0.92; 95% CI: 0.77 to 1.11; p = 0.41), along with similar rates of in-hospital major adverse cardiovascular events (OR: 1.16; 95% CI: 0.83 to 1.62; p = 0.39) and stroke (OR: 0.68; 95% CI: 0.20 to 2.35; p = 0.54). In propensity score-matched analyses, lower inpatient mortality was observed in the EPD group (OR: 0.46; 95% CI: 0.13 to 0.80; p = 0.002), although the adjusted risk for the periprocedural no-reflow or slow-flow phenomenon was higher in patients in whom EPDs were used (OR: 2.16; 95% CI: 1.71 to 2.73; p < 0.001). CONCLUSIONS: In this contemporary cohort, EPDs were used more commonly in higher risk patients but were associated with similar clinical outcomes in multivariate analyses. Lower inpatient mortality was observed in the EPD group in univariate and propensity score-matched analyses.

Major Bleeding and Adverse Outcome following Percutaneous Coronary Intervention.

Advances in anti-thrombotic and anti-platelet therapies have improved outcomes in patients undergoing percutaneous coronary interventions (PCIs) through a reduction in ischaemic events, at the expense of peri-procedural bleeding complications. These may occur through either the access site through which the PCI was performed or through non-access-related sites. There are currently over 10 definitions of major bleeding events consisting of clinical events, changes in laboratory parameters and clinical outcomes, where different definitions will differentially influence the reported incidence of major bleeding events. Use of different major bleeding definitions has been shown to change the reported outcome of a number of therapeutic strategies in randomised controlled trials but as yet a universal bleeding definition has not gained widespread adoption in assessing the efficacy of such therapeutic interventions. Major bleeding complications are independently associated with adverse mortality and major adverse cardiovascular event (MACE) outcomes, irrespective of the definition of major bleeding used, with the worst outcomes associate with non-access-site related bleeds. We consider the mechanisms through which bleeding complications may affect longer-term outcomes and discuss bleeding avoidance strategies, including access site choice, pharmacological considerations and formal bleeding risk assessment to minimise such bleeding events.

Atrial fibrillation, arrhythmia burden and thrombogenesis.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, which is associated with substantial risk of stroke and thromboembolism. The epidemiology and health care burden associated with AF have increased significantly, and will continue to rise. Until recently, the concept and/or quantification of disease burden in AF tended to be ignored nor its consequences recognised. However, AF burden can now be assessed more accurately and reliably with the aid of cardiac rhythm management devices. There is a lot of interest on the issue of 'how much AF is needed to cause thromboembolism?' and this article summarises the available literature on this topic, with the aim of providing a better understanding of the clinical importance of device-detected atrial high-rate episodes and an overview of arrhythmia burden on thrombogenesis and clinical thromboembolism.

Assessment of left atrial volume: a focus on echocardiographic methods and clinical implications.

Left atrial enlargement is an important predictor of cardiovascular events such as atrial fibrillation, stroke, heart failure and mortality. A number of methods of left atrial size assessment by echocardiography have been reported, from the simple antero-posterior diameter in the parasternal long axis view to the more complex ellipsoid, area-length and Simpson's method of estimating left atrial volume. These different methods of left atrial size assessment, their clinical implications and some common pitfalls are discussed in this review.

Insights from the dabigatran versus warfarin in patients with atrial fibrillation (RE-LY) trial.

Oral anticoagulants such as warfarin have been used widely for the treatment of venous thromboembolism and stroke prevention in atrial fibrillation (AF) patients. Warfarin has significant limitations and also requires frequent monitoring. Thus, there is an unmet need, with the quest for alternative oral anticoagulants with stable pharmacokinetics and pharmacodynamics that do not need monitoring. The paper under evaluation provides us with up-to-date information on the safety and efficacy of a new oral anticoagulant, dabigatran, compared with warfarin for stroke prevention in AF patients.

The prevention and treatment of venous thromboembolism with LMWHs and new anticoagulants.

As the risk factors for thrombosis are becoming better understood, so is the need for anticoagulation. The inherent difficulties with warfarin are such that a low-molecular-weight heparin (LMWH) is often the key therapeutic. However, there are several different species of LMWH available to the practitioner, which leads to the need for an objective guide. New agents are coming onto the marketplace, and these may supersede both warfarin and the heparins. The current report will review the biochemistry and pharmacology of different LWMHs and identify which are more suitable for the different presentations of venous thromboembolism. It will conclude with a brief synopsis of new agents which may supersede warfarin and heparin.

Clinical outcomes of acute stroke patients with atrial fibrillation.

Evaluation of: Kazumi K, Yasuyuki I, Kensaku S, Takeshi I, Shinji Y, Junya A. IV-tPA therapy in acute stroke patients with atrial fibrillation. J. Neurol. Sci. 276(1-2), 6-8 (2009). Stroke is the leading cause of disability and the second most common cause of death worldwide. The care and treatment of stroke patients have evolved over the last two decades, with increasing use of thrombolysis (e.g., intravenous tissue plasminogen activator in acute stroke patients), which has improved survival and recovery following stroke. The article under evaluation offers a greater insight into the relationship of clinical outcome of stroke and atrial fibrillation after tissue plasminogen activator infusion.

Burden of atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia seen in clinical practice and has attracted much attention due to its association with a substantial mortality and morbidity, particularly from stroke, thromboembolism and heart failure. This Editorial Commentary provides a brief overview of the clinical, economic and epidemiological burden of AF, particularly in the context of hospital readmission of patients with AF. It concludes that further studies on identifying factors and reasons for readmission in AF patients are therefore warranted. Understanding the patterns and factors that are responsible for readmission would help clinicians optimise the treatment strategies for AF patients and in turn improve quality of care and potentially lessen the large burden of AF on healthcare systems.

Acute management of atrial fibrillation.

Acute atrial fibrillation (AF) is the most common cardiac rhythm encountered in clinical practice and is commonly seen in acutely ill patients in critical care. In the latter setting, AF may have two main clinical sequelae: (1) haemodynamic instability and (2) thromboembolism. The approach to the management of AF can broadly be divided into a rate control strategy or a rhythm control strategy, and is largely driven by symptom assessment and functional status. A crucial part of AF management requires the appropriate use of thromboprophylaxis. In patients who are haemodynamically unstable with AF, urgent direct current cardioversion should be considered. Apart from electrical cardioversion, drugs are commonly used, and Class I (flecainide, propafenone) and Class III (amiodarone) antiarrhythmic drugs are more likely to revert AF to sinus rhythm. Beta blockers and rate limiting calcium blockers, as well as digoxin, are often used in controlling heart rate in patients with acute onset AF. The aim of this review article is to provide an overview of the management of AF in the critical care setting.