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BACKGROUND: Dual antiplatelet therapy (DAPT) reduces ischemic events but increases bleeding risk, especially in patients with high bleeding risk (HBR). This study aimed to compare outcomes of abbreviated versus standard DAPT strategies in patients with HBR with acute coronary syndrome undergoing percutaneous coronary intervention. METHODS AND RESULTS: Patients from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-Based Bare in Heart Disease Evaluated According to Recommended Therapies) registry with at least 1 HBR criterion who underwent percutaneous coronary intervention for acute coronary syndrome were identified and included. Patients were divided into 2 groups based on their planned DAPT time at discharge: 12-month DAPT or an abbreviated DAPT strategy and matched according to their prescribed P2Y12 inhibitor at discharge. The primary outcome assessed was time to net adverse clinical events at 1 year, which encompassed cardiac death, myocardial infarction, ischemic stroke, or clinically significant bleeding. Time to major adverse cardiovascular events and the individual components of net adverse clinical events were considered secondary end points. A total of 4583 patients were included in each group. The most frequently met HBR criteria was age older than 75 years (65.6%) and Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy score ≥25 (44.6%) in the standard DAPT group and oral anticoagulant therapy (79.6%) and age 75 years and older (55.2%) in the abbreviated DAPT group. There was no statistically significant difference in net adverse clinical events (12.9% versus 13.1%; hazard ratio [HR], 0.99 [95% CI, 0.88-1.11], P=0.83), major adverse cardiovascular events (8.6% versus 7.9%; HR, 1.08 [95% CI, 0.94-1.25]), or their components between groups. The results were consistent among all of the investigated subgroups. CONCLUSIONS: In patients with HBR undergoing percutaneous coronary intervention due to acute coronary syndrome, abbreviated DAPT was associated with comparable rates of net adverse clinical events and major adverse cardiovascular events to a DAPT duration of 12 months.
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Síndrome Coronario Agudo , Terapia Antiplaquetaria Doble , Hemorragia , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Sistema de Registros , Humanos , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/complicaciones , Intervención Coronaria Percutánea/efectos adversos , Masculino , Femenino , Anciano , Terapia Antiplaquetaria Doble/efectos adversos , Terapia Antiplaquetaria Doble/métodos , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Persona de Mediana Edad , Factores de Tiempo , Suecia/epidemiología , Factores de Riesgo , Medición de Riesgo , Resultado del Tratamiento , Esquema de Medicación , Anciano de 80 o más Años , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , Antagonistas del Receptor Purinérgico P2Y/administración & dosificación , Antagonistas del Receptor Purinérgico P2Y/uso terapéuticoRESUMEN
BACKGROUND: The recent guidelines from the European Society of Cardiology recommends using high-sensitivity cardiac troponin (hs-cTn) in either 0/1-h or 0/2-h algorithms to identify or rule out acute myocardial infarction (AMI). Several studies have reported good diagnostic accuracy with both algorithms, but few have compared the algorithms directly. OBJECTIVE: We aimed to compare the diagnostic accuracy of the algorithms head-to-head, in the same patients. METHODS: This was a secondary analysis of data from a prospective observational study; 1167 consecutive patients presenting with chest pain to the emergency department at Skåne University Hospital (Lund, Sweden) were enrolled. Only patients with a hs-cTnT sample at presentation AND after 1 AND 2 h were included in the analysis. We compared sensitivity, specificity, and negative (NPV) and positive predictive value (PPV). The primary outcome was index visit AMI. RESULTS: A total of 710 patients were included, of whom 56 (7.9%) had AMI. Both algorithms had a sensitivity of 98.2% and an NPV of 99.8% for ruling out AMI, but the 0/2-h algorithm ruled out significantly more patients (69.3% vs. 66.2%, p < 0.001). For rule-in, the 0/2-h algorithm had higher PPV (73.4% vs. 65.2%) and slightly better specificity (97.4% vs. 96.3%, p = 0.016) than the 0/1-h algorithm. CONCLUSION: Both algorithms had good diagnostic accuracy, with a slight advantage for the 0/2-h algorithm. Which algorithm to implement may thus depend on practical issues such as the ability to exploit the theoretical time saved with the 0/1-h algorithm. Further studies comparing the algorithms in combination with electrocardiography, history, or risk scores are needed.
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Algoritmos , Dolor en el Pecho , Servicio de Urgencia en Hospital , Infarto del Miocardio , Humanos , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/etiología , Masculino , Femenino , Estudios Prospectivos , Persona de Mediana Edad , Anciano , Infarto del Miocardio/diagnóstico , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Sensibilidad y Especificidad , Suecia , Factores de Tiempo , Valor Predictivo de las Pruebas , Cardiología/normas , Cardiología/métodos , Biomarcadores/sangre , Sociedades Médicas , Troponina T/sangre , Troponina T/análisisRESUMEN
Background: Ruling out acute myocardial infarction (AMI) in the emergency department (ED) is challenging. Studies have shown that a high-sensitivity cardiac troponin T (hs-cTnT) <5 ng/L or <6 ng/L at presentation (0 h) can be used to rule out AMI. The objective of this study was to identify whether an even higher hs-cTnT threshold can be used for a safe rule out of AMI in the ED. Methods: The derivation cohort consisted of 24,973 ED patients with a primary complaint of chest pain. In this cohort, we identified the highest concentration of 0 h hs-cTnT that corresponded to a negative predictive value (NPV) of ≥99.5% for the primary endpoint of AMI/all-cause death within 30 days and the secondary endpoint of all-cause death within one year. The results were validated in two cohorts consisting of 132,021 and 1167 ED chest pain patients. Results: The 0 h hs-cTnT threshold corresponding to a NPV of ≥99.5% for the primary endpoint was <9 ng/L (NPV: 99.6% and 95% CI: 99.5-99.7). This cutoff provided a sensitivity of 96.2% (95% CI: 95.2-97.1) and identified 59.7% of the patients as low risk compared to 35.8% and 43.9% with a 0 h hs-cTnT <5 ng/L and <6 ng/L, respectively. The results were similar in the validation cohorts and seemed to perform even better in patients where the 0 h hs-cTnT was measured >3 h after symptom onset and in those with a nonischemic ECG and nonhigh risk history. Conclusions: A 0 h hs-cTnT cutoff of <9 ng/L safely rules out AMI/death within 30 days in a majority of chest pain patients and is a more effective strategy than the currently recommended <5 ng/L and <6 ng/L cutoffs. This trial is registered with NCT03421873.
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INTRODUCTION: With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management. METHODS: This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications. RESULTS: Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting. CONCLUSION: With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources.
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It is estimated that 80% of all synthetic drugs are derived from medicinal plants, and nowadays, many synthetic drugs are derived from medicinal plants. Valeriana officinalis can treat many diseases of the nervous system. A crucial aspect of valerian extract is that it inhibits the proliferation of breast cancer cells. To optimize the yield of bioactive compounds in the V. officinalis root extraction, a response surface methodology-based D-optimal design was used. To fulfill this aim, the effects of various factors such as solvent type and concentration, mixing temperature, ultrasound time, and drying method were examined. The optimal conditions for solvent percentages, mixing temperature, ultrasound time, solvent type, and drying methods were determined to be 94.88%, 25 °C, 48.95 min, methanol, and microwave, respectively, with a desirability of 0.921. The predicted valerenic acid, total phenols, total flavonoids, and antioxidant activity in V. officinalis extract were 1.19 (mg/g DW), 8.22 (mg/g DW), 5.27 (mg/g DW), and 92.64%, respectively. In optimal conditions, the extracted amounts of valerenic acid, total phenols, total flavonoids, and antioxidant activity were 2.07 mg/g DW, 7.96 mg/g DW, 5.52 mg/g DW, and 78.68%, respectively, which were consistent with the model predicted amounts (based on 95% prediction interval). This study could be useful as a model for demonstrating the efficacy of microwave drying to maximize the biochemical content of V. officinalis, as well as the antioxidant activity of the root extracts of V. officinalis on industrial scale.
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Antioxidantes , Extractos Vegetales , Raíces de Plantas , Valeriana , Valeriana/química , Extractos Vegetales/química , Raíces de Plantas/química , Antioxidantes/química , Antioxidantes/farmacología , Fenoles/análisis , Flavonoides/análisis , Solventes/química , Microondas , Indenos , SesquiterpenosRESUMEN
We present an experimental study of plasmonic slanted slit gratings (PSSGs) designed to achieve directional coupling between an incident light beam and surface plasmon polaritons (SPPs) propagating along the surface of the structure. We also investigate mirrored PSSG pairs interconnected by a plasmonic slab waveguide. The structures are fabricated using direct milling by a gallium focused ion beam (FIB). In a mirrored pair arrangement, the first PSSG couples a perpendicularly-incident light beam to SPPs propagating in one direction along the waveguide, while the second PSSG decouples SPPs to perpendicularly-emerging light. This configuration shows promise for sensing applications due to the high sensitivity of the excited SPPs to changes in the refractive index of the bounding medium, and the separation of the optics from the fluidics by the substrate. The design also exhibits robustness to fabrication tolerances. The optical characteristics and sensing potential are investigated theoretically and experimentally, highlighting its potential for a wide range of applications.
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BACKGROUND: Electrocardiographic detection of patients with occlusion myocardial infarction (OMI) can be difficult in patients with left bundle branch block (LBBB) or ventricular paced rhythm (VPR) and several ECG criteria for the detection of OMI in LBBB/VPR exist. Most recently, the Barcelona criteria, which includes concordant ST deviation and discordant ST deviation in leads with low R/S amplitudes, showed superior diagnostic accuracy but has not been validated externally. We aimed to describe the diagnostic accuracy of four available ECG criteria for OMI detection in patients with LBBB/VPR at the emergency department. METHODS: The unweighted Sgarbossa criteria, the modified Sgarbossa criteria (MSC), the Barcelona criteria and the Selvester criteria were applied to chest pain patients with LBBB or VPR in a prospectively acquired database from five emergency departments. RESULTS: In total, 623 patients were included, among which 441 (71%) had LBBB and 182 (29%) had VPR. Among these, 82 (13%) patients were diagnosed with AMI, and an OMI was identified in 15 (2.4%) cases. Sensitivity/specificity of the original unweighted Sgarbossa criteria were 26.7/86.2%, for MSC 60.0/86.0%, for Barcelona criteria 53.3/82.2%, and for Selvester criteria 46.7/88.3%. In this setting with low prevalence of OMI, positive predictive values were low (Sgarbossa: 4.6%; MSC: 9.4%; Barcelona criteria: 6.9%; Selvester criteria: 9.0%) and negative predictive values were high (all >98.0%). CONCLUSIONS: Our results suggests that ECG criteria alone are insufficient in predicting presence of OMI in an ED setting with low prevalence of OMI, and the search for better rapid diagnostic instruments in this setting should continue.
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Bloqueo de Rama , Infarto del Miocardio , Humanos , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/terapia , Bloqueo de Rama/epidemiología , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Servicio de Urgencia en Hospital , Sensibilidad y Especificidad , Electrocardiografía/métodosRESUMEN
Influenza vaccination reduces the risk of adverse cardiovascular events.The IAMI trial randomly assigned 2571 patients with acute myocardial infarction (AMI) to receive influenza vaccine or saline placebo during their index hospital admission. It was conducted at 30 centers in 8 countries from October 1, 2016 to March 1, 2020. In this post-hoc exploratory sub-study, we compare the trial outcomes in patients receiving early season vaccination (n = 1188) and late season vaccination (n = 1344).The primary endpoint wasthe composite of all-cause death, myocardial infarction (MI), or stent thrombosis at 12 months. Thecumulative incidence of the primary and key secondary endpoints by randomized treatment and early or late vaccination was estimated using the Kaplan-Meier method. In the early vaccinated group, the primary composite endpoint occurred in 36 participants (6.0%) assigned to influenza vaccine and 49 (8.4%) assigned to placebo (HR 0.69; 95% CI 0.45 to 1.07), compared to 31 participants (4.7%) assigned to influenza vaccine and 42 (6.2%) assigned to placebo (HR 0.74; 95% CI 0.47 to 1.18) in the late vaccinated group (P = 0.848 for interaction on HR scale at 1 year). We observed similar estimates for the key secondary endpoints of all-cause death and CV death. There was no statistically significant difference in vaccine effectiveness against adverse cardiovascular events by timing of vaccination. The effect of vaccination on all-cause death at one year was more pronounced in the group receiving early vaccination (HR 0.50; 95% CI, 0.29 to 0.86) compared late vaccination group (HR 0.75; 35% CI, 0.40 to 1.40) but there was no statistically significant difference between these groups (Interaction P = 0.335). In conclusion,there is insufficient evidence from the trial to establish whether there is a difference in efficacy between early and late vaccinationbut regardless of vaccination timing we strongly recommend influenza vaccination in all patients with cardiovascular diseases.
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Vacunas contra la Influenza , Gripe Humana , Infarto del Miocardio , Trombosis , Humanos , Gripe Humana/prevención & control , Gripe Humana/complicaciones , Vacunación/métodosRESUMEN
Optical biosensors target widespread applications, such as drug discovery, medical diagnostics, food quality control, and environmental monitoring. Here, we propose a novel plasmonic biosensor on the end-facet of a dual-core single-mode optical fiber. The concept uses slanted metal gratings on each core, interconnected by a metal stripe biosensing waveguide to couple the cores via the propagation of surface plasmons along the end facet. The scheme enables operation in transmission (core-to-core), thereby eliminating the need to separate the reflected light from the incident light. Importantly, this simplifies and reduces the cost of the interrogation setup because a broadband polarization-maintaining optical fiber coupler or circulator is not required. The proposed biosensor enables remote sensing because the interrogation optoelectronics can be located remotely. In vivo biosensing and brain studies are also enabled because the end-facet can be inserted into a living body, once properly packaged. It can also be dipped into a vial, precluding the need for microfluidic channels or pumps. Bulk sensitivities of 880 nm/RIU and surface sensitivities of 1 nm/nm are predicted under spectral interrogation using cross-correlation analysis. The configuration is embodied by robust and experimentally realizable designs that can be fabricated, e.g., using metal evaporation and focused ion beam milling.
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Técnicas Biosensibles , Fibras Ópticas , MicrofluídicaRESUMEN
BACKGROUND: In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hs-cTn)-based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. METHODS: In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability (ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. RESULTS: Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline-recommended strategy. CONCLUSION: We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care. TRIAL REGISTRATION NUMBERS: Data of following cohorts were used for this project: BACC ( www. CLINICALTRIALS: gov ; NCT02355457), stenoCardia ( www. CLINICALTRIALS: gov ; NCT03227159), ADAPT-BSN ( www.australianclinicaltrials.gov.au ; ACTRN12611001069943), IMPACT ( www.australianclinicaltrials.gov.au , ACTRN12611000206921), ADAPT-RCT ( www.anzctr.org.au ; ANZCTR12610000766011), EDACS-RCT ( www.anzctr.org.au ; ANZCTR12613000745741); DROP-ACS ( https://www.umin.ac.jp , UMIN000030668); High-STEACS ( www. CLINICALTRIALS: gov ; NCT01852123), LUND ( www. CLINICALTRIALS: gov ; NCT05484544), RAPID-CPU ( www. CLINICALTRIALS: gov ; NCT03111862), ROMI ( www. CLINICALTRIALS: gov ; NCT01994577), SAMIE ( https://anzctr.org.au ; ACTRN12621000053820), SEIGE and SAFETY ( www. CLINICALTRIALS: gov ; NCT04772157), STOP-CP ( www. CLINICALTRIALS: gov ; NCT02984436), UTROPIA ( www. CLINICALTRIALS: gov ; NCT02060760).
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Infarto del Miocardio , Troponina I , Humanos , Angina de Pecho , Biomarcadores , Infarto del Miocardio/diagnóstico , Curva ROC , Troponina T , Estudios Clínicos como AsuntoRESUMEN
Aerococcus sanguinicola is a bacterium that can cause urinary tract infections and on rare occasions infective endocarditis (IE). The prognosis of IE caused by aerococci is generally favourable despite that the patients are typically old and have multiple comorbidities. Here we report a case of A. sanguinicola native valve aortic IE in a 68-year-old man with an underlying urinary tract condition. The infection led to severe aortic valve insufficiency and rapid death before the patient could be subjected to surgery. This demonstrates that IE caused by A. sanguinicola can be severe and cause valve destruction. In addition to the case report, we provide a review of the current literature on A. sanguinicola IE.
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AIMS: In the present study, we aimed to evaluate the performance of machine learning (ML) models for identification of acute myocardial infarction (AMI) or death within 30 days among emergency department (ED) chest pain patients. METHODS AND RESULTS: Using data from 9519 consecutive ED chest pain patients, we created ML models based on logistic regression or artificial neural networks. Model inputs included sex, age, ECG and the first blood tests at patient presentation: High sensitivity TnT (hs-cTnT), glucose, creatinine, and hemoglobin. For a safe rule-out, the models were adapted to achieve a sensitivity > 99% and a negative predictive value (NPV) > 99.5% for 30-day AMI/death. For rule-in, we set the models to achieve a specificity > 90% and a positive predictive value (PPV) of > 70%. The models were also compared with the 0 h arm of the European Society of Cardiology algorithm (ESC 0 h); An initial hs-cTnT < 5 ng/L for rule-out and ≥ 52 ng/L for rule-in. A convolutional neural network was the best model and identified 55% of the patients for rule-out and 5.3% for rule-in, while maintaining the required sensitivity, specificity, NPV and PPV levels. ESC 0 h failed to reach these performance levels. DISCUSSION: An ML model based on age, sex, ECG and blood tests at ED arrival can identify six out of ten chest pain patients for safe early rule-out or rule-in with no need for serial blood tests. Future studies should attempt to improve these ML models further, e.g. by including additional input data.
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Infarto del Miocardio , Troponina T , Humanos , Estudios Prospectivos , Biomarcadores , Infarto del Miocardio/diagnóstico , Dolor en el Pecho/diagnóstico , Valor Predictivo de las Pruebas , Electrocardiografía , Servicio de Urgencia en HospitalRESUMEN
BACKGROUND: Influenza vaccination early after myocardial infarction (MI) improves prognosis but vaccine effectiveness may differ dependent on type of MI. METHODS: A total of 2,571 participants were prospectively enrolled in the Influenza vaccination after myocardial infarction (IAMI) trial and randomly assigned to receive in-hospital inactivated influenza vaccine or saline placebo. The trial was conducted at 30 centers in eight countries from October 1, 2016 to March 1, 2020. Here we report vaccine effectiveness in the 2,467 participants with ST-segment elevation MI (STEMI, n = 1,348) or non-ST-segment elevation MI (NSTEMI, n = 1,119). The primary endpoint was the composite of all-cause death, MI, or stent thrombosis at 12 months. Cumulative incidence of the primary and key secondary endpoints by randomized treatment and NSTEMI/STEMI was estimated using the Kaplan-Meier method. Treatment effects were evaluated with formal interaction testing to assess for effect modification. RESULTS: Baseline risk was higher in participants with NSTEMI. In the NSTEMI group the primary endpoint occurred in 6.5% of participants assigned to influenza vaccine and 10.5% assigned to placebo (hazard ratio [HR], 0.60; 95% CI, 0.39-0.91), compared to 4.1% assigned to influenza vaccine and 4.5% assigned to placebo in the STEMI group (HR, 0.90; 95% CI, 0.54-1.50, P = .237 for interaction). Similar findings were seen for the key secondary endpoints of all-cause death and cardiovascular death. The Kaplan-Meier risk difference in all-cause death at one year was more pronounced in participants with NSTEMI (NSTEMI: HR, 0.47; 95% CI 0.28-0.80, STEMI: HR, 0.86; 95% CI, 0.43-1.70, interaction P = .028). CONCLUSIONS: The beneficial effect of influenza vaccination on adverse cardiovascular events may be enhanced in patients with NSTEMI compared to those with STEMI.
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Vacunas contra la Influenza , Gripe Humana , Infarto del Miocardio , Infarto del Miocardio sin Elevación del ST , Infarto del Miocardio con Elevación del ST , Humanos , Gripe Humana/complicaciones , Gripe Humana/prevención & control , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio sin Elevación del ST/complicaciones , Infarto del Miocardio/complicaciones , Resultado del Tratamiento , Factores de RiesgoRESUMEN
AIMS: The clinical usefulness of historical concentrations of high-sensitivity cardiac troponin T (hs-cTnT) is unknown. This study investigated the ability to rule out myocardial infarction (MI) with the use of historical hs-cTnT concentrations among patients with chest pain in the emergency department (ED). METHODS AND RESULTS: The derivation cohort consisted of patients presenting with chest pain to nine different EDs (n = 60â071), where we included those with ≥1 hs-cTnT analysed at the index visit and ≥1 hs-cTnT results prior to the visit. We developed an algorithm to rule out MI within 30 days with a pre-specified target negative predictive value (NPV) of ≥99.5%. The performance was then validated in a separate cohort of ED chest pain patients (n = 10â994). A historical hs-cTnT < 12 ng/L and a < 3 ng/L absolute change between the historical and the index visit hs-cTnT had the best performance and ruled out 24â862 (41%) patients in the derivation cohort. In the validation cohort, these criteria identified 4764 (43%) low-risk patients in whom 18 (0.4%) MIs within 30 days occurred, and had an NPV for MI of 99.6% (99.4-99.8), a sensitivity of 96.9% (95.2-.2), and an LR- of 0.11 (0.07-0.14). CONCLUSION: Combining a historical hs-cTnT with a single new hs-cTnT may safely rule out MI and thereby reduce the need for serial hs-cTnT measurements in ED patients with chest pain.
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Infarto del Miocardio , Troponina T , Biomarcadores , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/etiología , Servicio de Urgencia en Hospital , Humanos , Infarto del Miocardio/diagnóstico , Valor Predictivo de las PruebasRESUMEN
OBJECTIVES: The augmented inflammatory response to cardiac surgery is a recognized cause of postoperative acute kidney injury. The present study aimed to investigate the effects of preoperative cyclosporine treatment on cytokine production and delineate factors associated with postoperative kidney impairment. DESIGN: A randomized, double-blind, placebo-controlled, single-center study. SETTING: At a tertiary care, university hospital. PARTICIPANTS: Patients eligible for elective coronary artery bypass grafting surgery; 67 patients were enrolled. INTERVENTIONS: Patients were randomized to receive 2.5 mg/kg cyclosporine or placebo before surgery. Cytokine levels were measured after the induction of anesthesia and 4 hours after the end of cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Tissue-aggressive (interleukin [IL]-1ß, macrophage inflammatory protein [MIP]-1ß, granulocyte colony-stimulating factor [G-CSF], IL-6, IL-8, IL-17, MCP-1), as well tissue-lenient (IL-4) cytokines, were significantly elevated in response to surgery. Changes in cytokine levels were not affected by cyclosporine pretreatment. CONCLUSIONS: Elective coronary artery bypass grafting surgery with cardiopulmonary bypass triggers cytokine activation. This activation was not impacted by preoperative cyclosporine treatment.
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Puente de Arteria Coronaria , Ciclosporina , Puente Cardiopulmonar , Puente de Arteria Coronaria/efectos adversos , Ciclosporina/farmacología , Citocinas/farmacología , Humanos , Riñón/fisiologíaRESUMEN
BACKGROUND: The Second Primary Angioplasty in Myocardial Infarction (PAMI-II) risk score is recommended by guidelines to identify low-risk patients with ST-elevation myocardial infarction (STEMI) for an early discharge strategy. AIMS: We aimed to assess the safety of early discharge (≤2 days) for low-risk STEMI patients treated with primary percutaneous coronary intervention (PCI). METHODS: Using nationwide data from the SWEDEHEART registry, we identified patients with STEMI treated with primary PCI during the period 2009-2017, of whom 8,092 (26.4%) were identified as low risk with the PAMI-II score. Low-risk patients were stratified according to their length of hospital stay (≤2 days vs >2 days). The primary endpoint was major adverse cardiovascular events (MACE, including death, reinfarction treated with PCI, stroke or heart failure hospitalisation) at one year, assessed using a Cox proportional hazards model with propensity score as well as an inverse probability weighting propensity score of average treatment effect to adjust for confounders. RESULTS: A total of 1,449 (17.9%) patients were discharged ≤2 days from admission. After adjustment, the one-year MACE rate was not higher for patients discharged at >2 days from admission than for patients discharged ≤2 days (4.3% vs 3.2%; adjusted HR 1.31, 95% confidence interval [CI]: 0.92-1.87, p=0.14), and no difference was observed regarding any of the individual components of the main outcome. Results were consistent across all subgroups with no difference in MACE between early and late discharge patients. CONCLUSIONS: Nationwide observational data suggest that early discharge of low-risk patients with STEMI treated with PCI is not associated with an increase in one-year MACE.
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Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Estudios de Cohortes , Hospitales , Humanos , Alta del Paciente , Intervención Coronaria Percutánea/efectos adversos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)-based strategies for triage of patients with suspected acute myocardial infarction (AMI). PURPOSE: To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479). STUDY SELECTION: Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI. DATA EXTRACTION: The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality. DATA SYNTHESIS: A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score <140 and pain-free) compared with studies that used clinical criteria (90.2% [CI, 82.9 to 94.6] vs. 98.4% [CI, 88.6 to 99.8]). All 3 algorithms had similar specificities and positive predictive values for ruling in AMI, but heterogeneity across studies was substantial. Diagnostic performance was similar across the hs-cTnT (Elecsys; Roche), hs-cTnI (Architect; Abbott), and hs-cTnI (Centaur/Atellica; Siemens) assays. LIMITATION: Diagnostic accuracy, inclusion and exclusion criteria, and cardiac troponin sampling time varied among studies. CONCLUSION: The ESC 0/1-hour and 0/2-hour algorithms have higher sensitivities and NPVs than the 0/3-hour algorithm for index AMI. PRIMARY FUNDING SOURCE: National Taiwan University Hospital.
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Algoritmos , Biomarcadores/sangre , Infarto del Miocardio/diagnóstico , Guías de Práctica Clínica como Asunto , Triaje/métodos , Troponina/sangre , Diagnóstico Diferencial , Europa (Continente) , Humanos , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Factores de Riesgo , Sociedades Médicas , Factores de TiempoRESUMEN
Background. Glucose is emerging as a biomarker for early and safe rule-out of acute myocardial infarction in emergency department (ED) chest pain patients. We evaluated the diagnostic accuracy of dual testing with high sensitivity TnT (hs-cTnT) and glucose for prediction of major adverse cardiac events (MACE) within 30 days. Methods. This was a secondary analysis of a single-center prospective observational study of 1167 ED chest-pain patients with hs-cTnT and glucose testing at presentation (0 h), and hs-cTnT 1 h later. We tested the addition of glucose <5.6 mmol/L to three MACE rule-out strategies: hs-cTnT <5 ng/L, ≤14 ng/L or a 0 h/1h algorithm, i.e. initial hs-cTnT <12 ng/L with a 1 h change of <3 ng/L. We also tested the addition of glucose ≥11mmol/L to three rule-in strategies: hs-cTnT ≥52 ng/L, a 1 h change ≥5 ng/L or hs-cTnT >14 ng/L. The outcomes were 30-day MACE and 30-day MACE without UA. Results. Two dual-testing approaches reached our target NPV for rule-out: A 0 h hs-cTnT ≤14 ng/L and glucose <5.6 mmol/L identified 252 patients (24.4%) with a 98.8% NPV for 30-day MACE and 99.6% for MACE without UA. The 0 h/1h hs-cTnT algorithm combined with glucose identified 240 patients (23.2%) with a 99.2% NPV for 30-day MACE and 100.0% for MACE without UA. No dual rule-in strategy performed better than using hs-cTnT alone. Conclusions. A combination of hs-cTnT and blood glucose at presentation can be used to identify almost » of ED chest pain patients with a very low risk of 30-day MACE where further testing is not needed. Adding glucose did not improve the rule-in of 30-day MACE.
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Glucosa , Troponina T , Biomarcadores , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/etiología , Servicio de Urgencia en Hospital , Corazón , HumanosRESUMEN
BACKGROUND: Observational and small, randomized studies suggest that influenza vaccine may reduce future cardiovascular events in patients with cardiovascular disease. METHODS: We conducted an investigator-initiated, randomized, double-blind trial to compare inactivated influenza vaccine with saline placebo administered shortly after myocardial infarction (MI; 99.7% of patients) or high-risk stable coronary heart disease (0.3%). The primary end point was the composite of all-cause death, MI, or stent thrombosis at 12 months. A hierarchical testing strategy was used for the key secondary end points: all-cause death, cardiovascular death, MI, and stent thrombosis. RESULTS: Because of the COVID-19 pandemic, the data safety and monitoring board recommended to halt the trial before attaining the prespecified sample size. Between October 1, 2016, and March 1, 2020, 2571 participants were randomized at 30 centers across 8 countries. Participants assigned to influenza vaccine totaled 1290 and individuals assigned to placebo equaled 1281; of these, 2532 received the study treatment (1272 influenza vaccine and 1260 placebo) and were included in the modified intention to treat analysis. Over the 12-month follow-up, the primary outcome occurred in 67 participants (5.3%) assigned influenza vaccine and 91 participants (7.2%) assigned placebo (hazard ratio, 0.72 [95% CI, 0.52-0.99]; P=0.040). Rates of all-cause death were 2.9% and 4.9% (hazard ratio, 0.59 [95% CI, 0.39-0.89]; P=0.010), rates of cardiovascular death were 2.7% and 4.5%, (hazard ratio, 0.59 [95% CI, 0.39-0.90]; P=0.014), and rates of MI were 2.0% and 2.4% (hazard ratio, 0.86 [95% CI, 0.50-1.46]; P=0.57) in the influenza vaccine and placebo groups, respectively. CONCLUSIONS: Influenza vaccination early after an MI or in high-risk coronary heart disease resulted in a lower risk of a composite of all-cause death, MI, or stent thrombosis, and a lower risk of all-cause death and cardiovascular death, as well, at 12 months compared with placebo. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02831608.
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Vacunas contra la Influenza/administración & dosificación , Infarto del Miocardio/inmunología , Método Doble Ciego , Femenino , Humanos , Vacunas contra la Influenza/inmunología , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Ultrasound plays an important role in several medical fields. The heart was the first organ for which ultrasound gained clinical utility, followed by obstetric and gynecological applications. Shortly thereafter, abdominal organs and blood vessels became targets for ultrasound examination. The lung was long considered inaccessible for ultrasound due to its high air content. Work since the 1990s has however established a role for lung ultrasound, in leveraging several technical artefacts generated in the normal lung and in conditions with reduced air content, to allow rapid diagnosis of interstitial fluid accumulation, pneumothorax, pneumonia among others. In this article, we provide an overview of the potential of lung ultrasound, particularly as a promising method for assessment of patients presenting with acute dyspnea in the emergency department and for monitoring residual fluid in patients with decompensated heart failure. We also discuss limitations and caveats of the method.