ABSTRACT
BACKGROUND: There is currently little evidence for transcatheter edge-to-edge mitral valve repair (TEER) for mitral regurgitation (MR) in patients with cardiogenic shock (CS). Therefore, this study investigated the characteristics and outcomes of CS patients who underwent TEER for MR. METHODS: PubMed, EMBASE were searched in July 2023. Case series and observational studies reporting clinical characteristics and outcomes in CS patients with MR who underwent TEER were included. We performed a one-group meta-analysis using a random effects model. RESULTS: A total of 4060 patients from 7 case series and 5 observational studies were included. The mean age was 68.2 (95% confidence interval [CI]: 64.1-72.2) years, and 41.4% of patients (95% CI: 39.1%-43.7%) were female. Pre-TEER, severe MR was present in 85.3% (95% CI: 76.1%-91.3%) of patients. Mean left ventricular ejection fraction was 36.7% (95% CI: 29.2%-44.2%), and 54.6% (95% CI: 36.9%-71.2%) of patients received mechanical circulatory support. The severity of MR post-TEER was less than 2+ in 88% (95% CI: 87%-89%) of patients. In-hospital mortality was 11% (95% CI: 10%-13%), whereas 30-day and 1-year mortality rates were 15% (95% CI: 13%-16%), and 36% (95% CI: 21%-54%), respectively. CONCLUSIONS: This systematic review and meta-analysis assessed the clinical characteristics and outcomes of TEER in CS patients with MR. TEER for MR in patients with CS has been successful in reducing MR in most of the patients, but with a high mortality rate. Randomized controlled trials of TEER for MR and CS are needed.
Subject(s)
Heart Valve Prosthesis Implantation , Mitral Valve Insufficiency , Humans , Female , Aged , Male , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/surgery , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/etiology , Shock, Cardiogenic/therapy , Stroke Volume , Ventricular Function, Left , Treatment Outcome , Heart Valve Prosthesis Implantation/adverse effectsABSTRACT
BACKGROUND: Transcatheter edge-to-edge repair (TEER) may have potential benefits in the treatment of atrial functional mitral regurgitation (AFMR), but robust evidence is currently lacking. We conducted a systematic review and meta-analysis to investigate the clinical outcomes of TEER for AFMR, including comparisons to ventricular functional MR (VFMR). METHODS: MEDLINE and EMBASE were searched through January 2023 to identify studies eligible for analysis. The primary outcome was postprocedural MR severity. Postprocedural New York Heart Association (NYHA) functional class classification and all-cause mortality were also evaluated. Outcomes were stratified into short term (postprocedure to 6 months) and long term (6 months to 2 years). RESULTS: A total of eight observational studies met the inclusion criteria, enrolling 539 AFMR and 3486 VFMR patients. Postprocedural MR grade ≤2 in the AFMR group was observed in 93.7% (454/491 patients; 95% confidence interval (CI), 91.1%-96.2%, I2 = 24.3%) and 97.1% (89/93 patients; 95% CI, 92.9%-100%, I2 = 26.4%) in short- and long-term follow-up, respectively. There was no difference in the rates of postprocedural MR grade ≤2 between AFMR and VFMR either in short-term (risk ratio [RR], 1.00 [95% CI, 0.95-1.06]; p = 0.90; I2 = 53%) or long-term follow-up (RR, 1.08 [95% CI, 0.89-1.32]; p = 0.44; I2 = 22%). Similarly, no difference was observed between AFMR and VFMR in the rates of postprocedural NYHA class ≤2 or all-cause mortality. CONCLUSION: TEER provides similar clinical outcomes for AFMR and VFMR. A high rate of MR grade ≤2 was observed in patients at both short- and long-term follow-ups. Further prospective studies with TEER versus medical therapy and/or rhythm control for AFMR are warranted.
Subject(s)
Atrial Fibrillation , Heart Valve Prosthesis Implantation , Mitral Valve Insufficiency , Humans , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/surgery , Prospective Studies , Treatment Outcome , Heart Atria , Heart Valve Prosthesis Implantation/adverse effectsABSTRACT
OBJECTIVES: We aimed to investigate the invasive hemodynamic changes with transcatheter mitral valve replacement (TMVR) in patients with severe mitral stenosis due to severe mitral annular calcification. BACKGROUND: The hemodynamic response to TMVR in patients with mitral stenosis related to degenerative mitral annular calcification has not been fully elucidated. METHODS: We conducted retrospective review of patients who underwent successful transseptal TMVR with balloon-expandable valves for symptomatic severe mitral stenosis due to mitral annular calcification at our institution between January 2014 and February 2020. Invasive hemodynamic measurements were obtained both before valve implantation (predeployment) and after (postdeployment). RESULTS: Eighteen patients (age 72 ± 10 years, 44% female) were included for the analysis. There was a significant reduction in mean left atrial pressure (23.7 ± 5.6 mmHg versus 20.6 ± 4.8 mmHg; p = .01), left atrial v-wave (mean 39.3 ± 10.2 mmHg versus 32.9 ± 9.9 mmHg; p = .01), and an increase in systemic mean blood pressure (72.6 mmHg ±11.2 versus 79.5 ± 9.9 mmHg; p = .02) postdeployment compared to predeployment. Patients who had symptom improvement at 30-day follow-up tended to have greater reduction in mean left atrial pressure (4.4 ± 4.4 mmHg versus 0.5 ± 5.2 mmHg; p = .16) and v-wave (8.6 ± 9.0 mmHg versus 0.7 ± 8.4 mmHg; p = .10) compared to those who did not experience improvement of symptoms. CONCLUSIONS: Transseptal TMVR for severe mitral stenosis due to mitral annular calcification is associated with reductions in mean left atrial pressure and left atrial v-wave, and an increase in systemic arterial pressure.
Subject(s)
Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Mitral Valve Stenosis , Aged , Aged, 80 and over , Cardiac Catheterization , Female , Heart Valve Prosthesis Implantation/adverse effects , Hemodynamics , Humans , Male , Middle Aged , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve Stenosis/complications , Mitral Valve Stenosis/diagnostic imaging , Mitral Valve Stenosis/surgery , Retrospective Studies , Treatment OutcomeABSTRACT
INTRODUCTION: Previous studies have reported lower rates of coronary angiography and revascularization, and significantly higher mortality among patients infected with human immunodeficiency virus (HIV) presenting with acute myocardial infarction (AMI). This observational study was designed to evaluate characteristics and inpatient outcomes of patients with seropositive HIV infection presenting with AMI. METHODS: Using the National Inpatient Sample (NIS) database, we identified patients (admissions) with a primary diagnosis of myocardial infarction and a co-occurring HIV. We described baseline characteristics and outcomes. Our primary outcomes of interest were prevalence of coronary angiography, revascularization (percutaneous coronary intervention (PCI) or CABG), and mortality. RESULTS: From 2010 to 2014, of about 2,977,387 patients with a primary diagnosis of AMI, 10,907 (0.4%) were HIV seropositive. Patients with HIV were younger and more likely to be African American or Hispanic. Coronary angiography and revascularization were performed more frequently in the HIV population. The higher prevalence of revascularization was driven by a higher incidence of PCI. In a multivariable model, patients with HIV were no more likely to undergo revascularization than the general population. This was also the case for PCI. Unadjusted all-cause mortality was lower among patients with HIV. After controlling for confounders, this finding was not significant (OR 0.97, 95% CI 0.75-1.25, p = 0.79). The length of stay between both groups was comparable. CONCLUSION: In this current analysis, we did not note any treatment bias or difference in the rate of in-hospital total mortality for HIV-seropositive patients presenting with AMI compared with the general population.
Subject(s)
HIV Infections , Myocardial Infarction , Percutaneous Coronary Intervention , HIV Infections/complications , HIV Infections/epidemiology , HIV Infections/therapy , Hospital Mortality , Hospitalization , Humans , Myocardial Infarction/epidemiology , Myocardial Infarction/therapy , Treatment OutcomeABSTRACT
Antegrade transseptal approach was utilized in the first human case of transcatheter aortic valve replacement (TAVR) and in the early phase of TAVR. Various challenges with the antegrade transseptal approach including procedural complexity, need for atrial septal crossing, and potential for injury to the mitral valve apparatus led it to being supplanted by other approaches. These challenges have now largely been mitigated as structural interventionalists routinely perform left atrial procedures. We report a case of antegrade transseptal TAVR using a large bore sheath placed in the mid left ventricle across the mitral orifice to protect the mitral valve apparatus and facilitate valve deployment. An 84-year-old man with heart failure symptoms was seen for severe aortic stenosis. The severity of peripheral arterial disease precluded femoral, axillary, carotid, or transcaval routes. After transseptal puncture and creation of an arteriovenous rail, a long 26-Fr sheath was advanced from the right femoral vein transseptally over the arteriovenous rail, past the mitral valve inflow to the mid left ventricular cavity. The sheath provided a stable platform with stable intraprocedure hemodynamics. Balloon valvuloplasty was performed in an antegrade manner, after which a 29-mm SAPIEN S3 prosthesis was advanced into the aortic valve position and deployed under rapid pacing. We observed no injury to the mitral leaflets or subvalvular apparatus after the procedure. The antegrade transseptal approach should be revisited as an option for patients at high surgical risk with no other suitable access site. The use of a large bore sheath facilitates this approach.
Subject(s)
Aortic Valve Stenosis/surgery , Aortic Valve/surgery , Cardiac Catheterization , Transcatheter Aortic Valve Replacement , Aged, 80 and over , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/physiopathology , Cardiac Catheterization/instrumentation , Cardiac Catheters , Fatal Outcome , Heart Failure/diagnostic imaging , Heart Failure/physiopathology , Heart Valve Prosthesis , Humans , Male , Severity of Illness Index , Transcatheter Aortic Valve Replacement/instrumentation , Treatment OutcomeABSTRACT
OBJECTIVE: We aimed to investigate the current practice patterns of permanent pacing, especially the timing of implantation, for high-degree AV block (HDAVB) following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). BACKGROUND: Comparative data regarding current practice patterns of permanent pacing for HDAVB between TAVI and SAVR is limited. METHODS: Using the National Inpatient Sample database, we identified patients who underwent TAVI or SAVR between 2012 and 2014. The incidence of HDAVB, the rate of permanent pacemaker implantation, and the timing of implantations were compared between TAVI and SAVR groups. RESULTS: We identified 33 690 and 202 110 patients who underwent TAVI and SAVR, respectively. HDAVB occurred in 3480 patients (10.3%) in the TAVI group and 11 405 patients (5.6%) in the SAVR group (P < 0.001). Among the patients who developed HDAVB, patients in the TAVI group were more likely to undergo permanent pacemaker implantation than those in the SAVR group (74.1% vs 64.7%; P < 0.001). The median interval from TAVI to pacemaker implantation was 2 days (interquartile range 1-3 days) vs 5 days (interquartile range 3-7 days) from SAVR to pacemaker implantation (P < 0.001). Among the patients who developed HDAVB, TAVI was associated with higher rates of permanent pacemaker implantation after adjusting for other comorbidities (odds ratio 1.41:95% confidence interval 1.13-1.77; P = 0.003). CONCLUSIONS: HDAVB occurred more commonly after TAVI compared to SAVR. HDAVB after TAVI compared to SAVR was associated with a higher rate of permanent pacemaker implantation at an earlier timing from the index procedure.
Subject(s)
Aortic Valve/surgery , Atrioventricular Block/therapy , Cardiac Pacing, Artificial/trends , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation/trends , Practice Patterns, Physicians'/trends , Transcatheter Aortic Valve Replacement/trends , Aged , Aged, 80 and over , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Atrioventricular Block/diagnosis , Atrioventricular Block/epidemiology , Atrioventricular Block/physiopathology , Cardiac Pacing, Artificial/adverse effects , Databases, Factual , Female , Heart Valve Diseases/diagnostic imaging , Heart Valve Diseases/epidemiology , Heart Valve Diseases/physiopathology , Heart Valve Prosthesis Implantation/adverse effects , Hospital Mortality/trends , Humans , Incidence , Inpatients , Length of Stay/trends , Male , Risk Factors , Time Factors , Time-to-Treatment/trends , Transcatheter Aortic Valve Replacement/adverse effects , Treatment Outcome , United States/epidemiologyABSTRACT
INTRODUCTION: Malignancy is a common cause of morbidity and mortality in the United States and around the world and the second leading cause of death in the United States. There is little data on the impact of metastatic cancer on the risk of hemorrhagic stroke or mortality among patients undergoing fibrinolytic therapy (FT) for acute PE. METHODS: Using the National Inpatient Sample (NIS) database, we extracted admissions with a primary diagnosis of acute pulmonary embolism that underwent FT from 2010 to 2014. We performed a case control matched analysis between patients with and without metastatic cancer. Our primary outcome of interest was Mortality and our secondary outcome of interest was hemorrhagic stroke (HS). RESULTS: Of the 883,183 patients with a primary diagnosis of acute PE between 2010 and 12014, 23,690 patients (2.7%) underwent FT. After exclusion, 22,592 patients were included in the analysis. Of these, 941 patients (4.2%) were reported to have metastatic cancer. There was a higher incidence of cerebrovascular accidents and intubation/mechanical ventilation in the metastatic cancer arm. Mortality was significantly higher in the metastatic cancer arm with no difference in the incidence of HS. In multivariate regression analysis, among all patients that underwent FT for acute PE, metastatic cancer was associated with a significant odds for mortality (OR 1.91, 95% CI 1.11-5.82, pâ¯<â¯.001). CONCLUSION: The presence of metastatic cancer in patients undergoing fibrinolytic therapy for acute pulmonary embolism is associated with increase mortality.
Subject(s)
Neoplasms/pathology , Pulmonary Embolism/drug therapy , Thrombolytic Therapy/methods , Acute Disease , Adult , Aged , Case-Control Studies , Databases, Factual , Female , Humans , Intracranial Hemorrhages/epidemiology , Male , Middle Aged , Neoplasm Metastasis , Neoplasms/mortality , Pulmonary Embolism/mortality , Retrospective Studies , Stroke/epidemiology , United States/epidemiologyABSTRACT
PURPOSE OF REVIEW: Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics. RECENT FINDINGS: The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.
Subject(s)
Acute Coronary Syndrome/therapy , Myocardial Revascularization/methods , Non-ST Elevated Myocardial Infarction/therapy , Acute Coronary Syndrome/complications , Diabetes Complications , Humans , Meta-Analysis as Topic , Non-ST Elevated Myocardial Infarction/etiology , Percutaneous Coronary Intervention , Randomized Controlled Trials as Topic , Risk Assessment , Time Factors , Treatment OutcomeABSTRACT
The present meta-analysis found no significant difference between hybrid coronary revascularization (HCR) and bypass surgery (CABG) regarding intermediate-term major adverse cardiac and cerebrovascular events. HCR is feasible, historically with higher revascularization rates but less perioperative morbidity With a comparable frequency of repeat revascularization between current-generation drug-eluting stents and CABG, future trials of HCR are considering multi-vessel PCI as the new comparator.
Subject(s)
Coronary Artery Disease , Percutaneous Coronary Intervention , Coronary Artery Bypass , Drug-Eluting Stents , Humans , Treatment OutcomeABSTRACT
BACKGROUND: Pharmacologic reperfusion therapy is a recommended and effective strategy in patients with ST-elevation myocardial infarction (STEMI) when percutaneous coronary intervention (PCI) is not available. This study investigates temporal trends and outcomes of fibrinolytic therapy (FT) in elderly patients with STEMI. METHODS: Using the Nationwide Inpatient Sample database, we extracted patients ≥80 years a primary diagnosis of STEMI admitted between 2010 and 2014. Using ICD codes, we identified patients who underwent FT. We performed temporal trend analysis, then compared characteristics and inpatient outcomes in the FT group versus no-FT group. Our primary outcome of interest was hemorrhagic stroke (HS). We also assessed the impact of HS on mortality and discharge to skilled nursing facility (SNF). RESULTS: Of the 917,307 patients with STEMI, 16.1% (n = 147,874) were aged 80 or older. Primary PCI was performed in 46.2%, 2.4% underwent FT, and 51.3% had neither pharmacologic nor mechanical revascularization. The rate of FT increased (1.9%-2.4%) in a nonlinear trend over the five years of the study. The FT group was eight times more likely to suffer HS (P < 0.001). FT was an independent predictor of HS (OR 7.90, 95% CI 4.36-14.30; P < 0.001), whether they underwent PCI or not. HS was an independent predictor of mortality and SNF discharge. CONCLUSION: FT in patients 80 years or older presenting with STEMI was associated with an eight-fold increase in HS and no associated mortality advantage, both with or without PCI. These data underscore the increased risk of FT in the elderly.
Subject(s)
ST Elevation Myocardial Infarction/drug therapy , Thrombolytic Therapy/trends , Age Factors , Aged, 80 and over , Databases, Factual , Female , Humans , Incidence , Inpatients , Intracranial Hemorrhages/epidemiology , Male , Patient Discharge/trends , Retrospective Studies , Risk Assessment , Risk Factors , ST Elevation Myocardial Infarction/mortality , Skilled Nursing Facilities/trends , Stroke/epidemiology , Thrombolytic Therapy/adverse effects , Thrombolytic Therapy/mortality , Time Factors , Treatment Outcome , United States/epidemiologyABSTRACT
BACKGROUND: Prior studies have shown that routine follow-up coronary angiography (CAG) following percutaneous coronary intervention (PCI) increases the incidence of revascularization without a clear reduction in major adverse clinical events. However, none of these prior studies were adequately powered to evaluate hard clinical endpoints such as myocardial infarction (MI) or death and thus the clinical utility of such practice remains to be determined.MethodsâandâResults:We conducted a systematic review and meta-analysis of randomized trials that compared clinical outcomes after PCI between patients who underwent routine follow-up CAG and those who only had clinical follow-up. Five randomized trials, totaling 4,584 patients met our inclusion criteria, including studies that used sub-randomization and ones that assigned consecutive patients per study protocol. Our results showed that routine follow-up CAG was associated with a lower rate of MI (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.46-0.91; P=0.01) without reduction in all-cause mortality (OR 0.87; 95% CI 0.59-1.28; P=0.48), and a higher rate of target lesion revascularization (OR 1.73; 95% CI 1.42-2.11; P<0.001). CONCLUSIONS: Our meta-analysis demonstrated that routine follow-up CAG after PCI was associated with a higher rate of revascularization, but also with a reduction in the rate of subsequent MI. Further studies investigating the potential role of routine follow-up angiography may be warranted.
Subject(s)
Coronary Angiography , Percutaneous Coronary Intervention , Endpoint Determination , Humans , Randomized Controlled Trials as TopicABSTRACT
BACKGROUND: Positive T wave in lead aVR has been shown to predict an adverse in-hospital outcome in patients with anterior wall ST-segment elevation myocardial infarction (STEMI). However, the prognostic value of positive T wave in lead aVR on a long-term outcome has not been fully explored. METHODS: We performed a retrospective analysis of 190 consecutive patients with first anterior wall STEMI who underwent an emergent coronary angiogram. Patients were divided into those with positive T wave > 0 mV and those with negative T wave ⦠0 mV in lead aVR. Baseline and angiographic characteristics, and in-hospital revascularization procedures were recorded. In addition, in-hospital and 1-year major adverse cardiac events (MACE) including death, recurrent myocardial infarction, and target vessel revascularization were recorded. RESULTS: Among 190 patients, 37 patients (19%) had positive T wave and 153 patients (81%) had negative T wave in lead aVR. Patients with positive T wave had higher rate of left main disease defined as stenosis ≥50% (11% vs. 2%, p = .028) than those with negative T wave. Patients with positive T wave had higher rate of 1-year MACE (38% vs. 13%, p < .001) driven by higher all-cause mortality (27% vs. 5%, p < .001). Positive T wave was an independent predictor for 1-year MACE (OR 2.74; 95% CI 1.04-7.15; p = .04). CONCLUSION: Positive T wave in lead aVR was an independent predictor for 1-year MACE in patients with first anterior wall STEMI.
Subject(s)
Electrocardiography/methods , ST Elevation Myocardial Infarction/diagnosis , Aged , Coronary Angiography/methods , Female , Hospital Mortality , Humans , Male , Middle Aged , Recurrence , Retrospective Studies , ST Elevation Myocardial Infarction/diagnostic imagingABSTRACT
BACKGROUND: Low QRS voltage was reported to predict adverse outcomes in acute myocardial infarction in the pre-thrombolytic era. However, the association between low voltage and angiographic findings has not been fully addressed. METHODS: We performed a retrospective analysis of patients with anterior ST-segment elevation myocardial infarction (STEMI). Low QRS voltage was defined as either peak to peak QRS complex voltage <1.0mV in all precordial leads or <0.5mV in all limb leads. RESULTS: Among 190 patients, 37 patients (19%) had low voltage. Patients with low voltage had a higher rate of multi-vessel disease (MVD) (76% vs. 52%, p=0.01). Patients with low voltage were more likely to undergo coronary artery bypass grafting (CABG) during admission (11% vs. 2%, p=0.028). Low voltage was an independent predictor for MVD (OR 2.50; 95% CI 1.12 to 6.03; p=0.032). CONCLUSION: Low QRS voltage was associated with MVD and in-hospital CABG in anterior STEMI.
Subject(s)
Electrocardiography/methods , ST Elevation Myocardial Infarction/diagnosis , Aged , Coronary Angiography , Coronary Artery Bypass , Diagnosis, Differential , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prognosis , Risk Factors , ST Elevation Myocardial Infarction/physiopathology , ST Elevation Myocardial Infarction/surgery , Treatment OutcomeABSTRACT
BACKGROUND: ST-segment elevation in lead aVR predicts left main and/or three-vessel disease (LM/3VD) in patients with acute coronary syndromes. ST-segment elevation in lead aVR is generally reciprocal to and accompanied by ST-segment depression in precordial leads. Previous studies have assessed the independent predictive value of ST-segment elevation in lead aVR for LM/3VD in non-ST-segment elevation acute coronary syndrome and have reported conflicting results. METHODS: We performed a retrospective analysis of 379 patients with non-ST-segment elevation myocardial infarction (NSTEMI). Electrocardiograms on presentation were reviewed especially for ST-segment elevation ≥0.05 mV in lead aVR and ST-segment depression ≥0.05 mV in more than two contiguous leads in any other leads. RESULTS: Among 379 patients, 97 (26%) patients had ST-segment elevation in lead aVR and 88 (23%) patients had LM/3VD. Patients with ST-segment elevation in lead aVR had a higher rate of LM/3VD (39% vs. 18%; P < 0.001) and in-hospital revascularization (73% vs. 60%; P = 0.02) driven by a higher rate of in-hospital coronary artery bypass grafting (19% vs. 7%; P < 0.001) than those without ST-segment elevation in lead aVR. On multivariate analysis, ST-segment elevation in lead aVR (odds ratio [OR] 2.05; 95% confidence interval [CI] 1.10-3.77; P = 0.02) and ST-segment depression in leads V1 -V4 (OR 2.99; 95% CI 1.46-6.15; P = 0.003) were independent predictors of LM/3VD. CONCLUSION: This study demonstrates that ST-segment elevation in lead aVR is an independent predictor of LM/3VD in patients with NSTEMI.
Subject(s)
Acute Coronary Syndrome/diagnosis , Coronary Artery Disease/diagnosis , Electrocardiography , Myocardial Infarction/diagnosis , Aged , Coronary Angiography , Female , Humans , Male , Middle Aged , Prognosis , Retrospective StudiesABSTRACT
BACKGROUND: Emergency medical services (EMS) transportation is associated with shorter door-to-balloon (DTB) time in patients with ST-segment elevation myocardial infarction (STEMI). In addition to EMS transportation, prehospital notification of STEMI by EMS to receiving hospital might be able to further shorten DTB time. We evaluated the impact of STEMI notification on DTB time as well as infarct size. METHODS: We performed a retrospective analysis of consecutive patients with anterior wall STEMI who underwent emergent coronary angiography. We excluded patients who presented with cardiac arrest and those who were transferred from non-percutaneous coronary intervention-capable hospitals. Mode of transportation were categorized into the 3 groups: (1) EMS transport with STEMI notification, (2) EMS transport without STEMI notification, and (3) self-transport. Baseline characteristics, laboratory data, left ventricular ejection fraction (LVEF), and DTB time were compared among the 3 groups. RESULTS: A total of 148 patients were included in the final analysis. Of the 148 patients, 56 patients arrived by EMS transport with STEMI notification, 56 patients arrived by EMS transport without STEMI notification, and 36 patients arrived by self-transport. Patients who arrived by EMS transport with STEMI notification had the shortest DTB time among the 3 groups. Patients who arrived by EMS transport with STEMI notification had smaller infarct size, as indicated by lower peak creatine kinase value and higher LVEF, compared with those who arrived by EMS transport without STEMI notification. CONCLUSION: Emergency medical services transport with STEMI notification was associated with shorter DTB time and smaller infarct size in patients with anterior wall STEMI.
Subject(s)
Angioplasty, Balloon, Coronary , Electrocardiography , Emergency Medical Services/standards , ST Elevation Myocardial Infarction/diagnosis , Time-to-Treatment/standards , Transportation of Patients/standards , Aged , Coronary Angiography , Echocardiography , Female , Follow-Up Studies , Humans , Male , Middle Aged , Retrospective Studies , ST Elevation Myocardial Infarction/therapy , Severity of Illness Index , Time FactorsABSTRACT
BACKGROUND: The prognostic value of ST-segment elevation in lead V1 (STE in V1) in anterior ST-segment elevation myocardial infarction (STEMI) has not been elucidated. METHODS: We performed a retrospective analysis of 190 consecutive first anterior STEMI patients. STE in V1 ≥0.1mV was recorded. Major adverse cardiac events (MACE) were defined as a composite of all-cause death, recurrent myocardial infarction, or target vessel revascularization. RESULTS: Among 190 patients, 42 patients did not have STE in V1. The patient without STE in V1 had a higher peak creatine kinase value and a higher incidence of 1-year MACE (36% vs. 13%, p<0.001), driven by a higher mortality (24% vs. 5%, p<0.001). The absence of STE in V1 was an independent predictor for 1-year MACE (odds ratio 3.16; 95% confidence interval 1.28-7.83; p=0.01). CONCLUSION: The absence of STE in V1 was an independent predictor for worse long-term outcomes in patients with first anterior STEMI.
Subject(s)
Coronary Artery Disease/mortality , Electrocardiography/statistics & numerical data , Myocardial Infarction/diagnosis , Myocardial Infarction/mortality , Aged , Causality , Comorbidity , Coronary Artery Disease/diagnosis , Diagnosis, Computer-Assisted/methods , Diagnosis, Computer-Assisted/statistics & numerical data , Electrocardiography/methods , Female , Humans , Incidence , Longitudinal Studies , Male , Middle Aged , New York/epidemiology , Prognosis , Reproducibility of Results , Retrospective Studies , Risk Factors , Sensitivity and Specificity , Survival RateSubject(s)
Myocardial Infarction/psychology , Patient Compliance/statistics & numerical data , Patient Discharge/statistics & numerical data , Aged , Case-Control Studies , Comorbidity , Female , Humans , Male , Middle Aged , Myocardial Infarction/epidemiology , Patient Compliance/psychology , Retrospective Studies , Risk Factors , Sex DistributionABSTRACT
Spontaneous coronary artery dissection (SCAD) is not uncommon but remains arguably an under-diagnosed etiology for acute coronary syndrome (ACS). It occurs predominantly in young-to-middle aged women who have no or few traditional atherosclerotic cardiovascular disease risk factors. Post-infarction mechanical complications are a dreaded outcome of ACS. However, very few case reports describe these mechanical complications related to SCAD. Unsuccessful revascularization is a particular concern for patients presenting with SCAD-induced ACS, which can increase the risk for certain mechanical complications. We present a case of a middle-aged woman who presented with anterior ST-segment elevation myocardial infarction and was found to have SCAD of left anterior descending coronary artery. Two attempts at revascularization were unsuccessful. Thereafter, her clinical course was complicated by the development of heart failure as a result of a reduced ejection fraction and a left ventricular pseudoaneurysm. Importantly she also suffered a ventricular septal rupture necessitating surgical intervention. Fortunately, our patient had a favorable longer-term outcome. Current literature, including five published case reports on SCAD complicated by mechanical complications are reviewed. Clinicians must remain aware of post-infarction mechanical complications in patients with high-risk and non-revascularized SCAD.
Subject(s)
Acute Coronary Syndrome , ST Elevation Myocardial Infarction , Ventricular Septal Rupture , Middle Aged , Humans , Female , Coronary Vessels/diagnostic imaging , Coronary Vessels/surgery , Ventricular Septal Rupture/surgery , Ventricular Septal Rupture/complications , Coronary Angiography/adverse effects , Acute Coronary Syndrome/complications , ST Elevation Myocardial Infarction/etiologyABSTRACT
There is an increasing prevalence of patients who have both liver cirrhosis (LC) and severe valvular heart disease. This combination typically poses prohibitive risk for liver transplantation. LC related malnourishment, hypoalbuminemia and hyperdynamic circulation places patients with severe LC at higher rates for significant bleeding and/or thrombosis, as well as infectious and renal complications, after either surgical or transcatheter valvular interventions. Although there remains scarce comparative evidence, the preponderance of data suggest that percutaneous strategies are preferred over surgical ones. A multidisciplinary team is ideal for identifying those patients with LC who would benefit from transcatheter valvular heart interventions.
Subject(s)
Aortic Valve Stenosis , Heart Valve Diseases , Heart Valve Prosthesis Implantation , Transcatheter Aortic Valve Replacement , Humans , Heart Valve Prosthesis Implantation/adverse effects , Aortic Valve Stenosis/surgery , Treatment Outcome , Liver Cirrhosis/complications , Liver Cirrhosis/diagnosis , Liver Cirrhosis/therapy , Heart Valve Diseases/diagnosis , Heart Valve Diseases/surgery , Aortic Valve/surgery , Risk FactorsABSTRACT
BACKGROUND: For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated. METHODS: Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed. RESULTS: This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24). CONCLUSION: Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.