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BACKGROUND: The prognostic implications of phenotypes along the preshock to cardiogenic shock (CS) continuum remain uncertain. OBJECTIVES: This study sought to better characterize pre- or early shock and normotensive CS phenotypes and examine outcomes compared to those with conventional CS. METHODS: The CCCTN (Critical Care Cardiology Trials Network) is a registry of contemporary cardiac intensive care units. Consecutive admissions (N = 28,703 across 47 sites) meeting specific criteria based on hemodynamic variables, perfusion parameters, and investigator-reported CS were classified into 1 of 4 groups or none: isolated low cardiac output (CO), heart failure with isolated hypotension, normotensive CS, or SCAI (Society of Cardiovascular Angiography and Intervention) stage C CS. Outcomes of interest were in-hospital mortality and incidence of subsequent hypoperfusion among pre- and early shock states. RESULTS: A total of 2,498 admissions were assigned to the 4 groups with the following distribution: 4.8% isolated low CO, 4.4% isolated hypotension, 12.1% normotensive CS, and 78.7% SCAI stage C CS. Overall in-hospital mortality was 21.3% (95% CI: 19.7%-23.0%), with a gradient across phenotypes (isolated low CO 3.6% [95% CI: 1.0%-9.0%]; isolated hypotension 11.0% [95% CI: 6.9%-16.6%]; normotensive CS 17.0% [95% CI 13.0%-21.8%]; SCAI stage C CS 24.0% [95% CI: 22.1%-26.0%]; global P < 0.001). Among those with an isolated low CO and isolated hypotension on admission, 47 (42.3%) and 56 (30.9%) subsequently developed hypoperfusion. CONCLUSIONS: In a large contemporary registry of cardiac critical illness, there exists a gradient of mortality for phenotypes along the preshock to CS continuum with risk for subsequent worsening of preshock states. These data may inform refinement of CS definitions and severity staging.
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Optimal targets for red blood cell exchange (RCE) are not well defined in the chronic management of sickle cell disease. We analysed transfusion requirements and iron-related outcomes in 101 patients on chronic RCE with a post-procedure haematocrit (Ht) targeted at 34%, which is higher than typically used. A majority were of HbSS/HbSß0 genotype (n = 72) and enrolled for neurological complications (n = 53). Fifty patients had a positive Ht balance with RCE (>2% mean increase from pre-procedure level), while 43 patients maintained a neutral balance. The first group required fewer red blood cell units/year (65 vs. 80, p < 0.001), but a significant proportion were iron overloaded based on R2* with liver MRI (32% vs. none performed) and prescription of iron chelation (52% vs. 0%, p < 0.001, after a median of 19 months). The second group was more likely to receive iron supplementation (6% vs. 56%, p < 0.001). Chronic automated RCE with a post-procedure Ht targeted at 34% is not iron-neutral, and personalized Ht goals may be more appropriate in certain settings. This higher target should be compared with a lower Ht strategy in individuals with similar baseline red cell volumes to assess iron homeostasis and blood product requirements.
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While the efficacy of GpIIb-IIIa-inhibitors during primary PCI (pPCI) for ST-elevated myocardial infarction (STEMI) has previously been demonstrated, its ongoing role and safety in combination with newer P2Y12-inhibitors is unclear. We therefore sought to compare outcomes between two centers with divergent approaches to the use of GpIIbIIIa antagonists in pPCI. We performed a retrospective chart review of all-comer STEMI patients treated with pPCI at two high-volume Montreal academic tertiary care centers. One center tended to use GpIIb-IIIa-inhibitors up-front in a large proportion of patients (liberal strategy) and the other preferring a bail-out approach (conservative strategy). Baseline patient characteristics and procedural data were compared between the two groups. The main efficacy outcome was rate of no-reflow/slow-reflow and the main safety outcome was BARC ≥ 2 bleeding events. A total of 459 patients were included, of whom 167 (36.5%) were exposed to a GpIIb-IIIa-antagonist. There was a significant overall difference in use of GpIIb-IIIa-antagonist between the two centers (60.5% vs. 16.1%, p < 0.01). Rate of no-reflow/slow-reflow was similar between groups (2.6% vs. 1.4%, p = 0.22). In-hospital rates of unplanned revascularization, stroke and death were also not different between groups. Use of a liberal GpIIb--IIIa-antagonist strategy was however associated with a higher risk of bleeding (OR 3.16, 95% CI 1.57-6.37, p < 0.01), which persisted after adjustment for covariables (adjusted OR 2.85, 95% CI 1.40-5.81, p < 0.01). In this contemporary retrospective cohort, a conservative, bail-out only GpIIb--IIIa-antagonist strategy was associated with a lower incidence of clinically relevant bleeding without any signal for an increase in no-reflow/slow-reflow or ischemic clinical events.
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Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria , Infarto del Miocardio con Elevación del ST , Humanos , Masculino , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Femenino , Persona de Mediana Edad , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Infarto del Miocardio con Elevación del ST/terapia , Anciano , Estudios Retrospectivos , Intervención Coronaria Percutánea/métodos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Resultado del Tratamiento , HemorragiaRESUMEN
BACKGROUND: Patients with heart defects are at risk of developing cardiovascular disease. Our objective was to determine if non-cardiac birth defects are associated with the risk of cardiovascular hospitalisation. METHODS: We conducted a longitudinal cohort study of 1 451 409 parous women in Quebec, Canada. We compared patients with cardiac and non-cardiac birth defects of the urinary, central nervous and other systems against patients without defects between 1989 and 2022. The main outcome was hospitalisation for coronary artery disease, ischaemic stroke and other cardiovascular outcomes during 33 years of follow-up. We computed cardiovascular hospitalisation rates and used Cox proportional hazards regression models to measure the association (HR; 95% CI) between non-cardiac defects and later risk of cardiovascular hospitalisation, adjusted for patient characteristics. RESULTS: Women with any birth defect had a higher rate of cardiovascular hospitalisation than women without defects (7.0 vs 3.3 per 1000 person-years). Non-cardiac defects overall were associated with 1.61 times the risk of cardiovascular hospitalisation over time, compared with no defect (95% CI 1.56 to 1.66). Isolated urinary (HR 3.93, 95% CI 3.65 to 4.23), central nervous system (HR 3.33, 95% CI 2.94 to 3.76) and digestive defects (HR 2.39, 95% CI 2.16 to 2.65) were associated with the greatest risk of cardiovascular hospitalisation. These anomalies were associated with cardiovascular hospitalisation whether they presented alone or clustered with other defects. Nevertheless, heart defects were associated with the greatest risk of cardiovascular hospitalisation (HR 10.30, 95% CI 9.86 to 10.75). CONCLUSION: The findings suggest that both cardiac and non-cardiac birth defects are associated with an increased risk of developing cardiovascular disease among parous women.
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Hospitalización , Humanos , Femenino , Hospitalización/estadística & datos numéricos , Quebec/epidemiología , Persona de Mediana Edad , Adulto , Estudios Longitudinales , Enfermedades Cardiovasculares/epidemiología , Factores de Riesgo , Medición de Riesgo , Factores de Tiempo , Anomalías Congénitas/epidemiologíaRESUMEN
BACKGROUND: Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. METHODS: The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. RESULTS: Among 3665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10-point increase and decrease from 4 to 24 hours, respectively. The 4 and 24-hour VIS were each associated with cardiac intensive care unit mortality (13%-45% and 11%-73% for VIS <10 to ≥40, respectively; Ptrend <0.0001 for each). Stratifying by the 4-hour VIS, changes in VIS from 4 to 24 hours had a graded association with mortality, ranging from a 2- to >4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS (Ptrend <0.0001). The change in VIS alone provided good discrimination of cardiac intensive care unit mortality (C-statistic, 0.72 [95% CI, 0.70-0.75]) and improved discrimination of the 24-hour Sequential Organ Failure Assessment score (0.72 [95% CI, 0.69-0.74] to 0.76 [95% CI, 0.74-0.78]) and the clinician-assessed Society for Cardiovascular Angiography and Interventions shock stage (0.72 [95% CI, 0.70-0.74] to 0.77 [95% CI, 0.75-0.79]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with versus without mechanical circulatory support (odds ratio per 10-point higher 24-hour VIS, 1.36 [95% CI, 1.23-1.49] versus 1.84 [95% CI, 1.69-2.01]; Pinteraction <0.0001). CONCLUSIONS: Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.
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Sistema de Registros , Choque Cardiogénico , Humanos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapia , Masculino , Femenino , Anciano , Persona de Mediana Edad , Cuidados Críticos/métodos , Factores de Tiempo , Mortalidad Hospitalaria , Pronóstico , Medición de RiesgoRESUMEN
BACKGROUND: Severe lung disease frequently presents with both refractory hypoxemia and right ventricular (RV) failure. Right ventricular assist device with an oxygenator (OxyRVAD) is an extracorporeal membrane oxygenation (ECMO) configuration of RV bypass that also supplements gas exchange. This systematic review summarises the available literature regarding the use of OxyRVAD in the setting of severe lung disease with associated RV failure. METHODS: PubMed, Embase, and Google Scholar were queried on September 27, 2023, for articles describing the use of an OxyRVAD configuration. The main outcome of interest was survival to intensive care unit (ICU) discharge. Data on the duration of OxyRVAD support and device-related complications were also recorded. RESULTS: Out of 475 identified articles, 33 were retained for analysis. Twenty-one articles were case reports, and 12 were case series, representing a total of 103 patients. No article provided a comparison group. Most patients (76.4%) were moved to OxyRVAD from another type of mechanical support. OxyRVAD was used as a bridge to transplant or curative surgery in 37.4% and as a bridge to recovery or decision in 62.6%. Thirty-one patients (30.1%) were managed with the dedicated single-access dual-lumen ProtekDuo cannula. Median time on OxyRVAD was 12 days (interquartile range 8-23 days), and survival to ICU discharge was 63.9%. Device-related complications were infrequently reported. CONCLUSION: OxyRVAD support is a promising alternative for RV support when gas exchange is compromised, with good ICU survival in selected cases. Comparative analyses in patients with RV failure with and without severe lung disease are needed.
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Background: Myocardial infarction with nonobstructive coronary artery disease (MINOCA) is defined as acute myocardial infarction (AMI) with angiographically nonobstructive coronary artery disease. MINOCA represents 6% of all AMI cases and is associated with increased mortality and morbidity. However, the wide array of pathophysiological factors and causes associated with MINOCA presents a diagnostic conundrum. Therefore, we conducted a contemporary systematic review of the pathophysiology of MINOCA. Methods: A comprehensive systematic review of MINOCA was carried out through the utilization of the PubMed database. All systematic reviews, meta-analyses, randomized controlled trials, and cohort studies available in English or French that reported on the pathophysiology of MINOCA published after January 1, 2013 were retained. Results: Of the 600 identified records, 80 records were retained. Central to the concept of MINOCA is the definition of AMI, characterized by the presence of myocardial damage reflected by elevated cardiac biomarkers in the setting of acute myocardial ischemia. As a result, a structured approach should be adopted to thoroughly assess and address clinically overlooked obstructive coronary artery disease, and cardiac and extracardiac mechanisms of myocyte injury. Once these options have been ruled out, a diagnosis of MINOCA can be established, and the appropriate multimodal assessment can be conducted to determine its specific underlying cause (plaque disruption, epicardial coronary vasospasm, coronary microvascular dysfunction, and coronary embolism and/or spontaneous coronary dissection or supply-demand mismatch). Conclusions: Integrating a suitable definition of AMI and understanding the pathophysiological mechanisms of MINOCA are crucial to ensure an effective multimodal diagnostic evaluation and the provision of adequate tailored therapies.
Contexte: L'infarctus du myocarde sans obstruction des artères coronaires (MINOCA) est défini comme un infarctus aigu du myocarde (IAM) en présence d'une coronaropathie non obstructive confirmée par angiographie. Le MINOCA représente 6 % de tous les cas d'IAM et est associé à une hausse des taux de mortalité et de morbidité. Cependant, le large éventail de facteurs physiopathologiques et de causes associés au MINOCA représente une énigme diagnostique. C'est pourquoi nous avons réalisé une analyse systématique des publications contemporaines sur la physiopathologie du MINOCA. Méthodologie: Une analyse exhaustive des publications sur le MINOCA a été menée au moyen de la base de données PubMed. L'ensemble des analyses systématiques, des méta-analyses, des essais contrôlés randomisés et des études de cohorte publiés en anglais ou en français après le 1er janvier 2013 qui faisaient état de la physiopathologie du MINOCA ont été retenus. Résultats: Parmi les 600 dossiers relevés, 80 ont été retenus. La définition de l'IAM était centrale au concept de MINOCA et était caractérisée par la présence d'une lésion myocardique attestée par des taux élevés de biomarqueurs cardiaques en contexte d'ischémie myocardique aiguë. Par conséquent, une approche structurée devrait être adoptée pour évaluer pleinement et traiter les coronaropathies obstructives qui passent inaperçues en clinique ainsi que les mécanismes cardiaques et extracardiaques des lésions aux myocytes. Une fois ces options exclues, un diagnostic de MINOCA peut être établi et l'évaluation multimodale appropriée peut être menée pour déterminer la cause sous-jacente précise (rupture de plaque, vasospasme d'une artère coronaire épicardique, dysfonction microvasculaire coronarienne et embolie coronarienne et/ou dissection spontanée d'une artère coronaire ou déséquilibre entre apports et besoins). Conclusions: Il est crucial d'intégrer une définition convenable de l'IAM et de comprendre les mécanismes physiopathologiques du MINOCA pour assurer une évaluation diagnostique multimodale efficace et une prestation de traitements adaptés et adéquats.
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Background: In patients with anterior ST-elevation myocardial infarction (STEMI) and new-onset antero-apical wall motion abnormalities (WMAs), whether the rate of prophylaxis against left ventricular thrombus and outcomes differ between men and women is unknown. Methods: A multicentre retrospective cohort study of patients with STEMI and new-onset antero-apical WMAs treated with primary percutaneous coronary intervention was conducted. Patients with an established indication of oral anticoagulation (OAC) were excluded. The rates of triple therapy (double antiplatelet therapy + OAC) at discharge were compared for women vs men. The rates of net adverse clinical events, a composite of mortality, myocardial infarction, stroke or transient ischemic attack, systemic thromboembolism or Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding at 6 months were compared across sex using a multivariate logistic regression model. Results: A total of 1664 patients were included in the primary analysis, of whom 402 (24.2%) were women and 1262 (75.8%) were men. A total of 138 women (34.3%) and 489 men (38.7%) received a triple therapy prescription at discharge (P = 0.11). At 6 months, 33 women (8.2%) and 96 men (7.6%) experienced a net adverse clinical event (adjusted odds ratio 0.82; 95% confidence interval 0.49-1.37). No difference occurred in the risk of bleeding events and ischemic events between men and women, when these were analyzed separately. Conclusions: The rates of OAC prescription for left ventricular thrombus prophylaxis and clinical outcomes at 6 months were similar in women and men following anterior STEMI with new-onset antero-apical WMAs.
Contexte: On ignore si le taux de prophylaxie contre le thrombus ventriculaire gauche et les résultats thérapeutiques diffèrent entre les hommes et les femmes qui ont subi un infarctus du myocarde avec élévation du segment ST (STEMI) antérieur et ont des anomalies du mouvement pariétal (AMP) antéroapical d'apparition récente. Méthodes: Nous avons mené une étude de cohorte rétrospective multicentrique auprès de patients qui ont subi un STEMI et ont des AMP d'apparition récente traitées par une intervention coronarienne percutanée primaire. Nous avons exclu les patients chez lesquels il existait une indication établie à l'anticoagulation orale (ACO). Nous avons comparé les taux de trithérapie (bithérapie antiplaquettaire + ACO) à la sortie de l'hôpital entre les femmes et les hommes. Nous avons comparé les taux d'événements indésirables cliniques nets, le critère composite de mortalité, d'infarctus du myocarde, d'accident vasculaire cérébral ou d'accident ischémique transitoire, la thromboembolie systémique ou l'hémorragie de type 3 ou 5 selon le Bleeding Academic Research Consortium (BARC) après 6 mois entre les sexes au moyen du modèle de régression logistique multivariée. Résultats: Au sein des 1 664 patients de l'analyse principale, 402 (24,2 %) étaient des femmes et 1262 (75,8 %) étaient des hommes. Un total de 138 femmes (34,3 %) et de 489 hommes (38,7 %) ont reçu une ordonnance de trithérapie à la sortie de l'hôpital (P = 0,11). Après 6 mois, 33 femmes (8,2 %) et 96 hommes (7,6 %) ont subi un événement indésirable net (rapport de cotes ajusté 0,82 ; intervalle de confiance à 95 % 0,49-1,37). Aucune différence n'a été notée dans le risque d'événements hémorragiques et d'événements ischémiques entre les hommes et les femmes lorsque ces événements étaient analysés séparément. Conclusions: Les taux d'ordonnances d'ACO en prophylaxie du thrombus ventriculaire gauche et les résultats cliniques après 6 mois étaient similaires entre les femmes et les hommes à la suite du STEMI antérieur et des AMP antéroapicale d'apparition récente.
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Background: Cardiovascular disease continues to be the primary cause of premature mortality in women, who previously have been overlooked in clinical trials. Several studies showed that women undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) present more cardiovascular risk factors at baseline, develop more postprocedural complications, and have a higher mortality rate than men. The goal of this review is to analyze the difference between men and women in terms of the prevalence of individual cardiovascular risk factors. Methods: A meta-analysis was conducted of original investigations with adult subjects who underwent surgical intervention or PCIs in which cardiovascular risk factors were evaluated, using the MEDLINE, Cochrane, Evidence-Based Medicine Reviews (EBMR), Ovid Embase, Google Scholar, and PubMed databases. Results: Of the 4567 identified records found, 18 were retained for qualitative analysis. Prevalence of hypertension (CABG: 71% (95% confidence interval [CI] 64%, 78%]); PCI: (59% [95% CI 48%,70%]), and diabetes (CABG: 48% [95% CI 38%, 57%]); PCI 43% (95% CI 27%, 59%]) was high in women. Women who underwent either CABG or PCI had higher odds of having hypertension (CABG: odds ratio [OR] 1.92 [95% CI 1.47-2.50], P < 0.05); PCI: OR 1.86 [95% CI 1.76-1.97], P < 0.05]), and diabetes (CABG: OR 1.94 [95% CI 1.55-2.42], P < 0.05; PCI: OR 1.97 [95% CI 1.54-2.53], P < 0.05)). However, the prevalence of smoking among women, compared to men, was lower (CABG: 0.17 [95% CI 0.06-0.52], P < 0.05; PCI: 0.22 [95% CI 0.06-0.86], P < 0.03). Conclusion: The review shows that women who underwent either surgical or percutaneous revascularization had higher odds of hypertension and diabetes, compared to men.
Contexte: Les maladies cardiovasculaires demeurent la principale cause de décès prématurés chez les femmes, qui ont antérieurement été négligées dans les essais cliniques. Or, plusieurs études ont révélé que les femmes qui subissent un pontage aortocoronarien (PAC) ou une intervention coronarienne percutanée (ICP) présentent initialement plus de facteurs de risque cardiovasculaire, connaissent plus de complications postopératoires et affichent un taux de mortalité plus élevé que les hommes. Cette analyse visait à dégager les différences entre les hommes et les femmes quant à la prévalence de chacun des facteurs de risque cardiovasculaire. Méthodologie: Une méta-analyse a été menée sur des enquêtes originales auprès d'adultes ayant subi une intervention chirurgicale ou des ICP chez qui les facteurs de risque cardiovasculaire ont été évalués. Les bases de données interrogées étaient les suivantes : MEDLINE, Cochrane, Evidence-Based Medicine Reviews (EBMR), Ovid Embase, Google Scholar et PubMed. Résultats: Parmi les 4567 dossiers recensés, 18 ont été retenus pour une analyse qualitative. La prévalence de l'hypertension (PAC : 71 % [intervalle de confiance {IC} à 95 % : 64 %; 78 %]); ICP : 59 % [IC à 95 % : 48 %; 70 %]) et du diabète (PAC : 48 % [IC à 95 % : 38 %; 57 %]); ICP : 43 % (IC à 95 % : 27 %; 59 %]) était élevée chez les femmes. Les femmes qui ont subi un PAC ou une ICP présentaient un risque accru d'hypertension (PAC : rapport de cotes [RC] de 1.92 [IC à 95 % : 1,47-2,50], p < 0,05); ICP : RC de 1,86 [IC à 95 % : 1,76-1,97], p < 0,05]) et de diabète (PAC : RC de 1,94 [IC à 95 % : 1,55-2,42], p < 0,05; ICP : RC de 1,97 [IC à 95 % : 1,54-2,53], p < 0,05). Cependant, le tabagisme était moins prévalent chez les femmes que chez les hommes (PAC : 0,17 [IC à 95 % : 0,06-0,52], p < 0,05; ICP : 0,22 [IC à 95 % : 0,06-0,86], p < 0,03). Conclusion: L'analyse révèle que, par rapport aux hommes, les femmes qui ont subi une revascularisation chirurgicale ou percutanée présentaient plus de risque d'hypertension et de diabète.
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BACKGROUND: Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. METHODS: The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17â 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. RESULTS: The median age of the study population was 66 (56-77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%-87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST-elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. CONCLUSIONS: In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.
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Cardiología , Monitorización Hemodinámica , Anciano , Femenino , Humanos , Masculino , Unidades de Cuidados Coronarios , Cuidados Críticos , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Sistema de Registros , Estados Unidos/epidemiología , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Ensayos Clínicos como AsuntoRESUMEN
BACKGROUND: Several two-sample Mendelian randomization studies have reported discordant results concerning the association between grip strength and cardiovascular disease, possibly due to the number of instrumental variables used, pleiotropic bias, and/ or effect modification by age and sex. METHODS: We conducted a sex- and age-stratified one-sample Mendelian randomization study in the Canadian Longitudinal Study on Aging. We investigated whether grip strength is associated with carotid intima media thickness (cIMT), a marker of vascular atherosclerosis event risk, using eighteen single nucleotide polymorphisms (SNP) identified as specifically associated with grip strength. RESULTS: A total of 20,258 participants of self-reported European ancestry were included in the analytic sample. Our Mendelian randomization findings suggest a statistically significant association between grip strength and cIMT (MR coefficient of 0.02 (95% CI: 0.01, 0.04)). We found no statistically significant differences between sexes (p-value = 0.201), or age groups [(≤ 60 years old versus >60 years old); p-value = 0.421]. CONCLUSION: This study provides evidence that grip strength is inversely associated with cIMT. Our one-sample MR study design allowed us to demonstrate that there is no evidence of heterogeneity of effects according to age group or biological sex.
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Enfermedades de las Arterias Carótidas , Grosor Intima-Media Carotídeo , Humanos , Persona de Mediana Edad , Estudios Longitudinales , Análisis de la Aleatorización Mendeliana , Factores de Riesgo , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/epidemiología , Enfermedades de las Arterias Carótidas/genética , Canadá/epidemiología , Envejecimiento/genética , Fuerza de la ManoRESUMEN
Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.
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Síndrome Coronario Agudo , Cardiología , Intervención Coronaria Percutánea , Humanos , Inhibidores de Agregación Plaquetaria , Canadá , Revisiones Sistemáticas como Asunto , Síndrome Coronario Agudo/tratamiento farmacológico , Resultado del TratamientoRESUMEN
BACKGROUND: A strategy of administering a transfusion only when the hemoglobin level falls below 7 or 8 g per deciliter has been widely adopted. However, patients with acute myocardial infarction may benefit from a higher hemoglobin level. METHODS: In this phase 3, interventional trial, we randomly assigned patients with myocardial infarction and a hemoglobin level of less than 10 g per deciliter to a restrictive transfusion strategy (hemoglobin cutoff for transfusion, 7 or 8 g per deciliter) or a liberal transfusion strategy (hemoglobin cutoff, <10 g per deciliter). The primary outcome was a composite of myocardial infarction or death at 30 days. RESULTS: A total of 3504 patients were included in the primary analysis. The mean (±SD) number of red-cell units that were transfused was 0.7±1.6 in the restrictive-strategy group and 2.5±2.3 in the liberal-strategy group. The mean hemoglobin level was 1.3 to 1.6 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group on days 1 to 3 after randomization. A primary-outcome event occurred in 295 of 1749 patients (16.9%) in the restrictive-strategy group and in 255 of 1755 patients (14.5%) in the liberal-strategy group (risk ratio modeled with multiple imputation for incomplete follow-up, 1.15; 95% confidence interval [CI], 0.99 to 1.34; P = 0.07). Death occurred in 9.9% of the patients with the restrictive strategy and in 8.3% of the patients with the liberal strategy (risk ratio, 1.19; 95% CI, 0.96 to 1.47); myocardial infarction occurred in 8.5% and 7.2% of the patients, respectively (risk ratio, 1.19; 95% CI, 0.94 to 1.49). CONCLUSIONS: In patients with acute myocardial infarction and anemia, a liberal transfusion strategy did not significantly reduce the risk of recurrent myocardial infarction or death at 30 days. However, potential harms of a restrictive transfusion strategy cannot be excluded. (Funded by the National Heart, Lung, and Blood Institute and others; MINT ClinicalTrials.gov number, NCT02981407.).
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Anemia , Transfusión Sanguínea , Infarto del Miocardio , Humanos , Anemia/sangre , Anemia/etiología , Anemia/terapia , Transfusión Sanguínea/métodos , Transfusión de Eritrocitos/efectos adversos , Transfusión de Eritrocitos/métodos , Hemoglobinas/análisis , Infarto del Miocardio/sangre , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , RecurrenciaRESUMEN
AIMS: Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. METHODS AND RESULTS: The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018-2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th-75th percentile, 1.6-2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66-86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. CONCLUSION: In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.
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Hemodinámica , Choque Cardiogénico , Humanos , Pronóstico , Resistencia Vascular , LactatosRESUMEN
Background: Adherence to guidelines is associated with better patient outcomes. Although studies show suboptimal adherence to cardiovascular prevention guidelines among general practitioners, adherence among specialist physicians is understudied. The aim of this analysis was to identify practice gaps among cardiologists in a tertiary academic centre. Methods: We retrospectively audited cardiology outpatient clinic notes taken at the Cardiology Clinic at the Centre hospitalier de l'Université de Montréal (CHUM), from the period January 1, 2019 to February 28, 2019. Data were abstracted from hospital medical records. The primary outcome of interest was the rate of adherence to cardiovascular prevention guidelines. We compared the chart-documented practice at our centre to the Canadian hypertension, lipid, diabetes, antiplatelet, and heart failure guidelines in effect at the time of the audit. We also collected information regarding discussions of smoking, alcohol consumption, physical activity, and diet. Results: A total of 2503 patients were included, with a mean age of 65.6 ± 14.5 years. Dyslipidemia occurred in 63% of patients, hypertension in 55%, and coronary artery disease in 41%. Optimal low-density lipoprotein control was documented as having been achieved in just 39% of cases. Blood pressure control was adequate for 65% of patients, and glycemic control was achieved in 47% of patients with diabetes. Heart failure treatment was optimal in 34% of patients. Nearly all patients with coronary artery disease (95%) had appropriate antithrombotic therapy. The incidence of discussion of nonpharmacologic interventions varied, ranging from 91% (smoking) to 16% (diet). Conclusions: Primary and secondary prevention of cardiovascular events was found to be suboptimal in an academic tertiary-care outpatient cardiology clinic and may be representative of similar shortcomings nationwide. Strategies to ensure guideline adherence are needed.
Contexte: Le respect des lignes directrices est associé à de meilleurs résultats pour les patients. Bien que les études montrent que les omnipraticiens adhèrent de façon sous-optimale aux lignes directrices en matière de prévention des événements cardiovasculaires, l'observance chez les médecins spécialistes n'a pas été assez étudiée. Notre analyse a pour objectif de déceler les lacunes dans la pratique des cardiologues exerçant dans des centres universitaires de soins tertiaires. Méthodologie: Nous avons examiné de manière rétrospective les notes cliniques consignées au dossier des patients du Centre cardiovasculaire du Centre hospitalier de l'Université de Montréal (CHUM) et résumé les données issues des consultations ayant eu lieu du 1er janvier au 28 février 2019. Le principal résultat d'intérêt était le taux d'adhésion aux lignes directrices en matière de prévention des événements cardiovasculaires. Nous avons comparé les pratiques enregistrées dans les dossiers de notre centre aux lignes directrices canadiennes sur la prise en charge de l'hypertension, de la lipidémie, du diabète, du traitement antiplaquettaire et de l'insuffisance cardiaque en place au moment de l'évaluation. Nous avons aussi recueilli de l'information sur les discussions entourant le tabagisme, la consommation d'alcool, l'activité physique et l'alimentation. Résultats: Les données de 2 503 patients, âgés en moyenne de 65,6 ± 14,5 ans, ont été retenues. De ces patients, 63 % présentaient une dyslipidémie, 55 %, une hypertension et 41 %, une maladie coronarienne. Le taux de lipoprotéines de basse densité n'était maîtrisé de façon optimale que dans 39 % des cas. La normalisation de la pression artérielle était adéquate chez 65 % des patients, et 47 % des patients diabétiques atteignaient les cibles glycémiques. L'insuffisance cardiaque était optimalement traitée chez 34 % des patients. Presque tous les patients atteints de maladie coronarienne (95 %) recevaient un traitement antithrombotique approprié. La fréquence des discussions sur les interventions non pharmacologiques variait, allant de 91 % dans le cas du tabagisme à 16 % dans celui de l'alimentation. Conclusions: La prévention primaire et secondaire des événements cardiovasculaires s'est révélée sous-optimale dans une clinique externe de cardiologie d'un hôpital universitaire et pourrait être représentative de lacunes similaires dans l'ensemble du pays. Des stratégies visant à assurer le respect des lignes directrices sont nécessaires.
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It is increasingly recognized that strong geographic variations in cardiovascular risk cannot be explained using traditional cardiovascular risk factors alone. Indeed, it is highly unlikely that heredity and classic risk factors such as hypertension, diabetes, dyslipidemia, and tobacco use can explain the tenfold variation observed in cardiovascular mortality among men in Russia and those in Switzerland. Since the advent of industrialization and resultant changes to our climate, it is now clear that environmental stressors also influence cardiovascular health and our thinking around cardiovascular risk prediction is in need of a paradigm shift. Herein, we review the basis for this shift in our understanding of the interplay of environmental factors with cardiovascular health. We illustrate how air pollution, hyperprocessed foods, the amount of green space, and population activity levels are now considered the 4 major environmental determinants of cardiovascular health and provide a framework for how these considerations might be incorporated into clinical risk assessment. We also outline the clinical and socioeconomic effects of the environment on cardiovascular health and review key recommendations from major medical societies.
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Contaminación del Aire , Enfermedades Cardiovasculares , Sistema Cardiovascular , Hipertensión , Masculino , Humanos , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/etiología , Exposición a Riesgos Ambientales/efectos adversos , Contaminación del Aire/efectos adversos , Hipertensión/complicaciones , Factores de RiesgoRESUMEN
Background Hyperemesis gravidarum is associated with preeclampsia, but it is unclear whether hyperemesis gravidarum is a risk factor for cardiovascular disease. We assessed the long-term risk of cardiovascular disease in women who experienced hyperemesis gravidarum with or without preeclampsia. Methods and Results We analyzed a longitudinal cohort of 1 413 166 pregnant women in Quebec between 1989 and 2021. Women were followed from their first pregnancy up to 3 decades later. We computed hazard ratios (HRs) and 95% CIs for the association of hyperemesis gravidarum, preeclampsia, or both conditions with subsequent risk of cardiovascular hospitalization using Cox regression models adjusted for baseline characteristics. Among 1 413 166 women, 16 288 (1.2%) had hyperemesis gravidarum only, 69 645 (4.9%) preeclampsia only, and 1103 (0.08%) had both conditions. After 32 years of follow-up, cardiovascular disease incidence was 17.7 per 100 women with hyperemesis gravidarum only, 28.2 per 100 women with preeclampsia only, 30.9 per 100 women with both exposures, and 14.0 per 100 women with neither exposure. Compared with no exposure, women with both hyperemesis and preeclampsia had the greatest risk of cardiovascular hospitalization (HR, 3.54 [95% CI, 3.03-4.14]), followed by women with preeclampsia only (HR, 2.58 [95% CI, 2.51-2.64]) and hyperemesis only (HR, 1.46 [95% CI, 1.38-1.54]). Having both hyperemesis gravidarum and preeclampsia was strongly associated with valve disease (HR, 3.38 [95% CI, 1.69-6.75]), heart failure (HR, 3.43 [95% CI, 1.79-6.59]), and cardiomyopathy (HR, 4.17 [95% CI, 1.99-8.76]). Conclusions Hyperemesis gravidarum is associated with the development of cardiovascular disease, whether preeclampsia is present or not.
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Enfermedades Cardiovasculares , Hiperemesis Gravídica , Preeclampsia , Humanos , Femenino , Embarazo , Hiperemesis Gravídica/epidemiología , Hiperemesis Gravídica/complicaciones , Preeclampsia/epidemiología , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/complicaciones , Modelos de Riesgos Proporcionales , Factores de RiesgoRESUMEN
BACKGROUND: Most approaches to the creation of an interatrial shunt require placement of a permanent implant to maintain patency. OBJECTIVES: The goal of this study was to investigate the safety and efficacy of a no-implant interatrial shunt for patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF). METHODS: This was a multicenter, uncontrolled study of patients with HFpEF/HFmrEF and NYHA functional class ≥II, ejection fraction >40%, and pulmonary capillary wedge pressure (PCWP) during supine exercise ≥25 mm Hg with PCWP-to-right atrial gradient ≥5 mm Hg. Follow-up was through 6 months with imaging to assess shunt durability. RESULTS: A total of 28 patients were enrolled: mean age was 68 ± 9 years, and 68% were female. Baseline resting and peak exercise PCWP were 19 ± 7 mm Hg and 40 ± 11 mm Hg, respectively. All procedures displayed technical success with confirmation of left-to-right flow (shunt diameter 7.1 ± 0.9 mm). At 1 month, peak exercise PCWP decreased 5.4 ± 9.6 mm Hg (P = 0.011) with no change in right atrial pressure. There were no serious device or procedure-related adverse events through 6 months. Mean 6-minute walk distance increased 101 ± 71 meters (P < 0.001); Kansas City Cardiomyopathy Questionnaire Overall Summary Score increased 26 ± 19 points (P < 0.001); N-terminal pro-B-type natriuretic peptide decreased 372 ± 857 pg/mL (P = 0.018); and shunt patency was confirmed with unchanged diameter. CONCLUSIONS: In these feasibility studies of a no-implant interatrial shunt, HFpEF/HFmrEF shunts exhibited stability with favorable safety and early efficacy signals. The results show promise toward this new approach for treating patients with HFpEF/HFmrEF and an appropriate hemodynamic profile. (Evaluation of the Safety and Feasibility of a Percutaneously Created Interatrial Shunt to Alleviate Heart Failure Symptoms in Patients With Chronic Heart Failure and Preserved or Mid-Range Left Ventricular Ejection Fraction [ALLEVIATE-HF-1]; NCT04583527; Evaluation of the Safety and Effectiveness of a Percutaneously Created Interatrial Shunt to Alleviate Heart Failure Symptoms in Patients With Chronic Heart Failure and Preserved or Mid-Range Left Ventricular Ejection Fraction [ALLEVIATE-HF-2]; NCT04838353).
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Insuficiencia Cardíaca , Disfunción Ventricular Izquierda , Humanos , Femenino , Persona de Mediana Edad , Anciano , Masculino , Volumen Sistólico , Función Ventricular Izquierda , Estudios de Factibilidad , Cateterismo Cardíaco , Disfunción Ventricular Izquierda/etiologíaRESUMEN
Background: The management of atrial fibrillation and flutter (AF) patients undergoing percutaneous coronary intervention (PCI) has evolved rapidly in the past decade. We determine whether the publication of the 2016 Canadian Cardiovascular Society AF guidelines were associated with a shift in practice patterns. Methods: Using Quebec provincial administrative database information for the period from 2010-2017, a retrospective cohort of patients with inpatient or outpatient coding for AF, who subsequently underwent PCI with placement of a coronary stent, was created and analyzed for the antithrombotic regimen received in the following year. Prescribing behavior was compared among 3 time periods (2010-2011, 2012-2015, 2016-2017), and use of antithrombotics was compared to guideline-predicted therapy using the χ2 test. Predictors of oral anticoagulation (OAC) prescription were identified using adjusted logistic regression. Results: A total of 3740 AF patients undergoing PCI were included. The proportion of OAC prescription increased over time (2010-2011 = 51.4%; 2012-2015 = 54.3%; 2016-2017 = 56.6%; P = 0.13), with a significant increase in direct OAC prescription (P < 0.01). A substantial treatment gap in OAC prescription persisted after publication of the 2016 guidelines (56.6% observed vs 89.7% predicted; P < 0.01). Previous stroke, CHADS2 score, Charlson Comorbidity Index ≥ 4, and prior use of direct OAC or warfarin were predictors of being exposed to OAC claims; previous major bleeding, and low-dose acetylsalicylic acid or P2Y12 inhibitor use were predictors of not being exposed to OACs. Conclusion: Expert guidance contributed to an increase in OAC prescription following PCI, but up to 2017, substantial further changes in practice patterns would have been required to achieve the recommended rates of OAC prescription.
Contexte: La prise en charge des patients qui sont atteints de fibrillation auriculaire (FA) ou de flutter auriculaire et qui subissent une intervention coronarienne percutanée (ICP) a évolué rapidement au cours de la dernière décennie. Nous avons voulu déterminer si la publication des lignes directrices sur la fibrillation auriculaire de la Société canadienne de cardiologie en 2016 s'était traduite par un changement de pratiques. Méthodologie: À partir de renseignements recueillis dans la base de données administratives du Québec en ciblant la période allant de 2010 à 2017, nous avons créé une cohorte rétrospective de patients qui, selon le code diagnostique, avaient été hospitalisés ou reçus en consultation externe pour cause de FA ou de flutter auriculaire et qui avaient par la suite subi une ICP avec mise en place d'une endoprothèse coronaire. La cohorte a été l'objet d'une analyse visant à caractériser le traitement antithrombotique administré au cours de l'année suivant l'opération, et le comportement des prescripteurs a été comparé sur trois périodes (2010-2011, 2012-2015, 2016-2017). En outre, le recours aux antithrombotiques a été comparé au traitement prévu suivant les lignes directrices au moyen du test χ2. Les facteurs prédictifs de prescription d'anticoagulants oraux (ACO) ont été cernés par régression logistique corrigée. Résultats: Au total, 3 740 patients atteints de FA ou de flutter auriculaire et ayant subi une ICP ont été inclus dans la cohorte. La proportion d'ordonnances d'ACO a augmenté au fil du temps (2010-2011 = 51,4 %, 2012-2015 = 54,3 %, 2016-2017 = 56,6 %; P = 0,13), et la prescription d'ACO directs a connu une augmentation significative (P < 0,01). Un écart important sur le plan thérapeutique en matière de prescription d'ACO a persisté après la publication des lignes directrices en 2016 (proportion observée de 56,6 % vs proportion prévue de 89,7 %; P < 0,01). Les antécédents d'AVC, le score CHADS2, un indice de comorbidité de Charlson ≥ 4 et les antécédents de traitement par des ACO directs ou la warfarine étaient des facteurs prédictifs d'exposition aux ACO; les antécédents de saignement majeur et la prise à faible dose d'acide acétylsalicylique ou d'un inhibiteur de P2Y12 étaient des facteurs prédictifs de non-exposition aux ACO. Conclusion: Les avis des spécialistes ont contribué à une augmentation de la prescription d'ACO après une ICP. Toutefois, jusqu'en 2017, d'autres changements de pratique substantiels auraient été nécessaires pour atteindre les taux recommandés d'utilisation des ACO.
RESUMEN
BACKGROUND: The incidence of left ventricular thrombus (LVT) after anterior acute myocardial infarction (AMI) has not been well established in the era of primary percutaneous coronary intervention (pPCI) and potent dual antiplatelet therapy. The objective of this study is to establish the contemporary incidence of LVT in this population, to identify their risk factors, and to examine their association with clinical outcomes. METHODS: A multicenter retrospective cohort study including AMI patients with new-onset antero-apical wall motion abnormalities treated with pPCI between 2009 and 2017 was conducted. The primary outcome was LVT during the index hospitalization. Predictors of LVT were identified using multivariate logistic regression. Net adverse clinical events (NACE), a composite of mortality, myocardial infarction, stroke or transient ischemic attack, systemic thromboembolism or BARC type 3 or 5 bleeding at 6 months were compared between the LVT and no LVT groups. RESULTS: Among the 2136 patients included, 83 (3.9%) patients developed a LVT during index hospitalization. A lower left ventricular ejection fraction (LVEF) [adjusted odds ratio (aOR) 0.97; 95% confidence intervals (CI) 0.94-0.99] and the degree of worse anterior WMA (aOR 4.34; 95% CI 2.24-8.40) were independent predictors of LVT. A NACE occurred in 5 (5.72 per 100 patient-year) patients in the LVT group and in 127 (6.71 per 100 patient-year) patients in the no LVT group at 6 months [adjusted hazard ratio (aHR): 0.87; 95% CI 0.35-2.14]. CONCLUSIONS: The risk of LVT after anterior AMI with new-onset wall motion abnormalities is low, but this complication remains present in the contemporary era of timely pPCI and potent dual antiplatelet therapy .