Low-dose prasugrel versus standard-dose ticagrelor in east Asian patients with acute coronary syndrome.

Low-dose prasugrel demonstrated a similar effectiveness profile to clopidogrel in East Asian ACS patients, but its comparison with another new-generation potent P2Y12 inhibitor, ticagrelor, remains unclear. To compare the effectiveness and safety of low-dose prasugrel against those of standard-dose ticagrelor in East Asian patients with ACS. This retrospective cohort study used Taiwan's National Health and Welfare Database. This study included ACS patients who underwent percutaneous coronary intervention and, at discharge between January 1, 2018 and December 31, 2020, were prescribed with low-dose prasugrel plus aspirin or standard-dose ticagrelor plus aspirin. Stabilized inverse probability of treatment weighting was used to balance the covariates across these two groups. The primary effectiveness outcome was a composite of acute myocardial infarction, ischemic stroke, and cardiovascular death; the secondary effectiveness outcome was each of the individual components of the primary outcome, transient ischemic attack, and repeat revascularization. The primary safety outcome was a composite of intracranial hemorrhage and gastrointestinal bleeding, and the two secondary safety outcomes were intracranial hemorrhage and gastrointestinal bleeding. A total of 24,807 patients were included in this study. Among them, 1,493 were low-dose prasugrel users and 23,314 were standard-dose ticagrelor users. No significant differences were found in primary effectiveness [HR: 0.97 (0.74-1.28)] or primary safety outcomes [HR: 1.22 (0.73-2.01)] between the two study groups. For East Asian patients with ACS, low-dose prasugrel provides comparable effectiveness without increasing bleeding risk compared to standard-dose ticagrelor. Low-dose prasugrel may be an appropriate alternative for East Asian populations.

Costs and Cardiovascular Benefits of a Fourth-Generation Synchronous Telehealth Program on Mortality and Cardiovascular Outcomes for Patients With Atrial Fibrillation: Retrospective Cohort Study.

BACKGROUND: The prevalence of atrial fibrillation (AF) continues to increase in modern aging society. Patients with AF are at high risk for multiple adverse cardiovascular events, including heart failure, stroke, and mortality. Improved medical care is needed for patients with AF to enhance their quality of life and limit their medical resource utilization. With advances in the internet and technology, telehealth programs are now widely used in medical care. A fourth-generation telehealth program offers synchronous and continuous medical attention in response to physiological parameters measured at home. Although we have previously shown the benefits of this telehealth program for some patients with a high risk of cardiovascular disease, its benefits for patients with AF remains uncertain. OBJECTIVE: This study aims to investigate the benefits of participating in a fourth-generation telehealth program for patients with AF in relation to cardiovascular outcomes. METHODS: This was a retrospective cohort study. We retrospectively searched the medical records database of a tertiary medical center in Northern Taiwan between January 2007 and December 2017. We screened 5062 patients with cardiovascular disease and enrolled 537 patients with AF, of which 279 participated in the telehealth program and 258 did not. Bias was reduced using the inverse probability of treatment weighting adjustment based on the propensity score. Outcomes were collected and analyzed, including all-cause readmission, admission for heart failure, acute coronary syndrome, ischemic stroke, systemic embolism, bleeding events, all-cause mortality, and cardiovascular death within the follow-up period. Total medical expenses and medical costs in different departments were also compared. Subgroup analyses were conducted on ischemic stroke stratified by several subgroup variables. RESULTS: The mean follow-up period was 3.0 (SD 1.7) years for the telehealth group and 3.4 (SD 1.9) years for the control group. After inverse probability of treatment weighting adjustment, the patients in the telehealth program had significantly fewer ischemic strokes (2.0 vs 4.5 events per 100 person-years; subdistribution hazard ratio [SHR] 0.45, 95% CI 0.22-0.92) and cardiovascular deaths (2.5 vs 5.9 events per 100 person-years; SHR 0.43, 95% CI 0.18-0.99) at the follow-up. The telehealth program particularly benefited patients comorbid with vascular disease (SHR 0.11, 95% CI 0.02-0.53 vs SHR 1.16, 95% CI 0.44-3.09; P=.01 for interaction). The total medical expenses during follow-up were similar in the telehealth and control groups. CONCLUSIONS: This study demonstrated the benefits of participating in the fourth-generation telehealth program for patients with AF by significantly reducing their ischemic stroke risk while spending the same amount on medical expenses.

Accurate Prediction of Retrograde Collateral Channel Crossing in Coronary Artery Chronic Total Occlusion Intervention.

Successful collateral channel (CC) crossing is an essential step in retrograde chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). We previously developed a dedicated CC score based on CC size and tortuosity to facilitate target CC selection. Validation and comparison to other scoring systems were lacking. Thus, the aims of this study were to (1) validate the CC score in a larger independent cohort, and (2) compare its accuracy and clinical usefulness with the J-channel score. All coronary CTO PCIs attempted by experienced high-volume operators from January 2017 to December 2021 were enrolled. The CC and J-channel scores were calculated for all attempted CCs with bi-plane high-resolution cine angiography images. CC crossing success was defined as guidewire reaching the distal true lumen retrogradely. In total, 502 patients who received CTO PCI were included. The retrograde approach was utilized in 244 target CTOs, and a total of 329 CCs were attempted. The overall CC crossing rate was 67.8% (223 of 329) and final technical success rate 92.2% (225 of 244). The average CC score was 2.0 and average J-channel score was 0.71. The sensitivity and specificity of successful CC crossing with the CC score ≥2 were 81.2%, and 84.0%, respectively. Comparison between the CC score (area under the curve 0.87; 95% confidence interval 0.83 to 0.90) and the J-channel score (area under the curve 0.61, 95% confidence interval 0.55 to 0.67) demonstrated superior predictive performance of the CC score (p <0.001). The CC score was an easy-to-use and accurate tool for the prediction of successful CC crossing in retrograde CTO PCI. The CC score can help operators select the ideal target CC, thereby facilitating final procedural success.

Predictors of Left Ventricular Ejection Fraction Improvement in Patients with Early-Stage Heart Failure with Reduced Ejection Fraction.

Objectives: To identify the predictors of left ventricular ejection fraction (LVEF) recovery in patients with heart failure with reduced ejection fraction (HFrEF) and compare the mortality rate between patients with HFrEF and heart failure with improved ejection fraction (HFimpEF). Methods: Patients in a post-acute care program from 2018 to 2021 were enrolled. A series of echocardiograms were arranged during follow-up. Mortality, cardiovascular death and sudden cardiac death events were recorded. A total of 259 patients were enrolled and followed for at least 1 year; 158 (61%) patients fulfilled the criteria of HFimpEF, 87 (33.6%) were defined as having persistent HFrEF, and 14 (5.4%) were defined as having heart failure with mildly reduced ejection fraction. The patients with HFimpEF and persistent HFrEF were included for analysis. Results: The mean follow-up duration was 1090 ± 414 days, and the median time to LVEF recovery was 159 days (IQR 112-289 days). Multivariate logistic regression analysis showed that beta-blocker prescription was the only independent predictor of HFimpEF [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.10-4.08, p = 0.03]. Diagnosis of ischemic cardiomyopathy (ICM) and QRS duration ≥ 110 ms were negative predictors of HFimpEF (OR 0.49, 95% CI 0.27-0.88, p = 0.02, and OR 0.4, 95% CI 0.21-0.77, p = 0.005, respectively). The patients with HfimpEF had a significantly better prognosis with lower mortality (hazard ratio 0.2, 95% CI 0.08-0.50, log-rank p < 0.001) than the patients with persistent HFrEF. Conclusions: Beta-blocker prescription was an independent predictor of HFimpEF, while the diagnosis of ICM and QRS duration ≥ 110 ms were negative predictors of HFimpEF. Patients with HfimpEF had a significantly lower mortality rate compared to those with persistent HFrEF.

Renal Impact of Culprit-Only versus Multi-Vessel Revascularization for Cardiogenic Shock Complicating Acute Myocardial Infarction: Systematic Review and Meta-Analysis.

Background: The optimal strategy of percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) complicated with cardiogenic shock (CS) remains controversial. We aimed to elucidate the renal and cardiovascular impact of culprit-only (C) revascularization versus additional interventions on non-infarct-related arteries. Methods: PubMed, Embase, MEDLINE, and Cochrane Library were searched for relevant literature. A total of 96,812 subjects [C-PCI: 69,986; multi-vessel (MV)-PCI: 26,826] in nine studies (one randomized control trial; eight observational cohort studies) were enrolled. Results: MV-PCI was associated with a higher kidney event rate [relative risk (RR): 1.29, 95% confidence interval (CI): 1.12-1.49; p < 0.001]. However, the all-cause mortality rate was comparable both during admission (RR: 1.07, 95% CI: 0.94-1.22; p = 0.30) and at one year (RR: 0.96, 95% CI: 0.79-1.16; p = 0.65). MV-PCI was associated with a greater risk of stroke (RR: 1.19, 95% CI: 1.08-1.32; p < 0.001) and bleeding events (RR: 1.27, 95% CI: 1.07-1.51; p = 0.006), but reduced risk of recurrent MI (RR: 0.89, 95% CI: 0.82-0.97; p = 0.009) and repeat revascularization (RR: 0.34, 95% CI: 0.16-0.71; p = 0.004). No increased risk of coronary artery bypass grafting was present (RR: 1.09, 95% CI: 0.38-3.17; p = 0.87). Conclusions: C-PCI was associated with a lower rate of renal dysfunction but not all-cause mortality in patients with CS complicating acute MI.

Results of streamlining TAVR procedure towards a minimalist approach: a single center experience in Taiwan.

Trans-femoral transcatheter aortic valve replacement (TF-TAVR) performed under conscious sedation (LACS) is not yet become routine practice in Taiwan. We aimed to compared the results between patients received general anesthesia (GA) versus LACS. Our cohort was divided into 3 groups: initial 48 patients received TF-TAVR under routine GA (GA group), subsequent 50 patients under routine LACS (LACS group 1), and recent 125 patients under LACS (LACS group 2). The baseline, procedural characteristics and all outcomes were prospectively collected and retrospectively compared. From Sep 2010 to July 2019, a total of 223 patients were included. The procedure time (157.6 ± 39.4 min vs 131.6 ± 30.3 vs 95.2 ± 40.0, < 0.0001), contrast medium consumption (245.6 ± 92.6 ml vs 207.8 ± 77.9 vs 175.1 ± 64.6, < 0.0001), length of intensive care unit (2 [1-5] days vs 2 [1-3] vs 1 [1-1], P = 0.0001) and hospital stay (9 [7-13] days vs 8 [6-11] vs 6 [5-9], P = 0.0001) decreased significantly with LACS, combined with a trend of less hospital acquired pneumonia (12.5% vs 6.0% vs 5.6%, P = 0.427). 1-year survival rate were also different among 3 groups (83.3% vs 90.0% vs 93.6%, P = 0.053). In our single center experience, a "minimalist" approach of TF-TAVR procedure resulted in less medical resources usage, along with more favorable clinical outcomes.

Correction: Effect of Telehealth Services on Mitral and Tricuspid Regurgitation Progression: Retrospective Study.

[This corrects the article DOI: 10.2196/47947.].

Effect of Telehealth Services on Mitral and Tricuspid Regurgitation Progression: Retrospective Study.

BACKGROUND: Mitral regurgitation (MR) and tricuspid regurgitation (TR) are common cardiac conditions with high mortality risks, which can be improved through early intervention. Telehealth services, which allow for remote monitoring of patient conditions, have been proven to improve the health management of chronic diseases, but the effects on MR and TR progression are unknown. OBJECTIVE: This study aimed to explore whether patients receiving telehealth services have less MR and TR progression compared with a control group. We also aimed to identify the determinants of MR and TR progression. METHODS: This single-center retrospective study conducted at the National Taiwan University Hospital compared MR and TR progression (defined as either progression to moderate or greater MR and TR or MR and TR progression by ≥2 grades during the study period) between the telehealth and control groups. Patients had a minimum of 2 transthoracic echocardiograms at least 6 months apart; baseline mild-moderate MR and TR or lower; and no prior surgeries on the mitral or tricuspid valve. Telehealth patients were defined as those who received telehealth services for at least 28 days within 3 months of baseline. Basic demographics, baseline blood pressure measurements, prescribed medication, and Charlson Comorbidity Index components were obtained for all patients. RESULTS: A total of 1081 patients (n=226 in the telehealth group and n=855 in the control group) were included in the study analyses. The telehealth group showed significantly lower baseline systolic blood pressure (P<.001), higher Charlson Comorbidity Index (P=.02), higher prevalence of prior myocardial infarction (P=.01) and heart failure (P<.001), higher beta-blocker (P=.03) and diuretic (P=.04) use, and lower nitrate use (P=.04). Both groups showed similar cardiac remodeling conditions at baseline. Telehealth was found to be neutral for both MR (hazard ratio 1.10, 95% CI 0.80-1.52; P=.52) and TR (hazard ratio 1.27, 95% CI 0.92-1.74; P=.14) progression. Determinants for moderate or greater MR progression included older age, female sex, diuretic use, larger left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction. Determinants of moderate or greater TR progression included older age, female sex, diuretic use, presence of atrial fibrillation, LA dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction; statin use was found to be protective. CONCLUSIONS: This is the first study to assess the association between telehealth services and the progression of MR and TR. Telehealth patients, who had more comorbidities, displayed similar MR and TR progression versus control patients, indicating that telehealth may slow MR and TR progression. Determinants of MR and TR progression included easy-to-measure traditional echo parameters of cardiac function, older age, female sex, and atrial fibrillation, which can be incorporated into a telehealth platform and advanced alert system, improving patient outcomes through personalized care.

Quantification of cardiac pumping mechanics in TAVI patients: A pilot study utilizing minimally invasive method for pressure-volume analysis.

The ventriculo-arterial coupling (VAC) and left ventricle (LV) mechanics are crucial and play an important role in the pathophysiology of aortic stenosis (AS). The pressure-volume (PV) analysis is a powerful tool to study VAC and LV mechanics. We proposed a novel minimally-invasive method for PV analysis in patients with severe AS receiving transcatheter aortic valve implantation (TAVI). Patients with severe AS were prospectively enrolled in a single center. LV pressure and cardiac output were recorded before and after TAVI. We constructed the PV loop for analysis by analyzing LV pressure and the assumed flow. 26 patients were included for final analysis. The effective arterial elastance (Ea) decreased after TAVI (3.7 ± 1.3 vs. 2.9 ± 1.1 mmHg/mL, p < 0.0001). The LV end-systolic elastance (Ees) did not change immediately after TAVI (2.4 ± 1.3 vs. 2.6 ± 1.1 mmHg/mL, p = 0.3670). The Ea/Ees improved after TAVI (1.8 ± 0.8 vs. 1.2 ± 0.4, p < 0.0001), demonstrating an immediate improvement of VAC. The stroke work (SW) did not change (7669.6 ± 1913.8 vs. 7626.2 ± 2546.9, p = 0.9330), but the pressure-volume area (PVA) decreased (14469.0 ± 4974.1 vs. 12177.4 ± 4499.9, p = 0.0374) after TAVI. The SW/PVA increased after TAVI (0.55 ± 0.12 vs. 0.63 ± 0.08, p < 0.0001) representing an improvement of LV efficiency. We proposed a novel minimally invasive method for PV analysis in patients with severe AS receiving TAVI. The VAC and LV efficiency improved immediately after TAVI.

On-Table Catheter-Based Neurosalvage Performed by Cardiologists for Embolic Complication during an Endovascular Procedure.

Objectives: To report our experience and clinical results of neurosalvage techniques, performed by interventional cardiologists without moving the patient, to manage cerebral thromboembolic complications. Background: Iatrogenic emboli may be released during an endovascular procedure, causing permanent neurological complications and catastrophic outcomes. Methods: Between July 2013 and December 2017, a total of eight patients suffered from embolic complications during endovascular procedures (two radiofrequency catheter ablation, five coronary angiogram/angioplasty, and one subclavian artery angioplasty). Catheter-based neurosalvage was attempted by experienced interventional cardiologists promptly in the same catheterization room. Results: The embolized locations were the M1 segment of the middle cerebral artery in four patients, the M2/M3 segments in three, and the basilar artery in one. Access to the supra-aortic vessels was achieved. Local intra-arterial thrombolysis was given in five patients (63%) and balloon angioplasty in three (38%). Intra-arterial thrombectomy with a stent retriever was attempted in three patients but failed in one. A combination of different techniques was used in three patients (38%). Final thrombolysis in cerebral infarction grade 3 flow was achieved in seven patients (88%). Favorable clinical outcomes at 1-month follow-up (modified Rankin scale of 0-2) were observed in seven patients (88%), and none of the patients had died at 12 months. Conclusions: Our experience demonstrated that acute embolic complications during an endovascular procedure can be salvaged by interventional cardiologists with acceptable angiographic and clinical results.

Detection of Carotid Artery Stenosis Based on Video Motion Analysis for Fast Screening.

Background Carotid artery stenosis (CAS) is a common cause of ischemic stroke, and the early detection of CAS may improve patient outcomes. Carotid Doppler ultrasound is commonly used to diagnose CAS. However, it is costly and may not be practical for regular screening practice. This article presents a novel noninvasive and noncontact detection technique using video-based motion analysis (VMA) to extract useful information from subtle pulses on the skin surface to screen for CAS. Methods and Results We prospectively enrolled 202 patients with prior carotid Doppler ultrasound data. A short 30-second video clip of the neck was taken using a commercial mobile device and analyzed by VMA with mathematical quantification of the amplitude of skin motion changes in a blinded manner. The first 40 subjects were used to set up the VMA protocol and define cutoff values, and the following 162 subjects were used for validation. Overall, 54% of the 202 subjects had ultrasound-confirmed CAS. Using receiver operating characteristic curve analysis, the area under the curve of VMA-derived discrepancy values to differentiate patients with and without CAS was excellent (area under the curve, 0.914 [95% CI, 0.874-0.954]; P<0.01). The best cutoff value of VMA-derived discrepancy values to screen for CAS was 5.1, with a sensitivity of 87% and a specificity of 87%. The diagnostic accuracy was consistently high in different subject subgroups. Conclusions A simple and accurate screening technique to quickly screen for CAS using a VMA system is feasible, with acceptable sensitivity and specificity.

Serial neurocognitive changes following transcatheter aortic valve replacement: comparison between low and intermediate-high risk groups.

BACKGROUND: Data comparing the neurocognitive trajectory between low and intermediate-high risk patients following transcatheter aortic valve replacement (TAVR) is never reported. AIMS: To report serial neurocognitive changes up to 1 year post-TAVR in low and intermediate-high risk groups as well as overall cohort. METHODS: Prospective neurological assessments (NIHSS and Barthel Index), global cognitive tests (MMSE and Alzheimer Disease Assessment Scale-Cognitive Subtest, ADAS-cog) and executive performances (Color Trail Test A and B and verbal fluency), were applied at baseline, 3 months and 1 year post-TAVR. RESULTS: In overall cohort, persistent improvement to 1 year in MMSE, ADAS-cog, Color Trail Test A and B was found. According to the STS score, the study cohort was divided into low (<4%, N = 81) and intermediate-high (≧4%, N = 75) risk groups. The baseline neurologic and cognitive performance was significantly worse in intermediate-high risk group. Slight improvement on general neurological functions (Barthel index and proportion of NIHSS>0 patients) at 1 year could be observed only in intermediate-high risk group. In global cognitive assessments, improvement in MMSE and ADAS-cog at 1 year was found in both groups, but the proportion of cognitive improvement was more obvious in intermediate-high risk group. In Color Trail Tests and verbal fluency, significant and persistent improvement up to 1 year could be observed only in low risk group. CONCLUSIONS: TAVR was associated with persistent improvement in global cognitive function, as well as in attention and psychomotor processing speed, up to 1 year in overall cohort. However, improvement in tests for executive functions can only be seen in low risk group.

The Logistics of Medication and Patient Flow in Video-Based Virtual Clinics During a Sudden COVID-19 Outbreak in Taiwan: Observational Study.

BACKGROUND: The COVID-19 pandemic was well controlled in Taiwan until an outbreak in May 2021. Telemedicine was rapidly implemented to avoid further patient exposure and to unload the already burdened medical system. OBJECTIVE: To understand the effect of COVID-19 on the implementation of video-based virtual clinic visits during this outbreak, we analyzed the logistics of prescribing medications and patient flow for such virtual visits at a tertiary medical center. METHODS: We retrospectively collected information on video-based virtual clinic visits and face-to-face outpatient visits from May 1 to August 31, 2021, from the administrative database at National Taiwan University Hospital. The number of daily new confirmed COVID-19 cases in Taiwan was obtained from an open resource. RESULTS: There were 782 virtual clinic visits during these 3 months, mostly for the departments of internal medicine, neurology, and surgery. The 3 most common categories of medications prescribed were cardiovascular, diabetic, and gastrointestinal, of which cardiovascular medications comprised around one-third of all medications prescribed during virtual clinic visits. The number of virtual clinic visits was significantly correlated with the number of daily new confirmed COVID-19 cases, with approximately a 20-day delay (correlation coefficient 0.735; P<.001). The patient waiting time for video-based virtual clinic visits was significantly shorter compared with face-to-face clinic visits during the same period (median 3, IQR 2-6 min vs median 20, IQR 9-42 min; rank sum P<.001). Although the time saved was appreciated by the patients, online payment with direct delivery of medications without the need to visit a hospital was still their major concern. CONCLUSIONS: Our data showed that video-based virtual clinics can be implemented rapidly after a COVID-19 outbreak. The virtual clinics were efficient, as demonstrated by the significantly reduced waiting time. However, there are still some barriers to the large-scale implementation of video-based virtual clinics. Better preparation is required to improve performance in possible future large outbreaks.

Comparison between drug-coated balloons and drug-eluting stents in very small coronary artery interventions.

The optimal management of very small vessel (reference diameter from 2.0 to 2.25 mm) in percutaneous coronary interventions (PCIs) is controversial. We aimed to compare the efficacy and safety of drug-coated balloons (DCBs) and drug-eluting stents (DESs) for de-novo very small vessel interventions. We conducted a retrospective analysis of consecutive patients who received very small vessel PCI with a DCB or DES between January 2018 and March 2021. The outcome measures were the incidence of ischemia-driven target lesion revascularization (TLR) and major adverse cardiac and cerebrovascular events (MACCEs) within 1 year after PCI. MACCEs were defined as the composite of ischemia-driven TLR, all-cause death, non-fatal acute coronary syndrome, stroke, or heart failure requiring hospitalization. A total of 205 patients undergoing PCI with a DCB or DES were enrolled in this study. The procedural complication rate was 2.5% in the DES group and 1.7% in the DCB group (P = 1.000). After 1-year of follow-up, the cumulative incidence of TLR was 7.2% in the DCB group and 4.9% in the DES group (P = 0.530). The cumulative incidence of MACCEs was 10.6% in the DCB group and 12.7% in the DES group (P = 0.769). Only female gender, acute coronary syndrome on presentation, and dual antiplatelet therapy duration < 3 months were significantly associated with MACCEs at 1 year, but the use of DCB or DES was not. The use of DCBs or DESs in de novo very small vessel intervention was not associated with different outcomes at 1 year.

Conus branch artery utilization in percutaneous coronary intervention for chronic total occlusion.

Data on the prevalence of conus branch artery (CBA) is scarce, and its utilization in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is non-existing. The present study examined carefully in a large cohort the angiographic prevalence of CBA, its role as a collateral channel for the occlusion, and the potential usage of CBA in contemporary CTO PCI. We retrospectively examined consecutive CTO PCIs from our database between 2016 and 2019. All CTO PCIs were evaluated and the results with complications were recorded to determine the prevalence and utilization of CBA. From January 2016 to December 2019, a total of 556 CTO PCI attempts in 546 patients by high-volume operators were enrolled. The clinical, angiographic, and procedural details were collected. CBA was identifiable in 85.3% of these patients, and CBA providing visible collaterals connected to CTO distal lumen was found in 27.8% of patients. 84 CBA were used for balloon anchoring, 17 for selective distal true lumen visualization, and 9 as actual retrograde interventional collateral channel during CTO PCI. Only 1 patient suffered from chest pain during CBA balloon anchoring, and no other procedural complication such as arrhythmia or perforation occurred.CBA is frequently seen in coronary CTO. Its existence provided potential for various CTO PCI technique applications, without increase in risk.

The CSP (Cardiogenic Shock Prognosis) Score: A Tool for Risk Stratification of Cardiogenic Shock.

Background: Cardiogenic shock (CS) is a critical condition and the leading cause of mortality after acute myocardial infarction (AMI). Scores that predict mortality have been established, but a patient's clinical course is often nonlinear. Thus, factors present during acute care management may be explored. This study intended to develop a risk-predictive model for patients with CS. Methods: In this observational study, adult patients who received inotropic support at the Emergency Room (ER) from January 2017 to August 2020 and were admitted to the cardiac care unit (CCU) with a diagnosis of CS were enrolled in this study. Patients with out-of-hospital cardiac arrest, inotropic support for bradycardia, and survival <24 h after ER arrival were excluded. A total of 311 patients were enrolled and categorized into derivation (n = 243) and validation (n = 68) cohorts. Results: A history of coronary artery disease, multiple inotrope use, ejection fraction <40%, lower hemoglobin concentration, longer cardiopulmonary resuscitation duration, albumin infusion, and renal replacement therapy were identified as independent prognostic factors for in-hospital mortality. The cardiogenic shock prognosis (CSP) score was established as a nomogram and three risk groups were identified: low-risk (score 115, 0% of mortality), medium-risk (score 116-209, 8.75% of mortality), and high-risk (score 210, 66.67% of mortality). The area-under-the-curve (AUC) of the CSP score was 0.941, and the discrimination value in the validation cohort was consistent (AUC = 0.813). Conclusions: The CSP score represents a risk-predictive model for in-hospital mortality in patients with CS in acute care settings. Patients identified as the high-risk category may have a poor prognosis.

The Impact of Synchronous Telehealth Services With a Digital Platform on Day-by-Day Home Blood Pressure Variability in Patients with Cardiovascular Diseases: Retrospective Cohort Study.

BACKGROUND: Hypertension is associated with a large global disease burden with variable control rates across different regions and races. Telehealth has recently emerged as a health care strategy for managing chronic diseases, but there are few reports regarding the effects of synchronous telehealth services on home blood pressure (BP) control and variability. OBJECTIVE: The objective of this study is to investigate the effect of synchronous telehealth services with a digital platform on home BP. METHODS: This retrospective study was conducted by the Taiwan ELEctroHEALTH study group at the Telehealth Center of the National Taiwan University Hospital. We analyzed home BP data taken from 2888 patients with cardiovascular disease (CVD) enrolled in our telehealth program between 2009 to 2017. Of the 2888 patients with CVD, 348 (12.05%) patients who received home BP surveillance for ≥56 days were selected for BP analysis. Patients were stratified into three groups: (1) poorly controlled hypertension, (2) well-controlled hypertension, and (3) nonhypertension. The mean, SD, coefficient of variation (CV), and average real variability were calculated. RESULTS: Telehealth interventions significantly and steadily reduced systolic blood pressure (SBP) in the poorly controlled hypertension group from 144.8.2±9.2 to 133.7±10.2 mmHg after 2 months (P<.001). BP variability reduced in all patients: SBP-SD decreased from 7.8±3.4 to 7.3±3.4 after 2 months (P=.004), and SBP-CV decreased from 6.3±2.5 to 5.9±2.6 after 2 months (P=.004). Event-free survival (admission) analysis stratified by SBP-SD showed longer time to first hospitalization for Q1 patients compared with Q4 patients (P=.02, odds ratio 2.15, 95% CI 1.18-3.89). CONCLUSIONS: Synchronous telehealth intervention may improve home BP control and decrease day-by-day home BP variability in patients with CVD.

Long-Term Clinical Outcomes of Fractional Flow Reserve-Guided Coronary Artery Revascularization in Chronic Kidney Disease.

Fractional flow reserve (FFR)-guided percutaneous coronary intervention has shown favorable long-term clinical outcomes. However, limited data exist evaluating the FFR assessment among the chronic kidney disease (CKD) population. The aim of this study was to evaluate the long-term clinical outcomes of FFR-guided coronary revascularization in patients with CKD. A total of 242 CKD patients who underwent FFR assessment were retrospectively analyzed. Patients were divided into two groups: revascularization (FFR ≤ 0.80) and non-revascularization (FFR > 0.80). The primary endpoint was the composite of cardiac death, non-fatal myocardial infarction, and target vessel failure (TVF). The key secondary endpoint was TVF. The Cox regression model was used for risk evaluation. With 91% of the ischemic vessels revascularized, the revascularization group had higher risks for both the primary endpoint (adjusted hazard ratio [aHR]: 2.06; 95% confidence interval [CI], 1.07-3.97; p = 0.030) and key secondary endpoint (aHR: 2.19, 95% CI: 1.10-4.37; p = 0.026), during a median follow-up of 2.9 years. This result was consistent among different CKD severities. In patients with CKD, functional ischemia in coronary artery stenosis was associated with poor clinical outcomes despite coronary revascularization.

The periprocedural and 30-day outcomes of carotid stenting in patients with carotid artery near-occlusion.

The safety of endovascular revascularization in patients with carotid artery near occlusion (CANO) is unknown. We aimed to evaluate the peri-procedural risk in CANO patients receiving carotid artery stenting (CAS). A prospective data base with retrospective review was performed to identify patients who underwent CAS with CANO from July 2006 to July 2020, and had at least 1-month clinical follow-up data. The primary endpoints were stroke, hyperperfusion syndrome, and death within 30 days after CAS. A total of 198 patients with carotid artery stenosis were enrolled including 92 patients with CANO and 106 age and sex-matched patients with 70-99% conventional carotid stenosis. Full distal carotid collapse was found in 45 CANO patients (45/92, 49%). The technical success rate was 100%. The CANO patients had significantly longer lesion lengths compared with those of the non-CANO group. The incidence of hyperperfusion syndrome was comparable (CANO: 2.2%, non-CANO: 0.9%, P = 0.598). The risks of ischemic stroke and death within 30 days were 1.1% and 0% in the CANO group; and 1.9% and 0.9%, in the non-CANO group, respectively, without statistical difference. In conclusion, CAS is safe for patients with CANO, with a similar low 30-day peri-procedural event rate comparable to those of non-CANO.

Impact of conduction disturbances on left ventricular mass regression and geometry change following transcatheter aortic valve replacement.

Our study aimed to compare the difference of LV mass regression and remodeling in regard of conduction disturbances (CD) following transcatheter aortic valve replacement (TAVR). A prospective analysis of 152 consecutive TAVR patients was performed. 53 patients (34.9%) had CD following TAVR, including 30 (19.7%) permanent pacemaker implantation and 23 (15.2%) new left bundle branch block. In 123 patients with 1-year follow-up, significant improvement of LV ejection fraction (LVEF) (baseline vs 12-month: 65.1 ± 13.2 vs 68.7 ± 9.1, P = 0.017) and reduced LV end-systolic volume (LVESV) (39.8 ± 25.8 vs 34.3 ± 17.1, P = 0.011) was found in non-CD group (N = 85), but not in CD group (N = 38). Both groups had significant decrease in LV mass index (baseline vs 12-month: 148.6 ± 36.9 vs. 136.4 ± 34.7 in CD group, p = 0.023; 153.0 ± 50.5 vs. 125.6 ± 35.1 in non-CD group, p < 0.0001). In 46 patients with 3-year follow-up, only non-CD patients (N = 28) had statistically significant decrease in LV mass index (Baseline vs 36-month: 180.8 ± 58.8 vs 129.8 ± 39.1, p = 0.0001). Our study showed the improvement of LV systolic function, reduced LVESV and LV mass regression at 1 year could be observed in patients without CD after TAVR. Sustained LV mass regression within 3-year was found only in patients without CD.