ABSTRACT
This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.
ABSTRACT
BACKGROUND: In chronic heart failure many patients have recurrent hospital admissions and it is the leading cause of admission in people aged over 65 years. In those with end-stage heart failure, there is limited evidence that furosemide can be given subcutaneously to relieve symptoms and avoid hospital admission. METHOD: We initiated a community-based continuous subcutaneous infusion (CSCI) furosemide service for the treatment of advanced heart failure. We aimed to increase patient choice, offer an alternative to hospital admission and, in patients at the end of their life, allow them to die at their preferred place of care with symptom alleviation. We retrospectively reviewed case notes. RESULTS: 36 consecutive episodes of CSCI of treatment were recorded in 28 patients. 15 patients (54%) survived beyond the initial treatment course with 13 patients (87%) avoiding acute hospital admission. There was a reduction in mean hospital admission rates from 2.87 to 0.73 (p<0.001) in the 6-month periods either side of the first episode of CSCI furosemide. A median reduction of 4 kg weight loss was recorded. 13 patients died during the initial treatment course. 12 (92%) died at home and 1 died at the hospital palliative care unit. All had symptoms controlled. CONCLUSION: Subcutaneous furosemide can be successfully delivered in the community. In addition to palliation in the final days of life, community subcutaneous furosemide can be an effective treatment leading to weight loss and improved symptoms with survival for several months.
Subject(s)
Furosemide , Heart Failure , Humans , Aged , Furosemide/therapeutic use , Diuretics , Retrospective Studies , Heart Failure/drug therapy , Infusions, Subcutaneous , Weight LossABSTRACT
BACKGROUND: Pericarditis is a common cardiology presentation, most often due to a viral or idiopathic cause. Listeria as a cause of pericarditis is rare. Listeria is an infection that is readily treatable with antibiotics following accurate identification. Without adequate treatment, Listeria infection has a high mortality rate. CASE SUMMARY: In this case, a fit and well 59-year-old man complained of headaches and fever to the emergency department (ED). He was provisionally diagnosed with giant cell arteritis (GCA) and commenced on management pathways for GCA. He represented to the ED with chest pain and electrocardiogram (ECG) changes suggestive of a clinical presentation of pericarditis. He received treatment for idiopathic pericarditis with no clinical resolution. Cardiac magnetic resonance imaging (MRI) showed myopericardial inflammation associated with a right atrial mural thrombus. After 2 weeks of poor treatment response, peripheral blood cultures grew Listeria monocytogenes and the patient responded well to antibiotic treatment. Repeat cardiac MRI after an extended course of antibiotics showed resolution of MRI signs. DISCUSSION: This is a case of Listeria myopericarditis. Physicians should consider rarer causes of myopericarditis in treatment resistance cases. Cardiac MRI has utility in atypical or treatment resistant patients to assess myopericardial inflammation and response to treatment.
ABSTRACT
The National Institute for Health and Care Excellence (NICE) and NHS England have shown a commitment to embedding shared decision-making (SDM) in clinical practice and developing decision aids based on clinical guidelines. Healthcare policy makers are keen to enhance the engagement of patients in SDM in the belief that it improves the benefits accrued from healthcare interventions. This may be important for interventions such as implantable cardioverter-defibrillator (ICD) implantation, where cost-effectiveness is under scrutiny. NHS England invited the ICD implanters in the north of England to participate in a regional commissioning quality incentive (CQUIN) project to improve decision- making around a primary prevention ICD implant. A collaborative project included the development of a specific SDM tool, the first of its kind in the UK, followed by training and education of the clinical teams. The project illustrates that this approach is practical and deliverable and could be applied and used in other regions, and considered in additional clinical areas.
ABSTRACT
Occasionally complex congenital cardiac disease presents for the first time in adulthood, encouraging us to reflect anew on our understanding of familiar conditions. A 59-year-old woman, who had had two normal pregnancies, attended with breathlessness and was found to have a double inlet left ventricle with concordant ventriculoarterial connections and a straddling tricuspid valve adherent to the malaligned ventricular septum.
