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2.
Int J Cardiol ; 2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-32057476

RESUMO

BACKGROUND: Evidence is lacking on long-term outcomes in unselected patients surviving the first year following myocardial infarction (MI). METHODS AND RESULTS: The TIGRIS (long-Term rIsk, clinical manaGement and healthcare Resource utilization of stable coronary artery dISease in post-myocardial infarction patients) prospective registry enrolled 9176 eligible patients aged ≥50 years, 1-3 years post-MI, from 25 countries. All had ≥1 risk factor: age ≥ 65 years, diabetes mellitus, second prior MI, multivessel coronary artery disease, chronic kidney disease (CKD). Primary outcome was a composite of MI, unstable angina with urgent revascularization, stroke, or all-cause death at 2-year follow-up. Bleeding requiring hospitalization was also recorded. 9027 patients (98.4%) provided follow-up data: the primary outcome occurred in 621 (7.0%), all-cause mortality in 295 (3.3%), and bleeding in 109 (1.2%) patients. Events accrued linearly over time. In multivariable analyses, qualifying risk factors were associated with increased risk of primary outcome (incidence rate ratio [RR] per 100 patient-years [95% confidence interval]): CKD 2.06 (1.66, 2.55), second prior MI 1.71 (1.38, 2.10), diabetes mellitus 1.63 (1.39, 1.92), age ≥ 65 years 1.53 (1.28, 1.83), and multivessel disease 1.24 (1.05, 1.48). Risk of bleeding events was greater in older patients (vs <65 years) 65-74 years 2.68 (1.53, 4.70), ≥75 years 4.62 (2.57, 8.28), and those with CKD 1.99 (1.18, 3.35). CONCLUSION: In stable patients recruited 1-3 years post-MI, recurrent cardiovascular and bleeding events accrued linearly over 2 years. Factors independently predictive of ischemic and bleeding events were identified, providing a context for deciding on treatment options.

3.
Clin Cardiol ; 43(1): 24-32, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31713893

RESUMO

BACKGROUND: Risk prediction tools are lacking for patients with stable disease some years after myocardial infarction (MI). HYPOTHESIS: A practical long-term cardiovascular risk index can be developed. METHODS: The long-Term rIsk, Clinical manaGement and healthcare Resource utilization of stable coronary artery dISease in post-myocardial infarction patients prospective global registry enrolled patients 1 to 3 years post-MI (369 centers; 25 countries), all with ≥1 risk factor (age ≥65 years, diabetes mellitus requiring medication, second prior MI, multivessel coronary artery disease, or chronic non-end-stage kidney disease [CKD]). Self-reported health was assessed with EuroQoL-5 dimensions. Multivariable Poisson regression models were used to determine key predictors of the primary composite outcome (MI, unstable angina with urgent revascularization [UA], stroke, or all-cause death) over 2 years. RESULTS: The primary outcome occurred in 621 (6.9%) of 9027 eligible patients: death 295 (3.3%), MI 195 (2.2%), UA 103 (1.1%), and stroke 58 (0.6%). All events accrued linearly. In a multivariable model, 11 significant predictors of primary outcome (age ≥65 years, diabetes, second prior MI, CKD, history of major bleed, peripheral arterial disease, heart failure, cardiovascular hospitalization (prior 6 months), medical management (index MI), on diuretic, and poor self-reported health) were identified and combined into a user-friendly risk index. Compared with lowest-risk patients, those in the top 16% had a rate ratio of 6.9 for the primary composite, and 18.7 for all-cause death (overall c-statistic; 0.686, and 0.768, respectively). External validation was performed using the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events registry (c-statistic; 0.748, and 0.849, respectively). CONCLUSIONS: In patients >1-year post-MI, recurrent cardiovascular events and deaths accrue linearly. A simple risk index can stratify patients, potentially helping to guide management.

4.
J Am Heart Assoc ; 8(24): e014287, 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31795822

RESUMO

Background Oral anticoagulant (OAC) therapy reduces the risk of stroke in people with atrial fibrillation (AF), and is considered best practice; however, there is little Australian evidence around the uptake of OACs in this population. Methods and Results We used linked hospital admissions, pharmaceutical dispensing claims, medical services, and mortality data for people in Australia's 2 most populous states (July 2010 to June 2015). Among OAC-naïve people hospitalized with AF, we estimated initiation of OAC therapy within 30 days of discharge, and persistence with therapy in the first year. We analyzed both outcomes using multivariable Cox regression. In 71 184 people with AF (median age 78 years, 49% female), 22.7% initiated OAC therapy. Initiation was lowest in July to December 2011 (17.0%) and highest in July to December 2014 (30.1%) after subsidy of the direct OACs. In adjusted analyses, initiation was most likely in people with a CHA2DS2-VA score ≥7 (versus 0) (hazard ratio=6.25, 95% CI 5.08-7.69), and a history of venous thromboembolism (hazard ratio=2.65, 95% CI 2.49-2.83). Of the people who initiated OAC therapy, 39.9% discontinued within 1 year; a lower risk of discontinuation was associated with a CHA2DS2-VA score ≥7 (versus 0) (hazard ratio=0.22, 95% CI 0.14-0.35), or initiation on a direct OAC (versus warfarin) (hazard ratio=0.55, 95% CI 0.50-0.60). Conclusions We found that OAC therapy was severely underutilized in people hospitalized with AF, even among high-risk individuals. Reasons for this underuse, whether patient, prescriber, or hospital related, should be identified and addressed to reduce stroke-related morbidity and mortality in people with AF.

5.
J Am Heart Assoc ; 8(21): e013296, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31672080

RESUMO

Background Programs targeting the standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, hypercholesterolemia, smoking) are critical to tackling coronary heart disease at a community level. However, myocardial infarction in SMuRF-less individuals is not uncommon. This study uses 2 sequential large, multicenter registries to examine the proportion and outcomes of SMuRF-less ST-segment-elevation myocardial infarction (STEMI) patients. Methods and Results We identified 3081 STEMI patients without a prior history of cardiovascular disease in the Australian GRACE (Global Registry of Acute Coronary Events) and CONCORDANCE (Cooperative National Registry of Acute Coronary Syndrome Care) registries, encompassing 42 hospitals, between 1999 and 2017. We examined the proportion that were SMuRF-less as well as outcomes. The primary outcome was in-hospital mortality, and the secondary outcome was major adverse cardiovascular events (death, myocardial infarction, or heart failure, during the index admission). Multivariate regression models were used to identify predictors of major adverse cardiovascular events. Of STEMI patients without a prior history of cardiovascular disease 19% also had no history of SMuRFs. This proportion increased from 14% to 23% during the study period (P=0.0067). SMuRF-less individuals had a higher in-hospital mortality rate than individuals with 1 or more SMuRFs. There were no clinically significant differences in major adverse cardiovascular events at 6 months between the 2 groups. Conclusions A substantial and increasing proportion of STEMI presentations occur independently of SMuRFs. Discovery of new markers and mechanisms of disease beyond standard risk factors may facilitate novel preventative strategies. Studies to assess longer-term outcomes of SMuRF-less STEMI patients are warranted.

6.
Heart ; 2019 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-31611326

RESUMO

OBJECTIVE: Low levels of total cholesterol (TC) are associated with adverse outcomes in older populations. Whether this phenomenon is independent of statin use is unknown. We investigated the association between low TC levels and long-term major adverse cardiovascular events (MACE) in a prospective study of men aged ≥70 years without ischaemic heart disease (IHD) and whether this was influenced by statin use. METHODS: The CHAMP (Concord Health and Ageing in Men Project) cohort is a prospective cohort study of community-dwelling men aged ≥70 years. The relationship between TC and long-term MACE was analysed using Cox-regression modelling adjusted for comorbidities and stratified by statin use. RESULTS: The study cohort comprised 1289 men (mean (±SD) age, 77.0±5.5 years; mean follow-up, 6.4±2.7 years). Decreasing TC level was associated with increased comorbidity burden, frailty and MACE (linear trend p<0.001). In men not on statin therapy (n=731), each 1 mmol/L decrease in TC was associated with increased MACE (HR 1.27, 95% CI 1.10 to 1.45, p=0.001) and mortality (HR 1.22, 95% CI 1.03 to 1.44, p=0.02) adjusted for comorbidities. In contrast, low TC in men on statins (n=558) was not associated with MACE (HR 0.91, 95% CI 0.74 to 1.11) or mortality (HR 0.86, 95% CI 0.68 to 1.09). CONCLUSION: Low TC is associated with increased risk of MACE in older men without IHD who are not taking statin therapy but not in those on statins.

7.
Circulation ; 140(23): 1921-1932, 2019 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-31557056

RESUMO

BACKGROUND: The safety and efficacy of antithrombotic regimens may differ between patients with atrial fibrillation who have acute coronary syndromes (ACS), treated medically or with percutaneous coronary intervention (PCI), and those undergoing elective PCI. METHODS: Using a 2×2 factorial design, we compared apixaban with vitamin K antagonists and aspirin with placebo in patients with atrial fibrillation who had ACS or were undergoing PCI and were receiving a P2Y12 inhibitor. We explored bleeding, death and hospitalization, as well as death and ischemic events, by antithrombotic strategy in 3 prespecified subgroups: patients with ACS treated medically, patients with ACS treated with PCI, and those undergoing elective PCI. RESULTS: Of 4614 patients enrolled, 1097 (23.9%) had ACS treated medically, 1714 (37.3%) had ACS treated with PCI, and 1784 (38.8%) had elective PCI. Apixaban compared with vitamin K antagonist reduced International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding in patients with ACS treated medically (hazard ratio [HR], 0.44 [95% CI, 0.28-0.68]), patients with ACS treated with PCI (HR, 0.68 [95% CI, 0.52-0.89]), and patients undergoing elective PCI (HR, 0.82 [95% CI, 0.64-1.04]; Pinteraction=0.052) and reduced death or hospitalization in the ACS treated medically (HR, 0.71 [95% CI, 0.54-0.92]), ACS treated with PCI (HR, 0.88 [95% CI, 0.74-1.06]), and elective PCI (HR, 0.87 [95% CI, 0.72-1.04]; Pinteraction=0.345) groups. Compared with vitamin K antagonists, apixaban resulted in a similar effect on death and ischemic events in the ACS treated medically, ACS treated with PCI, and elective PCI groups (Pinteraction=0.356). Aspirin had a higher rate of bleeding than did placebo in patients with ACS treated medically (HR, 1.49 [95% CI, 0.98-2.26]), those with ACS treated with PCI (HR, 2.02 [95% CI, 1.53-2.67]), and those undergoing elective PCI (HR, 1.91 [95% CI, 1.48-2.47]; Pinteraction=0.479). For the same comparison, there was no difference in outcomes among the 3 groups for the composite of death or hospitalization (Pinteraction=0.787) and death and ischemic events (Pinteraction=0.710). CONCLUSIONS: An antithrombotic regimen consisting of apixaban and a P2Y12 inhibitor without aspirin provides superior safety and similar efficacy in patients with atrial fibrillation who have ACS, whether managed medically or with PCI, and those undergoing elective PCI compared with regimens that include vitamin K antagonists, aspirin, or both. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02415400.

8.
BMJ Open ; 9(9): e032165, 2019 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-31492797

RESUMO

INTRODUCTION: For non-ST-segment elevation acute coronary syndrome (NSTEACS) there is a gap between the use of class I guideline recommended therapies and clinical practice. The Global Registry of Acute Coronary Events (GRACE) risk score is recommended in international guidelines for the risk stratification of NSTEACS, but its impact on adherence to guideline-indicated treatments and reducing adverse clinical outcomes is unknown. The objective of the UK GRACE Risk Score Intervention Study (UKGRIS) trial is to assess the effectiveness of the GRACE risk score tool and associated treatment recommendations on the use of guideline-indicated care and clinical outcomes. METHODS AND ANALYSIS: The UKGRIS, a parallel-group cluster randomised registry-based controlled trial, will allocate hospitals in a 1:1 ratio to manage NSTEACS by standard care or according to the GRACE risk score and associated international guidelines. UKGRIS will recruit a minimum of 3000 patients from at least 30 English National Health Service hospitals and collect healthcare data from national electronic health records. The co-primary endpoints are the use of guideline-indicated therapies, and the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospitalisation or cardiovascular readmission at 12 months. Secondary endpoints include duration of inpatient hospital stay over 12 months, EQ-5D-5L responses and utilities, unscheduled revascularisation and the components of the composite endpoint over 12 months follow-up. ETHICS AND DISSEMINATION: The study has ethical approval (North East - Tyne & Wear South Research Ethics Committee reference: 14/NE/1180). Findings will be announced at relevant conferences and published in peer-reviewed journals in line with the funder's open access policy. TRIAL REGISTRATION NUMBER: ISRCTN29731761; Pre-results.

9.
Intern Med J ; 2019 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-31424594

RESUMO

BACKGROUND: Cardiac troponin assays are a very widely requested test, particularly in emergency departments. Thus, many seriously ill patients who may not have heart disease as their primary discharge diagnosis have undergone troponin testing during hospitalisation. METHODS AND RESULTS: Over a 2-year period (2006-2008) 172,753 hospitalised patients had a quantatitive or qualitative troponin assay performed in New South Wales (Australia). The associations were examined, using data linked to late outcomes, between elevations in levels of troponins T or I and 1-year mortality. Mortality was determined for International Statistical Classification of Diseases 10th Revision (ICD-10-AM) diagnostic groups. Of 172,753 patients undergoing troponin testing 44,357 (25%) had a cardiovascular diagnosis of whom (7% had myocardial infarction) 47,827 (28%) had a probable ischaemic heart disease (IHD) diagnosis if the 23,873 (14%) of patients coded with 'chest pain' were included. In patients with a cardiovascular diagnosis and elevated troponin 3,060 (1.8%) died in 12 months in comparison to 6,262 (3.6%) in those with a non-cardiovascular disease diagnoses and elevated troponin. The 1-year mortality hazard with respect to a troponin elevation was 2.5 (95% Conficence Interval (CI) 2.3-2.7) and 2.0 [95% CIs 1.99-2.01] for those with a cardiovascular and non-cardiovascular diagnosis, respectively. CONCLUSION: In a very large state-wide hospitalised patient cohort, among patients with elevated troponin levels and non-cardiac diagnoses, mortality was higher than in those with cardiovascular diagnoses, including MI. This article is protected by copyright. All rights reserved.

11.
J Psychosom Res ; 124: 109748, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31443818

RESUMO

OBJECTIVE: Cardiac patients with psychological distress have a poorer prognosis than patients without distress, potentially reflecting differences in preventive care. We aimed to examine distress-related variation in guideline-recommended medication use for secondary prevention of cardiovascular disease (CVD). METHODS: Baseline questionnaire data from the 45 and Up Study (collected 2006-2009) were linked to hospitalisation, pharmaceutical dispensing and death records (to exclude those who died). Among participants hospitalised with myocardial infarction, angina, stroke/transient ischaemic attack in the six years before the questionnaire, Modified Poisson regression was used to estimate relative risks (RR) for distress (Kessler 10 scores: low[10- < 12], mild[12- < 16], moderate[16- < 22] and high[22-50]) and use of both blood pressure- and lipid-lowering medications, and use of neither medication in the three months following the questionnaire, adjusting for sociodemographic and health characteristics. RESULTS: Among 7598 participants, 34.0% had low, 35.4% mild, 18.3% moderate and 12.3% high psychological distress. Around two-thirds (63.4%) were using both medications and the proportion declined with increasing levels of distress: RRs were 1.01(95%CI:0.97-1.05), 0.95(0.90-1.00) and 0.91(0.86-0.97) for mild, moderate and high compared to low distress, respectively (p(trend) = 0.001). The proportion using neither medication was 9.1% and increased with increasing distress: RRs for mild, moderate and high compared to low distress were 0.99(0.82-1.19), 1.30(1.06-1.59) and 1.60(1.28-1.98), respectively (p(trend) < 0.001). CONCLUSION: Patients with psychological distress may need more support to optimise their use of secondary CVD prevention medications. Increasing the use of these medications for distressed patients may improve prognosis for patients with distress and improve population-level secondary prevention of CVD more broadly.

12.
J Invasive Cardiol ; 31(11): 314-318, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31303602

RESUMO

BACKGROUND: Approximately 50% of patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) have multivessel coronary disease (MVD). Evidence on the best PCI approach for these patients is conflicting. The aim of this study is to examine Australian data from the CONCORDANCE registry to describe the practice and outcomes of patients receiving multivessel vs culprit-only PCI. METHODS: Two cohorts were constructed from MVD-STEMI patients undergoing primary PCI at 41 hospitals between 2009 and 2015: culprit-only PCI (n = 587; 87%) and multivessel PCI (n = 82; 12%). Clinical characteristics were described, and the outcomes were all-cause mortality, heart failure, and myocardial reinfarction, in-hospital and at 6-month follow-up. The relative prevalence of each procedure over time was also described. RESULTS: The patient cohorts were comparable in age, sex, and cardiovascular risk factors. Patients with higher Killip scores were more likely to receive multivessel PCI (P=.02). The multivessel group was significantly more likely to have in-hospital cardiogenic shock (P<.01), myocardial reinfarction (P=.02), cardiac arrest (P=.02), and stroke (P=.01). There was no difference in the incidence of ischemic events at 6 months, but the multivessel group had a lower rate of planned repeat revascularizations (12% vs 2%; P=.03). There was no difference in the relative frequency of multivessel vs culprit-only PCI during the observation period. CONCLUSIONS: The relative frequency of multivessel vs culprit-only PCI has not changed from 2009-2015. Index complete revascularization for STEMI-MVD patients is more likely to be performed in those with worse presentations and is associated with worse in-hospital complications.

13.
Clin Cardiol ; 2019 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-31216067

RESUMO

BACKGROUND: Anemia commonly accompanies acute coronary syndromes (ACS) and is associated with poorer outcomes. This study examines the associations between anemia, management and outcomes in an Australian ACS population. METHODS: This analysis of the CONCORDANCE database included 8665 ACS patients presenting to 41 Australian hospitals. Baseline characteristics, management, and outcomes were compared between patients with anemia (Hb ≤ 130 for males, Hb ≤ 120 g/L for females) and non-anemia. RESULTS: A total of 1880 (21.7%) patients presenting with ACS were anemic. These patients were older (72 years vs 63 years, P < .0001), with higher prevalence of comorbidities. STEMI patients with anemia were less likely to be emergently reperfused with either thrombolytic therapy (22% vs 33%, P < .0001) or primary percutaneous coronary intervention (PCI) (45% vs 51% P = 0.033). For all ACS, anemic patients less frequently received: coronary angiography (63% vs 86%, P < .0001); drug eluting stents if undergoing PCI (50% vs 58%, P < .0001); dual antiplatelet therapy (80% vs 89%, P < .0001) ;and parenteral anticoagulants (82% vs 88%, P < .0001). In hospital complications of heart failure (20% vs 9%, P < .0001), renal failure (13% vs 4%, P < .0001), and re-infarction (4% vs 2%, P = .0006) were more common among anemic patients. There was a near-linear inverse relationship between admission hemoglobin and in hospital mortality. CONCLUSIONS: Anemic patients with ACS are a high risk group less likely to undergo invasive and antithrombotic therapy. Further investigation is required to determine if more active treatment of anemic patients presenting with ACS will improve their outcomes.

14.
Open Heart ; 6(1): e000959, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31168375

RESUMO

Objectives: To describe changes in mortality among patients undergoing coronary artery bypass grafting (CABG) in New South Wales (NSW) Australia from 2000 to 2013. Methods: Patients undergoing CABG were identified from the NSW Admission Patient Data Collection (APDC) registry, linked to the NSW state-wide death registry database. Changes in all-cause mortality over time were observed following stratification of the study cohort into two year groups. Results: We identified 54 767 patients undergoing CABG during the study period. The risk profile of patients increased over time with significant increases in age, comorbidities and concomitant valve surgery (all p < 0.0001). During a median follow-up period of 6 years, a total 12 161 (22.2%) of patients had died. Survival curves and adjusted analyses showed a steady fall in mortality rate: those operated on during 2012-2013 had 40 % lower mortality than those operated on during 2000-2001 (HR 0.61; 95% CI 0.53 to 0.69). This was contributed to both by a fall in mortality both in hospital (HR 0.48, 95% CI 0.37 to 0.62) and postdischarge (HR 0.73; 95% CI 0.61 to 0.86). Conclusions: We report a consistent reduction in medium-term mortality among a large unselected cohort of NSW patients undergoing CABG between 2000 and 2013. This fall is attributable both to an improvement in outcomes in hospital and in the postdischarge period.

15.
Heart Lung Circ ; 28(10): 1484-1489, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31078427

RESUMO

A coronary chronic total occlusion (CTO) is a common finding during coronary angiography and is associated with increased mortality and poorer cardiovascular prognosis. Technological developments in percutaneous strategies for revascularisation have resulted in increased interest in this area. However, until recently, there has been a paucity of robust scientific randomised data comparing the efficacy of medical management with percutaneous strategies. Both observational data, and to a lesser extent, randomised data, suggest that CTO percutaneous coronary intervention (PCI) should be considered in symptomatic patients. However, in the absence of any randomised data, CTO PCI should not be performed for prognostic benefit. Ongoing trials are needed to confirm these findings as well as to identify the optimal timing and strategy of such interventions.


Assuntos
Oclusão Coronária/cirurgia , Vasos Coronários/cirurgia , Intervenção Coronária Percutânea/métodos , Doença Crônica , Angiografia Coronária/métodos , Oclusão Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Humanos , Fatores de Tempo
16.
Heart Lung Circ ; 28(10): 1535-1548, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31088726

RESUMO

OBJECTIVE: To determine whether sex differences exist in the assessment of cardiovascular disease (CVD) risk scores/risk factors in primary health care. DESIGN/METHODS: PubMed and EMBASE were systematically searched on 31 January 2017. Clinical trials and observational studies were included if they reported on the assessment of CVD risk score, blood pressure (BP), cholesterol or smoking status in primary health care, stratified by sex. Meta-analyses were performed, using random effects models, to determine differences between sexes, separately for adjusted and unadjusted data. RESULTS: Of 14,928 studies found in the search, 22 studies (including 4,754,782 patients) were included in the systematic review with the meta-analysis for quantitative assessment. Overall, the assessment rates of CVD risk score and risk factors were similar in women and men (CVD risk score: 30.7% vs. 35.2% [difference (95% CI): -4.5 (-5.1, -3.9)]; BP: 91.3% vs. 88.5% [2.8 (2.5, 3.0)]; cholesterol: 69.9% vs. 71.0% [-1.1 (-1.5, -0.8)]; and smoking: 85.9% vs. 86.7% [-0.8 (-1.1, -0.5)]). The pooled, adjusted likelihood of having the risk score, BP and cholesterol assessments were comparable between women and men: OR (95% CI): 0.87 (0.70, 1.07); 1.41 (0.89, 2.25); and 1.15 (0.82, 1.60), respectively. However, women were 32% less likely to be assessed for smoking (0.68 [0.47, 1.00]). There was substantial heterogeneity between studies and the risk of publication bias was moderate. CONCLUSION: Despite the guideline recommendations, assessment of CVD risk score in primary health care was low in both sexes. Further, women were less likely to be assessed for their smoking status than men, whereas no sex discrepancies were found for BP and cholesterol assessments.


Assuntos
Doenças Cardiovasculares/epidemiologia , Atenção Primária à Saúde/métodos , Prevenção Primária/métodos , Medição de Risco/métodos , Doenças Cardiovasculares/prevenção & controle , Saúde Global , Humanos , Morbidade/tendências , Fatores de Risco , Distribuição por Sexo , Fatores Sexuais
17.
Int J Clin Pharm ; 41(3): 682-686, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31016680

RESUMO

Background The direct oral anticoagulants (DOACs) offer several advantages over warfarin in the management atrial fibrillation, including the provision of fixed dosing without a requirement for regular monitoring. Recently however the subject of DOAC monitoring has been probed after several post-hoc analyses demonstrated an association between plasma levels and efficacy and safety events. Objective The aim of this pilot study was to explore the acceptability of DOAC plasma monitoring amongst patients with atrial fibrillation and the factors that may influence these attitudes. Method A simple DOAC monitoring schedule based on the dabigatran pharmacokinetic profile was developed. A cross-sectional survey was distributed to patients with atrial fibrillation asking them to indicate their likelihood of taking a particular DOAC subjected to plasma monitoring. Results Thirty patients participated in the study. Most patients (63.3%) favoured taking a DOAC subjected to monitoring under the proposed schedule, citing increased efficacy and reduced toxicity as the reasons for their response. Conclusion There is some suggestion that atrial fibrillation patients may in fact favour taking a DOAC subjected to infrequent monitoring if this enhanced safety and efficacy.


Assuntos
Anticoagulantes/administração & dosagem , Anticoagulantes/sangue , Fibrilação Atrial/sangue , Fibrilação Atrial/tratamento farmacológico , Monitoramento de Medicamentos/métodos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/psicologia , Estudos Transversais , Dabigatrana/administração & dosagem , Dabigatrana/sangue , Monitoramento de Medicamentos/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto
18.
BMC Cardiovasc Disord ; 19(1): 87, 2019 04 08.
Artigo em Inglês | MEDLINE | ID: mdl-30961544

RESUMO

BACKGROUND: The role of intravenous hydration at the time of primary percutaneous intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remains unclear. Guidelines are vague, supported by low level evidence, and hydration is used less often than other clinical settings.To perform a systematic review and meta-analysis of all randomized controlled trials assessing intravenous hydration compared with non-hydration for prevention of contrast induced nephropathy (CIN) and In-hospital mortality in patients with STEMI undergoing primary PCI. METHODS: Medline, EMBASE and the Cochrane Register were searched to September 2018. Included studies reported the incidence of CIN, In-hospital mortality, requirement for dialysis and heart failure. Relative risks with 95% confidence intervals (CIs) for individual trials were pooled using a random effects model. RESULTS: Three moderate quality trials were identified including 1074 patients. Overall, compared with no hydration, intravenous hydration significantly reduced the incidence of CIN by 42% (RR 0.58; 95% CI: 0.45 to 0.74, p < 0.001). The estimated effects upon all-cause mortality (RR 0.56; 95% CI: 0.30 to 1.02, p = 0.057) and the requirement for dialysis (RR 0.52, 95% CI 0.14-1.88, p = 0.462) were not statistically significant. The outcome of heart failure was not consistently reported. CONCLUSIONS: Intravenous hydration likely reduces the incidence of CIN in patients with STEMI undergoing primary PCI. However, for key clinical outcomes such as mortality, heart failure and dialysis the effect estimates were imprecise. Further high quality studies are needed to clarify the appropriate volume of fluid and effects on outcomes.


Assuntos
Meios de Contraste/efeitos adversos , Angiografia Coronária/efeitos adversos , Hidratação , Mortalidade Hospitalar , Nefropatias/prevenção & controle , Intervenção Coronária Percutânea/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Meios de Contraste/administração & dosagem , Angiografia Coronária/mortalidade , Feminino , Hidratação/efeitos adversos , Hidratação/mortalidade , Humanos , Incidência , Infusões Intravenosas , Nefropatias/induzido quimicamente , Nefropatias/diagnóstico , Nefropatias/mortalidade , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/mortalidade , Fatores de Proteção , Ensaios Clínicos Controlados Aleatórios como Assunto , Diálise Renal , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento
20.
Heart Asia ; 11(1): e011122, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30728864

RESUMO

Objective: To ascertain the use of secondary prevention medications and cardiac rehabilitation after an acute coronary syndrome (ACS) and the impact on 2-year outcomes. Methods: CONCORDANCE (Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events) is a prospective, observational registry of 41 Australian hospitals. A representative sample of 6859 patients with an ACS and 6 months' follow-up on 31 May 2016 were included. The main outcome measure was use of ≥75% of indicated medications (≥4/5 (or ≥3/4 if contraindicated) of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker, beta-blocker, lipid-lowering therapy, aspirin and other antiplatelet). Major adverse cardiovascular events (MACE) included myocardial infarction, stroke or cardiovascular death. Results: The mean age was 65±13 years, 29% were women, and the mean Global Registry of Acute Coronary Events (GRACE) score was 106±30. At discharge, 92% were on aspirin, 93% lipid-lowering therapy, 78% beta-blocker, 74% ACE/angiotensin receptor blocker and 73% a second antiplatelet; 89% were taking ≥75% of medications at discharge, 78% at 6 months and 66% at 2 years. At 6 months, 38% attended cardiac rehabilitation, 58% received dietary advice and 32% of smokers reported quitting. Among 1896 patients followed to 2 years, death/MACE was less frequent among patients on ≥75% vs <75% of medications (8.3% vs 13.9%; adjusted OR 0.75, 95 % CI 0.56 to 0.99), and was less frequent in patients who attended versus who did not attend cardiac rehabilitation (4.6% vs 13.4%; adjusted OR 0.44, 95% CI 0.31 to 0.62). Conclusions: Use of secondary prevention therapies diminishes over time following an ACS. Patients receiving secondary prevention had decreased rates of death and MACE at 2 years.

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