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2.
Eur Heart J ; 2020 May 08.
Artigo em Inglês | MEDLINE | ID: mdl-32385490
4.
J Invasive Cardiol ; 32(5): E122-E129, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32357133

RESUMO

INTRODUCTION: The purpose of the current study is to determine the accuracy of machine learning in predicting bleeding outcomes post percutaneous coronary intervention (PCI) in comparison with the American College of Cardiology CathPCI bleeding risk (ACC-BR) model. METHODS: Mayo Clinic CathPCI registry data were retrospectively analyzed from January, 2003 to June, 2018, including 15,603 patients who underwent PCI. The cohort was randomly divided into a training sample of 11,703 patients (75%) and a unique test sample of 3900 patients (25%) prior to model generation. The risk-prediction model was generated utilizing a boosted classification tree algorithm of 105 unique variables to predict the risk of major and minor bleeding complications within 72 hours after PCI or before hospital discharge. The receiver operating characteristic (ROC) curves and areas under the curve (AUC) for the boosted classification tree algorithm (AI-BR) model and ACC-BR model were compared for the test cohort. RESULTS: The mean age of the patient cohort was 67 ± 12.7 years, and women constituted 30% of the cohort. The rate of major bleeding complications in the entire cohort was 1.8%. The sensitivity and specificity of the AIBR model were 77.3% and 80.9%, respectively. The ROC-AUC for the AI-BR model (0.873) was superior vs the ACC-BR model (0.764; P=.02) in predicting major bleeding for the test cohort. CONCLUSION: The AI-BR model accurately predicts bleeding post PCI and outperforms the ACC-BR model in predicting the risk of bleeding in patients undergoing PCI.

5.
J Am Heart Assoc ; 9(8): e05035, 2020 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-32308107
6.
ESC Heart Fail ; 2020 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-32239806

RESUMO

AIMS: The aim of this study is to evaluate the contemporary use of a pulmonary artery catheter (PAC) in acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS AND RESULTS: A retrospective cohort of AMI-CS admissions using the National Inpatient Sample (2000-2014) was identified. Admissions with concomitant cardiac surgery or non-AMI aetiology for cardiogenic shock were excluded. The outcomes of interest were in-hospital mortality, resource utilization, and temporal trends in cohorts with and without PAC use. In the non-PAC cohort, the use and outcomes of right heart catheterization was evaluated. Multivariable regression and propensity matching was used to adjust for confounding. During 2000-2014, 364 001 admissions with AMI-CS were included. PAC was used in 8.1% with a 75% decrease during over the study period (13.9% to 5.4%). Greater proportion of admissions to urban teaching hospitals received PACs (9.5%) compared with urban non-teaching (7.1%) and rural hospitals (5.4%); P < 0.001. Younger age, male sex, white race, higher comorbidity, noncardiac organ failure, use of mechanical circulatory support, and noncardiac support were independent predictors of PAC use. The PAC cohort had higher in-hospital mortality (adjusted odds ratio 1.07 [95% confidence interval 1.04-1.10]), longer length of stay (10.9 ± 10.9 vs. 8.2 ± 9.3 days), higher hospitalization costs ($128 247 ± 138 181 vs. $96 509 ± 116 060), and lesser discharges to home (36.3% vs. 46.4%) (all P < 0.001). In 6200 propensity-matched pairs, in-hospital mortality was comparable between the two cohorts (odds ratio 1.01 [95% confidence interval 0.94-1.08]). Right heart catheterization was used in 12.5% of non-PAC admissions and was a marker of greater severity but did not indicate worse outcomes. CONCLUSIONS: In AMI-CS, there was a 75% decrease in PAC use between 2000 and 2014. Admissions receiving a PAC were a higher risk cohort with worse clinical outcomes.

9.
EuroIntervention ; 15(17): 1483-1484, 2020 Apr 17.
Artigo em Inglês | MEDLINE | ID: mdl-32301711
10.
Am J Cardiol ; 125(11): 1644-1650, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32273055

RESUMO

Data on the efficacy of left atrial appendage occlusion (LAAO) in clinical practice are limited. We performed a systematic review and meta-analysis of observational studies that reported observed versus expected rates of ischemic strokes and/or major bleeding following LAAO. Our primary end points were the pooled relative risk reduction (RRR) in ischemic stroke and major bleeding with corresponding 95% confidence intervals compared with what was expected by the CHA2DS2-VASc and HASBLED scores, respectively. Twenty-nine studies including 11,071 patients (age 74.0 ± 8.7 years, 60% males) met the inclusion criteria. The mean CHA2DS2-VASc score was 4.22 ± 1.48, and the mean HASBLED score was 3.04 ± 1.16. During 19,567 patient-year follow-up, 290 of 11,071 patients (2.62%) suffered an acute ischemic stroke. This represented a 73.6% (95% confidence interval 68.9-78.2%) RRR in ischemic strokes compared with what was expected based on the CHA2DS2-VASc score. A total of 26 studies reported observed versus expected major bleeding (10,056 patients; age 74.0 ± 8.7, 60% males). During 16,967 patient-year follow-up, 404 of 10,056 patients (4.0%) suffered a major bleeding event. This represented a 55% (95% confidence interval 44.2% to -65.9%) RRR in major bleeding compared with what was expected based on the HASBLED score. These estimates were consistent across subgroups stratified according to age, CHADS2VASc, HASBLED scores and type of LAAO device used. In conclusion, LAAO is associated with a favorable observed/expected ratio with regards to ischemic stroke and major bleeding in clinical practice. Future clinical trials remain essential to further assess the efficacy of LAAO via a direct comparison with oral anticoagulation.

11.
J Invasive Cardiol ; 32(4): 129-137, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32198316

RESUMO

OBJECTIVE: Cardiac power index (CPI) is an integrative hemodynamic measure of cardiac pumping capability and is the product of the simultaneously measured mean arterial pressure and the cardiac output. We assessed the association between baseline resting CPI and survival post transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: We retrospectively abstracted data of patients who underwent TAVR at the Mayo Clinic Foundation with follow-up data available at 1 year. Baseline demographic, clinical, and echocardiographic data were abstracted. CPI was calculated using the formula, (cardiac output x mean arterial blood pressure) / (451 x body surface area) W/m². Patients were divided into CPI <0.48 W/m² (group 1) and CPI ≥0.48 W/m² (group 2). Survival according to CPI was determined using Kaplan-Meier method. Multivariate Cox regression analysis was performed to adjust for covariates. Nine hundred and seventy-five patients were included in the final analysis. CPI in group 1 vs group 2 was 0.41 ± 0.05 W/m² vs 0.66 ± 0.14 W/m², respectively (P<.001, two-sided t-test). Patients in group 1 were more likely to be male and to have a prior history of myocardial infarction, coronary revascularization, peripheral arterial disease, diabetes mellitus, transient ischemic attack, carotid artery disease, atrial fibrillation, lower left ventricular ejection fraction, and moderate to severe mitral and tricuspid regurgitation. After adjusting for baseline covariates, a lower CPI was associated with higher 1-year mortality among patients undergoing TAVR (24.39% in group 1 vs 8.28% in group 2; P<.001). CONCLUSION: Low baseline CPI (<0.48 W/m²) confers higher mortality risk among patients undergoing TAVR and provides additional prognostic information, which can help risk-stratify patients.

12.
Circ Heart Fail ; 13(2): e006661, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32059628

RESUMO

BACKGROUND: There are few studies evaluating regional disparities in the care of acute myocardial infarction-cardiogenic shock (AMI-CS). METHODS AND RESULTS: Using the National Inpatient Sample from 2000 to 2016, we identified adults with a primary diagnosis of AMI and concomitant CS admitted to the United States census regions of Northeast, Midwest, South, and West. Interhospital transfers were excluded. End points of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support, hospitalization costs, length of stay, and discharge disposition. Multivariable regression was used to adjust for potential confounding. Of the 402 825 AMI-CS admissions, 16.8%, 22.5%, 39.3%, and 21.4% were admitted to the Northeast, Midwest, South, and West, respectively. Higher rates of ST-elevation AMI-CS were noted in the Midwest and West. Admissions to the Northeast were on average characterized by a higher frequency of whites, Medicare beneficiaries, and lower rates of cardiac arrest. Admissions to the Northeast were less likely to receive coronary angiography, percutaneous coronary intervention, and mechanical circulatory support, despite the highest rates of extracorporeal membrane oxygenation use. Compared with the Northeast, in-hospital mortality was lower in the Midwest (adjusted odds ratio [aOR], 0.96 [95% CI, 0.93-0.98]; P<0.001) and West (aOR, 0.96 [95% CI, 0.94-0.98]; P=0.001) but higher in the South (aOR, 1.04 [95% CI, 1.01-1.06]; P=0.002). The Midwest (aOR, 1.68 [95% CI, 1.62-1.74]; P<0.001), South (aOR, 1.86 [95% CI, 1.80-1.92]; P<0.001), and West (aOR, 1.93 [95% CI, 1.86-2.00]; P<0.001) had higher discharges to home. CONCLUSIONS: There remain significant regional disparities in the management and outcomes of AMI-CS.

13.
Circulation ; 141(13): 1071-1079, 2020 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-32098500

RESUMO

BACKGROUND: Patients with bicuspid aortic valve (AV) stenosis were excluded from the pivotal evaluations of transcatheter AV replacement (TAVR) devices. We sought to evaluate the outcomes of TAVR in patients with bicuspid AV stenosis in comparison with those with tricuspid AV stenosis. METHODS: We used data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry (November 2011 through November 2018) to determine device success, procedural outcomes, post-TAVR valve performance, and in-hospital clinical outcomes (mortality, stroke, and major bleeding) according to valve morphology (bicuspid versus tricuspid). Results were stratified by older and current (Sapien 3 and Evolut R) generation valve prostheses. Medicare administrative claims were used to evaluate mortality and stroke to 1 year among eligible individuals (≥65 years). RESULTS: After exclusions, there were 170 959 eligible procedures at 593 sites during the specified interval. Of these, 5412 TAVR procedures (3.2%) were performed in patients with bicuspid AV, including 3705 with current-generation devices. In comparison with patients with tricuspid valves, patients with bicuspid AV were younger and had a lower Society of Thoracic Surgeons Predicted Risk of Operative Mortality score. When current-generation devices were used to treat patients with bicuspid AV, device success increased (93.5 versus 96.3; P=0.001) and the incidence of 2+ aortic insufficiency declined (14.0% versus 2.7%; P<0.001) in comparison with older-generation devices. With current-generation devices, device success was slightly lower in the bicuspid (versus tricuspid) AV group (96.3% in bicuspid versus 97.4% in tricuspid, P=0.07), with a slightly higher incidence of residual moderate or severe aortic insufficiency among patients with bicuspid AV (2.7% versus 2.1%; P<0.001). A lower 1-year adjusted risk of mortality (hazard ratio, 0.88 [95% CI, 0.78-0.99]) was observed for patients with bicuspid AV versus patients with tricuspid AV in the Medicare-linked cohort, whereas no difference was observed in the 1-year adjusted risk of stroke (hazard ratio, 1.14 [95% CI, 0.94-1.39]). CONCLUSIONS: Using current-generation devices, procedural, postprocedural, and 1-year outcomes were comparable following TAVR for bicuspid AV versus tricuspid AV disease. With newer-generation devices, TAVR is a viable treatment option for patients with bicuspid AV disease.

14.
ESC Heart Fail ; 7(2): 474-481, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32059084

RESUMO

AIMS: Left ventricular (LV) remodelling after ST-segment elevation myocardial infarction (STEMI) worsens outcome. The effect of sex on LV post-infarct remodelling is unknown. We therefore investigated the sex distribution and long-term prognosis of LV post-infarct remodelling after STEMI in the contemporary era of primary percutaneous coronary intervention (PCI) and optimal pharmacotherapy. METHODS AND RESULTS: Data were obtained from an ongoing primary PCI STEMI registry. LV remodelling was defined as ≥20% increase in LV end-diastolic volume at either 3, 6, or 12 months post-infarct, and LV remodelling impact on outcome was evaluated with a log-rank test. A total population of 1995 STEMI patients were analysed (mean age 60 ± 12 years): 1527 (77%) men and 468 (23%) women. The mean age of male patients was 60±11 versus 63±13 years for women (P < 0.001). A total of 953 (48%) patients experienced LV remodelling in the first 12 months of follow-up, and it was equally frequent amongst men (n = 729, 48%) and women (n = 224, 48%). After a median follow-up of 94 (interquartile range 69-119) months, 225 patients died: 171 (11%) men and 54 (12%) women. No survival difference was seen between remodellers and non-remodellers in the male (P = 0.113) and female (P = 0.920) groups. CONCLUSION: LV post-infarct remodelling incidence, as well as long-term survival of LV remodellers and non-remodellers, was similar in men and women who were treated with primary PCI and optimal pharmacotherapy post-STEMI.

15.
Clin Biomech (Bristol, Avon) ; 71: 221-229, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32035338

RESUMO

BACKGROUND: Most individuals with spinal cord injury who use manual wheelchairs experience shoulder pain related to wheelchair use, potentially in part from mechanical impingement of soft tissue structures within the subacromial space. There is evidence suggesting that scapula and humerus motion during certain wheelchair tasks occurs in directions that may reduce the subacromial space, but it hasn't been thoroughly characterized in this context. METHODS: Shoulder motion was imaged and quantified during scapular plane elevation with/without handheld load, propulsion with/without added resistance, sideways lean, and weight-relief raise in ten manual wheelchair users with spinal cord injury using biplane fluoroscopy and computed tomography. For each position, minimum distance between rotator cuff tendon insertions (infraspinatus, subscapularis, supraspinatus) and the coracoacromial arch was determined. Tendon thickness was measured with ultrasound, and impingement risk scores were defined for each task based on frequency and amount of tendon compression. FINDINGS: Periods of impingement were identified during scapular plane elevation and propulsion but not during pressure reliefs in most participants. There was a significant effect of activity on impingement risk scores (P < 0.0001), with greatest impingement risk during scapular plane elevation followed by propulsion. Impingement risk scores were not significantly different between scapular plane elevation loading conditions (P = 0.202) or propulsion resistances (P = 0.223). The infraspinatus and supraspinatus tendons were both susceptible to impingement during scapular plane elevation (by acromion), whereas the supraspinatus was most susceptible during propulsion (by acromion and coracoacromial ligament). INTERPRETATION: The occurrence of mechanical impingement during certain manual wheelchair tasks, even without increased load/resistance, demonstrates the importance of kinematics inherent to a task as a determinant of impingement. Frequency of and technique used to complete daily tasks should be carefully considered to reduce impingement risk, which may help preserve shoulder health long-term.

16.
Circ Cardiovasc Interv ; 13(2): e008494, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32019343

RESUMO

BACKGROUND: Direct stenting without pre-dilation or post-dilation has been advocated for saphenous vein graft percutaneous coronary intervention to decrease the incidence of distal embolization, periprocedural myocardial infarction, and target lesion revascularization. METHODS: We performed a post hoc analysis of patients enrolled in the DIVA (Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Angioplasty; NCT01121224) prospective, double-blind, randomized controlled trial. Patients were stratified into stent-only and balloon-stent groups. Primary end point was 12-month incidence of target vessel failure (defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization). Secondary end points included all-cause death, stent thrombosis, myocardial infarction, and target lesion revascularization during follow-up. RESULTS: Of the 575 patients included in this substudy, 185 (32%) patients underwent stent-only percutaneous coronary intervention. Patients in the stent-only versus balloon-stent group had similar baseline characteristics and similar incidence of target vessel failure at 12-months (15% versus 19%; hazard ratio, 1.34 [95% CI, 0.86-2.08]; P=0.19). During long-term follow-up (median of 2.7 years), the incidence of definite stent thrombosis (1% versus 5%; hazard ratio, 9.20 [95% CI, 1.23-68.92]; P=0.0085), the composite of definite or probable stent thrombosis (5% versus 11%; hazard ratio, 2.52 [95% CI, 1.23-5.18]; P=0.009), and target vessel myocardial infarction (8% versus 14%; hazard ratio, 1.92 [95% CI, 1.08-3.40]; P=0.023) was lower in the stent-only group. Multivariable analysis showed that a higher number of years since coronary artery bypass grafting and >1 target saphenous vein graft lesions were associated with increased target vessel failure during entire follow-up, while preintervention Thrombolysis in Myocardial Infarction-3 flow was protective. CONCLUSIONS: In patients undergoing percutaneous coronary intervention of de novo saphenous vein graft lesions, there was no difference in target vessel failure at 12 months and long-term follow-up in the stent-only versus the balloon-stent group; however, the incidence of stent thrombosis was lower in the stent-only group, as was target vessel myocardial infarction. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01121224.

17.
Card Electrophysiol Clin ; 12(1): 1-11, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32067639

RESUMO

Atrial fibrillation (AF) has been a source of fascination for more than 100 years. Most early investigations centered on the mechanisms of the arrhythmia (reentry versus automaticity; site of origin; approaches to treatment or prevention; and the clinical consequences), specifically tachycardia-induced cardiomyopathy and the potential for lethal events in special circumstances (eg, preexcitation syndromes). The current increased interest in AF has been heightened by increasing information on the clinical volume and number of patients affected. Recent data identify a current prevalence rate of 6 million patients in the United States, which is predicted to become 12 million by 2030.

19.
JAMA Netw Open ; 3(2): e1921326, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32058558

RESUMO

Importance: Data on the contemporary changes in risk profile and outcomes of patients undergoing percutaneous coronary intervention (PCI) or coronary bypass grafting (CABG) are limited. Objective: To assess the contemporary trends in the characteristics and outcomes of patients undergoing PCI or CABG in the United States. Design, Setting, and Participants: This retrospective cohort study used a national inpatient claims-based database to identify patients undergoing PCI or CABG from January 1, 2003, to December 31, 2016. Data analysis was performed from July 15 to October 4, 2019. Main Outcomes and Measures: Demographic characteristics, prevalence of risk factors, and clinical presentation divided into 3 eras (2003-2007, 2008-2012, and 2013-2016) and in-hospital mortality of PCI and CABG stratified by clinical indication. Results: A total of 12 062 081 revascularization hospitalizations were identified: 8 687 338 PCIs (72.0%; mean [SD] patient age, 66.0 [10.8] years; 66.2% male) and 3 374 743 CABGs (28.0%; mean [SD] patient age, 64.5 [12.4] years; 72.1% male). The annual PCI volume decreased from 366 to 180 per 100 000 US adults and the annual CABG volume from 159 to 82 per 100 000 US adults. A temporal increase in the proportions of older, male, nonwhite, and lower-income patients and in the prevalence of atherosclerotic and nonatherosclerotic risk factors was found in both groups. The percentage of revascularization for myocardial infarction (MI) increased in the PCI group (22.8% to 53.1%) and in the CABG group (19.5% to 28.2%). Risk-adjusted mortality increased slightly after PCI for ST-segment elevation MI (4.9% to 5.3%; P < .001 for trend) and unstable angina or stable ischemic heart disease (0.8% to 1.0%; P < .001 for trend) but remained stable after PCI for non-ST-segment elevation MI (1.6% to 1.6%; P = .18 for trend). Risk-adjusted CABG morality markedly decreased in patients with MI (5.6% to 3.4% for all CABG and 4.8% to 3.0% for isolated CABG) and in those without MI (2.8% to 1.7% for all CABG and 2.1% to 1.2% for isolated CABG) (P < .001 for all). Conclusions and Relevance: Significant changes were found in the characteristics of patients undergoing PCI and CABG in the United States between 2003 and 2016. Risk-adjusted mortality decreased significantly after CABG but not after PCI across all clinical indications.

20.
Int J Cardiol ; 310: 9-15, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32085862

RESUMO

BACKGROUND: There are limited data on the outcomes of acute myocardial infarction with cardiogenic shock (AMI-CS) in patients with prior coronary artery bypass grafting (CABG). METHODS: A retrospective cohort of AMI-CS admissions during 2000-2016 from the National Inpatient Sample was created and prior CABG status was identified. Outcomes of interest included in-hospital mortality and resource utilization in the two cohorts. Temporal trends of prevalence, in-hospital mortality, and cardiac procedures were evaluated. RESULTS: In 513,288 AMI-CS admissions, prior CABG was performed in 22,832 (4.4%). Adjusted temporal trends showed a 2-fold increase in CS in both cohorts. There was a temporal increase in coronary angiography and percutaneous coronary intervention (PCI) across both cohorts. The cohort with prior CABG was on average older, of male sex, of white race, and with higher comorbidity. The cohort with prior CABG received coronary angiography (50% vs. 75%), PCI (32% vs. 49%), right heart catheterization/pulmonary artery catheterization (15% vs. 20%), mechanical circulatory support (26% vs. 46%) less frequently compared to those without (all p < 0.001). The cohort with CABG had higher in-hospital mortality (53% vs. 37%; adjusted odds ratio 1.41 [95% confidence interval 1.36-1.46]), greater use of do not resuscitate status (13% vs. 6%), shorter lengths of hospital stay (7 ± 8 vs. 10 ± 12 days), lower hospitalization costs ($92,346 ± 139,565 vs. 138,508 ± 172,895) and fewer discharges to home (39% vs. 43%) (all p < 0.001). CONCLUSIONS: In AMI-CS, admission with prior CABG was older and had lower use of cardiac procedures and higher in-hospital mortality compared to those without prior CABG.

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