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1.
Resuscitation ; 2019 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-31759071

RESUMO

BACKGROUND: There are limited data on the timing and outcomes of in-hospital cardiac arrest (IHCA) in patients with ST-elevation myocardial infarction (STEMI) receiving primary percutaneous coronary intervention (pPCI). This study sought to examine the in-hospital mortality, temporal trends and resource utilization in early vs. delayed IHCA in STEMI. METHODS: Retrospective cohort study from the National Inpatient Sample of all STEMI admissions during 2000-2014 receiving pPCI on hospital day zero. Admissions transferred from other hospitals, with do-not-resuscitate status, without information on IHCA timing, and receiving surgical revascularization were excluded. IHCA was classified as early (hospital day zero) and delayed (on/after hospital day 1). The primary outcome was in-hospital mortality and secondary outcomes included prevalence, temporal trends, and resource utilization. RESULTS: During this 15-year period, 19,185 admissions met the inclusion criteria, with 15,404 (80%) experiencing an early IHCA. The cohort with delayed IHCA was on average older, female, with higher comorbidity, and greater prevalence of non-shockable rhythms and acute organ failure. There was a temporal increase in early IHCA (adjusted odds ratio [aOR] 1.67 [95% confidence interval {CI} 1.35-2.08]) and a decrease in delayed IHCA (aOR 0.60 [95% CI 0.48-0.74]) in 2014 compared to 2000. Compared to the early IHCA cohort, the delayed IHCA cohort had higher in-hospital mortality (aOR 5.35 [95% CI 4.83-5.94]), higher hospitalization costs ($115,165 ± 109,848 vs. 139,038 ± 142,745) and less frequent discharges to home (74% vs. 52%). CONCLUSIONS: Delayed IHCA (on or after hospital day 1) was associated with higher in-hospital mortality and resource utilization compared to early IHCA.

2.
Clin Biochem ; 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31669512

RESUMO

BACKGROUND: In order to manage risks of bleeding and thrombosis after some surgical procedures, platelet function is often measured repeatedly over days or weeks using laboratory tests of platelet function. To interpret test results in the perioperative period, it is necessary to understand analytical, biological and between-person variation. METHODS: We collected three separate blood specimens from 16 healthy volunteers on the first study day, and one additional specimen from each volunteer 1, 2, and 3 months later. Arachidonic acid-induced and adenosine diphosphate (ADP)-induced platelet function were measured in duplicate by whole blood impedance aggregometry using Multiplate (ASPI/ADP tests) and VerifyNow (Aspirin Reaction Units [ARU] and P2Y12 Reaction Units [PRU]). The analytical variation (CVA), within-subject variation (CVI), between-subject variation (CVG), index of individuality (II), and reference change values (RCV) were calculated. RESULTS: VerifyNow ARU demonstrated the smallest short-term and long-term variability (CVA, CVI, and CVG ~1%), resulting in short- and long-term RCV values <5%. II was also higher (1.92) for VerifyNow ARU than other platelet function tests. Multiplate ASPI and ADP tests had the highest RCV both short-(19.0% and 25.2%, respectively) and long-term (32.1% and 39.6%, respectively) due to increased CVA (>5%) and CVI (3.9-13.1%). VerifyNow PRU had a lower RCV than Multiplate ADP; but was the only test with II <0.6. CONCLUSIONS: VerifyNow ARU results can be interpreted relative to a fixed cut-off or population-based reference interval; or relative to small changes in an individual's previous values. VerifyNow PRU and Multiplate ASPI and ADP tests should only be interpreted based upon relative change; and can only distinguish relatively large (>23%) changes over several weeks.

4.
6.
PLoS One ; 14(9): e0222894, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31532793

RESUMO

BACKGROUND: There are limited data on acute kidney injury (AKI) complicating acute myocardial infarction with cardiogenic shock (AMI-CS). This study sought to evaluate 15-year national prevalence, temporal trends and outcomes of AKI with no need for hemodialysis (AKI-ND) and requiring hemodialysis (AKI-D) following AMI-CS. METHODS: This was a retrospective cohort study from 2000-2014 from the National Inpatient Sample (20% stratified sample of all community hospitals in the United States). Adult patients (>18 years) admitted with a primary diagnosis of AMI and secondary diagnosis of CS were included. The primary outcome was in-hospital mortality in cohorts with no AKI, AKI-ND, and AKI-D. Secondary outcomes included predictors, resource utilization and disposition. RESULTS: During this 15-year period, 440,257 admissions for AMI-CS were included, with AKI in 155,610 (35.3%) and hemodialysis use in 14,950 (3.4%). Older age, black race, non-private insurance, higher comorbidity, organ failure, and use of cardiac and non-cardiac organ support were associated with the AKI development and hemodialysis use. There was a 2.6-fold higher adjusted risk of developing AKI in 2014 compared to 2000. Presence of AKI-ND and AKI-D was associated with a 1.3 and 1.7-fold higher adjusted risk of mortality. Compared to the cohort without AKI, AKI-ND and AKI-D were associated with longer length of stay (9±10, 12±13, and 18±19 days respectively; p<0.001) and higher hospitalization costs ($101,859±116,204, $159,804±190,766, and $265,875 ± 254,919 respectively; p<0.001). CONCLUSION: AKI-ND and AKI-D are associated with higher in-hospital mortality and resource utilization in AMI-CS.

7.
Clin Chem ; 65(10): 1221-1227, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31387884

RESUMO

The IFCC Committee on Clinical Applications of Cardiac Bio-Markers (C-CB) has directives and initiatives focused on providing evidence-based educational resources to aid and improve understanding around key analytical and clinical aspects of cardiac biomarkers used in clinical practice and the research setting. As a task force, we have previously published position statements and recommendations focused on use and analytical aspects of high-sensitivity cardiac troponin assays. The current educational document is the first from the C-CB highlighting important biochemical, analytical, and clinical aspects as they relate to the natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), with a focus on heart failure.

8.
Am Heart J ; 215: 12-19, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31260901

RESUMO

Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years. METHODS: We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression. RESULTS: We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94-0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85-0.96, P = .002) a critical care discharge diagnosis. CONCLUSIONS: We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time.

9.
ESC Heart Fail ; 6(4): 874-877, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31271517

RESUMO

AIMS: To evaluate sex-specific disparities in acute kidney injury (AKI) complicating acute myocardial infarction-related cardiogenic shock (AMI-CS) in the United States. METHODS AND RESULTS: This was a retrospective cohort study from 2000 to 2014 from the National Inpatient Sample (20% sample of all hospitals in the United States). Patients >18 years admitted with a primary diagnosis of AMI and concomitant CS that developed AKI were included. The endpoints of interest were the prevalence, trends, and outcomes of men and women with AKI in AMI-CS. Multivariable hierarchical logistic regression was used to control for confounding, and a two-sided P < 0.05 was considered statistically significant. During this 15 year period, 440 257 admissions with AMI-CS met the inclusion criteria, with AKI noted in 155 610 (35.3%). Women constituted 36.3% of the cohort and were older, of non-White race, and with higher co-morbidity compared with men. Women with AKI less often received coronary angiography (59% vs. 66%), percutaneous coronary intervention (39% vs. 43%), mechanical circulatory support (39% vs. 48%), mechanical ventilation (49% vs. 54%), and haemodialysis (9% vs. 10%) compared with men (all P < 0.001). Adjusted in-hospital mortality was higher in women-odds ratio 1.16 (95% confidence interval 1.14-1.19); P < 0.001-compared with men. Women had shorter lengths of stay (12 ± 14 vs. 13 ± 14 days), lower hospital costs ($150 071 ± 180 796 vs. $181 260 ± 209 674), and were less often discharged to home (19% vs. 31%) (all P < 0.001). CONCLUSIONS: Women with AKI in AMI-CS received fewer cardiac and non-cardiac interventions, had higher in-hospital mortality, and were less often discharged to home compared with men.

10.
Eur Heart J ; 40(33): 2810-2812, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31243435
11.
J Am Coll Cardiol ; 73(18): 2286-2295, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31072572

RESUMO

BACKGROUND: Galectin-3 (Gal-3) is implicated in cardiac fibrosis, but its association with adverse outcomes after myocardial infarction (MI) is unknown. OBJECTIVES: The purpose of this study was to examine the prognostic value of Gal-3 in a community cohort of incident MI. METHODS: A population-based incidence MI cohort was prospectively assembled in Olmsted County, Minnesota, between 2002 and 2012. Gal-3 levels were measured at the time of MI. Patients were followed for heart failure (HF) and death. RESULTS: A total of 1,342 patients were enrolled (mean age 67.1 years; 61.3% male; 78.8% non-ST-segment elevation MI). Patients with elevated Gal-3 were older and had more comorbidities. Over a mean follow-up of 5.4 years, 484 patients (36.1%) died and 368 (27.4%) developed HF. After adjustment for age, sex, comorbidities, and troponin, patients with Gal-3 values in tertiles 2 and 3 had a 1.3-fold (95% confidence interval [CI]: 0.9-fold to 1.7-fold) and a 2.4-fold (95% CI: 1.8-fold to 3.2-fold) increased risk of death, respectively (ptrend < 0.001) compared with patients with Gal-3 values in tertile 1. Patients with Gal-3 values in tertiles 2 and 3 had a higher risk of HF with hazard ratios of 1.4 (95% CI: 1.0 to 2.0) and 2.3 (95% CI: 1.6 to 3.2), respectively (ptrend < 0.001). With further adjustment for soluble suppression of tumorigenicity-2, elevated Gal-3 remained associated with increased risk of death and HF. The increased risk of HF did not differ by HF type and was independent of the occurrence of recurrent MI. CONCLUSIONS: Gal-3 is an independent predictor of mortality and HF post-MI. These findings suggest a role for measuring Gal-3 levels for risk stratification post-MI.

12.
J Am Coll Cardiol ; 73(14): 1781-1791, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30975295

RESUMO

BACKGROUND: There are limited data on acute noncardiac multiorgan failure in cardiogenic shock complicating acute myocardial infarction (AMI-CS). OBJECTIVES: The authors sought to evaluate the 15-year national trends, resource utilization, and outcomes of single and multiple noncardiac organ failures in AMI-CS. METHODS: This was a retrospective cohort study of AMI-CS using the National Inpatient Sample database from 2000 to 2014. Previously validated codes for respiratory, renal, hepatic, hematologic, and neurological failure were used to identify single or multiorgan (≥2 organ systems) noncardiac organ failure. Outcomes of interest were in-hospital mortality, temporal trends, and resource utilization. The effects of every additional organ failure on in-hospital mortality and resource utilization were assessed. RESULTS: In 444,253 AMI-CS admissions, noncardiac single or multiorgan failure was noted in 32.4% and 31.9%, respectively. Multiorgan failure was seen more commonly in admissions with non-ST-segment elevation AMI-CS, nonwhite race, and higher baseline comorbidity. There was a steady increase in the prevalence of single and multiorgan failure. Coronary angiography and revascularization were performed less commonly in multiorgan failure. Single-organ failure (odds ratio: 1.28; 95% confidence interval: 1.26 to 1.30) and multiorgan failure (odds ratio: 2.23; 95% confidence interval: 2.19 to 2.27) were independently associated with higher in-hospital mortality, greater resource utilization, and fewer discharges to home. There was a stepwise increase in in-hospital mortality and resource utilization with each additional organ failure. CONCLUSIONS: There has been a steady increase in the prevalence of multiorgan failure in AMI-CS. Presence of multiorgan failure was independently associated with higher in-hospital mortality and greater resource utilization.

13.
J Am Coll Cardiol ; 73(14): 1846-1860, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30975302

RESUMO

Acute myocardial infarction (MI) can occur from increased myocardial oxygen demand and/or reduced supply in the absence of acute atherothrombotic plaque disruption; a condition called type 2 myocardial infarction (T2MI). As with any MI subtype, there must be clinical evidence of myocardial ischemia to make the diagnosis. This condition is increasingly diagnosed due to the increasing sensitivity of cardiac troponin assays and is associated with adverse short-term and long-term prognoses. Limited data exist defining optimal management strategies because T2MI is a heterogeneous entity with varying etiologies and triggers. Thus, these patients require individualized care. A major barrier is the absence of a uniform definition that can be operationalized with high reproducibility. This document provides a synthesis of the data about T2MI to assist clinicians' understanding of its pathobiology, when to deploy the diagnosis, and its associated treatments. It also clarifies prognosis, identifies gaps in knowledge, and provides recommendations for moving forward.

14.
Heart ; 105(16): 1231-1236, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30948519

RESUMO

BACKGROUND: Invasive angiography in the setting of cardiac troponin elevation may reveal non-obstructive coronary arteries leading to uncertainty in diagnosis. Cardiac MR (CMR) may aid in diagnosis, however, the spectrum of diagnostic findings in the patient presenting with symptoms of cardiac ischaemia, elevated cardiac biomarkers and a negative invasive coronary angiogram is yet to be completely described. METHODS: We queried the Mayo Clinic, Rochester inpatient record from 1 January 2000 to 31 December 2016 to identify patients who: (1) had an elevated troponin T during admission, (2) underwent coronary angiography within 30 days of troponin T elevation which was considered negative for obstructive coronary arterial disease and (3) underwent CMR within 30 days of troponin T elevation. CMR diagnoses were classified as either (1) myocarditis, (2) small area myocardial infarction, (3) stress cardiomyopathy, (4) non-ischaemic cardiomyopathy or (5) normal. RESULTS: Of 215 patients, the spectrum of disease seen on CMR was myocarditis (32%), small area infarction (22%), non-ischaemic cardiomyopathy (20%) and stress cardiomyopathy (9.3%). CONCLUSION: In the largest single-centre study assessing the role of CMR in patients admitted with elevated troponin T with a non-obstructive coronary disease on an angiogram, small area infarction was seen in 22% of patients.

16.
J Am Heart Assoc ; 8(6): e008626, 2019 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-30871395

RESUMO

Background The recent introduction of high-sensitivity cardiac troponin (hs-cTn) assays has allowed clinicians to measure hs-cTn before and after cardiac stress testing, but the hs-cTn release pattern and potential utility in identifying inducible myocardial ischemia are unclear. We thus conducted a systematic review and meta-analysis to improve our understanding of hs-cTn release associated with exercise and pharmacological stress testing. Methods and Results Studies published between January 2008 and July 2016 that reported hs-cTn change values (high-sensitivity cardiac troponin T [hs-cTnT] or high-sensitivity cardiac troponin I [hs-cTnI]) in relation to cardiac stress testing were searched and reviewed by 2 independent screeners. Primary outcomes were pooled estimates of absolute and relative hs-cTn changes after cardiac stress test, stratified by the presence of inducible myocardial ischemia. This meta-analysis included 11 studies (n=2432 patients). After exercise stress testing, hs-cTnT increased by 0.5 ng/L or 11% (6 studies, n=406) and hs-cTnI by 2.4 ng/L or 41% (4 studies, n=365) in patients with inducible myocardial ischemia versus hs-cTnT by 1.1 ng/L or 18% (8 studies, n=629; P=0.29) and hs-cTnI by 1.8 ng/L or 72% (4 studies, n=831; P=0.61) in patients who did not develop inducible myocardial ischemia. After pharmacological stress test, hs-cTnT changed by -0.1 ng/L or -0.4% (6 studies, n=251) and hs-cTnI by 2.4 ng/L or 32% (2 studies, n=108) in patients with inducible myocardial ischemia versus hs-cTnT by 0.7 ng/L or 11% (5 studies, n=443, P=0.44) and hs-cTnI by 1.7 ng/L or 38% (2 studies, n=116; P=0.62) in patients who did not develop inducible myocardial ischemia. Conclusions hs-cTn rising patterns after exercise and pharmacological stress testing appear inconsistent and comparably small, and do not appear to be correlated with inducible myocardial ischemia.

17.
Clin Chem Lab Med ; 57(5): 745-751, 2019 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-30838842

RESUMO

Background Manufacturers of high-sensitivity cardiac troponin (hs-cTn) assays have restricted use of what sample types or matrices are acceptable to use for measurement. Our goal was to evaluate the comparability of the Siemens ADVIA Centaur hs-cTnI assay across different matrices and under different storage conditions. Methods Three different QC-plasma matrices were evaluated for imprecision <10 ng/L. Passing-Bablok regression and difference plots were determined for cTnI concentrations spanning the reference interval (limit of quantification to male 99th-percentile: 2.5 ng/L to <60 ng/L) between serum and lithium heparin plasma, lithium heparin and EDTA plasma and between the Siemens and Abbott hs-cTnI assays. Stability at room temperature (RT) and 2-8 °C was also assessed across the three matrices. Results Over 16-weeks the SDs were ≤1.0 ng/L for QCs ranging from 5.0 to 8.3 ng/L. Across the reference interval there was excellent agreement between lithium heparin plasma and serum for the Siemens hs-cTnI assay (slope=0.98/intercept=-0.1), however, cTnI concentrations were proportionally lower in EDTA as compared to lithium heparin plasma (slope=0.90, 95% CI: 0.88-0.92). In lithium heparin plasma the Siemens hs-cTnI concentrations were higher than the Abbott hs-cTnI concentrations (slope=1.26/intercept=-0.2). Stability of cTnI in lithium heparin plasma as compared in serum and EDTA plasma appeared more labile, with decreases ≥20% in concentrations evident as early as 1-day in storage at RT. Conclusions There is excellent agreement in concentrations between lithium heparin plasma and serum with the Siemens ADVIA Centaur hs-cTnI assay; however, cTnI concentrations in EDTA plasma are lower. Reference intervals and clinical studies in EDTA plasma for the Centaur hs-cTnI assay are required before clinical use.

18.
Int J Cardiol ; 285: 6-10, 2019 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-30871802

RESUMO

BACKGROUND: There are limited data on prolonged invasive mechanical ventilation (IMV) and tracheostomy use in intubated acute myocardial infarction with cardiogenic shock (AMI-CS) patients. METHODS: Using the National Inpatient Sample, all admissions with AMI-CS requiring IMV between January 1, 2000, and December 31, 2014, were included. Prolonged IMV was defined as IMV use >96 h. Outcomes of interest included temporal trends in use of prolonged IMV and tracheostomy, in-hospital mortality, and resource utilization. RESULTS: In this 15-year period, 185,589 intubated AMI-CS admissions met the inclusion criteria. Prolonged IMV (>96 h) and tracheostomy use were noted in 68,544 (36.9%) and 10,645 (5.7%), respectively. Prolonged IMV and tracheostomy were used more commonly in younger patients. The cohort with prolonged IMV had higher organ failure and greater use of cardiac and non-cardiac organ support. Temporal trends showed a decline in prolonged IMV (adjusted odds ratio {aOR} 0.61 [95% confidence interval {CI} 0.57-0.65]) and tracheostomy use (aOR 0.80 [95% CI 0.70-0.90]) in 2014 compared to 2000. Prolonged IMV (aOR 0.45 [95% CI 0.44-0.47]; p < 0.001) and tracheostomy (aOR 0.28 [95% CI 0.27-0.29]; p < 0.001) were associated with lower in-hospital mortality with a decreasing trend between 2000 and 2014 in intubated AMI-CS admissions. Patients with prolonged IMV and tracheostomy use had nearly three-fold higher health care costs, and four-fold longer hospital stays. CONCLUSIONS: In this cohort of intubated AMI-CS admissions, prolonged IMV and tracheostomy showed a temporal decrease between 2000 and 2014. Prolonged IMV and tracheostomy use was associated with high resource utilization.

19.
J Am Coll Cardiol ; 73(9): 1059-1077, 2019 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-30798981

RESUMO

High-sensitivity cardiac troponin (hs-cTn) I or T methods have been in use in certain regions for years but are now increasingly globally adopted, including in the United States. Accordingly, inevitable challenges are created for institutions transitioning from conventional cardiac troponin (cTn) assays. hs-cTn assays have higher analytic precision at lower concentrations, yielding greater clinical sensitivity for myocardial injury and allowing accurate recognition of small changes in troponin concentration (rise or fall) within a short time frame. Although much of the knowledge regarding troponin biology that was applicable with older troponin assays still holds true, considerable education regarding the differences between conventional cTn and hs-cTn is needed before medical systems convert to the newer methods. This includes a basic understanding of how hs-cTn testing differs from conventional cTn testing and how it is best deployed in different settings, such as the emergency department and inpatient services. This Expert Panel will review important concepts for institutional transition to hs-cTn methodology, providing recommendations useful for education before implementation.

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