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1.
Am J Med ; 2021 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-34648779

RESUMO

BACKGROUND: Mitral regurgitation is the most common form of valvular heart disease worldwide, however, there is an incomplete understanding of predictors of mortality in this population. This study sought to identify risk factors of mortality in a real-world population with mitral regurgitation. METHODS: All patients with moderate or severe mitral regurgitation were identified at a single center from 1/1/16 to 8/31/17. Multivariate regression was performed to evaluate variables independently associated with all-cause mortality. RESULTS: A total of 490 patients with moderate (76.3%) or severe (23.7%) mitral regurgitation due to primary (20.8%) or secondary (79.2%) etiology were identified. The mean age was 66.7 years, 50% were male. At a median follow-up of 3.1 years, the incidence of all-cause mortality was 30.1%, heart failure hospitalization 23.1%, and mitral valve intervention 11.6%. Of 117 variables, multivariate analysis demonstrated 5 that were independently predictive of mortality: baseline creatinine (HR 1.2, 95% CI 1.0-1.3, p=.02), right atrial pressure by echocardiogram (HR 1.3, 95% CI 1.07-1.55, p=.008), hemoglobin (HR 0.65, 95% CI 0.52-0.83, p=.001), hospitalization for heart failure (HR 1.6, 95% CI 1.1-2.4, p=.015), and mitral valve intervention (HR 0.40, 95% CI 0.16-0.83, p=.049). CONCLUSION: In this retrospective, pragmatic analysis of patients with moderate or severe mitral regurgitation, admission for heart failure exacerbation, elevated right atrial pressure, renal dysfunction, anemia, and lack of mitral valve intervention were independently associated with increased risk of all-cause mortality. Whether these risk factors may better identify select patients who may benefit from more intensive monitoring or earlier intervention should be considered in future studies.

2.
PLoS One ; 16(7): e0254635, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34264974

RESUMO

BACKGROUND: Statins have anti-inflammatory and immunomodulatory effects that may reduce the severity of coronavirus disease 2019 (COVID-19), in which organ dysfunction is mediated by severe inflammation. Large studies with diverse populations evaluating statin use and outcomes in COVID-19 are lacking. METHODS AND RESULTS: We used data from 10,541 patients hospitalized with COVID-19 through September 2020 at 104 US hospitals enrolled in the American Heart Association's COVID-19 Cardiovascular Disease (CVD) Registry to evaluate the associations between statin use and outcomes. Prior to admission, 42% of subjects (n = 4,449) used statins (7% on statins alone, 35% on statins plus anti-hypertensives). Death (or discharge to hospice) occurred in 2,212 subjects (21%). Outpatient use of statins, either alone or with anti-hypertensives, was associated with a reduced risk of death (adjusted odds ratio [aOR] 0.59, 95% CI 0.50-0.69), adjusting for demographic characteristics, insurance status, hospital site, and concurrent medications by logistic regression. In propensity-matched analyses, use of statins and/or anti-hypertensives was associated with a reduced risk of death among those with a history of CVD and/or hypertension (aOR 0.68, 95% CI 0.58-0.81). An observed 16% reduction in odds of death among those without CVD and/or hypertension was not statistically significant. CONCLUSIONS: Patients taking statins prior to hospitalization for COVID-19 had substantially lower odds of death, primarily among individuals with a history of CVD and/or hypertension. These observations support the continuation and aggressive initiation of statin and anti-hypertensive therapies among patients at risk for COVID-19, if these treatments are indicated based upon underlying medical conditions.


Assuntos
Anti-Hipertensivos/administração & dosagem , COVID-19/epidemiologia , Doenças Cardiovasculares/epidemiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Sistema de Registros/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , American Heart Association , Anti-Hipertensivos/uso terapêutico , COVID-19/mortalidade , Doenças Cardiovasculares/tratamento farmacológico , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Grupos Populacionais/estatística & dados numéricos , Estados Unidos
3.
Catheter Cardiovasc Interv ; 97(2): E249-E252, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-32383284

RESUMO

A 48-year-old woman with a past medical history of migraines and hyperlipidemia presented due to severe retrosternal chest pain with no other associated signs or symptoms. The patient was hemodynamically stable and was found to have an elevated troponin with electrocardiogram showing no ischemic changes. Computed tomography of the coronary arteries showed a left dominant system with dissection extending from the mid-to-distal left anterior descending (LAD) artery. The patient was subsequently discharged on medical therapy but returned 3 days later due to worsening chest pain. Electrocardiogram revealed inferior and anteroseptal ST segment changes with peak troponin of 14.9 ng/ml (reference range <0.80 ng/ml). Coronavirus disease 2019 (COVID-19) nasopharyngeal swab was performed prior to urgent coronary angiogram. Coronary angiogram was performed with full personal protective equipment for respiratory and droplet precautions due to pending COVID-19 testing results. Angiogram revealed spontaneous coronary artery dissection (SCAD) extending from the ostium of the LAD to the distal vessel. COVID-19 testing returned positive while in intensive care unit. The patient was not a percutaneous coronary intervention candidate due to the extent of the dissection and was not a surgical candidate due to a lack of graftable target and medical management was continued. To our knowledge, this case is the first in which SCAD has been reported in the LAD in a patient with COVID-19 with no other symptoms of respiratory illness or symptoms classically associated with the novel coronavirus. SCAD should be considered on the differential as one of the various cardiac manifestations of COVID-19 infection.


Assuntos
COVID-19/complicações , COVID-19/diagnóstico , Anomalias dos Vasos Coronários/diagnóstico , Anomalias dos Vasos Coronários/virologia , Doenças Vasculares/congênito , COVID-19/terapia , Angiografia Coronária , Anomalias dos Vasos Coronários/terapia , Eletrocardiografia , Feminino , Humanos , Pessoa de Meia-Idade , Doenças Vasculares/diagnóstico , Doenças Vasculares/terapia , Doenças Vasculares/virologia
5.
Cureus ; 12(7): e9027, 2020 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-32775106

RESUMO

Intracardiac thrombi are not uncommon, but right atrial (RA) thrombi are exceedingly rare. Thrombi can lead to a variety of complications, such as systemic and pulmonary embolism. While various imaging modalities are helpful in the diagnosis, an echocardiogram is the most commonly used one. Principle management of the condition involves anticoagulation. However, management can vary among different patient groups, depending on the location and size of thrombi. We present a case of an RA thrombosis due to dilation of the atria and trauma from an infected central venous catheter in a patient with a past medical history of pulmonary artery hypertension (PAH).

7.
J Thromb Thrombolysis ; 50(4): 867-873, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32607653

RESUMO

Among patients who have undergone percutaneous coronary intervention (PCI), the use of dual antiplatelet therapy (DAPT) is associated with increased risk of bleeding, but decreased stent thrombosis and myocardial infarction unrelated to the stent. As PCI techniques and devices have progressed, the optimal duration of DAPT has come into question. We identified all randomized controlled trials (RCTs) of patients undergoing PCI, who received one or more drug eluting stents (DES) for stable coronary artery disease (CAD) or acute coronary syndrome (ACS), and randomized to short (1-3 months) versus standard duration DAPT. The prespecified primary outcome was major adverse cardiovascular events (MACE). Important secondary outcomes were net adverse clinical events (NACE) defined as MACE and major bleeding; any bleeding; major bleeding; all-cause death; cardiovascular death. We calculated hazard ratios (HR) and 95% confidence intervals (CI) using random-effects model. Analysis included 7 RCTs, comprising 35,857 patients and 53,321 patient-years of follow-up. The mean (SD) age of patients was 64.4 (10.6) years, 49.6% of patients presented with ACS, and 25.5% were female. There was no difference between short and standard-length DAPT in regards to MACE (HR = 0.93; 95% CI 0.84-1.03; p = 0.19), NACE (HR = 0.93; 95% CI 0.85-1.02; p = 0.12), all-cause death (HR = 0.92; 95% CI 0.80-1.05; p = 0.21), or cardiovascular death (HR = 0.85; 95% CI 0.64-1.13; p = 0.26). However, short-term DAPT was associated with significantly reduced major bleeding events (HR = 0.67; 95% CI 0.47-0.95; p = 0.03) and any bleeding event (HR = 0.63; 95% CI 0.44-0.90; p = 0.01) compared with standard-length DAPT. Among patients undergoing PCI for CAD, the use of short-term DAPT (1-3 months) followed by single antiplatelet therapy was associated with a lower incidence of clinically relevant bleeding events, but with similar risk of MACE, all-cause death, and cardiovascular death compared with standard duration DAPT.

8.
Am J Med ; 133(11): e625-e630, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32389659

RESUMO

BACKGROUND: We aimed to conduct this study with the goal of further clarifying the role of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with preexisting heart failure with reduced ejection fraction with or without diabetes and to leverage increased sample size and power to evaluate clinically important secondary safety and efficacy outcomes. METHODS: This meta-analysis was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Secondary outcomes included the individual components of the primary outcome; major adverse cardiovascular events (defined as a composite of cardiovascular death, myocardial infarction, stroke), any death, myocardial infarction, or stroke, along with adverse events such as volume depletion, acute kidney injury, adverse events leading to drug discontinuation, amputation, and severe hypoglycemia. Other outcomes included the Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score and changes in N-terminal pro-hormone BNP (NT-proBNP). Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for dichotomous variables and weighted difference (MD) and 95% CI for continuous variables. RESULTS: Compared with placebo, SGLT2i use was associated with a significant reduction of cardiovascular death or heart failure hospitalization (HR = 0.74; 95% CI = 0.66-0.82; P <0.01), heart failure hospitalization (HR = 0.69; 95% CI = 0.57-0.84; P <0.01), cardiovascular death (HR = 0.79; 95% CI = 0.68-0.92; P <0.01), and any death (HR = 0.80; 95% CI = 0.70-0.92; P <0.01). CONCLUSIONS: SGLT2i was associated with a decreased risk of clinically relevant cardiovascular death, heart failure hospitalization, and heart failure symptoms with similar rates of adverse events.


Assuntos
Doenças Cardiovasculares/mortalidade , Diabetes Mellitus Tipo 2/tratamento farmacológico , Insuficiência Cardíaca/tratamento farmacológico , Hospitalização/estatística & dados numéricos , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Injúria Renal Aguda/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipoglicemia/induzido quimicamente , Hipoglicemia/epidemiologia , Infarto do Miocárdio/epidemiologia , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/epidemiologia , Volume Sistólico
10.
Am J Med ; 133(11): 1336-1342.e1, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32325047

RESUMO

BACKGROUND: The purpose of this study was to identify predictors of mortality and potentially modifiable factors related to arrhythmias in patients that undergo transcatheter aortic valve replacement (TAVR). Patients that undergo TAVR are at risk for complete heart block requiring pacemaker implant. Additionally, other arrhythmias, specifically atrial fibrillation (AF), are common in this population. It is unclear how arrhythmias and their management contribute to mortality risk. METHODS: The study analyzed 176 patients who underwent TAVR at a single center. Factors associated with pacemaker implantation within 30 days were analyzed by logistic regression. Factors associated with mortality were analyzed by Kaplan-Meier and Cox regression analyses. RESULTS: Mean age was 80 ± 8.5 years. AF was present in 69 patients, and 39 received anticoagulation. Post-TAVR, a pacemaker was implanted in 25 patients within 30 days. Over a follow up of 566 ± 496 days, 49 patients died. In multivariable analysis, right bundle branch block remained significant (odds ratio 4.212, P = 0.012) for pacemaker implant within 30 days. The AF (hazard ratio [HR] 3.905, P = 0.001), albumin level (HR 0.316, P = 0.034), and diabetes (HR 2.323, P = 0.027) were predictors of death in a multivariate analysis, while pacemaker implant within 30 days was not. Patients with AF who were anticoagulated had improved survival in a stratified Kaplan-Meier analysis compared with those who were not anticoagulated (P = 0.0001). CONCLUSION: AF, diabetes, and low albumin levels are independently associated with mortality after TAVR. In particular, patients with AF who are not anticoagulated are at highest risk for death. Efforts to identify AF and consider anticoagulation should be emphasized.


Assuntos
Estenose da Valva Aórtica/cirurgia , Fibrilação Atrial/epidemiologia , Bloqueio de Ramo/epidemiologia , Estimulação Cardíaca Artificial/estatística & dados numéricos , Hipoalbuminemia/epidemiologia , Mortalidade , Marca-Passo Artificial/estatística & dados numéricos , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Estenose da Valva Aórtica/epidemiologia , Fibrilação Atrial/tratamento farmacológico , Bloqueio de Ramo/terapia , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Bloqueio Cardíaco/epidemiologia , Bloqueio Cardíaco/terapia , Humanos , Hipoalbuminemia/metabolismo , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Análise Multivariada , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Albumina Sérica/metabolismo
12.
Catheter Cardiovasc Interv ; 96(1): 117-120, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31696630

RESUMO

A 69-year-old woman with diabetes was found to have multi-vessel coronary artery disease and underwent 5-vessel coronary artery bypass grafting. Patient had persistent cardiogenic shock postoperatively despite intra-aortic balloon pump and escalating pressor requirements. Electrocardiogram showed new ischemic changes and the patient was urgently taken to the catheterization lab for coronary angiography and placement of an Impella CP for higher degree of hemodynamic support via the left femoral artery. Due to limitations in vascular access the Impella CP sheath was utilized for vascular access for diagnostic angiography and coronary intervention concurrently with ongoing Impella CP support. The first obtuse marginal had severe proximal disease and was treated with percutaneous coronary intervention (PCI) with a drug eluting stent. To our knowledge, this case is the first in which successful diagnostic angiography as well as multi-vessel PCI was performed via an Impella sheath while concurrently using the percutaneous mechanical circulatory support system of the Impella CP. Multiple guide catheters and a pigtail catheter were successfully passed via the Impella CP sheath to perform PCI. This novel method of vascular access could be an important tool to use in high-risk patients with limitations in access sites and decrease potential bleeding complications by limiting the number of arterial punctures.


Assuntos
Cateterismo Cardíaco/instrumentação , Cateteres Cardíacos , Cateterismo Periférico , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/terapia , Stents Farmacológicos , Coração Auxiliar , Intervenção Coronária Percutânea/instrumentação , Choque Cardiogênico/terapia , Idoso , Cateterismo Cardíaco/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Feminino , Hemodinâmica , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Punções , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Função Ventricular Esquerda
14.
JACC Case Rep ; 1(5): 823-831, 2019 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-34316940

RESUMO

An 82-year-old woman with severe respiratory distress and limitations in functional status was found to have severe mitral valve stenosis with annular calcification and referred for transcatheter mitral valve replacement. Prophylactic alcohol septal ablation was used pre-procedurally to minimize mortality risk due to obstruction of the left ventricular outflow tract. (Level of Difficulty: Intermediate.).

15.
Curr Cardiol Rev ; 14(2): 92-96, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29737261

RESUMO

BACKGROUND: Out of hospital cardiac arrest management of patients with non-ST myocardial infarction per current American Heart Association and European Resuscitation Council guidelines leave the decision in regard to early angiography up to the physician operators. Guidelines are clear on the positive impact of early intervention on survival and improvement on left ventricular function in patients presenting with cardiac arrest and ST elevation myocardial infarction on electrocardiogram. This review aims to analyze the data that current guidelines are based upon in regards to out of hospital cardiac arrest with electrocardiogram findings of non-ST elevation myocardial infarction as well as review of other clinical trials that support early angiography and reperfusion strategies. CONCLUSION: Analysis of current literature shows that early coronary evaluation in patients with no finding of ST elevation on ECG can help improve survival in patients suffering out of hospital cardiac arrest.


Assuntos
Cateterismo Cardíaco/métodos , Reanimação Cardiopulmonar/métodos , Feminino , Humanos , Masculino , Resultado do Tratamento
16.
J Mol Microbiol Biotechnol ; 19(1-2): 5-104, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-20962537

RESUMO

P-type ATPases function to provide homeostasis in higher eukaryotes, but they are essentially ubiquitous, being found in all domains of life. Thever and Saier [J Memb Biol 2009;229:115-130] recently reported analyses of eukaryotic P-type ATPases, dividing them into nine functionally characterized and 13 functionally uncharacterized (FUPA) families. In this report, we analyze P-type ATPases in all major prokaryotic phyla for which complete genome sequence data are available, and we compare the results with those for eukaryotic P-type ATPases. Topological type I (heavy metal) P-type ATPases predominate in prokaryotes (approx. tenfold) while type II ATPases (specific for Na(+),K(+), H(+) Ca(2+), Mg(2+) and phospholipids) predominate in eukaryotes (approx. twofold). Many P-type ATPase families are found exclusively in prokaryotes (e.g. Kdp-type K(+) uptake ATPases (type III) and all ten prokaryotic FUPA familes), while others are restricted to eukaryotes (e.g. phospholipid flippases and all 13 eukaryotic FUPA families). Horizontal gene transfer has occurred frequently among bacteria and archaea, which have similar distributions of these enzymes, but rarely between most eukaryotic kingdoms, and even more rarely between eukaryotes and prokaryotes. In some bacterial phyla (e.g. Bacteroidetes, Flavobacteria and Fusobacteria), ATPase gene gain and loss as well as horizontal transfer occurred seldom in contrast to most other bacterial phyla. Some families (i.e. Kdp-type ATPases) underwent far less horizontal gene transfer than other prokaryotic families, possibly due to their multisubunit characteristics. Functional motifs are better conserved across family lines than across organismal lines, and these motifs can be family specific, facilitating functional predictions. In some cases, gene fusion events created P-type ATPases covalently linked to regulatory catalytic enzymes. In one family (FUPA Family 24), a type I ATPase gene (N-terminal) is fused to a type II ATPase gene (C-terminal) with retention of function only for the latter. Several pseudogene-encoded nonfunctional ATPases were identified. Genome minimalization led to preferential loss of P-type ATPase genes. We suggest that in prokaryotes and some unicellular eukaryotes, the primary function of P-type ATPases is protection from extreme environmental stress conditions. The classification of P-type ATPases of unknown function into phylogenetic families provides guides for future molecular biological studies.


Assuntos
Adenosina Trifosfatases/classificação , Motivos de Aminoácidos , Archaea/enzimologia , Bactérias/enzimologia , Eucariotos/enzimologia , Adenosina Trifosfatases/genética , Archaea/genética , Bactérias/genética , Sequência de Bases , Sequência Conservada , Eucariotos/genética , Transferência Genética Horizontal , Genoma Bacteriano , Bombas de Íon/metabolismo , Transporte de Íons , Dados de Sequência Molecular , Filogenia , Pseudogenes
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