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1.
Intern Emerg Med ; 2020 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-32034673

RESUMO

Elderly patients are often excluded from a chest pain unit (CPU)-based evaluation of chest pain due to concern about adverse events and poorer outcomes. The aim of this study was to assess the feasibility and safety of thoroughly evaluating elderly patients ≥ 65 years of age presented with acute chest pain via a CPU. We evaluated 1220 consecutive patients admitted to our CPU, and stratified them according to age: those over and those under 65 years. Patients were evaluated for outcomes during hospitalization and for a composite endpoint at 60 days post discharge which included: recurrent hospitalization due to chest pain, need for coronary revascularization, acute coronary syndrome, and death. Overall, 241 (20%) patients were in the ≥ 65-year-old group and 979 (80%) patients in the group < 65 years of age. Older patients were more likely to be female, have more co-morbidities, and a history of prior coronary artery disease. There was no difference between the two groups regarding in-hospital course, including hospitalization in the CPU (9.5% vs. 11.6%, p = 0.37), coronary angiography (7.9% vs. 9.8%, p = 0.37), and revascularization performed during the evaluation period (4.5% vs. 3.3%, p = 0.42). Of those discharged, the primary endpoint at 60 days was observed in 11 (1.5%) and 7 (3.9%) patients in those under and over 65 years, respectively, (p = 0.13). No mortalities were recorded. Comprehensive evaluation via a CPU of patients who are ≥ 65 years of age is feasible and safe with in-hospital and short-term outcomes compared to their younger counterparts.

2.
Isr Med Assoc J ; 22(1): 60-63, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31927808

RESUMO

BACKGROUND: In this review, the authors re-examine the role of aspirin in the primary prevention of cardiovascular disease. They discuss the history of the use of aspirin in primary prevention, the current guidelines, and the recent evidence surrounding aspirin use as primary prevention in special populations such as those with moderate cardiovascular risk, diabetes mellitus, and the elderly.


Assuntos
Aspirina/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Fibrinolíticos/uso terapêutico , Aspirina/efeitos adversos , Fibrinolíticos/efeitos adversos , Humanos , Guias de Prática Clínica como Assunto , Prevenção Primária/métodos
3.
Am J Med ; 2019 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-31712098

RESUMO

BACKGROUND: There are controversial data regarding the outcome and management of patients hospitalized with clinically diagnosed acute myocarditis. METHODS: We retrospectively evaluated data of 322 consecutive patients admitted to the Sheba Medical Center with clinically suspected acute myocarditis from January 2005 to December 2017. Patients were subdivided into 2 groups based on their left ventricular ejection fraction (LVEF) at presentation: 1) patients with an LVEF <50% (n = 60) and 2) patients with an LVEF ≥50% (n = 260). We aimed to evaluate the clinical characteristics, management, and in-hospital outcome as well as short-term and 1-year outcome of patients admitted with acute myocarditis. RESULTS: The mean age of the study population was 37 ± 14 years, most of them (84%) males. Although chest pain was the main complaint in 89% of the patients at presentation, only 35% had typical pericardial pain. Patients with a LVEF <50% were more likely to demonstrate ST depression or T wave inversion on their electrocardiogram (ECG) at presentation (33% vs 18%, P = 0.007), and have higher levels of admission and peak troponin compared to those with LVEF ≥50%,(12.7 µ/L ± 15 µ/L vs 5.5 µ/L ± 9.2 µ/L, P = 0.001 for admission troponin, 18.8 µ/L ± 19.9 µ/L vs 8.4 µ/L ± 11.6 µ/L, P <0.001, for peak troponin). Univariate analysis showed that patients with an LVEF <50% were more likely to suffer from adverse cardiovascular events, defined as a composite of the following: 1) acute decompensated congestive heart failure; 2) ventricular arrhythmias; and 3) in-hospital mortality, compared to those with an LVEF ≥50% (15 [25%] vs10 [4%], P <0.001). Consistently, multivariable analysis showed that patients with an LVEF <50% had a 4-fold increased risk of adverse cardiovascular events compared to those patients with an LVEF ≥50% (heart rate [HR] = 4.30; 95% confidence interval [CI] 1.59-11.49; P <0.001). CONCLUSIONS: Patients with clinical acute myocarditis seem to have an overall good prognosis. Although patients with an LVEF <50% are at a higher risk of in-hospital adverse events compared to those with an LVEF ≥50%, this propensity is not reflected during 1-year of follow-up.

4.
Eur J Intern Med ; 65: 32-36, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31054804

RESUMO

BACKGROUND: Intermediate-risk pulmonary embolism (PE) patients present a therapeutic dilemma. While some are at risk for developing adverse events, possibly requiring escalation therapy, most will have a benign course. Our aim was to define predictors which will identify those patients who will not deteriorate despite the presence of RV involvement. METHODS: We evaluated 179 consecutive intermediate-risk PE patients (47% males; mean age: 66 ±â€¯16 years), allocating them to those who did and did not need escalation therapy and evaluating the predictors for deterioration. We then formulated a score to distinguish between those who would not require escalation therapy. RESULTS: Twenty-six patients (15%) required escalation therapy which was associated with significantly more episodes of syncope (42% vs. 15%, p = 0.001), higher D-Dimer levels (10,810 ±â€¯19,147 vs. 3816 ±â€¯6255, p < 0.001), echocardiographic evidence of severe right ventricular (RV) dysfunction (42% vs. 19%, p < 0.01), or a higher RV/left ventricular (LV) diameter ratio on computed tomography (CT) (1.9 ±â€¯0.6 vs. 1.46 ±â€¯0.5, p < 0.001). On multivariate analysis the presence of syncope (HR 2.8 CI 1.1-7.1) and severe RV dysfunction on echocardiography (HR 3.5 CI 1.4-9.3) were found to be independent predictors for escalation therapy. A combined score of 1 was associated with only a 1.9% risk for escalation, while a maximum score of 4 was associated with a 57% risk for escalation therapy (P for trend<0.001). CONCLUSIONS: A small but significant number of intermediate-risk PE patients required escalation therapy. A combined score comprising clinical, imaging, and laboratory parameters might aid in further risk stratification, identifying those intermediate risk PE patients with a more benign clinical course.

5.
Atherosclerosis ; 286: 14-19, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31082760

RESUMO

BACKGROUND AND AIMS: The beneficial effect of statin therapy has been well established for both primary and secondary prevention of cardiovascular disease. Nevertheless, it remains under-used among patients with chronic kidney disease (CKD). We aimed to investigate the impact of statin therapy across a wide spectrum of CKD patients presenting with acute coronary syndrome (ACS). METHODS: We included all patients with ACS enrolled in the Acute Coronary Syndrome Israel Survey (ACSIS) between the years 2006 and 2016, and allocated them to 3 groups according to their renal function based on an estimated glomerular filtration rate (eGFR) calculation on admission (MDRD formula): eGFR<30 ml/min/1.73 m2 (n = 525, 6%), eGFR 30-59 ml/min/1.73 m2 (n = 1919, 21%), and eGFR>60 ml/min/1.73 m2 (n = 6501, 73%). Primary outcome included in-hospital, 30-day, and 1-year major adverse cardiovascular events (MACE), and the independent prognostic effect of statins among CKD patients with ACS, by Cox regression analysis. RESULTS: All 8945 consecutive ACS patients were included in our analysis. On hospital discharge, statin prescriptions were negatively associated with eGFR ]eGFR>60 ml/min/1.73 m2 -95%, eGFR 30-59 ml/min/1.73 m2 -90%, eGFR<30 ml/min/1.73 m2 -78% (p < 0.001 for trend). Kaplan-Meier curves demonstrated both short and long-term higher mortality rates in those prescribed compared with those not prescribed statins (p < 0.001), regardless of renal function. Cox regression analysis revealed the protective effect of discharge statins (HR-0.25, 95% C.I 0.2-0.3, p < 0.001). CONCLUSIONS: In our study, the beneficial effect of statins was maintained among CKD patients presenting with ACS. Therefore, these patients should be treated with statins regardless of their eGFR.

6.
Harefuah ; 158(3): 168-172, 2019 Mar.
Artigo em Hebraico | MEDLINE | ID: mdl-30916503

RESUMO

INTRODUCTION: Light transmission aggregometry (LTA) is the most commonly used test for the diagnosis of platelet function disorders, but requires large amounts of blood samples and normal platelet count. OBJECTIVES: To compare flow cytometric (FC) platelet function testing to standard LTA in the general population, in patients treated with anti-platelets drugs and in term and preterm neonates. METHODS: Platelet function was assessed with LTA and FC using PAC1 binding and p-selectin expression, as platelet activation markers, in response to agonist activation. A comparison between LTA and FC was performed in a Clopidogrel treated patient, before and after (24 and 72 hours) loading the drug. The platelet activation markers PAC1 and p-selectin, were compared in umbilical cord blood samples of in-term and preterm neonates. RESULTS: ADP-induced platelet aggregation was comparable to p-selectin expression assayed by FC (r=0.79-0.86) as measured before and after Clopidogrel loading. Both tests showed good response to Clopidogrel in 72 hours but not in 24 hours after its loading. Preterm cord blood platelets showed decreased ADP-induced activation in both activation markers: PAC1 and p-selectin, but only p-selectin reached statistical significance. We identified possible platelet activation markers in response to commonly used agonists' stimulation for FC analysis. CONCLUSIONS: FC analysis of platelet function has added value in the diagnosis of impaired platelet function and anti-platelet drug response. Using FC enables us to test platelet function in minimal blood volume and regardless of platelet count. Identification of the unique activation marker for each agonist is prerequisite for FC analysis of platelet function.


Assuntos
Plaquetas , Citometria de Fluxo , Agregação Plaquetária , Difosfato de Adenosina , Humanos , Inibidores da Agregação de Plaquetas , Ticlopidina
7.
Int J Cardiol ; 281: 22-27, 2019 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-30709558

RESUMO

BACKGROUND: While women ≥80 years old have a high prevalence of coronary artery disease (CAD), little data exist regarding their outcome following acute coronary syndrome (ACS). METHODS: In a retrospective study based on data of 3518 ACS women patients who were enrolled in the ACS Israel Survey (ACSIS), we first evaluated and compared the clinical outcomes of 858 ACS women ≥80 years with 2660 ACS women <80 years, hospitalized during 2000-2016. Secondly, we evaluated the clinical outcome of 450 women ≥80 years hospitalized during 2000-2006 ('early period') and compared them with 408 ACS women of the same age group hospitalized during 2008-2016 ('late period'). RESULTS: Implementation of the ACS AHA/ACC/ESC therapeutic guidelines was lower in ACS women ≥80 years compared with women <80 years. Multivariate Cox regression analysis demonstrated a worse 1-year survival rate in the ACS women ≥80 years compared with those <80 years. During the late period women ≥80 years were treated more frequently with guideline-recommended therapies compared with patients from the same age group who were hospitalized in the early period. A significant decline in in-hospital mortality rates in ACS women ≥80 years hospitalized in the late compared with the early period was demonstrated. However, 7-day, 30-day and 1-year mortality rates were not significantly changed. CONCLUSION: Adverse outcome rates of ACS women ≥80 years were significantly higher compared with those <80 years. In-hospital survival rates of ACS women patients ≥80 years improved during the 2000-2016 period; however, long-term survival rates were not significantly changed.


Assuntos
Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Gerenciamento Clínico , Mortalidade Hospitalar/tendências , Síndrome Coronariana Aguda/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Israel/epidemiologia , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Inquéritos e Questionários , Taxa de Sobrevida/tendências , Resultado do Tratamento
8.
J Cardiol ; 73(4): 271-275, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30591318

RESUMO

BACKGROUND: The GRACE risk score is currently recommended as the major score for risk prediction on admission in patients with acute coronary syndrome (ACS). Anemia in patients with ACS adversely affects their clinical outcomes, yet hemoglobin level on admission is not included as a parameter in the GRACE score. We hypothesized that hemoglobin level on admission would improve the predictive value of the GRACE score. METHODS: We retrospectively studied one-year mortality in consecutive ACS patients included in the ACSIS (acute coronary syndrome Israeli Survey) registry between the years 2008 and 2013. Patients were classified into groups according to the GRACE score - ≥140 or <140, and according to the hemoglobin level: severe anemia - <8g/dl; mild anemia - 8-12g/dl; no anemia - >12g/dl. We analyzed the incremental predictive value of admission hemoglobin levels over the GRACE score. RESULTS: We studied 11,505 patients. The GRACE score predicted 1-year mortality with an area under the curve (ROC) of 0.68 (95% CI 0.66-0.7). When hemoglobin level on admission was incorporated into the model, the ROC increased to 0.73 (95% CI 0.71-0.75, p<0.001). The incremental value of hemoglobin levels on admission was significant only in the low (<140) GRACE score group. CONCLUSIONS: In patients a with low GRACE score (<140), anemia on admission has additional predictive value for one-year mortality. In contrast, in patients with a high GRACE risk score, hemoglobin level on admission did not improve prediction accuracy.

9.
Am J Cardiol ; 2019 Dec 28.
Artigo em Inglês | MEDLINE | ID: mdl-31948664

RESUMO

Patients with intermediate-risk pulmonary emboli (PE) present a challenging clinical problem. Although syncope has been suggested as a marker for adverse outcomes in these patients, data remain scarce. We aimed to investigate the clinical outcomes of intermediate risk PE patients presenting with syncope. We performed a retrospective cohort study comprised of consecutive, normotensive, PE patients, with evidence of right ventricular involvement. The primary outcome of major adverse clinical events included either one or a combination of mechanical ventilation, hemodynamic instability and need for inotropic support, reperfusion therapy, and in-hospital mortality. Secondary outcomes included each of the above individual components including major bleeding and renal failure. Overall, 212 patients were evaluated, 40 (19%) presented with syncope, and had a higher prevalence of major adverse clinical events (29% vs 9.4%, p = 0.003), as well as each of the individual secondary end points: mechanical ventilation (10% vs 1.8%, p = 0.026), hemodynamic instability (18% vs 2.9%, p = 0.02), increased need of inotropic support (10% vs 0.6%, p = 0.005), and bleeding (15% vs 2.4%, p = 0.004). The prevalence of in-hospital mortality was very low (0.5%) with no significant difference between those with and without syncope. There was no significant difference in the need for reperfusion therapy. Upon multivariable analysis, syncope was found to be an independent predictor of adverse clinical outcomes (odds ratio 3.8, confidence interval 1.48 to 9.76, p = 0.005). In conclusion, in intermediate-risk PE patients with right ventricular involvement, the presence of syncope is associated with a more complicated in-hospital course.

10.
Gen Hosp Psychiatry ; 53: 131-138, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29779574

RESUMO

According to Edmondson's Enduring Somatic Threat (EST) Model of PTSD Due to Acute Life-Threatening Medical Events, the nature of PTSD in the context of illness may differ from the nature of "traditional" PTSD in that it includes future-oriented alongside past-related intrusive thoughts. Yet almost no empirical studies to date have assessed the putative future-oriented quality of cardiac-disease-induced PTSD (CDI-PTSD). In the current study, we assessed the hypothesized associations between CDI-PTSD and fear of illness progression (FoP) - a novel theoretical conceptualization of patients' future-related anxieties. We hypothesized that FoP would be positively associated with CDI-PTSD, and especially with its specific items of intrusive thoughts. Patients (N = 112) were interviewed three months post-hospitalization for an acute coronary event via use of the PSS-SR-5 (to assess PTSD symptomatology), the FoP-Q-SF (to assess fear of illness progression), and the HADS (to assess anxiety and depression levels). Results indicated a strong positive association between CDI-PTSD and FoP, even when controlling for anxiety and depression. As hypothesized, the concepts of CDI-PTSD and fear of illness progression were strongly associated both at the level of the clusters as well as at the level of the specific items. The current study provides an initial empirical validation of the EST Model, especially regarding the future-oriented nature of PTSD resulting from acute cardiovascular disease.


Assuntos
Progressão da Doença , Medo/fisiologia , Cardiopatias/complicações , Transtornos de Estresse Pós-Traumáticos/etiologia , Transtornos de Estresse Pós-Traumáticos/fisiopatologia , Doença Aguda , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
11.
PLoS One ; 13(4): e0195504, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29624604

RESUMO

OBJECTIVES: The clinical significance of the laboratory-based phenomenon of clopidogrel hypo-responsiveness and platelet reactivity associated with acute myocardial infarction, despite chronic clopidogrel therapy, is largely unknown. We aimed to determine platelet reactivity and clinical and angiographic features in 29 consecutive patients sustaining an acute myocardial infarction despite chronic (≥1 month) clopidogrel therapy. METHODS: Platelet reactivity was determined on admission using conventional aggregometry. All patients underwent coronary angiography within 24 hours of admission. Patients were matched with clopidogrel-naïve acute myocardial infarction patients. Clopidogrel-naïve patients received a 600 mg clopidogrel loading dose and 75 mg/day thereafter. RESULTS: Of the 29 study patients, 19 (66%) presented with ST-elevation myocardial infarction, and in 25% the infarction was related to angiographically-proved definite stent thrombosis. Two-thirds of these patients were poor responders to clopidogrel (adenosine diphosphate-induced platelet aggregation >50%) and dual antiplatelet poor responsiveness was found in 57% in the chronic clopidogrel therapy group. Compared with clopidogrel-naïve patients, chronic clopidogrel therapy patients were more likely to demonstrate clopidogrel poor responsiveness (66% versus 38%, p = 0.02), to be diabetic (52% versus 33%, p = 0.1) and to have multi-vessel coronary disease (79% versus 55%, p = 0.03). CONCLUSIONS: Patients sustaining acute coronary syndrome despite chronic clopidogrel therapy are more likely to exhibit inadequate platelet inhibition with clopidogrel.


Assuntos
Infarto do Miocárdio/etiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Stents/efeitos adversos , Trombose/etiologia , Ticlopidina/análogos & derivados , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/etiologia , Idoso , Idoso de 80 Anos ou mais , Clopidogrel , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico por imagem , Agregação Plaquetária/efeitos dos fármacos , Estudos Prospectivos , Trombose/sangue , Trombose/diagnóstico por imagem , Ticlopidina/efeitos adversos , Falha de Tratamento
12.
Eur Heart J Acute Cardiovasc Care ; 7(6): 497-503, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28107026

RESUMO

BACKGROUND: Ischemic time has prognostic importance in ST-elevation myocardial infarction patients. Mobile intensive care unit use can reduce components of total ischemic time by appropriate triage of ST-elevation myocardial infarction patients. METHODS: Data from the Acute Coronary Survey in Israel registry 2000-2010 were analyzed to evaluate factors associated with mobile intensive care unit use and its impact on total ischemic time and patient outcomes. RESULTS: The study comprised 5474 ST-elevation myocardial infarction patients enrolled in the Acute Coronary Survey in Israel registry, of whom 46% ( n=2538) arrived via mobile intensive care units. There was a significant increase in rates of mobile intensive care unit utilization from 36% in 2000 to over 50% in 2010 ( p<0.001). Independent predictors of mobile intensive care unit use were Killip>1 (odds ratio=1.32, p<0.001), the presence of cardiac arrest (odds ratio=1.44, p=0.02), and a systolic blood pressure <100 mm Hg (odds ratio=2.01, p<0.001) at presentation. Patients arriving via mobile intensive care units benefitted from increased rates of primary reperfusion therapy (odds ratio=1.58, p<0.001). Among ST-elevation myocardial infarction patients undergoing primary reperfusion, those arriving by mobile intensive care unit benefitted from shorter median total ischemic time compared with non-mobile intensive care unit patients (175 (interquartile range 120-262) vs 195 (interquartile range 130-333) min, respectively ( p<0.001)). Upon a multivariate analysis, mobile intensive care unit use was the most important predictor in achieving door-to-balloon time <90 min (odds ratio=2.56, p<0.001) and door-to-needle time <30 min (odds ratio=2.96, p<0.001). One-year mortality rates were 10.7% in both groups (log-rank p-value=0.98), however inverse propensity weight model, adjusted for significant differences between both groups, revealed a significant reduction in one-year mortality in favor of the mobile intensive care unit group (odds ratio=0.79, 95% confidence interval (0.66-0.94), p=0.01). CONCLUSIONS: Among patients with ST-elevation myocardial infarction, the utilization of mobile intensive care units is associated with increased rates of primary reperfusion, a reduction in the time interval to reperfusion, and a reduction in one-year adjusted mortality.


Assuntos
Síndrome Coronariana Aguda/complicações , Ambulâncias/estatística & dados numéricos , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Inquéritos e Questionários , Tempo para o Tratamento/tendências , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Angiografia Coronária , Eletrocardiografia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Taxa de Sobrevida/tendências
13.
JAMA Cardiol ; 2(12): 1380-1384, 2017 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29071332

RESUMO

Importance: Dual anti-platelet therapy represents standard care for treating patients with ST-segment elevation myocardial infarction (STEMI). Ticagrelor is a direct-acting P2Y12 inhibitor and, unlike clopidogrel and prasugrel, does not require metabolic activation. Objective: To evaluate whether chewing a loading dose (LD) of ticagrelor, 180 mg, vs traditional oral administration of an equal dose enhances platelet inhibition at 30 minutes and 1 hour after LD administration in patients with STEMI. Design, Setting, and Participants: A randomized clinical trial was conducted in adults aged 30 to 87 years from May to October 2016 in a large tertiary care center. Analyses were intention-to-treat. Interventions: Fifty patients with STEMI were randomized to either chewing an LD of ticagrelor, 180 mg, or standard oral administration of an equal dose. Main Outcomes and Measures: P2Y12 reaction units were evaluated using VerifyNow (Accumentrics) at baseline, 30 minutes, 1 hour, and 4 hours after LD. Results: Baseline characteristics were similar in both groups. The mean (SD) of P2Y12 reaction units in the chewing group compared with the standard group at baseline, 30 minutes, 1 hour, and 4 hours after ticagrelor LD were 224 (33) vs 219 (44) (95% CI, -16.77 to 27.73; P = .26), 168 (78) vs 230 (69) (95% CI, -103.77 to -19.75; P = .003), 106 (90) vs 181 (89) (95% CI, -125.15 to -26.29; P = .005), and 43 (41) vs 51 (61) (95% CI, -36.34 to 21.14; P = .30), respectively. Platelet reactivity in the chewing group was significantly reduced by 24% at 30 minutes after LD (95% CI, 19.75 to 103.77; P = .001). The relative inhibition of platelet aggregation in the chewing vs the standard group were 51% vs 10% (95% CI, 13.69 to 67.67; P = .005) at 1 hour and 81% vs 76% (95% CI, -12.32 to 16.79; P = .24) at 4 hours, respectively. Major adverse cardiac and cardiovascular event rate at 30 days was low (4%) and occurred in 1 patient in each group (95% CI, 0.06 to 16.93; P > .99). Conclusions and Relevance: Chewing an LD of ticagrelor, 180 mg, in patients with STEMI is feasible and facilitates better early platelet inhibition compared with a standard oral LD. Larger studies are warranted to see if our preliminary findings translate into clinical outcomes. Trial Registration: clinicaltrials.gov Identifier: NCT02725099.


Assuntos
Deglutição , Mastigação , Inibidores da Agregação de Plaquetas/administração & dosagem , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Ticagrelor/administração & dosagem , Administração Oral , Idoso , Aspirina/uso terapêutico , Quimioterapia Combinada , Estudos de Viabilidade , Feminino , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Agregação Plaquetária , Testes de Função Plaquetária , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Resultado do Tratamento
14.
Am J Cardiol ; 120(10): 1715-1719, 2017 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-28864323

RESUMO

Treatment delays in patients with acute myocardial infarction (AMI) are related to increased morbidity and mortality. Hence, identifying determinants of delay may help reduce time to treatment. Importantly, limited data suggest that there may be sex-related disparities in benchmark timelines. Although guidelines advocate the use of the first medical contact (FMC) rather than hospital admission as the moment from which delays to treatment should be monitored, the latter is still often used for quality purposes. We aimed to identify factors associated with treatment delays, with an emphasis on sex-related disparities. We reviewed data on 3,658 patients with AMI from 2 contemporary, consecutive multicenter surveys. Measured delays were FMC-to-electrocardiogram >10 minutes in ST-elevation MI (STEMI) and non-STEMI, FMC-to-primary percutaneous coronary intervention >90 minutes in STEMI, and invasive angiography >72 hours after admission in non-STEMI patients. Timely electrocardiogram was performed in 48% of patients with STEMI and in 39.8% of non-STEMI patients without significant sex-related differences. Independent determinants of delay included atypical chest pain (CP) and presentation during daytime. In patients with STEMI, 37.5% had primary percutaneous coronary intervention in less than 90 minutes without significant sex-related disparities. Independent determinants of delay included atypical CP, night presentation, and diabetes. In non-STEMI patients, independent determinants of delayed invasive approach were female sex, age >75 years, atypical CP, and renal failure. In conclusion, significant treatment delays in patients with AMI are still frequent in contemporary practice, highlighting the need for improvement and guidelines implementation. Predictors of delay identified in our study may facilitate targeting of interventions to improve adherence to guidelines.


Assuntos
Benchmarking/organização & administração , Hospitalização/tendências , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Sistema de Registros , Tempo para o Tratamento/organização & administração , Fatores Etários , Idoso , Serviços Médicos de Emergência , Feminino , Seguimentos , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo
15.
Int J Cardiol ; 246: 7-13, 2017 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-28867023

RESUMO

BACKGROUND: Risk scores for prediction of mortality 30-days following a ST-segment elevation myocardial infarction (STEMI) have been developed using a conventional statistical approach. OBJECTIVE: To evaluate an array of machine learning (ML) algorithms for prediction of mortality at 30-days in STEMI patients and to compare these to the conventional validated risk scores. METHODS: This was a retrospective, supervised learning, data mining study. Out of a cohort of 13,422 patients from the Acute Coronary Syndrome Israeli Survey (ACSIS) registry, 2782 patients fulfilled inclusion criteria and 54 variables were considered. Prediction models for overall mortality 30days after STEMI were developed using 6 ML algorithms. Models were compared to each other and to the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis In Myocardial Infarction (TIMI) scores. RESULTS: Depending on the algorithm, using all available variables, prediction models' performance measured in an area under the receiver operating characteristic curve (AUC) ranged from 0.64 to 0.91. The best models performed similarly to the Global Registry of Acute Coronary Events (GRACE) score (0.87 SD 0.06) and outperformed the Thrombolysis In Myocardial Infarction (TIMI) score (0.82 SD 0.06, p<0.05). Performance of most algorithms plateaued when introduced with 15 variables. Among the top predictors were creatinine, Killip class on admission, blood pressure, glucose level, and age. CONCLUSIONS: We present a data mining approach for prediction of mortality post-ST-segment elevation myocardial infarction. The algorithms selected showed competence in prediction across an increasing number of variables. ML may be used for outcome prediction in complex cardiology settings.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Algoritmos , Mineração de Dados/métodos , Aprendizado de Máquina , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Inquéritos e Questionários , Idoso , Feminino , Mortalidade Hospitalar/tendências , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Curva ROC , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taxa de Sobrevida/tendências
16.
Cardiology ; 138(3): 195-199, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28793300

RESUMO

OBJECTIVES: During the past decade, the most common causes of mortality and morbidity were cardiovascular diseases and malignancies. The aim of the current study was to describe the incidence, course of admission, and short-term (30-day) prognosis of patients with and without malignancy, admitted to a tertiary center intensive cardiovascular care unit (ICCU). METHODS: A prospective observational study of 2,259 patients admitted to the ICCU was conducted between January 2014 and December 2015. Patients with malignancies (n = 256) were divided into 2 groups: those with solid and those with homogenous tumors. RESULTS: The time of diagnosis was categorized into 3 patient groups: recent (<6 months), 59 patients (23%); late (6-24 months), 49 patients (19%), and very late (>24 months), 148 patients (58%). Those with a history of malignancy were older (73 ± 12 vs. 64 ± 15, p < 0.001) and were more likely to be female (p = 0.002). After using a multivariate logistic regression model analysis, no differences were found in therapeutic interventions and clinical outcomes, including major bleeding and acute renal failure, between patients with and without malignancies. CONCLUSIONS: Patients with a malignancy comprised about 10% of the entire ICCU population. While mortality was independently associated with advanced age, renal failure, and a diagnosis of ST-elevation myocardial infarction, malignancy alone was not found to be independently associated with a higher mortality rate at 30 days of follow-up.


Assuntos
Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Neoplasias/complicações , Neoplasias/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Efeitos Psicossociais da Doença , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Israel/epidemiologia , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Centros de Atenção Terciária , Fatores de Tempo
17.
J Am Heart Assoc ; 6(7)2017 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-28743786

RESUMO

BACKGROUND: Few data are available regarding the optimal management of ST-elevation myocardial infarction patients with clinically defined spontaneous reperfusion (SR). We report on the characteristics and outcomes of patients with SR in the primary percutaneous coronary intervention era, and assess whether immediate reperfusion can be deferred. METHODS AND RESULTS: Data were drawn from a prospective nationwide survey, ACSIS (Acute Coronary Syndrome Israeli Survey). Definition of SR was predefined as both (1) ≥70% reduction in ST-segment elevation on consecutive ECGs and (2) ≥70% resolution of pain. Of 2361 consecutive ST-elevation-acute coronary syndrome patients in Killip class 1, 405 (17%) were not treated with primary reperfusion therapy because of SR. Intervention in SR patients was performed a median of 26 hours after admission. These patients were compared with the 1956 ST-elevation myocardial infarction patients who underwent primary reperfusion with a median door-to-balloon of 66 minutes (interquartile range 38-106). Baseline characteristics were similar except for slightly higher incidence of renal dysfunction and prior angina pectoris in SR patients. Time from symptom onset to medical contact was significantly greater in SR patients. Patients with SR had significantly less in-hospital heart failure (4% versus 11%) and cardiogenic shock (0% versus 2%) (P<0.01 for all). No significant differences were found in in-hospital mortality (1% versus 2%), 30-day major cardiac events (4% versus 4%), and mortality at 30 days (1% versus 2%) and 1 year (4% versus 4%). CONCLUSIONS: Patients with clinically defined SR have a favorable prognosis. Deferring immediate intervention seems to be safe in patients with clinical indices of spontaneous reperfusion.


Assuntos
Síndrome Coronariana Aguda/diagnóstico por imagem , Angiografia Coronária , Circulação Coronária , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/fisiopatologia , Síndrome Coronariana Aguda/terapia , Idoso , Angioplastia Coronária com Balão , Eletrocardiografia , Feminino , Inquéritos Epidemiológicos , Mortalidade Hospitalar , Humanos , Israel , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Recuperação de Função Fisiológica , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento
18.
Am J Med ; 130(11): 1324.e15-1324.e22, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28623174

RESUMO

BACKGROUND: Young women are usually protected against coronary artery disease due to hormonal and risk-factor profile. Previous studies have suggested poorer outcome in women hospitalized with acute coronary syndrome as compared with men. However, when adjusted for age and other risk factors, this difference does not remain significant. We compared the risk profile and outcome between young (≤55 years) women and men admitted with acute coronary syndrome. METHODS: We analyzed clinical characteristics, management strategies, and outcomes of men and women ≤55 years of age enrolled in the biennial Acute Coronary Syndrome Israeli Surveys between 2000 and 2013. RESULTS: Among 11,536 patients enrolled, 3949 (34%) were ≤55 years old (407 women, 3542 men). Women were slightly older (48.9 ± 5.7 vs 48.3 ± 5.5, P = .007) and suffered more from diabetes (34% vs 24%) and hypertension (47% vs 37%, P <.001 for both). Rates of prior myocardial infarction were high in both sexes (18% vs 21%). Women presented less often with ST-elevation myocardial infarction (50% vs 57%, P = .007) and with typical chest pain (73% vs 80%, P = .004), and had higher rates of Global Registry of Acute Coronary Events (GRACE) score ≥140 (19% vs 12%, P = .007). After adjustment for GRACE score, diabetes, and enrollment year, women had a lower likelihood to undergo coronary angiography during hospitalization (odds ratio 0.6, P = .007). Female sex was independently associated with higher risk of in-hospital mortality (hazard ratio [HR] 4.1; 95% confidence interval [CI], 1.15-14.0), 30-day major adverse cardiac and cerebral events (HR 2.1; 95% CI, 1.31-3.36), and 5-year mortality (HR 1.96; 95% CI, 1.3-2.8). CONCLUSIONS: Young women admitted with acute coronary syndrome are a unique high-risk group that presents a diagnostic challenge for clinicians. Women receive less invasive therapy during hospitalization and have worse in-hospital and long-term outcomes.


Assuntos
Síndrome Coronariana Aguda , Angiografia Coronária/estatística & dados numéricos , Gerenciamento Clínico , Hospitalização/estatística & dados numéricos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Adulto , Comorbidade , Feminino , Inquéritos Epidemiológicos/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores Sexuais
19.
Isr Med Assoc J ; 19(6): 368-371, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28647935

RESUMO

BACKGROUND: While patients presenting to emergency departments (ER) with chest pain are increasingly managed in chest pain units (CPU) that utilize accelerated diagnostic protocols for risk stratification, such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), data are lacking regarding the prognostic implications of mildly abnormal scans in this population. OBJECTIVES: To evaluate the prognostic implications of mildly abnormal SPECT MPI results in patients with acute chest pain. METHODS: Of the 3753 chest pain patients admitted to the CPU at the Leviev Heart Center, Sheba Medical Center 1593 were further evaluated by SPECT MPI. Scans were scored by extent and severity of stress-induced perfusion defects, with 1221 patients classified as normal, 82 with myocardial infarction without ischemia, 236 with mild ischemia, and 54 with more than mild ischemia. Mild ischemia patients were further classified to those who did and did not undergo coronary angiography within 7 days. RESULTS: Mild ischemia patients who underwent coronary angiography were more likely to be male (92% vs. 81%, P = 0.01) and to have left anterior descending ischemia (67% vs. 42%, P = 0.004). After 50 months, these patients returned less often to the ER with chest pain (53% vs. 87%, P < 0.001) and had a lower combined endpoint of acute coronary syndrome and death (8% vs. 16%, P < 0.001). CONCLUSIONS: Compared to patients with chronic stable angina, patients presenting with acute chest pain exhibiting mildly abnormal SPECT MPI findings should perhaps undergo a more aggressive diagnostic and therapeutic approach.


Assuntos
Dor no Peito/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Tomografia Computadorizada de Emissão de Fóton Único , Doença Aguda , Angiografia Coronária , Humanos , Masculino , Prognóstico
20.
Int J Cardiol ; 240: 14-19, 2017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28477961

RESUMO

BACKGROUND: Endothelial function is a marker for cardiovascular risk. Thus, abnormal endothelial function may be associated with adverse 1-year outcome in patients presenting to the emergency department chest pain unit (CPU). METHODS: Following endothelial function testing, using EndoPAT 2000 in 300 consecutive subjects with chest pain and no history of coronary artery disease (CAD) presenting to CPU, patients underwent coronary computerized tomographic angiography (CCTA) or single-photon emission computed tomography according to availability. RESULTS: Mean 10-year Framingham risk score (FRS) was 6.6±5.9%, median reactive hyperemia index (RHI) as a measure of endothelial function 2.08 and mean was 2.0±0.4. During a 1-year follow-up, the 20 (6.6%) patients who developed major adverse cardiovascular end-points (MACE), including all-cause mortality, non-fatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting and percutaneous coronary interventions, had higher 10-year FRS (10.5±8.2% vs 6.3±5.7%; p<0.001), lower baseline RHI (1.43±0.41 vs 2.10±0.44; p<0.001) and a greater extent of coronary atherosclerosis lesions (70% vs 3.9%, p<0.001) in the CPU CCTA, compared to those without MACE. RHI≤the median was associated with higher 1-year MACE (13% vs 0.7%, p<0.001) compared to RHI>the median. Multivariate analysis demonstrated that RHI≤the median is an independent predictor of coronary atherosclerosis lesions in the CPU CCTA (OR 5.98, 95% CI 03.29-10.88; p<0.001) and 1-year MACE (OR 15.207, 95% CI 2.00-115.33; p<0.01). CONCLUSIONS: Our findings suggest that non-invasive endothelial function testing may have clinical utility in triaging patients in the CPU and in predicting 1-year MACE.


Assuntos
Dor no Peito/diagnóstico por imagem , Dor no Peito/fisiopatologia , Serviço Hospitalar de Emergência/tendências , Endotélio Vascular/diagnóstico por imagem , Endotélio Vascular/fisiopatologia , Hospitalização/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/terapia , Eletrocardiografia/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
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