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1.
Crit Pathw Cardiol ; 2021 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-33958520

RESUMO

Chest pain is one of the most common reasons for patients to present to healthcare professionals. One of the main challenges with the management of chest pain is the wide differential diagnosis, ranging from minor chest trauma to potentially life threatening acute myocardial infarction. In a patient-centered health service pathway, the aim is to assess, investigate, diagnose and treat patients in the safest and most accurate, time and cost-efficient manner. This report describes the concept of clinical pathways and their importance. It iterates different perspectives of the investigation of chest pain and the barriers to understanding the clinical sequence of events. By considering the patient, clinician and healthcare service perspective it is possible to critically evaluate the current stable chest pain pathway. This exercise gives consideration into the way in which patient care could be improved.

2.
Crit Pathw Cardiol ; 2021 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-33606411

RESUMO

Despite the availability of tests to diagnose acute myocardial infarction (AMI), cases are still missed. We systematic reviewed the literature to determine how missed AMI has been defined, the reported rates of misdiagnosed AMI, the outcomes patients with misdiagnosed AMI have, what diagnosis was initially suspected in missed AMI cases, and what factors are associated with misdiagnosed AMI. We searched MEDLINE and EMBASE in September 2020 for studies that evaluated missed AMI. Data was extracted from studies that met the inclusion criteria and the results were narratively synthesized. A total of 15 studies were included in this review. The number of patients with missed AMI in individual studies ranged from 64 to 4,707. There was no consistently used definition for misdiagnosed AMI but most studies reported rates of approximately 1-2%. Compared to AMI that was recognized, one study found no difference in mortality for misdiagnosed AMI at 30 days and 1 year. The common initial misdiagnoses that subsequently had AMI were ischemic heart disease, non-specific chest pain, gastrointestinal disease, musculoskeletal pain and arrhythmias. Reasons for missed AMI include incorrect electrocardiogram interpretation and failure to order appropriate diagnostic tests. Hospitals in rural areas and those with a low proportion of classical chest pain patients that turned out to have AMI were at greater risk of missed AMI. Misdiagnosed AMI is an unfortunate part of everyday clinical practice and better training in electrocardiogram interpretation and education about atypical presentations of AMI may reduce the number of misdiagnosed AMI.

3.
Elife ; 92020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33046214

RESUMO

Laboratory studies have suggested oncogenic roles of lipids, as well as anticarcinogenic effects of statins. Here we assess the potential effect of statin therapy on cancer risk using evidence from human genetics. We obtained associations of lipid-related genetic variants with the risk of overall and 22 site-specific cancers for 367,703 individuals in the UK Biobank. In total, 75,037 individuals had a cancer event. Variants in the HMGCR gene region, which represent proxies for statin treatment, were associated with overall cancer risk (odds ratio [OR] per one standard deviation decrease in low-density lipoprotein [LDL] cholesterol 0.76, 95% confidence interval [CI] 0.65-0.88, p=0.0003) but variants in gene regions representing alternative lipid-lowering treatment targets (PCSK9, LDLR, NPC1L1, APOC3, LPL) were not. Genetically predicted LDL-cholesterol was not associated with overall cancer risk (OR per standard deviation increase 1.01, 95% CI 0.98-1.05, p=0.50). Our results predict that statins reduce cancer risk but other lipid-lowering treatments do not. This suggests that statins reduce cancer risk through a cholesterol independent pathway.

4.
PLoS One ; 15(10): e0241357, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33108366

RESUMO

Non-alcoholic fatty liver disease (NAFLD) is common and strongly associated with the metabolic syndrome. Though NAFLD may progress to end-stage liver disease, the top cause of mortality in NAFLD is cardiovascular disease (CVD). Most of the data on liver-related mortality in NAFLD derives from specialist liver centres. It is not clear if the higher reported mortality rates in individuals with non-cirrhotic NAFLD are entirely accounted for by complications of atherosclerosis and diabetes. Therefore, we aimed to describe the CVD burden and mortality in NAFLD when adjusting for metabolic risk factors using a 'real world' cohort. We performed a retrospective study of patients followed-up after an admission to non-specialist hospitals with a NAFLD-spectrum diagnosis. Non-cirrhotic NAFLD and NAFLD-cirrhosis patients were defined by ICD-10 codes. Cases were age-/sex-matched with non-NAFLD hospitalised patients. All-cause mortality over 14-years follow-up after discharge was compared between groups using Cox proportional hazard models adjusted for demographics, CVD, and metabolic syndrome components. We identified 1,802 patients with NAFLD-diagnoses: 1,091 with non-cirrhotic NAFLD and 711 with NAFLD-cirrhosis, matched to 24,737 controls. There was an increasing burden of CVD with progression of NAFLD: for congestive heart failure 3.5% control, 4.2% non-cirrhotic NAFLD, 6.6% NAFLD-cirrhosis; and for atrial fibrillation 4.7% control, 5.9% non-cirrhotic NAFLD, 12.1% NAFLD-cirrhosis. Over 14-years follow-up, crude mortality rates were 14.7% control, 13.7% non-cirrhotic NAFLD, and 40.5% NAFLD-cirrhosis. However, after adjusting for demographics, non-cirrhotic NAFLD (HR 1.3 (95% CI 1.1-1.5)) as well as NAFLD-cirrhosis (HR 3.7 (95% CI 3.0-4.5)) patients had higher mortality compared to controls. These differences remained after adjusting for CVD and metabolic syndrome components: non-cirrhotic NAFLD (HR 1.2 (95% CI 1.0-1.4)) and NAFLD-cirrhosis (HR 3.4 (95% CI 2.8-4.2)). In conclusion, from a large non-specialist registry of hospitalised patients, those with non-cirrhotic NAFLD had increased overall mortality compared to controls even after adjusting for CVD.

5.
Eur Heart J Acute Cardiovasc Care ; 9(8): 975-983, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30407069

RESUMO

BACKGROUND: Myocardial inflammation often complicates leptospirosis, a re-emerging global zoonosis. Leptospirosis associated myocardial dysfunction is equivocal and the pattern of cardiac involvement may not differ from that of sepsis associated myocarditis. METHODS: We prospectively compared cardiac involvement in 113 intensive care unit patients with severe leptospirosis to 31 patients with sepsis syndrome using a comprehensive assessment comprising of clinical presentation, electrocardiography, two-dimensional echocardiography (with global longitudinal strain calculation), and cardiac biomarker evaluation. Binomial logistic regression was performed to identify independent predictors of left ventricular systolic dysfunction in leptospirosis. RESULTS: Compared to sepsis syndrome, leptospirosis patients were younger, had higher body mass index measurements and were more likely to be smokers. Electrocardiography abnormalities were common and similar in both groups. Myocardial systolic dysfunction was common in both groups (leptospirosis: 55.86% vs sepsis syndrome: 51.61%, p=0.675) with subclinical left ventricular systolic dysfunction (characterized by abnormal global longitudinal strain and normal left ventricular ejection fraction) being most frequent followed by isolated right ventricular systolic dysfunction, isolated left ventricular systolic dysfunction, and bi-ventricular systolic dysfunction (leptospirosis: 31.43%, 18.42%, 13.16%, 10.53%, respectively; sepsis syndrome: 22.22%, 12.00%, 12.00%, 8.00%, respectively (p>0.05 for each comparator)). Leptospirosis patients had a trend towards greater troponin-T elevation (61.0% vs 40.0%, p=0.057). ST-segment elevation and elevated troponin were independent predictors of reduced left ventricular ejection fraction in leptospirosis. CONCLUSIONS: Cardiac involvement in leptospirosis appears to be similar to that of sepsis syndrome, with myocardial systolic dysfunction being common. As such, clinical vigilance pertaining to cardiac status is paramount in these high-risk patients.

6.
J Am Coll Cardiol ; 73(23): 2915-2929, 2019 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-31196447

RESUMO

BACKGROUND: The efficacy and safety of aspirin for primary prevention of cardiovascular disease (CVD) remain debatable. OBJECTIVES: The purpose of this study was to examine the clinical outcomes with aspirin for primary prevention of CVD after the recent publication of large trials adding >45,000 individuals to the published data. METHODS: Randomized controlled trials comparing clinical outcomes with aspirin versus control for primary prevention with follow-up duration of ≥1 year were included. Efficacy outcomes included all-cause death, cardiovascular (CV) death, myocardial infarction (MI), stroke, transient ischemic attack (TIA), and major adverse cardiovascular events. Safety outcomes included major bleeding, intracranial bleeding, fatal bleeding, and major gastrointestinal (GI) bleeding. Random effects DerSimonian-Laird risk ratios (RRs) for outcomes were calculated. RESULTS: A total of 15 randomized controlled trials including 165,502 participants (aspirin n = 83,529, control n = 81,973) were available for analysis. Compared with control, aspirin was associated with similar all-cause death (RR: 0.97; 95% confidence interval [CI]: 0.93 to 1.01), CV death (RR: 0.93; 95% CI: 0.86 to 1.00), and non-CV death (RR: 0.98; 95% CI: 0.92 to 1.05), but a lower risk of nonfatal MI (RR: 0.82; 95% CI: 0.72 to 0.94), TIA (RR: 0.79; 95% CI: 0.71 to 0.89), and ischemic stroke (RR: 0.87; 95% CI: 0.79 to 0.95). Aspirin was associated with a higher risk of major bleeding (RR: 1.5; 95% CI: 1.33 to 1.69), intracranial bleeding (RR: 1.32; 95% CI: 1.12 to 1.55), and major GI bleeding (RR: 1.52; 95% CI: 1.34 to 1.73), with similar rates of fatal bleeding (RR: 1.09; 95% CI: 0.78 to 1.55) compared with the control subjects. Total cancer and cancer-related deaths were similar in both groups within the follow-up period of the study. CONCLUSIONS: Aspirin for primary prevention reduces nonfatal ischemic events but significantly increases nonfatal bleeding events.


Assuntos
Anti-Inflamatórios não Esteroides/administração & dosagem , Aspirina/administração & dosagem , Doenças Cardiovasculares/prevenção & controle , Hemorragia Gastrointestinal/induzido quimicamente , Prevenção Primária/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Anti-Inflamatórios não Esteroides/efeitos adversos , Aspirina/efeitos adversos , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/mortalidade , Humanos , Prevenção Primária/tendências
7.
J Am Coll Cardiol ; 73(17): 2166-2177, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-30846341

RESUMO

BACKGROUND: The relationship between respiratory diseases and individual cardiovascular diseases, and the impact of cardiovascular diseases on mortality in patients with respiratory disease, are unclear. OBJECTIVES: This study sought to determine the relationship between chronic obstructive pulmonary disease (COPD), asthma and interstitial lung disease (ILD), and individual cardiovascular diseases, and evaluate the impact of individual cardiovascular diseases on all-cause mortality in respiratory conditions. METHODS: The authors conducted a cohort study of all patients admitted to 7 National Health Service hospitals across the North West of England, between January 1, 2000, and March 31, 2013, with relevant respiratory diagnoses, with age-matched and sex-matched control groups. RESULTS: A total of 31,646 COPD, 60,424 asthma, and 1,662 ILD patients were included. Control groups comprised 158,230, 302,120, and 8,310 patients, respectively (total follow-up 2,968,182 patient-years). COPD was independently associated with ischemic heart disease (IHD), heart failure (HF), atrial fibrillation, and peripheral vascular disease, all of which were associated with all-cause mortality (e.g., odds ratio for the association of COPD with HF: 2.18 [95% confidence interval (CI): 2.08 to 2.26]; hazard ratio for the contribution of HF to mortality in COPD: 1.65 [95% CI: 1.61 to 1.68]). Asthma was independently associated with IHD, and multiple cardiovascular diseases contributed to mortality (e.g., HF hazard ratio: 1.81 [95% CI: 1.75 to 1.87]). ILD was independently associated with IHD and HF, both of which were associated with mortality. Patients with lung disease were less likely to receive coronary revascularization. CONCLUSIONS: Lung disease is independently associated with cardiovascular diseases, particularly IHD and HF, which contribute significantly to all-cause mortality. However, patients with lung disease are less likely to receive coronary revascularization.


Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Causas de Morte , Doenças Respiratórias/diagnóstico , Doenças Respiratórias/epidemiologia , Fatores Etários , Idoso , Asma/diagnóstico , Asma/epidemiologia , Estudos de Casos e Controles , Comorbidade , Inglaterra , Feminino , Humanos , Estimativa de Kaplan-Meier , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Modelos de Riscos Proporcionais , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Fatores Sexuais , Análise de Sobrevida
11.
J Thorac Dis ; 10(1): 102-105, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29600032
12.
Int J Cardiol ; 252: 117-121, 2018 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-29249421

RESUMO

BACKGROUND: There is concern that the development of heart failure and atrial fibrillation has a detrimental influence on clinical outcomes. The aim of this study was to assess all-cause mortality and length of hospital stay in patients with chronic and new-onset concomitant AF and HF. METHODS: Using the ACALM registry, we analysed adults hospitalised between 2000 and 2013 with AF and HF and assessed prevalence, mortality and length of hospital stay. Patients with HF and/or AF at baseline (study-entry) were compared with patients who developed new-onset disease during follow-up. RESULTS: Of 929,552 patients, 31,695 (3.4%) were in AF without HF, 20,768 (2.2%) had HF in sinus rhythm, and 10,992 (1.2%) had HF in AF. Patients with HF in AF had the greatest all-cause mortality (70.8%), followed by HF in sinus rhythm (64.1%) and AF alone (45.1%, p<0.0001). Patients that developed new-onset AF, HF or both had significantly worse mortality (58.5%, 70.7% and 74.8% respectively) compared to those already with the condition at baseline (48.5%, 63.7% and 67.2% respectively, p<0.0001). Patients with HF in AF had the longest length of hospital stay (9.41days, 95% CI 8.90-9.92), followed by HF in sinus rhythm (7.67, 95% CI 7.34-8.00) and AF alone (6.05, 95% CI 5.78-6.31). CONCLUSIONS: Patients with HF in AF are at a greater risk of mortality and longer hospital stay compared to patients without the combination. New-onset AF or HF is associated with significantly worse prognosis than long-standing disease.


Assuntos
Algoritmos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Tempo de Internação/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/terapia , Comorbidade , Estudos Transversais , Feminino , Seguimentos , Insuficiência Cardíaca/terapia , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Estudos Prospectivos , Sistema de Registros , Fatores de Tempo , Reino Unido/epidemiologia
15.
Int J Cardiol ; 207: 292-6, 2016 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-26814630

RESUMO

BACKGROUND: Heart failure (HF) is a major healthcare problem contributing significantly to hospital admission stays and National Health Service (NHS) spending. Reducing length of hospital stay (LoS) in HF is paramount in reducing this burden and is influenced by factors relating to the condition, sociodemographics and comorbidities. Psychiatric comorbidities are being increasingly identified amongst HF patients but their impact on LoS has not been studied in the UK. METHODS: We investigated the impact of psychiatric comorbidities on LoS amongst 31,760 HF patients admitted to hospitals in North England between 1st January 2000 and 31st March 2013 from the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study. The ACALM protocol uses ICD-10 and OPCS-4 coding to trace HF patients, psychiatric comorbidities and demographics including LoS. RESULTS: Amongst 31,760 HF patients mean LoS in the absence of psychiatric comorbidities was 11.2days. The presence of a psychiatric comorbidity increased LoS by 3.3days. Logistic regression accounting for age, gender and ethnicity showed that LoS was significantly longer in patients suffering from depression (3.4days, p<0.001), bipolar disorder (8.8days, p<0.001) and all types of dementia (4.2days, p<0.001). CONCLUSIONS: Our results demonstrate that psychiatric comorbidities have a significant and clinically important impact on LoS in HF patients in the UK. Clinicians should be actively aware of psychiatric conditions amongst HF patients and manage them to reduce LoS and ultimately the risk for patients and financial burden for the NHS.


Assuntos
Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/psicologia , Tempo de Internação , Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Insuficiência Cardíaca/diagnóstico , Hospitalização/tendências , Humanos , Tempo de Internação/tendências , Masculino , Transtornos Mentais/diagnóstico , Pessoa de Meia-Idade
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