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2.
Artigo em Inglês | MEDLINE | ID: mdl-30291678

RESUMO

OBJECTIVES: The number of elderly patients undergoing coronary revascularization is steadily increasing, and data on the impact of gender on outcomes are scarce. This study sought to assess gender-related differences in outcomes in elderly patients with acute coronary syndromes (ACS). METHODS: We investigated outcomes in elderly ACS patients referred for coronary angiography and prospectively enrolled in the Swiss ACS Cohort between December 2009 and October 2012. Adjudicated major adverse cardiovascular and cerebrovascular events (MACCE) included all-cause death, non-fatal myocardial infarction, clinically indicated repeat coronary revascularization, definite stent thrombosis, and transient ischemic attack/stroke. RESULTS: Among 2,168 patients recruited, 481 (22%) patients were >75 years of age (37% women). In patients >75 years, 1-year MACCE rates were 15% and 23% in women and men (OR 0.59, 95% CI 0.36-0.97, P = 0.04), respectively, and differences remained significant after adjustments for baseline variables (adjusted OR 0.48, 95% CI 0.26-0.90, P = 0.02). Women >75 years had a lower cardiovascular mortality (6% versus 12%, adjusted OR 0.31, 95% CI 0.12-0.81, P = 0.02). In patients ≤75 years, 1-year MACCE rates did not differ between gender (10% and 8% for women and men, adjusted OR 1.28, 95% CI 0.77-2.14, P = 0.34). Rates of TIMI major bleeding for women and men were 4% and 4% in patients >75 years (P = 0.96), and 5% and 3% in those ≤75 years (P = 0.11). CONCLUSIONS: The low rates of MACCE observed in elderly women in this patient cohort suggest that with current interventional strategies the gender gap in ACS management has been attenuated.

3.
Int J Cardiol ; 270: 7-13, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29885826

RESUMO

BACKGROUND: This study sought to investigate the predictive value of the age, creatinine, and ejection fraction (ACEF) score in patients with acute coronary syndromes (ACS). The ACEF score (age/left ventricular ejection fraction +1 [if creatinine > 176 µmol/L]) has been established in patients evaluated for coronary artery bypass surgery. Data on its predictive value in all-comer ACS patients undergoing percutaneous coronary intervention are scarce. METHODS: A total of 1901 patients prospectively enrolled in the Swiss ACS Cohort were included in the analysis. Optimal ACEF score cut-off values were calculated by decision tree analysis, and patients divided into low-risk (≤1.45), intermediate-risk (>1.45 and ≤2.0), and high-risk groups (>2.0). The primary endpoint was all-cause mortality. Major adverse cardiac and cerebrovascular events (MACCE) included all-cause death, non-fatal myocardial infarction, clinically indicated repeat coronary revascularization, definite stent thrombosis, and transient ischemic attack/stroke. RESULTS: One-year rates of all-cause death increased across ACEF score groups (1.6% versus 5.6% versus 23.0%, p < 0.001). In multivariate analysis, the ACEF score was related with an increased risk of all-cause mortality (adjusted HR 3.53, 95% CI 2.90-4.31, p < 0.001), MACCE (adjusted HR 2.23, 95% CI 1.88-2.65, p < 0.001), and transient ischemic attack/stroke (adjusted HR 2.58, 95% CI 1.71-3.89, p < 0.001) at 1 year. Rates of Thrombolysis in Myocardial Infarction (TIMI) major and Global use of Strategies to Open Occluded Coronary Arteries (GUSTO) severe bleeding paralleled the increased ischemic risk across the groups (p < 0.001). CONCLUSIONS: The ACEF score is a simple and useful risk stratification tool in patients with ACS referred for coronary revascularization.

4.
Cardiology ; 126(1): 15-23, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23912448

RESUMO

OBJECTIVES: In the evaluation of patients considered for transcatheter aortic valve implantation (TAVI), the EuroScore II might be superior to established risk scores. METHODS: We assessed the performance of the EuroScore II in predicting mortality in a cohort of 350 TAVI patients. RESULTS: The EuroScore II and the logistic EuroScore were higher in nonsurvivors compared to survivors at 30 days (12.6 ± 1.8 vs. 7.5 ± 0.3%, p < 0.001 for EuroScore II, and 27.7 ± 2.8 vs. 22.1 ± 0.8%, p = 0.04 for logistic EuroScore), while the STS-PROM score did not differ (7.3 ± 0.8 vs. 6.4 ± 0.3%, p = 0.09). The area under the curve (AUC) was 0.70 for the EuroScore II, 0.61 for the logistic EuroScore and 0.59 for the STS-PROM score for predicting 30-day mortality. Based on the estimated 30-day mortality risk, 3 risk groups were identified, a low-risk (EuroScore II ≤4%, 30-day mortality 1.2%), an intermediate-risk (EuroScore II between 4% and 9%, 30-day mortality 8.6%) and a high-risk group (EuroScore II >9%, 30-day mortality, 17.1%; p = 0.03). Regarding cumulative mortality, the AUC was 0.67 for the EuroScore II, 0.62 for the logistic EuroScore and 0.55 for the STS-PROM score for predicting mortality at total follow-up. CONCLUSIONS: In this patient cohort, the EuroScore II performed best in predicting short- and long-term mortality.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/mortalidade , Próteses Valvulares Cardíacas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Curva ROC , Medição de Risco/métodos
5.
Echocardiography ; 30(10): 1143-50, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23742210

RESUMO

BACKGROUND: The effect of age and gender on left ventricular (LV) size, muscle mass, and systolic function as determined by two-dimensional echocardiography has not yet been investigated in a large population. METHODS: Normal transthoracic two-dimensional echocardiography studies of 5307 subjects (47% males) performed between March 1990 and December 2011 were analyzed. LV end-diastolic volume index (LVEDVI), LV muscle mass index (LVMMI), LV ejection fraction (LVEF), and LV fractional shortening (LVFS) were compared in different age groups. RESULTS: LVMMI increased in females from 66.4 ± 1.3 g/m(2) (7-20 years) to 76.3 ± 0.9 g/m(2) (60-80 years; P < 0.0001) and in males from 81.9 ± 1.7 g/m(2) (7-20 years) to 94.6 ± 1.3 g/m(2) (60-80 years; P < 0.0001). LVEDVI decreased in females from 49.8 ± 0.9 mL/m(2) (7-20 years) to 42.8 ± 0.6 mL/m(2) (60-80 years; P < 0.0001) and in males from 56.6 ± 0.8 mL/m(2) (7-20 years) to 49.0 ± 0.7 mL/m(2) (60-80 years; P < 0.0001). A significant increase in LVEF was observed with age (P < 0.0001 for both genders), but it was more pronounced in females (62 ± 0.5% [age 7-20 years] vs. 65 ± 0.3% [age 60-80 years]) than in males (62 ± 0.5% [age 7-20 years] vs. 64 ± 0.3% [age 60-80 years]). Similarly, LVFS increased in females from 37.7 ± 0.5% (7-20 years) to 42.4 ± 0.4% (60-80 years; P < 0.001) and in males from 37.3 ± 0.5% (7-20 years) to 39.4 ± 0.5% (60-80 years; P < 0.001). CONCLUSIONS: LVEF, LVFS, and LVMMI increase with advancing age, in particular in females. In contrast, LVEDVI decreases with age. These findings indicate that the LV undergoes a lifelong remodeling.


Assuntos
Envelhecimento/fisiologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/crescimento & desenvolvimento , Sístole/fisiologia , Função Ventricular Esquerda/fisiologia , Remodelação Ventricular/fisiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Volume Cardíaco/fisiologia , Criança , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/citologia , Valores de Referência , Estudos Retrospectivos , Caracteres Sexuais , Volume Sistólico/fisiologia , Adulto Jovem
6.
J Invasive Cardiol ; 24(8): 407-11, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22865312

RESUMO

AIMS: Surgical aortic valve replacement (AVR) has been associated with systemic inflammatory reactions. Yet, the role of inflammation following transcatheter aortic valve implantation (TAVI) has not been fully elucidated. METHODS AND RESULTS: In a total of 40 patients evaluated by the 'heart team,' this retrospective study assessed levels of high-sensitive C-reactive protein (hs-CRP) and leukocyte counts following 'uneventful' AVR and TAVI. Four groups of matched patients were compared (AVR; transapical and transfemoral Edwards SAPIEN [TA ES and TF ES, respectively]; and transfemoral Medtronic CoreValve [TF CV]). A postprocedural increase of both hs-CRP levels and leukocyte counts was observed (P<.001) with peak levels 48 hours after the procedures. Comparing treatment groups, hs-CRP levels at 48 hours were significantly higher following AVR and TA ES compared to TF ES and TF CV (P<.04). Leukocyte counts at 48 hours were higher following TA ES compared to TF ES and TF CV (P<.03). Multivariate analysis incorporating both hs-CRP levels and leukocyte counts confirmed significant differences for all measurements over time (P<.001). Furthermore, the treatment group significantly influenced postprocedural hs-CRP levels and leukocyte counts (P<.001). CONCLUSION: Both AVR and TAVI evoke a postprocedural inflammatory response. Higher hs-CRP levels and leukocyte counts following AVR and apical TAVI suggest less inflammation following femoral procedures.


Assuntos
Estenose da Valva Aórtica/cirurgia , Proteína C-Reativa/análise , Cateterismo Cardíaco , Cateterismo Periférico , Implante de Prótese de Valva Cardíaca , Inflamação , Contagem de Leucócitos/métodos , Complicações Pós-Operatórias/sangue , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/métodos , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/métodos , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Inflamação/sangue , Inflamação/etiologia , Masculino , Projetos Piloto , Cuidados Pós-Operatórios/métodos , Projetos de Pesquisa , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
7.
Eur Heart J ; 31(12): 1457-69, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20447947

RESUMO

AIMS: Inflammation plays a key role in acute coronary syndromes (ACS). Toll-like receptors (TLR) on leucocytes mediate inflammation and immune responses. We characterized leucocytes and TLR expression within coronary thrombi and compared cytokine levels from the site of coronary occlusion with aortic blood (AB) in ACS patients. METHODS AND RESULTS: In 18 ACS patients, thrombi were collected by aspiration during primary percutaneous coronary intervention. Thrombi and AB from these patients as well as AB from 10 age-matched controls without coronary artery disease were assessed by FACS analysis for cellular distribution and TLR expression. For further discrimination of ACS specificity, seven non-coronary intravascular thrombi and eight thrombi generated in vitro were analysed. In 17 additional patients, cytokine levels were determined in blood samples from the site of coronary occlusion under distal occlusion and compared with AB. In coronary thrombi from ACS, the percentage of monocytes related to the total leucocyte count was greater than in AB (47 vs. 20%, P = 0.0002). In thrombi, TLR-4 and TLR-2 were overexpressed on CD14-labelled monocytes, and TLR-2 was increased on CD66b-labelled granulocytes, in comparison with leucocytes in AB. In contrast, in vitro and non-coronary thrombi exhibited no overexpression of TLR-4. Local blood samples taken under distal occlusion revealed elevated concentrations of chemokines (IL-8, MCP-1, eotaxin, MIP-1alpha, and IP-10) and cytokines (IL-1ra, IL-6, IL-7, IL-12, IL-17, IFN-alpha, and granulocyte-macrophage colony-stimulating factor) regulating both innate and adaptive immunity (all P < 0.05). CONCLUSION: In ACS patients, monocytes accumulate within thrombi and specifically overexpress TLR-4. Together with the local expression patterns of chemokines and cytokines, the increase of TLR-4 reflects a concerted activation of this inflammatory pathway at the site of coronary occlusion in ACS.


Assuntos
Síndrome Coronariana Aguda/metabolismo , Oclusão Coronária/metabolismo , Trombose Coronária/metabolismo , Citocinas/metabolismo , Monócitos/metabolismo , Receptores Toll-Like/metabolismo , Síndrome Coronariana Aguda/patologia , Idoso , Aorta , Estudos de Casos e Controles , Trombose Coronária/patologia , Feminino , Humanos , Imuno-Histoquímica , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
8.
Lancet ; 374(9683): 48-55, 2009 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-19552948

RESUMO

BACKGROUND: Placental-site trophoblastic tumours are a rare form of gestational trophoblastic disease and consequently information about optimum management or prognostic factors is restricted. We aimed to assess the long-term outcome of stage-adapted management by surgery, chemotherapy, or both for patients with the disorder. METHODS: 35 550 women were registered with gestational trophoblastic disease in the UK (1976-2006), of whom 62 were diagnosed with placental-site trophoblastic tumours and included, retrospectively, in the study. Patients were treated by surgery, chemotherapy, or both. We estimated the probabilities of overall survival and survival without recurrence of disease 5 and 10 years after the date of first treatment, and calculated the association of these endpoints with prognostic factors, including time since antecedent pregnancy, serum concentration of beta-human chorionic gonadotropin, and stage of disease, with both univariate and multivariate analyses. FINDINGS: Probabilities of overall and recurrence-free survival 10 years after first treatment were 70% (95% CI 54-82) and 73% (54-85), respectively. Patients with stage I disease had a 10-year probability of overall survival of 90% (77-100) and did not benefit from postoperative chemotherapy. By contrast, patients with stage II, III, and IV disease required combined treatment with surgery and chemotherapy; probability of overall survival at 10 years was 52% (3-100) for patients with stage II disease and 49% (26-72) for stage III or IV disease. Outcome for patients who had recurrent or refractory disease was poor: only four (22%) patients achieved long-term survival beyond 60 months. Multivariate analysis showed that the only significant independent predictor of overall and recurrence-free survival was time since antecedent pregnancy. A cutoff point of 48 months since antecedent pregnancy could differentiate between patients' probability of survival (<48 months) or death (>/=48 months) with 93% specificity and 100% sensitivity, and with a positive predictive value of 100% and a negative predictive value of 98%. INTERPRETATION: Stage-adapted management with surgery for stage I disease, and combined surgery and chemotherapy for stage II, III, and IV disease could improve the effectiveness of treatment for placental-site trophoblastic tumours. Use of 48 months since antecedent pregnancy as a prognostic indicator of survival could help select patients for risk-adapted treatment. FUNDING: National Commissioning Group.


Assuntos
Tumor Trofoblástico de Localização Placentária/diagnóstico , Tumor Trofoblástico de Localização Placentária/terapia , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/terapia , Adulto , Análise de Variância , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Biomarcadores Tumorais/metabolismo , Gonadotropina Coriônica/metabolismo , Terapia Combinada , Ciclofosfamida/uso terapêutico , Dactinomicina/uso terapêutico , Etoposídeo/uso terapêutico , Feminino , Humanos , Histerectomia , Estimativa de Kaplan-Meier , Metotrexato/uso terapêutico , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Gravidez , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Tumor Trofoblástico de Localização Placentária/metabolismo , Tumor Trofoblástico de Localização Placentária/mortalidade , Reino Unido/epidemiologia , Neoplasias Uterinas/metabolismo , Neoplasias Uterinas/mortalidade , Vincristina/uso terapêutico
9.
Eur Heart J ; 28(8): 941-8, 2007 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-17387139

RESUMO

AIMS: We investigated whether myeloid-related protein 8/14 complex (MRP8/14) expressed by infiltrating monocytes and granulocytes may represent a mediator and early biomarker of acute coronary syndromes (ACS). METHODS AND RESULTS: Immunohistochemistry of coronary thrombi was done in 41 ACS patients. Subsequently, levels of MRP8/14 were assessed systemically in 75 patients with ACS and culprit lesions, with stable coronary artery disease (CAD), or with normal coronary arteries. In a subset of patients, MRP8/14 was measured systemically and at the site of coronary occlusion. Macrophages and granulocytes, but not platelets stained positive for MRP8/14 in 76% of 41 thrombi patients. In ACS, local MRP8/14 levels [22.0 (16.2-41.5) mg/L] were increased when compared with systemic levels [13.4 (8.1-14.7) mg/L, P = 0.03]. Systemic levels of MRP8/14 were markedly elevated [15.1 (12.1-21.8) mg/L, P = 0.001] in ACS when compared with stable CAD [4.6 (3.5-7.1) mg/L] or normals [4.8 (4.0-6.3) mg/L]. Using a cut-off level of 8 mg/L, MRP8/14 but not myoglobin or troponin, identified ACS presenting within 3 h from symptom onset. CONCLUSION: In ACS, MRP8/14 is markedly expressed at the site of coronary occlusion by invading phagocytes. The occurrence of elevated MRP8/14 in the systemic circulation prior to markers of myocardial necrosis makes it a prime candidate for the detection of unstable plaques and management of ACS.


Assuntos
Calgranulina A/metabolismo , Calgranulina B/metabolismo , Doença da Artéria Coronariana/diagnóstico , Trombose Coronária/diagnóstico , Granulócitos/metabolismo , Complexo Antígeno L1 Leucocitário/metabolismo , Monócitos/metabolismo , Idoso , Biomarcadores/metabolismo , Feminino , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Síndrome
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