Risk factors for potential drug-drug interactions of statins in patients with acute coronary syndrome

Abstract The aim of our study was to assess risk factors for potential drug-drug interactions (pDDIs) of statins across different phases of treatment of acute coronary syndrome (ACS) patients: from the point of first medical contact to the coronary angiography (first phase), after coronary angiography to the last day of hospitalization (second phase) and at discharge from hospital (third phase). This was a post hoc analysis of the data collected during the retrospective observational cohort study conducted at the Clinic for Cardiology of the Clinical Centre Kragujevac, Serbia. Patients prescribed statins were identified from the original study population: 156, 240 and 236 patients for the first, second and third phases, respectively. At least one statin pDDI was present in 113 (72.4%), 161 (67.1%) and 139 (58.9%) patients in the first, second and third phases, respectively. Heart failure, arrhythmias after ACS, CRP, triglycerides, length of hospitalization, number of prescribed drugs, antiarrhythmic drugs, and clopidogrel seem to increase the risk of statin pDDIs in at least one treatment phase. Physicians should be vigilant to the possibility of statin pDDIs in ACS patients who have factors that may increase their rate.

Upper limb principal arteries variations: A cadaveric study with terminological implication.

Although the variability of the upper limb arteries is a clinically important problem, the prevalence is varying across the existing studies and classification is rather complicated, not well established and sometimes even unclear for simple and direct understanding and usage. Multiple case reports appearing in the last years apply incorrect, inappropriate, and sometimes misleading terminology. We performed an anatomical cadaveric study of the variability of the arteries of the upper limb, namely, the axilla, arm, and forearm, in 423 upper limbs embalmed with classical formaldehyde method (Central European population). We proposed to apply the Equality system based on the common trunks for denomination of the axillary artery branches principal variations: Truncus subscapulocircumflexus (22.9%), truncus profundocircumflexus (13.75%), and truncus bicircumflexus (13.95%). Further, we proposed the terminology system developed by Rodríguez-Niedenführ et al. for the free upper limb principal arterial trunk variations based on the origin, location (in the arm only, or in the arm and forearm), and course (related to the forearm flexor muscles) of the involved artery: Arteria brachialis superficialis (9.5%), arteria brachioradialis superficialis (6.4%), arteria brachioulnaris superficialis (1.9%), arteria brachiomediana superficialis (0.5%), and arteria comitans nervi mediani manus (3.3%). Extensive development of the catheterization methods via the arteria radialis et ulnaris as well as surgical procedures using flaps based on perforating branches of these arteries (including arteria brachioradialis superficialis et brachioulnaris superficialis) necessitate thorough data on prevalence of the variant vessels for safe performance of these procedures to prevent any unexpected situations or to react adequately in such.

SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.

BACKGROUND: The outcome of cardiogenic shock complicating myocardial infarction has not appreciably changed in the last 30 years despite the development of various percutaneous mechanical circulatory support options. It is clear that there are varying degrees of cardiogenic shock but there is no robust classification scheme to categorize this disease state. METHODS: A multidisciplinary group of experts convened by the Society for Cardiovascular Angiography and Interventions was assembled to derive a proposed classification schema for cardiogenic shock. Representatives from cardiology (interventional, advanced heart failure, noninvasive), emergency medicine, critical care, and cardiac nursing all collaborated to develop the proposed schema. RESULTS: A system describing stages of cardiogenic shock from A to E was developed. Stage A is "at risk" for cardiogenic shock, stage B is "beginning" shock, stage C is "classic" cardiogenic shock, stage D is "deteriorating", and E is "extremis". The difference between stages B and C is the presence of hypoperfusion which is present in stages C and higher. Stage D implies that the initial set of interventions chosen have not restored stability and adequate perfusion despite at least 30 minutes of observation and stage E is the patient in extremis, highly unstable, often with cardiovascular collapse. CONCLUSION: This proposed classification system is simple, clinically applicable across the care spectrum from pre-hospital providers to intensive care staff but will require future validation studies to assess its utility and potential prognostic implications.

Power of resting echocardiographic measurements to classify pulmonary hypertension patients according to European society of cardiology exercise testing risk stratification cut-offs.

BACKGROUND: Right ventricular function is the major determinant of morbidity and mortality in pulmonary arterial hypertension (PAH). The ESC risk assessment strategy for PAH is based on clinical status, exercise testing, NTproBNP, imaging and haemodynamics but does not include right ventricular function. Our aims were to test the power of resting echocardiographic measurements to classify PAH patients according to ESC exercise testing risk stratification cut-offs and to determine if the classification power of echocardiographic parameters varied in chronic thrombo-embolic pulmonary hypertension (CTEPH). METHODS: We prospectively and consecutively recruited 46 PAH patients and 42 CTEPH patients referred for cardio-pulmonary exercise testing and comprehensive transthoracic echocardiography. Exercise testing parameters analyzed were peak oxygen consumption, percentage of predicted maximal oxygen consumption and the slope of ventilation against carbon dioxide production. Receiver operator characteristic curves were used to determine the optimal diagnostic cut-off values of echocardiographic parameters for classifying the patients in intermediate or high risk category according to exercise testing. RESULTS: Measurements of right ventricular systolic function were the best for classifying in PAH (area under the curve 0.815 to 0.935). Measurements of right ventricular pressure overload (0.810 to 0.909) were optimal for classifying according to exercise testing in CTEPH. Measurements of left ventricular function were of no use in either group. CONCLUSIONS: Measurements of right ventricular systolic function can classify according to exercise testing risk stratification cut-offs in PAH. However, this is not the case in CTEPH where pressure overload, rather than right ventricular function seems to be linked to exercise performance.

Ramos do arco aórtico e da aorta torácica em bicho-preguiça (Bradypus variegatus) / Branches of the aortic arch and thoracic aorta of the sloth (Bradypus variegatus)

As preguiças são mamíferos arborícolas, bem específicos quanto aos hábitos e à morfofisiologia. Essa condição faz delas ainda mais vulneráveis aos impactos ambientais. Com o objetivo de fornecer informações que auxiliem na clínica médico-cirúrgica desses Xenarthras, realizou-se um estudo do arco aórtico e da artéria aorta torácica, a fim de se identificarem seus principais ramos. Foram utilizados 10 animais da espécie Bradypus variegatus, sendo uma fêmea e três machos submetidos a dissecação, por meio da qual foram obtidas medidas de diâmetro e comprimento dos vasos, enquanto três fêmeas e três machos destinaram-se à técnica de radiografia digital com contraste. Constatou-se uma sintopia uniforme do arco, bem como da porção descendente da artéria aorta no tórax. No entanto, a topografia difere consideravelmente. Com base nos ramos, percebeu-se, independentemente do sexo, uma maior variação naqueles originados do arco e dos que emergem da artéria aorta torácica e irrigam estruturas medianas e do antímero direito do tórax. Foram obtidos valores maiores para o diâmetro das artérias na fêmea do que nos machos e, para o comprimento da artéria aorta torácica, foram encontrados valores correspondentes em ambos. Toda essa variação dos bradipodídeos apresenta diferenças em relação a outros mamíferos.(AU)

Sloths are arboreal mammals, very specific, regarding their habits and morphology. This condition makes them even more vulnerable to environmental impacts. In order to provide information to assist in the medical and surgical assistance to these Xenarthras, a study of the aortic arch and thoracic portion of the descending aorta was carried out with the purpose of identify its main branches. Ten animals of the Bradypus variegatus species were used. One female and three males were submitted to dissection, where measurements of vessel diameter and length were obtained, while three females and three males were submitted to the digital contrast x-ray technique. There was a uniform syntopy of the arch, as well as of the descending portion of the aorta in the thorax. However, the topography differs considerably. Based on the branches, regardless of gender, a greater variation was observed in those originating from the arch, and those that emerge from the thoracic aorta and irrigate medial structures and the right antimere of the thorax. Greater values were obtained for the diameter of the arteries in the female than in the males and corresponding values for the length of the thoracic aorta in both. All this variation is possibly related to the adaptive processes of Bradipodidae over time.(AU)

Generalización diagnóstica fractal de la morfología cardiaca ventricular izquierda: anormalidades moderadas y severas a partir del ventriculograma / Fractal Diagnostic Generalization of Left Ventricular Cardiac Morphology: Moderate and Severe Anormalities from Ventriculography

Introducción: La irregularidad cardiaca es adecuadamente descrita mediante geometría fractal, la cual fue base para el desarrollo de un diagnóstico del ventriculograma izquierdo. Métodos: Se simularon la totalidad de permutaciones posibles de grados de similitud de las dimensiones fractales del ventrículo en sístole, diástole y totalidad, definidas entre los valores mínimos y máximos de los grados de similitud para anormalidad moderada y severa previamente establecidos. Resultados: Se estableció el número total de prototipos ventriculares entre anormalidad moderada y severa. El número total de prototipos de estructura ventricular posibles fue de 1614: 794 ventrículos con anonnalidad moderada y 820 con anonnalidad severa. Medidas previas de ventrículos con diagnóstico de anonnalidad moderada y severa se encontraron incluidas dentro de la generalización. Conclusiones: Se desarrolló una metodología geométrica objetiva y de ayuda diagnóstica a nivel clínico, que determinó todas las posibles estructuras ventriculares izquierdas con anonnalidad moderada y severa, independientemente de clasificaciones clínicas.

Introduction: The cardiac irregularity is adequately described by means of fractal geometry, which was the basis for the development of a diagnosis of left ventriculography. Methods: All possible pennutations of similarity degrees from fractal dimensions were done for the ventricle in systole. diastole and the totality. Pennutations were defined between the previously established mínimum and máximum valúes of similarity degrees for modérate and severe anonnality. Results: It was established the total number of possible ventricular prototypes between modérate and severe anonnality. The total number of possible ventricular structure prototypes is 1614: 794 of ventricles with modérate anonnality and 820 of ventricles with severe anonnality. Practical measures made previously were found within the generalization. Conclusions: It was developed an objective geometric methodology. which is of diagnostic aid in the clinical practice. It detennined all possible left ventricular structures with modérate and severe anonnality independent of clinical classifications.

Medical Devices; Cardiovascular Devices; Classification of the Adjunctive Cardiovascular Status Indicator. Final order.

The Food and Drug Administration (FDA) is classifying the adjunctive cardiovascular status indicator into class II (special controls). The special controls that will apply to the device are identified in this order and will be part of the codified language for the adjunctive cardiovascular status indicator's classification. The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

The value of independent specialty designation for interventional cardiology.

Interventional cardiology has finally completed, after 26 years of advocacy, a professional hat trick: independent board certification, membership as a unique specialty in the American Medical Association House of Delegates (AMA HOD), and recognition by the Centers for Medicaid and Medicare Services (CMS) as a separate medical specialty. This article points out how these distinctions for interventional cardiology and its professional society, the Society for Cardiovascular Angiography and Interventions (SCAI), have led to clear and definite benefits for interventional cardiologists and their patients. We focus on the least understood of these three-recognition by CMS and its implications for reimbursement and quality assessment for interventional cardiologists. © 2016 Wiley Periodicals, Inc.

The dawn of a new era in onco-cardiology: The Kumamoto Classification.

The term "onco-cardiology" has been used in reference to cardiotoxicity in the treatment of malignant disease. In actual clinical situations, however, cardiovascular disease (CVD) associated with malignant disease and the concurrence of atherosclerotic disease with malignant disease are commonly observed, complicating the course of treatment. Patients with malignant disease associated with coronary artery disease often die from the cardiovascular disease, so it is essential to classify these disease states. Additionally, the prevalence of these classifications makes it easy to manage patients with malignant disease and coronary artery disease. We divided the broad field of onco-cardiology into 4 classifications based on clinical scenarios (CSs): CS1 represents the so-called paraneoplastic syndrome. CS2 represents cardiotoxicity during treatment of malignant diseases. CS3 represents the concurrence of atherosclerotic disease with malignant disease, and CS4 represents cardiovascular disease with benign tumors. This classification facilitates the management of patients with malignant disease and coronary artery disease by promoting not only the primary but also the secondary prevention of CVD.

Medical Devices; Cardiovascular Devices; Classification of the Esophageal Thermal Regulation Device. Final order.

The Food and Drug Administration (FDA) is classifying the esophageal thermal regulation device into class II (special controls). The special controls that will apply to the device are identified in this order and will be part of the codified language for the esophageal thermal regulation device's classification. The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

A connecting system for cardiological lexicons.

The purpose of this paper is to present the approach and the development of a software application ("lexicons connecting" system) to correlate effectively and unambiguously the correspondence between the specialist medical vocabulary and the familiar medical vocabulary for the cardiovascular domain. To investigate the question, the idea, the design, and the implementation of such system will be described. To this end, firstly, a number of research methodologies will be examined including domain ontologies development, database design and implementation. Then, the following implementation methodology and its results are presented. Finally, an example of the application use will be depicted and future work will be briefly described.

A novel hybrid classification model of genetic algorithms, modified k-Nearest Neighbor and developed backpropagation neural network.

Among numerous artificial intelligence approaches, k-Nearest Neighbor algorithms, genetic algorithms, and artificial neural networks are considered as the most common and effective methods in classification problems in numerous studies. In the present study, the results of the implementation of a novel hybrid feature selection-classification model using the above mentioned methods are presented. The purpose is benefitting from the synergies obtained from combining these technologies for the development of classification models. Such a combination creates an opportunity to invest in the strength of each algorithm, and is an approach to make up for their deficiencies. To develop proposed model, with the aim of obtaining the best array of features, first, feature ranking techniques such as the Fisher's discriminant ratio and class separability criteria were used to prioritize features. Second, the obtained results that included arrays of the top-ranked features were used as the initial population of a genetic algorithm to produce optimum arrays of features. Third, using a modified k-Nearest Neighbor method as well as an improved method of backpropagation neural networks, the classification process was advanced based on optimum arrays of the features selected by genetic algorithms. The performance of the proposed model was compared with thirteen well-known classification models based on seven datasets. Furthermore, the statistical analysis was performed using the Friedman test followed by post-hoc tests. The experimental findings indicated that the novel proposed hybrid model resulted in significantly better classification performance compared with all 13 classification methods. Finally, the performance results of the proposed model was benchmarked against the best ones reported as the state-of-the-art classifiers in terms of classification accuracy for the same data sets. The substantial findings of the comprehensive comparative study revealed that performance of the proposed model in terms of classification accuracy is desirable, promising, and competitive to the existing state-of-the-art classification models.

Coronary artery revascularisation: selecting the appropriate strategy.

Advances in interventional cardiology, particularly in better efficacy and safety of drug-eluting stents, have made percutaneous coronary revascularisation practical for most patients requiring revascularisation. While this has reduced the perceived need for coronary bypass surgery, it has also focused attention on the appropriate use of coronary stents and the complexity of choosing the right revascularisation strategy. To achieve the best outcomes, it would seem that collaboration rather than competition between cardiac surgeons and interventional cardiologists is necessary.

Usability-driven pruning of large ontologies: the case of SNOMED CT.

OBJECTIVES: To study ontology modularization techniques when applied to SNOMED CT in a scenario in which no previous corpus of information exists and to examine if frequency-based filtering using MEDLINE can reduce subset size without discarding relevant concepts. MATERIALS AND METHODS: Subsets were first extracted using four graph-traversal heuristics and one logic-based technique, and were subsequently filtered with frequency information from MEDLINE. Twenty manually coded discharge summaries from cardiology patients were used as signatures and test sets. The coverage, size, and precision of extracted subsets were measured. RESULTS: Graph-traversal heuristics provided high coverage (71-96% of terms in the test sets of discharge summaries) at the expense of subset size (17-51% of the size of SNOMED CT). Pre-computed subsets and logic-based techniques extracted small subsets (1%), but coverage was limited (24-55%). Filtering reduced the size of large subsets to 10% while still providing 80% coverage. DISCUSSION: Extracting subsets to annotate discharge summaries is challenging when no previous corpus exists. Ontology modularization provides valuable techniques, but the resulting modules grow as signatures spread across subhierarchies, yielding a very low precision. CONCLUSION: Graph-traversal strategies and frequency data from an authoritative source can prune large biomedical ontologies and produce useful subsets that still exhibit acceptable coverage. However, a clinical corpus closer to the specific use case is preferred when available.

ACC/AHA classification of care metrics: performance measures and quality metrics: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have provided leadership in enhancing the quality of cardiovascular care, including the development of clinical performance measures and clinical registries that permit the evaluation of quality of care and stimulate quality improvement. Compliance with ACC/AHA performance measures and metrics encourages the provision of the strongest evidence-based quality of care, including therapies that are life-extending or life-enhancing. Among quality metrics, only a subset should be considered performance measures-that is, those measures specifically suitable for public reporting, external comparisons, and possibly pay-for-performance programs, in addition to quality improvement. These performance measures have been developed using ACC/AHA methodology, often in collaboration with other organizations, and include the process of public comment and peer review. Quality metrics are those measures that have been developed to support self assessment and quality improvement at the provider, hospital, and/or health care system level. These metrics represent valuable tools to aid clinicians and hospitals in improving quality of care and enhancing patient outcomes, but may not meet all specifications of formal performance measures. These quality metrics may also be considered "candidate" measures that with further research of field testing would meet the criteria for formal performance measures in the future. This measure classification is intended to aid providers, hospitals, health systems, and payers in identifying those measures that the ACC and AHA formally endorse as performance measures, while at the same time promoting the broader range of clinical metrics that are useful for quality improvement efforts.