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1.
Int J Occup Environ Med ; 11(4): 179-187, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33098402

RESUMO

BACKGROUND: Besides the traditional cardiovascular risk factor, some novel risk factors like occupation and career can play an important role in cardiovascular disease (CVDs) incidence. OBJECTIVE: To assess the association between occupational categories and their positions with cardiovascular events (CVEs) in an Iranian male population. METHODS: We followed 2134 men aged 35-65 years for 14 years during the Isfahan Cohort Study (2001-2015) for CVEs including ischemic heart disease and stroke. Firstly, Occupations were classified into 10 categories of International Standard Classification of Occupation (ISCO). Each category was then classified into one of the 4 pre-specified categories, namely high/low skilled white collars and high/low skilled blue collars. White-collar workers referred to managerial and professional workers in contrast with blue collar workers, whose job requires manual labor. RESULTS: The mean age of studied participants was 46.9 (SD 8.3) years. 286 CVE incidents were recorded; unstable angina had the highest rate (46%); fatal stroke, the lowest (3%). There were no significant difference was observed between white and blue collars in terms of CVE incidence, as well as their high and low skilled subgroups. Hazard ratio analysis indicated a significantly higher risk of CVEs only for low-skilled white-collar workers (crude HR 1.47, 95% CI 1.01 to 2.13); this was not significant after adjustment for confounding variables. CONCLUSION: There is no association between occupational categories and incidence of cardiovascular events among Iranian male population.


Assuntos
Angina Instável/epidemiologia , Isquemia Miocárdica/epidemiologia , Doenças Profissionais/epidemiologia , Ocupações/classificação , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Estudos de Coortes , Humanos , Incidência , Irã (Geográfico)/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco
3.
Int Heart J ; 61(5): 888-895, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921675

RESUMO

Although B-type natriuretic peptide (BNP) has gradually gained recognition as an indicator in risk stratification for patients with acute myocardial infarction (AMI), the prognostic impact on long-term clinical outcomes in patients with non-ST-segment elevation acute myocardial infarction (NSTEMI) without creatine kinase (CK) elevation remains unclear.This prospective multicenter study assessed 3,283 consecutive patients with AMI admitted to 28 institutions in Japan between 2012 and 2014. We analyzed 218 patients with NSTEMI without CK elevation (NSTEMI-CK) for whom BNP was available. In the NSTEMI-CK group, patients were assigned to high- and low-BNP groups according to BNP values (cut-off BNP, 100 pg/mL). The primary endpoint was defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. Primary endpoints were observed in 60 (33.3%) events among patients with NSTEMI-CK. Kaplan-Meier analysis revealed a significantly higher event rate for primary endpoints among patients with high BNP (log-rank P < 0.001). After adjusting for covariates, a higher BNP level was significantly associated with long-term clinical outcomes in NSTEMI-CK (adjusted hazard ratio, 4.86; 95% confidence interval, 2.18-12.44; P < 0.001).The BNP concentration is associated with adverse long-term clinical outcomes among patients with NSTEMI-CK who are considered low risk. Careful clinical management may be warranted for secondary prevention in patients with NSTEMI-CK with high BNP levels.


Assuntos
Angina Instável/epidemiologia , Creatina Quinase/sangue , Insuficiência Cardíaca/epidemiologia , Mortalidade , Infarto do Miocárdio/epidemiologia , Peptídeo Natriurético Encefálico/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/cirurgia , Causas de Morte , Feminino , Humanos , Japão/epidemiologia , Masculino , Revascularização Miocárdica/estatística & dados numéricos , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Prognóstico , Modelos de Riscos Proporcionais
4.
Am J Cardiol ; 128: 28-34, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650921

RESUMO

Involvement of atherosclerosis in extracardiac vascular territories may identify coronary artery disease (CAD) patients at higher risk for adverse events. We investigated the long-term prognostic implications of polyvascular disease in patients with CAD, and further analyzed lipid goal attainment and its relation to patient outcomes. The study was a retrospective analysis of 10,297 patients who underwent coronary revascularization, categorized as having CAD alone (83.1%) or with multisite artery disease (MSAD) (16.9%) including cerebrovascular disease (CBVD) and/or peripheral artery disease (PAD). Incidence rates and hazard ratios (HR) for major adverse cardiovascular events (MACE) (myocardial infarction, ischemic stroke, or all-cause death) according to vascular territories involved, and in relation to most-recent lipid levels attained, were analyzed. Patients with MSAD were older with higher burden of co-morbidities. The rate of MACE (myocardial infarction, ischemic stroke, or all-cause death) and its individual components increased with the number of affected vascular beds. Adjusted HR (95% confidence interval) for MACE was 1.41 (1.24 to 1.59) in patients with CAD and CBVD, 1.46 (1.33 to 1.62) in CAD and PAD, and 1.69 (1.49 to 1.92) in those with CAD and CBVD and PAD, compared with CAD alone. Most-recent low-density lipoprotein cholesterol (LDL-C) levels <55 mg/dl and <70 mg/dl were attained by 21.8% and 44.6% of patients with CAD alone, in comparison to 22.7% and 43.3% in MSAD. Compared with patients with most-recent LDL-C > 100 mg/dl, attaining LDL-C < 70 mg/dl had an adjusted HR for MACE of 0.52 (0.47 to 0.57) in CAD only patients and 0.66 (0.57 to 0.78) in MSAD patients. In conclusion, the presence of CBVD and/or PAD in patients with CAD is associated with higher burden of co-morbidities and progressive increase in long-term MACE. More than half of CAD patients with or without MSAD do not achieve lipid goals, which are associated with a significantly lower risk for adverse events.


Assuntos
Transtornos Cerebrovasculares/epidemiologia , Doença da Artéria Coronariana/cirurgia , Hipercolesterolemia/terapia , Infarto do Miocárdio/epidemiologia , Revascularização Miocárdica , Doença Arterial Periférica/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/epidemiologia , Angina Instável/cirurgia , Aneurisma da Aorta Abdominal/epidemiologia , Causas de Morte , LDL-Colesterol/sangue , Comorbidade , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Hipercolesterolemia/sangue , Hipercolesterolemia/epidemiologia , Incidência , Israel/epidemiologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia
5.
Am J Med Sci ; 360(3): 268-278, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32563567

RESUMO

BACKGROUND: Sex and age may affect the pathogenesis of coronary heart disease, such as cardiovascular risk factors, treatment and prognosis, but this information is not well known. METHODS: This was a single-center retrospective cohort study. Patients with unstable angina pectoris between January 2013 and June 2018 were included and stratified into 4 age groups (<55, 55-64, 65-74 and ≥75 years). The cardiovascular risk factors profile, treatment and in-hospital prognosis differences by sex and age were explored. RESULTS: This study included 5,908 patients (2,198 women). The women were older than the men (mean age 67 vs. 62 years). Approximately 2 of 3 patients had ≥3 cardiovascular risk factors. Men were more likely to be smokers, and women had a higher level of total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. Hypertension, diabetes and chronic kidney disease were more frequent in women ≥ 65 years old than in similarly aged men. Men and women less than 65 years of age had more frequent family history of coronary heart disease, higher body mass index, higher fasting plasma glucose, and higher lipid levels, especially for patients <55 years of age. More women tended to receive medical therapy than men (51.6% vs. 42.8%, P < 0.01). The overall incidence of in-hospital major adverse cardiovascular events was higher in men than in women (4.1% vs. 2.6%, P < 0.05), whereas there was no sex difference in the in-hospital cardiac mortality (0.2% vs. 0.2%, P > 0.05). CONCLUSIONS: Women had higher cholesterol levels, and were less likely to undergo revascularization therapy than similarly aged men, and elderly women had a higher prevalence of hypertension, diabetes, and chronic kidney disease than elderly men. In-hospital major adverse cardiovascular events were lower in women than in men; however, there was no sex difference in the in-hospital cardiac mortality.


Assuntos
Fatores Etários , Angina Instável/epidemiologia , Fatores Sexuais , Idoso , Índice de Massa Corporal , Doenças Cardiovasculares/epidemiologia , Colesterol/sangue , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Estudos de Coortes , Doença das Coronárias/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fumar/epidemiologia
6.
N Engl J Med ; 382(15): 1395-1407, 2020 04 09.
Artigo em Inglês | MEDLINE | ID: mdl-32227755

RESUMO

BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).


Assuntos
Cateterismo Cardíaco , Ponte de Artéria Coronária , Doença das Coronárias/tratamento farmacológico , Doença das Coronárias/cirurgia , Revascularização Miocárdica/métodos , Intervenção Coronária Percutânea , Idoso , Angina Instável/epidemiologia , Teorema de Bayes , Doenças Cardiovasculares/mortalidade , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/terapia , Qualidade de Vida
8.
Am J Cardiol ; 125(8): 1142-1147, 2020 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-32087994

RESUMO

Bleeding risk stratification is an unresolved issue in older adults. Anemia may reflect subclinical blood losses that can be exacerbated after percutaneous coronary intervention . We sought to prospectively determine the contribution of anemia to the risk of bleeding in 448 consecutive patients aged 75 or more years, treated by percutaneous coronary interventions without concomitant indication for oral anticoagulation. We evaluated the effect of WHO-defined anemia on the incidence of 1-year nonaccess site-related major bleeding. The prevalence of anemia was 39%, and 13.1% of anemic and 5.2% of nonanemic patients suffered a bleeding event (hazard ratio 2.75, 95% confidence interval 1.37 to 5.54, p = 0.004). Neither PRECISE-DAPT nor CRUSADE scores were superior to hemoglobin for the prediction of bleeding. In conclusion, anemia is a powerful predictor of bleeding with potential utility for simplifying tailoring therapies.


Assuntos
Síndrome Coronariana Aguda/cirurgia , Anemia/epidemiologia , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Hemorragia Pós-Operatória/epidemiologia , Síndrome Coronariana Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/epidemiologia , Angina Instável/cirurgia , Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Aspirina/uso terapêutico , Causas de Morte , Clopidogrel/uso terapêutico , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Stents Farmacológicos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/mortalidade , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Heparina/uso terapêutico , Hirudinas , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/mortalidade , Estimativa de Kaplan-Meier , Masculino , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/cirurgia , Fragmentos de Peptídeos/uso terapêutico , Cuidados Pós-Operatórios , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/mortalidade , Cloridrato de Prasugrel/uso terapêutico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Proteínas Recombinantes/uso terapêutico , Medição de Risco , Stents , Ticagrelor/uso terapêutico , Doenças Urológicas/induzido quimicamente , Doenças Urológicas/epidemiologia , Doenças Urológicas/mortalidade
9.
JACC Cardiovasc Interv ; 13(8): 938-950, 2020 04 27.
Artigo em Inglês | MEDLINE | ID: mdl-32061612

RESUMO

OBJECTIVES: This study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries. BACKGROUND: Evidence about incidence and outcomes of ACS after TAVR is scarce. METHODS: We identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non-ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis. RESULTS: Out of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non-ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001). CONCLUSIONS: After TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Angina Instável/epidemiologia , Estenose da Valva Aórtica/cirurgia , Medicare , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/diagnóstico , Angina Instável/mortalidade , Angina Instável/terapia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia
10.
Am Heart J ; 221: 60-66, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31927126

RESUMO

BACKGROUND: High-density lipoprotein cholesterol (HDL-C) concentration is inversely related to risk of major adverse cardiovascular events (MACE) in epidemiologic studies but is a poorer predictor of MACE in patients with established coronary heart disease. HDL particle concentration (HDLP) has been proposed as a better predictor of risk. We investigated whether HDLP is associated with risk of MACE after acute coronary syndrome (ACS). METHODS: The dal-Outcomes trial compared the CETP inhibitor dalcetrapib with placebo in patients with recent ACS. In a nested case-cohort analysis, total, large, medium, and small HDLPs were measured by nuclear magnetic resonance spectroscopy at baseline (4-12 weeks after ACS) in 476 cases with MACE and 902 controls. Hazard ratios (HRs; case-control) for 1-SD increment of HDLP or HDL-C at baseline were calculated with and without adjustment for demographic, clinical, laboratory, and treatment variables. Similarly, HRs for MACE were calculated for changes in HDLP or HDL-C from baseline to month 3 of assigned treatment. RESULTS: Over median follow-up of 28 months, the risk of MACE was not associated with baseline HDLP (adjusted HR = 0.98, 95% CI = 0.84-1.15, P = .81), any HDLP subclass, or HDL-C. Dalcetrapib increased HDL-C and total, medium, and large HDLP and decreased small HDLP but had no effect on MACE compared with placebo. There were no association of risk of MACE with change in HDLP or HDL-C and no interaction with assigned study treatment. CONCLUSIONS: Neither baseline HDLP nor the change in HDLP on treatment with dalcetrapib or placebo was associated with risk of MACE after ACS.


Assuntos
Síndrome Coronariana Aguda/sangue , Angina Instável/epidemiologia , Doença das Coronárias/mortalidade , Hospitalização/estatística & dados numéricos , Lipoproteínas HDL/sangue , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Síndrome Coronariana Aguda/tratamento farmacológico , Idoso , Anticolesterolemiantes/uso terapêutico , Estudos de Casos e Controles , HDL-Colesterol/sangue , Feminino , Humanos , Espectroscopia de Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Compostos de Sulfidrila/uso terapêutico
11.
Am Heart J ; 221: 84-94, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31954328

RESUMO

BACKGROUND: High-sensitivity cardiac troponin (hs-cTn) assays enhance detection of lower circulating troponin concentrations, but the impact on outcomes in clinical practice is unclear. Our objective was to compare outcomes of chest pain patients discharged from emergency departments (EDs) using hs-cTn and conventional troponin (cTn) assays. METHODS: We conducted an observational study of chest pain patients aged 40-105 years who presented to an ED from April 1, 2013, to March 31, 2017, and were discharged home. We compared 30-day and 1-year outcomes of EDs that used hs-cTn versus cTn assays. The primary outcome was a composite of all-cause death, myocardial infarction or unstable angina. Comparisons were conducted with (1) no adjustment; (2) adjustment for demographic, socioeconomic, and hospital characteristics; and (3) full clinical adjustment. RESULTS: Among the 394,910 patients, 62,138 (15.7%) were evaluated at hs-cTn EDs and 332,772 (84.3%) were evaluated at cTn EDs. Patients discharged from hs-cTn EDs were less likely to have diabetes, hypertension, or prior heart disease. At 30 days, the unadjusted primary outcome rate was lower in hs-cTn EDs (0.9% vs 1.0%, P < .001). The 30-day hazard ratios for the primary outcome were 0.84 (95% CI 0.77-0.92) for no adjustment and 0.98 (95% CI 0.88-1.08) for full adjustment. Over 1 year, patients discharged from hs-cTn EDs had significantly fewer primary outcomes (3.7% vs 4.1%, P < .001) and lower hazard ratio (0.93; 95% CI 0.89-0.98) even after full adjustment. CONCLUSIONS: Hs-cTn testing was associated with a significantly lower adjusted hazard of myocardial infarction, angina, and all-cause hospitalization at 1 year but not 30 days.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Angina Instável/epidemiologia , Dor no Peito/etiologia , Técnicas de Laboratório Clínico/métodos , Mortalidade , Infarto do Miocárdio/epidemiologia , Troponina I/análise , Troponina T/análise , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Alta do Paciente , Modelos de Riscos Proporcionais , Troponina I/metabolismo , Troponina T/metabolismo
12.
Am J Cardiol ; 125(5): 661-669, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-31898965

RESUMO

An elevated white blood cell (WBC) count is associated with an increased risk of ischemic events among acute coronary syndrome (ACS) patients, but the association between WBC count and bleeding in ACS patients is not well established. The aim of this analysis was to assess and compare the association between WBC count and the occurrence of short- and long-term bleeding and ischemic events. This was a post hoc analysis of the ATLAS ACS2-TIMI 51 trial. A subset of patients had a WBC count measurement at baseline (n = 14,231, 91.6%). Univariate and multivariable Cox proportional hazard models were constructed to determine if there is an association between WBC count at baseline and a composite outcome of Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeds at 30 days and 1 year. Variables with a p <0.2 in the univariate analysis were included as potential parameters in the backward selection process A similar multivariable model was constructed to assess the association between WBC count and a composite ischemic endpoint of cardiovascular death, myocardial infarction and stroke. An increased risk of bleeding per a 1 × 109/L increase in WBC at baseline was observed at 30 days (Adjusted hazard ratio [HR] 1.08 95% confidence interval [CI] 1.01 to 1.17, p = 0.019) but not at 1 year (Adjusted HR 1.02 95% CI 0.97 to 1.08, p = 0.409). Additionally, an increased risk of ischemia per a 1 × 109/L increase in WBC at baseline was observed at 30 days (Adjusted HR 1.07, 95% CI: 1.03 to 1.12, p = 0.002) and at 1 year (Adjusted HR 1.05 95% CI 1.02 to 1.08, p = 0.001 at 1 year). In conclusion, a higher WBC count at baseline was associated with an increased risk of the composite bleeding endpoint by 30 days but not at 1 year. The association between WBC count and the risk of the composite ischemic endpoint was significant at 30 days and 1 year.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Doenças Cardiovasculares/mortalidade , Hemorragia/epidemiologia , Leucocitose/epidemiologia , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Síndrome Coronariana Aguda/tratamento farmacológico , Idoso , Angina Instável/tratamento farmacológico , Angina Instável/epidemiologia , Inibidores do Fator Xa/uso terapêutico , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio sem Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Rivaroxabana/uso terapêutico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia
13.
Circ Cardiovasc Interv ; 13(2): e008620, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31992059

RESUMO

BACKGROUND: Scarce data exist on coronary events following transcatheter aortic valve replacement (TAVR), and no study has determined the factors associated with poorer outcomes in this setting. This study sought to determine the clinical characteristics, outcomes, and prognostic factors of acute coronary syndrome (ACS) events following TAVR. METHODS: Multicenter cohort study including a total of 270 patients presenting an ACS after a median time of 12 (interquartile range, 5-17) months post-TAVR. Post-ACS death, myocardial infarction, stroke, and overall major adverse cardiovascular or cerebrovascular events were recorded. RESULTS: The ACS clinical presentation consisted of non-ST-segment-elevation myocardial infarction (STEMI) type 2 (31.9%), non-STEMI type 1 (31.5%), unstable angina (28.5%), and STEMI (8.1%). An invasive strategy was used in 163 patients (60.4%), and a percutaneous coronary intervention was performed in 97 patients (35.9%). Coronary access issues were observed in 2.5% and 2.1% of coronary angiography and percutaneous coronary intervention procedures, respectively. The in-hospital mortality rate was 10.0%, and at a median follow-up of 17 (interquartile range, 5-32) months, the rates of death, stroke, myocardial infarction, and major adverse cardiovascular or cerebrovascular events were 43.0%, 4.1%, 15.2%, and 52.6%, respectively. By multivariable analysis, revascularization at ACS time was associated with a reduction of the risk of all-cause death (hazard ratio, 0.54 [95% CI, 0.36-0.81] P=0.003), whereas STEMI increased the risk of all-cause death (hazard ratio, 2.06 [95% CI, 1.05-4.03] P=0.036) and major adverse cardiovascular or cerebrovascular events (hazard ratio, 1.97 [95% CI, 1.08-3.57] P=0.026). CONCLUSIONS: ACS events in TAVR recipients exhibited specific characteristics (ACS presentation, low use of invasive procedures, coronary access issues) and were associated with a poor prognosis, with a very high in-hospital and late death rate. STEMI and the lack of coronary revascularization determined an increased risk. These results should inform future studies to improve both the prevention and management of ACS post-TAVR.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Angina Instável/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Angina Instável/diagnóstico , Angina Instável/mortalidade , Angina Instável/terapia , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Espanha/epidemiologia , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
14.
Neurology ; 94(5): e497-e510, 2020 02 04.
Artigo em Inglês | MEDLINE | ID: mdl-31852816

RESUMO

OBJECTIVE: To examine the cardiovascular, cerebrovascular, and peripheral vascular safety of erenumab across migraine prevention studies. METHODS: Vascular adverse events (AEs) and blood pressure data were integrated across 4 double-blind, placebo-controlled studies of erenumab and their open-label extensions in patients with chronic or episodic migraine. Subgroup analyses were conducted by acute migraine-specific medication use and number of vascular risk factors at baseline. Standardized search terms were used to identify vascular AEs (cardiovascular, cerebrovascular, or peripheral). An independent committee adjudicated whether targeted events were vascular in origin. RESULTS: In placebo-controlled studies, 2,443 patients received placebo (n = 1,043), erenumab 70 mg (n = 893), or erenumab 140 mg (n = 507) subcutaneously once monthly. Regardless of acute migraine-specific medication use or vascular risk factors at baseline, AE incidence was similar across the placebo and erenumab treatment groups. Hypertension AEs were reported for 0.9% (placebo), 0.8% (erenumab 70 mg), and 0.2% (erenumab 140 mg) of patients. Vascular AEs, which were similar across double-blind and open-label treatment, generally were confounded, with plausible alternative etiologies. In 18 patients with events reviewed by the independent committee, 4 events were positively adjudicated as cardiovascular in origin: 2 deaths and 2 vascular events. All 4 positively adjudicated cardiovascular events occurred during open-label erenumab treatment. CONCLUSION: Selective blockade of the canonical calcitonin gene-related peptide receptor with erenumab for migraine prevention had a vascular safety profile comparable to that of placebo over 12 weeks, with no increased emergence of events over time. Further study of long-term safety of erenumab in patients with migraine is needed. CLINICALTRIALSGOV IDENTIFIERS: NCT02066415, NCT02456740, NCT01952574, NCT02483585, NCT02174861, and NCT01723514. CLASSIFICATION OF EVIDENCE: This analysis provides Class II evidence that for patients with migraine, erenumab does not increase the risk of vascular AEs.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/uso terapêutico , Transtornos de Enxaqueca/prevenção & controle , Adulto , Angina Instável/induzido quimicamente , Angina Instável/epidemiologia , Angina Instável/cirurgia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/induzido quimicamente , Hipertensão/epidemiologia , Ataque Isquêmico Transitório/induzido quimicamente , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/induzido quimicamente , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica/estatística & dados numéricos , Doença Arterial Periférica/induzido quimicamente , Doença Arterial Periférica/epidemiologia , Doença Arterial Periférica/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/induzido quimicamente , Acidente Vascular Cerebral/epidemiologia , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos
15.
Clin Exp Hypertens ; 42(1): 16-23, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30554536

RESUMO

Objective: The aim of this study was to assess indices of a comprehensive panel of central aortic pressure and arterial stiffness for prediction of cardiovascular events in a hypertensive cohort.Methods: Noninvasive measurements of central aortic blood pressure, brachial pressure, wave reflection augmentation index, pressure amplification, pulse wave velocity (PWV) and carotid intima-media thickness (IMT) were obtained in 675 hypertensive patients (age 61 ± 9 years, 425 males) for a mean follow-up period 25 ± 4 months. The primary endpoints were defined as cardiovascular disease (CVD) events or death from CVD.Results: After adjusting for confounding factors, central systolic (cSBP) and pulse pressure (cPP) showed higher hazard ratios (HR/10 mmHg) for cardiovascular events (CV) compared to peripheral pressure indices (pSBP, pPP) at age >60 years (cSBP: HR = 1.18, pSBP: HR = 1.17, p = 0.034; cPP: HR = 1.28, pPP: HR = 1.2, p = 0.019). Each SD increase in IMT and in central augmented pressure (cAP) entailed a 1.4 times higher risk of increased total events in elderly patients (age >60 years). For males, each SD increase in cAP was associated with 1.36 times higher risk of increased total events. For females, each SD increase in cAIx and cAP was associated with 0.4 and 0.5 times lower risk of increased total and major CV, respectively. This sex difference is most likely due to lack of age-related increase of cAIx in females after age >60 years compared to males.Conclusions: Central pressure improved prediction of CVD compared to peripheral pressure during a relatively short-term follow up of approximately 2 years at age >60 years.


Assuntos
Pressão Arterial , Hipertensão/fisiopatologia , Rigidez Vascular , Idoso , Angina Instável/epidemiologia , Aorta , Determinação da Pressão Arterial , Espessura Intima-Media Carotídea , Ponte de Artéria Coronária/estatística & dados numéricos , Morte Súbita Cardíaca/epidemiologia , Feminino , Seguimentos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Intervenção Coronária Percutânea/estatística & dados numéricos , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Análise de Onda de Pulso , Ressuscitação/estatística & dados numéricos , Acidente Vascular Cerebral/epidemiologia
16.
J Am Coll Cardiol ; 74(7): 842-854, 2019 08 20.
Artigo em Inglês | MEDLINE | ID: mdl-31416527

RESUMO

BACKGROUND: Early and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. OBJECTIVES: The goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. METHODS: Patients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization. RESULTS: Among 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. CONCLUSIONS: The ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).


Assuntos
Algoritmos , Infarto do Miocárdio/epidemiologia , Troponina/sangue , Idoso , Angina Instável/diagnóstico , Angina Instável/epidemiologia , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/epidemiologia , Bloqueio Atrioventricular/diagnóstico , Bloqueio Atrioventricular/epidemiologia , Biomarcadores/sangue , Eletrocardiografia , Serviço Hospitalar de Emergência , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Revascularização Miocárdica , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/epidemiologia
17.
Int J Evid Based Healthc ; 17 Suppl 1: S43-S47, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31283581

RESUMO

Coronary heart disease, sometimes also referred to as ischemic heart disease, remains the leading condition causing most deaths and disability-adjusted life years worldwide. Acute coronary syndrome (ACS) represents a subset that is defined by sudden reduction of blood supply in the coronary arteries. ACS consists of unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).The current short communication aims to provide current ACS prevalence and incidence data analysis to inform development of clinical practice guidelines in the Czech Republic.The Institute of Health Information and Statistics of the Czech Republic has provided the data that are collected by the National Health Information System with the National Register of Reimbursed Health Services as a primary source providing data for the period from 2015 to 2017.There has been a slight decrease in the number of hospitalized patients for ACS in the Czech Republic from 2015 to 2017. Sex difference remains large, with majority (two thirds) of those hospitalized for unstable angina, NSTEMI, or STEMI being men. Hospitalization with STEMI is reported in younger age with no sex difference compared with NSTEMI and unstable angina.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Angina Instável/epidemiologia , Infarto do Miocárdio/epidemiologia , Fatores Etários , República Tcheca/epidemiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Prevalência , Fatores Sexuais
18.
J Cardiovasc Med (Hagerstown) ; 20(8): 525-530, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31260420

RESUMO

AIM: Differences exist in the diagnosis and treatment of acute coronary syndrome (ACS) between men and women. However, recent advancements in the management of ACSs might have attenuated this sex gap. We evaluated the status of ACS management in a multicenter registry in 10 tertiary Spanish hospitals. METHODS: We enrolled 1056 patients in our study, including only those with type 1 myocardial infarctions or unstable angina presumably not related to a secondary cause in an 'all-comers' design. RESULTS: The women enrolled (29%) were older than men (71.0 ±â€Š12.8 vs. 64.0 ±â€Š12.3, P = 0.001), with a higher prevalence of hypertension (71.0 vs. 56.5%, P < 0.001), insulin-treated diabetes (13.7 vs. 7.9%, P = 0.003), dyslipidemia (62.2 vs. 55.3%, P = 0.038), and chronic kidney disease (16.9 vs. 9.1%, P = 0.001). Women presented more frequently with back or arm pain radiation (57.3 vs. 49.7%, P = 0.025), palpitations (5.9 vs. 2.0%, P = 0.001), or dyspnea (33.0 vs. 19.4%, P = 0.001). ACS without significant coronary stenosis was more prevalent in women (16.8 vs. 8.1%, P = 0.001). There were no differences in percutaneous revascularization rates, but drug-eluting stents were less frequently employed in women (75.4 vs. 67.8%, P = 0.024); women were less often referred to a cardiac rehabilitation program (19.9 vs. 33.9%, P = 0.001). There were no significant differences in in-hospital complications such as thrombosis or bleeding. CONCLUSION: ACS presenting with atypical symptoms and without significant coronary artery stenosis is more frequent in women. Selection of either an invasive procedure or conservative management is not influenced by sex. Cardiac rehabilitation referral on discharge is underused, especially in women.


Assuntos
Síndrome Coronariana Aguda/terapia , Angina Instável/terapia , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Infarto do Miocárdio/terapia , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angina Instável/diagnóstico por imagem , Angina Instável/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/epidemiologia , Prevalência , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores Sexuais , Espanha/epidemiologia , Resultado do Tratamento
19.
Arthritis Rheumatol ; 71(10): 1651-1659, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31165591

RESUMO

OBJECTIVE: This study aimed to assess whether subclinical atherosclerosis, as evaluated by carotid ultrasound, could predict incident cardiovascular events (CVEs) in patients with psoriatic disease (PsD) and determine whether incorporation of imaging data could improve CV risk prediction by the Framingham Risk Score (FRS). METHODS: In this cohort analysis, patients with PsD underwent ultrasound assessment of the carotid arteries at baseline. The extent of atherosclerosis was assessed using carotid intima-media thickness (CIMT) and total plaque area (TPA). Incident CVEs (new or recurrent) that occurred following the ultrasound assessment were identified. The association between measures of carotid atherosclerosis and the risk of developing an incident CVE was evaluated using Cox proportional hazards models, with adjustment for the FRS. RESULTS: In total, 559 patients with PsD were assessed, of whom 23 had incident CVEs ascertained. The calculated rate of developing a first CVE during the study period was 1.11 events per 100 patient-years (95% confidence interval [95% CI] 0.74-1.67). When analyzed separately in Cox proportional hazards models that were controlled for the FRS, the TPA (hazard ratio [HR] 3.74, 95% CI 1.55-8.85; P = 0.003), mean CIMT (HR 1.21, 95% CI 1.03-1.42; P = 0.02), maximal CIMT (HR 1.11, 95% CI 1.01-1.22; P = 0.03), and high TPA category (HR 3.25, 95% CI 1.18-8.95; P = 0.02) were each predictive of incident CVEs in patients with PsD. CONCLUSION: The burden of carotid atherosclerosis is associated with an increased risk of developing future CVEs. Combining vascular imaging data with information on traditional CV risk factors could improve the accuracy of CV risk stratification in patients with PsD.


Assuntos
Artrite Psoriásica/epidemiologia , Doenças Cardiovasculares/epidemiologia , Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Placa Aterosclerótica/diagnóstico por imagem , Adulto , Idoso , Angina Estável/epidemiologia , Angina Instável/epidemiologia , Doenças Cardiovasculares/mortalidade , Espessura Intima-Media Carotídea , Endarterectomia das Carótidas/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Revascularização Miocárdica/estatística & dados numéricos , Ontário/epidemiologia , Modelos de Riscos Proporcionais , Psoríase/epidemiologia , Estudos Retrospectivos , Medição de Risco , Acidente Vascular Cerebral/epidemiologia , Ultrassonografia
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