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1.
Am Heart J ; 228: 65-71, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32866927

RESUMO

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has been shown in clinical trials, registries, and meta-analyses to reduce recurrent major adverse cardiovascular events after PCI. However, IVUS utilization remains low. An increasing number of high-risk or complex coronary artery lesions are treated with PCI, and we hypothesize that the impact of IVUS in guiding treatment of these complex lesions will be of increased importance in reducing major adverse cardiovascular events while remaining cost-effective. The "IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact" trial (registered on clinicaltrials.gov: NCT04221815) is a multicenter, international, clinical trial randomizing subjects to IVUS-guided versus angiography-guided PCI in a 1:1 ratio. Patients undergoing PCI involving a complex lesion are eligible for enrollment. Complex lesion is defined as involving at least 1 of the following characteristics: chronic total occlusion, in-stent restenosis, severe coronary artery calcification, long lesion (≥28 mm), or bifurcation lesion. The clinical investigation will be conducted at approximately 120 centers in North America and Europe, enrolling approximately 2,500 to 3,100 randomized subjects with an adaptive design. The primary clinical end point is the rate of target vessel failure at 12 months, defined as the composite of cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization. The co-primary imaging end point is the final post-PCI minimum stent area assessed by IVUS. The primary objective of this study is to assess the impact of IVUS guidance on the PCI treatment of complex lesions.


Assuntos
Doença da Artéria Coronariana , Vasos Coronários/diagnóstico por imagem , Intervenção Coronária Percutânea , Complicações Pós-Operatórias , Risco Ajustado/métodos , Ultrassonografia de Intervenção , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Cirurgia Assistida por Computador/métodos , Ultrassonografia de Intervenção/economia , Ultrassonografia de Intervenção/métodos
2.
Am Heart J ; 228: 72-80, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32871327

RESUMO

BACKGROUND: The clinical value of intracoronary imaging for percutaneous coronary intervention (PCI) guidance is well acknowledged. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are the most commonly used intravascular imaging to guide and optimize PCI in day-to-day practice. However, the comparative effectiveness of IVUS-guided versus OCT-guided PCI with respect to clinical end points remains unknown. METHODS AND DESIGN: The OCTIVUS study is a prospective, multicenter, open-label, parallel-arm, randomized trial comparing the effectiveness of 2 imaging-guided strategies in patients with stable angina or acute coronary syndromes undergoing PCI in Korea. A total of 2,000 patients are randomly assigned in a 1:1 ratio to either an OCT-guided PCI strategy or an IVUS-guided PCI strategy. The trial uses a pragmatic comparative effectiveness design with inclusion criteria designed to capture a broad range of real-world patients with diverse clinical and anatomical features. PCI optimization criteria are predefined using a common algorithm for online OCT or IVUS. The primary end point, which was tested for both noninferiority (margin, 3.1 percentage points for the risk difference) and superiority, is target-vessel failure (cardiac death, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization) at 1 year. RESULTS: Up to the end of July 2020, approximately 1,200 "real-world" PCI patients have been randomly enrolled over 2 years. Enrollment is expected to be completed around the midterm of 2021, and primary results will be available by late 2022 or early 2023. CONCLUSION: This large-scale, multicenter, pragmatic-design clinical trial will provide valuable clinical evidence on the relative efficacy and safety of OCT-guided versus IVUS-guided PCI strategies in a broad population of patients undergoing PCI in the daily clinical practice.


Assuntos
Vasos Coronários/diagnóstico por imagem , Intervenção Coronária Percutânea , Complicações Pós-Operatórias/prevenção & controle , Cirurgia Assistida por Computador/métodos , Tomografia de Coerência Óptica/métodos , Ultrassonografia de Intervenção/métodos , Pesquisa Comparativa da Efetividade , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/diagnóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Risco Ajustado/métodos
3.
Am Heart J ; 228: 91-97, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32871328

RESUMO

BACKGROUND: The optimal role of radial artery grafts in coronary artery bypass grafting (CABG) remains uncertain. The purpose of this study was to examine angiographic and clinical outcomes following CABG among patients who received a radial artery graft. METHODS: Patients in the angiographic cohort of the PREVENT-IV trial were stratified based upon having received a radial artery graft or not during CABG. Baseline characteristics and 1-year angiographic and 5-year clinical outcomes were compared between patients. RESULTS: Of 1,923 patients in the angiographic cohort of PREVENT-IV, 117 received a radial artery graft. These patients had longer surgical procedures (median 253 vs 228 minutes, P < .001) and had a greater number of grafts placed (P < .0001). Radial artery grafts had a graft-level failure rate of 23.0%, which was similar to vein grafts (25.2%) and higher than left internal mammary artery grafts (8.3%). The hazard of the composite clinical outcome of death, myocardial infarction, or repeat revascularization was similar for both cohorts (adjusted hazard ratio 0.896, 95% CI 0.609-1.319, P = .58). Radial graft failure rates were higher when used to bypass moderately stenotic lesions (<75% stenosis, 37% failure) compared with severely stenotic lesions (≥75% stenosis, 15% failure). CONCLUSIONS: Radial artery grafts had early failure rates comparable to saphenous vein and higher than left internal mammary artery grafts. Use of a radial graft was not associated with a different rate of death, myocardial infarction, or postoperative revascularization. Despite the significant potential for residual confounding associated with post hoc observational analyses of clinical trial data, these findings suggest that when clinical circumstances permit, the radial artery is an acceptable alternative to saphenous vein and should be used to bypass severely stenotic target vessels.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana , Oclusão de Enxerto Vascular , Artéria Radial/transplante , Reoperação , Angiografia Coronária/métodos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Feminino , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Reoperação/métodos , Reoperação/estatística & dados numéricos , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos
4.
Am Heart J ; 228: 109-115, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32882569

RESUMO

BACKGROUND: Patients aged ≥80 years are often treated with new-generation drug-eluting stents (DES), but data from randomized studies are scarce owing to underrepresentation in most trials. We assessed 1-year clinical outcome of octogenarians treated with new-generation DES versus younger patients. METHODS: We pooled patient-level data of 9,204 participants in the TWENTE, DUTCH PEERS, BIO-RESORT, and BIONYX (TWENTE I-IV) randomized trials. The main clinical end point was target vessel failure (TVF), a composite of cardiac death, target vessel-related myocardial infarction (MI), or clinically indicated target vessel revascularization. RESULTS: The 671 octogenarian trial participants had significantly more comorbidities. TVF was higher in octogenarians than in 8,533 patients <80 years (7.3% vs 5.3%, hazard ratio [HR]: 1.36, 95% CI: 1.0-1.83, P = .04). The cardiac death rate was higher in octogenarians (3.9% vs 0.8%, P < .001). There was no significant between-group difference in target vessel MI (2.3% vs 2.3%, P = .88) and repeat target vessel revascularization (1.9% vs 2.8%, P = .16). In multivariate analyses, age ≥ 80 years showed no independent association with TVF (adjusted HR: 1.04, 95% CI: 0.76-1.42), whereas the risk of cardiac death remained higher in octogenarians (adjusted HR: 3.38, 95% CI: 2.07-5.52, P < .001). In 6,002 trial participants, in whom data on major bleeding were recorded, octogenarians (n = 459) showed a higher major bleeding risk (5.9% vs 1.9%; HR: 3.08, 95% CI: 2.01-4.74, P < .001). CONCLUSIONS: Octogenarian participants in 4 large-scale randomized DES trials had more comorbidities and a higher incidence of the main end point TVF. Cardiac mortality was higher in octogenarians, whereas there was no increase in MI or target vessel revascularization rates. Treatment of octogenarian patients with new-generation DES appears to be safe and effective.


Assuntos
Stents Farmacológicos/classificação , Everolimo/farmacologia , Infarto do Miocárdio , Complicações Pós-Operatórias , Sirolimo/análogos & derivados , Sirolimo/farmacologia , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , Imunossupressores/farmacologia , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Reoperação/métodos , Reoperação/estatística & dados numéricos , Risco Ajustado/métodos , Fatores de Risco , Resultado do Tratamento
5.
BMC Med Genet ; 21(1): 178, 2020 09 10.
Artigo em Inglês | MEDLINE | ID: mdl-32912153

RESUMO

BACKGROUND: A Genetic risk score for coronary artery disease (CAD) improves the ability of predicting coronary heart disease (CHD). It is unclear whether i) the use of a CAD genetic risk score is superior to the measurement of coronary artery calcification (CAC) for CHD risk assessment and ii) the CHD risk assessment using a CAD genetic risk score differs between men and women. METHODS: We included 4041 participants (age-range: 45-76 years, 1919 men) of the Heinz Nixdorf Recall study without CHD or stroke at baseline. A standardized weighted CAD genetic risk score was constructed using 70 known genetic variants. The risk score was divided into quintiles (Q1-Q5). We specified low (Q1), intermediate (Q2-Q4) and high (Q5) genetic risk groups. Incident CHD was defined as fatal and non-fatal myocardial infarction, stroke and coronary death. The association between the genetic risk score and genetic risk groups with incident CHD was assessed using Cox models to estimate hazard ratios (HR) and 95%-confidence intervals (CI). The models were adjusted by age and sex (Model1), as well as by established CHD risk factors (RF) and CAC (Model2). The analyses were further stratified by sex and controlled for multiple testing. RESULTS: During a median follow-up time of 11.6 ± 3.7 years, 343 participants experienced CHD events (219 men). Per-standard deviation (SD) increase in the genetic risk score was associated with 18% increased risk for incident CHD (Model1: p = 0.002) which did not change after full adjustment (Model2: HR = 1.18 per-SD (p = 0.003)). In Model2 we observed a 60% increased CHD risk in the high (p = 0.009) compared to the low genetic risk group. Stratifying by sex, only men showed statistically significantly higher risk for CHD (Model2: HR = 1.23 per-SD (p = 0.004); intermediate: HR = 1.52 (p = 0.04) and high: HR = 1.88 (p = 0.008)) with no statistically significant risk observed in women. CONCLUSION: Our results suggest that the CAD genetic risk score could be useful for CHD risk prediction, at least in men belonging to the higher genetic risk group, but it does not outbalance the value of CT-based quantification of CAC which works independently on both men and women and allows better risk stratification in both the genders.


Assuntos
Doença da Artéria Coronariana/genética , Infarto do Miocárdio/genética , Medição de Risco/estatística & dados numéricos , Acidente Vascular Cerebral/genética , Idoso , Doença da Artéria Coronariana/diagnóstico , Feminino , Humanos , Masculino , Análise da Randomização Mendeliana , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Prognóstico , Modelos de Riscos Proporcionais , Medição de Risco/métodos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Tomografia Computadorizada por Raios X
6.
Am J Cardiol ; 132: 8-14, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32773225

RESUMO

We examined the 10-year risk of myocardial infarction (MI) and death in patients without obstructive coronary artery disease (CAD) compared with the general population. We conducted a cohort study of every patient without obstructive CAD by coronary angiography (CAG) between 2003 and 2016 in Western Denmark. Patients were matched by gender and age with individuals from the general population of Western Denmark with no history of CAD. End points were MI and death. Ten-year risk differences in cumulative incidence proportions were computed, accounting for the competing risk of death in the case of MI. Unadjusted and adjusted incidence rate ratios (aIRRs) were estimated using conditional Poisson regression. We included 46,467 patients and 234,654 individuals from the general population. Median follow-up was 7.7 years. The 10-year cumulative incidence of MI was 2.40% (95% confidence interval [CI] 2.24 to 2.57) in patients without obstructive CAD in the CAG and 2.70% (95% CI 2.62 to 2.78) in the general population, with a reduced absolute 10-year risk (risk difference -0.30%, 95% CI -0.49 to -0.12) and a reduced aIRR (aIRR 0.70, 95% CI 0.63 to 0.77). Ten-year mortality was higher in patients without obstructive CAD in the CAG (21.44%, 95% CI 20.99 to 21.89) compared with the general population (17.25%, 95% CI 17.06 to 17.44). However, mortality rates were similar after adjustment (aIRR 1.00, 95% CI 0.96 to 1.02). In conclusion, the absence of obstructive CAD according to CAG is associated with a lower risk of MI than in the general population, and similar 10-year mortality.


Assuntos
Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Infarto do Miocárdio/epidemiologia , Sistema de Registros , Medição de Risco/métodos , Idoso , Dinamarca/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo
7.
Am Heart J ; 228: 8-16, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32745734

RESUMO

BACKGROUND: Gastrointestinal injury is a common complication in patients treated with antiplatelet agents after percutaneous coronary intervention (PCI). However, the effects of different antiplatelet regimens on the incidence and severity of gastrointestinal injury have not been well studied, principally due to the lack of a low-risk sensitive and accurate detection system. TRIAL DESIGN: OPT-PEACE is a multicenter, randomized, double-blind, placebo-controlled trial. Gastrointestinal injury will be evaluated with the ANKON magnetically controlled capsule endoscopy system (AMCE), a minimally invasive approach for detecting mucosal lesions in the stomach, duodenum and small intestine. Patients without AMCE-detected gastrointestinal erosions, ulceration or bleeding after drug-eluting stent implantation are enrolled and treated with open-label aspirin (100 mg/d) plus clopidogrel (75 mg/d) for 6 months. Thereafter, 480 event-free patients will undergo repeat AMCE and are randomly assigned in a 1:1:1 ratio to receive aspirin plus clopidogrel, aspirin plus placebo or clopidogrel plus placebo for an additional 6 months. A final AMCE is performed at 12 months. The primary endpoint is the incidence of gastric or intestinal mucosal lesions (erosions, ulceration, or bleeding) within 12 months after enrollment. CONCLUSIONS: OPT-PEACE is the first study to investigate the incidence and severity of gastrointestinal injury in patients receiving different antiplatelet therapy regimens after stent implantation. This trial will inform clinical decision-making for personalized antiplatelet therapy post-PCI.


Assuntos
Aspirina , Endoscopia por Cápsula/métodos , Clopidogrel , Doença da Artéria Coronariana , Hemorragia Gastrointestinal , Intervenção Coronária Percutânea , Adulto , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/cirurgia , Método Duplo-Cego , Stents Farmacológicos , Terapia Antiplaquetária Dupla/métodos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/prevenção & controle , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/instrumentação , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Risco Ajustado/métodos
8.
PLoS One ; 15(8): e0237579, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32810196

RESUMO

OBJECTIVE: Patients with CAD have substantial residual risk of mortality, and whether hitherto unknown small-molecule metabolites and metabolic pathways contribute to this risk is unclear. We sought to determine the predictive value of plasma metabolomic profiling in patients with CAD. APPROACH AND RESULTS: Untargeted high-resolution plasma metabolomic profiling of subjects undergoing coronary angiography was performed using liquid chromatography/mass spectrometry. Metabolic features and pathways associated with mortality were identified in 454 subjects using metabolome-wide association studies and Mummichog, respectively, and validated in 322 subjects. A metabolomic risk score comprising of log-transformed HR estimates of metabolites that associated with mortality and passed LASSO regression was created and its performance validated. In 776 subjects (66.8 years, 64% male, 17% Black), 433 and 357 features associated with mortality (FDR-adjusted q<0.20); and clustered into 21 and 9 metabolic pathways in first and second cohorts, respectively. Six pathways (urea cycle/amino group, tryptophan, aspartate/asparagine, lysine, tyrosine, and carnitine shuttle) were common. A metabolomic risk score comprising of 7 metabolites independently predicted mortality in the second cohort (HR per 1-unit increase 2.14, 95%CI 1.62, 2.83). Adding the score to a model of clinical predictors improved risk discrimination (delta C-statistic 0.039, 95%CI -0.006, 0.086; and Integrated Discrimination Index 0.084, 95%CI 0.030, 0.151) and reclassification (continuous Net Reclassification Index 23.3%, 95%CI 7.9%, 38.2%). CONCLUSIONS: Differential regulation of six metabolic pathways involved in myocardial energetics and systemic inflammation is independently associated with mortality in patients with CAD. A novel risk score consisting of representative metabolites is highly predictive of mortality.


Assuntos
Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Metaboloma/fisiologia , Metabolômica/métodos , Idoso , Biomarcadores/sangue , Biomarcadores/metabolismo , Análise Química do Sangue/métodos , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Redes e Vias Metabólicas , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Medição de Risco
9.
Am Surg ; 86(8): 976-980, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32762469

RESUMO

BACKGROUND: Coronary artery disease (CAD) is a leading cause of mortality following orthotopic liver transplant, yet there is no standardized protocol for pre-liver-transplant coronary artery disease assessment. The main objective of this study was to determine the agreement between 2 methods of cardiac risk assessment: dobutamine stress echocardiogram (DSE) and coronary calcium score (CCS) and to determine which test was best able to predict coronary calcification in low-risk patients. METHODS: A retrospective study was performed using the medical records of 436 patients who received cardiac clearance for a liver transplant. A total of 152 patients' medical records were included based on the inclusion of patients who had received both DSE and CCS. A kappa coefficient was calculated to determine the agreement between the DSE and CCS results. In addition, the positive predictive values (PPVs) of both the CCS and DSE along with cardiac catheterization indicating abdominal occlusion were analyzed to compare the accuracy of the 2 tests. RESULTS: It was determined that there was a 12% agreement between DSE results and CCS. It was found that the DSE had a PPV of 56% and the CCS had a PPV of 80%. CONCLUSION: From this data, it was concluded that there was no agreement between the results of the CCS and the DSE. While neither the CCS nor the DSE presents an optimal method of risk assessment, the CCS had a much higher PPV and was therefore determined to be the more accurate test.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Transplante de Fígado , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Adulto , Idoso , Biomarcadores/metabolismo , Cálcio/metabolismo , Cateterismo Cardíaco , Regras de Decisão Clínica , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/metabolismo , Ecocardiografia sob Estresse , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade
10.
BMC Neurol ; 20(1): 318, 2020 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-32854663

RESUMO

BACKGROUND: Current guidelines recommend measurement of troponin in acute ischemic stroke (AIS) patients. In AIS patients, troponin elevation is associated with increased mortality and worse outcome. However, uncertainty remains regarding the underlying pathophysiology of troponin elevation after stroke, particularly regarding diagnostic and therapeutic consequences. Troponin elevation may be caused by coronary artery disease (CAD) and more precisely acute coronary syndrome (ACS). Both have a high prevalence in stroke patients and contribute to poor outcome. Therefore, better diagnostic algorithms are needed to identify those AIS patients likely to have ACS or other manifestations of CAD. METHODS/DESIGN: The primary goal of the "PRediction of Acute coronary syndrome in acute Ischemic StrokE" (PRAISE) study is to develop a diagnostic algorithm for prediction of ACS in AIS patients. The primary hypothesis will test whether dynamic high-sensitivity troponin levels determined by repeat measurements (i.e., "rise or fall-pattern") indicate presence of ACS when compared to stable (chronic) troponin elevation. PRAISE is a prospective, multicenter, observational trial with central reading and predefined endpoints guided by a steering committee. Clinical symptoms, troponin levels as well as findings on electrocardiogram, echocardiogram, and coronary angiogram will be recorded and assessed by central academic core laboratories. Diagnosis of ACS will be made by an endpoint adjudication committee. Severe adverse events will be evaluated by a critical event committee. Safety will be judged by a data and safety monitoring board. Follow-up will be conducted at three and twelve months and will record new vascular events (i.e., stroke and myocardial infarction) as well as death, functional and cognitive status. According to sample size calculation, 251 patients have to be included. DISCUSSION: PRAISE will prospectively determine the frequency of ACS and characterize cardiac and coronary pathologies in a large, multicenter cohort of AIS patients with troponin elevation. The findings will elucidate the origin of troponin elevation, shed light on its impact on necessary diagnostic procedures and provide data on the safety and diagnostic yield of coronary angiography early after stroke. Thereby, PRAISE will help to refine algorithms and develop guidelines for the cardiac workup in AIS. TRIAL REGISTRATION: NCT03609385 registered 1st August 2018.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Isquemia Encefálica/complicações , Acidente Vascular Cerebral/complicações , Troponina/análise , Biomarcadores/análise , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Eletrocardiografia/métodos , Humanos , Infarto do Miocárdio/diagnóstico , Estudos Prospectivos
11.
Mayo Clin Proc ; 95(8): 1740-1749, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32646743

RESUMO

Allocation of statin therapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in borderline- and intermediate-risk patients has traditionally been based on population-based global risk assessment and other clinical and laboratory characteristics. Patient-specific treatment decisions are needed to provide maximal benefit and avoid unnecessary treatment. Guideline-based lipid management proposes that coronary artery calcium scoring is reasonable to implement in patients with a 10-year risk of 5.0% to 19.9% (borderline to intermediate risk) by using the pooled cohort equations when the decision about whether to initiate statin therapy is uncertain. We report data from both observational studies and a large primary prevention randomized controlled trial that support the position that this decision is, in fact, uncertain in about half of such patients because of risk misclassification. Such misclassification can be largely avoided by more widespread implementation of coronary calcium scoring, which helps to identify those with coronary artery calcium scores of 0, a finding associated with a less than 5.0% 10-year probability of an ASCVD event. Deferral of statin therapy in such patients, in the absence of smoking, diabetes, or a family history of premature ASCVD, provides more individualized and appropriate care and avoids the expense and potential adverse effects of statin therapy in those with low potential for absolute risk reduction. A rationale is also provided for the importance of coronary artery calcium scoring in women 50 years and older, possibly in place of 1 screening mammogram in women at least 55 years of age to avoid incremental radiation exposure, on the basis of the substantially higher lifetime risk of morbidity and mortality from ASCVD than from breast cancer. In patients with borderline or intermediate ASCVD risk, coronary artery calcium scoring should be used, whenever possible, as an aid to rational statin allocation for the primary prevention of ASCVD.


Assuntos
Doença da Artéria Coronariana/prevenção & controle , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Prevenção Primária/métodos , Adulto , Idoso , Tomada de Decisão Clínica , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/etiologia , Tomada de Decisão Compartilhada , Feminino , Custos de Cuidados de Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Prevenção Primária/economia , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Calcificação Vascular/diagnóstico
14.
Cardiovasc Ther ; 2020: 3057168, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32695228

RESUMO

Aims: Acetylsalicylic acid (ASA) is widely used for the prevention of atherothrombotic events in patients with chronic coronary artery disease (CAD) and peripheral artery disease (PAD), but the risk of vascular events remains high. We aimed at identifying randomised controlled trials (RCTs) on antithrombotic treatments in patients with chronic CAD or PAD. Methods: Searches were conducted on MEDLINE, EMBASE, and CENTRAL on March 1st, 2018. This systematic review (SR) uses a narrative synthesis to summarize the evidence for the efficacy and safety of antiplatelet and anticoagulant therapies in the population of both chronic CAD or PAD patients. Results: Four RCTs from 27 publications were included. Study groups included 15,603 to 27,395 patients. ASA alone was the most extensively studied (n = 3); other studies included rivaroxaban with or without ASA (n = 1), vorapaxar alone (n = 1), and clopidogrel with (n = 1) or without ASA (n = 1). Clopidogrel alone and clopidogrel plus ASA compared to ASA presented similar efficacy with comparable safety profile. Rivaroxaban plus ASA significantly reduced the risk of the composite of cardiovascular death, myocardial infarction, and stroke compared to ASA alone, although major bleeding with rivaroxaban plus ASA increased. Conclusion: There is limited and heterogeneous evidence on the prevention of atherothrombotic events in patients with chronic CAD or PAD. Clopidogrel alone and clopidogrel plus ASA did not demonstrate superiority over ASA alone. A combination of rivaroxaban plus ASA may offer significant additional benefit in reducing cardiovascular outcomes, yet it may increase the risk of bleeding, compared to ASA alone.


Assuntos
Anticoagulantes/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/prevenção & controle , Idoso , Anticoagulantes/efeitos adversos , Doença Crônica , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Terapia Antiplaquetária Dupla , Feminino , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Trombose/diagnóstico , Trombose/epidemiologia , Resultado do Tratamento
15.
Cardiovasc Diabetol ; 19(1): 104, 2020 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-32631321

RESUMO

BACKGROUND: The atherogenicity of remnant cholesterol (RC) has been underlined by recent guidelines, which was linked to coronary artery disease (CAD), especially for patients with diabetes mellitus (DM). This study aimed to examine the prognostic value of plasma RC in the patients with CAD under different glucose metabolism status. METHODS: Fasting plasma RC were directly calculated or measured in 4331 patients with CAD. Patients were followed for the occurrence of major adverse cardiovascular events (MACEs) and categorized according to both glucose metabolism status [DM, pre-DM, normoglycemia (NG)] and RC levels. Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals. RESULTS: During a mean follow-up of 5.1 years, 541 (12.5%) MACEs occurred. The risk for MACEs was significantly higher in patients with elevated RC levels after adjustment for potential confounders. No significant difference in MACEs was observed between pre-DM and NG groups (p > 0.05). When stratified by combined status of glucose metabolism and RC, highest levels of calculated and measured RC were significant and independent predictors of developing MACEs in pre-DM (HR: 1.64 and 1.98; both p < 0.05) and DM (HR: 1.62 and 2.05; both p < 0.05). High RC levels were also positively associated with MACEs in patients with uncontrolled DM. . CONCLUSIONS: In this large-scale and long-term follow-up cohort study, data firstly demonstrated that higher RC levels were significantly associated with the worse prognosis in DM and pre-DM patients with CAD, suggesting that RC may be a target for patients with impaired glucose metabolism.


Assuntos
Glicemia/metabolismo , Colesterol/sangue , Remanescentes de Quilomícrons/sangue , Doença da Artéria Coronariana/sangue , Diabetes Mellitus/sangue , Estado Pré-Diabético/sangue , Idoso , Biomarcadores/sangue , China/epidemiologia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estado Pré-Diabético/diagnóstico , Estado Pré-Diabético/epidemiologia , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
16.
MMW Fortschr Med ; 162(Suppl 5): 21-27, 2020 07.
Artigo em Alemão | MEDLINE | ID: mdl-32661891

RESUMO

BACKGROUND: Sex/gender differences pose a challenge in the care of patients with chronic coronary artery disease (CAD) especially in the resident sector. The aim of the AURORA trial was to obtain a nationwide overview on how resident cardiologists deal with sex/gender-specific aspects of symptomatic chronic CAD in their medical routine care and in the interplay with general practitioners, as well as derive insights out of it for general practice. METHOD: Between October 2018 and April 2019 a survey among German cardiologists (n = 360) in the outpatient sector was performed using a structured questionnaire. Items focused on the cardiologists' personal assessment of sex/gender aspects in the diagnosis and treatment and consequences for the overall medical care of patients with chronic CAD. RESULTS: The range of symptoms of chronic CAD in male and female patients was differently assessed by the participating male or female cardiologists. General practitioners referred men at an earlier stage than women to a cardiologist for further testing. In male and female patients with non-obstructive CAD cardiovascular risk was largely assessed as comparable to patients with obstructive CAD. In terms of medical care, it was shown that therapeutic decisions made by cardiologists were generally considered and continued by the general practitioners. CONCLUSIONS: Results from previous trials on sex/gender differences in ischemic heart disease have made their way into medical care. However, they also show potential for optimization in diagnosis, treatment and collaboration between resident cardiologists and general practitioners. Overall the results indicate that sex/gender differences in chronic CAD gain more medical attention. However, there is a current lack of concise sex-specific guidelines for prevention, diagnosis and treatment.


Assuntos
Cardiologistas , Doença da Artéria Coronariana , Isquemia Miocárdica , Padrões de Prática Médica , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Feminino , Humanos , Masculino , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/terapia , Fatores Sexuais , Inquéritos e Questionários
17.
Am J Med Sci ; 360(3): 229-235, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32653160

RESUMO

BACKGROUND: The outbreak of the coronavirus disease (COVID-19) has led to a major concern and caused a pandemic globally. The goal of this study was to clarify the clinical characteristics of recovery and death in patients with severe or critical COVID-19. MATERIALS AND METHODS: In this retrospective single-center study, clinical data were collected from 74 severe or critical COVID-19 patients in Wuhan Fourth Hospital between Jan. 25th and Feb. 26th, 2020. All patients were divided into a recovery group or a death group according to clinical outcomes, and the differences between the groups were compared. RESULTS: Of the 74 patients enrolled in the study, 48 (64.9%) were severe cases and 26 (35.1%) were critical cases. Sixty (81.1%) patients were recovered and 14 (18.9%) died. Compared with recovery patients, patients in the death group were older, and had higher incidences of hypertension, coronary disease and dyspnea at admission. Laboratory tests for lactate dehydrogenase, creatine kinase, myoglobin, brain natriuretic peptide and D-dimer indicated higher levels in the death group. The PaO2:FiO2 ratio and minimum SpO2 were lower in the death group, and a higher proportion of these patients received noninvasive mechanical ventilation, invasive mechanical ventilation and extracorporeal membrane oxygenation treatment. CONCLUSIONS: Elderly patients with comorbidities are at higher risk of severe COVID-19 or death. Patients with a low blood gas index and poor coagulation function at admission had a high mortality rate. For such patients, comprehensive treatment should be performed as soon as possible to improve the prognosis and reduce mortality.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Estado Terminal/epidemiologia , Estado Terminal/terapia , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Índice de Gravidade de Doença , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Infecções por Coronavirus/diagnóstico , Dispneia/diagnóstico , Dispneia/epidemiologia , Dispneia/terapia , Feminino , Hospitalização/tendências , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/terapia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Estudos Retrospectivos , Resultado do Tratamento
18.
J Interv Cardiol ; 2020: 4829647, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32508541

RESUMO

Background: The index of microcirculatory resistance is an invasive measure of coronary microvascular function that has to be calculated during maximal hyperemia, classically achieved with intravenous adenosine (IV). The aim of this study was to evaluate the use of intracoronary (IC) adenosine for the calculation of IMR. Methods and Results: 31 patients with stable coronary artery disease were included in the study. Coronary pressure and thermodilution measurements were obtained at rest and during maximal hyperemia using a pressure-temperature sensor-tipped coronary guidewire. Duplicate measurements were performed using first IC and then IV adenosine. Dispersion of transit times was comparable for IC and IV adenosine. IMR values based on IC vs IV adenosine showed a high level of agreement and an intraclass correlation coefficient of 0.90. Applying an upper normal limit of 25, misclassification of IMR using IC adenosine was seen in just one patient in whom IC adenosine resulted in a lower value. A simplified procedure based on a single bolus dose of saline did not change the level of agreement or the rate of misclassification. Conclusions: We found an excellent agreement between IMR values measured during hyperemia induced by IC as compared to IV adenosine. The use of IC adenosine may facilitate invasive assessment of microvascular function and is potentially time- and cost-saving with less patient discomfort as compared to IV infusion. The trail is registered with NCT03369184.


Assuntos
Adenosina/farmacologia , Doença da Artéria Coronariana , Circulação Coronária , Injeções Intra-Arteriais/métodos , Microcirculação , Resistência Vascular , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Hiperemia/induzido quimicamente , Hiperemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Vasodilatadores/farmacologia
19.
Postgrad Med ; 132(7): 624-628, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32594846

RESUMO

The prevalence of isolated diastolic hypertension (IDH) has been increased in hypertensive subjects with the new 2017 ACC/AHA blood pressure treatment guidelines to 6.5% from 1.3% by the JNC-7 guidelines. However, its clinical significance as a cause of adverse cardiovascular (CV) events especially in older subjects has been debated by several investigators, who have demonstrated no adverse CV effects of untreated IDH, but not by others. It is also more common in the young subjects who are at low CV risk and quite rare in the older subjects, who are at increased CV risk. Treatment of IDH in the older subjects could increase the CV complications due to a J-curve effect and, in addition, could increase the incidence of stroke from further lowering the normal systolic blood pressure (SBP). Very low SBP and DBP cannot be sustained by the cerebral blood flow autoregulation and could lead to cerebral ischemia. In order to get a better perspective of the current status of the treatment of IDH, a review of the English language literature of the available studies was conducted and 12 papers with pertinent information were retrieved. The analysis of results from these studies suggests that IDH is associated with adverse CV events in younger persons and it should be treated. In contrast, the prevalence of IDH is low in older subjects and is not associated with adverse CV events in the majority of cases. Thus, its further lowering should be avoided to prevent further decrease in normal SBP and prevent the onset of adverse CV events. However, the decision to treat IDH in older subjects should be individualized.


Assuntos
Doença da Artéria Coronariana/etiologia , Hipertensão/fisiopatologia , Sístole , Adulto , Fatores Etários , Idoso , Pressão Sanguínea , Determinação da Pressão Arterial , Doença da Artéria Coronariana/diagnóstico , Feminino , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco
20.
Nutr Metab Cardiovasc Dis ; 30(10): 1697-1705, 2020 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-32571615

RESUMO

BACKGROUND AND AIMS: Lipid goals have become more stringent in high risk patients. However, no studies have analyzed lipid control defined as the composite achievement of goals in low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (Non-HDL-C) and apolipoproteinB-100 (ApoB-100), in patients with premature coronary artery disease (CAD). We aimed to analyze lipid control rates, and the associated factors with its poor achievement in patients with premature CAD. METHODS AND RESULTS: The study included 1196 patients with CAD diagnosed before 55 and 65 years old in men and women, respectively. The American Heart Association/American College of Cardiology (non-strict) and the American Association of Clinical Endocrinologists (strict) criteria were used to analyze lipid control rates. Sociodemographic, dietary-healthy and clinical characteristics of the patients were collected. Participants were 54 ± 8 years old, 19.7% were women, and median CAD evolution was 2.4 years. Non-strict and strict lipid control was achieved in 23.0% and 8.9% of the patients, respectively. Moreover, 46.5% and 62.8% of the patients did not achieve any lipid goal using both criteria. Sociodemographic data were not different among patients who achieved or not lipid control. Treatment adherence<85%, prescription of low- and moderate-intensity statins, and obesity were consistently associated with poor lipid control. CONCLUSIONS: Lipid control is suboptimal in patients with premature CAD. Low lipid-lowering treatment adherence, low prescription of high-intensity statins, and obesity were independently associated with poor lipid control. Novel preventive programs and more aggressive pharmacological intervention should be implemented in order to reduce the burden of premature CAD.


Assuntos
Doença da Artéria Coronariana/prevenção & controle , Dislipidemias/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Lipídeos/sangue , Idade de Início , Idoso , Apolipoproteína B-100/sangue , Biomarcadores/sangue , LDL-Colesterol/sangue , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Estudos Transversais , Dislipidemias/sangue , Dislipidemias/diagnóstico , Dislipidemias/epidemiologia , Feminino , Humanos , Masculino , Adesão à Medicação , México/epidemiologia , Pessoa de Meia-Idade , Obesidade/epidemiologia , Padrões de Prática Médica , Prevalência , Medição de Risco , Fatores de Risco , Resultado do Tratamento
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