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1.
Indian Heart J ; 72(3): 192-193, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32768020

RESUMO

There has been a huge impact of the COVID-19 pandemic on global healthcare systems. Advisories across the world have appealed to people to stay at home and observe social distancing to slow down the pandemic. However it is important to realize as to how this is affecting acute cardiovascular care. Recent studies from Europe and USA have reported > 50% reduction in hospital admissions for ACS and declining rates of coronary interventions. The possible reasons for this noticeable reduction in patients with ACS/STEMI during the COVID-19 pandemic are multi-factorial. On one hand, it is due to change in thresholds for referring patients of ACS/STEMI for cardiac catheterization, with fibrinolysis being acceptable for many stable STEMI patients and conservative management being preferred for NSTEMI patients. Theories abound on how "staying at home" strategy may have led to an reduction in acute coronary events due to healthier lifestyle, better compliance and reduced stress. Realistically however, a more disquieting reason would be a "pseudo-reduction" ie. the incidence of ACS/STEMI is actually the same, but these patients are staying away from hospitals due to fear of contracting the infection. Lockdown restrictions have also limited transport options for patients seeking to reach hospitals in time. Healthcare systems need to be prepared for an anticipated downstream deluge of such untreated patients who may present with sequelae like heart failure, reinfarction, arrhythmias, mechanical complications etc. Scientific societies should have proactive campaigns to alleviate patient concerns, and encourage them to seek timely medical attention despite the COVID-19 pandemic.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Infecções por Coronavirus/epidemiologia , Hospitalização/estatística & dados numéricos , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Infecções por Coronavirus/prevenção & controle , Assistência à Saúde/organização & administração , Europa (Continente) , Feminino , Saúde Global , Humanos , Incidência , Controle de Infecções/métodos , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Medição de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Estados Unidos
2.
Arch Cardiovasc Dis ; 113(6-7): 443-447, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32636131

RESUMO

BACKGROUND: How coronavirus 2019 (COVID-19) is affecting management of myocardial infarction is a matter of concern, as medical resources have been massively reorientated and the population has been in lockdown since 17 March 2020 in France. AIMS: To describe how lockdown has affected the evolution of the weekly rate of myocardial infarctions (non-ST-segment and ST-segment elevation) hospital admissions in Lyon, the second largest city in France. To verify the trend observed, the same analysis was conducted for an identical time window during 2018-2019 and for an unavoidable emergency, i.e. birth. METHODS: Based on the national hospitalisation database [Programme de médicalisation des systèmes d'information (PMSI)], all patients admitted to the main public hospitals for a principal diagnosis of myocardial infarction or birth during the 2nd to the 14th week of 2020 were included. These were compared with the average number of patients admitted for the same diagnosis during the same time window in 2018 and 2019. RESULTS: Before lockdown, the number of admissions for myocardial infarction in 2020 differed from that in 2018-2019 by less than 10%; after the start of lockdown, it decreased by 31% compared to the corresponding time window in 2018-2019. Conversely, the numbers of births remained stable across years and before and after the start of lockdown. CONCLUSION: This study strongly suggests a decrease in the number of admissions for myocardial infarction during lockdown. Although we do not have a long follow-up to determine whether this trend will endure, this is an important warning for the medical community and health authorities.


Assuntos
Infecções por Coronavirus/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Admissão do Paciente/tendências , Pneumonia Viral/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Betacoronavirus/patogenicidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , França/epidemiologia , Humanos , Incidência , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Prognóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Fatores de Tempo , Virulência
3.
Medicine (Baltimore) ; 99(24): e20585, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541489

RESUMO

RATIONALE: De Winter et al first described a new ST-segment elevation myocardial infarction (STEMI)-equivalent pattern associated with acute occlusion of the left anterior descending coronary artery (LAD). Studies show that this pattern has a positive predictive value of 95.2% to 100%. However, some cases of non-STEMI, caused by acute right coronary artery or LAD diagonal branch occlusion, have been reported, which exhibit electrocardiogram (ECG) changes similar to the de Winter pattern. Few cases of de Winter ECG pattern caused by left circumflex artery (LCX) stenosis have been reported. PATIENT CONCERNS: A 57-year-old man was admitted to the emergency department 12 hours after suffering from oppressive chest pain and diaphoresis. The patient had a history of diabetes and smoking. An initial ECG showed atrial fibrillation, upsloping ST-segment depression at the J point, followed by peaked, positive T waves in leads V2 to V6 and slight ST-segment elevation in lead aVR, with poor R-wave progression. Coronary angiography showed tubular stenosis (up to 95%) of the proximal portion of the LCX. DIAGNOSIS: LCX stenosis led to a diagnosis of non-STEMI. INTERVENTIONS: Left coronary artery stenosis was successfully treated with angioplasty and insertion of a drug-eluting stent. OUTCOMES: The patient's chest pain resolved completely after stent implantation. No myocardial infarction occurred during the 6-month follow-up period. LESSONS: De Winter ECG pattern cannot be presumed to be associated with LAD stenosis and 18-lead ECG is required to support the identification of the "criminal" artery and to rule out posterior myocardial infarction.


Assuntos
Estenose Coronária/complicações , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Estenose Coronária/diagnóstico , Eletrocardiografia , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico
4.
PLoS One ; 15(6): e0233272, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32542011

RESUMO

BACKGROUND: There is limited evidence of non-ST elevation acute coronary syndrome (NSTE-ACS) in patients aged 80 or older in Vietnam. AIM: To describe the clinical characteristics of patients aged≥80 with NSTE-ACS in Vietnam, and to examine the effect of percutaneous coronary intervention (PCI) on adverse outcomes. METHODS: Consecutive patients aged ≥80 with a diagnosis of NSTE-ACS admitted to two tertiary hospitals in Vietnam from 12/2018 to 06/2019 were recruited. The major outcomes were: (1) the composite of all-cause mortality, recurrent myocardial infarction and stroke, (2) re-admission rate during 3 months. Cox proportional-hazards regressions were conducted to examine the impact of PCI on the study outcomes, with results presented as hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: There were 120 participants, mean age 84.8 ± 3.8, 50% were female. Angiography and PCI were performed in 42 participants (35.0%). Most of the participants had multimorbidity and multiple coronary vessel disease. Compared to participants who did not receive PCI, participants who received PCI had significantly lower rates of adverse events during hospitalisation and during 3 months of follow up. Cox proportional hazards models adjusted to age and GRACE score show that PCI was significantly associated with reduced the composite outcome of all-cause mortality, recurrent myocardial infarction and stroke during 3 months follow-up (adjusted HR 0.32, 95%CI 0.12-0.86). PCI was also associated with reduced re-admission. CONCLUSIONS: The rate of PCI was low in the very elderly patients with NSTE-ACS in this study, although PCI was significantly associated with reduced adverse outcomes.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Intervenção Coronária Percutânea/efeitos adversos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Idoso de 80 Anos ou mais , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Intervenção Coronária Percutânea/métodos , Modelos de Riscos Proporcionais , Acidente Vascular Cerebral/complicações , Resultado do Tratamento , Vietnã/epidemiologia
5.
Tunis Med ; 98(1): 70-79, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32395780

RESUMO

BACKGROUND: Strain has shown a promising diagnostic and prognostic value in acute coronary syndromes. With, however, less data in non-ST elevation myocardial infarction (NSEMI). AIM: to evaluate in NSTEMI patients, the ability of strain to predict the severity of the disease, by assessing correlations to established prognostic parameters, and to predict culprit and occluded coronary arteries (CA). Secondary, to determine factors associated to strain changes during follow-up. METHODS: The study was prospective, NSTEMI patients with significant coronary lesion and without significant non-ischaemic disease were included. Angiographic and echocardiographic investigation including global (GLS) and territorial (TLS) longitudinal strain were performed within 24h from admission. Syntax I score was calculated. Severe coronary artery disease (CAD) was defined by left main of three-vessel disease. RESULTS: Seventy NSTEMI patients aged 60.2±10.1 years were enrolled; 61% were smokers, 54% diabetics and 46% hypertensive. 34% had a severe CAD, 7% had an acute coronary occlusion (ACO) and 14% a chronic coronary total occlusion (CTO). GLS >-15.3% predicted a left ventricular ejection fraction (LVEF) <50% with 80% Sensitivity (Se) and 78% Specificity (Sp). GLS was associated to CAD complexity and severity. GLS > -14.1% detected severe CAD with 83% Se and 80%Sp. TLS determined the culprit artery in 74% of cases and TLS > -9.2% predicted ACO with 85% Se and 85% Sp. TLS was also associated to CTO. At a 10 months median follow-up [3-12months], GLS significantly improved, baseline LVEF, GLS, wall motion score index and revascularization were the predictors of this improvement. CONCLUSION: In NSTEMI patients, GLS detected severe CAD and poor myocardial function. TLS predicted the culprit vessel and its occlusion. GLS improvement at midterm was predicted by baseline systolic LV function parameters and myocardial revascularization.


Assuntos
Técnicas de Diagnóstico Cardiovascular , Eletrocardiografia/métodos , Teste de Esforço , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Idoso , Angiografia Coronária , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/patologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia
6.
Angiology ; 71(9): 799-803, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32462903

RESUMO

The purpose of this study is to investigate the relation between residual SYNTAX score (rSS) and contrast-induced nephropathy (CIN) development in patients with non-ST segment elevation myocardial infarction (NSTEMI) with normal or near-to-normal left ventricular ejection fraction (LVEF) who underwent percutaneous coronary intervention (PCI). A total of 306 patients who underwent PCI with NSTEMI were included in our study. SYNTAX scores were calculated for the periods before and after PCI. Patients were divided into 2 groups as developed CIN following PCI (CIN +) and patients did not (CIN -). Fifty-four (17.6%) of patients who were included in the study developed CIN. Age (P = .001) and rSS (P = .002) were significantly higher and LVEF was lower (P = .034) in the CIN (+) group. Age (P = .031, odds ratio [OR]: 1.031, 95% CI, 1.003-1.059) and rSS (P = .04, OR: 1.036, 95% CI, 1.002-1.071) were independent predictors for CIN. In receiver operating characteristic analyses, when the cutoff value of rSS was taken as 3.5, it determined CIN with 79% sensitivity and 65% specificity. Contrast-induced nephropathy may develop more frequently in patients with increased rSS value. The rSS may be useful to follow-up these patients for CIN development.


Assuntos
Meios de Contraste/efeitos adversos , Nefropatias/induzido quimicamente , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Razão de Chances , Intervenção Coronária Percutânea , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Volume Sistólico
7.
Medicine (Baltimore) ; 99(19): e20133, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384494

RESUMO

RATIONALE: The De Winter ST/T-wave complex is a rare and special electrocardiogram (ECG) manifestation in some patients with a total or subtotal occlusion in the proximal left anterior descending (LAD) coronary artery. It mainly appears as an ST-segment superior oblique depression instead of an ST elevation. However, a transitory change of the De Winter ST/T-wave complex has not been reported previously. PATIENT CONCERNS: A 40-year-old man developed sudden precordial dull and unrelieved pain. One hour later, he suddenly lost consciousness when he arrived at the emergency department. After successful cardiopulmonary resuscitation (CPR), 2 ECGs were taken at 22-minute interval, which showed completely different manifestations. The first ECG showed acute inferior-wall ST elevation myocardial infarction (STEMI), while the second ECG showed a De Winter ST/T-wave complex, which indicated acute anterior-wall myocardial infarction. DIAGNOSIS: The patient was diagnosed with acute myocardial infarction. INTERVENTIONS: The patient responded to urgent treatment by percutaneous coronary intervention (PCI). OUTCOMES: It was confirmed that the case was consistent with the main characteristics of a De Winter ST/T-wave complex after PCI. The first ECG was a rare transitory change of the De Winter ST/T-wave complex. The patient was well recovered and discharged. LESSONS: The De Winter ST/T-wave complex is an extremely dangerous and rare ECG manifestation that is not widely recognized at present. Although the mechanism is not very clear, it should be considered as indicating an equivalent risk of STEMI because it may suggest total or subtotal occlusion in the proximal LAD coronary artery. It is believed that in the near future, the mechanism of ECG including its transitory changes, will be fully revealed.


Assuntos
Eletrocardiografia/métodos , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/patologia , Adulto , Reanimação Cardiopulmonar/métodos , Humanos , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea/métodos
8.
Cardiovasc Ther ; 2020: 6760205, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32411301

RESUMO

Aim: The marked variation in bifurcation anatomy has brought about an ongoing search for stents specifically constructed for coronary bifurcations. This study aimed to analyze the angiographic restenosis prevalence and patterns and predictors of different patterns in dedicated bifurcation BiOSS® vs. current generation drug-eluting stents implanted in coronary bifurcation lesions based on data from two clinical trials POLBOS I and II. Methods: Dedicated bifurcation BiOSS® stents were compared with drug-eluting stents (DES) in patients with stable coronary artery disease (CAD) or nonST elevation acute coronary syndrome (NSTE-ACS) (POLBOS I: paclitaxel eluting BiOSS® Expert vs. DES; POLBOS II: sirolimus eluting BiOSS® LIM vs. DES). Provisional T-stenting was the default treatment. Morphological pattern of in-stent restenosis according to the modified Mehran classification adopted for bifurcation lesions was assessed with bifurcation dedicated quantitative coronary angiographic software (CAAS 5.11, Pie Medical Imaging BV, the Netherlands). Results: In total, 445 patients (222 patients in BiOSS group and 223 patients in DES group) were included into the analysis. In BiOSS group 24 cases of angiographic restenosis (10.8%) were recorded, and in DES group-17 cases (7.6%) at 12 months follow-up (angiographic control rate at follow-up-90.3%). In the BiOSS group most frequent medina classification in restenotic cases was 0.0.1 (25%), whereas in DES-0.0.1 and 0.1.1 (23.5% each). In multivariate regression analysis proximal optimization technique was associated with the lowest chance for restenosis (OR 0.15, 95% CI 0.06-0.33), whereas diabetes on insulin was associated with the highest risk of restenosis (OR 4.21, 95% CI 1.48-11.44). Conclusions: The angiographic restenosis pattern and rate was similar between BiOSS stents and DES in coronary bifurcation lesions.


Assuntos
Síndrome Coronariana Aguda/terapia , Angiografia Coronária , Doença da Artéria Coronariana/terapia , Reestenose Coronária/diagnóstico por imagem , Stents Farmacológicos , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea/instrumentação , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/epidemiologia , Idoso , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Reestenose Coronária/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Intervenção Coronária Percutânea/efeitos adversos , Polônia/epidemiologia , Valor Preditivo dos Testes , Prevalência , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Resultado do Tratamento
9.
Angiology ; 71(9): 793-798, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32347104

RESUMO

The main aim of this study was to investigate the relation between anterior tragal crease (ATC) and coronary artery lesion complexity and severity assessed using the SYNTAX score (SXscore) in patients with non-ST-segment elevation myocardial infarction (NSTEMI). A total of 121 patients with a first-time diagnosis of NSTEMI were consecutively enrolled. ATC was defined as ≥1 crease that was close to the tragus and descended anteriorly. SXscore was calculated using the SXscore algorithm. The SXscore was higher in the ATC-positive group than in the ATC-negative group (11.85 ± 8.20 vs 7.52 ± 6.38, P = .003). In the univariate analysis, hemoglobin (male: 11.7-17.4 g/dL, female: 11.7-16.1 g/dL; P = .006), diabetes mellitus (P = .031), current smoking (P = .022), and presence of ATC (P = .022) were significantly associated with increased SXscore. Multivariate analysis revealed ATC (95% confidence interval [CI]: 1.313-7.800, P = .011), current smoking (95% CI: 2.034-13.893, P = .001), and hemoglobin (95% CI: 0.433-0.822, P = .002) as independent determinants of increased SXscore. Anterior tragal crease is easily detected by physical examination. Presence of ATC in patients with NSTEMI may be a warning signal of complexity and severity of coronary artery disease (CAD).


Assuntos
Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Pavilhão Auricular , Pescoço , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Envelhecimento da Pele , Idoso , Algoritmos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Exame Físico , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença
10.
Med. intensiva (Madr., Ed. impr.) ; 44(2): 88-95, mar. 2020. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-188657

RESUMO

Objetivo: Los objetivos del estudio son evaluar el rendimiento diagnóstico de la troponina cardiaca T de alta sensibilidad (TnTc-hs) en pacientes con sospecha de síndrome coronario agudo sin elevación del segmento ST (SCASEST), confirmar si permite acortar el tiempo hasta el diagnóstico y analizar las consecuencias clínicas derivadas de su utilización. Método: Se trata de un estudio observacional, longitudinal y prospectivo, realizado en 5 servicios de urgencias hospitalarias. Se incluyó de forma consecutiva a los pacientes que acudían por dolor torácico sospechoso de SCASEST. El manejo del paciente y el tratamiento aplicado siguieron los protocolos internos basados en las guías de consenso de la Sociedad Europea de Cardiología. Se realizaron determinaciones seriadas de Tnc convencional (4ªG) y de TnTc-hs. Resultados: Se incluyó en el estudio a 351 pacientes. El diagnóstico final de infarto agudo de miocardio (IAM) se estableció en 77 pacientes del total, angina inestable en 102 y 172 fueron pacientes diagnosticados como sin síndrome coronario agudo. Los valores de TnTc-hs estaban por encima del p99 en un alto número de pacientes sin IAM. En la determinación inicial del paciente, la sensibilidad diagnóstica de la TnTc-hs fue significativamente superior a la de la TnTc 4ªG (87,0 vs. 42,9%), lo que comportó un valor predictivo negativo del 95,1%. Conclusiones: La TnTc-hs mejora el rendimiento diagnóstico al compararla con el ensayo de Tnc convencional, acorta el tiempo hasta el diagnóstico y reconoce mayor número de pacientes con IAM más pequeños


Objective: To assess the diagnostic performance of high-sensitivity troponin T (hs-TnT) in patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS); confirm whether it shortens the time to diagnosis; and analyze the clinical consequences derived from its use. Method: A prospective, longitudinal observational study was carried out in 5 emergency care departments. Patients seen for chest pain with suspected of NSTE-ACS were consecutively included. Patient care followed the internal protocols of the center, based on the consensus guidelines of the European Society of Cardiology. Serial conventional cardiac troponin (cTn) and hs-TnT determinations were made. Results: A total of 351 patients were included in the study. A final diagnosis of acute myocardial infarction (AMI) was established in 77 patients, with unstable angina in 102, and no acute coronary syndrome in 172 patients. The hs-TnT values were above percentile 99% in a large number of patients without AMI. In the initial determination, the diagnostic sensitivity of the hs-TnT was significantly greater than that of cTn (87.0% vs. 42.9%), which led to a negative predictive value of 95.1%. Conclusions: High-sensitivity troponin T improves diagnostic performance compared with conventional troponin assay, shortens the time to diagnosis, and identifies a larger number of patients with smaller myocardial infarctions


Assuntos
Humanos , Masculino , Idoso , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Troponina T/sangue , Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/etiologia , Valor Preditivo dos Testes , Biomarcadores/sangue , Estudos Longitudinais , Estudos Prospectivos , Serviços Médicos de Emergência , Sociedades Médicas/normas , Angina Instável/diagnóstico , Fatores de Risco
11.
Open Heart ; 7(1): e001163, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32206316

RESUMO

Objectives: The primary objective was to examine the association between hyperlipidaemia (HLP) and 5-year survival after incident acute myocardial infarction (AMI). The secondary objectives were to assess the effect of HLP on survival to discharge across patient subgroups, and the impact of statin prescription, intensity and long-term statin adherence on 5-year survival. Methods: Retrospective cohort study of 7071 patients hospitalised for AMI at Mayo Clinic from 2001 through 2011. Of these, 2091 patients with HLP (age (mean±SD) 69.7±13.5) were propensity score matched to 2091 patients without HLP (age 70.6±14.2). Results: In matched patients, HLP was associated with higher rate of survival to discharge than no HLP (95% vs 91%; log-rank <0.0001). At year 5, the adjusted HR for all-cause mortality in patients with HLP versus no HLP was 0.66 (95% CI 0.58-0.74), and patients with prescription statin versus no statin was 0.24 (95% CI 0.21 to 0.28). The mean survival was 0.35 year greater in patients with HLP than in those with no HLP (95% CI 0.25 to 0.46). Patients with HLP gained on an average 0.17 life year and those treated with statin 0.67 life year at 5 years after AMI. The benefit of concurrent HLP was consistent across study subgroups. Conclusions: In patients with AMI, concomitant HLP was associated with increased survival and a net gain in life years, independent of survival benefit from statin therapy. The results also reaffirm the role of statin prescription, intensity and adherence in reducing the mortality after incident AMI.


Assuntos
Hospitalização , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hiperlipidemias/tratamento farmacológico , Lipídeos/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Hiperlipidemias/sangue , Hiperlipidemias/diagnóstico , Hiperlipidemias/mortalidade , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Prognóstico , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo
12.
J Interv Cardiol ; 2020: 8513257, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32206045

RESUMO

Objective: To obtain a real-world perspective of the optimal timing of angiography performed within 24 hours of admission with non-ST elevation myocardial infarction (NSTEMI). Background: Current guidelines recommend angiography within 24 hours of hospitalisation with NSTEMI. The recent VERDICT trial found that angiography within 12 hours of admission with NSTEMI was associated with improved cardiovascular outcomes among high-risk patients. We compared the outcomes of real-world NSTEMI patients undergoing angiography within 12 hours of admission with those of patients undergoing angiography 12 to 24 hours after admission. Methods: NSTEMI patients without life-threatening features who received angiography within 24 hours of admission were obtained from the SPUM-ACS registry, a cohort of consecutive patients admitted with acute coronary syndromes to four university hospitals in Switzerland. Cox models assessed for an association between door-to-catheter time and one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, and stroke). Results: Of 2672 NSTEMI patients, 1832 met the inclusion criteria. Among them, 1464 patients underwent angiography within 12 hours (12 h group) compared with 368 patients between 12 and 24 hours (12-24 h group). Multiple logistic regression identified out-of-hours admission as the only factor associated with delayed angiography. After 2 : 1 propensity score matching, 736 patients from the 12 h group and 368 patients from the 12-24 h group demonstrated no significant difference in rates of one-year MACE (7.7% vs. 7.3%, HR: 1.050, 95% CI 0.637-1.733, p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (. Conclusions: In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of admission was not associated with improved one-year cardiovascular outcomes when compared with angiography 12 and 24 hours after admission, even among high-risk patients.


Assuntos
Cateterismo Cardíaco , Angiografia Coronária , Infarto do Miocárdio sem Supradesnível do Segmento ST , Tempo para o Tratamento/normas , Idoso , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/estatística & dados numéricos , Angiografia Coronária/métodos , Angiografia Coronária/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/complicações , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde , Modelos de Riscos Proporcionais , Risco Ajustado/métodos , Suíça/epidemiologia
13.
Open Heart ; 7(1): e001197, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32201588

RESUMO

Objective: A score to distinguish Takotsubo syndrome (TS) from acute coronary syndrome would be useful to facilitate appropriate patient investigation and management. This study sought to derive and validate a simple score using demographic, clinical and ECG data to distinguish women with non-ST elevation myocardial infarction (NSTEMI) from NSTE-TS. Methods: The derivation cohort consisted of women with NSTE-TS (n=100) and NSTEMI (n=100). Logistic regression was used to derive the score using ECG values available on the postacute ward round on day 1 post-hospital admission. The score was then temporally validated in subsequent consecutive patients with NSTE-TS (n=40) and NSTEMI (n=70). Results: The five variables in the score and their relative weights were: T-wave inversion in ≥6 leads (+3), recent stress (+2), diabetes (-1), prior cardiovascular disease (-2) and ST-depression in any lead (-3). When calculated using ECG values obtained at admission, discrimination between conditions was very good (area under the curve (AUC) 0.87 95% CI 0.83 to 0.92). The optimal score cut-point of ≥1 to predict NSTE-TS had 73% sensitivity and 90% specificity. When applied to the validation cohort at admission, AUC was 0.82 (95% CI 0.75 to 0.90) and positive and negative predictive values were 78% and 81%, respectively. On day 1 post-admission, AUC was 0.92 (95% CI 0.87 to 0.97), with positive and negative predictive values of 77% and 91%, respectively. Conclusion: This NSTE-TS score is easy to use and may prove useful in clinical practice to distinguish women with NSTE-TS from NSTEMI. Further validation in external cohorts is needed.


Assuntos
Técnicas de Apoio para a Decisão , Eletrocardiografia , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Testes Imediatos , Cardiomiopatia de Takotsubo/diagnóstico , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Pessoa de Meia-Idade , Nova Zelândia , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Admissão do Paciente , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco , Fatores Sexuais , Cardiomiopatia de Takotsubo/etiologia , Cardiomiopatia de Takotsubo/fisiopatologia , Fatores de Tempo
14.
Circ Cardiovasc Qual Outcomes ; 13(2): e006363, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32063040

RESUMO

BACKGROUND: In patients presenting with ST-segment-elevation myocardial infarction, percutaneous coronary intervention (PCI) reduces mortality when compared with fibrinolysis. In other forms of coronary artery disease (CAD), however, it has been controversial whether PCI reduces mortality. In this meta-analysis, we examine the benefits of PCI in (1) patients post-myocardial infarction (MI) who did not receive immediate revascularization; (2) patients who have undergone primary PCI for ST-segment-elevation myocardial infarction but have residual coronary lesions; (3) patients who have suffered a non-ST-segment-elevation acute coronary syndrome; and (4) patients with truly stable CAD with no recent infarct. This analysis includes data from the recently presented International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) and Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) trials. METHODS AND RESULTS: We systematically identified all randomized trials of PCI on a background of medical therapy for the treatment of CAD. The ISCHEMIA trial, presented in November 2019, was eligible for inclusion. Data were combined using a random-effects meta-analysis. The primary end point was all-cause mortality. Forty-six trials, including 37 757 patients, were eligible. In the 3 unstable scenarios, PCI had the following effects on mortality: unrevascularized post-MI relative risk (RR) 0.68 (95% CI, 0.45-1.03); P=0.07; multivessel disease following ST-segment-elevation myocardial infarction (RR, 0.84 [95% CI, 0.69-1.04]; P=0.11); non-ST-segment-elevation acute coronary syndrome (RR, 0.84 [95% CI, 0.72-0.97]; P=0.02). Overall, in these unstable scenarios PCI was associated with a significant reduction in mortality (RR, 0.84 [95% CI, 0.75-0.93]; P=0.02). In unstable CAD, PCI also reduced cardiac death (RR, 0.69 [95% CI, 0.53-0.90]; P=0.007) and MI (RR, 0.74 [95% CI, 0.62-0.90]; P=0.002). For stable CAD, PCI did not reduce mortality (RR, 0.98 [95% CI, 0.87-1.11]), cardiac death (RR, 0.89 [95% CI, 0.71-1.12]; P=0.33), or MI (RR, 0.96 [95% CI, 0.86-1.08]; P=0.54). CONCLUSIONS: PCI prevents death, cardiac death, and MI in patients with unstable CAD. For patients with stable CAD, PCI shows no evidence of an effect on any of these outcomes.


Assuntos
Síndrome Coronariana Aguda/terapia , Doença da Artéria Coronariana/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Tomada de Decisão Clínica , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
15.
PLoS One ; 15(2): e0229491, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32106261

RESUMO

BACKGROUND: Patients 65 years old and older largely represent (>50%) hospital-admitted patients with acute coronary syndrome (ACS). Data are conflicting comparing efficacy of early routine invasive (within 48-72 hours of initial evaluation) versus conservative management of ACS in this population. OBJECTIVE: We aimed to determine the effectiveness of routine early invasive strategy compared to conservative treatment in reducing major adverse cardiovascular events in patients 65 years old and older with non-ST elevation (NSTE) ACS. DATA SOURCES: We conducted a systematic review of randomized controlled trials (RCTs) through PubMed, Cochrane, and Google Scholar database. STUDY SELECTION: The studies included were RCTs that evaluated the effectiveness of invasive strategy compared to conservative treatment among patients ≥ 65 years old diagnosed with NSTEACS. Studies were included if they assessed any of the following outcomes of death, cardiovascular mortality, myocardial infarction (MI), stroke, recurrent angina, and need for revascularization. Six articles were subsequently included in the meta-analysis. DATA EXTRACTION: Three independent reviewers extracted the data of interest from the articles using a standardized data collection form that included study quality indicators. Disparity in assessment was adjudicated by another reviewer. DATA SYNTHESIS: All pooled analyses were initially done using Fixed Effects model. For pooled analyses with significant heterogeneity (I2≥ 50%), the Random Effects model was used. A total of 3,768 patients were included, 1,986 in the invasive strategy group, and 1,782 in the conservative treatment group. RESULTS: Meta-analysis showed less incidence of revascularization in the invasive (2%) over conservative treatment groups (8%), with overall risk ratio of 0.29 (95% CI 0.14 to 0.59). Across all pooled studies, no significant effect of invasive strategy on all-cause mortality, cardiovascular mortality, stroke, and MI was observed. Only one study assessed the outcome of recurrent angina. CONCLUSION: There was a significantly lower rate of revascularization in the invasive strategy group compared to the conservative treatment group. In the reduction of all-cause mortality, cardiovascular mortality, MI, and stroke there was no significant effect of invasive strategy versus conservative treatment. This finding does not support the bias against early routine invasive intervention in patients ≥ 65 years old with NSTEACS. Further studies focusing on these patients with larger population sizes are still needed.


Assuntos
Síndrome Coronariana Aguda/terapia , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Tratamento Conservador , Ponte de Artéria Coronária , Feminino , Humanos , Masculino , Revascularização Miocárdica , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea , Ensaios Clínicos Controlados Aleatórios como Assunto
16.
Rev. esp. cardiol. (Ed. impr.) ; 73(1): 35-42, ene. 2020. ilus, graf
Artigo em Espanhol | IBECS | ID: ibc-ET5-797

RESUMO

INTRODUCCIÓN Y OBJETIVOS: El objetivo de este estudio es analizar la asociación de la coronariografía precoz con la mortalidad por cualquier causa y la mortalidad cardiovascular en los pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) utilizando una gran cohorte contemporánea de pacientes con SCASEST de 2 hospitales terciarios españoles. MÉTODOS: Este estudio observacional retrospectivo incluyó a 5.673 pacientes con SCASEST consecutivos de 2 hospitales españoles entre los años 2005 y 2016. Se emparejó por puntuación de propensión para obtener un subconjunto bien equilibrado de pacientes con la misma probabilidad de una coronariografía temprana, lo que dio como resultado 3.780 pacientes. RESULTADOS: Entre los participantes del estudio, se realizó una coronariografía precoz a solo 2.087 pacientes (40,9%). La mediana de seguimiento fue de 59,0 [intervalo intercuartílico, 25,0-80,0] meses. La mortalidad por cualquier causa fue del 19,0%; la mortalidad cardiovascular, del 12,8%, y el 51,1% de los pacientes sufrieron al menos 1 evento cardiovascular mayor (mortalidad, infarto agudo de miocardio, hospitalización por insuficiencia cardiaca o revascularización no planeada) en el seguimiento. Después de emparejar por puntuación de propensión, la revascularización temprana se asoció con una mortalidad significativamente menor (HR=0,79; IC95%, 0,62-0,98), en los pacientes con SCASEST de alto riesgo. La coronariografía precoz mostró una tendencia inversa no significativa en los pacientes con puntuación GRACE <140. CONCLUSIONES: En los pacientes con SCASEST de alto riesgo (puntuación GRACE ≥ 140) de un registro contemporáneo de la práctica clínica, la coronariografía temprana (las primeras 24 h tras el ingreso hospitalario) puede estar asociada con una reducción de la mortalidad por cualquier causa y la mortalidad cardiovascular en el seguimiento a largo plazo


INTRODUCTION AND OBJECTIVES: This study sought to analyze the association of early coronary angiography with all-cause mortality and cardiovascular mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) using a large contemporary cohort of patients with NSTEACS from 2 Spanish tertiary hospitals. METHODS: This retrospective observational study included 5673 consecutive NSTEACS patients from 2 Spanish hospitals between 2005 and 2016. We performed propensity score matching to obtain a well-balanced subset of patients with the same probability of undergoing an early strategy, resulting in 3780 patients. Survival analyses were performed by Cox regression models once proportional risk test were verified. RESULTS: Among the study participants, only 2087 patients (40.9%) underwent early invasive coronary angiography. The median follow-up was 59.0 months [interquartile range, 25.0-80.0 months]. All-cause mortality was 19.0%, cardiovascular mortality was 12.8%, and 51.1% patients experienced at least 1 major cardiovascular adverse event in the follow-up. After propensity score matching, the early strategy was associated with significantly lower mortality (hazard ratio: 0.79; 95% confidence interval 0.62-0.98) in high-risk NSTEACS patients. The early strategy showed a nonsignificant inverse tendency in patients with GRACE score <140. CONCLUSIONS: In high-risk (GRACE score ≥ 140) NSTEACS patients in a contemporary real-world registry, early coronary angiography (first 24 hours after hospital admission) may be associated with reduced all- cause mortality and cardiovascular mortality at long-term follow-up


Assuntos
Humanos , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Intervenção Coronária Percutânea/métodos , Pontuação de Propensão , Registros , Causas de Morte/tendências , Angiografia Coronária , Eletrocardiografia , Seguimentos , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Prognóstico , Fatores de Risco , Espanha/epidemiologia , Taxa de Sobrevida/tendências , Fatores de Tempo
17.
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
18.
Am J Med ; 133(8): 976-985, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31987803

RESUMO

BACKGROUND: Compared with troponin T/I test, the introduction of a high-sensitive (hs) troponin test may result in a higher proportion of positive test results in patients with chest pain and over-testing in patients without acute coronary syndrome. We assessed the impact of the introduction of the hs-troponin assay on the discharge diagnoses and the number of diagnostic tests in patients presenting with chest pain in a real-life setting in an emergency department. METHODS: Retrospective chart review of patients presenting with chest pain to one of the largest hospitals in Switzerland. We compared the standard troponin period (December 2009 to November 2010) with the hs-troponin period (December 2010 to December 2011). RESULTS: Data from 1274 patients (standard 597 [46.9%], hs-troponin 677 [53.1%]) were analyzed. The proportion of patients with non-ST-segment elevation myocardial infarction increased (hs-troponin 14.9%, compared with 9.7%); the proportion in unstable angina (1.5% to 4.0%) and other cardiac illnesses (8.1% to 11.7%) decreased. Although the proportion of noncardiac chest pain illnesses (67%) remained unchanged, the proportion of positive hs-troponin was higher (6.1% vs 2.0%). The average number of additional tests/person decreased in troponin-positive patients (2.0 to 1.7 test per patient; P = .02) and troponin-negative patients (3.1 to 2.8 tests; P < .0001). CONCLUSION: Although the introduction of the hs-troponin test resulted in a higher proportion of positive hs-troponin tests in patients with noncardiac chest pain, the average number of diagnostic tests decreased in patients with chest pain presenting to an emergency department, indicating an increased confidence of clinicians in their diagnosis.


Assuntos
Síndrome Coronariana Aguda/sangue , Angina Instável/sangue , Análise Química do Sangue/métodos , Dor no Peito/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Troponina T/sangue , Síndrome Coronariana Aguda/diagnóstico , Adulto , Idoso , Angina Instável/diagnóstico , Dor no Peito/etiologia , Angiografia Coronária/estatística & dados numéricos , Ecocardiografia/estatística & dados numéricos , Serviço Hospitalar de Emergência , Teste de Esforço/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão do Miocárdio/estatística & dados numéricos , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Estudos Retrospectivos , Suíça , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Ultrassonografia/estatística & dados numéricos
19.
PLoS One ; 15(1): e0226892, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31923216

RESUMO

BACKGROUND: Serial conventional cardiac troponin (cTn) measurements 6-9 hours apart are recommended for non-ST-elevation MI (NSTEMI) diagnosis. We sought to develop a pathway with 3-hour changes for major adverse cardiac event (MACE) identification and assess the added value of the HEART [History, Electrocardiogram (ECG), Age, Risk factors, Troponin] score to the pathway. METHODS: We prospectively enrolled adults with NSTEMI symptoms at two-large emergency departments (EDs) over 32-months. Patients with STEMI, unstable angina and one cTn were excluded. We collected baseline characteristics, Siemens Vista conventional cTnI at 0, 3 or 6-hours after ED presentation; HEART score predictors; disposition and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (acute MI, revascularization, or death due to cardiac ischemia/unknown cause). We analyzed multiples of 99th percentile cut-off cTnI values (45, 100 and 250ng/L). RESULTS: 1,683 patients (mean age 64.7 years; 55.3% female; median LOS 7-hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI≤45 ng/L; and 155 (9.2%) of the 213 patients with one value≥100ng/L but both<250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one of the two values>45ng/L but<100ng/L based on 3 or 6-hour cTnI, one patient with absolute change<10ng/L and 6 of the 19 patients with≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95% CI 93.8-100%) and 94.6% specificity (95% CI 93.3-95.6%). Addition of the HEART score improved the sensitivity to 100% (95% CI 95.9-100%) and decreased the specificity to 26.5% (95% CI 24.3-28.7%). CONCLUSION: The OTP with conventional cTnI 3-hours apart, should lead to better NSTEMI identification particularly those with values >99th percentile, standardize management and reduce the ED LOS.


Assuntos
Miocárdio/metabolismo , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/metabolismo , Troponina I/metabolismo , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico
20.
Hosp Pract (1995) ; 48(1): 1-11, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31815570

RESUMO

Non-ST-segment elevation myocardial infarction (NSTEMI) is defined as elevated cardiac biomarkers of necrosis in the absence of persistent ST-segment elevation in the setting of anginal symptoms or other acute event. It carries a poorer prognosis than most ST-segment elevation events, owing to the typical comorbidity burden of the older NSTEMI patients as well as diverse etiologies that add complexity to therapeutic decision-making. It may result from an acute atherothrombotic event ('Type 1') or as the result of other causes of mismatch of myocardial oxygen supply and demand ('Type 2'). Regardless of type and other clinical factors, the hospital medicine specialist is increasingly responsible for managing or coordinating the care of these patients. Following published guidelines for risk stratification and basing anti-anginal, anticoagulant, antiplatelet, other pharmacologic therapies, and overall management approach on that individualized patient risk assessment can be expected to result in better short- and long-term clinical outcomes, including near-term readmission and recurrent events. We present here a review of the evidence basis and expert commentary to assist the hospitalist in achieving those improved outcomes in NSTEMI. Given that the Society for Hospital Medicine cites care of patients with acute coronary syndrome as a core competency for hospitalists, it is essential that those specialists stay current on optimal NSTEMI care.Abbreviations: ACC: American college of cardiology; ACCOAST: comparison of prasugrel at the time of diagnosis in patients with non-ST elevation myocardial infarction; ACS: acute coronary syndrome; ADP: adenosine diphosphate; AHA: American heart association; ARB: angiotensin II receptor blocker; ASA: acetylsalicylic acid; CABG: coronary artery bypass graft: CAD: coronary artery disease; CCTA: coronary computed tomography angiography; cTn: cardiac troponin; CRUSADE: can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines; CURE: clopidogrel in unstable angina to prevent recurrent events; CURRENT: OASIS-7 clopidogrel and aspirin optimal dose usage to reduce recurrent events-seventh organization to assess strategies in ischemic syndromes; ECG: electrocardiogram; ED: emergency department; ESRD: endstage renal disease; ESC: European society of cardiology; FDA: food and drug administration; GRACE: global registry of acute coronary events; LVEF: left ventricular ejection fraction; MACE: major adverse cardiac event; MI: myocardial infarction; MVO2: myocardial oxygen demand; NSTEMI: non-ST-segment-elevation myocardial infarction; NTG: Nitroglycerin; PCI: percutaneous coronary intervention; plato: platelet inhibition and patient outcomes; PPI: proton pump inhibitor; PURSUIT: platelet glycoprotein IIb/IIIa in unstable angina: Receptor Suppression Using Integrilin Therapy; RAAS: Renin-Angiotensin-Aldosterone System; SHM: society of hospital medicine; STEMI: ST-segment-elevation myocardial infarction; TIMI: Thrombolysis in Myocardial Infarction; TRITON-TIMI:trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-thrombolysis in myocardial infarction.


Assuntos
Médicos Hospitalares , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Fatores Etários , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/complicações , Comorbidade , Angiografia Coronária/métodos , Diagnóstico Diferencial , Eletrocardiografia , Fibrinolíticos/uso terapêutico , Hemodinâmica , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Testes de Função Renal , Adesão à Medicação , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Oximetria , Oxigenoterapia/métodos , Equipe de Assistência ao Paciente/organização & administração , Guias de Prática Clínica como Assunto , Medição de Risco , Fatores Sexuais , Troponina/sangue
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