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Goyal A, Shoaib A, Khan MT, Salim N, Ajaz I, Fareed A, Sulaiman SA, Sheikh AB, AlJaroudi W. Invasive Versus Conservative Strategies in Older Adults With Non-ST Elevation Acute Coronary Syndrome: An Updated Meta-Analysis of Randomized Controlled Trials. Catheter Cardiovasc Interv 2025. [PMID: 40231483 DOI: 10.1002/ccd.31533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2024] [Revised: 03/10/2025] [Accepted: 03/28/2025] [Indexed: 04/16/2025]
Abstract
Non-ST-elevation acute coronary syndrome (NSTE-ACS) is a common condition among older adults. However, due to frailty and comorbidities, older adults are often underrepresented in clinical trials, making the decision between an invasive or conservative approach for optimal management controversial. Our meta-analysis seeks to address this issue by focusing exclusively on randomized controlled trials (RCTs). A systematic database literature search was conducted via PubMed, the Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov to identify RCTs comparing invasive and conservative management strategies in older adults with NSTE-ACS. Data on unplanned revascularization, myocardial infarction (MI), bleeding, all-cause mortality, composite of major adverse outcomes, and stroke were extracted and pooled. Random-effects models to calculate pooled risk ratios (RR) with 95% confidence intervals (CI) were analyzed using the Review Manager software. A total of seven RCTs and a total of 2997 patients were included in the meta-analysis. The invasive approach demonstrated a lower risk of unplanned revascularization (RR: 0.36; 95% CI: 0.23, 0.55; p < 0.00001; I² = 28%) and MI (RR: 0.72; 95% CI: 0.56, 0.94; p = 0.01; I² = 34%). No significant differences were found for major bleeding episodes (RR: 1.40; 95% CI: 0.93, 2.14; p = 0.11), all-cause mortality (RR: 1.01; 95% CI: 0.91, 1.12; p = 0.49), composite of major adverse events (RR: 0.87; 95% CI: 0.73, 1.05; p = 0.14) and risk of stroke (RR: 0.84; 95% CI: 0.59, 1.20; p = 0.34) between the two strategies. Our findings reveal that, in older adults with NSTE-ACS, an invasive strategy reduces the risk of subsequent MI and unplanned revascularization. However, no significant differences in mortality, bleeding, or stroke were observed between the two groups.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Aqsa Shoaib
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Muhammad Taha Khan
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Najwa Salim
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Izma Ajaz
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Areeba Fareed
- Department of Internal Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Wael AlJaroudi
- Division of Cardiovascular Medicine, Wellstar MCG Health, Augusta, Georgia, USA
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Zhou H, Qiu M, Guan S, Liang Z, Li Y, Han Y. Association between in-hospital hemoglobin drop without overt bleeding and 1-year outcome of percutaneous coronary intervention in acute myocardial infarction patients. Sci Rep 2025; 15:12773. [PMID: 40229404 DOI: 10.1038/s41598-025-97762-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Accepted: 04/07/2025] [Indexed: 04/16/2025] Open
Abstract
Whether an in-hospital hemoglobin drop adversely affects the prognosis of patients with acute myocardial infarction (AMI) remains controversial. The present study aimed to investigate the impacts of in-hospital hemoglobin drop without overt bleeding on 1-year clinical outcomes of AMI patients after percutaneous coronary intervention (PCI). A total of 5,036 AMI patients who underwent PCI and presented with an in-hospital hemoglobin decline without overt bleeding were recruited in this study. Subsequently, these patients were stratified into three cohorts based on tertiles of hemoglobin drop values: < 0.8 g/dL (n = 1652), 0.8-1.49 g/dL (n = 1651) and ≥ 1.5 g/dL (n = 1733). The primary endpoint was defined as ischemic events at 1 year, composed of cardiac death, myocardial infarction (MI), and stroke. Secondary endpoints were defined as 1-year all-cause death, Bleeding Academic Research Consortium (BARC) types 2, 3, or 5, and 3 or 5 bleeding. There were significant differences in 1-year incidence of ischemic events (1.88% vs. 3.27% vs. 3.46%; P = 0.0114), all-cause death (1.45% vs. 2.18% vs. 2.94%; P = 0.0128), as well as cardiac death (1.15% vs. 1.82% vs. 2.37%; P = 0.0282) and MI (0.30% vs. 1.15% vs. 0.92%; P = 0.0175) across tertiles of hemoglobin drop values. For each 1 g/dL drop in hemoglobin values, the adjusted risk for ischemic events and all-cause death increased by 2% and 3%, respectively. Among AMI patients undergoing PCI, an in-hospital decline in hemoglobin levels was associated with an increased risk of 1-year ischemic events and all-cause death, even in the absence of overt bleeding.
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Affiliation(s)
- He Zhou
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, China
| | - Miaohan Qiu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, China
| | - Shaoyi Guan
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, China
| | - Zhenyang Liang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, China
| | - Yi Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, China
| | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, China.
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Singh N, Cohen DJ, Shah MA, Kosinski AS, Brothers L, Vemulapalli S, Elmariah S. Trends, Predictors, and Outcomes of Bleeding Complications After Mitral Transcatheter Edge-to-Edge Repair: TVT Registry Insights. JACC Cardiovasc Interv 2024; 17:2337-2349. [PMID: 39477637 DOI: 10.1016/j.jcin.2024.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 08/25/2024] [Accepted: 09/03/2024] [Indexed: 03/30/2025]
Abstract
BACKGROUND Bleeding events after arterial transcatheter procedures are associated with increased morbidity and mortality. The frequency and clinical implications of bleeding after mitral transcatheter edge-to-edge repair (M-TEER) have not been well-studied. OBJECTIVES The authors sought to explore the association of in-hospital bleeding events after M-TEER with patient outcomes. METHODS Patients undergoing M-TEER who were included in the TVT (Transcatheter Valve Therapy) Registry between 2013 and 2022 were included. Rates of the primary endpoint, the composite of death or hospital readmission at 30 days, were compared between patients who experienced in-hospital major or life-threatening bleeding vs those without bleeding. Secondary analyses examined the association between in-hospital bleeding and death or readmission at 1 year, as well as independent predictors of major in-hospital bleeding. RESULTS Over the study period, in-hospital major bleeding occurred in 1,205 (2.3%) of 51,533 patients. Rates of bleeding decreased over time (from 7.1% in 2013 to 2.0% in 2021; P < 0.001). In-hospital bleeding was associated with increased rates of death or readmission at both 30 days (adjusted OR: 2.15 [95% CI: 1.81-2.54]; P < 0.0001) and 1 year (adjusted HR: 1.43 [95% CI: 1.27-1.60]; P < 0.0001). The strongest correlates of in-hospital bleeding included female sex, prior percutaneous coronary intervention, baseline hemoglobin, greater procedure acuity, and longer procedure duration. CONCLUSIONS Bleeding after M-TEER is associated with increased risk of subsequent death and hospital readmission. Although reductions in bleeding complications over time are encouraging, continued efforts are needed to further mitigate hemorrhagic complications of M-TEER.
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Affiliation(s)
- Nickpreet Singh
- Division of Cardiology, New York Presbyterian-Weill Cornell Medical Center, New York, New York, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St. Francis Hospital and Heart Center, Roslyn, New York, USA
| | - Miloni A Shah
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Leo Brothers
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sammy Elmariah
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA.
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Bulguroglu S, Calapkulu Y, Koc U, Erdogan M, Gölbası Z. C-reactive protein to albumin ratio and radial artery thrombosis post transradial angiography. Biomark Med 2024; 18:469-476. [PMID: 39007835 DOI: 10.1080/17520363.2024.2345578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/08/2024] [Indexed: 07/16/2024] Open
Abstract
Aim: The aim is to evaluate the relationship between C-reactive protein (CRP) to albumin ratio (CAR) and radial artery thrombosis in patients undergoing radial angiography. Patients & methods: We prospectively included 261 consecutive patients undergoing radial angiography, assessing radial artery diameter and thrombosis presence. Results: The CRP values were significantly higher in radial artery thrombosis group compared with group without thrombosis (13.01 vs. 4.33 mg/l, p < 0.001, respectively). Also CAR was statistically significantly different between the group with thrombosis and the group without thrombosis (0.102 vs. 0.349, p < 0.001). Conclusion: Our study is the first to assess CAR in radial thrombus development post-procedure in patients undergoing radial angiography. CAR can be useful in determining radial artery thrombosis after the coronary angiography.
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Affiliation(s)
- Serkan Bulguroglu
- University of Health Sciences, Hatay Dörtyol State Hospital, Cardiology Department, Hatay, Turkey
| | - Yunus Calapkulu
- University of Health Sciences, Ankara Mamak State Hospital, Cardiology Department, Ankara, Turkey
| | - Ural Koc
- University of Health Sciences, Ankara Bilkent City Hospital, Radiology Department, Ankara, Turkey
| | - Mehmet Erdogan
- Ankara Yıldırım Beyazıt University Medical School, Cardiology Department, Ankara, Turkey
| | - Zehra Gölbası
- Ankara Yıldırım Beyazıt University Medical School, Cardiology Department, Ankara, Turkey
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Yoo AY, Joo MK, Park JJ, Lee BJ, Kim SH, Kim WS, Chun HJ. Recurrent Non-Variceal Upper Gastrointestinal Bleeding among Patients Receiving Dual Antiplatelet Therapy. Diagnostics (Basel) 2023; 13:3444. [PMID: 37998579 PMCID: PMC10670490 DOI: 10.3390/diagnostics13223444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Patients undergoing dual antiplatelet therapy (DAPT) may experience recurrent gastrointestinal bleeding (GIB). We investigated the clinical characteristics and risk factors for recurrent non-variceal upper gastrointestinal bleeding (NVUGIB) in patients who had experienced NVUGIB while receiving DAPT. METHODS We enrolled patients diagnosed with NVUGIB while receiving DAPT between 2006 and 2020. Definite bleeding was confirmed by esophagogastroduodenoscopy in all NVUGIB patients. RESULTS A total of 124 patients were diagnosed with NVUGIB while receiving DAPT. They were predominantly male (n = 103, 83.1%), bleeding mostly from the stomach (n = 94, 75.8%) and had peptic ulcers (n = 72, 58.1%). After the successful hemostasis of NVUGIB, 36 patients (29.0%) experienced at least one episode of recurrent upper GIB, 19 patients (15.3%) died, and 7 (5.6%) patients had a bleeding-related death. Multivariate analysis showed that age was a significant factor for re-bleeding (odds ratio [OR], 1.050; 95% confidence interval [CI]: 1.001-1.102; p-value: 0.047), all-cause mortality (OR, 1.096; 95% CI: 1.020-1.178, p = 0.013), and re-bleeding-related mortality (OR, 1.187; 95% CI: 1.032-1.364, p-value: 0.016). In Kaplan-Meier analysis, the cumulative probabilities of re-bleeding, death, and bleeding-related death were significantly higher in patients aged 70 and older (p = 0.008, <0.001, and 0.009, respectively). CONCLUSIONS Clinicians should be cautious about re-bleeding and mortality in elderly patients who experience NVUGIB while receiving DAPT.
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Affiliation(s)
- Ah Young Yoo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Jong-Jae Park
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Beom Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Seung Han Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Won Shik Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148, Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; (A.Y.Y.); (J.-J.P.); (B.J.L.); (S.H.K.); (W.S.K.)
| | - Hoon Jai Chun
- Division of Gastroenterology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul 02841, Republic of Korea;
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6
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Elfar S, Onsy A, Farouk MA. Clinical and Radiographic Predictors of Successful Coronary Angiography Through Right Radial Artery Access. Interv Cardiol 2023; 18:e21. [PMID: 37435602 PMCID: PMC10331560 DOI: 10.15420/icr.2023.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/23/2023] [Indexed: 07/13/2023] Open
Abstract
Background: One of the limitations of the right radial access approach is complex vessel anatomy, such as subclavian tortuosity. Several clinical predictors have been proposed for tortuosities, such as older age, female sex and hypertension. In this study, we hypothesised that chest radiography would add predictive value to the traditional predictors. Methods: This prospective blinded study included patients who underwent transradial access coronary angiography. They were classified into four groups according to difficulty: Group I, Group II, Group III and Group IV. Different groups were compared according to clinical and radiographic characteristics. Results: The study included 108 patients (54, 27, 17 and 10 patients in Groups I, II, III and IV, respectively). The rate of crossover to transfemoral access was 9.26%. Age, hypertension and female sex were associated with a greater difficulty and failure rates. Regarding radiographic parameters, a higher failure rate was associated with a higher diameter of the aortic knuckle (Group IV, 4.09 ± 1.32 cm versus Groups I, II and III combined, 3.26 ± 0.98 cm; p=0.015) and the width of the mediastinum (Group IV, 8.96 ± 2.88 cm versus Groups I, II and III combined, 7.28 ± 1.78 cm; p=0.009). The cut-off value for prominent aortic knuckle was 3.55 cm (sensitivity 70% and specificity 67.35%) and the width of mediastinum was 6.59 cm (sensitivity 90% and specificity 42.86%). Conclusion: Radiographic prominent aortic knuckle and wide mediastinum are valuable clinical parameters and useful predictors for transradial access failure caused by tortuosity of the right subclavian/brachiocephalic arteries or aorta.
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Affiliation(s)
- Sohil Elfar
- Cardiology Department, Faculty of Medicine, Port Said UniversityPort Said, Egypt
| | - Ahmed Onsy
- Cardiology Department, Faculty of Medicine, Ain Shams UniversityCairo, Egypt
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7
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Mohammad AM, Shammo NA, Saeed SY. Rates of the Trans-radial Approach in Elective and Emergency Coronary Angiography in Iraq: A Cross-Sectional Study. Cureus 2023; 15:e41193. [PMID: 37525759 PMCID: PMC10387262 DOI: 10.7759/cureus.41193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/02/2023] Open
Abstract
Background and aims The trans-radial access is becoming the default approach in many cardiac centers worldwide. Data from the Middle East, including Iraq, on the trends and rates of the use of trans-radial access are scarce. The aim of this study is to determine the rates of trans-radial approach (TRA) versus transfemoral approach (TFA) in patients with coronary artery syndromes undergoing coronary angiography and/or percutaneous coronary intervention (PCI) in Iraq. Methods In this multicenter prospective study, we collected 885 cases of coronary artery disease undergoing coronary angiography/PCI from three main cities of the Kurdistan Region in Iraq from 2022 to 2023. Results Of the total sample, 57.2% were diagnostic coronary angiography and 42.8% were PCI, 57.1% of all cases were TFA and 42.9% were TRA, and 64.3% of PCI cases were performed through TFA. Eghty-two percent of total emergency PCI included (primary PCI) cases underwent the procedure through the TFA, and only 18% of such cases were through the TRA. The overall crossover rate between both approaches happened in 14 (3.6%) cases. Conclusions Despite its main benefits, the radial access use in the Cath lab is yet underused in our region. Further steps in training programs are indicated to popularize the use of radial access among interventional cardiologists in addition to transfemoral access.
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Affiliation(s)
- Ameen M Mohammad
- Department of Internal Medicine, University of Duhok, Duhok, IRQ
| | - Nazar A Shammo
- Department of Internal Medicine, Azadi Cardiac Center, Duhok, IRQ
| | - Saad Y Saeed
- Department of Community Medicine, University of Duhok, Duhok, IRQ
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Coisne A, Aghezzaf S, Butruille L, Woitrain E, Ninni S, Juthier F, Sudre A, Vincentelli A, Lamblin N, Lemesle G, Montaigne D, Bauters C. Incidence, source, and prognostic impact of major bleeding across the spectrum of aortic stenosis. Am Heart J 2023; 262:140-147. [PMID: 37100186 DOI: 10.1016/j.ahj.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/30/2023] [Accepted: 04/07/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Severe aortic stenosis (AS) has been associated with bleeding. However, there is a lack of prospective assessment of bleeding events and their clinical significance in a large population of outpatients with variable degree of AS severity. OBJECTIVES To assess the incidence, source, determinants, and prognostic impact of major bleeding in patients with variable degree of AS severity. METHODS Between May 2016 and December 2017, consecutive outpatients were included. Major bleeding was defined as type ≥3 bleed using the Bleeding Academic Research Consortium definition. Cumulative incidence was calculated with death as the competing event. Data was censored at time of aortic valve replacement. RESULTS Among 2,830 patients, 46 major bleeding events occurred (0.7%/year) during a median follow-up of 2.1 years (interquartile range: 1.4-2.7). Most frequent sites of bleeding were gastrointestinal (50%) and intracranial (30.4%). Major bleeding was significantly associated with all-cause mortality (hazard ratio: 5.93 (95% confidence interval 3.64-9.65); P < .001). AS severity was associated with major bleedings (P = .041). By multivariable analysis, severe AS was an independent determinant of major bleeding (hazard ratio vs mild AS: 3.59 [95% confidence interval 1.56-8.29]; P = .003). The increased risk of bleeding associated with severe AS was significantly exacerbated in patients using oral anticoagulation. CONCLUSION In AS patients, major bleeding is rare but a strong independent predictor of death. AS severity is a determinant of bleeding events. Severe AS and oral anticoagulation should be identified as an association at very high risk of major bleeding.
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Affiliation(s)
- Augustin Coisne
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France; Cardiovascular Research Foundation, New York, NY.
| | - Samy Aghezzaf
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Laura Butruille
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Eloise Woitrain
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Sandro Ninni
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Francis Juthier
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Arnaud Sudre
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - André Vincentelli
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Nicolas Lamblin
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Gilles Lemesle
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France; Heart and Lung Institute, University hospital of Lille, Lille, France; FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - David Montaigne
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Christophe Bauters
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
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Kadiyala V, Long S, Has P, Lima FV, Sherrod CF, Heinl R, Williams MU, Nowak E, Kennedy K, Aronow HD, Abbott JD. PRECISE-DAPT and ARC-HBR Predict in-Hospital Outcomes in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2023; 191:43-50. [PMID: 36640599 DOI: 10.1016/j.amjcard.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/27/2022] [Accepted: 12/10/2022] [Indexed: 01/13/2023]
Abstract
Bleeding events result in morbidity and mortality in patients who underwent percutaneous coronary intervention (PCI). There are limited data on the predicting bleeding complications in patients who underwent stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) and Academic Research Consortium for High Bleeding Risk (ARC-HBR) scores' ability to predict in-hospital outcomes in patients who underwent PCI. Consecutive patients who underwent PCI at tertiary centers from January 2016 to March 2018 were identified and the bleeding risk scores were calculated. The primary end point was the National Cardiovascular Data Registry-defined in-hospital bleeding stratified by low versus high predicted bleeding risk. The major and net adverse cardiovascular events were also examined. The discriminatory ability of the risk models was determined using receiver operating characteristic curves. Among 3,659 patients studied, the in-hospital major bleeding was 3.3% (n = 121). The patients characterized as high bleeding risk by either criterion had significantly higher bleeding rates than those meeting the low-risk criteria (ARC-HBR 5.4% vs 3.3%, p <0.001; PRECISE-DAPT 5.8% vs 2.4%, p <0.001), and higher major adverse cardiovascular events and net adverse clinical events. These risk estimates showed moderate and similar predictive ability (ARC-HBR high-risk area under the receiver operating characteristic curve [AUC] 0.62, PRECISE-DAPT ≥25 AUC 0.61, p = 0.49), with no incremental benefit to adding the estimates (AUC 0.60). The subgroup analysis revealed that women had higher bleeding rates than men (5.53% vs 2.39%, p <0.001); however, the predictive ability of the criteria were similar in women and men. The patients identified as having a high bleeding risk by the PRECISE-DAPT and the ARC-HBR criteria before PCI are at high risk for in-hospital bleeding and adverse outcomes independent of gender. The 2 scores have moderate predictive ability for bleeds. Further study is needed to determine strategies to reduce risk in this population.
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Affiliation(s)
- Vishnu Kadiyala
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Sokunvichet Long
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Phinnara Has
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Fabio V Lima
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Charles F Sherrod
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Robert Heinl
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael U Williams
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Elizabeth Nowak
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kevin Kennedy
- Statistical Consultant, Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Herbert D Aronow
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - J Dawn Abbott
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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Meijers TA, Nap A, Aminian A, Dens J, Teeuwen K, van Kuijk JP, van Wely M, Schmitz T, Bataille Y, Kraaijeveld AO, Roolvink V, Hermanides RS, Braber TL, van Royen N, van Leeuwen MAH. ULTrasound-guided TRAnsfemoral puncture in COmplex Large bORe PCI: study protocol of the UltraCOLOR trial. BMJ Open 2022; 12:e065693. [PMID: 36456007 PMCID: PMC9716808 DOI: 10.1136/bmjopen-2022-065693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Although recently published evidence favours transradial access (TRA) when using large-bore guiding catheters for percutaneous coronary intervention (PCI) of complex coronary lesions, the femoral artery will still be used in a considerate proportion of patients undergoing complex PCI, especially in PCI of chronic total occlusions (CTO). Ultrasound-guided puncture of the femoral artery may reduce clinically relevant access site complications, but robust evidence is lacking up to date. METHODS AND ANALYSIS A total of 542 patients undergoing complex PCI, defined as PCI of CTO, complex bifurcation, heavy calcified lesion or left main, in which the 7-F or 8-F transfemoral access is required, will be randomised to ultrasound-guided puncture or fluoroscopy-guided puncture. The primary outcome is the incidence of the composite end-point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Access site complications and major adverse cardiovascular events up to 1 month will also be compared between both groups. ETHICS AND DISSEMINATION Ethical approval for the study was granted by the local Ethics Committee ('Medisch Ethische Toetsing Commissie Isala Zwolle') for all Dutch sites, 'Comité Medische Ethiek Ziekenhuis Oost-Limburg' for Hospital Oost-Limburg, 'Comité d'éthique CHU-Charleroi-ISPPC' for Centre Hospilatier Universitaire de Charleroi and 'Ethik Kommission de Ärztekammer Nordrhein' for Elisabeth-Krankenhaus). The trial outcomes will be published in peer-reviewed journals of the concerned literature. The ultrasound guided transfemoral access in complex large bore PCI trial has been administered in the ClinicalTrials.gov database, reference number: NCT03846752. REGISTRATION DETAILS ClinicalTrials.gov identifier: NCT03846752.
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Affiliation(s)
- Thomas A Meijers
- Department of Cardiology, Isala Heart Centre, Zwolle, The Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Joseph Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Koen Teeuwen
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Thomas Schmitz
- Department of Cardiology, Elisabeth-Krankenhaus-Essen GmbH, Essen, Germany
| | - Yoann Bataille
- Department of Cardiology, Jessa Ziekenhuis vwz, Hasselt, Belgium
| | - Adriaan O Kraaijeveld
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Vincent Roolvink
- Department of Cardiology, Isala Heart Centre, Zwolle, The Netherlands
| | | | - Thijs L Braber
- Department of Cardiology, Isala Heart Centre, Zwolle, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
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11
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Chakravartti J, Feser WJ, Plomondon ME, Valle JA, Rao SV, Gutierrez JA, Grunwald GK, Gunzburger E, Swaminathan RV. Access Site Selection and Outcomes for Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the VA CART Program. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100440. [PMID: 39132361 PMCID: PMC11308032 DOI: 10.1016/j.jscai.2022.100440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 08/13/2024]
Abstract
Background There has been increasing use of transradial access (TRA) for non-chronic total occlusion (CTO) percutaneous coronary intervention (PCI). There are limited data on TRA for CTO PCI. The objectives of this study were to assess the temporal trends in the use of TRA versus transfemoral access (TFA), identify procedural and lesion characteristics associated with the use of TRA and TFA, and evaluate the association of access site with procedural complications and technical success among veterans undergoing attempted CTO PCI. Methods We performed a retrospective analysis of veteran patients who underwent attempted CTO PCI to compare outcomes between TRA and TFA. Patients who had undergone attempted PCI of at least 1 CTO were included. Propensity score matching was used to evaluate the composite primary outcome of major procedural complications, in-hospital bleeding, or 30-day mortality and the secondary outcome of procedural success. Results In total, 4609 patients underwent attempted CTO PCI during 2010-2017. Rates of TRA for CTO PCI increased significantly, from 7% in 2010 to 38% in 2017 (P trend < .01). A greater percentage of CTO lesions in the TFA group was calcified and >20.0 mm in length. TRA was not associated with a reduction in the composite primary outcome (TRA 3.3% vs TFA 4.0%, P = .47) or procedural success (TRA 66.6% vs TFA 65.7%, P = .74) compared with TFA. Conclusions In this retrospective analysis of patients who underwent attempted CTO PCI, the proportion of TRA for CTO PCI has increased over time but was not associated with a greater safety or procedural success than TFA.
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Affiliation(s)
| | - William J. Feser
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Mary E. Plomondon
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Javier A. Valle
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Section of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sunil V. Rao
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
- Section of Cardiology, Department of Medicine, Durham VA Healthcare System, Durham, North Carolina
| | - J. Antonio Gutierrez
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
- Section of Cardiology, Department of Medicine, Durham VA Healthcare System, Durham, North Carolina
| | - Gary K. Grunwald
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | | | - Rajesh V. Swaminathan
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
- Section of Cardiology, Department of Medicine, Durham VA Healthcare System, Durham, North Carolina
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12
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Alkhars H, Haq W, Al-Tayeb A, Sigounas D. Feasibility and Safety of Transradial Aneurysm Embolization: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 165:e110-e127. [PMID: 35654332 DOI: 10.1016/j.wneu.2022.05.112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Use of the transradial access (TRA) approach for neuroendovascular procedures has been increasing in recent years. Our aim is to assess the feasibility, success rate, and complications associated with TRA for intracranial aneurysm embolization. METHODS PubMed, Scopus, and Embase were systematically searched for studies using TRA for intracranial aneurysm embolization. Random-effects models were used to obtain pooled rates of procedural success and complications. RESULTS Twenty-four studies comprising 1283 (85.9%) TRA and 122 (8.2%) distal TRA aneurysm embolization procedures were included. The pooled success rate of the 18 studies in the meta-analysis was 93.5% (95% confidence interval [CI], 91.1%-95.8%). The pooled thromboembolic complication rate was 0.5% (95% CI, 0.1%-0.9%), the hemorrhagic complication rate was 0.5% (95% CI, 0.1%-0.9%), and the access site complication rate was 0.8% (95% CI, 0.3%-1.3%). One study (4.3%) used exclusively a 7-French guide catheter, and most used a 6-French guide catheter (22 of 23 studies, 95.7%), which was further incorporated as part of a triaxial configuration through a sheathless 8-French system in 4 studies (17.4%), 7-French guide catheter in 2 studies (8.7%), and 8-French sheath in 1 study (4.3%). The embolization techniques used were flow diverter placement in 451 cases (39.1%), coiling in 376 (32.6%), stent-assisted coiling in 127 (11.0%), balloon-assisted coiling in 104 (9.0%), Woven EndoBridge system in 50 (4.3%), and flow diverter placement plus coiling in 42 (3.6%). CONCLUSIONS Treating intracranial aneurysms using various embolization techniques through TRA is feasible and associated with low access site and intraoperative complications.
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Affiliation(s)
- Hussain Alkhars
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Waqas Haq
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ahmed Al-Tayeb
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.
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13
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Abusnina W, Radaideh Q, Al-Abdouh A, Ismayl M, Algheriani H, Lee J, Alam M, Ben-Dor I, Jimenez E, Azrin M, Paul TK, Dahal K. Routine Invasive Strategy in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome: An Updated Systematic Review and Meta-analysis of Randomized Trials. Curr Probl Cardiol 2022; 47:101304. [PMID: 35803333 DOI: 10.1016/j.cpcardiol.2022.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Invasive treatment with coronary angiography is preferred approach for patients with non-ST elevation acute coronary syndrome (NSTE-ACS) compared to medical therapy alone. The results from the randomized clinical trials (RCT) that compared the invasive treatment strategy vs. conservative approach in the elderly (≥75 years) with NSTE-ACS has been inconsistent. AIM To compare invasive and conservative strategies in the elderly (>75 years) with NSTE-ACS. METHODS AND RESULTS We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 10, 2021) for RCTs comparing invasive and conservative strategies in the elderly with NSTE-ACS. We used random-effects model to calculate risk ratio (RR) with 95% confidence interval(CI). A total of 6 RCT including 2,323 patients were included in the meta-analysis. The median follow-up duration was 13.5 months. When invasive approach was compared to conservative strategy, it showed no difference in all-cause mortality in patients aged ≥75 years with NSTE-ACS (RR of 0.85; 95% CI 0.70-1.04; P = 0.12; I2 = 0%). There was significant reduction in MI (RR 0.59; 95% CI 0.49 0.71; P < 0.001; I2 = 0%) and unplanned revascularization (RR 0.30, 95% CI 0.17-0.53, P <0.001, I2 = 0%). Invasive strategy was associated with higher risk of major bleeding when compared to conservative treatment (RR 2.12, 95% CI 1.21-3.74, P=0.009, I2 = 0%). Comparison of both strategies showed no significant difference in stroke (RR 0.75; 95% CI 0.38-1.46, P = 0.40; I2 = 0%). CONCLUSION This updated meta-analysis suggests that in elderly patients (>75 years) with NSTE-ACS, a routine invasive strategy is associated with a reduction in MI and revascularization, while increasing the risk of major bleeding, but without difference in all-cause mortality and stroke.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE.
| | - Qais Radaideh
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | - Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, KY
| | - Mahmoud Ismayl
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | | | - Juyong Lee
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington DC
| | - Enrique Jimenez
- Section of Cardiology, Overton Brooks Veterans Affairs Medical Center, Shreveport, LA
| | - Michael Azrin
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Timir K Paul
- Department of medical education, University of Tennessee at Nashville, Nashville, TN
| | - Khagendra Dahal
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
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14
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Hu Q, Han YL, Zhou TN, Wang XZ, Zhang QY. Efficacy and Safety of the Reduced Bivalirudin in Patients Undergoing Coronary Angiography or Percutaneous Coronary Intervention Stratified by Renal Function (REDUCE BOLUS): A Single-Blind, Stratified Randomized, Non-inferiority Trial. Front Cardiovasc Med 2022; 9:864048. [PMID: 35548446 PMCID: PMC9081606 DOI: 10.3389/fcvm.2022.864048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/08/2022] [Indexed: 12/28/2022] Open
Abstract
Background In clinical practice, some cases indicated that the loading dose of bivalirudin increased the bleeding risk, particularly in patients with renal insufficiency. Therefore, this study aimed to assess the efficacy and safety of the low-dose (80%) bolus injection of bivalirudin in patients undergoing cardiac catheterization stratified by renal function. Methods A total of 204 individuals in the REDUCE BOLUS trial were stratified 1:1 to the estimated glomerular filtration rate (eGFR) ≥ 60 ml/min cohort or eGFR < 60 ml/min cohort, then randomized 1:1 to the reduced bolus bivalirudin group (i.e., the experimental group) or normal bolus bivalirudin group (i.e., the control group), respectively. The primary end point was to compare the differences of the area under the curve of activated clotting time (ACT) between the two groups. The secondary end points were the postoperative net adverse clinical events (NACEs) before discharge, defined as the all-cause mortality, recurrent myocardial infarction, ischemia-driven target vessel revascularization, stroke, and bleeding events. Results Between January 3, 2020, and March 26, 2021, 204 patients undergoing coronary angiography were randomly assigned, including 102 (i.e., 51 in the control group and 51 in the experimental group) with normal eGFR and 102 (i.e., 51 control and 51 experimental) with abnormal eGFR. No difference was observed in the curve of ACT between the control group and the experimental group (0.55 ± 0.09 vs. 0.56 ± 0.08, P = 0.542 and 0.55 ± 0.06 vs. 0.57 ± 0.05, P = 0.075, respectively, for normal eGFR cohort and abnormal eGFR cohort). The one-sided 97.5% lower confidence bound for the difference in the area under the ACT curve was –0.017 and 0.0015 in eGFR ≥ 60 ml/min and eGFR<60 ml/min cohort, respectively, both above the preset non-inferiority criterion of -0.07, establishing the non-inferiority. There was no incidence of NACE and stent thrombosis before discharge in each group. Conclusion In patients undergoing cardiac catheterization, the efficacy and safety of the reduced bolus of bivalirudin were non-inferior to the normal one, even in patients without chronic kidney disease. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [NCT03588611].
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Affiliation(s)
- Qiang Hu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Ya-Ling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Tie-Nan Zhou
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiao-Zeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- *Correspondence: Xiao-Zeng Wang,
| | - Quan-Yu Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Quan-Yu Zhang,
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15
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Current and Future Applications of Artificial Intelligence in Coronary Artery Disease. Healthcare (Basel) 2022; 10:healthcare10020232. [PMID: 35206847 PMCID: PMC8872080 DOI: 10.3390/healthcare10020232] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular diseases (CVDs) carry significant morbidity and mortality and are associated with substantial economic burden on healthcare systems around the world. Coronary artery disease, as one disease entity under the CVDs umbrella, had a prevalence of 7.2% among adults in the United States and incurred a financial burden of 360 billion US dollars in the years 2016–2017. The introduction of artificial intelligence (AI) and machine learning over the last two decades has unlocked new dimensions in the field of cardiovascular medicine. From automatic interpretations of heart rhythm disorders via smartwatches, to assisting in complex decision-making, AI has quickly expanded its realms in medicine and has demonstrated itself as a promising tool in helping clinicians guide treatment decisions. Understanding complex genetic interactions and developing clinical risk prediction models, advanced cardiac imaging, and improving mortality outcomes are just a few areas where AI has been applied in the domain of coronary artery disease. Through this review, we sought to summarize the advances in AI relating to coronary artery disease, current limitations, and future perspectives.
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16
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Meijers TA, Aminian A, van Wely M, Teeuwen K, Schmitz T, Dirksen MT, Rathore S, van der Schaaf RJ, Knaapen P, Dens J, Iglesias JF, Agostoni P, Roolvink V, Lemmert ME, Hermanides RS, van Royen N, van Leeuwen MAH. Extremity Dysfunction After Large-Bore Radial and Femoral Arterial Access. J Am Heart Assoc 2022; 11:e023691. [PMID: 35023343 PMCID: PMC9238521 DOI: 10.1161/jaha.121.023691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The use of large‐bore (LB) arterial access and guiding catheters has been advocated for complex percutaneous coronary intervention. However, the impact of LB transradial access (TRA) and transfemoral access (TFA) on extremity dysfunction is currently unknown. Methods and Results The predefined substudy of the COLOR (Complex Large‐Bore Radial PCI) trial aimed to assess upper and lower‐extremity dysfunction after LB radial and femoral access. Upper‐extremity function was assessed in LB TRA‐treated patients by the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and lower‐extremity function in LB TFA‐treated patients by the Lower Extremity Functional Scale questionnaire. Extremity pain and effect of access site complications and risk factors on extremity dysfunction was also analyzed. There were 343 patients who completed analyzable questionnaires. Overall, upper and lower‐extremity function did not decrease over time when LB TRA and TFA were used for complex percutaneous coronary intervention, as represented by the median Quick Disabilities of the Arm, Shoulder, and Hand score (6.8 at baseline and 2.1 at follow‐up, higher is worse) and Lower Extremity Functional Scale score (56 at baseline and 58 at follow‐up, lower is worse). Clinically relevant extremity dysfunction occurred in 6% after TRA and 9% after TFA. A trend for more pronounced upper‐limb dysfunction was present in female patients after LB TRA (P=0.05). Lower‐extremity pain at discharge was significantly higher in patients with femoral access site complications (P=0.02). Conclusions Following LB TRA and TFA, self‐reported upper and lower‐limb function did not decrease over time in the majority of patients. Clinically relevant limb dysfunction occurs in a small minority of patients regardless of radial or femoral access. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03846752.
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Affiliation(s)
- Thomas A Meijers
- Department of Cardiology Isala Heart Center Zwolle the Netherlands
| | - Adel Aminian
- Department of Cardiology Centre Hospitalier Universitaire de Charleroi Charleroi Belgium
| | - Marleen van Wely
- Department of Cardiology Radboud University Medical Center Nijmegen the Netherlands
| | - Koen Teeuwen
- Department of Cardiology Catharina Hospital Eindhoven the Netherlands
| | - Thomas Schmitz
- Department of Cardiology Elisabeth Krankenhaus Essen Germany
| | | | - Sudhir Rathore
- Department of Cardiology Frimley Health NHS Foundation Trust Surrey United Kingdom
| | - René J van der Schaaf
- Department of Cardiology Onze Lieve Vrouwe Gasthuis Hospital Amsterdam the Netherlands
| | - Paul Knaapen
- Department of Cardiology VU University Medical Center Amsterdam the Netherlands
| | - Joseph Dens
- Department of Cardiology Hospital Oost-Limburg Genk Belgium
| | - Juan F Iglesias
- Department of Cardiology Geneva University Hospital Geneva Switzerland
| | | | - Vincent Roolvink
- Department of Cardiology Isala Heart Center Zwolle the Netherlands
| | - Miguel E Lemmert
- Department of Cardiology Isala Heart Center Zwolle the Netherlands
| | | | - Niels van Royen
- Department of Cardiology Radboud University Medical Center Nijmegen the Netherlands
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17
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Thibert MJ, Fordyce CB, Cairns JA, Turgeon RD, Mackay M, Lee T, Tocher W, Singer J, Perry-Arnesen M, Wong GC. Access-Site vs Non-Access-Site Major Bleeding and In-Hospital Outcomes Among STEMI Patients Receiving Primary PCI. CJC Open 2021; 3:864-871. [PMID: 34401693 PMCID: PMC8347846 DOI: 10.1016/j.cjco.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 10/27/2022] Open
Abstract
Background Major bleeding (MB) is an independent predictor of mortality among ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Prevention of access-site MB has received significant attention. However, limited data have been obtained on the influence of access-site MB vs non-access-site MB and association with subsequent adverse in-hospital outcomes in the STEMI population undergoing pPCI. Methods We identified 1494 STEMI patients who underwent pPCI between 2012 and 2018. Unadjusted and adjusted differences among patients with no MB, access-site MB, non-access-site MB, and in-hospital clinical outcomes were assessed. The use of bleeding-avoidance strategies and their effects on MB were also evaluated. Results MB occurred in 121 (8.1%) patients. Access-site MB occurred in 34 (2.3%) patients, and non-access-site MB occurred in 87 (5.8%). The median reduction in hemoglobin was 31 g/L (interquartile range: 19-43) with access-site MB, and 44 g/L (interquartile range: 29-62) with non-access-site MB. After multivariable adjustment, non-access-site MB was independently associated with in-hospital death (adjusted odds ratio [aOR] 4.21; 95% confidence interval [CI] 2.04-8.68), cardiogenic shock (aOR 10.91; 95% CI 5.67-20.98), and cardiac arrest (aOR 5.63; 95% CI 2.88-11.01). Conversely, access-site MB was not associated with adverse in-hospital outcomes. Bleeding-avoidance strategies were used frequently; however, after multivariable adjustment, no single bleeding-avoidance strategy was significantly associated with reduced MB. Conclusions In STEMI patients undergoing pPCI, non-access-site MB was independently associated with adverse in-hospital outcomes, whereas access-site MB was not. Additional study of strategies to reduce the incidence and impact of non-access-site MB appears to be warranted.
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Affiliation(s)
- Michael J Thibert
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Cairns
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D Turgeon
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Martha Mackay
- Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,St Paul's Hospital Heart Centre, Vancouver, British Columbia, Canada.,University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy Tocher
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michele Perry-Arnesen
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,Burnaby Hospital, Fraser Health Authority, Burnaby, British Columbia, Canada
| | - Graham C Wong
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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18
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White K, Currey J, Considine J. Assessment Framework for Recognizing Clinical Deterioration in Patients With ACS Undergoing PCI. Crit Care Nurse 2021; 41:18-28. [PMID: 34333617 DOI: 10.4037/ccn2021904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC Patients with acute coronary syndrome undergoing primary percutaneous coronary intervention are at risk of clinical deterioration that results in similar general signs and symptoms regardless of its cause. However, specific causes and forms of clinical deterioration are associated with key differences in assessment findings. Focused clinical assessments using a modified primary survey enable nurses to rapidly identify the cause and form of clinical deterioration, facilitating targeted treatment. CLINICAL RELEVANCE Clinical deterioration during percutaneous coronary intervention is associated with increased mortality and morbidity. Previous studies identified nursing inconsistencies when recognizing clinical deterioration, with inconsistent collection of cues and prioritization of cues related to cardiac performance over more sensitive indicators of clinical deterioration. PURPOSE OF PAPER To describe a framework to help nurses optimize physiological cue collection to improve recognition of clinical deterioration during periprocedural care of patients undergoing percutaneous coronary intervention for unstable acute coronary syndrome. CONTENT COVERED Literature analysis revealed 7 forms of clinical deterioration in patients undergoing percutaneous coronary intervention: coronary artery occlusion, stroke, ventricular rupture, valvular insufficiency, lethal cardiac arrhythmias, access-site and non-access-site bleeding, and anaphylaxis. Evidence for the pathophysiology, incidence, severity, and clinical features of each form of clinical deterioration is identified. A framework is proposed to help nurses conduct highly focused patient assessments, enabling prompt recognition of and response to the specific forms of clinical deterioration that occur in patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Kevin White
- Kevin White is a clinical nurse educator in interventional cardiology at MonashHeart, Melbourne, Australia, and a national education and training representative for the Interventional Nurses Council of Australia and New Zealand
| | - Judy Currey
- Judy Currey is a Professor of Nursing at Deakin University, Melbourne
| | - Julie Considine
- Julie Considine is the Deakin University Chair of Nursing at Eastern Health, Melbourne
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Ren X, Liu K, Zhang H, Meng Y, Li H, Sun X, Sun H, Song Y, Wang L, Wang W, Wang C, Wang Y, Hou Z, Gao Y, Yin W, Zheng Z, Lu B. Coronary Evaluation Before Heart Valvular Surgery by Using Coronary Computed Tomographic Angiography Versus Invasive Coronary Angiography. J Am Heart Assoc 2021; 10:e019531. [PMID: 34320820 PMCID: PMC8475662 DOI: 10.1161/jaha.120.019531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Coronary computed tomography angiography (CCTA) is a noninvasive, less expensive, low‐radiation alternative to invasive coronary angiography (ICA). ICA is recommended for coronary evaluation before heart valvular surgery, and the supporting evidence for CCTA is insufficient. Our study is a single‐center, prospective cohort study designed to evaluate the feasibility of CCTA instead of ICA in detection of coronary artery disease before surgery. Methods and Results Heart valvular surgery candidates were consecutively enrolled between April 2017 and December 2018. Nine hundred fifty‐eight patients in the CCTA group underwent CCTA primarily, and those with ≥50% coronary stenosis or uncertain diagnosis underwent subsequent ICA. One thousand five hundred twenty‐five patients in the ICA group underwent ICA directly before surgery. Coronary artery bypass grafting decision was made by surgeons according to CCTA or ICA results. Most of the patients (78.8%) in the CCTA group avoided invasive angiography. Thirty‐day mortality (0.7% versus 0.9%, P=0.821), myocardial infarction (6.4% versus 6.9%, P=0.680 ), and low cardiac output syndrome (4.2% versus 2.8%, P=0.085) were similar in the CCTA and ICA groups. Median duration of follow‐up was 19.3 months (interquartile range, 14.2–30.0 months), cumulative rates of mortality (2.6% versus 2.6%, P=0.882) and major adverse cardiac events (9.6% versus 9.0%, P=0.607) showed no difference between the 2 groups. Coronary evaluation expense was lower in the CCTA group ($149.6 versus $636.0, P<0.001). Conclusions The strategy of using CCTA as a doorkeeper in coronary evaluation before heart valvular surgery showed noninferiority in identification of candidates for coronary artery bypass grafting and postoperative safety.
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Affiliation(s)
- Xinshuang Ren
- Department of Radiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Kun Liu
- Department of Radiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Heng Zhang
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Ying Meng
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Haojie Li
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xiaogang Sun
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Hansong Sun
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Yunhu Song
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Liqing Wang
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Wei Wang
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Chuangshi Wang
- Medical Research and Biometrics Center State Key Laboratory of Cardiovascular Disease Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Yang Wang
- Medical Research and Biometrics Center State Key Laboratory of Cardiovascular Disease Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Zhihui Hou
- Department of Radiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Yang Gao
- Department of Radiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Weihua Yin
- Department of Radiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Zhe Zheng
- Department of Surgery Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Bin Lu
- Department of Radiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
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20
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Roule V, Lemaitre A, Pommier W, Bignon M, Sabatier R, Blanchart K, Beygui F. Safety and efficacy of very short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy in older patients undergoing percutaneous coronary intervention: meta-analysis of randomised controlled trials. Age Ageing 2021; 50:1102-1107. [PMID: 33755049 DOI: 10.1093/ageing/afab047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND older patients undergoing percutaneous coronary intervention (PCI) represent a growing population sharing both a high ischemic and bleeding risk. Dual antiplatelet therapy (DAPT) reduces the incidence of thrombotic events but exposes patients to an increased risk of bleeding and subsequent mortality. Its optimal duration after PCI remains unclear. OBJECTIVE to assess the impact of short-duration DAPT on both bleeding and ischemic events in the specific population of older patients undergoing PCI. METHODS we performed a meta-analysis of randomised controlled trials comparing the safety and efficacy of standard versus very short duration (≤ 3 months, followed by P2Y12 inhibitor monotherapy) DAPT after PCI with a drug-eluting stent in older patients. RESULTS four studies, representing 8,961 older patients, were finally included. Compared with standard duration, short-duration DAPT was associated with similar rates of major bleeding (relative risks, RR 0.70 [0.47; 1.05]) and the composite efficacy endpoint (RR 0.85 [0.63; 1.14]). There was a high level of heterogeneity between the studies (I2 = 68%) regarding major bleeding. CONCLUSION our meta-analysis suggests that short DAPT may be a valid option in older patients after PCI but it also highlights the need for specific studies in such patients on optimal duration of antiplatelet therapy.
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Affiliation(s)
- Vincent Roule
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
- Normandie Univ, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000 Caen, France
| | - Adrien Lemaitre
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
| | - Wilhelm Pommier
- CHU de Caen Normandie, Service de Gériatrie, 14000 Caen, France
| | - Mathieu Bignon
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
| | - Rémi Sabatier
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
| | | | - Farzin Beygui
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
- Normandie Univ, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000 Caen, France
- ACTION Academic Group, Pitié Salpêtrière University Hospital, 75013, Paris, France
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21
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Kamran H, Malhotra R, Farhan S, Masoomi R, Garg A, Hooda A, Lascano R, Han D, Tadros R, Tarricone A, Baber U, Mehran R, Huber K, Krishnan P. Meta-Analysis of Anticoagulation Therapy for the Prevention of Cardiovascular Events in Patients With Peripheral Arterial Disease. Am J Cardiol 2021; 148:165-171. [PMID: 33667437 DOI: 10.1016/j.amjcard.2021.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
Peripheral artery disease (PAD) remains a major cause of morbidity and future cardiovascular events despite advancement in the surgical interventions and optimal medical therapy. The aim of our study is to evaluate the efficacy and safety of anticoagulation (AC) therapy for reducing cardiovascular and limb events in patients with PAD. PUBMED, Medline, and Cochrane Library were searched through 2020 for randomized clinical trials comparing major adverse cardiovascular events (MACE) and risk of major bleeding (MB), between AC and standard of care (SOC) therapy, among patients with PAD. Meta-analysis was performed using weighted pooled absolute risk difference (RD) with 95% confidence interval (CI) and fixed effects model for overall and sub-groups of full dose (FD) and low dose (LD) AC therapies. Amongst 17,684 patients from 7 different studies, the addition of AC to SOC therapy was associated with MACE reduction (RD -0.022, 95% CI -0.033 to -0.012, p <0.001) and increased MB (RD 0.02, 95% CI 0.014 to 0.025, p <0.001). For FD, MACE reduction was (RD -0.021, 95% CI -0.042 to 0.001, p = 0.061) and MB (RD 0.036, 95% CI 0.025 to 0.047, p <0.001). For LD, MACE reduction was (RD -0.023, 95% CI -0.035 to -0.011, p <0.001) and MB (RD 0.011, 95% CI 0.005 to 0.017, p <0.001). In conclusion, addition of AC to the current SOC therapy can mitigate future MACE events in patients with PAD albeit at risk of increased bleeding. LD AC is associated with an efficacy/safety net benefit compared to FD AC therapy.
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22
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Wang H, Wang HY, Yin D, Feng L, Song WH, Wang HJ, Zhu CG, Dou KF. Early radial artery occlusion following the use of a transradial 7-French sheath for complex coronary interventions in Chinese patients. Catheter Cardiovasc Interv 2021; 97 Suppl 2:1063-1071. [PMID: 33749972 DOI: 10.1002/ccd.29653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We aimed to explore the impact of 7-Fr sheaths on the incidence of early radial artery occlusion (RAO) after transradial coronary intervention (TRI) in Chinese patients. BACKGROUND RAO precludes future use of the vessel for vascular access. Transradial catheterization is usually performed via 5-Fr or 6-Fr catheters; 7-Fr sheath insertion enables complex coronary interventions but may increase the RAO risk. METHODS We prospectively enrolled 130 consecutive patients undergoing complex TRI using 7-Fr sheaths. Radial artery ultrasound assessment was performed before and after TRI. Early RAO was defined as the absence of flow on ultrasound within 6-24 hr after TRI. Multivariate logistic regression was used to determine the factors related to early RAO after TRI. RESULTS 7-Fr sheaths were mainly used for chronic total occlusion (44.6%), bifurcation (30.0%), and tortuous calcification (25.4%) lesions. All patients were successfully sheathed. Percutaneous coronary intervention (PCI) procedural success was 96.2%; 119 patients (91.5%) had preserved radial artery patency after TRI. All 11 RAO cases (8.5%) were asymptomatic. The radial artery diameter was significantly larger postoperatively (3.1 ± 0.4 mm) than preoperatively (2.6 ± 0.5 mm) (p < .001). No parameters significantly differed between patients with and without RAO. TRI history was the only independent risk factor of early RAO (odds ratio: 6.047, 95% confidence interval: 1.100-33.253, p = .039). CONCLUSIONS 7-Fr sheath use after transradial access for complex PCI is feasible and safe. Evaluating the radial artery within 24 hr after TRI allows timely RAO recognition, important for taking measures to maintain radial artery patency and preserve access for future TRIs.
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Affiliation(s)
- Hao Wang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao-Yu Wang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Yin
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Feng
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Hua Song
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Jian Wang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cheng-Gang Zhu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke-Fei Dou
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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23
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Galusko V, Protty M, Haboubi HN, Verhemel S, Bundhoo S, Yeoman AD. Endoscopy findings in patients on dual antiplatelet therapy following percutaneous coronary intervention. Postgrad Med J 2021; 98:591-597. [PMID: 33879553 DOI: 10.1136/postgradmedj-2021-139928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE OF STUDY This study examines the associations between dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) and gastrointestinal bleeding (GIB), to explore possible predictors of outcomes. STUDY DESIGN Retrospective analysis of 3342 patients who underwent PCI between 1 August 2011 and 31 December 2018 in a single centre was carried out. Oesophagogastroduodenoscopies (OGDs) for patients 12 months post-PCI were analysed. RESULTS Blood loss occurred in 2% of all (3342) patients post-PCI within 12 months. 128 patients (63% male, mean age (SD) of 69.8 (10) years) who had PCI subsequently underwent an OGD within 12 months of the index PCI procedure. GIB occurred within the first 30 days of DAPT in 36% (n=13/36) of cases. There were no thrombotic events associated with cessation of one antiplatelet agent. Increased age, haemoglobin (Hb) ≤109 g/L and Glasgow-Blatchford score ≥8 were associated with increased 12-month mortality. An Hb drop of ≥30 g/L was a sensitive and specific marker for significant pathology and evidence of bleeding on OGD (sensitivity=0.83, specificity=0.81). CONCLUSIONS GIB bleeding occurred infrequently in the patients post-PCI on DAPT. Risk assessment scores (such as Glasgow-Blatchford and Rockall scores) are useful tools to assess the urgency of OGD and need for endoscopic therapy.
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Affiliation(s)
- Victor Galusko
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Majd Protty
- Department of Cardiology, Royal Gwent Hospital, Newport, UK.,Systems Immunity University Research Institute, Cardiff University, Cardiff, UK
| | - Hasan N Haboubi
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Sarah Verhemel
- Department of Cardiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Shantu Bundhoo
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Andrew D Yeoman
- Department of Gastroenterology, Royal Gwent Hospital, Newport, UK
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24
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McHugh S, Noory A, Mishra S, Vanchiere C, Lakhter V. Vascular Access for Large Bore Access. Interv Cardiol Clin 2021; 10:157-167. [PMID: 33745666 DOI: 10.1016/j.iccl.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Recent advances in the field of interventional cardiology have allowed for more complex procedures to be performed percutaneously. Ability to obtain safe large bore vascular access is frequently the key factor to procedural success. Meticulous technique for successful vascular access incorporates the understanding of anatomic landmarks, ultrasound, fluoroscopy, and micropuncture. Adequate hemostasis at the end of the case can be achieved through careful use of commercially available vascular closure devices. Although access-related vascular complications are uncommon, early recognition is key to successful management. Arterial tortuosity and calcification can present a significant challenge to successful common femoral artery access.
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Affiliation(s)
- Stephen McHugh
- Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Ali Noory
- Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Suraj Mishra
- Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Catherine Vanchiere
- Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Vladimir Lakhter
- Division of Cardiovascular Diseases, Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, 3401 North Broad Street (9PP), Philadelphia, PA 19140, USA.
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25
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Sakai S, Tara S, Yamamoto T, Asano K, Kimura T, Fujimoto Y, Shiomura R, Matsuda J, Kadooka K, Takahashi K, Ko T, Sangen H, Saiki Y, Nakata J, Hosokawa Y, Takano H, Shimizu W. Gastrointestinal bleeding increases the risk of subsequent cardiovascular events in patients with acute cardiovascular diseases requiring intensive care. Heart Vessels 2021; 36:1327-1335. [PMID: 33683409 PMCID: PMC7937548 DOI: 10.1007/s00380-021-01822-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/26/2021] [Indexed: 11/17/2022]
Abstract
Gastrointestinal (GI) bleeding worsens the outcomes of critically ill patients in the intensive care unit (ICU). Owing to a lack of corresponding data, we aimed to investigate whether GI bleeding during cardiovascular-ICU (C-ICU) admission in acute cardiovascular (CV) disease patients is a risk factor for subsequent CV events. Totally, 492 consecutive C-ICU patients (40.9% acute coronary syndrome, 22.8% heart failure) were grouped into GI bleeding (n = 27; 12 upper GI and 15 lower GI) and non-GI bleeding (n = 465) groups. Thirty-nine patients died or developed CV events during hospitalization, and 453 were followed up from the date of C-ICU discharge to evaluate subsequent major adverse CV events. The GI bleeding group had a higher Acute Physiology and Chronic Health Evaluation II score (20.2 ± 8.2 vs. 15.1 ± 6.8, p < 0.001), higher frequency of mechanical ventilator use (29.6% vs. 13.1%, p = 0.039), and longer C-ICU admission duration (8 [5–16] days vs. 5 [3–8] days, p < 0.001) than the non-GI bleeding group. The in-hospital mortality rate did not differ between the groups. Of those who were followed-up, CV events after C-ICU discharge were identified in 34.6% and 14.3% of patients in the GI and non-GI bleeding groups, respectively, during a median follow-up period of 228 days (log rank, p < 0.001). GI bleeding was an independent risk factor for subsequent CV events (adjusted hazard ratio: 2.23, 95% confidence interval: 1.06–4.71; p = 0.035). GI bleeding during C-ICU admission was independently associated with subsequent CV events in such settings.
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Affiliation(s)
- Shin Sakai
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Shuhei Tara
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kazuhiro Asano
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Tokuhiro Kimura
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yuhi Fujimoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Reiko Shiomura
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Junya Matsuda
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kosuke Kadooka
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kenta Takahashi
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Toshinori Ko
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hideto Sangen
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yoshiyuki Saiki
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yusuke Hosokawa
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Wataru Shimizu
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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26
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Hishikari K, Hikita H, Abe F, Ito N, Kanno Y, Iiya M, Murai T, Takahashi A, Yonetsu T, Sasano T. Risk factors and prognostic impact of post-discharge bleeding after endovascular therapy for peripheral artery disease. Vasc Med 2021; 26:281-287. [PMID: 33645340 DOI: 10.1177/1358863x21992863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This study evaluated the incidence, predictors, and impact of bleeding requiring hospitalization following successful endovascular therapy (EVT) for peripheral artery disease. Platelet inhibition after EVT reduces the risk of major adverse limb events but increases the risk of bleeding. The incidence of post-discharge bleeding after EVT, its independent predictors, and its prognostic importance in clinical practice have not been fully addressed. We evaluated 779 consecutive patients who underwent EVT. We found that 77 patients (9.9%) were hospitalized for major bleeding during follow-up after EVT (median 39 months, range 22-66 months), with almost half (48.1%) of the bleeding categorized as gastrointestinal bleeding. Significant predictors of post-discharge bleeding were hemodialysis (hazard ratio (HR), 3.12; 95% CI: 1.93 to 5.05; p < 0.001) and dual antiplatelet therapy (DAPT) use (HR, 1.87; 95% CI: 1.03 to 3.41; p = 0.041). During follow-up, the all-cause mortality-free survival rate was significantly worse in patients who had experienced major bleeding than in those who had not (log-rank test χ2 = 54.6; p < 0.001). Cox proportional hazards analysis showed that major bleeding (HR, 2.78; 95% CI: 1.90 to 4.06; p < 0.001) was an independent predictor of all-cause death after EVT. Hospitalization for post-discharge bleeding after EVT is associated with a substantially increased risk of death, even after successful EVT. We concluded that patients' predicted bleeding risk should be considered when selecting patients likely to benefit from EVT, and that the risk should be considered especially thoroughly in hemodialysis patients.
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Affiliation(s)
- Keiichi Hishikari
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan.,Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Hikita
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Fumichika Abe
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Naruhiko Ito
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Yoshinori Kanno
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Munehiro Iiya
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Tadashi Murai
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | | | - Taishi Yonetsu
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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27
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Gupta K, Khan A, Kumar M, Sawalha K, Abozenah M, Singhania R. Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective. Dig Dis Sci 2021; 66:751-759. [PMID: 32436123 DOI: 10.1007/s10620-020-06315-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI. METHODS Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis. RESULTS Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72). CONCLUSIONS In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care.
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Affiliation(s)
- Kamesh Gupta
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA.
| | - Ahmad Khan
- Department of Internal Medicine, West Virginia University- Charleston Division, Charleston, WV, USA
| | - Manish Kumar
- Department of Internal Medicine, Yale-Danbury Hospital, Danbury, CT, USA
| | - Khalid Sawalha
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA
| | - Mohammed Abozenah
- Department of Internal Medicine, UMMS-Baystate Medical Center, Springfield, MA, USA
| | - Rohit Singhania
- Department of Gastroenterology, UMMS-Baystate Medical Center, Springfield, MA, USA
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Ybarra LF, Rinfret S, Brilakis ES, Karmpaliotis D, Azzalini L, Grantham JA, Kandzari DE, Mashayekhi K, Spratt JC, Wijeysundera HC, Ali ZA, Buller CE, Carlino M, Cohen DJ, Cutlip DE, De Martini T, Di Mario C, Farb A, Finn AV, Galassi AR, Gibson CM, Hanratty C, Hill JM, Jaffer FA, Krucoff MW, Lombardi WL, Maehara A, Magee PFA, Mehran R, Moses JW, Nicholson WJ, Onuma Y, Sianos G, Sumitsuji S, Tsuchikane E, Virmani R, Walsh SJ, Werner GS, Yamane M, Stone GW, Rinfret S, Stone GW. Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO-ARC Consensus Recommendations. Circulation 2021; 143:479-500. [PMID: 33523728 DOI: 10.1161/circulationaha.120.046754] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Over the past 2 decades, chronic total occlusion (CTO) percutaneous coronary intervention has developed into its own subspecialty of interventional cardiology. Dedicated terminology, techniques, devices, courses, and training programs have enabled progressive advancements. However, only a few randomized trials have been performed to evaluate the safety and efficacy of CTO percutaneous coronary intervention. Moreover, several published observational studies have shown conflicting data. Part of the paucity of clinical data stems from the fact that prior studies have been suboptimally designed and performed. The absence of standardized end points and the discrepancy in definitions also prevent consistency and uniform interpretability of reported results in CTO intervention. To standardize the field, we therefore assembled a broad consortium comprising academicians, practicing physicians, researchers, medical society representatives, and regulators (US Food and Drug Administration) to develop methods, end points, biomarkers, parameters, data, materials, processes, procedures, evaluations, tools, and techniques for CTO interventions. This article summarizes the effort and is organized into 3 sections: key elements and procedural definitions, end point definitions, and clinical trial design principles. The Chronic Total Occlusion Academic Research Consortium is a first step toward improved comparability and interpretability of study results, supplying an increasingly growing body of CTO percutaneous coronary intervention evidence.
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Affiliation(s)
- Luiz F Ybarra
- London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada (L.F.Y.)
| | - Stéphane Rinfret
- McGill University Health Centre, McGill University, Montreal, Quebec, Canada (S.R.)
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (E.S.B.)
| | - Dimitri Karmpaliotis
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | - Lorenzo Azzalini
- Cardiac Catheterization Laboratory, Mount Sinai Hospital, New York, NY (L.A.)
| | - J Aaron Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.G.)
| | | | - Kambis Mashayekhi
- Department of Cardiology and Angiology II University Heart Center (K.M.), Freiburg, Bad Krozingen, Germany
| | - James C Spratt
- St George's University Hospital NHS Trust, London, United Kingdom (J.C.S.)
| | - Harindra C Wijeysundera
- Schulich Heart Center, Sunnybrook Research Institute, and Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, and Institute for Health Policy, Management, and Evaluation (H.C.W.), University of Toronto, Ontario, Canada
| | - Ziad A Ali
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | | | - Mauro Carlino
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.C.)
| | - David J Cohen
- Baim Institute for Clinical Research, Boston, MA (D.J.C., C.M.G.)
| | | | - Tony De Martini
- Southern Illinois University School of Medicine, Memorial Medical Center, Springfield, IL (T.D.M.)
| | - Carlo Di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy (C.D.M.)
| | - Andrew Farb
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD (A.F., R.V.).,School of Medicine, University of Maryland, Baltimore (A.F.)
| | - Aloke V Finn
- US Food and Drug Administration, Silver Spring, MD (A.V.F., P.F.A.M.)
| | - Alfredo R Galassi
- Cardiology, Department of PROMISE, University of Palermo, Italy (A.R.G.)
| | - C Michael Gibson
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.J.C., C.M.G.)
| | - Colm Hanratty
- Belfast Health and Social Care Trust, United Kingdom (C.H.)
| | | | - Farouc A Jaffer
- Cardiology Division, Massachusetts General Hospital, Boston (F.A.J.)
| | - Mitchell W Krucoff
- Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (M.W.K.)
| | | | - Akiko Maehara
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | - P F Adrian Magee
- US Food and Drug Administration, Silver Spring, MD (A.V.F., P.F.A.M.)
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
| | - Jeffrey W Moses
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | | | - Yoshinobu Onuma
- Cardialysis Clinical Trials Management and Core Laboratories, Rotterdam, the Netherlands (Y.O.).,Department of Cardiology, National University of Ireland Galway, United Kingdom (Y.O.)
| | | | - Satoru Sumitsuji
- Division of Cardiology for International Education and Research, Osaka University Graduate School of Medicine, Suita, Japan (S.S.)
| | | | - Renu Virmani
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD (A.F., R.V.)
| | - Simon J Walsh
- Belfast Health and Social Care Trust, United Kingdom. Medizinische Klinik I Klinikum Darmstadt GmbH, Germany (S.J.W.)
| | | | | | - Gregg W Stone
- The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.).,Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
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29
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Tung YC, See LC, Chang SH, Liu JR, Kuo CT, Chang CJ. Impact of bleeding during dual antiplatelet therapy in patients with coronary artery disease. Sci Rep 2020; 10:21345. [PMID: 33288822 PMCID: PMC7721794 DOI: 10.1038/s41598-020-78400-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 11/10/2020] [Indexed: 11/09/2022] Open
Abstract
This nationwide retrospective cohort study used the National Health Insurance Research Database of Taiwan to compare the impact of bleeding on clinical outcomes in patients with acute myocardial infarction (AMI) versus chronic coronary syndrome (CCS). Between July 2007 and December 2010, patients with AMI (n = 15,391) and CCS (n = 19,724) who received dual antiplatelet therapy after coronary stenting were identified from the database. AMI was associated with increased risks of MI (AMI vs. CCS: 0.38 vs. 0.16 per 100 patient-months; p < 0.01), all-cause death (0.49 vs. 0.32 per 100 patient-months; p < 0.01), and BARC type 3 bleeding (0.22 vs. 0.13 per 100 patient-months; p < 0.01) at 1 year compared with CCS, while the risk of BARC type 2 bleeding was marginally higher in the CCS patients than in the AMI patients (1.32 vs. 1.4 per 100 person-months; p = 0.06). Bleeding was an independent predictor of MI, stroke, and all-cause death in this East Asian population, regardless of the initial presentation. Among the patients with bleeding, AMI was associated with a higher risk of ischemic events at 1 year after bleeding compared with CCS (MI: 0.34 vs. 0.25 per 100 patient-months; p = 0.06; ischemic stroke: 0.22 vs. 0.13 per 100 patient-months; p = 0.02). The 1-year mortality after bleeding was comparable between the two groups after propensity score weighting. In conclusion, bleeding conferred an increased risk of adverse outcomes in East Asian patients with AMI and CCS.
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Affiliation(s)
- Ying-Chang Tung
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan, ROC.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Shu-Hao Chang
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Jia-Rou Liu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Tai Kuo
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC.,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Chi-Jen Chang
- Cardiovascular Department, Linkou Chang Gung Memorial Hospital, No. 5, Fusing St., Gueishan Dist., Taoyuan City, 33305, Taiwan, ROC. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.
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30
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Lemesle G, Ninni S, de Groote P, Schurtz G, Lamblin N, Bauters C. Relative impact of bleedings over ischaemic events in patients with heart failure: insights from the CARDIONOR registry. ESC Heart Fail 2020; 7:3821-3829. [PMID: 32918405 PMCID: PMC7754769 DOI: 10.1002/ehf2.12971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 01/05/2023] Open
Abstract
AIMS Major bleeding events in heart failure (HF) patients are poorly described. We sought to investigate the importance of major bleeding and its impact on outcomes in HF patients. METHODS AND RESULTS We analysed incident bleeding and ischaemic events during a 3 year follow-up in 2910 HF outpatients included in a prospective multicentre registry. Major bleeding was defined as a Type ≥3 bleed using the Bleeding Academic Research Consortium definition. Ischaemic event was a composite of ischaemic stroke and myocardial infarction. Events were adjudicated by a blinded committee. At inclusion, most patients (89%) received at least one antithrombotic: anticoagulation (53.9%) and/or antiplatelet therapy (46.2%). Bleeding occurred in 111 patients {3 year cumulative incidence: 3.6% [95% confidence interval (CI) 3.0-4.3]} and ischaemic events in 102 patients [3 year cumulative incidence: 3.3% (95% CI 2.7-4.0)]. Most bleedings were Bleeding Academic Research Consortium 3a (32.5%) or 3b (31.5%). Most frequent sites of bleeding were gastrointestinal (40.6%) and intracranial (27.9%). Variables associated with bleeding were atrial fibrillation [hazard ratio (HR) = 2.63 (95% CI 1.66-4.19), P < 0.0001], diabetes [HR = 1.62 (95% CI 1.11-2.38), P = 0.012], and older age [HR = 1.19 per 10 year increase (95% CI 1.00-1.41), P = 0.049]. Anticoagulation use was associated with a two-fold increase in the bleeding risk. Bleeding events as well as ischaemic events were strongly associated with subsequent mortality [adjusted HRs: 5.67 (4.41-7.29), P < 0.0001 and 4.29 (3.18-5.78), P < 0.0001, respectively]. CONCLUSIONS In HF outpatients, antithrombotics are widely used. Bleeding occurs at a stable rate of 1.2% annually (as frequent as ischaemic events) and is associated with a dramatic increase in mortality (at least as severe as ischaemic events). Most events occurred in patients receiving anticoagulation. Knowledge of these findings may help physicians to manage antithrombotics in HF patients.
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Affiliation(s)
- Gilles Lemesle
- Institut Cœur PoumonCentre Hospitalier Universitaire de LilleLilleFrance
- Faculté de Médecine de LilleUniversité de LilleLilleFrance
- Institut Pasteur de LilleInserm U1011LilleFrance
- FACT (French Alliance for Cardiovascular Trials)ParisFrance
| | - Sandro Ninni
- Institut Cœur PoumonCentre Hospitalier Universitaire de LilleLilleFrance
- Faculté de Médecine de LilleUniversité de LilleLilleFrance
- Institut Pasteur de LilleInserm U1011LilleFrance
| | - Pascal de Groote
- Institut Cœur PoumonCentre Hospitalier Universitaire de LilleLilleFrance
- Institut Pasteur de LilleInserm U1167LilleFrance
| | - Guillaume Schurtz
- Institut Cœur PoumonCentre Hospitalier Universitaire de LilleLilleFrance
| | - Nicolas Lamblin
- Institut Cœur PoumonCentre Hospitalier Universitaire de LilleLilleFrance
- Faculté de Médecine de LilleUniversité de LilleLilleFrance
- Institut Pasteur de LilleInserm U1167LilleFrance
| | - Christophe Bauters
- Institut Cœur PoumonCentre Hospitalier Universitaire de LilleLilleFrance
- Faculté de Médecine de LilleUniversité de LilleLilleFrance
- Institut Pasteur de LilleInserm U1167LilleFrance
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31
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Mohadjer A, Brown G, Shah SR, Nallapati C, Waheed N, Bavry AA, Park K. Sex-Based Differences in Coronary and Structural Percutaneous Interventions. Cardiol Ther 2020; 9:257-273. [PMID: 32440761 PMCID: PMC7584690 DOI: 10.1007/s40119-020-00176-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Indexed: 02/06/2023] Open
Abstract
In the current state of interventional cardiology, the ability to offer advanced therapies to patients who historically were not surgical candidates has grown exponentially in the last few decades. As therapies have expanded in complex coronary and structural interventions, the nuances of treating certain populations have emerged. In particular, the role of sex-based anatomic and outcome differences has been increasingly recognized. As guidelines for cardiovascular prevention and treatment for certain conditions may vary by sex, therapeutic interventions in the structural and percutaneous coronary areas may also vary. In this review, we aim to discuss these differences, the current literature available on these topics, and areas of focus for the future.
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Affiliation(s)
- Ashley Mohadjer
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Garrett Brown
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of South Florida, Tampa, FL, USA
| | - Syed R Shah
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - Charishma Nallapati
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Nida Waheed
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Anthony A Bavry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
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32
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Zhang Y, Zhang Y, Liu Z, Zhang B, Liu G, Chen K. Bivalirudin versus unfractionated heparin during percutaneous coronary intervention in high-bleeding-risk patients with acute coronary syndrome in contemporary practice. Biomed Pharmacother 2020; 130:110758. [PMID: 34321166 DOI: 10.1016/j.biopha.2020.110758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Bivalirudin, as compared with unfractionated heparin (UFH), has been shown to reduce bleeding complications and supply a better safety profile among low/medium-bleeding-risk patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) in some previous studies. Whether this advantage persists in patients at high risk of bleeding according to contemporary practice characterized by frequent use of radial-artery access and novel P2Y12 inhibitors, and low use of glycoprotein IIb/IIIa inhibitors (GPIs) is unclear. AIM OF THE STUDY This study aimed to assess the efficacy and safety of bivalirudin compared with UFH in high bleeding risk patients with ACS undergoing PCI in current practice. MATERIALS AND METHODS All consecutive high-bleeding-risk patients who underwent PCI for ACS at the First Affiliated Hospital of Zhengzhou University from January to September 2019 were retrospectively analyzed. The 30-day primary outcome was a composite of major bleeding, myocardial infarction, all-cause death, or stroke (net adverse clinical events [NACEs]), and the secondary outcomes at 30 days included a composite of myocardial infarction, stoke, or all-cause death (major adverse cardiovascular events [MACEs]), each component of the primary outcome, target vessel revascularization (TVR) and stent thrombosis (ST). Besides, we assessed angina-related health status at 30 days, the length of hospital stay, and hospitalization costs. A logistic regression model was used to adjust for baseline differences. Consistency of the treatment effect of bivalirudin for NACEs and MACEs compared with UFH was evaluated in 15 prespecified subgroups. RESULTS From January to September 2019, 823 patients (361 treated with bivalirudin and 462 treated with UFH) were enrolled in the study. GPIs, novel P2Y12 inhibitors, and radial approach was used in 5.6 %, 66.1 %, and 89.7 % of the patients, respectively. After adjusting for baseline differences, bivalirudin was associated with significant reduction in NACEs, MACEs, major bleeding, and myocardial infarction at 30 days compared with UFH. The individual endpoints of death, stroke, ST and TVR did not differ significantly between the 2 groups after adjusting for covariates. Furthermore, bivalirudin consistently reduced the rates of NACEs and MACEs in the 15 prespecified subgroups compared with UFH. These benefits of bivalirudin can translate into improved angina-related health status, shorter hospital stays, and lower hospitalization costs. CONCLUSIONS The treatment of bivalirudin showed better efficacy and safety as compared to UFH among patients with ACS undergoing PCI at high risk of bleeding in contemporary practice.
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Affiliation(s)
- Yahao Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Yanghui Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Zhiyu Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Bin Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Guizhi Liu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Kui Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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Soeda T, Okura H, Saito Y, Nakao K, Ozaki Y, Kimura K, Ako J, Noguchi T, Suwa S, Fujimoto K, Nakama Y, Morita T, Shimizu W, Hirohata A, Morita Y, Inoue T, Okamura A, Mano T, Hirata K, Tanabe K, Shibata Y, Owa M, Tsujita K, Funayama H, Kokubu N, Kozuma K, Uemura S, Toubaru T, Saku K, Oshima S, Miyamoto Y, Ogawa H, Ishihara M. Clinical characteristics and in-hospital outcomes in patients aged 80 years or over with cardiac troponin-positive acute myocardial infarction -J-MINUET study. J Cardiol 2020; 77:139-146. [PMID: 32938566 DOI: 10.1016/j.jjcc.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/19/2020] [Accepted: 07/27/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The prevalence of acute myocardial infarction (AMI) in elderly people is increasing worldwide. However, their characteristics and prognosis have been rarely investigated. This study aimed to investigate the characteristics and prognosis in elderly patients with cardiac troponin-positive AMI. METHODS Consecutive patients with AMI from the J-MINUET study were divided into the following 3 groups: patients aged less than 65 years, those aged between 65 and 79 years, and those aged 80 years or over. Their characteristics and in-hospital outcomes were compared. RESULTS Patients with AMI aged 80 years or over had the highest incidence of female gender, and the highest incidence of hypertension, chronic kidney disease, and cardiovascular disease, such as peripheral artery disease, atrial fibrillation, and stroke, whereas they had the lowest body mass index, and the lowest incidence of current smoker, diabetes mellitus, and dyslipidemia. Patients with AMI aged 80 years or over had significantly longer onset to door time and longer door to device time, and lower peak creatine kinase (CK). The incidence of ST-segment elevation myocardial infarction (STEMI) was the lowest in the AMI patients aged 80 years or over, but the patients had a higher incidence of in-hospital death and cardiac failure than the other two groups. In addition, the presentation with STEMI and non-ST-segment elevation myocardial infarction with CK elevation among patients aged 80 years or over showed the highest incidence of in-hospital death and cardiac failure. CONCLUSIONS J-MINUET showed different clinical characteristics between the aged and younger populations. The incidence of in-hospital death and cardiac failure in patients aged 80 years or over with AMI was poorer than their younger counterparts.
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Affiliation(s)
- Tsunenari Soeda
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan.
| | - Hiroyuki Okura
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan; Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University, Sagamihara, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Kazuteru Fujimoto
- Department of Cardiology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Yasuharu Nakama
- Department of Cardiology, Miyoshi Central Hospital, Miyoshi, Japan
| | - Takashi Morita
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Atsushi Hirohata
- Department of Cardiovascular Medicine, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Yasuhiro Morita
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Teruo Inoue
- Department of Cardiovascular Medicine, Dokkyo Medical University, Tochigi, Japan
| | - Atsunori Okamura
- Department of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Toshiaki Mano
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Kazuhito Hirata
- Department of Cardiology, Okinawa Chubu Hospital, Uruma, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Mafumi Owa
- Department of Cardiovascular Medicine, Suwa Red Cross Hospital, Suwa, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Funayama
- Division of Cardiovascular Medicine, Saitama Medical Center Jichi Medical University, Saitama, Japan
| | - Nobuaki Kokubu
- Department of Cardiovascular, Renal and Medabolic Medicine, Sapporo Medical University, Sapporo, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University, Tokyo, Japan
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Tetsuya Toubaru
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Keijirou Saku
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Shigeru Oshima
- Department of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Sweid A, Das S, Weinberg JH, E l Naamani K, Kim J, Curtis D, Joffe D, Hiranaka CG, Vijaywargiya D, Sioka C, Oneissi M, El Hajjar AH, Gooch MR, Herial N, Tjoumakaris SI, Rosenwasser RH, Jabbour P. Transradial approach for diagnostic cerebral angiograms in the elderly: a comparative observational study. J Neurointerv Surg 2020; 12:1235-1241. [DOI: 10.1136/neurintsurg-2020-016140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 11/03/2022]
Abstract
BackgroundThe transradial approach (TRA) reduces mortality, morbidity, access site complications, hospital cost, and length of stay while maximizing patient satisfaction. We aimed to assess the technical success and safety of TRA for elderly patients (aged ≥75 years).MethodsA retrospective chart review and comparative analysis was performed for elderly patients undergoing a diagnostic cerebral angiogram performed via TRA versus transfemoral approach (TFA). Also, a second comparative analysis was performed among the TRA cohort between elderly patients and their younger counterparts.ResultsComparative analysis in the elderly (TRA vs TFA) showed no significant differences for contrast dose per vessel (43.7 vs 34.6 mL, P=0.106), fluoroscopy time per vessel (5.7 vs 5.2 min, P=0.849), procedure duration (59.8 vs 65.2 min, P=0.057), conversion rate (5.8% vs 2.9%, P=0.650), and access site complications (2.3% vs 2.9%, P=1.00). Radiation exposure per vessel (18.9 vs 51.9 Gy cm2, P=0.001) was significantly lower in the elderly TRA group.The second comparison (TRA in elderly vs TRA in the young) showed no significant differences for contrast dose per vessel (43.7 vs 37.8 mL, P=0.185), radiation exposure per vessel (18.9 vs 16.5 Gy cm2, P=0.507), procedure duration (59.8 vs 58.3 min, P=0.788), access site complication (2.3% vs 1.7%, P=0.55), and conversation rate (5.8% vs 1.8%, P=0.092). A trend for prolonged fluoroscopy time per vessel (5.7 vs 4.7 min, P=0.050) was observed in the elderly TRA group.ConclusionsTRA is a technically feasible and safe option for diagnostic neurointerventional procedures in the elderly. Our small elderly cohort was not powered enough to show a significant difference in terms of access site complications between TRA and TFA.
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Meijers TA, Aminian A, Teeuwen K, van Wely M, Schmitz T, Dirksen MT, van der Schaaf RJ, Iglesias JF, Agostoni P, Dens J, Knaapen P, Rathore S, Ottervanger JP, Dambrink JHE, Roolvink V, Gosselink ATM, Hermanides RS, van Royen N, van Leeuwen MAH. Complex Large-Bore Radial percutaneous coronary intervention: rationale of the COLOR trial study protocol. BMJ Open 2020; 10:e038042. [PMID: 32690749 PMCID: PMC7375502 DOI: 10.1136/bmjopen-2020-038042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The radial artery has become the standard access site for percutaneous coronary intervention (PCI) in stable coronary artery disease and acute coronary syndrome, because of less access site related bleeding complications. Patients with complex coronary lesions are under-represented in randomised trials comparing radial with femoral access with regard to safety and efficacy. The femoral artery is currently the most applied access site in patients with complex coronary lesions, especially when large bore guiding catheters are required. With slender technology, transradial PCI may be increasingly applied in patients with complex coronary lesions when large bore guiding catheters are mandatory and might be a safer alternative as compared with the transfemoral approach. METHODS AND ANALYSIS A total of 388 patients undergoing complex PCI will be randomised to radial 7 French access with Terumo Glidesheath Slender (Terumo, Japan) or femoral 7 French access as comparator. The primary outcome is the incidence of the composite end point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Procedural success and major adverse cardiovascular events up to 1 month will also be compared between both groups. ETHICS AND DISSEMINATION Ethical approval for the study was granted by the local Ethics Committee at each recruiting center ('Medisch Ethische Toetsing Commissie Isala Zwolle', 'Commissie voor medische ethiek ZNA', 'Comité Medische Ethiek Ziekenhuis Oost-Limburg', 'Comité d'éthique CHU-Charleroi-ISPPC', 'Commission cantonale d'éthique de la recherche CCER-Republique et Canton de Geneve', 'Ethik Kommission de Ärztekammer Nordrhein' and 'Riverside Research Ethics Committee'). The trial outcomes will be published in peer-reviewed journals of the concerned literature. TRIAL REGISTRATION NUMBER NCT03846752.
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Affiliation(s)
| | - Adel Aminian
- Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Wallonie, Belgium
| | - Koen Teeuwen
- Cardiology, Catharina Hospital, Eindhoven, Noord Brabant, The Netherlands
| | | | - Thomas Schmitz
- Cardiology, Elisabeth-Krankenhaus-Essen GmbH, Essen, Nordrhein-Westfalen, Germany
| | - Maurits T Dirksen
- Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
| | | | - Juan F Iglesias
- Cardiology, Geneva University Hospitals, Geneve, Genève, Switzerland
| | | | - Joseph Dens
- Cardiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Paul Knaapen
- Cardiology, Amsterdam UMC - Locatie VUMC, Amsterdam, Noord-Holland, The Netherlands
| | - Sudhir Rathore
- Cardiology, Frimley Health NHS Foundation Trust, Frimley, Surrey, UK
| | | | | | | | | | | | - Niels van Royen
- Cardiology, Radboudumc, Nijmegen, Gelderland, The Netherlands
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Völz S, Petursson P, Odenstedt J, Ioanes D, Haraldsson I, Angerås O, Dworeck C, Hirlekar G, Myredal A, Albertsson P, Råmunddal T, Redfors B, Omerovic E. Ticagrelor is Not Superior to Clopidogrel in Patients With Acute Coronary Syndromes Undergoing PCI: A Report from Swedish Coronary Angiography and Angioplasty Registry. J Am Heart Assoc 2020; 9:e015990. [PMID: 32662350 PMCID: PMC7660716 DOI: 10.1161/jaha.119.015990] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Ticagrelor reduces ischaemic end points in acute coronary syndromes. However, outcomes of ticagrelor versus clopidogrel in real‐world patients with acute coronary syndromes treated with percutaneous coronary intervention (PCI) remain unclear. We sought to examine whether treatment with ticagrelor is superior to clopidogrel in unselected patients with acute coronary syndromes treated with PCI. Methods and Results We used data from SCAAR (Swedish Coronary Angiography and Angioplasty Registry) for PCI performed in Västra Götaland County, Sweden. The database contains information about all PCI performed at 5 hospitals (∼20% of all data in SCAAR). All procedures between January 2005 and January 2015 for unstable angina/non‒ST‐segment‒elevation myocardial infarction and ST‐segment‒elevation myocardial infarction were included. We used instrumental variable 2‐stage least squares regression to adjust for confounders. The primary combined end point was mortality or stent thrombosis at 30 days, secondary end points were mortality at 30 days and 1‐year, stent thrombosis at 30 days, in‐hospital bleeding, in‐hospital neurologic complications and long‐term mortality. A total of 15 097 patients were included in the study of which 2929 (19.4%) were treated with ticagrelor. Treatment with ticagrelor was not associated with a lower risk for the primary end point (adjusted odds ratio [aOR], 1.20; 95% CI, 0.87–1.61; P=0.250). Estimated risk of death at 30 days (aOR, 1.18; 95% CI, 0.88–1.64; P=0.287) and at 1‐year (aOR, 1.28; 95% CI, 0.86–1.64; P=0.556) was not different between the groups. The risk of in‐hospital bleeding was higher with ticagrelor (aOR, 2.88; 95% CI, 1.53–5.44; P=0.001). Conclusions In this observational study, treatment with ticagrelor was not superior to clopidogrel in patients with acute coronary syndromes treated with PCI.
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Affiliation(s)
- Sebastian Völz
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Petur Petursson
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Jacob Odenstedt
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Dan Ioanes
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Inger Haraldsson
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Oskar Angerås
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Christian Dworeck
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Geir Hirlekar
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Anna Myredal
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Per Albertsson
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Truls Råmunddal
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Björn Redfors
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Elmir Omerovic
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
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Two Sides of a Coin With Disparate Effects: Mechanical Circulatory Support and Bleeding. JACC Cardiovasc Interv 2020; 13:1194-1197. [PMID: 32438989 DOI: 10.1016/j.jcin.2020.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
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Murali S, Vogrin S, Noaman S, Dinh DT, Brennan AL, Lefkovits J, Reid CM, Cox N, Chan W. Bleeding Severity in Percutaneous Coronary Intervention (PCI) and Its Impact on Short-Term Clinical Outcomes. J Clin Med 2020; 9:jcm9051426. [PMID: 32403442 PMCID: PMC7291133 DOI: 10.3390/jcm9051426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/27/2022] Open
Abstract
Bleeding severity in patients undergoing percutaneous coronary intervention (PCI), defined by the Bleeding Academic Research Consortium (BARC), portends adverse prognosis. We analysed data from 37,866 Australian patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR), and investigated the association between increasing BARC severity and in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) (a composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, or stroke). Independent predictors associated with major bleeding (BARC groups 3&5), and MACCE were also assessed. There was a stepwise increase in in-hospital and 30-day MACCE with greater severity of bleeding. Independent predictors of bleeding included female sex (Odds Ratio (OR) 1.34), age (OR 1.02), fibrinolytic therapy (OR 1.77), femoral access (OR 1.51), and ticagrelor (OR 1.42), all significant at the p < 0.001 level. Following adjustment of clinically important variables, BARC 3&5 bleeds (OR 4.37) were still predictive of cumulative in-hospital and 30-day MACCE. In conclusion, major bleeding is an uncommon but potentially fatal PCI complication and was independently associated with greater MACCE rates. Efforts to mitigate the occurrence of bleeding, including radial access and judicious use of potent antiplatelet therapies, may ameliorate the risk of short-term adverse clinical outcomes.
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Affiliation(s)
- Shashank Murali
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
| | - Sara Vogrin
- Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne 3010, Victoria, Australia;
| | - Samer Noaman
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
- Department of Cardiology, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Diem T. Dinh
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Angela L. Brennan
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Jeffrey Lefkovits
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Christopher M. Reid
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
- School of Public Health, Curtin University, Perth 6102, Western Australia, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
| | - William Chan
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
- Department of Cardiology, Alfred Health, Melbourne 3004, Victoria, Australia
- Correspondence: ; Tel.: +61-(03)-8345-1333
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Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, Watanabe H, Yamaji K, Watanabe H, Kato T, Saito N, Ando K, Kadota K, Furukawa Y, Kimura T. Transradial vs. Transfemoral Percutaneous Coronary Intervention in Patients With or Without High Bleeding Risk Criteria. Circ J 2020; 84:723-732. [PMID: 32188831 DOI: 10.1253/circj.cj-19-1117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The transradial approach is reportedly associated with reduced bleeding complications and mortality after percutaneous coronary intervention (PCI). It is unknown whether the clinical benefits of transradial vs. transfemoral PCI differ between high bleeding risk (HBR) and non-HBR patients. METHODS AND RESULTS After excluding patients with acute myocardial infarction, dialysis, and a transbrachial approach from the 13,087 patients undergoing first PCI in the CREDO-Kyoto Registry Cohort-2, 6,828 patients were eligible for this study. Patients were divided into 2 groups according to bleeding risk based on Academic Research Consortium HBR criteria, and then divided into a further 2 groups according to access site, radial or femoral: HBR-radial, n=1,054 (38.3%); HBR-femoral, n=1,699 (61.7%); non-HBR-radial, n=1,682 (41.3%); and non-HBR-femoral, n=2,393 (58.7%). In the HBR group, the 30-day incidence and adjusted risk for major bleeding (1.9% vs. 4.7% [P<0.001]; adjusted hazard ratio [aHR] 0.44, 95% confidence interval [CI] 0.26-0.71 [P<0.001]) and all-cause death (0.3% vs. 0.9% [P=0.04]; aHR 0.30, 95% CI 0.07-0.93 [P=0.04]) were significantly lower in the radial than femoral group. There were no significant differences in the 30-day incidence and adjusted risk for major bleeding (0.5% vs. 1.0% [P=0.09]; aHR 0.68, 95% CI 0.30-1.45 [P=0.33]) or all-cause death (0.1% vs. 0.1% [P=0.96]; aHR 1.51, 95% CI 0.19-9.54 [P=0.67]) between the radial and femoral approaches in the non-HBR group. CONCLUSIONS Compared with transfemoral PCI, transradial PCI was associated with lower risk for 30-day major bleeding and mortality in HBR but not non-HBR patients.
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Affiliation(s)
- Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Hiroki Watanabe
- Division of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kenji Ando
- Division of Cardiology, Kokura Memorial Hospital
| | | | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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Dhruva SS, Ross JS, Mortazavi BJ, Hurley NC, Krumholz HM, Curtis JP, Berkowitz A, Masoudi FA, Messenger JC, Parzynski CS, Ngufor C, Girotra S, Amin AP, Shah ND, Desai NR. Association of Use of an Intravascular Microaxial Left Ventricular Assist Device vs Intra-aortic Balloon Pump With In-Hospital Mortality and Major Bleeding Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock. JAMA 2020; 323:734-745. [PMID: 32040163 PMCID: PMC7042879 DOI: 10.1001/jama.2020.0254] [Citation(s) in RCA: 278] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with substantial morbidity and mortality. Although intravascular microaxial left ventricular assist devices (LVADs) provide greater hemodynamic support as compared with intra-aortic balloon pumps (IABPs), little is known about clinical outcomes associated with intravascular microaxial LVAD use in clinical practice. OBJECTIVE To examine outcomes among patients undergoing percutaneous coronary intervention (PCI) for AMI complicated by cardiogenic shock treated with mechanical circulatory support (MCS) devices. DESIGN, SETTING, AND PARTICIPANTS A propensity-matched registry-based retrospective cohort study of patients with AMI complicated by cardiogenic shock undergoing PCI between October 1, 2015, and December 31, 2017, who were included in data from hospitals participating in the CathPCI and the Chest Pain-MI registries, both part of the American College of Cardiology's National Cardiovascular Data Registry. Patients receiving an intravascular microaxial LVAD were matched with those receiving IABP on demographics, clinical history, presentation, infarct location, coronary anatomy, and clinical laboratory data, with final follow-up through December 31, 2017. EXPOSURES Hemodynamic support, categorized as intravascular microaxial LVAD use only, IABP only, other (such as use of a percutaneous extracorporeal ventricular assist system, extracorporeal membrane oxygenation, or a combination of MCS device use), or medical therapy only. MAIN OUTCOMES AND MEASURES The primary outcomes were in-hospital mortality and in-hospital major bleeding. RESULTS Among 28 304 patients undergoing PCI for AMI complicated by cardiogenic shock, the mean (SD) age was 65.0 (12.6) years, 67.0% were men, 81.3% had an ST-elevation myocardial infarction, and 43.3% had cardiac arrest. Over the study period among patients with AMI, an intravascular microaxial LVAD was used in 6.2% of patients, and IABP was used in 29.9%. Among 1680 propensity-matched pairs, there was a significantly higher risk of in-hospital death associated with use of an intravascular microaxial LVAD (45.0%) vs with an IABP (34.1% [absolute risk difference, 10.9 percentage points {95% CI, 7.6-14.2}; P < .001) and also higher risk of in-hospital major bleeding (intravascular microaxial LVAD [31.3%] vs IABP [16.0%]; absolute risk difference, 15.4 percentage points [95% CI, 12.5-18.2]; P < .001). These associations were consistent regardless of whether patients received a device before or after initiation of PCI. CONCLUSIONS AND RELEVANCE Among patients undergoing PCI for AMI complicated by cardiogenic shock from 2015 to 2017, use of an intravascular microaxial LVAD compared with IABP was associated with higher adjusted risk of in-hospital death and major bleeding complications, although study interpretation is limited by the observational design. Further research may be needed to understand optimal device choice for these patients.
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Affiliation(s)
- Sanket S. Dhruva
- University of California, San Francisco School of Medicine, San Francisco
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Bobak J. Mortazavi
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Computer Science and Engineering, Texas A&M University, College Station
- Center for Remote Health Technologies and Systems, Texas A&M University, College Station
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nathan C. Hurley
- Department of Computer Science and Engineering, Texas A&M University, College Station
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alyssa Berkowitz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Frederick A. Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - John C. Messenger
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Craig S. Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Che Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Saket Girotra
- Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
| | - Amit P. Amin
- Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Tan MC, Duff K, Roberts L, Ramachandran V. Is activated clotting time necessary to guide sheath removal in heparinised patients undergoing endovascular intervention for peripheral vascular disease? J Med Imaging Radiat Oncol 2019; 64:23-26. [PMID: 31823475 DOI: 10.1111/1754-9485.12974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 10/29/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose was to evaluate the best practice for arterial sheath management in heparinised patients undergoing endovascular intervention for peripheral vascular disease (PVD) at Eastern Health. METHODS Patients undergoing endovascular intervention for PVD at Eastern Health between January 2016 and February 2018 were studied. Those who fulfilled the inclusion criteria were randomly assigned to five interventional radiologists and Category A (sheath removed upon return to recovery without activated clotting time (ACT)), Category B (ACT check 1-h postheparin and the sheath was removed without knowing the ACT) or Category C (ACT check 1-h postheparin and sheath removed once ACT < 160; our hospital's current protocol). Nurses removing sheaths independently have >3 years of experience. Data were collected on baseline clinical characteristics, dose of heparin administered, sheath size and direction, time from heparin administration to sheath removal, time to haemostasis, blood pressure at time of sheath removal and complications. RESULTS A total of 152 patients were included. About 74% of them were males, and the average age was 72 years. There was no significant difference in baseline characteristics influencing complications and other contributing factors. The only significant finding was that Category C experienced the longest mean time to sheath removal (143.4 ± 52.1 min) while Category A experienced the shortest mean time (62.2 ± 27.1 min, P = 0.0001). There was no significant difference in outcomes. CONCLUSION There was no significant difference in the outcomes among all groups, and therefore, it shows no reason to routinely measure ACT to guide sheath removal in heparinised patients undergoing endovascular intervention for PVD.
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Affiliation(s)
- Mae Chyi Tan
- Department of Medical Imaging, Eastern Health, Box Hill, Victoria, Australia
| | - Kylie Duff
- Department of Medical Imaging, Eastern Health, Box Hill, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
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Johannsen L, Mahabadi AA, Totzeck M, Krueger A, Jánosi RA, Rassaf T, Al-Rashid F. Access site complications following Impella-supported high-risk percutaneous coronary interventions. Sci Rep 2019; 9:17844. [PMID: 31780769 PMCID: PMC6882834 DOI: 10.1038/s41598-019-54277-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/09/2019] [Indexed: 01/22/2023] Open
Abstract
Mechanical circulatory support (MCS) devices are increasingly used to provide hemodynamic stability for patients with severe coronary artery disease, comorbidities, and/or impaired hemodynamics during high-risk percutaneous coronary interventions (PCI). Vascular access site complications, particularly those due to the use of large-bore sheaths, may limit outcomes in these patients. The aim of this study was to investigate the incidence and predictors of vascular complications in protected high-risk PCIs. Therefore, we included patients undergoing high-risk PCI with an Impella device from January 2016 to August 2018. Vascular complications were graded according to 'Valve Academic Research Consortium-2', a definition routinely used in transcatheter valve implantation procedures. In total, 61 patients (mean age 72 ± 11 years, 79% male, SYNTAX score 33 ± 7) were included, and angiographic- and fluoroscopic-guided vascular access was used for Impella implantation in all patients. Major vascular complications occurred in 5 male patients (8%). All major vascular complications were treated conservatively without the need for surgical intervention, and only one patient received a transfusion of three erythrocyte concentrates. Regression analysis revealed that patients with peripheral arterial disease of the lower extremities are at higher risk of major vascular complications. In conclusion, the utilization of Impella using a standardized protocol for angiographic- and fluoroscopic-guided vascular access was associated with a low rate of vascular complications.
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Affiliation(s)
- Laura Johannsen
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Amir A Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Andrea Krueger
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Rolf Alexander Jánosi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany
| | - Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Medical Faculty, University, Duisburg-Essen, Germany.
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Al-khadra Y, Kajy M, Idris A, Darmoch F, Pacha HM, Kabach A, Garcia S, Bagur R, Kwok CS, Kaki A, Glazier JJ, Kapadia S, Mamas M, Alraies MC. Comparison of Outcomes After Percutaneous Coronary Interventions in Patients of Eighty Years and Above Compared With Those Less Than 80 Years. Am J Cardiol 2019; 124:1372-1379. [PMID: 31500819 DOI: 10.1016/j.amjcard.2019.07.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/25/2022]
Abstract
Life expectancy in the United States has increased due to advances in health care. Despite increased utilization of percutaneous coronary intervention (PCI), octogenarian patients are less likely to be referred to the catheterization laboratory for coronary interventions. This is in part due to multiple patient co-morbidities and lack of established guidelines. We examined in-hospital clinical outcomes of octogenarian and nonoctogenarian patients who underwent PCI in the United States. Using the National Inpatient Sampling database, we identified all adult patients who are older than 18 years and underwent PCI. Patient were stratified by age into 2 groups, ≥80 years old and <80 years old and in-hospital adverse outcome rates were determined. A total of 11,056,559 patients underwent PCI between the years of 2002 and 2014 and 1,544,563 patients were ≥80 years old (14%). After multivariable adjustment, patients who are ≥80 years old had higher in-hospital mortality (3.3% vs 1.3%, adjusted Odds Ratio, 1.624; 95% confidence interval, 1.602 to 1.647, p <0.0001) and longer length of stay (median length of stay days 3, range 2 to 8 days vs median 2 days, range 1 to 4 days) (p <0.0001). Patients ≥80 years old had a higher rate of cardiopulmonary complications, postprocedural stroke, acute kidney injury, postprocedural thromboembolic complications, and hemorrhage requiring transfusion. There was no difference in vascular complications between the 2 groups. In conclusion, octogenarians who underwent PCI were at increased risk for in-hospital mortality and morbidity compared with nonoctogenarians. The decision to proceed with PCI in this patient population should be individualized, taking into consideration known risk factors and patient's wishes.
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Völz S, Petursson P, Angerås O, Odenstedt J, Ioanes D, Haraldsson I, Dworeck C, Hirlekar G, Redfors B, Myredal A, Libungan B, Albertsson P, Råmunddal T, Omerovic E. Prognostic impact of percutaneous coronary intervention in octogenarians with non-ST elevation myocardial infarction: A report from SWEDEHEART. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:480-487. [PMID: 31517503 DOI: 10.1177/2048872619877287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS Percutaneous coronary intervention (PCI) improves outcomes in non-ST elevation acute coronary syndromes (NSTE-ACSs). Octogenarians, however, were underrepresented in the pivotal trials. This study aimed to assess the effect of PCI in patients ≥80 years old. METHODS AND RESULTS We used data from the SWEDEHEART registry for all hospital admissions at eight cardiac care centres within Västra Götaland County. Consecutive patients ≥80 years old admitted for NSTE-ACS between January 2000 and December 2011 were included. We performed instrumental variable analysis with propensity score. The primary endpoint was all-cause mortality at 30 days and one year after index hospitalization. During the study period 5200 patients fulfilled the inclusion criteria. In total, 586 (11.2%) patients underwent PCI, the remaining 4613 patients were treated conservatively. Total mortality at 30 days was 19.4% (1007 events) and 39.4% (1876 events) at one year. Thirty-day mortality was 20.7% in conservatively treated patients and 8.5% in the PCI group (adjusted odds ratio 0.34; 95% confidence interval 0.12-0.97, p = 0.044). One-year mortality was 42.1% in the conservatively treated group and 16.3% in the PCI group (adjusted odds ratio 0.97; 95% confidence interval 0.36-2.51, p = 0.847). CONCLUSIONS PCI in octogenarians with NSTE-ACS was associated with a lower risk of mortality at 30 days. However, this survival benefit was not sustained during the entire study-period of one-year.
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Affiliation(s)
- Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Haraldsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Myredal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Berglind Libungan
- Department of Cardiology, Landspitali University Hospital of Iceland, Reykjavik, Iceland
| | - Per Albertsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Aarhus University Hospital, Denmark
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Incidence and predictors of radial artery occlusion after transradial coronary catheterization. Egypt Heart J 2019; 71:12. [PMID: 31659526 PMCID: PMC6821412 DOI: 10.1186/s43044-019-0008-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023] Open
Abstract
Background Radial artery occlusion (RAO) is considered the most common and devastating complication of transradial approach (TRA). It has been described as the “Achilles’ heel” of the transradial technique. Our aim was to assess the incidence and predictors of radial artery occlusion after transradial coronary catheterization. Results This was a prospective study enrolling 164 patients undergoing percutaneous coronary interventions (PCI) via the transradial approach (TRA) using 6-F catheters. Doppler ultrasonography assessment of the radial artery (RA) was conducted on day 1 and 6 months following the procedure. The studied group included 104 male (63.4%) and 60 female (36.6%) patients with a mean age of 57.7 ± 8.8 years and a mean RA diameter of 2.8 ± 0.5 mm. On day 1, Doppler examination revealed RAO in 54 patients (32.9%). After 6 months, RAO was detected in 49 patients (29.9%). Interestingly, only 1 new case (0.9%) of RAO was noted, and 6 patients (11.1%) had regained their RA patency. On multivariate analysis, female gender, age, manual compression, and RA diameter emerged as independent predictors of RAO. Using TR band for hemostasis for only 2 h was recognized as a potent independent predictor of RA patency on day 1 and 6 months after the procedure (n = 2, 3.7% in the RAO group, vs. n = 23, 20.9% in the non-RAO group, p = 0.004). Conclusion RAO, although clinically a silent issue, has been the main complication following TRA. In patients with high predictors of RAO, careful management and close follow-up are required to ensure radial artery long-term patency.
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Shi W, Wang W, Wang K, Huang W. Percutaneous mechanical circulatory support devices in high-risk patients undergoing percutaneous coronary intervention: A meta-analysis of randomized trials. Medicine (Baltimore) 2019; 98:e17107. [PMID: 31517843 PMCID: PMC6750338 DOI: 10.1097/md.0000000000017107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Percutaneous mechanical circulatory support devices (pMCSDs) are increasingly used on the assumption (but without solid proof) that their use will improve prognosis. A meta-analysis was undertaken according to the PRISMA guidelines to evaluate the benefits of pMCSDs in patients undergoing high-risk percutaneous coronary intervention (hr-PCI). METHODS We searched PubMed, EMbase, Cochrane Library, Clinical Trial.gov, and other databases to identify eligible studies. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for 30-day and 6-month all-cause mortality rates, reinfarction, and other adverse events using a random effect model. RESULTS Sixteen randomized controlled trials (RCTs) were included in this study. In the pooled analysis, intra-aortic balloon pump (IABP) was not associated with a decrease in 30-day and 6-month all-cause mortality (RR 1.01 95% CI 0.61-1.66; RR 0.88 95% CI 0.66-1.17), reinfarction (RR 0.89 95% CI 0.69-1.14), stroke/transient ischemic attack (TIA) (RR 1.75 95% CI 0.47-6.42), heart failure (HF) (RR 0.54 95% CI 0.11-2.66), repeat revascularization (RR 0.73 95% CI 0.25-2.10), embolization (RR 3.00 95% CI 0.13-71.61), or arrhythmia (RR 2.81 95% CI 0.30-26.11). Compared with IABP, left ventricular assist devices (LVADs) were not associated with a decrease in 30-day and 6-month all-cause mortality (RR 0.96 95% CI 0.71-1.29; RR 1.23 95% CI 0.88-1.72), reinfarction (RR 0.98 95% CI 0.68-1.42), stroke/TIA (RR 0.45 95% CI 0.1-1.95), acute kidney injury (AKI) (RR 0.83 95% CI 0.38-1.80), or arrhythmia (RR 1.52 95% CI 0.71-3.27), but LVADs were associated with a decrease in repeat revascularization (RR 0.26 95% CI 0.08-0.83). However, LVADs significantly increased the risk of bleeding compared with IABP (RR 2.85 95% CI 1.72-4.73). CONCLUSIONS Neither LVADs nor IABP improves short or long-term survival in hr-PCI patients. LVADs are more likely to reduce repeat revascularization after PCI, but to increase the risk of bleeding events than IABP.
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Affiliation(s)
- Wenhai Shi
- Department of Cardiology, the Sixth People's Hospital of Chengdu, Chengdu
| | - Wuwan Wang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kechun Wang
- Department of Cardiology, the Sixth People's Hospital of Chengdu, Chengdu
| | - Wei Huang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Cesaro A, Moscarella E, Gragnano F, Perrotta R, Diana V, Pariggiano I, Concilio C, Alfieri A, Cesaro F, Mercone G, Falato S, Esposito A, Di Girolamo D, Limongelli G, Calabrò P. Transradial access versus transfemoral access: a comparison of outcomes and efficacy in reducing hemorrhagic events. Expert Rev Cardiovasc Ther 2019; 17:435-447. [PMID: 31213156 DOI: 10.1080/14779072.2019.1627873] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Introduction: The radial artery is currently the most widely used access site for PCI procedures both acute and stable patient settings. Thanks to advantages in pharmacological therapy as well as in interventional devices, the rate of ischemic complications following PCI has significantly decreased. Nevertheless, this has been counterbalanced by an increased risk of periprocedural and late bleeding event, that can occur both at access and non-access sites. Choice of access site for PCI is of paramount importance to reduce the risk of access-related bleeding events. Areas covered: The aim of this review is to provide an overview of the actual available evidence comparing the transradial versus transfemoral approach to reduce hemorrhagic events. The most robust evidence comes from large randomized trials, partly also from observational registries, which compared the transradial and transfemoral approach. Expert opinion: Results show that radial access has proved to be decisive in reducing the incidence of hemorrhagic events. Furthermore, it showed a significant reduction in mortality and AKI compared to transfemoral access. However, increased experience in the use of the radial approach has led to less practice in the use of the femoral approach, which may be useful in cases of emergency, complications or inability to use the radial artery.
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Affiliation(s)
- Arturo Cesaro
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Elisabetta Moscarella
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Felice Gragnano
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Rocco Perrotta
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy
| | - Vincenzo Diana
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Ivana Pariggiano
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Claudia Concilio
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Alfonso Alfieri
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy
| | - Francesco Cesaro
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy
| | - Giuseppe Mercone
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy
| | - Sergio Falato
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Augusto Esposito
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Domenico Di Girolamo
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy
| | - Giuseppe Limongelli
- b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Paolo Calabrò
- a Division of Clinical Cardiology , A.O.R.N. "Sant'Anna e San Sebastiano" , Caserta , Italy.,b Department of Translational Medical Sciences , University of Campania "Luigi Vanvitelli" , Naples , Italy
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Mitsuse T, Kaikita K, Ishii M, Oimatsu Y, Nakanishi N, Ito M, Arima Y, Sueta D, Iwashita S, Fujisue K, Kanazawa H, Takashio S, Araki S, Usuku H, Suzuki S, Sakamoto K, Yamamoto E, Soejima H, Tsujita K. Total Thrombus-Formation Analysis System can Predict 1-Year Bleeding Events in Patients with Coronary Artery Disease. J Atheroscler Thromb 2019; 27:215-225. [PMID: 31391352 PMCID: PMC7113144 DOI: 10.5551/jat.49700] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aims: The assessment of bleeding risk in patients with coronary artery disease (CAD) is clinically important. We recently developed the Total Thrombus-Formation Analysis System (T-TAS) for the quantitative analysis of thrombus formation using microchips with thrombogenic surfaces. Here, we assessed the utility of T-TAS parameters in predicting 1-year bleeding events in patients with CAD. Methods: The study subjects were 561 consecutive patients who underwent coronary angiography (CAG) between August 2013 and September 2016 for suspected CAD. Blood samples collected at the time of CAG were used for T-TAS to compute the area under the curve (AUC) (AR10-AUC30) in the AR chip. Patients were divided into three groups according to AR10-AUC30 (low: ≤ 1603, intermediate, and high: > 1765, n = 187 each). One-year bleeding events were defined by the Platelet Inhibition and Patient Outcomes criteria. Results: Bleeding occurred in 21 (3.7%) patients and was classified as major (8 [1.4%]) and minor (13 [2.3%]). The AR10-AUC30 levels were significantly lower in the bleeding group than the non-bleeding group (median [interquartile range] 1590 [1442–1734] vs. 1687 [1546–1797], p = 0.04). Univariate Cox regression analysis demonstrated that low AR10-AUC30, high prothrombin time-international normalized ratio levels, and diabetes correlated with bleeding events. Multivariate Cox regression analysis identified low AR10-AUC30 levels as a significant determinant of bleeding events. Kaplan-Meier survival curves showed a higher rate of bleeding events in the low than the high AR10-AUC30 group (p = 0.007). Conclusions: The results highlight the potential usefulness of the AR10-AUC30 levels in the prediction of 1-year bleeding events in patients with CAD treated with various antithrombotic therapies.
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Affiliation(s)
- Tatsuro Mitsuse
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Yu Oimatsu
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Nobuhiro Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Miwa Ito
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Satomi Iwashita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Koichiro Fujisue
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Hisanori Kanazawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Satoshi Araki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Satoru Suzuki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Hirofumi Soejima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
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Albeiruti R, Chaudhary F, Alqahtani F, Kupec J, Balla S, Alkhouli M. Incidence, Predictors, and Outcomes of Gastrointestinal Bleeding in Patients Admitted With ST-Elevation Myocardial Infarction. Am J Cardiol 2019; 124:343-348. [PMID: 31182211 DOI: 10.1016/j.amjcard.2019.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/23/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
Gastrointestinal bleeding (GIB) complicating ST-elevation myocardial infarction (STEMI) poses significant management challenges and may be associated with poor outcomes. We sought to evaluate the incidence and outcomes of GIB in STEMI patients using a nationwide database. We identified adults admitted with STEMI between in the National Inpatient Sample (2003 to 2016), and compared the morbidity, mortality, resource utilization, and cost in patients with and without GIB. We assessed rates of endoscopy referral and its associated with mortality. Among 1,450,696 weighted STEMI hospitalizations, 32,624 (2.2%) were complicated with GIB. Patients with GIB were older, and had distinctive characteristics compared to those without GIB. Older age, cardiogenic shock; history of peptic ulcer disease, cirrhosis, anemia, or alcohol use disorder were the strongest predictors of GIB during STEMI hospitalizations. In-hospital mortality was higher in the GIB group (28.2% vs 11.1%, p <0.001). The excess mortality associated with GIB persisted after propensity-score matching, and in sensitivity analyses excluding patients who underwent coronary intervention >24-hours after admission, and those transferred to another hospital. Post-STEMI GIB was associated with more strokes and acute kidney injury, longer hospitalizations, and higher cost. In a logistic regression analysis, GIB was independently associated with mortality (odds ratios [OR] 1.91, 95% confidence interval [CI] 1.85 to 1.97, p <0.001). There was a correlation between undergoing endoscopy and lower in-hospital mortality (unadjusted OR 0.27; 95% CI, 0.24 to 0.29; adjusted-OR 0.30; 95% CI, 0.27 to 0.33; p <0.001). In conclusion, GIB complicating STEMI is uncommon but is associated with excess morbidity, mortality, resource utilization and cost. Referral to endoscopy in this cohort may be associated with reduced in-hospital mortality.
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Association of Thrombocytopenia, Revascularization, and In-Hospital Outcomes in Patients with Acute Myocardial Infarction. Am J Med 2019; 132:942-948.e5. [PMID: 31034804 PMCID: PMC6744313 DOI: 10.1016/j.amjmed.2019.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/21/2019] [Accepted: 04/01/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The impact of thrombocytopenia on revascularization and outcomes in patients presenting with acute myocardial infarction remains poorly understood. We sought to evaluate associations between thrombocytopenia, in-hospital management, bleeding, and cardiovascular outcomes in patients hospitalized for acute myocardial infarction in the United States. METHODS Patients hospitalized from 2004 to 2014 with a primary diagnosis of acute myocardial infarction were identified from the National Inpatient Sample. Management of acute myocardial infarction was compared between patients with and without thrombocytopenia. Multivariable logistic regression models were used to estimate odds of in-hospital adverse events stratified by thrombocytopenia and adjusted for demographics, cardiovascular risk factors, comorbidities, and treatment. RESULTS A total of 6,717,769 patients were hospitalized with a primary diagnosis of acute myocardial infarction, and thrombocytopenia was reported in 219,351 (3.3%). Patients with thrombocytopenia were older, more likely to have other medical comorbidities, were more likely to undergo coronary artery bypass grafting (28.8% vs 8.2%, P < .001), and were less likely to receive a drug-eluting stent (15.5% vs 29.5%, P < .001). After multivariable adjustment, thrombocytopenia was independently associated with nearly twofold increased odds of in-hospital mortality (adjusted odds ratio 1.91; 95% confidence interval, 1.86-1.97). Thrombocytopenia was also independently associated with ischemic stroke, cardiogenic shock, cardiac arrest, and bleeding complications. CONCLUSIONS Patients with thrombocytopenia in the setting of acute myocardial infarction had increased odds of bleeding, cardiovascular outcomes, and mortality compared with patients without thrombocytopenia. Future investigations to mitigate the poor prognosis of patients with acute myocardial infarction and thrombocytopenia are warranted.
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