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Lower Risk of Death and Kidney Failure Associated With Higher Target (Vs Below-Target) Doses of RAS Inhibitors in Octogenarians With Hfref
No full textBackground: Renin-angiotensin system (RAS) inhibitors at higher target doses reduce the risk of death in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about their effectiveness in octogenarians, the examination of which was the objective of this study. Methods: Of the 32,964 veterans ≥ 80 years with HFrEF (ejection fraction ≤ 40%) receiving RAS inhibitors, 6655 received them at target doses. Using propensity scores for the receipts of target-dose, calculated for each of the 32,964 patients, we assembled a matched cohort of 13,284 patients balanced on 66 baseline characteristics. Hazard ratios (95% CI) for 5-year mortality and kidney failure associated with target (vs below-target) dose RAS inhibitor use were estimated in the matched cohort. Kidney failure was defined as receipt of kidney replacement therapy or estimated glomerular filtration rate (eGFR) \u3c 15 mL/min/1.73m2 measured twice \u3e30 days apart. Results: Patients had mean (±SD) age 84.5 (±3.4) years, EF 31.3 (±8.2) %, and eGFR 58.5 (±18.2) mL/min/1.73m2. All-cause mortality occurred in 71.2% and 69.5% of matched patients in below-target and target dose RAS inhibitor groups, respectively (HR associated with target-dose RAS inhibitor, 0.95; 95% CI, 0.91-0.99; P =.009). Respective rates for kidney failure were 1.8% and 1.5%, with a trend toward a lower risk in the target-dose group (HR, 0.80; 95% CI, 0.61-1.04; P =.094). Consequently, there was a lower risk of the composite endpoint of kidney failure or death (HR, 0.94; 95% CI, 0.91-0.98; P =.004). Conclusions: These findings provide evidence that in octogenarians with HFrEF, the use of RAS inhibitors at higher target (vs below-target) doses is associated with lower risks of death and kidney failure
Abbreviated Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
No full textBackground: Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 receptor inhibitor, is a standard post-percutaneous coronary intervention (PCI) treatment to reduce thrombosis and ischemic events. However, the optimal DAPT duration remains unclear, with concerns about bleeding risks associated with long-term potent P2Y12 inhibitors. This systematic review and meta-analysis investigates the safety and efficacy of shortened DAPT regimens. Methods: A comprehensive search of PubMed, Scopus, and EMBASE identified randomized controlled trials (RCTs) comparing conventional DAPT (≥ 12 months) and abbreviated DAPT (≤ 3 months) post-PCI. Primary outcomes were 1-year all-cause mortality and bleeding, assessed using the Bleeding Academic Research Consortium (BARC) classification. Secondary outcomes included cardiovascular mortality, non-fatal myocardial infarction (MI), stroke, and major adverse cardiovascular events (MACE). Risk of bias was assessed with the Cochrane tool, and meta-analyses used random-effects models. Results: Forty studies involving 54,233 participants were included. Abbreviated DAPT significantly reduced all-cause mortality (RR: 0.90, 95%CI: 0.82–0.98) and bleeding (BARC 3 or 5: RR: 0.77, 95%CI: 0.60–0.97). No significant differences were observed in cardiovascular mortality, stroke, non-fatal MI, revascularization, or in-stent thrombosis. Subgroup analyses showed lower mortality with 1-month DAPT and reduced bleeding in patients with high bleeding risk, acute coronary syndrome (ACS), and complex PCI. Conclusions: Abbreviated DAPT post-PCI is associated with lower all-cause mortality and bleeding without compromising ischemic protection, supporting its use in specific patient populations. Individualized DAPT durations should be considered to balance bleeding and ischemic risks
A Nuanced Scrutiny of the Segmental Renal Artery Spectral Doppler in “Pickering” the Right Diagnosis
No full textApproximately 5–10% of patients with hypertension have secondary hypertension. We describe a case of secondary hypertension from bilateral renal artery stenosis (RAS): “Pickering syndrome.” This is a case of hypertension secondary to bilateral RAS which provides an opportunity to review secondary hypertension with a specific focus on RAS, in terms of when to consider work up, causes of secondary hypertension, diagnostic testing, and treatment
Axillary Artery Access Considerations in Impella 5.5 Insertion: Insights From Exclusive Axillary Approach for Successful Support
No full textBackground: The Impella 5.5® is commonly inserted via the axillary artery (AX) in patients with cardiogenic shock. The right AX has traditionally been preferred to avoid crossing the aortic arch, and a minimum diameter of 7 mm has been recommended to accommodate the device (21 Fr). There is limited data on choice of laterality of access and AX size required, both in terms of technicality of the procedure as well as outcomes. Methods: We performed a single-center retrospective cohort analysis of patients who underwent Impella 5.5® implantation between December 2020 and February 2024 (N = 75). Data including demographics and outcomes were stratified both by diameter (small, \u3c7 mm vs. normal, ≥7 mm) and laterality of access (right vs. left). Adverse events included stroke, limb ischemia, procedural bleeding or infection, and unplanned explant due to complications. Delivery time was defined as time from advancing the first wire to activation of the device. Results: AX approach was attempted in all (N = 74) but one requiring innominate access, with a technical success rate of 95.9% (N = 71/74). The mean age was 58.8 ± 13.3 years, with 81.1% males. The median delivery time was 7.0 (25th, 75th percentiles: 4.0, 11.5) min with a median support duration of 13 (7.7, 24) days. Ten patients (13.5%) had a small AX, with a mean diameter of 6.3 ± 0.5 mm and were more likely to be younger compared to the normal AX group. Fifty-nine patients (79.7%) had insertion via the right AX. Median delivery time was comparable across all groups (small, 5.4 [3.5, 10.9] vs. normal, 7 [4.0, 12.1] min, p = 0.59) and (right, 10.4 [5.3, 15.2] vs. left, 6 [3.7, 10.4] min, p = 0.35). There was no difference between the rates of stroke, ischemia, bleeding, or infection when comparing by size or laterality. Survival to discharge was 59.5%, with 21.1% mortality on support, all in patients with a normal AX diameter, but with no difference between right versus left. Conclusion: In our study, laterality and a small diameter of AX access did not affect outcomes of Impella 5.5®, with a similar safety profile
Transcatheter Vacuum-Assisted Mass Extraction on a Mitral Bioprosthesis
No full textAn 84-year-old woman with a history of mitral valve replacement, ascending aorta replacement, and pacemaker implantation presented with malaise and progressive shortness of breath. Transthoracic echocardiography and transesophageal echocardiography revealed a left ventricular ejection fraction of 10% to 15% and a floating mass on the mitral prosthesis. She was suspected to have bioprosthetic endocarditis, despite being afebrile and having negative blood cultures. Reoperative mitral valve replacement was considered but deemed too high risk, and a transseptal aspiration of a mass was performed to mitigate systemic embolization risk. Postprocedural transesophageal echocardiography showed no residual mass and a well-functioning bioprosthesis. The pathologic examination revealed extensive fibrin accompanied by inflammation and a fibroblastic reaction. Vacuum-assisted aspiration using the AngioVac has been well described for right-sided intracardiac structure, but left-sided mass extraction has rarely been reported. This successful case illustrates a transcatheter treatment option in an otherwise inoperable patient
Single-Center Experience of Extended Brain-Death Donor Heart Preservation With the Organ Care System
No full textBackground: The Organ Care System (OCS) (Transmedics, Andover, MA) reduces cold ischemic time of donor hearts by producing a normothermic beating state during ex vivo perfusion, enabling extended ex situ intervals, which potentially increases donor pool. We aimed to compare outcomes in utilization of OCS and conventional cold storage technique. Methods: Consecutive heart transplants following brain death at our institution between May 2022 and July 2023 were analyzed. Recipients were divided into those receiving hearts preserved with OCS [N = 15] and those with conventional cold storage (Control, N = 27), with OCS utilization when anticipated ischemic time was more than 4 h. Pre-transplant characteristics and transplant outcomes were compared. Results: OCS utilization allowed a significant increase in distance traveled for heart retrieval (OCS, 624 ± 269 vs. Control, 153 ± 128 miles, p \u3c 0.001), with longer mean total preservation times (6.2 ± 1.1 vs 2.6 ± 0.6 h, p \u3c 0.001). All but one patient displayed a general decrease or plateau in lactate throughout perfusion time by OCS. Both groups experienced similar rates of severe primary graft dysfunction (OCS, 6.7% [N = 1] vs. Control, 11.1% [N = 3], p = 0.63), with 100% in-hospital survival in the OCS group compared to 96.3% in the Control group (p = 0.34). Kaplan–Meier survival analysis showed that estimated one-year survival were comparable (OCS, 93.3 ± 6.4% vs. Control, 88.9 ± 6.0%, p = 0.61). Conclusion: With a mean preservation time of around 6 h and distance covered of over 600 miles, our results using OCS indicate a potential to safely increase the quantity and viability of accessible organs, thus broadening the donor pool without negatively affecting outcomes
Obesity Portends an Increased Risk of Thromboembolic Events in Severely Injured Geriatric Trauma, a Retrospective Study
No full textBackground: Obesity is a known risk factor for thromboembolic complications in trauma patients. The aim of our study is to evaluate the prevalence of thrombotic complications in obese geriatric patients. Methods: We performed a retrospective analysis of TQIP (2017–2019). A total of 119,906 patients≥65 years who sustained severe trauma were included. Primary outcomes were thrombotic complications including stroke/cerebrovascular accidents (CVA), myocardial infarction (MI), deep vein thrombosis (DVT) and pulmonary embolism (PE). Outcomes were compared between patients with obesity (BMI≥30 kg∖m2) and overweight (25 kg∖m2≤BMI\u3c30 kg∖m2) and normal weight (19 kg∖m2≤BMI\u3c25 kg∖m2) patients. Results: A total number of 30,356 (26.8 %) patients were obese. All clotting complications (stroke/CVA, MI, DVT and PE) were significantly more frequent among obese patients (p \u3c 0.001for all). Multivariate logistic regression showed that obese patients had significantly increased odds of stroke/CVA (OR = 1.207), MI (OR = 1.301), DVT (OR = 1.311) and PE (OR = 1.241) (p \u3c 0.001 for all). Conclusion: Obese geriatric patients who sustain severe traumatic injuries are at increased risk of thromboembolic complications compared to non-obese patients. Level of evidence: Level III retrospective study
Thrombectomy Selection in the Large Core Era: Implications for Regional Transfers
No full textPurpose of Review: This review aims to evaluate recent advances in large core stroke management with a focus on diagnostic imaging protocols to select patients for endovascular therapy. Recent Findings: Recent randomized controlled trials have shown that thrombectomy can lead to favorable outcomes in patients with large infarcts, contradicting previous assumptions that thrombectomy was not indicated in such patients due to higher risks and very low benefits. Summary: Although mechanical thrombectomy remains the gold standard of medical treatment for large vessel occlusions with demonstrated salvageable brain tissue, analysis of the results of recent randomized trials in patients with large ischemic stroke should help us expand patient selection, optimize timing, and explore different management modalities to improve the outcomes of therapy in these patients
