1,721,103 research outputs found
Guiding catheters for transradial approach: New designs and summary of experiences with VDL/VDR catheters. A novel score for PCI technical complexity
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SEX-BASED DIFFERENCES IN SHORT TERM SURVIVAL AFTER PRIMARY PERCUTANEOUS CORONARY INTERVENTION: THE ROLE OF SYSTEM DELAY
No full textBackground: Conflicting information exists on sex based differences in outcomes after pPCI. Worse outcomes after pPCI in women may
be due to delay in presentation
Methods: We, investigated the relationship among sex, prehospital delays and risks of adverse short clinical outcomes after pPCI using the
ISACS-TC (NCT01218776) registry from 2010 - 2015. The study populations consisted of 6679 pts with STEMI who had pPCI within 24h
of symptom onset. Multivariate logistic regression models were adjusted to covariates significantly different between groups in univariate
analysis.The primary endpoint was 30 day mortality
Results: Compared with a hospital admission greater than 2h, a time of 2h or less was associated with a lower incidence of death (6.5%
vs 8.9%). Admission delays >2h were significantly more frequent in women than in men (67.7% vs 32.3%). There were no significant sex
differences in door to balloon times (median: 45 vs 45 min). Unadjusted 30 days mortality was significantly higher in women than men
(12.2% vs 6.6%). After multivariable adjustment, women remained significantly associated with a higher risk of death, OR: 1.33 CI 1.07-
1.66. Sex differences were no longer observed in the cohort, when the analysis was restricted to patients with hospital admission ≤2h, OR
0.89 CI 0.52-1.53
Conclusions: Among patients undergoing pPCI, women have a significantly higher risk of short-term mortality than men
Invasive versus conservative strategy in acute coronary syndromes: The paradox in women's outcomes
No full textBACKGROUND: We explored benefits and risks of an early invasive compared with a conservative strategy in women versus men after non-ST elevation acute coronary syndromes (NSTE-ACS) using the ISACS-TC database.
METHODS: From October 2010 to May 2014, 4145 patients were diagnosed as having a NSTE-ACS. We excluded 258 patients managed with coronary bypass surgery. Of the remaining 3887 patients, 1737 underwent PCI (26% women). The primary endpoint was the composite of 30-day mortality and severe left ventricular dysfunction defined as an ejection fraction <40% at discharge.
RESULTS: Women were older and more likely to exhibit more risk factors and Killip Class ≥2 at admission as compared with men. In patients who underwent PCI, peri-procedural myocardial injury was not different among sexes (3.1% vs. 3.2%). Women undergoing PCI experienced higher rates of the composite endpoint (8.9% vs. 4.9%, p=0.002) and 30-day mortality (4.4% vs. 2.0%, p=0.008) compared with men, whereas those who managed with only routine medical therapy (RMT) did not show any sex difference in outcomes. In multivariable analysis, female sex was associated with favorable outcomes (adjusted HR for the composite endpoint: 0.72, 95% CI: 0.58-0.91) in patients managed with RMT, but not in those undergoing PCI (adjusted HR: 0.96, 95% CI: 0.61-1.52).
CONCLUSIONS: We observed a more favorable outcome in women than men when patients were managed with RMT. Women and men undergoing PCI have similar outcomes. These data suggest caution in extrapolating the results from men to women in an overall population of patients in the context of different therapeutic strategies
Sex-Specific Treatment Effects After Primary Percutaneous Intervention: A Study on Coronary Blood Flow and Delay to Hospital Presentation
Full text linkBackground We hypothesized that female sex is a treatment effect modifier of blood flow and related 30-day mortality after primary percutaneous coronary intervention ( PCI ) for ST -segment-elevation myocardial infarction and that the magnitude of the effect on outcomes differs depending on delay to hospital presentation. Methods and Results We identified 2596 patients enrolled in the ISACS - TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry from 2010 to 2016. Primary outcome was the occurrence of 30-day mortality. Key secondary outcome was the rate of suboptimal post- PCI Thrombolysis in Myocardial Infarction ( TIMI ; flow grade 0-2). Multivariate logistic regression and inverse probability of treatment weighted models were adjusted for baseline clinical covariates. We characterized patient outcomes associated with a delay from symptom onset to hospital presentation of ≤120 minutes. In multivariable regression models, female sex was associated with postprocedural TIMI flow grade 0 to 2 (odds ratio [ OR ], 1.68; 95% CI , 1.15-2.44) and higher mortality ( OR, 1.72; 95% CI , 1.02-2.90). Using inverse probability of treatment weighting, 30-day mortality was higher in women compared with men (4.8% versus 2.5%; OR , 2.00; 95% CI , 1.27-3.15). Likewise, we found a significant sex difference in post- PCI TIMI flow grade 0 to 2 (8.8% versus 5.0%; OR , 1.83; 95% CI , 1.31-2.56). The sex gap in mortality was no longer significant for patients having hospital presentation of ≤120 minutes ( OR , 1.28; 95% CI , 0.35-4.69). Sex difference in post- PCI TIMI flow grade was consistent regardless of time to hospital presentation. Conclusions Delay to hospital presentation and suboptimal post- PCI TIMI flow grade are variables independently associated with excess mortality in women, suggesting complementary mechanisms of reduced survival. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01218776
Association between comorbidities and absence of chest pain in acute coronary syndrome with in-hospital outcome
No full textBackground To evaluate the impact of comorbidities on the management and outcomes of acute coronary syndrome (ACS) patients without chest pain/discomfort (i.e. ACS without typical presentation). Methods Of the 11,458 ACS patients, enrolled by the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC; ClinicalTrials.gov: NCT01218776), 8.7% did not have typical presentation at the initial evaluation, and 40.2% had comorbidities. The odds of atypical presentation increased proportionally with the number of comorbidities (odds ratio [OR]: 1, no-comorbid; OR: 1.64, 1 comorbidity; OR: 2.52, 2 comorbidities; OR: 4.57, ≥ 3 comorbidities). Results Stratifying the study population by the presence/absence of comorbidities and typical presentation, we found a decreasing trend for use of medications and percutaneous intervention (OR: 1, typical presentation and no-comorbidities; OR: 0.70, typical presentation and comorbidities; OR: 0.23, atypical presentation and no-comorbidities; OR: 0.18, atypical presentation and comorbidities). On the opposite, compared with patients with typical presentation and no-comorbidities (OR: 1, referent), there was an increasing trend (p < 0.001) in the risk of death (OR: 2.00, OR: 2.52 and OR: 4.83) in the above subgroups. However, after adjusting for comorbidities, medications and invasive procedures, atypical presentation was not a predictor of in-hospital death. Independent predictors of poor outcome were history of stroke (OR: 2.04), chronic kidney disease (OR: 1.57), diabetes mellitus (OR: 1.49) and underuse of invasive procedures. Conclusions In the ISACS-TC, atypical ACS presentation was often associated with comorbidities. Atypical presentation and comorbidities influenced underuse of in-hospital treatments. The latter and comorbidities are related with poor in-hospital outcome, but not atypical presentation, per se
The no-reflow phenomenon in the young and in the elderly
No full textBACKGROUND: The objectives of this study were to evaluate the incidence of no-reflow as independent predictor of adverse events and to assess whether baseline pre-procedural treatment options may affect clinical outcomes.
METHODS: Data were derived from the ISACS-TC registry (NCT01218776) from October 2010 to January 2015. No-reflow was defined as post-PCI TIMI flow grades 0-1, in the absence of post-procedural significant (≥25%) residual stenosis, abrupt vessel closure, dissection, perforation, thrombus of the original target lesion, or epicardial spasm. The outcome measure was in-hospital mortality.
RESULTS: No-reflow was identified in 128 of 5997 patients who have undergone PCI (2.1%). On multivariate analysis, patients with no-reflow were more likely to be older (OR: 1.20, 95% CI: 1.01-1.44), to have a history of hypercholesterolemia (OR: 1.95, 95% CI: 1.31-2.91) and to be admitted with a diagnosis of STEMI (OR: 2.96, 95% CI: 1.85-4.72). Angiographic characteristics associated with no-reflow phenomenon were: stenosis ≥50% of the right coronary artery, presence of multivessel disease and pre-procedural TIMI blood flow grades 0-1. No-reflow was highly predictive of in-hospital mortality (17.2% vs. 4.2%; adjusted OR: 4.60, 95% CI: 2.61-8.09). Administration of pre-procedural unfractioned heparin or 600mg clopidogrel loading dose was associated with less incidence of no-reflow (OR: 0.65, 95% CI: 0.43-0.99 and 0.61, 95% CI: 0.37-1.00, respectively). Aspirin, enoxaparin, and 300mg clopidogrel loading dose, did not significantly impact the occurrence of the no-reflow.
CONCLUSIONS: We found that pre-procedural administration of 600mg loading dose of clopidogrel and/or unfractioned heparin is associated with reduced incidence of no-reflow
DELAY TO HOSPITAL ADMISSION AND ACUTE CORONARY CARE IN THE ELDERLY AND IN THE VERY ELDERLY
No full textbout benefits and risks of invasive treatments are more pronounced in the setting of a very advanced age and concomitant acute
coronary syndrome (ACS). This retrospective, cohort study aims to provide insights into the short-term survival of ACS patients undergoing
percutaneus coronary intervention (PCI) in relation to age (70 to 85, and ≥85 years).
Methods: Between 2010 and 2015, 4,041 patients ≥ 70 years old (mean age 76.5 ± 4.9 years, 54.9% male) were admitted with a diagnosis
of ACS at 57 hospitals included in the network of the ISACS-TC registry (ClinicalTrials.gov, NCT01218776). Of these patients 302 (7.5%)
were over 85 years old. The primary end-point was all cause 30 day mortality.
Results: 1,699 elderly patients underwent PCI (42%). Thirty day mortality rates were 14.7% (268 patients) in women and 12.2% (271
patients) in men. The rate of death was greater in the very-elderly (≥85 years) than in the young-elderly (≥ 70 years, but <85 years) (24.2%
vs 12.5%, P<0.001; OR: 2.24, 95% CI: 11.69-2.96). Following multi-variable analysis, age≥85 (odds ratio [OR] 2.03, 95% confidence
interval [CI] 1.31 to 3.13), Killip class ≥II (OR 5.21, 95% CI 3.85 to 7.06) and chronic kidney disease (OR 2.08, 95% CI 1.46 to 2.98)
emerged as independent predictors of 30 day mortality rates. PCI within 24 hours from admission was a predictor of survival (OR 0.55,
95% CI 0.39 to 0.77). Difference in mortality between very-elderly and young-elderly was no longer observed, when time from symptom
onset to admission ≤60 minutes was included in the analysis (OR: 1.60, 95%CI 0.68-3.76). PCI remained a predictor of survival (OR 0.49,
95% CI 0.26 to 0.94).
Conclusions: PCI appears to be a safe treatment option in the elderly and very elderly patients, provided that they are timely admitted to
hospital. The selection of the optimal therapeutic strategy seems to be determined more by time to hospital presentation than by age
Primary percutaneous coronary intervention in octogenarians
No full textLBACKGROUND: Limited data are available on the outcome of primary percutaneous coronary intervention (PCI) in octogenarian patients, as the elderly are under-represented in randomized trials. This study aims to provide insights on clinical characteristics, management and outcome of the elderly and very elderly presenting with STEMI.
METHODS: 2225 STEMI patients ≥70years old (mean age 76.8±5.1years and 53.8% men) were admitted into the network of the ISACS-TC registry. Of these patients, 72.8% were ≥70 to 79years old (elderly) and 27.2% were ≥80years old (very-elderly). The primary end-point was 30-day mortality.
RESULTS: Thirty-day mortality rates were 13.4% in the elderly and 23.9% in the very-elderly. Primary PCI decreased the unadjusted risk of death both in the elderly (OR: 0.32, 95% CI: 0.24-0.43) and very-elderly patients (OR: 0.45, 95% CI 0.30-0.68), without significant difference between groups. In the very-elderly hypertension and Killip class ≥2 were the only independent factors associated with mortality; whereas in the elderly female gender, prior stroke, chronic kidney disease and Killip class ≥2 were all factors independently associated with mortality. Factors associated with the lack of use of reperfusion were female gender and atypical chest pain in the very-elderly and in the elderly; in the elderly, however, there were some more factors, namely: history of diabetes, current smoking, prior stroke, Killip class ≥2 and history chronic kidney disease.
CONCLUSIONS: Age is relevant in the prognosis of STEMI, but its importance should not be considered secondary to other major clinical factors. Primary PCI appears to have beneficial effects in the octogenarian STEMI patients
Reperfusion Therapy for ST-Elevation Acute Myocardial Infarction in Eastern Europe: the ISACS-TC Registry
No full textAims : Widespread availability of tertiary hospitals with catheterization facilities, although vigorously promoted, has yet to become a reality in many countries with economy in transition. We sought to evaluate the clinical profile and mortality of patients who were hospitalized with a diagnosis of ST-segment elevation myocardial infarction (STEMI) and either received reperfusion therapy or remained without reperfusion in Eastern Europe.
Methods and results: Data were obtained from the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC; NCT01218776) on STEMI patients admitted to 57 hospitals in Eastern European countries from January 2010 to February 2015. The primary endpoint was 30-day mortality. Of 7982 patients, 65 (0.8%) had a documented contraindication to reperfusion, 5973 (75.5%) received fibrinolysis (n=1032) or underwent primary percutaneous coronary intervention (p-PCI; n=4941), and 1944 patients (24.6%) did not receive any reperfusion therapy. The overall unadjusted 30-day mortality rate was 7.9%. Thirty-day mortality rates were higher in non-reperfusion patients (16.0% vs. 5.0% in the p-PCI group and 7.4% in fibrinolysis group). The strongest factors associated with not attempting reperfusion therapy among these patients were female sex (OR:1.29 CI: 1.07-1.56), age (OR:1.02 CI: 1.01–1.03), prior MI (OR:1.79 CI:1.38–2.32), prior cerebrovascular events (OR: 1.87 CI: 1.30–2.68), chronic kidney disease (OR:1.76 CI:1.22–2.53), Killip class >1 (OR:1.31 CI: 1.06 –1.62), and time to admission >12 hours (OR:15.9 CI: 13.1-19.3).
Conclusions: A substantial number of patients are still not offered any reperfusion therapy in many Eastern European countries with economy in transition, and this was associated with increased 30-day mortality. Time from symptoms onset to admission>12 hours was the highest ranking among factors related to lack of reperfusion therapy. Quality improvement efforts should focus on minimizing delay to hospital admission among STEMI patient
Coronary revascularization and sex differences in cardiovascular mortality after myocardial infarction in 12 high and middle-income European countries
Full text linkBackground Existing data on female sex and excess cardiovascular mortality after myocardial infarction (MI) mostly come from high-income countries (HICs). This study aimed to investigate how sex disparities in treatments and outcomes vary across countries with different income levels.Methods Data from the ISACS Archives registry included 22 087 MI patients from 6 HICs and 6 middle-income countries (MICs). MI data were disaggregated by clinical presentation: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). The primary outcome was 30-day mortality.Results Among STEMI patients, women in MICs had nearly double the 30-day mortality rate of men [12.4% vs. 5.8%; adjusted risk ratio (RR) 2.30, 95% CI 1.98-2.68]. This difference was less pronounced in HICs (6.8% vs. 5.1%; RR 1.36, 95% CI 1.05-1.75). Despite more frequent treatments and timely revascularization in MICs, sex-based mortality differences persisted even after revascularization (8.0% vs. 4.1%; RR 2.05, 95% CI, 1.68-2.50 in MICs and 5.6% vs. 2.6%; RR 2.17, 95% CI, 1.48-3.18) in HICs. Additionally, women from MICs had higher diabetes rates compared to HICs (31.8% vs. 25.1%, standardized difference = 0.15). NSTEMI outcomes were relatively similar between sexes and income groups.Conclusions Sex disparities in mortality rates following STEMI are more pronounced in MICs compared to HICs. These disparities cannot be solely attributed to sex-related inequities in revascularization. Variations in mortality may also be influenced by sex differences in socioeconomic factors and baseline comorbidities
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