1,722,152 research outputs found
Hobson's choice: platelet inhibition and thrombocytopenia
No full textThomas Hobson was a livery stable owner in Cambridge, England, in the 17th century who had an extensive stable of over 40 horses and ran a thriving horse rental business. His customers believed that, on entry, they would be given their choice of mounts, when in fact he offered them no choice: Hobson required that all his customers choose the horse in the stall closest to the door or have no horse at all. Literally, they had no choice but Hobson’s choice. Similarly, in percutaneous coronary intervention (PCI), adjunctive pharmacotherapy with platelet inhibitors and anticoagulant regimes have improved clinical outcomes through a reduction in ischemic events, including stent thrombosis,1–3 albeit at the expense of increased bleeding complications.4 Although the delivery of antiplatelet agents and anticoagulant regimes can be personalized at an individual patient level in an attempt to balance the reduction in ischemic risk while minimizing the increased risk of major bleeding, like Hobson’s choice in the 17th century, there is currently no option to avoid these agents altogether in PCI in patients with high bleeding risk. Thus, in general, it is either antiplatelet inhibition or no PCI—a 21st century interventional cardiologist’s manifestation of Hobson’s choice
Invasive management and in-hospital outcomes of myocardial infarction patients in rural versus urban hospitals in the United States
No full textObjectives: The variation in the management and outcome of acute myocardial infarction (AMI) between rural and urban settings has been previously recognized, but there has previously been no nationwide data reported that is inclusive of the whole adult population. Methods: All discharge records between 2004 and 2018 with AMI diagnosis were extracted from the National Inpatient Sample (NIS) database and stratified by hospital location. The primary outcome was in-hospital mortality, and secondary outcomes included (a) major adverse cardiovascular and cerebrovascular events (MACCE), (b) major bleeding, (c) acute ischemic stroke, the utilization of invasive management in the form of (d) coronary angiography (CA), and (e) percutaneous coronary intervention (PCI). The adjusted odds ratios (aOR) and 95 % confidence interval (95 % CI) were determined using multivariable logistic regression. Results: 9,728,878 records with AMI were identified, of which 1,011,637 (10.4 %) discharges were from rural hospitals. Rural patients were older (median of 71 years vs. 67 years, p < 0.001) and had lower prevalence of the highest risk presentations of AMI than their urban counterparts. After multivariable adjustment, patients from rural hospitals had increased aOR of all-cause mortality (aOR 1.15 95 % CI 1.13–1.16) and MACCE (aOR 1.04 95 % CI 1.04–1.05), as well as the decreased aOR of coronary angiography (aOR 0.29, 95 % CI 0.29–0.29, p < 0.001) and PCI (aOR 0.40, 95 % CI 0.39–0.40, p < 0.001), compared to their urban counterparts. Conclusion: Between 2004 and 2018, the risk of in-hospital mortality and MACCE in AMI patients was significantly higher in rural hospitals, with considerably lower utilization of invasive angiography and revascularization.</p
Association of myocardial injury with adverse long-term survival among cancer patients
No full textAims: over time, cardiovascular disease (CVD) deaths increasingly exceed those from malignancy among cancer survivors. However, the association of myocardial injury with long-term survival (beyond 3 years) in cancer patients has not been previously described.Methods and results: the high-sensitivity cardiac troponin (hs-cTn) and morbidities databases from the National Health and Nutrition Examination Survey (1999–2004) were linked with the latest mortality dataset isolating records were respondents reported cancer diagnosis by a healthcare professional. Myocardial injury was then determined by elevated hs-cTn. A total of 16 225 560 weighted records (1058 unweighted) were included in this observational study, with myocardial injury identified in 14.2%. Those with myocardial injury had progressively worse survival at 5 (51.6 vs. 89.5%), 10 (28.3 vs. 76.0%), and 15 years (12.6 vs. 61.4%) compared with those without myocardial injury. After adjusting for baseline characteristics, those with myocardial injury had an adjusted hazard ratio (aHR) of 2.10 [95% confidence interval (CI) 2.09–2.10, P < 0.001] for all-cause mortality, 2.23 (2.22–2.24, P < 0.001) for cardiovascular mortality, and 1.59 (95% CI 1.59–1.60, P < 0.001) for cancer mortality compared with those without myocardial injury. Among patients with no pre-existing CVD, the hs-cTn I Ortho assay was a strong independent predictor of all-cause (aHR 6.29, 95% CI 6.25–6.33, P < 0.001), CVD (aHR 11.38, 95% CI 11.23–11.54, P < 0.001), and cancer (aHR 5.02, 95% CI 4.96–5.07, P < 0.001) mortalities.Conclusion: as a marker for myocardial injury, hs-cTns were independently associated with worse long-term survival among cancer patients with a stronger relationship with all-cause, cardiovascular, and cancer mortalities using hs-cTn I Ortho assay
Change in angiogram-derived management strategy of patients with chest pain when some FFR data are available: how consistent is the effect?
No full textBackgroundThe assessment of patients presenting with angina using invasive angiography alone is imperfect. By contrast, fractional flow reserve (FFR) allows for assessment of lesion-specific ischemia, which is predictive of clinical outcome. A series of studies has demonstrated that the availability of FFR data at the time of diagnostic angiography leads to significant differences in the management of those patients.Hypothesis: The objective of this paper is to describe assess the consistency in the difference in management resulting from an FFR-directed versus and angiogram-directed strategy in appropriate observational and randomized trials.MethodsA methodical search was made using MEDLINE, Current Contents Connect, Google Scholar, EMBASE, Cochrane library, PubMed, Science Direct, and Web of Science.ResultsEight studies were identified using the eligibility criteria. A total of 2468 patients were recommended to have optimal medical therapy (OMT) alone after initial angiographic assessment but, after FFR results were available, a total of 716 (29.0%) were referred for revascularization (PCI 626 patients [25.36%]; CABG 90 patients [3.64%]). Similarly, 3766 patients were originally committed to PCI after initial angiography: of these 1454 patients (38.61%) were reconsidered to be suitable for OMT alone and 71 individuals (1.8%) were deemed suitable for CABG after FFR data were available. Further, of 366 patients referred for CABG based on angiographic data, the availability of FFR data changed the final decision to OMT alone in 65 patients (17.76%) and PCI in 51 patients (13.9%). Overall, the angiogram-derived management was changed in 22%–48% of these study populations when FFR data were available.ConclusionsSome use of FFR during coronary angiography alters the angiogram-directed management in a remarkably consistent manner. These data suggest that routine use of FFR at the diagnostic angiogram would improve patient care
Comparative effectiveness of statins on non-high density lipoprotein cholesterol in people with diabetes and at risk of cardiovascular disease: systematic review and network meta-analysis
No full textObjective: to compare the efficacy of different statin treatments by intensity on levels of non-high density lipoprotein cholesterol (non-HDL-C) for the prevention of cardiovascular disease in people with diabetes.Design: systematic review and network meta-analysis.Data sources: Medline, Cochrane Central Register of Controlled Trials, and Embase from inception to 1 December 2021.Review methods: randomised controlled trials comparing different types and intensities of statins, including placebo, in adults with type 1 or type 2 diabetes mellitus were included. The primary outcome was changes in levels of non-HDL-C, calculated from measures of total cholesterol and HDL-C. Secondary outcomes were changes in levels of low density lipoprotein cholesterol (LDL-C) and total cholesterol, three point major cardiovascular events (non-fatal stroke, non-fatal myocardial infarction, and death related to cardiovascular disease), and discontinuations because of adverse events. A bayesian network meta-analysis of statin intensity (low, moderate, or high) with random effects evaluated the treatment effect on non-HDL-C by mean differences and 95% credible intervals. Subgroup analysis of patients at greater risk of major cardiovascular events was compared with patients at low or moderate risk. The confidence in network meta-analysis (CINeMA) framework was applied to determine the certainty of evidence.Results: in 42 randomised controlled trials involving 20 193 adults, 11 698 were included in the meta-analysis. Compared with placebo, the greatest reductions in levels of non-HDL-C were seen with rosuvastatin at high (−2.31 mmol/L, 95% credible interval −3.39 to −1.21) and moderate (−2.27, −3.00 to −1.49) intensities, and simvastatin (−2.26, −2.99 to −1.51) and atorvastatin (−2.20, −2.69 to −1.70) at high intensity. Atorvastatin and simvastatin at any intensity and pravastatin at low intensity were also effective in reducing levels of non-HDL-C. In 4670 patients at greater risk of a major cardiovascular events, atorvastatin at high intensity showed the largest reduction in levels of non-HDL-C (−1.98, −4.16 to 0.26, surface under the cumulative ranking curve 64%). Simvastatin (−1.93, −2.63 to −1.21) and rosuvastatin (−1.76, −2.37 to −1.15) at high intensity were the most effective treatment options for reducing LDL-C. Significant reductions in non-fatal myocardial infarction were found for atorvastatin at moderate intensity compared with placebo (relative risk=0.57, confidence interval 0.43 to 0.76, n=4 studies). No significant differences were found for discontinuations, non-fatal stroke, and cardiovascular deaths.Conclusions: this network meta-analysis indicated that rosuvastatin, at moderate and high intensity doses, and simvastatin and atorvastatin, at high intensity doses, were most effective at moderately reducing levels of non-HDL-C in patients with diabetes. Given the potential improvement in accuracy in predicting cardiovascular disease when reduction in levels of non-HDL-C is used as the primary target, these findings provide guidance on which statin types and intensities are most effective by reducing non-HDL-C in patients with diabetes.Systematic review registration: PROSPERO CRD42021258819
Operator volumes and in-hospital outcomes: an analysis of 7,740 rotational atherectomy procedures from the BCIS national database
No full textObjectives
The aims of this study were to use a national percutaneous coronary intervention (PCI) registry to study temporal changes in procedure volumes of PCI using rotational atherectomy (ROTA-PCI), the patient and procedural factors associated with differing quartiles of operator ROTA-PCI volume, and the relationship between operator ROTA-PCI volumes and in-hospital patient outcomes.
Background
Whether higher operator volume is associated with improved outcomes after ROTA-PCI is poorly defined.
Methods
Data from the British Cardiovascular Intervention Society national PCI database were analyzed for all ROTA-PCI procedures performed in the United Kingdom between 2013 and 2016. Individual logistic regressions were performed to quantify the independent association between annual operator ROTA-PCI volume and in-hospital outcomes.
Results
In total, 7,740 ROTA-PCI procedures were performed, with a negatively skewed distribution and an annualized operator volume median of 2.5 procedures/year (range: 0.25 to 55.25). Higher volume operators undertook more complex procedures in patients with greater comorbid burdens than lower volume operators. A significant inverse association was observed between operator ROTA-PCI volume and in-hospital mortality (odds ratio [OR]: 0.986/case; 95% confidence interval (CI): 0.975 to 0.996; p = 0.007) and major adverse cardiac and cerebral events (OR: 0.983/case; 95% CI: 0.975 to 0.993; p < 0.001). Additionally, lower rates of emergency cardiac surgery (OR: 0.964/case; 95% CI: 0.939 to 0.991; p = 0.008), arterial complications (OR: 0.975/case; 95% CI: 0.975 to 0.982; p < 0.001) and in-hospital major bleeding (OR: 0.985/case; 95% CI: 0.977 to 0.993; p < 0.001) were associated with higher ROTA-PCI operator volume. Sensitivity analyses in several subgroups demonstrated a consistency of improved outcomes as annual ROTA-PCI volume increased. An annual volume of <4 ROTA-PCI procedures/year was observed to be associated with increased major adverse cardiac and cerebral events, with 239 of 432 operators (55%) not exceeding this threshold.
Conclusions
In-hospital adverse outcomes occurred less frequently as ROTA-PCI operator volume increased. These data suggest that operator volume is an important factor determining outcome after ROTA-PCI
Risk of venous thromboembolism with gout flares
Full text linkObjective: Previous studies reported an increased risk of venous thromboembolism (VTE) in gout, but not whether there was a temporal association between gout flare and VTE. We evaluated whether there was a temporal association between gout flare and VTE. Methods: Electronic primary-care records from the UK's Clinical Practice Research Datalink linked to hospitalization and mortality registers were used. Self-controlled case series analysis adjusted for season and age evaluated the temporal association between gout flare and VTE. The 90 days after primary-care consultation or hospitalization for gout flare was the exposed period. This was divided into three 30-day intervals. The baseline period was up to 2 years before the start of and up to 2 years after the end of exposed period. The association between gout flare and VTE was measured using adjusted incidence rate ratio (aIRR) with 95% confidence interval (95%CI). Results: 314 patients met the inclusion criteria (age ≥18 years, incident gout, without VTE or primary-care anticoagulant prescription before pre-exposure period started) and were included. VTE incidence was significantly higher in the exposed period than in baseline period [aIRR (95%CI) 1.83 (1.30-2.59)]. The aIRR (95%CI) of VTE during the first 30 days after gout flare was 2.31 (1.39-3.82) compared with baseline period. No increase in aIRR (95%CI) were observed in days 31-60 [aIRR (95%CI) 1.49, (0.79-2.81)] and days 61-90 [aIRR (95%CI) 1.67 (0.91-3.06)]. Results were consistent across sensitivity analyses. Conclusion: There was a transient increase in VTE rate within 30 days after primary-care consultation or hospitalization for gout flare
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