1,721,786 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
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
Short-Term Risk of Cardiovascular Events in People Newly Diagnosed With Gout
Full text linkObjectiveTo investigate the temporal association between first diagnosis of gout and cardiovascular events in the short-term.MethodsWe performed a self-controlled case series analysis and a cohort study using data from linked primary care, hospitalisation, and mortality records from the UK's Clinical Practice Research Database (GOLD). We included individuals with a new diagnosis of gout either in the primary care or secondary care between 01/01/1997 and 31/12/2020.The first consultation at which gout was diagnosed was the exposure of interest. The main outcome consisted of cardiovascular events (i.e., a composite of fatal and non-fatal myocardial infarction, ischaemic or haemorrhagic stroke, and transient ischaemic attack).Results4,398 patients (66.9% male, mean age 74.6 years) had a cardiovascular event within ±2 years of their first recorded diagnosis of gout. The incidence of cardiovascular events was significantly higher in the 30 days after the first diagnosis of gout compared to baseline (adjusted incidence rate ratio: 1.55 ((95% confidence interval) 95%CI: 1.33-1.83)).Among 76,440 patients (72.9% male, mean age 63.2 years) included in the cohort study, the incidence of cardiovascular events in the 30 days after the first gout diagnosis (31.2 events/1,000 person-years, 95%CI: 27.1-35.9) was significantly higher than in days 31-730 after gout diagnosis (21.6 events/1,000 person-years, 95%CI:20.8-22.4) with a rate difference of -9.6 events/1,000 person-years, 95%CI: -14.0 to -5.1).ConclusionIndividuals had a short-term increased risk of cardiovascular events in the 30 days following the first consultation at which gout was diagnosed
Impact of Society Guidelines on Trends in Use of Newer P2Y 12 Inhibitors for Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention.
No full textBACKGROUND: Over the past decade, major society guidelines have recommended the use of newer P2Y 12 inhibitors over clopidogrel for those undergoing percutaneous coronary intervention for acute coronary syndrome. It is unclear what impact these recommendations had on clinical practice. METHODS AND RESULTS: All percutaneous coronary intervention procedures (n=534 210) for acute coronary syndrome in England and Wales (April 1, 2010, to March 31, 2022) were retrospectively analyzed, stratified by choice of preprocedural P2Y 12 inhibitor (clopidogrel, ticagrelor, and prasugrel). Multivariable logistic regression models were used to examine odds ratios of receipt of ticagrelor and prasugrel (versus clopidogrel) over time, and predictors of their receipt. Overall, there was a significant increase in receipt of newer P2Y 12 inhibitors from 2010 to 2020 (2022 versus 2010: ticagrelor odds ratio, 8.12 [95% CI, 7.67-8.60]; prasugrel odds ratio, 6.14 [95% CI, 5.53-6.81]), more so in ST-segment-elevation myocardial infarction than non-ST-segment-elevation acute coronary syndrome indication. The most significant increase in odds of receipt of prasugrel was observed between 2020 and 2022 ( P<0.001), following a decline/plateau in its use in earlier years (2011-2019). In contrast, the odds of receipt of ticagrelor significantly increased in earlier years (2012-2017, P trend<0.001), after which the trend was stable ( P trend=0.093). CONCLUSIONS: Over a 13-year-period, there has been a significant increase in use of newer P2Y 12 inhibitors, although uptake of prasugrel use remained significantly lower than ticagrelor. Earlier society guidelines (pre-2017) were associated with the highest rates of ticagrelor use for non-ST-segment-elevation acute coronary syndrome and ST-segment-elevation myocardial infarction cases while the ISAR-REACT 5 (Prospective, Randomized Trial of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome) trial and later society guidelines were associated with higher prasugrel use, mainly for ST-segment-elevation myocardial infarction indication. </p
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