2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Restrictive Versus Liberal Transfusion in Patients With Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the MINT Trial

BACKGROUND

The MINT trial (Myocardial Ischemia and Transfusion) raised concern for harm from a restrictive versus liberal transfusion strategy in patients with acute myocardial infarction (MI) and anemia. Type 1 and type 2 MI are distinct pathophysiologic entities that may respond differently to blood transfusion. This analysis sought to determine whether the effects of transfusion varied among patients with a type 1 or a type 2 MI and anemia. The authors hypothesized that the liberal transfusion strategy would be of greater benefit in type 2 than in type 1 MI.

METHODS

The authors compared rates of death or MI at 30 days in patients with type 1 (n=1460) and type 2 (n=1955) MI and anemia who were randomly allocated to a restrictive (threshold, 7-8 g/dL) or a liberal (threshold, 10 g/dL) transfusion strategy.

RESULTS

The primary outcome of death or MI was observed in 16% of type 1 MI and 15.4% of type 2 MI patients. The rate of death or MI was higher in patients with type 1 MI randomized to a restrictive (18.2%) versus liberal (13.8%) transfusion strategy (relative risk [RR], 1.32 [95% CI, 1.04-1.67]) with no difference observed between the restrictive (15.8%) and liberal (15.1%) transfusion strategies in patients with type 2 MI (RR, 1.05 [95% CI, 0.85-1.29]). The test for a differential effect of transfusion strategy by MI type was not statistically significant (Pinteraction = 0.16).

CONCLUSIONS

The concern for harm with a restrictive transfusion strategy in patients with acute MI and anemia raised in the MINT primary outcome manuscript may be more apparent in patients with type 1 than type 2 MI.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02981407.

Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit

Poisoning and its aftermath are globally observed and acknowledged concerns. India has a large burden of "self-harm/suicides" with 12.4/per 100,000 population committing suicide. Consumption of poisonous substances is the second most common mode of self-harm in India. Patients present to both public and private institutions in a critically ill state. The Indian Society of Critical Care Medicine (ISCCM) and Indian College of Critical Care Medicine (ICCCM) decided to address common and contentious issues related to poisoning by developing a position statement that is expected to be appropriate in the Indian scenario by the constitution of an "expert group" to provide a "set of statements" aimed at addressing the common issues faced by intensivists in their practice in managing such patients. The structured approach, framework, and process adopted in developing the position statement on the approach to poisoning have been detailed in this statement. The formation of an expert advisory panel was followed by a literature search, and multiple sessions of consensus-building exercises to reach the current statement presented below. The statement consists of relevant questions with possible answers thereof. Each answer was further weighed against the data and evidence available in the literature. Recommendations were made using a simplified score to make the statement qualitatively meaningful.

How to cite this article

Rungta N, Ray B, Bhalla A, DP Samaddar, Paul G, Prasad S, et al. Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S217-S232.

Retinal vascular dynamics: A window for observing an irregular heartbeat. A case report

OBJECTIVE

We aimed to characterize several aspects of retinal vascular dynamics in a patient with arrythmia in order to elicit additional diagnostic information on microvascular dysfunction.

METHODS

A 68-year-old male patient with arrythmia and an age- and gender-matched control subject underwent ocular examination including dynamic retinal vessel assessment with flicker light provocation. Retinal vessel diameters were measured continuously following a standard protocol (IMEDOS Systems, Jena, Germany). The data were evaluated using methods of signal analysis.

RESULTS

Retinal vessel response following flicker provocation as well as local structural and functional behavior of retinal vessels were comparable between both individuals. The arrhythmia case demonstrated irregular arterial and venous heart rate (HR) pulsation with an average frequency of 1 Hz. Moreover, the case showed a higher magnitude and larger periods of low-frequency retinal vessel oscillations as well as lower periodicity of both HR pulsations and low-frequency vasomotions.

CONCLUSIONS

Besides numerical examination of irregular HR pulsations in case of arrhythmia, from the direct noninvasive assessment of retinal vessel dynamics one can derive more detailed information on microvascular function including the whole spectrum of retinal arterial and venous pulsations and vasomotions. This may have implications for health screening not limited to atrial fibrillation.

A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis

BACKGROUND

Invasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS.

METHODS

Relevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP.

RESULTS

A total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding.

CONCLUSION

An early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes. PROSPERO registration: CRD42023415574.

Value of stent boost imaging in decision making after coronary stenting

BACKGROUND

Several studies reported the comparability of digital stent enhancement techniques (including stent boost imaging) in detecting suboptimal results of coronary stenting with Intra Vascular Ultrasound and optical coherence tomography.

AIMS

to assess results of stent deployment and determine the incidence of suboptimal results requiring changing final decision using stent boost imaging.

METHODS

This cross-sectional study included 120 patients eligible for PCI were recruited during a period of one year (January 2021 to 2022) using DES.

RESULTS

Suboptimal results were found in 38% of the PCI cases with stents (angiography guided). Importantly it was found that improper lesion preparation in our practice could not help improving stent optimization. Also, angiography guided PCI has significant incidence of suboptimal results. Digital stent enhancement techniques like stent boost have significant and important value in better decision making. After adjusting for age and sex, six factors were identified as independent predictors for final decision change (stent length, LAD/RCA affection, proximal segment affection, calcification, and optical coherence tomography.

CONCLUSION

This study has confirmed the utility of stent boost for the optimization of PCI in daily practice. Stent Boost is a simple and costless technique that provides an accurate assessment of a deployed stent without extending the procedure time and without more risk. It appears to be useful for the immediate evaluation of stent expansion and optimization of PCI by additional post-dilatation, when appropriate. Future studies are needed to determine whether Stent Boost data will correlate with adverse long-term clinical outcomes in patients undergoing PCI.

Serum cystatin C predicts the risk of non-ST-elevation acute coronary syndrome

OBJECTIVE

Inflammation markers have been proposed as the predictors of adverse cardiac events in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). This study aimed to investigate prognostic value of serum cystatin C (Cys-C) for NSTE-ACS patients.

METHODS

Cys-C, neutrophil to lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hsCRP) were examined in 212 NSTE-ACS patients and 60 controls. Global registry of acute coronary events (GRACE) score and major adverse cardiac events (MACE) in NSTE-ACS patients were recorded.

RESULTS

Cys-C level in the serum was significantly higher in NSTE-ACS patients than in control, and was positively correlated with hsCRP level and NLR as well as GRACE score at admission and 6 months after discharge in NSTE-ACS patients. Serum Cys-C level was identified as a new predictor of MACE.

CONCLUSION

Serum Cys-C level may be an inflammation biomarker in patients with NSTE-ACS, and could be used as an independent predictor of MACE.

Exploring the Mechanistic Link Between Obesity and Heart Failure

PURPOSE OF REVIEW

Among subtypes of cardiovascular disease, obesity has a potent and unique association with heart failure (HF) that is unexplained by traditional cardiovascular risk mediators. The concomitant rise in the prevalence of obesity and HF necessitates better understanding of their relationship to develop effective prevention and treatment strategies. The purpose of this review is to provide mechanistic insight regarding the link between obesity and HF by elucidating the direct and indirect pathways linking the two conditions.

RECENT FINDINGS

Several direct pathophysiologic mechanisms contribute to HF risk in individuals with excess weight, including hemodynamic alterations, neurohormonal activation, hormonal effects of dysfunctional adipose tissue, ectopic fat deposition with resulting lipotoxicity and microvascular dysfunction. Obesity further predisposes to HF indirectly through causal associations with hypertension, dyslipidemia, and most importantly, diabetes via insulin resistance. Low levels of physical activity and fitness further influence HF risk in the context of obesity. These various processes lead to myocardial injury and cardiac remodeling that are reflected by abnormalities in cardiac biomarkers and cardiac function on myocardial imaging. Understanding and addressing obesity-associated HF is a pressing clinical and public health challenge which can be informed by a deeper understanding of the complex pathways linking these two conditions together.

Self-Reported Executive Function in Hospitalized Cardiac Patients and Associations With Patient Characteristics and Cardiac Rehabilitation Attendance

PURPOSE

Executive function (ExF), the ability to do complex cognitive tasks like planning and refraining from impulsive behavior, is associated with compliance with medical recommendations. The present study identified associations between self-reported ExF and demographics of patients with cardiac disease as well as with cardiac rehabilitation (CR) attendance.

METHODS

Self-reported ExF impairment was measured using the Behavior Rating Inventory of Executive Function (BRIEF) on 316 individuals hospitalized for CR-qualifying cardiac events. Scores were calculated for a global measure (Global Executive Composite [GEC]) and the two BRIEF indices: Behavioral Regulation Index and Metacognition Index (MCI). Participants were followed up post-discharge to determine CR attendance. Univariate logistic regressions between ExF measures and demographic variables were conducted, as were multiple logistic regressions to identify significant, independent predictors. Analyses were conducted using clinical (T scores ≥ 65) and subclinical (T scores ≥ 60) criteria for significant ExF impairment as outcomes. One-way analyses of variance were performed between ExF impairment and CR attendance.

RESULTS

Self-reported ExF deficits were relatively rare; 8.9% had at least subclinical scores on the GEC. Using the subclinical criterion for the MCI, having diabetes mellitus (DM) and being male were significant, independent predictors of MCI impairment. No significant relationship was found between ExF and CR attendance.

CONCLUSION

Using the subclinical criterion only, individuals with DM and males were significantly more likely to have MCI impairment. No significant effect of ExF impairment on CR attendance was found, suggesting that self-reported ExF measured in the hospital may not be an appropriate measure for predicting behavioral outcomes.

A Sniff Away From Death: A Rare Case of Cocaine-Induced Triple Vessel Coronary Artery Disease in a 41-Year-Old Male Patient

Cocaine-associated coronary artery disease and ST-segment elevation myocardial infarction (STEMI) have been well described in the literature. However, very few cases of cocaine-induced multivessel coronary artery disease have been reported. We report a very rare case of cocaine-associated triple vessel coronary artery disease in a 41-year-old male patient. The patient underwent urgent catheterization that revealed occlusion of his proximal left anterior descending artery (LAD), mid-circumflex artery, and right coronary artery with angioplasty and stent placement. His hospitalization course was complicated by cardiogenic shock, shock liver, acute renal failure, and sepsis.

Comparison of care and outcomes for myocardial infarction by heart failure status between United Kingdom and Japan

AIMS

Prognosis for ST-segment elevation myocardial infarction (STEMI) is worse when heart failure is present on admission. Understanding clinical practice in different health systems can identify areas for quality improvement initiatives to improve outcomes. In the absence of international comparison studies, we aimed to compare treatments and in-hospital outcomes of patients admitted with ST elevation myocardial infarction (STEMI) by heart failure status in two healthcare-wide cohorts.

METHODS AND RESULTS

We used two nationwide databases to capture admissions with STEMI in the United Kingdom (Myocardial ischemia National Audit Project, MINAP) and Japan (Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination, JROAD-DPC) between 2012 and 2017. Participants were stratified using the HF Killip classification into three groups; Killip 1: no congestive heart failure, Killip 2-3: congestive heart failure, Killip 4: cardiogenic shock. We calculated crude rate and case mix standardized risk ratios (CSRR) for use of treatments and in-hospital death. Patients were younger in the United Kingdom (65.4 [13.6] vs. 69.1 [13.0] years) and more likely to have co-morbidities in the United Kingdom except for diabetes and hypertension. Japan had a higher percentage of heart failure and cardiogenic shock patients among STEMI during admission than that in the United Kingdom. Primary percutaneous coronary intervention (pPCI) rates were lower in the United Kingdom compared with Japan, especially for patients presenting with Killip 2-3 class heart failure (pPCI use in patients with Killip 1, 2-3, 4: Japan, 86.2%, 81.7%, 78.7%; United Kingdom, 79.6%, 58.2% and 79.9%). In contrast, beta-blocker use was consistently lower in Japan than in the United Kingdom (61.4% vs. 90.2%) across Killip classifications and length of hospital stay longer (17.0 [9.7] vs. 5.0 [7.4] days). The crude rate of in-hospital mortality increased with increasing Killip class group. Both the crude rate and CSRR was higher in the United Kingdom compared with Japan for Killip 2-3 (15.8% vs. 6.4%, CSRR 1.80 95% CI 1.73-1.87, P < 0.001), and similar for Killip 4 (36.9% vs. 36.3%, CSRR 1.11 95% CI 1.08-1.13, P < 0.001).

CONCLUSIONS

Important differences in the care and outcomes for STEMI with heart failure exist between the United Kingdom and Japan. Specifically, in the United Kingdom, there was a lower rate of pPCI, and in Japan, fewer patients were prescribed beta blockers and hospital length of stay was longer. This international comparison can inform targeted quality improvement programmes to narrow the outcome gap between health systems.

Identifying and comparing low-value care recommendations for coronary heart disease prevention, diagnosis, and treatment in the US and China

BACKGROUND

Low-value care provides little or no benefit, causes harm and incurs unnecessary costs. Low-value care for coronary heart disease (CHD) is particularly prevalent in the US and China. Identifying low-value care services is the first step in reducing these services. There is currently limited data on identifying a comprehensive CHD low-value care list in the US and China. We aimed to identify and compare low-value care recommendations for CHD prevention, diagnosis, and treatment in the US and China.

METHODS

Clinical practice guidelines (CPGs) related to CHD in the US and China were screened for do-not-do recommendations stating that specific services should be avoided. The similarities and discrepancies of low-value care recommendations for CHD between the two countries were then compared.

RESULTS

We found a total of 38 low-value care recommendations in 6 Chinese CPGs and 98 recommendations in 11 US CPGs. In the US, the most common types of low-value care recommendations were therapeutic medications (44, 44.9%), followed by therapeutic procedures (27, 27.6%), diagnostic imaging (16, 16.3%), diagnostic testing (9, 9.2%) and primary prevention (2, 2.0%). In China, the most common types were therapeutic medications (18, 47.4%), followed by therapeutic procedures (13, 34.2%), diagnostic testing (4, 10.5%), and diagnostic imaging (3, 7.9%).

CONCLUSION

In this study, a comprehensive list of low-value care for CHD in the US and China was established and potentially become the important targets for de-implementation for both countries. The findings may have important implications for other countries, especially low-and middle-income countries, to reduce low-value care for CHD.

Modifying effect of the serum level of brain-derived neurotrophic factor (BDNF) on the association between BDNF methylation and long-term cardiovascular outcomes in patients with acute coronary syndrome

Introduction

This study investigated the potential modifying effects of the serum brain-derived neurotrophic factor (sBDNF) level on the association between BDNF methylation status and long-term cardiovascular outcomes in acute coronary syndrome (ACS) patients.

Methods

From 2006 to 2012, hospitalized ACS patients were consecutively recruited. The sBDNF level and BDNF methylation status were assessed at baseline in 969 patients who were followed up for major adverse cardiac events (MACEs) over 5-12 years, until 2017 or death. Cox proportional hazards models were utilized to compare the time to first composite or individual MACEs between individuals with lower and those with higher average BDNF methylation levels in the low and high sBDNF groups, respectively. The modifying effects of the sBDNF and average BDNF methylation levels on first composite and individual MACEs were analyzed using Cox proportional hazards models after adjusting for potential covariates.

Results

In the low sBDNF group, a higher average BDNF methylation level was linked to an increase in composite MACEs independent of confounding variables, but not in the high sBDNF group [HR (95 percent CI) = 1.04 (0.76-1.44)]. The interaction effect between the sBDNF and average BDNF methylation levels on composite MACEs was significant after adjusting for covariates (P = 0.008).

Conclusion

Combining the BDNF methylation status and sBDNF levels may help identify ACS patients who are likely to have unfavorable clinical outcomes.

Modifying Effect of the Interleukin-18 Level on the Association between BDNF Methylation and Long-Term Cardiovascular Outcomes in Patients with Acute Coronary Syndrome

This study investigated the potential modifying effects of the level of the serum interleukin-18 (IL-18) on the association between BDNF methylation status and long-term cardiovascular outcomes in patients with acute coronary syndrome (ACS). Hospitalized ACS patients were recruited sequentially from 2006 to 2012. At baseline, the IL-18 level and BDNF methylation status were evaluated in 969 patients who were followed for major adverse cardiac events (MACEs) for 5-12 years, until 2017 or death. The time to first composite or individual MACE was compared between individuals with lower and higher average BDNF methylation levels (in the low- and high-IL-18 groups, respectively) using a Cox proportional hazards model. After adjusting for potential covariates, the modifying effects of IL-18 and average BDNF methylation levels on the initial composite and individual MACEs were examined. In the high-IL-18 group, but not in the low-IL-18 group, a higher average BDNF methylation level was associated with increases in composite MACEs (HR (95% CI) = 2.15 (1.42-3.26)), all-cause mortality (HR (95% CI) = 1.89 (1.11-3.22)), myocardial infarction (HR (95% CI) = 1.98 (1.07-3.67)), and percutaneous coronary intervention (HR (95% CI) = 1.81 (1.01-3.23)), independent of confounding variables. The interaction effect between the IL-18 and average BDNF methylation levels on composite MACEs (p = 0.019) and myocardial infarction (p = 0.027) was significant after adjusting for covariates. Analysis of BDNF methylation status and IL-18 levels may help identify ACS patients who are most likely to have adverse clinical outcomes.

Serial high-sensitivity cardiac troponin testing for the diagnosis of myocardial infarction: a scoping review

OBJECTIVES

We aimed to assess the diversity and practices of existing studies on several assays and algorithms for serial measurements of high-sensitivity cardiac troponin (hs-cTn) for risk stratification and the diagnosis of myocardial infarction (MI) and 30-day outcomes in patients suspected of having non-ST-segment elevation MI (NSTEMI).

METHODS

We searched multiple databases including MEDLINE, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews and the CENTRAL databases for studies published between January 2006 and November 2021. Studies that assessed the diagnostic accuracy of serial hs-cTn testing in patients suspected of having NSTEMI in the emergency department (ED) were eligible. Data were analysed using the scoping review method.

RESULTS

We included 86 publications, mainly from research centres in Europe, North America and Australasia. Two hs-cTn assays, manufactured by Abbott (43/86) and Roche (53/86), dominated the evaluations. The studies most commonly measured the concentrations of hs-cTn at two time points, at presentation and a few hours thereafter, to assess the two-strata or three-strata algorithm for diagnosing or ruling out MI. Although data from 83 studies (97%) were prospectively collected, 0%-90% of the eligible patients were excluded from the analysis due to missing blood samples or the lack of a final diagnosis in 53 studies (62%) that reported relevant data. Only 19 studies (22%) reported on head-to-head comparisons of alternative assays.

CONCLUSION

Evidence on the accuracy of serial hs-cTn testing was largely derived from selected research institutions and relied on two specific assays. The proportions of the eligible patients excluded from the study raise concerns about directly applying the study findings to clinical practice in frontline EDs.

PROSPERO REGISTRATION NUMBER

CRD42018106379.

Generating Practice-Based Evidence in the Use of Guideline-Recommended Combination Therapy for Secondary Prevention of Acute Myocardial Infarction

Background: Clinical guidelines recommend beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, and statins for the secondary prevention of acute myocardial infarction (AMI). It is not clear whether variation in real-world practice reflects poor quality-of-care or a balance of outcome tradeoffs across patients. Methods: The study cohort included Medicare fee-for-service beneficiaries hospitalized 2007-2008 for AMI. Treatment within 30-days post-discharge was grouped into one of eight possible combinations for the three drug classes. Outcomes included one-year overall survival, one-year cardiovascular-event-free survival, and 90-day adverse events. Treatment effects were estimated using an Instrumental Variables (IV) approach with instruments based on measures of local-area practice style. Pre-specified data elements were abstracted from hospital medical records for a stratified, random sample to create "unmeasured confounders" (per claims data) and assess model assumptions. Results: Each drug combination was observed in the final sample (N = 124,695), with 35.7% having all three, and 13.5% having none. Higher rates of guideline-recommended treatment were associated with both better survival and more adverse events. Unmeasured confounders were not associated with instrumental variable values. Conclusions: The results from this study suggest that providers consider both treatment benefits and harms in patients with AMIs. The investigation of estimator assumptions support the validity of the estimates.

Prediction of disorders with significant coronary lesions using machine learning in patients admitted with chest symptom

BACKGROUND

The early prediction of significant coronary artery lesion, including coronary vasospasm, have yet to be studied. It is essential to discern the disorders with significant coronary lesions (SCDs) requiring coronary angiography from mimicking disease. We aimed to determine which of all clinical variables were more important using conventional logistic regression (cLR) and machine learning (ML).

MATERIALS

Of 3382 patients with chest pain/discomfort or dyspnea in whom CAG was performed, 1893 were included. All clinical data were divided as follows (i): Demographics, history, and physical examination; (ii): (i) plus electrocardiography; and (iii): (ii) plus echocardiography, and analyzed by cLR and ML.

RESULTS

In multivariable analysis via cLR, the AUC and accuracy of the model using the final 20 variables were 0.795 and 72.62%, respectively. In multivariable analysis via ML, the best AUCs in the internal validation were 0.8 with (i), 0.81 with (ii), 0.83 with (iii), and in external validation, the best AUCs were 0.71 with (i), 0.74 with (ii), and 0.79 with (iii). The best AUCs and accuracy of the fittest model including 21 importance variables by ML were 0.81 and 72.48% in internal validation; and 0.75 and 70.5% in external validation, respectively. The importance variables in ML and cLR were similar, but slightly different and the additional discriminators via ML were found.

CONCLUSION

The assessment using the fittest importance variables can assist physicians in differentiating mimicking diseases in which coronary angiography may not be required in patients suspected of having acute coronary syndrome in emergency department.

The Prognostic Value of CAC Zero Among Individuals Presenting With Chest Pain: A Meta-Analysis

BACKGROUND

There is little consensus on whether absence of coronary artery calcium (CAC) can identify patients with chest pain (CP) who can safely avoid additional downstream testing.

OBJECTIVES

The purpose of this study was to conduct a systematic review and meta-analysis investigating the utility of CAC assessment for ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP, at low-to-intermediate risk of obstructive CAD undergoing coronary computed tomography angiography (CTA).

METHODS

The authors searched online databases for studies published between 2005 and 2021 examining the relationship between CAC and obstructive CAD (≥50% coronary luminal narrowing) on coronary CTA among patients with stable and acute CP.

RESULTS

In this review, the authors included 19 papers comprising 79,903 patients with stable CP and 13 papers including 12,376 patients with acute CP undergoing simultaneous CAC and coronary CTA assessment. Overall, 45% (95% CI: 40%-50%) of patients with stable CP and 58% (95% CI: 50%-66%) of patients with acute CP had CAC = 0. The negative predictive values for CAC = 0 ruling out obstructive CAD were 97% (95% CI: 96%-98%) and 98% (95% CI: 96%-99%) among patients with stable and acute CP, respectively. Additionally, the prevalence of nonobstructive CAD among those with CAC = 0 was 13% (95% CI: 10%-16%) among those with stable CP and 9% (95% CI: 5%-13%) among those with acute CP. A CAC score of zero predicted a low incidence of major adverse cardiac events among patients with stable CP (0.5% annual event rate) and acute CP (0.8% overall event rate).

CONCLUSIONS

Among over 92,000 patients with stable or acute CP, the absence of CAC was associated with a very low prevalence of obstructive CAD, a low prevalence of nonobstructive CAD, and a low annualized risk of major adverse cardiac events. These findings support the role of CAC = 0 in a value-based health care delivery model as a "gatekeeper" for more advanced imaging among patients presenting with CP.

Choosing Wisely in Adult Hospital Medicine: Co-creation of New Recommendations for Improved Healthcare Value by Clinicians and Patient Advocates

BACKGROUND

The American Board of Internal Medicine Foundation's Choosing Wisely campaign has resulted in a vast number of recommendations to reduce low-value care. Implementation of these recommendations, in conjunction with patient input, remains challenging.

OBJECTIVE

To create updated Society of Hospital Medicine Adult Hospitalist Choosing Wisely recommendations that incorporate patient input from inception.

DESIGN AND PARTICIPANTS

This was a multi-phase study conducted by the Society of Hospital Medicine's High Value Care Committee from July 2017 to January 2020 involving clinicians and patient advocates.

APPROACH

Phase 1 involved gathering low-value care recommendations from patients and clinicians across the USA. Recommendations were reviewed by the committee in phase 2. Phase 3 involved a modified Delphi scoring in which 7 committee members and 7 patient advocates voted on recommendations based on strength of evidence, potential for patient harm, and relevance to either hospital medicine or patients. A patient-friendly script was developed to allow advocates to better understand the clinical recommendations.

KEY RESULTS

A total of 1265 recommendations were submitted by clinicians and patients. After accounting for similar suggestions, 283 recommendations were categorized. Recommendations with more than 10 mentions were advanced to phase 3, leaving 22 recommendations for the committee and patient advocates to vote upon. Utilizing a 1-5 Likert scale, the top combined recommendations were reducing use of opioids (4.57), improving sleep (4.52), minimizing overuse of oxygen (4.52), reducing CK-MB use (4.50), appropriate venous thromboembolism prophylaxis (4.43), and decreasing daily chest x-rays (4.43).

CONCLUSIONS

Specific voting categories, along with the use of patient-friendly language, allowed for the successful co-creation of recommendations.

Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients With Cardiovascular Disease

IMPORTANCE

Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking.

OBJECTIVE

To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022.

EXPOSURES

Participation in 1 or more HBCR or CBCR sessions.

MAIN OUTCOMES AND MEASURES

The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics.

RESULTS

Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to β-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR.

CONCLUSIONS AND RELEVANCE

These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.

P2Y12 inhibitor pretreatment in patients with nonST-segment elevation acute coronary syndrome: A meta-analysis

BACKGROUND

The 2020 European Society of Cardiology guidelines do not recommend pretreatment for nonST-segment elevation myocardial infarction (NSTEMI) patients with unclear coronary anatomy, which is inconsistent with our routine preoperative approach to loading P2Y12 receptor inhibitors (e.g., preoperative loading of 300 mg of clopidogrel).

OBJECTIVES

The purpose of our study was to compare the safety and effectiveness of P2Y12 inhibitors administered before coronary angiography or at least before percutaneous coronary intervention (PCI) with during or after PCI.

METHODS

Cochrane, PubMed, and Embase databases were searched. The primary effect endpoint and safety endpoint were any-cause death and major bleeding, respectively. Major adverse cardiovascular events, myocardial infarction and revascularization were also analyzed.

RESULTS

Our search identified 9 trials. P2Y12 inhibitor pretreatment was associated with lower death from any cause (OR 0.62, 95% CI 0.53-0.72, P < 0.00001) without increasing the risk of bleeding (OR 1.02, 95% CI 0.80-1.30, P = 0.89). However, prasugrel or ticagrelor pretreatment was not associated with a lower risk of mortality (OR 0.70, 95% CI 0.31-1.59, P = 0.40) and increased the risk of bleeding (OR 1.67, 95% CI 1.10-2.54, P = 0.02).

CONCLUSIONS

In summary, clopidogrel pretreatment was associated with significantly lower mortality, major adverse cardiovascular events, myocardial infarction and revascularization with no increase in major bleeding. However, these advantages were not observed with prasugrel or ticagrelor pretreatment.

Internal medicine resident education improves cardiac rehabilitation knowledge, attitudes, and referral rates: A pilot study

Background

Referrals to cardiac rehabilitation (CR) remain low despite evidence showing reduction in cardiovascular mortality and hospital readmissions. Resident education and awareness may be an opportunity to address barriers to CR referrals.

Methods

This pilot study involves 20 internal medicine residents rotating at an ambulatory primary care clinic. Voluntary surveys were sent through an online-based survey platform. Following survey completion, residents received a 10-minute scripted lecture and an educational handout outlining CR components, availability, indications, insurance eligibility criteria, and referral process. Surveys were redistributed 2 months post-education to assess changes in mean aggregate knowledge scores and attitude ratings on a 5-point Likert scale. CR referral rates of eligible patients pre- and post-education were obtained through review of electronic medical records.

Results

Sixteen (80%) residents completed both pre and post surveys, and 13 (81%) reported no education on CR in the prior year. There was a significant increase in mean aggregate knowledge scores on CR components (5.1 versus 7.0, P = 0.001), insurance coverage (2.4 versus 5.6, P< 0.001), and eligible diagnoses (7.1 versus 9.9, P = 0.03) following education. Attitudes towards CR also improved following education, particularly in self-reported comfort level with explaining CR to patients (3.69 versus 2.06, P<0.001) and perceived familiarity with CR referral process (4.00 versus 2.18, P<0.001). CR referrals increased from 0% (0 out of 10 eligible patients) to 33% (3 out of 9 eligible patients) over a 2-month period before and after education, respectively (P = 0.09).

Conclusions

Internal medicine resident knowledge and attitudes towards CR significantly improved after formal education. Although there was a modest increase in the rates of CR referrals following resident education, this pilot study was not powered to detect statistical significance.

Home-to-Hospital Distance and Outcomes Among Community-Acquired Sepsis Hospitalizations

PURPOSE

To examine the hypothesis that longer distance from home-to-hospital is associated with worse outcomes among hospitalizations for community-acquired sepsis.

METHODS

A secondary analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort of 30,239 white and black US adults ≥ 45 years old was conducted. Self-reported hospitalizations for serious infection between 2003-2012 fulfilling 2/4 systemic inflammatory response syndrome criteria were included. Estimated driving distance was derived from geocoded data and evaluated continuously and as quartiles of very close, close, far, very far (<3.1, 3.1-5.8, 5.9-11.5, and >11.5 miles respectively). The primary outcome was 30-day mortality while the secondary outcome was sequential organ failure assessment (SOFA) score on arrival.

RESULTS

912 hospitalizations for community-acquired sepsis had adequate data for analysis. The median (interquartile range) estimated driving distance was 5.8 miles (3.1,11.7), and 54 (5.9%) experienced the primary outcome. Compared to living very close, participants living very far had a mortality odds ratio of 1.30 (95% CI 0.64,2.62) and presenting SOFA score difference of 0.33 (95% CI -0.03,0.68).

CONCLUSIONS

Among a national sample of community-acquired sepsis hospitalizations, there was no significant association between home-to-hospital distance and either 30-day mortality or SOFA score on hospital presentation.

Interaction effects of diabetes and brain-derived neurotrophic factor on suicidal ideation in patients with acute coronary syndrome

Acute coronary syndrome (ACS) is related to an increased risk of suicide. Although both diabetes and the brain-derived neurotrophic factor (BDNF) pathway are closely associated with ACS and suicide, the effects of these factors on suicidal behavior in ACS patients have not been assessed. We investigated the individual and interaction effects of diabetes and BDNF-related markers, namely the serum BDNF (sBDNF) level and the BDNF Val66Met polymorphism, on suicidal ideation (SI) in ACS patients. The presence of diabetes was ascertained, and sBDNF levels and the presence of the BDNF Val66Met polymorphism were measured in 969 patients within 2 weeks after an ACS episode. 711 patients were followed up at 1 year after the ACS episode. SI was assessed using the relevant items of the Montgomery–Åsberg Depression Rating Scale at baseline (acute SI) and the 1-year follow-up (chronic SI). Significant individual effects of low sBDNF levels were found on acute SI. The presence of both diabetes and a low sBDNF level or the BDNF Met/Met genotype was associated with acute SI, with multivariate logistic regression analyses revealing significant interaction effects. The highest frequency of chronic SI was seen in diabetic patients with an sBDNF level in the lowest tertile or with the BDNF Met/Met genotype, although the interaction terms were not statistically significant. Our study suggests that the combination of diabetes and BDNF-related markers, such as the sBDNF level and the BDNF Val66Met polymorphism, might provide a useful predictor of acute SI in ACS patients.

Chronic Kidney Disease Increases Risk of Incident HFrEF Following Percutaneous Coronary Intervention

Background

Chronic kidney disease (CKD) is very common in patients who are at a high risk of developing incident heart failure with reduced ejection fraction (HFrEF). However, the harmful effect of CKD on incident HFrEF has not yet been examined among patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI).

Methods

Patients undergoing PCI with baseline left ventricular ejection fraction (LVEF) ≥ 40% were included from January 2007 to December 2018 (ClinicalTrials.gov NCT04407936). We defined incident HFrEF as a follow-up LVEF of <40% within 3–12 months after discharge. Multivariable logistical regression was performed to examine the association of CKD with incident HFrEF.

Results

Overall, of 2,356 patients (mean age 62.4 ± 10.7 years, 22.2% women), 435 (18.5%) had CKD, and 83 (3.5%) developed incident HFrEF following PCI. The rate of incident HFrEF in the CKD group was higher than that in the non-CKD group (6.9 vs. 2.8%; p < 0.001). Multivariate logistic regression analysis indicated that CKD was an independent risk factor of incident HFrEF [adjusted odds ratio (aOR) = 1.75; 95% CI, 1.03–2.92; p = 0.035] after adjustment for confounders including age, gender, diabetes, hypertension, atrial fibrillation, congestive heart failure (CHF), baseline LVEF, ACEI/ARB, and statins. Furthermore, patients with incident HFrEF have a higher ratio of all-cause mortality compared to those without HFrEF (26.5 vs. 8.1%; p < 0.001).

Conclusions

Our results suggested that CKD was associated with increased risk of incident HFrEF, which was related to higher all-cause mortality in patients with CAD undergoing PCI. On this basis, more aggressive measures should be taken to prevent patients with CKD undergoing PCI from developing HFrEF.

Impact of accelerated washout of Technetium-99m-sestamibi on exercise tolerance in patients with acute coronary syndrome: single-center experience

Technetium-99m-sestamibi (^99mTc-sestamibi) single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with acute coronary syndrome (ACS) could be used to assess area-at-risks, as well as myocardial infarct or saved sizes. In patients with ACS, accelerated washout of ^99mTc-sestamibi during early and delayed imaging in the acute phase may suggest mitochondrial dysfunction in the injured but salvaged myocardium. However, the link between ^99mTc-sestamibi accelerated washout and exercise tolerance is unknown. The purpose of this study was to investigate a possible association between ^99mTc-sestamibi accelerated washout and exercise tolerance in acute ACS patients as they progressed into the chronic phase. One hundred and sixty-five patients with ACS who underwent ^99mTc-sestamibi SPECT MPI during the acute phase were recruited. On this basis, we calculated the total perfusion deficits (TPDs) for early (1 h after tracer injection) and delayed (4 h after tracer injection) images using automated quantification software. We then subtracted the early TPDs from the delayed TPDs to calculate the ΔTPD. We conducted a cardiopulmonary exercise test in acute and chronic phases. We divided two groups according to the median ΔTPD (the ΔTPD ≥ 4 group and the ΔTPD < 4 group) and compared anaerobic threshold (AT; ml/kg/min) between the groups. For anaerobic threshold (AT) improvement in data analysis, we employed multivariate logistic regression analysis. A total of 101 ST-segment elevation myocardial infarctions, 36 non-ST-elevation myocardial infarctions, and 28 unstable angina pectoris events were reported as ACS. From acute phase (10.8 ± 4.2 ml/kg/min) to chronic phase (11.9 ± 2.3 ml/kg/min), the AT in the ΔTPD ≥ 4 group was significantly increased (p < 0.0001). This trend was also seen in the ΔTPD < 4 group from acute (11.4 ± 1.8 ml/kg/min) to chronic phase (12.1 ± 2.2 ml/kg/min, p = 0.015). AT was lower in the ΔTPD ≥ 4 group in the acute phase (p = 0.027), but there was no difference in AT between the two groups in the chronic phase (p = 0.60). ΔTPD and the absence of diabetes were both independent predictors of AT improvement in multivariate logistic regression analysis. Receiver-operating characteristic curve analysis determined that ΔTPD = 6 was the best cut-off value, with 60.0% sensitivity and 71.4% specificity, respectively. The accelerated washout of ^99mTc-sestamibi in patients with ACS during the acute phase could help to predict improvement in exercise tolerance in the chronic phase.

Copeptin, miRNA-208, and miRNA-499 as New Biomarkers for Early Detection of Acute Coronary Syndrome

cTn and CK-MB are gold standard biomarkers for acute coronary syndrome (ACS) but are less sensitive in the first 3 h after onset of symptoms. A need thus exists for novel biomarkers for early detection of ACS. We evaluated circulating copeptin, miRNA-208, and miRNA-499 as possible biomarkers for early detection of unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI). Sixty-five patients with probable ACS that presented within 4 h of the onset of chest pain (23 UA and 42 NSTEMI) and 25 apparently healthy individuals were studied. Two sets of blood samples collected in the first 3 h and at 6 h after onset were analyzed for copeptin levels via ELISA and miRNA-208 and miRNA-499 expression via real-time PCR. Copeptin, miRNA-208, and miRNA-499 expression levels were significantly increased in UA and NSTEMI patients compared with controls (p < 0.001) and in NSTEMT compared with UA patients (p < 0.001). Levels were also significantly elevated in UA and NSTEMI patients with negative cardiac troponin in the first 3 h (p < 0.001). ROC curves displayed AUC for prediction of ACS of 0.96 for copeptin, 0.97 for miRNA-208, and 0.97 for miRNA-499. Their combination improved AUC to 0.98. Copeptin and miRNA-208 and miRNA-499 expression are promising biomarkers for UA and NSTEMI that present in the first 3 h of pain onset. A combination of these markers with cTn may increase the accuracy of diagnosis by avoiding the gray zone of cTn as a biomarker.

Platelet Function Test in Coronary Artery Bypass Grafting: Does It Predict Postoperative Bleeding?

Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased risk of perioperative bleeding and morbidity associated with transfusion as a result of acquired and pharmacologically induced impaired platelet function.

Settings and Design In this a prospective observational study where 52 patients underwent on-pump CABG were analyzed with ROTEM platelet aggregometry.

Materials and Methods Patients were assigned to the “nonexcessive” and “excessive” postoperative bleeding groups according to the postoperative chest tube drainage over 24 hours. Platelet function was assessed by ROTEM platelet using three different activators (arachidonic acid, adenosine diphosphate, and thrombin receptor-activating peptide), at two perioperative time points (T1, before heparinization and T2, 5–10 minutes after protamine administration).

Results There were no differences regarding demographic, pre–cardiopulmonary bypass (CPB) platelet count and antiplatelet therapy. Platelet function was impaired over the time course in all parameters with three different activators. At T2 point, area under the curve (AUC) of all the three platelet indices, that is, TRAPTEM, ARATEM, and ADPTEM, showed significant difference between excessive and nonexcessive groups. At both T1 and T2 points, the amplitude after 6 minutes (A6) and maximum slope (MS) parameters of TRAPTEM, ARATEM, and ADPTEM tests were not significantly different in excessive and nonexcessive groups. At T1 point, AUC was also not significantly different in all three ROTEM platelet tests. Results after protamine administration showed correlation with postoperative chest tube drainage. Cut-off values, as determined by receiver operating characteristics (ROC) analyses, had a consistently weak positive predictive value for all tests at T2 time point, whereas negative predictive values were higher.

Conclusion Platelet function analysis using ROTEM platelet can help to exclude platelet dysfunction as the reason for bleeding after cardiac surgery. Point-of-care platelet function analysis, particularly in combination with viscoelastic testing can reduce perioperative bleeding and transfusion requirements, as well as improve patient outcomes in cardiac surgery.

IRF2 contributes to myocardial infarction via regulation of GSDMD induced pyroptosis

Interferon regulatory factor (IRF) 2 is a transcription factor belonging to the IRF family, which is essential for gasdermin D (GSDMD)‑induced pyroptosis. Decreasing myocardial cell pyroptosis confers protection against heart damage and cardiac dysfunction caused by myocardial infarction (MI). The aim of the present study was to investigate the involvement of IRF2 in MI and the underlying mechanism of IRF2 in pyroptosis. To mimic MI, ligation of the left anterior descending coronary artery was performed to establish an in vivo mouse model and rat cardiomyocytes H9c2 cells were cultured under hypoxic conditions to establish an in vitro model. Transthoracic echocardiography was used to assess cardiac function. Hematoxylin and eosin staining was used to observe histopathological changes in the myocardial tissue. Immunohistochemistry and western blotting were performed to detect IRF2 expression levels. TUNEL staining and flow cytometry were used to detect apoptosis in myocardial tissue and cells. Chromatin immunoprecipitation and dual luciferase reporter assay were used to verify the effect of IRF2 on GSDMD transcription. IRF2 was upregulated in MI mice. MI induced pyroptosis, as evidenced by increased GSDMD, N‑terminal GSDMD (GSDMD‑N), and cleaved (c‑) caspase‑1 levels. MI increased IL‑1β and IL‑18 levels. These alterations were alleviated by IRF2 silencing. Furthermore, in hypoxia‑treated H9c2 cells, IRF2 silencing significantly decreased the elevated levels of IL‑1β and IL‑18 and pyroptosis‑associated proteins, including GSDMD, GSDMD‑N and c‑caspase1. Moreover, in hypoxia‑treated H9c2 cells, IRF2 directly bound to the GSDMD promoter to drive GSDMD transcription and promote pyroptosis and IRF2 expression may be regulated via the hypoxia inducible factor 1 signaling pathway. In conclusion, the present results demonstrated that IRF2 is a key regulator of MI by mediating pyroptosis, which triggers GSDMD activation.

MicroRNA-34a in coronary heart disease: Correlation with disease risk, blood lipid, stenosis degree, inflammatory cytokines, and cell adhesion molecules

Background

MicroRNA‐34a (miR‐34a) plays an essential role in regulating blood lipid, inflammation, cell adhesion molecules, and atherosclerosis, the latter factors are closely involved in the etiology of coronary heart disease (CHD). However, the clinical value of miR‐34a in CHD patients' management is rarely reported. Hence, this study aimed to assess the correlation of miR‐34a with disease risk, blood lipid, coronary artery stenosis, inflammatory cytokines, and cell adhesion molecules of CHD.

Methods

A total of 203 CHD patients and 100 controls were recruited in this study, then their plasma samples were collected to detect the miR‐34a by reverse transcription quantitative polymerase chain reaction. Furthermore, serum samples from CHD patients were obtained for inflammatory cytokines and cell adhesion molecule measurement by enzyme‐linked immunosorbent assay.

Results

MiR‐34a was elevated in CHD patients compared to controls (p < 0.001) and it disclosed a good diagnostic value of CHD (area under curve: 0.899, 95% confidence interval: 0.865–0.934). Besides, miR‐34a positively correlated with triglyceride (p < 0.001), total cholesterol (p = 0.022) and low‐density lipoprotein cholesterol (p = 0.004), but not with high‐density lipoprotein cholesterol (p = 0.110) in CHD patients. Moreover, miR‐34a associated with Gensini score in CHD patients (p < 0.001). As to inflammation‐related indexes and cell adhesion molecules, MiR‐34a expression was positively linked with C‐reactive protein (p < 0.001), tumor necrosis factor alpha (p = 0.005), interleukin (IL)‐1β (p = 0.020), IL‐17A (p < 0.001), vascular cell adhesion molecule‐1 (p < 0.001), and intercellular adhesion molecule‐1 (p = 0.010) in CHD patients, but not with IL‐6 (p = 0.118) and IL‐10 (p = 0.054).

Conclusion

MiR‐34a might serve as a biomarker in assistance of diagnosis and management of CHD.

Cardiac Complications of Common Drugs of Abuse: Pharmacology, Toxicology and Management

Cardiovascular complications from drugs of abuse are becoming more apparent due to increased usage worldwide. Substance abuse can cause both acute and chronic cardiovascular complications and is increasing in prevalence especially in young adults. These substances contribute to the development of acute coronary syndrome, type II myocardial injury, arrhythmias, cardiomyopathies and have numerous other cardiovascular complications. Although no screening guidelines exist, clinical awareness of these potential complications and their prevention, clinical presentation, diagnosis, and treatment are critically important. Management of cardiovascular disease should be coupled with appropriate social and mental health interventions to provide sustained clinical benefit. The higher the number of substances used recreationally, the greater the risk of premature heart disease. Epidemiological studies showed that 1 in 5 young adults misuse several substances and often start using at younger ages with a greater risk for adverse health outcomes over the long-term. The aim of this review is to highlight the basic epidemiology, cardiac complications, and disease-specific treatment options of commonly abused substances including methamphetamine, cocaine, alcohol, anabolic-androgenic steroids, cannabis, and tobacco.

Levels of miR-130b-5p in peripheral blood are associated with severity of coronary artery disease

BACKGROUND

Although patients with coronary artery disease (CAD) have a high mortality rate, the pathogenesis of CAD is still poorly understood. During the past decade, microRNAs (miRNAs) have emerged as new, potential diagnostic biomarkers in several diseases, including CAD. This study aimed to investigate the expression profiles of miRNAs in individuals with CAD and non-CAD.

METHODS AND RESULTS

The Agilent's microarray analyses were performed to compare the whole blood miRNA profile of selected individuals with severe CAD (n = 12, ≥ 90% stenosis) and non-CAD (n = 12, ≤ 20 stenosis). Expressions of selected differentially expressed miRNAs (DEMs) were analyzed for validation in individuals with critical CAD (n = 50) and non-CAD (n = 43) using real-time PCR. Target prediction tools were utilized to identify miRNA target genes. We identified 6 DEMs that were downregulated in CAD patients, which included hsa-miR-18a-3p and hsa-miR-130b-5p, that were analyzed for further testing. Expression levels of hsa-miR-130b-5p were found negatively correlated with SYNTAX score and stenosis in female CAD patients (p < 0.05). In addition, both miRNAs were found positively correlated with plasma HDL and inversely correlated with fasting triglyceride levels (p < 0.05). In linear regression analysis adjusted for several confounders, the correlations have remained statistically significant. Computational prediction of target genes indicated a relevant role of hsa-miR-130b-5p and hsa-miR-18a-3p in modulating the expression of genes associated with cardiovascular diseases.

CONCLUSION

Our findings highlight a significantly different pattern of miRNA expression in CAD patients in microarray results. Hsa-miR-18a-3p and hsa-miR-130b-5p might serve as biomarkers of CAD development and progression and warrant further attention.

Pharmacist Intervention to Improve Medication Adherence in Patients with Acute Coronary Syndrome: The PRIMA-ACS Study

Background

Despite ample evidence of benefit, adherence to secondary prevention medication therapy after acute coronary syndrome (ACS) is often suboptimal. Hospital pharmacists are uniquely positioned to improve adherence by providing medication education at discharge.

Objective

To determine whether a standardized counselling intervention at hospital discharge significantly improved patients' adherence to cardiovascular medications following ACS.

Methods

This single-centre, prospective, nonrandomized comparative study enrolled patients with a primary diagnosis of ACS (January 2014 to July 2015). Patients who received standardized discharge counselling from a clinical pharmacist were compared with patients who did not receive counselling. At 30 days and 1 year after discharge, follow-up patient surveys were conducted and community pharmacy refill data were obtained. Adherence was assessed using pharmacy refill data and patient self-reporting for 5 targeted medications: acetylsalicylic acid, P2Y purinoceptor 12 (P2Y12) inhibitors, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, β-blockers, and statins. Thirty-day and 1-year medication utilization, cardiovascular readmission rates, and all-cause mortality were also assessed.

Results

Of the 259 patients enrolled, 88 (34.0%) received discharge counselling. Medication data were obtained for 253 patients (97.7%) at 30 days and 242 patients (93.4%) at 1 year. At 1 year after discharge, there were no statistically significant differences between patients who did and did not receive counselling in terms of rates of nonadherence (11.9% versus 18.4%, p = 0.19), cardiovascular readmission (17.6% versus 22.3%, p = 0.42), and all-cause mortality (3.4% versus 4.2%, p > 0.99). Overall medication nonadherence was 2.8% (7/253) at 30 days and 16.1% (39/242) at 1 year.

Conclusions

Discharge medication counselling provided by hospital pharmacists after ACS was not associated with significantly better medication adherence at 1 year. Higher-quality evidence is needed to determine the most effective and practical interventions to ensure that patients adhere to their medication regimens and achieve positive outcomes after ACS.

Cardiotoxicity of Fluoropyrimidines: Epidemiology, Mechanisms, Diagnosis, and Management

Cancer is a growing public health problem; it is responsible annually for millions of deaths worldwide. Fluoropyrimidines are highly effective and commonly prescribed anti-neoplastic drugs used in a wide range of chemotherapy regimens against several types of malignancies. 5-fluorouracil and its prodrugs affect neoplastic cells in multiple ways by impairing their proliferation, principally through the inhibition of thymidylate synthase. Fluoropyrimidine-induced cardiotoxicity was described more than 50 years ago, but many details such as incidence, mechanisms, and treatment are unclear and remain disputed. Severe cardiotoxicity is not only life-threatening, but also leads to withdrawal from an optimal chemotherapy regimen and decreases survival rate. Differences in the frequency of cardiotoxicity are explained by different chemotherapy schedules, doses, criteria, and populations. Proposed pathophysiological mechanisms include coronary vasospasm, endothelial damage, oxidative stress, Krebs cycle disturbances, and toxic metabolites. Such varied pathophysiology of the cardiotoxicity phenomenon makes prevention and treatment more difficult. Cardiovascular disturbances, including chest pain, arrhythmias, and myocardial infarction, are among the most common side effects of this class of anti-neoplastic medication. This study aims to summarize the available data on fluoropyrimidine cardiotoxicity with respect to symptoms, incidence, metabolism, pathophysiological mechanism, diagnosis, management, and resistance.

Polymorphisms in the GCK gene increase the risk of clopidogrel resistance in stable coronary artery disease (SCAD) patients

BACKGROUND

Diabetes mellitus is a major factor in clopidogrel resistance (CR), and the glucokinase (GCK) gene plays a pivotal role in glucose homeostasis. This study investigated the contribution of GCK polymorphisms to CR risk.

METHODS

Two hundred SCAD patients were recruited, and their platelet functions were detected by the Verify-Now P2Y12 assay. The polymorphisms of GCK were tested based on the methods of polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). We investigated the associations of GCK polymorphisms and CR. Multivariate logistic regression was performed to analyse the correlations between GCK polymorphisms and clinical values.

RESULTS

Our study found that the SNPs rs4607517 and rs6975024 were associated with CR. Additionally, patients with the G allele of rs4607517had a greater CR risk, but the C allele of rs6975024 might be a protective factor. Finally, logistic regression revealed that CC + TC (rs6975024) as well as the values of albumin were correlated with a decreased risk of CR, and higher levels of uric acid (UA) may be positively associated with CR.

CONCLUSION

The GCK gene polymorphisms might increase the CR risk in SCAD patients. Meanwhile, higher albumin levels and lower UA values might decrease the risk.

Prognostic Value of Atherosclerosis Progression for Prediction of Cardiovascular Events in Patients with Nonobstructive Coronary Artery Disease

RATIONALE AND OBJECTIVES

Coronary CT angiography (CCTA) is a noninvasive reliable cardiovascular imaging technology to assess coronary atherosclerosis progression. However, there is limited data available to investigate the relationship between the atherosclerosis progression and cardiovascular events in patients with nonobstructive coronary artery disease (CAD).

MATERIALS AND METHODS

A total of 757 patients (53.4 ± 9.5 years, 61.2% male) with nonobstructive CAD (1%-49% diameter stenosis) who underwent baseline and follow-up CCTA were retrospectively included in this study. Coronary atherosclerosis and its changing were analyzed by these following semi-quantitative scores: (1) obstructive plaque scores (three-vessel plaque score and severe proximal plaque score); (2) scores exhibiting plaque distribution and extent (segment stenosis score and segment involvement score); (3) coronary artery calcium score. The end points of this study were the major adverse cardiac events (MACE), which included cardiac death, coronary revascularization, nonfatal myocardial infarction and hospitalization due to unstable angina.

RESULTS

The average time between scans was 2.0 years. After their second scan, 82 (10.8%) patients experienced MACE during 4.9 ± 1.0 years follow-up. Combined baseline and follow-up CCTA together, we found that the progression of coronary atherosclerosis was significantly higher in patients with MACE than those without (all p < 0.05). Diabetes mellitus (hazard ratio [HR] = 3.17, p < 0.001), dyslipidemia (HR = 1.69, p = 0.046), and family history of CAD (HR = 1.79, p = 0.005) were independently associated with MACE. Three vessel plaque progression (HR = 2.37, p = 0.026) and severe proximal plaque progression (HR = 3.65, p = 0.003) were strong predictors of MACE.

CONCLUSION

Coronary atherosclerosis progression had a predictive value of MACE in patients with nonobstructive CAD.

A study of anticoagulant therapy in patients with coronary artery disease

OBJECTIVES

One of the methods used to treat coronary artery disease (CAD) is anticoagulant therapy, which involves administering anticoagulants to patients that inhibit the arrangement and actuation of clotting factors. Anticoagulant therapy in patients with CAD must be monitored and evaluated because its greatest side effect is the risk of bleeding. The research aimed to analyze anticoagulants used in therapy for CAD patients and identify potential adverse drug reactions and adverse drug interactions.

METHODS

This was an observational study which collected data retrospectively at Bhayangkara Hospital Surabaya. Patient data had to meet the requirements for inclusion, which were patients treated for a diagnosis of CAD with anticoagulant therapy and were in conditions with or without complications and comorbid diseases. Data were obtained from 40 patient medical records. The data were then processed descriptively.

RESULTS

Most patients were male (80%) and aged 61-70 years old (37.5%). Fondaparinux was administered to 18 patients at a dose of 1 × 2.5 mg SC. Furthermore, enoxaparin was administered to 15 patients at a dose of 2 × 60 mg SC, and seven patients received warfarin at a dose of 1 × 2-4 mg per oral.

CONCLUSIONS

The anticoagulants used in this study were fondaparinux 1 × 2.5 mg SC (45%), enoxaparin 2 × 60 mg SC (37.5%), and warfarin 1 × 2-4 mg PO (17.5%). Side effects of the anticoagulants were absent. However, drug interactions with aspirin, clopidogrel, and allopurinol increased the risk of bleeding.

Health schools as an organizational form of realization of the "life course health development" concept

This study was conducted to evaluate the effectiveness of health education in the Tatarstan Republic by establishing educational programs - Health Schools - for groups of patients with a high risk of developing potentially fatal cardiac and respiratory conditions. The concept of "Life Course Health Development" implies the development of mechanisms for personalized health management. The goal of the study is to explore the effectiveness of the specialized Health Schools in Tatarstan. For the comparative study of health education effects on the overall state of personal health, 590 patients were surveyed in a randomized controlled trial. The groups of patients were compared in relation to their health education; their health status was observed prior to and afterward undergoing the educative preventative programs and estimated in comparison between the two groups. Extrapolation of the data on Tatarstan's patient population was obtained through this study, taking into account the state of health of the Health Schools students, obtaining the regression equations of population mortality and the effects of training on it. The effectiveness of Health Schools for patients with cardiovascular pathology has been proven. However, additional efforts are required to involve a wider range of patients and increase learning effectiveness to critical levels of awareness by introducing new forms of education in Health Schools since it statistically significantly increased the awareness level regarding disease nature and preventive measures.

Long-term cardiac outcomes of depression screening, diagnosis and treatment in patients with acute coronary syndrome: the DEPACS study

BACKGROUND

To investigate the impacts of depression screening, diagnosis and treatment on major adverse cardiac events (MACEs) in acute coronary syndrome (ACS).

METHODS

Prospective cohort study including a nested 24-week randomised clinical trial for treating depression was performed with 5-12 years after the index ACS. A total of 1152 patients recently hospitalised with ACS were recruited from 2006 to 2012, and were divided by depression screening and diagnosis at baseline and 24-week treatment allocation into five groups: 651 screening negative (N), 55 screening positive but no depressive disorder (S), 149 depressive disorder randomised to escitalopram (E), 151 depressive disorder randomised to placebo (P) and 146 depressive disorder receiving medical treatment only (M).

RESULTS

Cumulative MACE incidences over a median 8.4-year follow-up period were 29.6% in N, 43.6% in S, 40.9% in E, 53.6% in P and 59.6% in M. Compared to N, screening positive was associated with higher incidence of MACE [adjusted hazards ratio 2.15 (95% confidence interval 1.63-2.83)]. No differences were found between screening positive with and without a formal depressive disorder diagnosis. Of those screening positive, E was associated with a lower incidence of MACE than P and M. M had the worst outcomes even compared to P, despite significantly milder depressive symptoms at baseline.

CONCLUSIONS

Routine depression screening in patients with recent ACS and subsequent appropriate treatment of depression could improve long-term cardiac outcomes.

Systematic Evaluation of Clinical Efficacy and Platelet Function of Sofren Injection in the Treatment of Angina Pectoris

To systematically evaluate the efficacy and safety of sofren injection combined with conventional Western medicine in the treatment of angina pectoris. Randomized controlled trials (RCTs) on the treatment of angina pectoris with sofren injection combined with Western medicine were collected by searching PubMed, the Cochrane Library, Embase, Web of Science, CNKI, Wanfang Database, Weipu Database, and China Biomedical Literature Service System (CBM) by computer with the retrieval time from establishment of database to August 2020. After literature screening according to the predetermined inclusion and exclusion criteria, data of eligible studies were extracted, and then, a meta-analysis was conducted with the RevMan 5.3 software. The results of meta-analysis showed that the combination of sofren injection and Western medicine improved the platelet aggregation rate of patients (MD = -5.53, 95% CI (-6.42, -4.64), P < 0.00001), PAI-1 (SMD = -2.29, 95% CI (-2.57, -2.01), P < 0.00001), TXB2 (MD = -11.91, 95% CI (-14.50, -9.32), P < 0.00001), duration of angina attack (MD = -2.01, 95% CI (-3.14, -0.87), P=0.0005), ECG symptoms (RR = 1.29, 95% CI (1.20, 1.37), P < 0.00001), whole blood viscosity (MD = -1.07, 95% CI (-1.66, -0.48), P=0.0004), plasma viscosity (MD = -0.27, 95% CI (-0.35, -0.20), P < 0.00001), fibrinogen (MD = -0.67, 95% CI (-0.84, -0.50), P < 0.00001), whole blood high shear viscosity (MD = -1.04, 95% CI (-1.30, -0.79), P < 0.00001), whole blood low shear viscosity (MD = -2.03, 95% CI (-2.53, -1.53), P < 0.00001), CRP (MD = -1.96, 95% CI (-3.01, -0.91), P=0.0003), IL-6 (MD = -2.79, 95% CI (-4.02, -1.55), P < 0.00001), and TNF-α (MD = -17.34, 95% CI (-25.86, -8.81), P < 0.00001) and better than the Western medicine group, and there was no statistical significance in the incidence of adverse reactions between the two groups (P=0.48). The clinical application of sofren injection combined with conventional Western medicine in the treatment of angina pectoris is clear and safe, so it is recommended for clinical application.

Development and Psychometric Properties Evaluation of a Care Needs Questionnaire in Phase 1 Cardiac Rehabilitation for Patients with Coronary Artery Disease: CNCR-Q

Introduction: Cardiovascular diseases (CVDs) are one of the most common chronic illnesses and the leading cause of mortality worldwide. This study aimed to design and assess the psychometric properties of questionnaire to examine the care needs of patients with coronary artery disease (CAD) in phase 1 of cardiac rehabilitation (CR).

Methods: This sequential exploratory study used a mixed method with two phases. In the first phase, qualitative study was performed by analyzing the concept of Schwartz-Barcott-Kim hybrid model; and in the second phase, quantitative data were obtained and analyzed for the psychometric parameters of the designed tool.

Results: The questionnaire for care needs was based on the indicators of measurement, which was identified in the qualitative phase of the study, as a tool with 40 items. After conducting face validity qualitatively, all tool items were considered important and were retained for the next steps. After completing the steps for determining the content validity ratio (CVR) and content validity index (CVI) of 40 items, they were preserved for decision making at a later stage. The results of exploratory factor analysis revealed four factors; the factor analysis of three items was eliminated and the final version of the questionnaire CNCR-Q (Care Needs Cardiac Rehabilitation-Questionnaire) with 37 items remained.

Conclusion: The findings indicated that the questionnaire with properties, such as simple scoring, reliability and validity, is an appropriate tool for assessing care needs in Iranian patients with CAD. Moreover, the CNCR-Q is an effective instrument for assessing patient needs before discharge.

The Electrophysiology Laboratory: Anesthetic Considerations and Staffing Models

The electrophysiology laboratory facilitates complex procedures on patients, many of whom have advanced disease processes and extensive comorbidities. Historically, nurses administered sedation as required, but in recent years a shift to anesthesiologist-led sedation has been promoted for patient safety and advanced therapeutic considerations. Uncertainty remains, however, regarding whether the electrophysiology laboratory is best staffed with general or cardiothoracic anesthesiologists. In this article, the authors discuss the anesthetic considerations of some commonly performed electrophysiology and structural cardiac procedures and the pros and cons of staffing with general or cardiothoracic anesthesiologists.

Long-Term Prognostic Value of Coronary CTA in Orthotopic Heart Transplant Recipients

OBJECTIVE. This study aimed to evaluate the long-term prognostic value of coronary CTA (CCTA) in heart transplant recipients. MATERIALS AND METHODS. The records of 114 patients who had undergone a heart transplant (mean age, 61.7 ± 11.1 [SD] years; 83.3% men) and who underwent CCTA for the surveillance of coronary allograft vasculopathy (CAV) from June 2007 to December 2017 were retrospectively evaluated for the occurrence of major adverse cardiovascular events (MACEs) (cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, coronary revascularization, cardiac arrhythmias, stroke, and retransplant). Patients were classified according to the presence of nonobstructive CAV (lumen reduction < 50%) or obstructive disease (lumen reduction ≥ 50%) and using a coronary segment involvement score (SIS). Differences in MACE rate between groups were compared. RESULTS. Obstructive CAV was observed in 12 heart transplant recipients (10.5%). During a mean follow-up of 67.5 ± 41.4 months the overall rates of MACE were 50% and 14.7% in patients with obstructive and nonobstructive CAV, respectively (p < .05), resulting in an odds ratio for MACE of 6 (95% CI, 1.7-21.2). Comparison of event-free survival showed a hazard ratio (HR) of 5 (95% CI, 1.95-13; p =. 004) for patients with obstructive disease. The presence of four or more stenotic coronary segments (SIS ≥ 4) was associated with a higher rate of events (HR, 3.46; 95% CI, 1.46-8.23). CONCLUSION. In patients who have undergone a heart transplant, CCTA offers a significant long-term prognostic impact on the prediction of MACEs.

Treatment Preferences for Cardiac Procedures of Patients With Chronic Kidney Disease in Acute Coronary Syndrome: Design and Pilot Testing of a Discrete Choice Experiment

BACKGROUND

Chronic kidney disease is associated with a high incidence of acute coronary syndrome and related morbidity and mortality. Treatment choices for patients with chronic kidney disease involve trade-offs in the potential benefits and harms of invasive management options.

OBJECTIVE

The objective was to quantify preferences of patients with chronic kidney disease toward invasive heart procedures.

DESIGN

Design and pilot a discrete choice experiment.

SETTING

We piloted the discrete choice experiment in 2 multidisciplinary chronic kidney disease clinics in Calgary, Alberta, using an 8-question survey.

PATIENTS

Eligible patients included those aged 18 years and older, an estimated glomerular filtration rate < 45 mL/min/1.73 m2, not currently receiving dialysis, and able to communicate in English.

MEASUREMENTS

Quantification of the average importances of key attributes of invasive heart procedures.

METHODS

We identified attributes most important to patients and physicians concerning invasive versus conservative management for acute coronary syndrome, using semi-structured qualitative interviews. Levels for each attribute were derived from analysis of early invasive versus conservative acute coronary syndrome management clinical trials and cohort studies, where subgroups of patients with chronic kidney disease were reported. We designed the pilot study with patient partners with relevant lived experience and considered statistical efficiency to estimate main effects and interactions, as well as response efficiency. Hierarchical Bayesian estimation was used to quantify average importances of attributes.

RESULTS

We recruited 43 patients with chronic kidney disease, mean (SD) age 67 (14) years, 67% male, and 35% with a history of cardiovascular disease, of whom 39 completed the survey within 2 weeks of enrollment. The results of the pilot revealed acute kidney injury requiring dialysis and permanent kidney replacement therapy, as well as death within 1 year were the most important attributes. Measures of internal validity for the pilot discrete choice experiment were comparable to those for other published discrete choice experiments.

LIMITATIONS

Discrete choice experiments are complex instruments and often cognitively demanding for patients. This survey included multiple risk attributes which may have been challenging for some patients to understand.

CONCLUSIONS

This pilot study demonstrates the feasibility of a discrete choice experiment to quantify preferences of patients with chronic kidney disease toward the benefits and trade-offs related to invasive versus conservative management for acute coronary syndrome. These preliminary findings suggest that patients with chronic kidney disease may be on average similarly risk averse toward kidney replacement therapy and death. This pilot information will be used to inform a larger discrete choice experiment that will refine these estimates of patient preferences and characterize subgroups with distinct treatment preferences, which should provide new knowledge that can facilitate shared decision-making between patients with chronic kidney disease and their care providers in the setting of acute coronary syndrome.

Diagnostic value and prognostic significance of CTRP9 combined with pentraxin-3 in acute coronary syndrome

The present study aimed to explore the diagnostic value and prognostic significance of C1q/tumor necrosis factor-related protein 9 (CTRP9) combined with pentraxin-3 (PTX-3) in acute coronary syndrome (ACS). A total of 137 patients with coronary heart disease and chest pain were included. Among them, seventy-nine patients with ACS were allocated into a study group and fifty-eight patients with non-cardiac chest pain (NCCP) were allocated into a control group. The serum CTRP9, PTX-3 levels were quantified by ELISA, and their correlation with other ACS-related indexes, diagnostic value for ACS and predictive significance for poor prognosis were analyzed. In addition, the risk factors of the poor prognosis of ACS patients were studied. CTRP9 was lowly expressed and PTX-3 was highly expressed in the serum of ACS patients. CTRP9 was negatively correlated with cardiac troponin I (cTnI), creatine kinase-MB (CK-MB) and high-sensitivity C-reactive protein (hs-CRP) (P<0.05), while PTX-3 was positively correlated with them (P<0.05). Combined detection of CTRP9 and PTX-3 was of high value in the diagnosis and prognosis of ACS patients. In addition, CTRP9 and PTX-3 were independent risk factors for the poor prognosis of ACS. Patients with ACS had lower CTRP9 expression and higher PTX-3 expression than those without ACS. Moreover, the combined detection of CTRP9 and PTX-3 can better evaluate the diagnosis and prognosis of ACS patients.

Early Noninvasive Cardiac Testing After Emergency Department Evaluation for Suspected Acute Coronary Syndrome

IMPORTANCE

Professional guidelines recommend noninvasive cardiac testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI).

OBJECTIVE

To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive cardiac testing vs no testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge.

EXPOSURES

Noninvasive cardiac testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome.

MAIN OUTCOMES AND MEASURES

The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge.

RESULTS

A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin.

CONCLUSIONS AND RELEVANCE

Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.

Hyperoxia in portal vein causes enhanced vasoconstriction in arterial vascular bed

Long-term perfusion of liver grafts outside of the body may enable repair of poor-quality livers that are currently declined for transplantation, mitigating the global shortage of donor livers. In current ex vivo liver perfusion protocols, hyperoxic blood (arterial blood) is commonly delivered in the portal vein (PV). We perfused porcine livers for one week and investigated the effect of and mechanisms behind hyperoxia in the PV on hepatic arterial resistance. Applying PV hyperoxia in porcine livers (n = 5, arterial PV group), we observed an increased need for vasodilator Nitroprussiat (285 ± 162 ml/week) to maintain the reference hepatic artery flow of 0.25 l/min during ex vivo perfusion. With physiologic oxygenation (venous blood) in the PV the need for vasodilator could be reduced to 41 ± 34 ml/week (p = 0.011; n = 5, venous PV group). This phenomenon has not been reported previously, owing to the fact that such experiments are not feasible practically in vivo. We investigated the mechanism of the variation in HA resistance in response to blood oxygen saturation with a focus on the release of vasoactive substances, such as Endothelin 1 (ET-1) and nitric oxide (NO), at the protein and mRNA levels. However, no difference was found between groups for ET-1 and NO release. We propose direct oxygen sensing of endothelial cells and/or increased NO break down rate with hyperoxia as possible explanations for enhanced HA resistance.

Long-term antiplatelet therapy in medically managed non-ST-segment elevation acute coronary syndromes: The EPICOR Asia study

OBJECTIVES

To describe long-term antithrombotic management patterns (AMPs) in medically managed Asian patients with non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA).

BACKGROUND

Current guidelines support an early invasive strategy in NSTEMI and UA patients, but many are medically managed, and data are limited on long-term AMPs in Asia.

METHODS

Data were analyzed from medically managed NSTEMI and UA patients included in the prospective, observational EPICOR Asia study (NCT01361386). Survivors to hospital discharge were enrolled (June 2011 to May 2012) from 8 countries/regions across Asia. Baseline characteristics and AMP use up to 2 years post-discharge were collected. Outcomes were major adverse cardiovascular events (MACE: myocardial infarction, ischemic stroke, and death) and bleeding.

RESULTS

Among 2289 medically managed patients, dual antiplatelet therapy (DAPT) use at discharge was greater in NSTEMI than in UA patients (81.8% vs 65.3%), and was significantly associated with male sex, positive cardiac markers, and prior cardiovascular medications (p < 0.0001). By 2 years, 57.9% and 42.6% of NSTEMI and UA patients, respectively, were on DAPT. On multivariable Cox regression analysis, risk of MACE at 2 years was most significantly associated with older age (HR [95% CI] 1.85 [1.36, 2.50]), diagnosis of NSTEMI vs UA (1.96 [1.47, 2.61]), and chronic renal failure (2.14 [1.34, 3.41]), all p ≤ 0.001. Risk of bleeding was most significantly associated with region (East Asia vs Southeast/South Asia) and diabetes.

CONCLUSIONS

Approximately half of all patients were on DAPT at 2 years. MACE were more frequent in NSTEMI than UA patients during follow-up.

Blood group A: a risk factor for heart rupture after acute myocardial infarction

Introduction

Studies have been performed to identify the association between ABO blood groups and coronary artery disease. However, data is scarce about the impact of ABO blood groups on heart rupture (HR) after acute myocardial infarction (AMI).

Methods

We conducted a retrospective case–control study that included 61 consecutive patients with HR after AMI during a period from 1 January 2012 to 1 December 2019. The controls included 600 patients who were selected randomly from 8143 AMI patients without HR in a ratio of 1:10. Univariate and multivariate logistic regression analysis were used to identify the association between ABO blood groups and HR.

Results

Patients with blood group A had a greater risk of HR after AMI than those with non-A blood groups (12.35% vs 7.42%, P < 0.001). After adjusting for age, gender, heart rate at admission, body mass index (BMI), and systolic blood pressure (SBP), blood group A was independently related to the increased risk of HR after AMI (OR = 2.781, 95% CI 1.174–7.198, P = 0.035), and remained as an independent risk factor of HR after AMI in different multivariate regression models.

Conclusion

Blood group A is significantly associated with increased HR risk after AMI.