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Jeyaprakash P, Pathan F, Sivapathan S, Robledo KP, Madan K, Khor L, Yu C, Madronio C, Hallani H, Low G, Nundlall N, Burgess S, Fernandes C, Parikh D, Loh H, Mansberg R, Nguyen D, Ozawa K, Porter TR, Negishi K. Sonothrombolysis Before and After Percutaneous Coronary Intervention Provides the Largest Myocardial Salvage in ST Segment Elevation Myocardial Infarction. J Am Soc Echocardiogr 2024; 37:996-1007. [PMID: 38986920 DOI: 10.1016/j.echo.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Sonothrombolysis is a therapeutic application of ultrasound with ultrasound contrast for patients with ST elevation myocardial infarction (STEMI). Recent trials demonstrated that sonothrombolysis, delivered before and after primary percutaneous coronary intervention (pPCI), increases infarct vessel patency, improves microvascular flow, reduces infarct size, and improves ejection fraction. However, it is unclear whether pre-pPCI sonothrombolysis is essential for therapeutic benefit. We designed a parallel 3-arm sham-controlled randomized controlled trial to address this. METHODS Patients presenting with first STEMI undergoing pPCI within 6 hours of symptom onset were randomized 1:1:1 into 3 arms: sonothrombolysis pre-/post-pPCI (group 1), sham pre- sonothrombolysis post-pPCI (group 2), and sham pre-/post-pPCI (group 3). Our primary end point was infarct size (percentage of left ventricular mass) assessed by cardiac magnetic resonance imaging at day 4 ± 2. Secondary end points included myocardial salvage index (MSI) and echocardiographic parameters at day 4 ± 2 and 6 months. RESULTS Our trial was ceased early due to the COVID pandemic. From 122 patients screened between September 2020 and June 2021, 51 patients (age 60, male 82%) were included postrandomization. Median sonothrombolysis took 5 minutes pre-pPCI and 15 minutes post-, without significant door-to-balloon delay. There was a trend toward reduction in median infarct size between group 1 (8% [interquartile range, 4,11]), group 2 (11% [7, 19]), or group 3 (15% [9, 22]). Similarly there was a trend toward improved MSI in group 1 (79% [64, 85]) compared to groups 2 (51% [45, 70]) and 3 (48% [37, 73]) No major adverse cardiac events occurred during hospitalization. CONCLUSIONS Pre-pPCI sonothrombolysis may be key to improving MSI in STEMI. Multicenter trials and health economic analyses are required before clinical translation.
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Affiliation(s)
- Prajith Jeyaprakash
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Faraz Pathan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Shanthosh Sivapathan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Kristy P Robledo
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Kedar Madan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Lynn Khor
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christopher Yu
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christine Madronio
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Hisham Hallani
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Gary Low
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia
| | - Nishant Nundlall
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Sonya Burgess
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Clyne Fernandes
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Devang Parikh
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Han Loh
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Robert Mansberg
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Diep Nguyen
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Koya Ozawa
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia
| | - Thomas R Porter
- Department of Cardiology, University of Nebraska, Lincoln, Nebraska
| | - Kazuaki Negishi
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia.
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Chu M, De Maria GL, Dai R, Benenati S, Yu W, Zhong J, Kotronias R, Walsh J, Andreaggi S, Zuccarelli V, Chai J, Channon K, Banning A, Tu S. DCCAT: Dual-Coordinate Cross-Attention Transformer for thrombus segmentation on coronary OCT. Med Image Anal 2024; 97:103265. [PMID: 39029158 DOI: 10.1016/j.media.2024.103265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 06/02/2024] [Accepted: 07/01/2024] [Indexed: 07/21/2024]
Abstract
Acute coronary syndromes (ACS) are one of the leading causes of mortality worldwide, with atherosclerotic plaque rupture and subsequent thrombus formation as the main underlying substrate. Thrombus burden evaluation is important for tailoring treatment therapy and predicting prognosis. Coronary optical coherence tomography (OCT) enables in-vivo visualization of thrombus that cannot otherwise be achieved by other image modalities. However, automatic quantification of thrombus on OCT has not been implemented. The main challenges are due to the variation in location, size and irregularities of thrombus in addition to the small data set. In this paper, we propose a novel dual-coordinate cross-attention transformer network, termed DCCAT, to overcome the above challenges and achieve the first automatic segmentation of thrombus on OCT. Imaging features from both Cartesian and polar coordinates are encoded and fused based on long-range correspondence via multi-head cross-attention mechanism. The dual-coordinate cross-attention block is hierarchically stacked amid convolutional layers at multiple levels, allowing comprehensive feature enhancement. The model was developed based on 5,649 OCT frames from 339 patients and tested using independent external OCT data from 548 frames of 52 patients. DCCAT achieved Dice similarity score (DSC) of 0.706 in segmenting thrombus, which is significantly higher than the CNN-based (0.656) and Transformer-based (0.584) models. We prove that the additional input of polar image not only leverages discriminative features from another coordinate but also improves model robustness for geometrical transformation.Experiment results show that DCCAT achieves competitive performance with only 10% of the total data, highlighting its data efficiency. The proposed dual-coordinate cross-attention design can be easily integrated into other developed Transformer models to boost performance.
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Affiliation(s)
- Miao Chu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China; Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, UK.
| | - Ruobing Dai
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Stefano Benenati
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK; University of Genoa, Genoa, Italy
| | - Wei Yu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaxin Zhong
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China; Department of Cardiology, Fujian Medical University Union Hospital, Fujian, China
| | - Rafail Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, UK
| | - Jason Walsh
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, UK
| | - Stefano Andreaggi
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiology, Department of Medicine, University of Verona, Italy
| | | | - Jason Chai
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK
| | - Keith Channon
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, UK
| | - Adrian Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, UK; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, UK
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, UK.
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Ekström M, Andersson A, Papadopoulos S, Kipper T, Pedersen B, Kricka O, Sobrino P, Runold M, Palm A, Blomberg A, Hamed R, Lindberg E, Sundberg B, Hadziosmanovic N, Björklund F, Janson C, McDonald CF, Currow DC, Sundh J. Long-Term Oxygen Therapy for 24 or 15 Hours per Day in Severe Hypoxemia. N Engl J Med 2024; 391:977-988. [PMID: 39254466 DOI: 10.1056/nejmoa2402638] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND Long-term oxygen supplementation for at least 15 hours per day prolongs survival among patients with severe hypoxemia. On the basis of a nonrandomized comparison, long-term oxygen therapy has been recommended to be used for 24 hours per day, a more burdensome regimen. METHODS To test the hypothesis that long-term oxygen therapy used for 24 hours per day does not result in a lower risk of hospitalization or death at 1 year than therapy for 15 hours per day, we conducted a multicenter, registry-based, randomized, controlled trial involving patients who were starting oxygen therapy for chronic, severe hypoxemia at rest. The patients were randomly assigned to receive long-term oxygen therapy for 24 or 15 hours per day. The primary outcome, assessed in a time-to-event analysis, was a composite of hospitalization or death from any cause within 1 year. Secondary outcomes included the individual components of the primary outcome assessed at 3 and 12 months. RESULTS Between May 18, 2018, and April 4, 2022, a total of 241 patients were randomly assigned to receive long-term oxygen therapy for 24 hours per day (117 patients) or 15 hours per day (124 patients). No patient was lost to follow-up. At 12 months, the median patient-reported daily duration of oxygen therapy was 24.0 hours (interquartile range, 21.0 to 24.0) in the 24-hour group and 15.0 hours (interquartile range, 15.0 to 16.0) in the 15-hour group. The risk of hospitalization or death within 1 year in the 24-hour group was not lower than that in the 15-hour group (mean rate, 124.7 and 124.5 events per 100 person-years, respectively; hazard ratio, 0.99; 95% confidence interval [CI], 0.72 to 1.36; 90% CI, 0.76 to 1.29; P = 0.007 for nonsuperiority). The groups did not differ substantially in the incidence of hospitalization for any cause, death from any cause, or adverse events. CONCLUSIONS Among patients with severe hypoxemia, long-term oxygen therapy used for 24 hours per day did not result in a lower risk of hospitalization or death within 1 year than therapy for 15 hours per day. (Funded by the Crafoord Foundation and others; REDOX ClinicalTrials.gov number, NCT03441204.).
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Affiliation(s)
- Magnus Ekström
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Anders Andersson
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Savvas Papadopoulos
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Taivo Kipper
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Bo Pedersen
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Ozren Kricka
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Pierre Sobrino
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Michael Runold
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Andreas Palm
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Anders Blomberg
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Ranjh Hamed
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Eva Lindberg
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Björn Sundberg
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Nermin Hadziosmanovic
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Filip Björklund
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Christer Janson
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Christine F McDonald
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - David C Currow
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
| | - Josefin Sundh
- From Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund (M.E., F.B.), the Department of Medicine, Blekinge Hospital, Karlskrona (M.E.), the COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg (A.A.), and the Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital (S.P.), Gothenburg, Karlstad County Hospital, Karlstad (T.K.), Northern Älvsborg County Hospital, Trollhättan (B.P.), Linköping University Hospital, Linköping (O.K.), Falun Hospital, Falun (P.S.), the Department of Respiratory Medicine and Allergology, Faculty of Medicine, Karolinska University Hospital (M.R.), and Karolinska University Hospital Huddinge (R.H.), Stockholm, the Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University (A.P., E.L., C.J.), and the Uppsala Clinical Research Center (N.H.), Uppsala, the Center for Research and Development, Gävle Hospital, Gävle (A.P.), the Department of Public Health and Clinical Medicine, Umeå University, Umeå (A.B.), Sundsvall-Härnösand County Hospital, Sundsvall (B.S.), and the Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro (J.S.) - all in Sweden; the Institute for Breathing and Sleep and the Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC (C.F.M.), and the Graduate School of Medicine, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, NSW (D.C.C.) - both in Australia
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4
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Jeyaprakash P, Pathan F, Ozawa K, Robledo KP, Shah KK, Morton RL, Yu C, Madronio C, Hallani H, Loh H, Boyle A, Ford TJ, Porter TR, Negishi K. Restoring microvascular circulation with diagnostic ultrasound and contrast agent: rationale and design of the REDUCE trial. Am Heart J 2024; 275:163-172. [PMID: 38944262 DOI: 10.1016/j.ahj.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 06/22/2024] [Accepted: 06/22/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES This study aims to evaluate the efficacy and cost-effectiveness of sonothrombolysis delivered pre and post primary percutaneous coronary intervention (pPCI) on infarct size assessed by cardiac MRI, in patients presenting with STEMI, when compared against sham procedure. BACKGROUND More than a half of patients with successful pPCI have significant microvascular obstruction and residual infarction. Sonothrombolysis is a therapeutic use of ultrasound with contrast enhancement that may improve microcirculation and infarct size. The benefits and real time physiological effects of sonothrombolysis in a multicentre setting are unclear. METHODS The REDUCE (Restoring microvascular circulation with diagnostic ultrasound and contrast agent) trial is a prospective, multicentre, patient and outcome blinded, sham-controlled trial. Patients presenting with STEMI will be randomized to one of 2 treatment arms, to receive either sonothrombolysis treatment or sham echocardiography before and after pPCI. This tailored design is based on preliminary pilot data from our centre, showing that sonothrombolysis can be safely delivered, without prolonging door to balloon time. Our primary endpoint will be infarct size assessed on day 4±2 on Cardiac Magnetic Resonance (CMR). Patients will be followed up for 6 months post pPCI to assess secondary endpoints. Sample size calculations indicate we will need 150 patients recruited in total. CONCLUSIONS This multicentre trial will test whether sonothrombolysis delivered pre and post primary PCI can improve patient outcomes and is cost-effective, when compared with sham ultrasound delivered with primary PCI. The results from this trial may provide evidence for the utilization of sonothrombolysis as an adjunct therapy to pPCI to improve cardiovascular outcomes in STEMI. ANZ Clinical Trial Registration number: ACTRN 12620000807954.
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Affiliation(s)
- Prajith Jeyaprakash
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Faraz Pathan
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia; Department of Radiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Koya Ozawa
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Kristy P Robledo
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Karan K Shah
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Christopher Yu
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christine Madronio
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia
| | - Hisham Hallani
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Han Loh
- Department of Radiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Andrew Boyle
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia; University of Newcastle, New South Wales, Australia
| | - Thomas J Ford
- University of Newcastle, New South Wales, Australia; Department of Cardiology, Gosford Public Hospital, Gosford, New South Wales, Australia
| | - Thomas R Porter
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Kazuaki Negishi
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia.
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5
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Omerovic E, James S, Råmundal T, Fröbert O, Linder R, Danielewicz M, Hamid M, Pagonis C, Henareh L, Wagner H, Stewart J, Jensen J, Lindros P, Robertsson L, Wikström H, Ulvenstam A, Bhiladval P, Tödt T, Ioanes D, Kellerth T, Zagozdzon L, Götberg M, Andersson J, Angerås O, Östlund O, Held C, Koul S, Erlinge D. Bivalirudin versus heparin in ST and non-ST-segment elevation myocardial infarction-Outcomes at two years. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 66:43-50. [PMID: 38575449 DOI: 10.1016/j.carrev.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The registry-based randomized VALIDATE-SWEDEHEART trial (NCT02311231) compared bivalirudin vs. heparin in patients undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI). It showed no difference in the composite primary endpoint of death, MI, or major bleeding at 180 days. Here, we report outcomes at two years. METHODS Analysis of primary and secondary endpoints at two years of follow-up was prespecified in the study protocol. We report the study results for the extended follow-up time here. RESULTS In total, 6006 patients were enrolled, 3005 with ST-segment elevation MI (STEMI) and 3001 with Non-STEMI (NSTEMI), representing 70 % of all eligible patients with these diagnoses during the study. The primary endpoint occurred in 14.0 % (421 of 3004) in the bivalirudin group compared with 14.3 % (429 of 3002) in the heparin group (hazard ratio [HR] 0.97; 95 % confidence interval [CI], 0.85-1.11; P = 0.70) at one year and in 16.7 % (503 of 3004) compared with 17.1 % (514 of 3002), (HR 0.97; 95 % CI, 0.96-1.10; P = 0.66) at two years. The results were consistent in patients with STEMI and NSTEMI and across major subgroups. CONCLUSIONS Until the two-year follow-up, there were no differences in endpoints between patients with MI undergoing PCI and allocated to bivalirudin compared with those allocated to heparin. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02311231.
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Affiliation(s)
- Elmir Omerovic
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden.
| | - Stefan James
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Truls Råmundal
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Ole Fröbert
- Dept of Cardiology, Örebro University, Faculty of Health, Sweden
| | - Rikard Linder
- Dept of Cardiology, Danderyd, Karolinska University, Stockholm, Sweden
| | | | - Mehmet Hamid
- Dept of Cardiology, Mälarsjukhuset, Eskilstuna, Sweden
| | - Christos Pagonis
- Dept of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Loghman Henareh
- Dept of Cardiology, Karolinska Hospital, Karolinska University, Stockholm, Sweden
| | - Henrik Wagner
- Dept of Cardiology, Helsingborg Lasarett, Helsingborg, Sweden
| | - Jason Stewart
- Dept of Cardiology, Skaraborgs Hospital, Skövde, Sweden
| | - Jens Jensen
- Dept of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Unit of Cariology, Capio St Görans Sjukhus, Stockholm
| | | | | | - Helena Wikström
- Dept of Cardiology, Kristianstad Hospital, Kristianstad, Sweden
| | | | - Pallonji Bhiladval
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tim Tödt
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Dan Ioanes
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Thomas Kellerth
- Dept of Cardiology, Örebro University, Faculty of Health, Sweden
| | - Leszek Zagozdzon
- Dept of Cardiology, Örebro University, Faculty of Health, Sweden
| | - Matthias Götberg
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | | | - Oskar Angerås
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Ollie Östlund
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Claes Held
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Sasha Koul
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - David Erlinge
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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6
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Peters AE, Jones WS, Anderson B, Bramante CT, Broedl U, Hornik CP, Kehoe L, Knowlton KU, Krofah E, Landray M, Locke T, Patel MR, Psotka M, Rockhold FW, Roessig L, Rothman RL, Schofield L, Stockbridge N, Trontell A, Curtis LH, Tenaerts P, Hernandez AF. Framework of the strengths and challenges of clinically integrated trials: An expert panel report. Am Heart J 2024; 275:62-73. [PMID: 38795793 PMCID: PMC11330722 DOI: 10.1016/j.ahj.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024]
Abstract
The limitations of the explanatory clinical trial framework include the high expense of implementing explanatory trials, restrictive entry criteria for participants, and redundant logistical processes. These limitations can result in slow evidence generation that is not responsive to population health needs, yielding evidence that is not generalizable. Clinically integrated trials, which integrate clinical research into routine care, represent a potential solution to this challenge and an opportunity to support learning health systems. The operational and design features of clinically integrated trials include a focused scope, simplicity in design and requirements, the leveraging of existing data structures, and patient participation in the entire trial process. These features are designed to minimize barriers to participation and trial execution and reduce additional research burdens for participants and clinicians alike. Broad adoption and scalability of clinically integrated trials are dependent, in part, on continuing regulatory, healthcare system, and payer support. This analysis presents a framework of the strengths and challenges of clinically integrated trials and is based on a multidisciplinary expert "Think Tank" panel discussion that included representatives from patient populations, academia, non-profit funding agencies, the U.S. Food and Drug Administration, and industry.
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Affiliation(s)
- Anthony E Peters
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - W Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Carolyn T Bramante
- Departmentd of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | | | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Lindsay Kehoe
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Trevan Locke
- Margolis Institute for Health Policy, Duke University, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Frank W Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | | | | | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Anne Trontell
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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7
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Scheldeman L, Sinnaeve P, Albers GW, Lemmens R, Van de Werf F. Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review. Eur Heart J 2024; 45:2735-2747. [PMID: 38941344 DOI: 10.1093/eurheartj/ehae371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/16/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.
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Affiliation(s)
- Lauranne Scheldeman
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Gregory W Albers
- Department of Neurology, Stanford University Medical Center, Palo Alto, USA
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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8
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Sahami N, Akl E, Sanjanwala R, Shah AH. Safety and efficacy of low-dose intracoronary thrombolysis during primary percutaneous coronary intervention in patients with ST elevation myocardial infarction: A meta-analysis of randomized trials. Curr Probl Cardiol 2024; 49:102616. [PMID: 38718936 DOI: 10.1016/j.cpcardiol.2024.102616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/05/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND In patients with ST elevation myocardial infarction (STEMI), intracoronary thrombolysis (ICT) may reduce thrombotic burden and microvascular obstruction in the infarct-related artery. We performed a meta-analysis to evaluate the role of adjunctive low-dose ICT during primary percutaneous coronary intervention (PPCI) in improving clinical outcomes and indices of microvascular function. METHODS We searched electronic databases (Cochrane, EMBASE, Medline; inception to October 2023) for randomized controlled trials (RCTs) evaluating the effects of adjunctive ICT in STEMI patients undergoing PPCI, compared with placebo or usual care. Study-level data on efficacy and safety outcomes were pooled using a fixed-effect model. The primary outcome was major adverse cardiovascular events (MACE). RESULTS A total of 8 RCTs were included, comprising a total of 1,208 patients. Compared with placebo or usual care, ICT was associated with a trend towards lower MACE (11.3% vs. 15.1%; odds ratio [OR] 0.73, 95% confidence interval [CI] 0.51 to 1.04). Infarct size (mean difference [MD] -1.98, 95% CI -3.68 to -0.27; p=0.02), ST-segment resolution (MD: 6.06, 95% CI: 0.69 to 11.43; p=0.03) and corrected TIMI frame count (MD: -2.26, 95% CI: -4.03 to -0.48; p=0.01; I2=78%). The odds for major (0.7% vs. 0.7%; OR 0.94, 95% CI 0.24 to 3.7; p=0.93) and minor bleeding (7.7% vs. 4.3%; OR 1.81, 95% CI 0.87 to 3.76; p=0.11) were similar between the two groups. CONCLUSION Adjunctive low-dose ICT during PPCI is safe, associated with a trend towards lower MACE, and may improve surrogate markers of microvascular function. These hypothesis-generating findings warrant validation in larger, adequately powered randomized trials.
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Affiliation(s)
| | - Elie Akl
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada
| | - Rohan Sanjanwala
- Department of Internal Medicine, St. Boniface Hospital, University of Manitoba, Y3006-409, Tache Avenue, Winnipeg, MB R2H 2A6, Canada
| | - Ashish H Shah
- Department of Internal Medicine, St. Boniface Hospital, University of Manitoba, Y3006-409, Tache Avenue, Winnipeg, MB R2H 2A6, Canada.
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9
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Dimmer A, Stark R, Skarsgard ED, Puligandla PS. The promise and pitfalls of care standardization in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151445. [PMID: 38972215 DOI: 10.1016/j.sempedsurg.2024.151445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
The aim of standardizing care is to enhance patient outcomes and optimize healthcare delivery by minimizing variations in care and ensuring the efficient allocation of healthcare resources. Despite these potential benefits to patients, healthcare providers and the healthcare system, standardization may also disadvantage these groups. With a specific focus on congenital diaphragmatic hernia, this article will review the promise and pitfalls of standardization, as well as a potential path forward that uses standardization to improve outcomes in this rare and complex disease process.
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Affiliation(s)
- Alexandra Dimmer
- Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec
| | - Rebecca Stark
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, Washington
| | - Erik D Skarsgard
- Division of Pediatric Surgery, British Columbia Children's Hospital, Vancouver, British Columbia
| | - Pramod S Puligandla
- Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec.
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10
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Angus DC, Huang AJ, Lewis RJ, Abernethy AP, Califf RM, Landray M, Kass N, Bibbins-Domingo K. The Integration of Clinical Trials With the Practice of Medicine: Repairing a House Divided. JAMA 2024; 332:153-162. [PMID: 38829654 DOI: 10.1001/jama.2024.4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Importance Optimal health care delivery, both now and in the future, requires a continuous loop of knowledge generation, dissemination, and uptake on how best to provide care, not just determining what interventions work but also how best to ensure they are provided to those who need them. The randomized clinical trial (RCT) is the most rigorous instrument to determine what works in health care. However, major issues with both the clinical trials enterprise and the lack of integration of clinical trials with health care delivery compromise medicine's ability to best serve society. Observations In most resource-rich countries, the clinical trials and health care delivery enterprises function as separate entities, with siloed goals, infrastructure, and incentives. Consequently, RCTs are often poorly relevant and responsive to the needs of patients and those responsible for care delivery. At the same time, health care delivery systems are often disengaged from clinical trials and fail to rapidly incorporate knowledge generated from RCTs into practice. Though longstanding, these issues are more pressing given the lessons learned from the COVID-19 pandemic, heightened awareness of the disproportionate impact of poor access to optimal care on vulnerable populations, and the unprecedented opportunity for improvement offered by the digital revolution in health care. Four major areas must be improved. First, especially in the US, greater clarity is required to ensure appropriate regulation and oversight of implementation science, quality improvement, embedded clinical trials, and learning health systems. Second, greater adoption is required of study designs that improve statistical and logistical efficiency and lower the burden on participants and clinicians, allowing trials to be smarter, safer, and faster. Third, RCTs could be considerably more responsive and efficient if they were better integrated with electronic health records. However, this advance first requires greater adoption of standards and processes designed to ensure health data are adequately reliable and accurate and capable of being transferred responsibly and efficiently across platforms and organizations. Fourth, tackling the problems described above requires alignment of stakeholders in the clinical trials and health care delivery enterprises through financial and nonfinancial incentives, which could be enabled by new legislation. Solutions exist for each of these problems, and there are examples of success for each, but there is a failure to implement at adequate scale. Conclusions and Relevance The gulf between current care and that which could be delivered has arguably never been wider. A key contributor is that the 2 limbs of knowledge generation and implementation-the clinical trials and health care delivery enterprises-operate as a house divided. Better integration of these 2 worlds is key to accelerated improvement in health care delivery.
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Affiliation(s)
- Derek C Angus
- JAMA , Chicago, Illinois
- University of Pittsburgh Schools of the Health Sciences, Pittsburgh, Pennsylvania
| | | | - Roger J Lewis
- JAMA , Chicago, Illinois
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amy P Abernethy
- Verily Life Sciences, San Francisco, California
- Now with Highlander Health, Dallas, Texas
| | | | - Martin Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Protas, Manchester, United Kingdom
| | - Nancy Kass
- Johns Hopkins University, Baltimore, Maryland
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11
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Zhi Y, Madanchi M, Cioffi GM, Brunner J, Stutz L, Gnan E, Gjergjizi V, Attinger-Toller A, Cuculi F, Bossard M. Initial experience with a novel stent-based mechanical thrombectomy device for management of acute myocardial infarction cases with large thrombus burden. Cardiovasc Interv Ther 2024; 39:262-272. [PMID: 38642291 PMCID: PMC11164735 DOI: 10.1007/s12928-024-00998-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/18/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Patients with acute myocardial infarction (AMI) and large thrombus burden (LTB) still represent a challenge. Afflicted patients have a high morbidity and mortality. Aspiration thrombectomy is often ineffective in those cases. Mechanical thrombectomy devices (MTDs), which are effective for management of ischemic strokes, were recently CE-approved for treatment of thrombotic coronary lesions. Real-world data about their performance in AMI cases with LTB are scarce. This study sought to summarize our early experience with a novel MTD device in this context. METHODS We analyzed consecutive patients from the prospective OPTIMISER registry (NCT04988672), who have been managed with the NeVa™ MTD (Vesalio, USA) for AMI with LTB at a tertiary cardiology facility. Outcomes of interest included, among others, periprocedural complications, target lesion failure (TLF), target lesion revascularization (TLR) and target vessel myocardial infarction (TV-MI). RESULTS Overall, 15 patients underwent thrombectomy with the NeVa™ device. Thrombectomy was successfully performed in 14 (93%) patients. Final TIMI 3 flow was achieved in 13 (87%) patients, while 2 (13%) patients had TIMI 2 flow. We encountered no relevant periprocedural complications, especially no stroke, stent thrombosis or vessel closure. After a mean follow-up time of 26 ± 2.9 months, 1 (7%) patient presented with TLR due to stent thrombosis (10 months after treatment with the MTD and stenting). CONCLUSIONS In AMI patients with LTB, the deployment of the novel NeVa™ MTD seems efficient and safe. Further randomized trials are warranted to assess whether the use of the NeVa™ device in cases with LTB improves procedural and clinical outcomes.
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Affiliation(s)
- Yuan Zhi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mehdi Madanchi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Giacomo Maria Cioffi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Julian Brunner
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Leah Stutz
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Eleonora Gnan
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
- Università Statale Di Milano, Milan, Italy
| | - Varis Gjergjizi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
| | - Adrian Attinger-Toller
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, 6000, Lucerne 16, Switzerland.
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
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12
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Wang H, Li S, Yu J, Xu J, Xu Y. Role of leukocyte parameters in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with high thrombus burden. Front Cardiovasc Med 2024; 11:1397701. [PMID: 38962087 PMCID: PMC11221325 DOI: 10.3389/fcvm.2024.1397701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024] Open
Abstract
Objective Leukocyte parameters are associated with cardiovascular diseases. The aim of the present study was to investigate the role of leukocyte parameters in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) with high thrombus burden (HTB). Methods A total of 102 consecutive STEMI patients with HTB who underwent PPCI within 12 h from the onset of symptoms between June 2020 and September 2021 were enrolled in this study. In addition, 101 age- and sex-matched STEMI patients with low thrombus burden (LTB) who underwent PPCI within 12 h from the onset of symptoms were enrolled as controls. Leukocyte parameters, such as neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and monocyte to lymphocyte ratio (MLR), were calculated at the time of admission. Results The value of NLR and MLR were significantly higher in the HTB group than in the LTB group (6.24 ± 4.87 vs. 4.65 ± 3.47, p = 0.008; 0.40 ± 0.27 vs. 0.33 ± 0.20, p = 0.038). A cutoff value of >5.38 for NLR had a sensitivity and specificity of 53.9% and 74.3%, respectively, and MLR >0.29 had a sensitivity and specificity of 60.8% and 55.4%, respectively, for determining the STEMI patients with HTB [area under the receiver operating characteristic curve (AUC): 0.603, 95% confidence interval (CI): 0.524-0.681, p = 0.012; AUC: 0.578, 95% CI: 0.499-0.656, p = 0.046]. There was no significant difference of all-cause mortality rate and major adverse cardiac events (MACEs) between the STEMI patients with HTB or with LTB (3.92% in HTB group vs. 2.97% in LTB group, p = 0.712; 10.78% in HTB group vs. 8.91% in LTB group, p = 0.215). Compared with the HTB patients in the low NLR group, C-reactive protein, baseline troponin I, baseline brain natriuretic peptide, and leukocyte parameters, such as white blood cell, neutrophil, lymphocyte, NLR, PLR, and MLR, were also significantly higher in the high NLR group in STEMI patients who underwent PPCI with HTB (18.94 ± 19.06 vs. 35.23 ± 52.83, p = 0.037; 10.99 ± 18.07 vs. 21.37 ± 19.64, p = 0.007; 199.39 ± 323.67 vs. 430.72 ± 683.59, p = 0.028; 11.55 ± 3.56 vs. 9.31 ± 2.54, p = 0.001; 9.77 ± 3.17 vs. 5.79 ± 1.97, p = 0.000; 1.16 ± 0.44 vs. 2.69 ± 1.23, p = 0.000; 9.37 ± 4.60 vs 1.31 ± 2.58, p = 0.000; 200.88 ± 89.90 vs. 97.47 ± 50.99, p = 0.000; 0.52 ± 0.29 vs. 0.26 ± 0.14, p = 0.000, respectively). MACEs and heart failure in the high NLR group were significantly higher than that in the low NLR group of STEMI patients who underwent PPCI with HTB (20.45% vs. 4.25%, p = 0.041; 10.91% vs. 2.13%, p = 0.038). Conclusion The value of NLR and MLR were higher in STEMI patients who underwent PPCI with HTB. In STEMI patients who underwent PPCI with HTB, a raised NLR could effectively predict the occurrence of MACEs and heart failure.
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Affiliation(s)
| | | | | | | | - Yan Xu
- Department of Cardiology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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13
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Shiely F, O Shea N, Murphy E, Eustace J. Registry-based randomised controlled trials: conduct, advantages and challenges-a systematic review. Trials 2024; 25:375. [PMID: 38863017 PMCID: PMC11165819 DOI: 10.1186/s13063-024-08209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/29/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Registry-based randomised controlled trials (rRCTs) have been described as pragmatic studies utilising patient data embedded in large-scale registries to facilitate key clinical trial procedures including recruitment, randomisation and the collection of outcome data. Whilst the practice of utilising registries to support the conduct of randomised trials is increasing, the use of the registries within rRCTs is inconsistent. The purpose of this systematic review is to explore the conduct of rRCTs using a patient registry to facilitate trial recruitment and the collection of outcome data, and to discuss the advantages and challenges of rRCTs. METHODS A systematic search of the literature was conducted using five databases from inception to June 2020: PubMed, Embase (through Ovid), CINAHL, Scopus and the Cochrane Controlled Register of Trials (CENTRAL). The search strategy comprised of MESH terms and key words related to rRCTs. Study selection was performed independently by two reviewers. A risk of bias for each study was completed. A narrative synthesis was conducted. RESULTS A total 47,862 titles were screened and 24 rRCTs were included. Eleven rRCTs (45.8%) used more than one registry to facilitate trial conduct. Six rRCTs (25%) randomised participants via a specific randomisation module embedded within a registry. Recruitment ranged between 209 to 106,000 participants. Advantages of rRCTs are recruitment efficiency, shorter trial times, cost effectiveness, outcome data completeness, smaller carbon footprint, lower participant burden and the ability to conduct multiple trials from the same registry. Challenges are data collection/management, quality assurance issues and the timing of informed consent. CONCLUSIONS Optimising the design of rRCTs is dependent on the capabilities of the registry. New registries should be designed and existing registries reviewed to enable the conduct of rRCTs. At all times, data management and quality assurance of all registry data should be given key consideration. We suggest the inclusion of the term 'registry-based' in the title of all rRCT manuscripts and a clear simple breakdown of the registry-based conduct of the trial in the abstract to facilitate indexing in the major databases.
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Affiliation(s)
- Frances Shiely
- Trials Research and Methodologies Unit, HRB Clinical Research Facility, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland.
- School of Public Health, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland.
| | - Niamh O Shea
- Trials Research and Methodologies Unit, HRB Clinical Research Facility, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland
- Health Research Board, Trials Methodology Research Network, University College Cork, Cork, Ireland
| | - Ellen Murphy
- Trials Research and Methodologies Unit, HRB Clinical Research Facility, University College Cork, 4th Floor Western Gateway Building, Western Road, Cork, Ireland
- Health Research Board, Trials Methodology Research Network, University College Cork, Cork, Ireland
| | - Joseph Eustace
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
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14
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Ryan EG, Gao CX, Grantham KL, Thao LTP, Charles-Nelson A, Bowden R, Herschtal A, Lee KJ, Forbes AB, Heritier S, Phillipou A, Wolfe R. Advancing randomized controlled trial methodologies: The place of innovative trial design in eating disorders research. Int J Eat Disord 2024; 57:1337-1349. [PMID: 38469971 DOI: 10.1002/eat.24187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 03/13/2024]
Abstract
Randomized controlled trials can be used to generate evidence on the efficacy and safety of new treatments in eating disorders research. Many of the trials previously conducted in this area have been deemed to be of low quality, in part due to a number of practical constraints. This article provides an overview of established and more innovative clinical trial designs, accompanied by pertinent examples, to highlight how design choices can enhance flexibility and improve efficiency of both resource allocation and participant involvement. Trial designs include individually randomized, cluster randomized, and designs with randomizations at multiple time points and/or addressing several research questions (master protocol studies). Design features include the use of adaptations and considerations for pragmatic or registry-based trials. The appropriate choice of trial design, together with rigorous trial conduct, reporting and analysis, can establish high-quality evidence to advance knowledge in the field. It is anticipated that this article will provide a broad and contemporary introduction to trial designs and will help researchers make informed trial design choices for improved testing of new interventions in eating disorders. PUBLIC SIGNIFICANCE: There is a paucity of high quality randomized controlled trials that have been conducted in eating disorders, highlighting the need to identify where efficiency gains in trial design may be possible to advance the eating disorder research field. We provide an overview of some key trial designs and features which may offer solutions to practical constraints and increase trial efficiency.
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Affiliation(s)
- Elizabeth G Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Caroline X Gao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
| | - Kelsey L Grantham
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anaïs Charles-Nelson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rhys Bowden
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alan Herschtal
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea Phillipou
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
- Department of Mental Health, Austin Health, Melbourne, Victoria, Australia
- Department of Mental Health, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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15
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Derks L, Medendorp NM, Houterman S, Umans VAWM, Maessen JG, van Veghel D. Building a patient-centred nationwide integrated cardiac care registry: intermediate results from the Netherlands. Neth Heart J 2024; 32:228-237. [PMID: 38776039 PMCID: PMC11143093 DOI: 10.1007/s12471-024-01877-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
This paper presents an overview of the development of an integrated patient-centred cardiac care registry spanning the initial 5 years (September 2017 to December 2022). The Netherlands Heart Registration facilitates registration committees in which mandated cardiologists and cardiothoracic surgeons structurally evaluate quality of care using real-world data. With consistent attendance rates exceeding 60%, a valuable network is supported. Over time, the completeness level of the registry has increased. Presently, four out of six quality registries show over 95% completeness in variables that are part of the quality policies of cardiology and cardiothoracic surgery societies. Notably, 93% of the centres voluntarily report outcomes related to open heart surgery and (trans)catheter interventions publicly. Moreover, outcomes after implantable cardioverter-defibrillator and pacemaker procedures are transparently reported by 26 centres. Multiple innovation projects have been initiated by the committees, signalling a shift from publishing outcomes transparently to collaborative efforts in sharing healthcare processes and investigating improvement initiatives. The next steps will focus on the entire pathway of cardiac care for a specific medical condition instead of focusing solely on the outcomes of the procedures. This redirection of focus to a comprehensive assessment of the patient pathway in cardiac care ultimately aims to optimise outcomes for all patients.
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Affiliation(s)
- Lineke Derks
- Netherlands Heart Registration, Utrecht, The Netherlands.
| | | | | | | | - Jos G Maessen
- Netherlands Heart Registration, Utrecht, The Netherlands
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16
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Gautier A, Danchin N, Ducrocq G, Rousseau A, Cottin Y, Cayla G, Prunier F, Durand-Zaleski I, Ravaud P, Angoulvant D, Coste P, Lemesle G, Bouleti C, Popovic B, Ferrari E, Silvain J, Dubreuil O, Lhermusier T, Goube P, Schiele F, Vanzetto G, Aboyans V, Gallet R, Eltchaninoff H, Thuaire C, Dillinger JG, Paganelli F, Gourmelen J, Steg PG, Simon T. Rationale and design of the FRENch CoHort of myocardial Infarction Evaluation (FRENCHIE) study. Arch Cardiovasc Dis 2024; 117:417-426. [PMID: 38821761 DOI: 10.1016/j.acvd.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Despite major advances in prevention and treatment, cardiovascular diseases - particularly acute myocardial infarction - remain a leading cause of death worldwide and in France. Collecting contemporary data about the characteristics, management and outcomes of patients with acute myocardial infarction in France is important. AIMS The main objectives are to describe baseline characteristics, contemporary management, in-hospital and long-term outcomes of patients with acute myocardial infarction hospitalized in tertiary care centres in France; secondary objectives are to investigate determinants of prognosis (including periodontal disease and sleep-disordered breathing), to identify gaps between evidence-based recommendations and management and to assess medical care costs for the index hospitalization and during the follow-up period. METHODS FRENCHIE (FRENch CoHort of myocardial Infarction Evaluation) is an ongoing prospective multicentre observational study (ClinicalTrials.gov Identifier: NCT04050956) enrolling more than 19,000 patients hospitalized for acute myocardial infarction with onset of symptoms within 48hours in 35 participating centres in France since March 2019. Main exclusion criteria are age<18 years, lack of health coverage and procedure-related myocardial infarction (types 4a and 5). Detailed information was collected prospectively, starting at admission, including demographic data, risk factors, medical history and treatments, initial management, with prehospital care pathways and medication doses, and outcomes until hospital discharge. The follow-up period (up to 20 years for each patient) is ensured by linking with the French national health database (Système national des données de santé), and includes information on death, hospital admissions, major clinical events, healthcare consumption (including drug reimbursement) and total healthcare costs. FRENCHIE is also used as a platform for cohort-nested studies - currently three randomized trials and two observational studies. CONCLUSIONS This nationwide large contemporary cohort with very long-term follow-up will improve knowledge about acute myocardial infarction management and outcomes in France, and provide a useful platform for nested studies and trials.
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Affiliation(s)
- Alexandre Gautier
- French Alliance for Cardiovascular Trials, Laboratory for Vascular Translational Science, Inserm U1148, hôpital Bichat, AP-HP, 75018 Paris, France; Université Paris Cité, 75006 Paris, France
| | - Nicolas Danchin
- Hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France
| | - Gregory Ducrocq
- French Alliance for Cardiovascular Trials, Laboratory for Vascular Translational Science, Inserm U1148, hôpital Bichat, AP-HP, 75018 Paris, France; Université Paris Cité, 75006 Paris, France
| | - Alexandra Rousseau
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), French Alliance for Cardiovascular Trials, Hôpital Saint-Antoine, AP-HP, Sorbonne University, 75012 Paris, France
| | - Yves Cottin
- CHU François-Mitterrand, université de Bourgogne, 21000 Dijon, France
| | - Guillaume Cayla
- CHU de Nîmes, université de Montpellier, 30900 Nîmes, France
| | - Fabrice Prunier
- Équipe Carme, CNRS, Mitovasc, Inserm, CHU d'Angers, université d'Angers, 49100 Angers, France
| | - Isabelle Durand-Zaleski
- URC-Eco, service d'épidémiologie clinique, hôpital de l'Hôtel Dieu, AP-HP, CRESS, Inserm, INRAE, université Paris Cité, 75004 Paris, France; Santé Publique hôpital Henri-Mondor, 94000 Créteil, France
| | - Philippe Ravaud
- URC-Eco, service d'épidémiologie clinique, hôpital de l'Hôtel Dieu, AP-HP, CRESS, Inserm, INRAE, université Paris Cité, 75004 Paris, France
| | - Denis Angoulvant
- Service de cardiologie, CHRU de Tours, UMR Inserm 1327 ISCHEMIA, université de Tours, 37000 Tours, France
| | - Pierre Coste
- Service des maladies coronaires et vasculaires, hôpital cardiologique, CHU de Bordeaux, université de Bordeaux, 33604 Pessac, France
| | - Gilles Lemesle
- USIC et centre hémodynamique, institut cœur poumon, Institut Pasteur de Lille, INSERM UMR1011, French Alliance for Cardiovascular Trials, CHU de Lille, faculté de médecine de l'université de Lille, 59019 Lille, France
| | - Claire Bouleti
- Cardiology Department, Clinical Investigation Centre (Inserm 1204), CHU de Poitiers, 86000 Poitiers, France
| | - Batric Popovic
- Département de cardiologie, CHRU de Nancy, université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France
| | - Emile Ferrari
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Johanne Silvain
- ACTION Group, Inserm UMRS 1166, Sorbonne université, hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Olivier Dubreuil
- USIC, service de cardiologie, hôpital Saint-Joseph Saint-Luc, 69007 Lyon, France
| | - Thibault Lhermusier
- Service de cardiologie, UFR Santé de Toulouse, université Toulouse III Paul-Sabatier, CHU de Toulouse, 31400 Toulouse, France
| | - Pascal Goube
- Service de cardiologie, CH Sud-Francilien, 91100 Corbeil-Essonnes, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean Minjoz, EA3920, University of Burgundy Franche-Comte, 25000 Besançon, France
| | - Gérald Vanzetto
- Université Grenoble Alpes, Inserm U1039, CHU de Grenoble Alpes, 38700 La Tronche, France
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, EpiMaCT, Inserm 1098/IRD270, Limoges University, 87042 Limoges, France
| | - Romain Gallet
- Service de cardiologie, hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | - Hélène Eltchaninoff
- Inserm U955-IMRB, UPEC, 94010 Créteil, France; École nationale vétérinaire d'Alfort, 94700 Maisons-Alfort, France; Département de cardiologie, CHU de Rouen, Inserm U1096, université de Rouen Normandie, 76000 Rouen, France
| | | | - Jean-Guillaume Dillinger
- French Alliance for Cardiovascular Trials, Laboratory for Vascular Translational Science, Inserm U1148, hôpital Bichat, AP-HP, 75018 Paris, France; Department of Cardiology, hôpital Lariboisière, AP-HP, Inserm U-942, 75010 Paris, France
| | - Franck Paganelli
- Centre for CardioVascular and Nutrition Research (C2VN), INSERM, INRAE and Aix-Marseille University, 13005 Marseille, France
| | - Julie Gourmelen
- Inserm, UMS 011, Population-Based Epidemiological Cohorts, 94807 Villejuif, France
| | - Philippe Gabriel Steg
- French Alliance for Cardiovascular Trials, Laboratory for Vascular Translational Science, Inserm U1148, hôpital Bichat, AP-HP, 75018 Paris, France; Université Paris Cité, 75006 Paris, France; Institut universitaire de France, 75231 Paris, France.
| | - Tabassome Simon
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), French Alliance for Cardiovascular Trials, Hôpital Saint-Antoine, AP-HP, Sorbonne University, 75012 Paris, France
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17
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Abdelfattah OM, Kumfa P, Allencherril J. Coronary Embolism in ST-Segment-Elevation Myocardial Infarction and Atrial Fibrillation: Not One Size Fits All. J Am Heart Assoc 2024; 13:e035372. [PMID: 38742541 PMCID: PMC11179833 DOI: 10.1161/jaha.124.035372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Affiliation(s)
- Omar M Abdelfattah
- Division of Cardiovascular Medicine University of Texas Medical Branch Galveston TX USA
| | - Paul Kumfa
- Division of Cardiovascular Medicine University of Texas Medical Branch Galveston TX USA
| | - Joseph Allencherril
- Division of Cardiovascular Medicine University of Texas Medical Branch Galveston TX USA
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18
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Steg PG. Routine Beta-Blockers in Secondary Prevention - On Injured Reserve. N Engl J Med 2024; 390:1434-1436. [PMID: 38587255 DOI: 10.1056/nejme2402731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Affiliation(s)
- P Gabriel Steg
- From Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, INSERM Unité 1148, Laboratory for Vascular Translational Science, French Alliance for Cardiovascular Trials, Paris
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19
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Satti Z, Omari M, Bawamia B, Cartlidge T, Egred M, Farag M, Alkhalil M. The Use of Thrombectomy during Primary Percutaneous Coronary Intervention: Resurrecting an Old Concept in Contemporary Practice. J Clin Med 2024; 13:2291. [PMID: 38673564 PMCID: PMC11050836 DOI: 10.3390/jcm13082291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/29/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.
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Affiliation(s)
- Zahir Satti
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Muntaser Omari
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Bilal Bawamia
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Timothy Cartlidge
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Mohaned Egred
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Mohamed Farag
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
| | - Mohammad Alkhalil
- Cardiothoracic Department, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK; (Z.S.); (M.O.); (B.B.); (T.C.); (M.E.); (M.F.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
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20
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Peng S, Rempakos A, Mastrodemos OC, Rangan BV, Alexandrou M, Allana S, Al-Ogaili A, Mutlu D, Karacsonyi J, Bergstedt S, Khalid MS, Stanberry L, Brilakis ES. Use of the Indigo CAT RX aspiration system during percutaneous coronary intervention. Catheter Cardiovasc Interv 2024; 103:695-702. [PMID: 38419416 DOI: 10.1002/ccd.30994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/30/2024] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The use of the Indigo CAT RX Aspiration System (Penumbra Inc.) during percutaneous coronary intervention has received limited study. METHODS We retrospectively examined the clinical, angiographic, and procedural characteristics, outcomes, and follow-up of patients who underwent mechanical aspiration thrombectomy with the Indigo CAT RX system (Penumbra Inc.) at a large tertiary care hospital between January 2019 and April 2023. RESULTS During the study period, 83 patients (85 lesions) underwent thrombectomy with the Indigo CAT RX. Mean patient age was 64.9 ± 14.48 years and 31.2% were women. The most common presentations were ST-segment elevation myocardial infarction (MI) (66.2%) and non-ST-segment elevation MI (26.5%). A final thrombolysis in MI flow grade of 3 and final myocardial blush grade of 3 were achieved in 76% and 46% of the cases, respectively. Technical success was achieved in 88.9% of the cases that included Indigo CAT RX treatment only, compared with 57.1% of the cases that also included manual aspiration. There were no device-related serious adverse events. At 30-day postprocedure, the incidence of major adverse cardiac events (composite of cardiovascular death, recurrent MI, cardiogenic shock, new or worsening New York Heart Association Class IV heart failure, stroke) was 8.5%: 1.3% stroke (postprocedure, in-hospital), 1.3% MI, 6.1% cardiac death, and 7.5% developed cardiogenic shock. CONCLUSIONS Use of the Indigo CAT RX system is associated with high technical success and acceptable risk of complications, including stroke.
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Affiliation(s)
- Sydney Peng
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Athanasios Rempakos
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Olga C Mastrodemos
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Bavana V Rangan
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Michaella Alexandrou
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Salman Allana
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Ahmed Al-Ogaili
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Deniz Mutlu
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Judit Karacsonyi
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Seth Bergstedt
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Muhmmad S Khalid
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Larissa Stanberry
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Emmanouil S Brilakis
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
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21
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Krychtiuk KA, Andersson TL, Bodesheim U, Butler J, Curtis LH, Elkind M, Hernandez AF, Hornik C, Lyman GH, Khatri P, Mbagwu M, Murakami M, Nichols G, Roessig L, Young AQ, Schilsky RL, Pagidipati N. Drug development for major chronic health conditions-aligning with growing public health needs: Proceedings from a multistakeholder think tank. Am Heart J 2024; 270:23-43. [PMID: 38242417 DOI: 10.1016/j.ahj.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
The global pharmaceutical industry portfolio is skewed towards cancer and rare diseases due to more predictable development pathways and financial incentives. In contrast, drug development for major chronic health conditions that are responsible for a large part of mortality and disability worldwide is stalled. To examine the processes of novel drug development for common chronic health conditions, a multistakeholder Think Tank meeting, including thought leaders from academia, clinical practice, non-profit healthcare organizations, the pharmaceutical industry, the Food and Drug Administration (FDA), payors as well as investors, was convened in July 2022. Herein, we summarize the proceedings of this meeting, including an overview of the current state of drug development for chronic health conditions and key barriers that were identified. Six major action items were formulated to accelerate drug development for chronic diseases, with a focus on improving the efficiency of clinical trials and rapid implementation of evidence into clinical practice.
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Affiliation(s)
| | | | | | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, TX
| | | | - Mitchell Elkind
- American Heart Association, Dallas, TX; Columbia University, New York, NY
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22
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Eisenstein EL, Hill KD, Wood N, Kirchner JL, Anstrom KJ, Granger CB, Rao SV, Baldwin HS, Jacobs JP, Jacobs ML, Kannankeril PJ, Graham EM, O'Brien SM, Li JS. Evaluating registry-based trial economics: Results from the STRESS clinical trial. Contemp Clin Trials Commun 2024; 38:101257. [PMID: 38298917 PMCID: PMC10826145 DOI: 10.1016/j.conctc.2024.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
Background Registry-based trials have the potential to reduce randomized clinical trial (RCT) costs. However, observed cost differences also may be achieved through pragmatic trial designs. A systematic comparison of trial costs across different designs has not been previously performed. Methods We conducted a study to compare the current Steroids to Reduce Systemic inflammation after infant heart surgery (STRESS) registry-based RCT vs. two established designs: pragmatic RCT and explanatory RCT. The primary outcome was total RCT design costs. Secondary outcomes included: RCT duration and personnel hours. Costs were estimated using the Duke Clinical Research Institute's pricing model. Results The Registry-Based RCT estimated duration was 31.9 weeks greater than the other designs (259.5 vs. 227.6 weeks). This delay was caused by the Registry-Based design's periodic data harvesting that delayed site closing and statistical reporting. Total personnel hours were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design (52,488 vs 29,763 vs. 24,480 h, respectively). Total costs were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design ($10,140,263 vs. $4,164,863 vs. $3,268,504, respectively). Thus, Registry-Based total costs were 32 % of the Explanatory and 78 % of the Pragmatic design. Conclusion Total costs for the STRESS RCT with a registry-based design were less than those for a pragmatic design and much less than an explanatory design. Cost savings reflect design elements and leveraging of registry resources to improve cost efficiency, but delays to trial completion should be considered.
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Affiliation(s)
| | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
| | - Nancy Wood
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Kevin J. Anstrom
- Collaborative Studies Coordinating Center, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - H. Scott Baldwin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - Eric M. Graham
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Jennifer S. Li
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
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23
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Dawson LP, Rashid M, Dinh DT, Brennan A, Bloom JE, Biswas S, Lefkovits J, Shaw JA, Chan W, Clark DJ, Oqueli E, Hiew C, Freeman M, Taylor AJ, Reid CM, Ajani AE, Kaye DM, Mamas MA, Stub D. No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score. Circ Cardiovasc Interv 2024; 17:e013738. [PMID: 38487882 DOI: 10.1161/circinterventions.123.013738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/31/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI. METHODS We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort). RESULTS A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively. CONCLUSIONS The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.
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Affiliation(s)
- Luke P Dawson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Stroke on Trent, United Kingdom (M.R., A.E.A., M.A.M.)
- Department of Cardiovascular Sciences, National Institute for Health and Care Research (NIHR) Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester, United Kingdom (M.R., A.E.A.)
- University Hospitals of Leicester National Health Service (NHS) Trust, United Kingdom (M.R., A.E.A.)
| | - Diem T Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
| | - Jason E Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - Sinjini Biswas
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia (J.L.)
| | - James A Shaw
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - William Chan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Medicine, Melbourne University, Victoria, Australia (W.C.)
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (D.J.C.)
| | - Ernesto Oqueli
- Department of Cardiology, Grampians Health Ballarat, Victoria, Australia (E.O.)
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia (E.O.)
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Victoria, Australia (C.H.)
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia (M.F.)
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Centre of Clinical Research and Education, School of Public Health, Curtin University, Perth, Western Australia, Australia (C.M.R.)
| | - Andrew E Ajani
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Stroke on Trent, United Kingdom (M.R., A.E.A., M.A.M.)
- Department of Cardiovascular Sciences, National Institute for Health and Care Research (NIHR) Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester, United Kingdom (M.R., A.E.A.)
- University Hospitals of Leicester National Health Service (NHS) Trust, United Kingdom (M.R., A.E.A.)
| | - David M Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Stroke on Trent, United Kingdom (M.R., A.E.A., M.A.M.)
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
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Alexiou S, Patoulias D, Theodoropoulos KC, Didagelos M, Nasoufidou A, Samaras A, Ziakas A, Fragakis N, Dardiotis E, Kassimis G. Intracoronary Thrombolysis in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: an Updated Meta-analysis of Randomized Controlled Trials. Cardiovasc Drugs Ther 2024; 38:335-346. [PMID: 36346537 DOI: 10.1007/s10557-022-07402-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PPCI) is the standard reperfusion treatment in ST-segment elevation myocardial infarction (STEMI). Intracoronary thrombolysis (ICT) may reduce thrombotic burden in the infarct-related artery, which is often responsible for microvascular obstruction and no-reflow. METHODS We conducted, according to the PRISMA statement, the largest meta-analysis to date of ICT as adjuvant therapy to PPCI. All relevant studies were identified by searching the PubMed, Scopus, Cochrane Library, and Web of Science. RESULTS Thirteen randomized controlled trials (RCTs) involving a total of 1876 patients were included. Compared to the control group, STEMI ICT-treated patients had fewer major adverse cardiac events (MACE) (OR 0.65, 95% CI, 0.48-0.86, P = 0.003) and an improved 6-month left ventricular ejection fraction (MD 3.78, 95% CI, 1.53-6.02, P = 0.0010). Indices of enhanced myocardial microcirculation were better with ICT (Post-PCI corrected thrombolysis in myocardial infarction (TIMI) frame count (MD - 3.57; 95% CI, - 5.00 to - 2.14, P < 0.00001); myocardial blush grade (MBG) 2/3 (OR 1.76; 95% CI, 1.16-2.69, P = 0.008), and complete ST-segment resolution (OR 1.97; 95% CI, 1.33-2.91, P = 0.0007)). The odds for major bleeding were comparable between the 2 groups (OR 1.27; 95% CI, 0.61-2.63, P = 0.53). CONCLUSIONS The present meta-analysis suggests that ICT was associated with improved MACE and myocardial microcirculation in STEMI patients undergoing PPCI, without significant increase in major bleeding. However, these findings necessitate confirmation in a contemporary large RCT.
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Affiliation(s)
- Sophia Alexiou
- 2nd Cardiology Department, Medical School, Hippokration Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Road, 54642, Thessaloniki, Greece
| | - Dimitrios Patoulias
- 2nd Propaedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Matthaios Didagelos
- 1st Cardiology Department, AHEPA General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athina Nasoufidou
- 2nd Cardiology Department, Medical School, Hippokration Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Road, 54642, Thessaloniki, Greece
| | - Athanasios Samaras
- 2nd Cardiology Department, Medical School, Hippokration Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Road, 54642, Thessaloniki, Greece
| | - Antonios Ziakas
- 1st Cardiology Department, AHEPA General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Fragakis
- 2nd Cardiology Department, Medical School, Hippokration Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Road, 54642, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, School of Medicine, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George Kassimis
- 2nd Cardiology Department, Medical School, Hippokration Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Road, 54642, Thessaloniki, Greece.
- 1st Cardiology Department, AHEPA General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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25
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Antonopoulos AS, Simantiris S, Tousoulis D. Thrombus aspiration in STEMI: Whom we aspire it may help? Int J Cardiol 2024; 399:131671. [PMID: 38216061 DOI: 10.1016/j.ijcard.2023.131671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024]
Affiliation(s)
- Alexios S Antonopoulos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Greece
| | - Spyridon Simantiris
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Greece
| | - Dimitris Tousoulis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Greece.
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26
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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27
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Van Spall HGC, Bastien A, Gersh B, Greenberg B, Mohebi R, Min J, Strauss K, Thirstrup S, Zannad F. The role of early-phase trials and real-world evidence in drug development. NATURE CARDIOVASCULAR RESEARCH 2024; 3:110-117. [PMID: 39196202 DOI: 10.1038/s44161-024-00420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/22/2023] [Indexed: 08/29/2024]
Abstract
Phase 3 randomized controlled trials (RCTs), while the gold standard for treatment efficacy and safety, are not always feasible, are expensive, can be prolonged and can be limited in generalizability. Other under-recognized sources of evidence can also help advance drug development. Basic science, proof-of-concept studies and early-phase RCTs can provide evidence regarding the potential for clinical benefit. Real-world evidence generated from registries or observational datasets can provide insights into the treatment of rare diseases that often pose a challenge for trial recruitment. Pragmatic trials embedded in healthcare systems can assess the treatment effects in clinical settings among patient populations sometimes excluded from trials. This Perspective discusses potential sources of evidence that may be used to complement explanatory phase 3 RCTs and to speed the development of new cardiovascular medications. Content is derived from the 19th Global Cardiovascular Clinical Trialists meeting (December 2022), involving clinical trialists, patients, clinicians, regulators, funders and industry representatives.
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Affiliation(s)
- Harriette G C Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact; Research Institute of St. Joseph's, McMaster University, Hamilton, Ontario, Canada
- Baim Institute for Clinical Research, Boston, MA, USA
| | | | - Bernard Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Barry Greenberg
- Division of Cardiology, UC San Diego Health, San Diego, CA, USA
| | - Reza Mohebi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Center at Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy, Nancy, France.
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28
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Pol T, Karlström P, Lund LH. Heart failure registries - Future directions. J Cardiol 2024; 83:84-90. [PMID: 37844799 DOI: 10.1016/j.jjcc.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/13/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Abstract
Heart failure (HF) is a growing, global public health issue. Despite advances in HF care, many challenges remain and HF outcomes are poor. Some of the major reasons for this are the lack of understanding and treatment for certain HF sub-types as well as the lack of implementation of treatment in areas where effective treatment exists. HF registries provide the opportunity to transform clinical research and patient care. Recently the registry-based randomized clinical trial has emerged as a pragmatic and inexpensive alternative to the gold standard in clinical trial design, the randomized controlled trial. Registries may also provide platforms for strategy trials, implementation trials, and screening. Using examples from the Swedish Heart Failure Registry and others, the present review provides insights into how registry-based research can address many of the unmet needs in HF.
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Affiliation(s)
- Tymon Pol
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Region Jönköping County, Jönköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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29
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Omerovic E, Petrie M, Redfors B, Fremes S, Murphy G, Marquis-Gravel G, Lansky A, Velazquez E, Perera D, Reid C, Smith J, van der Meer P, Lipsic E, Juni P, McMurray J, Bauersachs J, Køber L, Rouleau JL, Doenst T. Pragmatic randomized controlled trials: strengthening the concept through a robust international collaborative network: PRIME-9-Pragmatic Research and Innovation through Multinational Experimentation. Trials 2024; 25:80. [PMID: 38263138 PMCID: PMC10807265 DOI: 10.1186/s13063-024-07935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
In an era focused on value-based healthcare, the quality of healthcare and resource allocation should be underpinned by empirical evidence. Pragmatic clinical trials (pRCTs) are essential in this endeavor, providing randomized controlled trial (RCT) insights that encapsulate real-world effects of interventions. The rising popularity of pRCTs can be attributed to their ability to mirror real-world practices, accommodate larger sample sizes, and provide cost advantages over traditional RCTs. By harmonizing efficacy with effectiveness, pRCTs assist decision-makers in prioritizing interventions that have a substantial public health impact and align with the tenets of value-based health care. An international network for pRCT provides several advantages, including larger and diverse patient populations, access to a broader range of healthcare settings, sharing knowledge and expertise, and overcoming ethical and regulatory barriers. The hypothesis and study design of pRCT answers the decision-maker's questions. pRCT compares clinically relevant alternative interventions, recruits participants from diverse practice settings, and collects data on various health outcomes. They are scarce because the medical products industry typically does not fund pRCT. Prioritizing these studies by expanding the infrastructure to conduct clinical research within the healthcare delivery system and increasing public and private funding for these studies will be necessary to facilitate pRCTs. These changes require more clinical and health policy decision-makers in clinical research priority setting, infrastructure development, and funding. This paper presents a comprehensive overview of pRCTs, emphasizing their importance in evidence-based medicine and the advantages of an international collaborative network for their execution. It details the development of PRIME-9, an international initiative across nine countries to advance pRCTs, and explores various statistical approaches for these trials. The paper underscores the need to overcome current challenges, such as funding limitations and infrastructural constraints, to leverage the full potential of pRCTs in optimizing healthcare quality and resource utilization.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden.
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden
| | - Stephen Fremes
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Gavin Murphy
- Cardiovascular Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | | | - Alexandra Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eric Velazquez
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence and National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Christopher Reid
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA, 6102, Australia
| | - Julian Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, VIC, Australia
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia
| | - Peter van der Meer
- Department of Cardiology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Eric Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Peter Juni
- Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK
| | - John McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, University Hospital, Jena, Germany
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30
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Brajcich BC, Ko CY, Liu JB, Ellis RJ, D'Angelica MI. A NSQIP-Based Randomized Clinical Trial Evaluating Choice of Prophylactic Antibiotics for Pancreaticoduodenectomy. Cancer Treat Res 2024; 192:131-145. [PMID: 39212919 DOI: 10.1007/978-3-031-61238-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Surgical site infection is a common complication following pancreaticoduodenectomy and is a major source of postoperative morbidity. Surgical site infection is more common among patients who undergo preoperative biliary instrumentation, likely because of the introduction of intestinal flora into the normally sterile biliary tree. Frequently, bacterial isolates from surgical site infections after pancreaticoduodenectomy demonstrate resistance to the antibiotic agents typically used for surgical prophylaxis, suggesting that broad-spectrum coverage may be beneficial. This chapter summarizes the current evidence regarding surgical site infection following pancreatic surgery and describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first U.S. randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials. The trial has successfully completed patient accrual, and study results are forthcoming.
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Affiliation(s)
- Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Department of Surgery, Northwestern Medicine, Northwestern Quality Improvement, Research, and Education in Surgery (NQUIRES), Chicago, IL, USA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Jason B Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ryan J Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Michael I D'Angelica
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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31
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Salluh JIF, Quintairos A, Dongelmans DA, Aryal D, Bagshaw S, Beane A, Burghi G, López MDPA, Finazzi S, Guidet B, Hashimoto S, Ichihara N, Litton E, Lone NI, Pari V, Sendagire C, Vijayaraghavan BKT, Haniffa R, Pisani L, Pilcher D. National ICU Registries as Enablers of Clinical Research and Quality Improvement. Crit Care Med 2024; 52:125-135. [PMID: 37698452 DOI: 10.1097/ccm.0000000000006050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement. DATA SOURCES English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix. STUDY SELECTION Original research, review articles, letters, and commentaries, were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs. CONCLUSIONS ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.
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Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Dave A Dongelmans
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Diptesh Aryal
- National Coordinator, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Sean Bagshaw
- Department of Medicine, Faculty of Medicine and Dentistry (Ling, Bagshaw), University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Division of Internal Medicine (Villeneuve), Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta and Grey Nuns Hospitals, Edmonton, AB, Canada
| | - Abigail Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Maria Del Pilar Arias López
- Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
- Intermediate Care Unit, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, service de réanimation, Paris, France
| | - Satoru Hashimoto
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Scottish Intensive Care Society Audit Group, United Kingdom
| | - Vrindha Pari
- Chennai Critical Care Consultants, Pvt Ltd, Chennai, India
| | - Cornelius Sendagire
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Anesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Crit Care Asia, Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Luigi Pisani
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - David Pilcher
- University College Hospital, London, United Kingdom
- Department of Intensive Care, Alfred Health, Prahran, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Camberwell, Australia
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32
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Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
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Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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33
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Al-Maashari S, Al-Malki Y, Al Lawati H, Al-Riyami A, Nadar SK. Angiographic Predictors of Viability During Intervention for a ST Elevation Myocardial Infarction. Sultan Qaboos Univ Med J 2023; 23:38-43. [PMID: 38161757 PMCID: PMC10754314 DOI: 10.18295/squmj.12.2023.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/09/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
Objectives This study aimed to identify angiographic features that would predict myocardial viability after coronary intervention for ST elevation myocardial infarction (STEMI). Methods This retrospective study included patients who attended Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019 with a STEMI. Results A total of 72 patients (61 male; mean age = 54.9 ± 12.7 years) were included in the study; 11 patients had evidence of non-viability on echocardiography. There were 13 patients with viable myocardium and 3 with non-viable myocardium who had a myocardial blush grade (MBG) of 2 or lower. Similarly, 10 patients with viability and 1 with non-viable myocardium had thrombolysis in myocardial infarction (TIMI) flow of 2 or lower in the infarct related artery (IRA). However, none of these were statistically significant. The TIMI flow in the IRA at the end of the procedure correlated with the MBG. Conclusion There were no clear angiographic features during primary angioplasty that could predict myocardial viability.
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Affiliation(s)
| | | | - Hatim Al Lawati
- Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Adil Al-Riyami
- Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Sunil K Nadar
- Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
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Zhang Z, Sheng Z, Che W, An S, Sun D, Zhai Z, Zhao X, Yang Y, Meng Z, Ye Z, Xie E, Li P, Yu C, Gao Y, Xiao Z, Wu Y, Dong F, Ren J, Zheng J. Design and rationale of the ATTRACTIVE trial: a randomised trial of intrAThrombus Thrombolysis versus aspiRAtion thrombeCTomy during prImary percutaneous coronary interVEntion in ST-segment elevation myocardial infarction patients with high thrombus burden. BMJ Open 2023; 13:e076476. [PMID: 37949622 PMCID: PMC10649700 DOI: 10.1136/bmjopen-2023-076476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION ST-segment elevation myocardial infarction (STEMI) with high thrombus burden is associated with a poor prognosis. Manual aspiration thrombectomy reduces coronary vessel distal embolisation, improves microvascular perfusion and reduces cardiovascular deaths, but it promotes more strokes and transient ischaemic attacks in the subgroup with high thrombus burden. Intrathrombus thrombolysis (ie, the local delivery of thrombolytics into the coronary thrombus) is a recently proposed treatment approach that theoretically reduces thrombus volume and the risk of microvascular dysfunction. However, the safety and efficacy of intrathrombus thrombolysis lack sufficient clinical evidence. METHODS AND ANALYSIS The intrAThrombus Thrombolysis versus aspiRAtion thrombeCTomy during prImary percutaneous coronary interVEntion trial is a multicentre, prospective, open-label, randomised controlled trial with the blinded assessment of outcomes. A total of 2500 STEMI patients with high thrombus burden who undergo primary percutaneous coronary intervention will be randomised 1:1 to intrathrombus thrombolysis with a pierced balloon or upfront routine manual aspiration thrombectomy. The primary outcome will be the composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, heart failure readmission, stent thrombosis and target-vessel revascularisation up to 180 days. ETHICS AND DISSEMINATION The trial was approved by Ethics Committees of China-Japan Friendship Hospital (2022-KY-013) and all other participating study centres. The results of this trial will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05554588.
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Affiliation(s)
- Zhen Zhang
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhaoxue Sheng
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Wuqiang Che
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Shuoyan An
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Di Sun
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhengqin Zhai
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Xuecheng Zhao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yaliu Yang
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhen Meng
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Zixiang Ye
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Enmin Xie
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peizhao Li
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Changan Yu
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yanxiang Gao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhu Xiao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yanfen Wu
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Fen Dong
- Department of Clinical Research and Data management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Jingyi Ren
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
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De Luca G, Algowhary M, Uguz B, Oliveira DC, Ganyukov V, Zimbakov Z, Cercek M, Okkels Jensen L, Loh PH, Calmac L, Roura I Ferrer G, Quadros A, Milewski M, Scotto Di Uccio F, von Birgelen C, Versaci F, Ten Berg J, Casella G, Wong Sung Lung A, Kala P, Díez Gil JL, Carrillo X, Dirksen M, Becerra-Munoz VM, Kang-Yin Lee M, Juzar DA, de Moura Joaquim R, De Simone C, Milicic D, Davlouros P, Bakraceski N, Zilio F, Donazzan L, Kraaijeveld A, Galasso G, Arpad L, Marinucci L, Guiducci V, Menichelli M, Scoccia A, Yamac AH, Ugur Mert K, Flores Rios X, Kovarnik T, Kidawa M, Moreu J, Flavien V, Fabris E, Lozano Martínez-Luengas I, Boccalatte M, Bosa Ojeda F, Arellano-Serrano C, Caiazzo G, Cirrincione G, Kao HL, Sanchis Forés J, Vignali L, Pereira H, Manzo-Silbermann S, Ordoñez S, Arat Özkan A, Scheller B, Lehtola H, Teles R, Mantis C, Antti Y, Brum Silveira JA, Bessonov I, Zoni R, Savonitto S, Kochiadakis G, Alexopoulos D, Uribe CE, Kanakakis J, Faurie B, Gabrielli G, Gutierrez Barrios A, Bachini JP, Rocha A, Tam FCC, Rodriguez A, Lukito AA, Bellemain-Appaix A, Pessah G, Cortese G, Parodi G, Burgadha MA, Kedhi E, Lamelas P, Suryapranata H, Nardin M, Verdoia M. SARS-CoV-2 Positivity, Stent Thrombosis, and 30-day Mortality in STEMI Patients Undergoing Mechanical Reperfusion. Angiology 2023; 74:987-996. [PMID: 36222189 DOI: 10.1177/00033197221129351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
SARS-Cov-2 has been suggested to promote thrombotic complications and higher mortality. The aim of the present study was to evaluate the impact of SARS-CoV-2 positivity on in-hospital outcome and 30-day mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) enrolled in the International Survey on Acute Coronary Syndromes ST-segment elevation Myocardial Infarction (ISACS-STEMI COVID-19 registry. The 109 SARS-CoV-2 positive patients were compared with 2005 SARS-CoV-2 negative patients. Positive patients were older (P = .002), less often active smokers (P = .002), and hypercholesterolemic (P = .006), they presented more often later than 12 h (P = .037), more often to the hub and were more often in cardiogenic shock (P = .02), or requiring rescue percutaneous coronary intervention after failed thrombolysis (P < .0001). Lower postprocedural Thrombolysis in Myocardial Infarction 3 flow (P = .029) and more thrombectomy (P = .046) were observed. SARS-CoV-2 was associated with a significantly higher in-hospital mortality (25.7 vs 7%, adjusted Odds Ratio (OR) [95% Confidence Interval] = 3.2 [1.71-5.99], P < .001) in-hospital definite in-stent thrombosis (6.4 vs 1.1%, adjusted Odds Ratio [95% CI] = 6.26 [2.41-16.25], P < .001) and 30-day mortality (34.4 vs 8.5%, adjusted Hazard Ratio [95% CI] = 2.16 [1.45-3.23], P < .001), confirming that SARS-CoV-2 positivity is associated with impaired reperfusion, with negative prognostic consequences.
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Affiliation(s)
- Giuseppe De Luca
- Division of Clinical and Experimental Cardiology, AOU Sassari, Sassari, Italy Division of Cardiology, Ospedale Nuovo Galeazzi, Milan, Italy
| | - Magdy Algowhary
- Division of Cardiology, Assiut University Heart Hospital, Assiut University, Asyut, Egypt
| | - Berat Uguz
- Division of Cardiology, Bursa City Hospital, Bursa, Turkey
| | - Dinaldo C Oliveira
- Pronto de Socorro Cardiologico Prof. Luis Tavares, Centro PROCAPE, Federal University of Pernambuco, Recife, Brasil
| | - Vladimir Ganyukov
- Department of Heart and Vascular Surgery, State Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - Zan Zimbakov
- University Clinic for Cardiology, Medical Faculty, Ss' Cyril and Methodius University, Skopje, North Macedonia
| | - Miha Cercek
- Centre for Intensive Internal Medicine, University Medical Centre, Ljubljana, Slovenia
| | | | - Poay Huan Loh
- Department of Cardiology, National University Hospital, Singapore
| | | | - Gerard Roura I Ferrer
- Interventional Cardiology Unit, Heart Disease Institute. Hospital Universitari de Bellvitge, Spain
| | | | - Marek Milewski
- Division of Cardiology, Medical University of Silezia, Katowice, Poland
| | | | - Clemens von Birgelen
- Department of Cardiology, Medisch Spectrum Twente, Thoraxcentrum Twente, Enschede, The Netherlands
- Technical Medical Centre, Health Technologies and Services Research, University of Twente, Enschede, Netherlands
| | | | - Jurrien Ten Berg
- Division of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Gianni Casella
- Division of Cardiology, Ospedale Maggiore Bologna, Italy
| | | | - Petr Kala
- University Hospital Brno, Medical Faculty of Masaryk University Brno, Czech Republic
| | | | | | - Maurits Dirksen
- Division of Cardiology, Northwest Clinics Alkmaar, The Netherlands
| | | | - Michael Kang-Yin Lee
- Department of Cardiology, Queen Elizabeth Hospital, University of Hong Kong, Hong Kong
| | - Dafsah Arifa Juzar
- Department of Cardiology and Vascular Medicine, University of Indonesia National Cardiovascular Center "Harapan Kita", Jakarta
| | | | - Ciro De Simone
- Division of Cardiology, Clinica Villa Dei Fiori, Acerra, Italy
| | - Davor Milicic
- Department of Cardiology, University Hospital Centre, University of Zagreb, Zagreb, Croatia
| | - Periklis Davlouros
- Invasive Cardiology and Congenital Heart Disease, Patras University Hospital, Patras, Greece
| | | | - Filippo Zilio
- Division of Cardiology, Ospedale Santa Chiara di Trento, Italy
| | - Luca Donazzan
- Division of Cardiology, Ospedale "S. Maurizio", Bolzano, Italy
| | | | - Gennaro Galasso
- Division of Cardiology, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy
| | - Lux Arpad
- Maastricht University Medical Center, Utrecht, Netherlands
| | - Lucia Marinucci
- Division of Cardiology, Azienda Ospedaliera "Ospedali Riuniti Marche Nord", Pesaro, Italy
| | | | | | | | - Aylin Hatice Yamac
- Department of Cardiology, Hospital Bezmialem Vakıf University İstanbul, Istanbul, Turkey
| | - Kadir Ugur Mert
- Division of Cardiology, Eskisehir Osmangazi University, Faculty of Medicine, Eskisehir, Turkey
| | | | | | - Michal Kidawa
- Central Hospital of Medical University of Lodz, Poland
| | - Josè Moreu
- Division of Cardiology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Vincent Flavien
- Division of Cardiology, Center Hospitalier Universitaire de Lille, Lille, France
| | - Enrico Fabris
- Azienda Ospedaliero - Universitaria Ospedali Riuniti Trieste, Italy
| | | | - Marco Boccalatte
- Division of Cardiology, Ospedale Santa Maria Delle Grazie, Pozzuoli, Italy
| | - Francisco Bosa Ojeda
- Division of Cardiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife
| | | | | | | | - Hsien-Li Kao
- Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital, Tapei, Taiwan
| | - Juan Sanchis Forés
- Division of Cardiology, Hospital Clinico Universitario de Valencia, Spain
| | - Luigi Vignali
- Interventional Cardiology Unit, Azienda Ospedaliera Sanitaria, Parma, Italy
| | - Helder Pereira
- Hospital Garcia de Orta, Cardiology Department, Pragal, Almada, Portugal
| | | | - Santiago Ordoñez
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Alev Arat Özkan
- Cardiology Institute, Instanbul University, Instanbul, Turkey
| | - Bruno Scheller
- Division of Cardiology, Clinical and Experimental Interventional Cardiology, University of Saarland, Germany
| | - Heidi Lehtola
- Division of Cardiology, Oulu University Hospital, Finland
| | - Rui Teles
- Division of Cardiology, Hospital de Santa Cruz, CHLO - Nova Medical School, CEDOC, Lisbon, Portugal
| | - Christos Mantis
- Division of Cardiology, Konstantopoulion Hospital, Athens, Greece
| | | | | | | | - Rodrigo Zoni
- Department of Teaching and Research, Instituto de Cardiología de Corrientes "Juana F. Cabral", Argentina
| | | | | | | | - Carlos E Uribe
- Carlos E Uribe, Division of Cardiology, Universidad UPB, Universidad CES, Medellin, Colombia
| | - John Kanakakis
- Division of Cardiology, Alexandra Hospital, Athens, Greece
| | - Benjamin Faurie
- Division of Cardiology, Groupe Hospitalier Mutualiste de Grenoble, France
| | - Gabriele Gabrielli
- Interventional Cardiology Unit, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | | | | | - Alex Rocha
- Department of Cardiology and Cardiovascular Interventions, Instituto Nacional de Cirugía Cardíaca, Montevideo, Uruguay
| | | | | | - Antonia Anna Lukito
- Cardiovascular Department Pelita Harapan University/Heart Center Siloam Lippo Village Hospital, Tangerang, Banten, Indonesia
| | | | - Gustavo Pessah
- Division of Cardiology, Hospiatl Cordoba, Cordoba, Argentina
| | | | - Guido Parodi
- Division of Cardiology, Ospedale di Lavagna, Italy
| | | | - Elvin Kedhi
- Division of Cardiology, Hopital Erasmus, Universitè Libre de Bruxelles, Belgium
| | | | - Harry Suryapranata
- Division of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matteo Nardin
- Department of Internal Medicine, Ospedale Riuniti, Brescia, Italy
| | - Monica Verdoia
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Italy
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James S. Improved patient care starts with data collection. Arch Cardiovasc Dis 2023; 116:487-488. [PMID: 37833115 DOI: 10.1016/j.acvd.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Stefan James
- Department of Medical Sciences, Uppsala University, 75185 Uppsala, Sweden.
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Dai C, Yang Z, Liu M, Zhou Y, Lu D, Chang S, Li C, Lu H, Chen Z, Qian J, Ge J. Prognostic value and clinical usefulness of PIANO score in patients undergoing primary percutaneous coronary intervention. Int J Cardiol 2023; 390:131258. [PMID: 37574024 DOI: 10.1016/j.ijcard.2023.131258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/29/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND In our previous study, the PIANO score was constructed to predict the occurrence of no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention (PCI). In the current analysis, we sought to evaluate the prognostic value and clinical usefulness of the PIANO score in this population. METHODS Patients with acute myocardial infarction (AMI) undergoing primary PCI were consecutively enrolled and followed up in this register. The endpoint of interest was all-cause mortality at 2 years after the procedure. The clinical benefits of thrombus aspiration (TA) during primary PCI in certain subgroups were also evaluated as exploratory analyses. RESULTS A total of 2100 patients were identified, and 54.3% had high (≥8) PIANO score. After 2-year follow-up, patients with high PIANO score had higher risk of all-cause mortality after adjustment for propensity score (6.7% vs. 3.1%, adjusted hazard ratio = 2.11 [1.21-3.68], p = 0.008), especially in the first month (adjusted hazard ratio = 2.33 [1.17-4.65], p = 0.017). Restricted cubic spline analysis indicated the linear association between the PIANO score and 2-year all-cause mortality (nonlinear p = 0.556). Further analysis demonstrated that TA did not reduce all-cause mortality in the overall patients, as well as in those with visible thrombus, high thrombus burden, or occlusive lesions. However, the PIANO score defined "high-risk" (PIANO score ≥ 8) patients could benefit from it. CONCLUSIONS The PIANO score had potential prognostic value in patients with AMI undergoing primary PCI. It might also be helpful for identifying patients who would benefit from TA. These observations require further confirmation in future studies.
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Affiliation(s)
- Chunfeng Dai
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zheng Yang
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Muyin Liu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - You Zhou
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Danbo Lu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Shufu Chang
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Chenguang Li
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Hao Lu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhangwei Chen
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Juying Qian
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China.
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Vogel RF, Delewi R, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC, Vlachojannis GJ. Direct Stenting versus Conventional Stenting in Patients with ST-Segment Elevation Myocardial Infarction-A COMPARE CRUSH Sub-Study. J Clin Med 2023; 12:6645. [PMID: 37892785 PMCID: PMC10607208 DOI: 10.3390/jcm12206645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Direct stenting (DS) compared with conventional stenting (CS) after balloon predilatation may reduce distal embolization during percutaneous coronary intervention (PCI), thereby improving tissue reperfusion. In contrast, DS may increase the risk of stent underexpansion and target lesion failure. METHODS In this sub-study of the randomized COMPARE CRUSH trial (NCT03296540), we reviewed the efficacy of DS versus CS in a cohort of contemporary, pretreated ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. We compared DS versus CS, assessing (1) stent diameter in the culprit lesion, (2) thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery post-PCI and complete ST-segment resolution (STR) one-hour post-PCI, and (3) target lesion failure at one year. For proportional variables, propensity score weighting was applied to account for potential treatment selection bias. RESULTS This prespecified sub-study included 446 patients, of whom 189 (42%) were treated with DS. Stent diameters were comparable between groups (3.2 ± 0.5 vs. 3.2 ± 0.5 mm, p = 0.17). Post-PCI TIMI 3 flow and complete STR post-PCI rates were similar between groups (DS 93% vs. CS 90%, adjusted OR 1.16 [95% CI, 0.56-2.39], p = 0.69, and DS 72% vs. CS 58%, adjusted OR 1.29 [95% CI 0.77-2.16], p = 0.34, respectively). Moreover, target lesion failure rates at one year were comparable (DS 2% vs. 1%, adjusted OR 2.93 [95% CI 0.52-16.49], p = 0.22). CONCLUSION In this contemporary pretreated STEMI cohort, we found no difference in early myocardial reperfusion outcomes between DS and CS. Moreover, DS seemed comparable to CS in terms of stent diameter and one-year vessel patency.
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Affiliation(s)
- Rosanne F. Vogel
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Amsterdam UMC Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen M. Wilschut
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Miguel E. Lemmert
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
- Department of Cardiology, Isala Hospital, 8025 AB Zwolle, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | | | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Gilles Montalescot
- ACTION Group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Sorbonne University, 75013 Paris, France
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32610, USA
| | - Mitchell W. Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | - Georgios J. Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
- Department of Cardiology, Euroclinic Athens, 11521 Athens, Greece
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Cioffi GM, Zhi Y, Madanchi M, Seiler T, Stutz L, Gjergjizi V, Romero JP, Attinger-Toller A, Bossard M, Cuculi F. Mitigating the risk of flow deterioration by deferring stent optimization in STEMI patients with large thrombus burden: Insights from a prospective cohort study. BMC Cardiovasc Disord 2023; 23:506. [PMID: 37828421 PMCID: PMC10571234 DOI: 10.1186/s12872-023-03540-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/27/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVES It is uncertain, if omitting post-dilatation and stent oversizing (stent optimization) is safe and may decrease the risk for distal thrombus embolization (DTE) in STEMI patients with large thrombus burden (LTB). BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) with stenting, (DTE) and flow deterioration are common and increase infarct size leading to worse outcomes. METHODS From a prospective registry, 74 consecutive STEMI patients with LTB undergoing pPCI with stenting and intentionally deferred stent optimization were analyzed. Imaging data and outcomes up to 2 years follow-up were analyzed. RESULTS Overall, 74 patients (18% females) underwent deferred stent optimization. Direct stenting was performed in 13 (18%) patients. No major complications occurred during pPCI. Staged stent optimization was performed after a median of 4 (interquartile range (IQR) 3; 7) days. On optical coherence tomography, under-expansion and residual thrombus were present in 59 (80%) and 27 (36%) cases, respectively. During deferred stent optimization, we encountered no case of flow deterioration (slow or no-reflow) or side branch occlusion. Minimal lumen area (mm2) and stent expansion (%) were corrected from 4.87±1.86mm to 6.82±2.36mm (p<0.05) and from 69±18% to 91±12% (p<0.001), respectively. During follow-up, 1 patient (1.4%) required target lesion revascularization and 1 (1.4%) patient succumbed from cardiovascular death. CONCLUSIONS Among STEMI patients with LTB, deferring stent optimization in the setting of pPCI appears safe and potentially mitigates the risk of DTE. The impact of this approach on infarct size and clinical outcomes warrants further investigation in a dedicated trial.
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Affiliation(s)
- Giacomo Maria Cioffi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
- Division of Cardiology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, McMaster University, Ontario, Hamilton, Canada
- Faculty of Health Sciences and Medicine, University of Lucerne, Luzerner Kantonsspital, 6000, Luzern 16, Switzerland
| | - Yuan Zhi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mehdi Madanchi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Luzerner Kantonsspital, 6000, Luzern 16, Switzerland
| | - Thomas Seiler
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Leah Stutz
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Varis Gjergjizi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Jean-Paul Romero
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Luzerner Kantonsspital, 6000, Luzern 16, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland.
- Faculty of Health Sciences and Medicine, University of Lucerne, Luzerner Kantonsspital, 6000, Luzern 16, Switzerland.
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 758] [Impact Index Per Article: 758.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Xu B, Zhang C, Wei W, Zhan Y, Yang M, Wang Y, Zhao J, Lin G, zhang WW, Huo X, Shi B, Fan L. Effect of optimized thrombus aspiration on myocardial perfusion and prognosis in acute ST-segment elevation myocardial infarction patients with primary percutaneous coronary intervention. Front Cardiovasc Med 2023; 10:1249924. [PMID: 37859682 PMCID: PMC10584146 DOI: 10.3389/fcvm.2023.1249924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/06/2023] [Indexed: 10/21/2023] Open
Abstract
Objective To investigate the impact of optimized thrombus aspiration on myocardial perfusion, prognosis, and safety in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention(primary PCI). Methods A total of 129 patients with STEMI were randomly allocated into control group (Subgroup A and B) and experimental group(Subgroup C and D). Control group received percutaneous transluminal coronary angioplasty (PTCA),thrombus aspiration and primary PCI. Experimental group received optimized thrombus aspiration and primary PCI. The number of thrombus aspiration was less than 4 times in Subgroup A and C. The number of thrombus aspiration was performed more than 4 times in Subgroups B and D. The classification of thrombi extracted, the TIMI flow grade, the incidence of no-reflow and slow flow, cTFC, TPI and CK-MB at 12 h and 24 h after stenting, ST segment resolution of ECG after stenting, NT-proBNP, LVEFat 24 h, 30 days and 180 days after stenting were compared between groups. The incidence of intraoperative and postoperative bleeding complications, stroke events and major cardiovascular events (MACE) were recorded and compared between groups. Results The classification of thrombi extracted in the experimental group was higher than that in the control group. The TIMI flow grade of the experimental group was better than the control group after thrombus aspiration. After stenting, the advantage still existed, but the difference was not statistically significant. On cTFC, the experimental group was lower than the control group, but the difference was not statistically significant; After stenting the experimental group was significantly lower than the control group. The CK-MB at 12 h and 24 h of the experimental group was lower than the control group. After thrombus aspiration the incidence of no-reflow in the experimental group was significantly lower than that in the control group; after stenting the incidence of no-reflow in the experimental group was still lower than the control group, but no statistically difference. After thrombus aspiration and stenting the incidence of slow flow in the experimental group were lower than that in the control group. After stenting, NT-proBNP at 24 h was lower in the experimental group than that in the control group, However, there was no statistical difference; after stenting, The NT-proBNP in the experimental group was lower than that in the control group at 30 days and 180 days. After stenting, LVEF of the experimental group was significantly higher than the control group at 24 h and 30 days; superiority remained after 180 days but no statistical difference. There was no statistical difference between two groups for intraoperative and postoperative bleeding complications, stroke events, and MACE events. In Subgroup analysis,there was no significant difference in the classification of thrombi extracted, TIMI flow grade, cTFC, CK-MB,NT-proBNP and LVEF between group C and D, but group A was better than group B. Analysis of variance showed that the optimal number of suction was 4-5 times. Conclusions Optimized thrombus aspiration can significantly improve myocardial perfusion and short-term and medium-term prognosis of STEMI patients after PCI, and reduce the incidence of slow flow and no-reflow. The optimal suction times were 4-5 times. Traditional aspiration method with more aspiration times is harmful to cardiac prognosis. Thrombus aspiration does not increase the incidence of stroke events and is safe.Clinical Trial Registration: identifier, ChiCTR2300073410.
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Affiliation(s)
- Boning Xu
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Chunxin Zhang
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Wei Wei
- Cath Lab, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Yun Zhan
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Mingguo Yang
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Yanjun Wang
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Jiajian Zhao
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Guiyang Lin
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Wen-wen zhang
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Xing Huo
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Bin Shi
- Cardiovascular Department, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
| | - Ling Fan
- Cath Lab, The Fifth Clinical College of China Medical University-Bengang General Hospital of China Resources Medical Group, Benxi, China
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Hailer NP, Furnes O, Mäkelä K, Overgaard S. Register-based randomized trials: the new power-tool in orthopedic research? Acta Orthop 2023; 94:490-492. [PMID: 37772890 PMCID: PMC10540786 DOI: 10.2340/17453674.2023.19661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Indexed: 09/30/2023] Open
Affiliation(s)
- Nils P Hailer
- Department of Surgical Sciences - Orthopaedics, Uppsala University, Uppsala, Sweden.
| | - Ove Furnes
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Keijo Mäkelä
- Turku University Hospital and University of Turku, Finland
| | - Søren Overgaard
- Copenhagen University Hospital, Bispebjerg, Department of Orthopaedic Surgery and Traumatology & University of Copenhagen Department of Clinical Medicine, Faculty of Health and Medical Sciences, Denmark
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Ghobrial M, Bawamia B, Cartlidge T, Spyridopoulos I, Kunadian V, Zaman A, Egred M, McDiarmid A, Williams M, Farag M, Alkhalil M. Microvascular Obstruction in Acute Myocardial Infarction, a Potential Therapeutic Target. J Clin Med 2023; 12:5934. [PMID: 37762875 PMCID: PMC10532390 DOI: 10.3390/jcm12185934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Microvascular obstruction (MVO) is a recognised phenomenon following mechanical reperfusion in patients presenting with ST-segment elevation myocardial infarction (STEMI). Invasive and non-invasive modalities to detect and measure the extent of MVO vary in their accuracy, suggesting that this phenomenon may reflect a spectrum of pathophysiological changes at the level of coronary microcirculation. The importance of detecting MVO lies in the observation that its presence adds incremental risk to patients following STEMI treatment. This increased risk is associated with adverse cardiac remodelling seen on cardiac imaging, increased infarct size, and worse patient outcomes. This review provides an outline of the pathophysiology, clinical implications, and prognosis of MVO in STEMI. It describes historic and novel pharmacological and non-pharmacological therapies to address this phenomenon in conjunction with primary PCI.
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Affiliation(s)
- Mina Ghobrial
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Bilal Bawamia
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Timothy Cartlidge
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Ioakim Spyridopoulos
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Vijay Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Mohaned Egred
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Adam McDiarmid
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Matthew Williams
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Mohamed Farag
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
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Kwon W, Choi KH, Yang JH, Chung YJ, Park TK, Lee JM, Song YB, Hahn JY, Choi SH, Ahn CM, Yu CW, Park IH, Jang WJ, Kim HJ, Bae JW, Kwon SU, Lee HJ, Lee WS, Jeong JO, Park SD, Gwon HC. Efficacy of thrombus aspiration in cardiogenic shock complicating acute myocardial infarction and high thrombus burden. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:719-728. [PMID: 36746233 DOI: 10.1016/j.rec.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND OBJECTIVES Current guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI. METHODS We included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V). RESULTS No significant difference was found in in-hospital death (28.9% vs 33.5%; P=.28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HRadj: 0.80; 95%CI, 0.59-1.09; P=.16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HRadj: 0.59; 95%CI, 0.41-0.85; P=.004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted Pint=.03). CONCLUSIONS Routine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008).
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Affiliation(s)
- Woochan Kwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Yu Jin Chung
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ik Hyun Park
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Woo Jin Jang
- Department of Cardiology, Ewha Woman's University Seoul Hospital, Ewha Woman's University School of Medicine, Seoul, Republic of Korea
| | - Hyun-Joong Kim
- Division of Cardiology, Department of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Sung Uk Kwon
- Division of Cardiology, Department of Internal Medicine, Ilsan Paik Hospital, University of Inje College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jong Lee
- Division of Cardiology, Department of Medicine, Sejong General Hospital, Bucheon, Republic of Korea
| | - Wang Soo Lee
- Division of Cardiology, Department of Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Sang-Don Park
- Division of Cardiology, Department of Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Albuquerque F, Gomes DA, Ferreira J, de Araújo Gonçalves P, Lopes PM, Presume J, Teles RC, de Sousa Almeida M. Upstream anticoagulation in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis. Clin Res Cardiol 2023; 112:1322-1330. [PMID: 37337010 DOI: 10.1007/s00392-023-02235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/15/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND AND AIM Parenteral anticoagulation is recommended for all patients presenting with ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PPCI). Whether upstream anticoagulation improves clinical outcomes is not well established. We conducted a systematic review and meta-analysis of contemporary evidence on parenteral anticoagulation timing for STEMI patients. METHODS We performed a systematic search of electronic databases (PubMed, CENTRAL, and Scopus) until December 2022. Studies were eligible if they (a) compared upstream anticoagulation with administration at the catheterization laboratory and (b) enrolled patients with STEMI undergoing PPCI. Efficacy outcomes included in-hospital or 30-day mortality, in-hospital cardiogenic shock (CS), and TIMI flow grade pre- and post-PPCI. Safety outcome was defined as in-hospital or 30-day major bleeding. RESULTS Overall, seven studies were included (all observational), with a total of 69,403 patients. Upstream anticoagulation was associated with a significant reduction in the incidence of in-hospital or 30-day all-cause mortality (OR 0.61; 95% CI 0.45-0.81; p < 0.001) and in-hospital CS (OR 0.68; 95% CI 0.58-0.81; p < 0.001) and with an increase in spontaneous reperfusion (pre-PPCI TIMI > 0: OR 1.46; 95% CI 1.35-1.57; p < 0.001). Pretreatment was not associated with an increase in major bleeding (OR 1.02; 95% CI 0.70-1.48; p = 0.930). CONCLUSIONS Upstream anticoagulation was associated with a significantly lower risk of 30-day all-cause mortality, incidence of in-hospital CS, and improved reperfusion of the infarct-related artery (IRA). These findings were not accompanied by an increased risk of major bleeding, suggesting an overall clinical benefit of early anticoagulation in STEMI. These results require confirmation in a dedicated randomized clinical trial.
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Affiliation(s)
- Francisco Albuquerque
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.
| | - Daniel A Gomes
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Jorge Ferreira
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Pedro de Araújo Gonçalves
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
- CHRC, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Pedro M Lopes
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - João Presume
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
- CHRC, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Rui Campante Teles
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Manuel de Sousa Almeida
- Department of Cardiology, Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
- CHRC, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal
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Vizzari G, De Luca G. Thrombus aspiration in AMI patients with cardiogenic shock: is thrombus burden the missing piece of the puzzle? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:677-678. [PMID: 37001812 DOI: 10.1016/j.rec.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/28/2023]
Affiliation(s)
- Giampiero Vizzari
- Division of Cardiology, AOU «Policlinico G. Martino», Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe De Luca
- Division of Cardiology, AOU «Policlinico G. Martino», Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy; Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy.
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Ndrepepa G, Kastrati A. Coronary No-Reflow after Primary Percutaneous Coronary Intervention-Current Knowledge on Pathophysiology, Diagnosis, Clinical Impact and Therapy. J Clin Med 2023; 12:5592. [PMID: 37685660 PMCID: PMC10488607 DOI: 10.3390/jcm12175592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/17/2023] [Accepted: 08/26/2023] [Indexed: 09/10/2023] Open
Abstract
Coronary no-reflow (CNR) is a frequent phenomenon that develops in patients with ST-segment elevation myocardial infarction (STEMI) following reperfusion therapy. CNR is highly dynamic, develops gradually (over hours) and persists for days to weeks after reperfusion. Microvascular obstruction (MVO) developing as a consequence of myocardial ischemia, distal embolization and reperfusion-related injury is the main pathophysiological mechanism of CNR. The frequency of CNR or MVO after primary PCI differs widely depending on the sensitivity of the tools used for diagnosis and timing of examination. Coronary angiography is readily available and most convenient to diagnose CNR but it is highly conservative and underestimates the true frequency of CNR. Cardiac magnetic resonance (CMR) imaging is the most sensitive method to diagnose MVO and CNR that provides information on the presence, localization and extent of MVO. CMR imaging detects intramyocardial hemorrhage and accurately estimates the infarct size. MVO and CNR markedly negate the benefits of reperfusion therapy and contribute to poor clinical outcomes including adverse remodeling of left ventricle, worsening or new congestive heart failure and reduced survival. Despite extensive research and the use of therapies that target almost all known pathophysiological mechanisms of CNR, no therapy has been found that prevents or reverses CNR and provides consistent clinical benefit in patients with STEMI undergoing reperfusion. Currently, the prevention or alleviation of MVO and CNR remain unmet goals in the therapy of STEMI that continue to be under intense research.
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Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany;
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
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Rajakariar K, Andrianopoulos N, Gayed D, Liang D, Backhouse B, Ajani AE, Duffy SJ, Brennan A, Roberts L, Reid CM, Oqueli E, Clark D, Freeman M. Outcomes of thrombus aspiration during primary percutaneous coronary intervention for ST-elevation myocardial infarction. Intern Med J 2023; 53:1376-1382. [PMID: 35670161 DOI: 10.1111/imj.15828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). AIM To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI. METHODS We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality. RESULTS We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P < 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P < 0.01), and current smoking (40% vs 36%; P < 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P < 0.01) with TIMI 0 flow (77% vs 56%; P < 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63-0.89; P < 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85-1.1; P = 0.73). CONCLUSION The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.
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Affiliation(s)
- Kevin Rajakariar
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel Gayed
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Danlu Liang
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Brendan Backhouse
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
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Rikken SAOF, Bor WL, Selvarajah A, Zheng KL, Hack AP, Gibson CM, Granger CB, Bentur OS, Coller BS, van 't Hof AWJ, Ten Berg JM. Prepercutaneous coronary intervention Zalunfiban dose-response relationship to target vessel blood flow at initial angiogram in st-elevation myocardial infarction - A post hoc analysis of the cel-02 phase IIa study. Am Heart J 2023; 262:75-82. [PMID: 37088164 PMCID: PMC10630984 DOI: 10.1016/j.ahj.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Zalunfiban (RUC-4) is a novel, subcutaneously administered glycoprotein IIb/IIIa inhibitor (GPI) designed for prehospital treatment to initiate reperfusion in the infarct-related artery (IRA) before primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction (STEMI). Since GPIs have been reported to rapidly reperfuse IRAs, we assessed whether there was a dose-dependent relationship between zalunfiban treatment and angiographic reperfusion indices and thrombus grade of the IRA at initial angiogram in patients with STEMI. METHODS This was a post hoc analysis from the open-label Phase IIa study that investigated the pharmacodynamics, pharmacokinetics, and tolerability of three doses of zalunfiban - 0.075, 0.090 and 0.110 mg/kg - in STEMI patients. This analysis explored dose-dependent associations between zalunfiban and three angiographic indices of the IRA, namely coronary and myocardial blood flow and thrombus burden. Zalunfiban was administered in the cardiac catheterization laboratory prior to vascular access, ∼10 to 15 minutes before the initial angiogram. All angiographic data were analyzed by a blinded, independent, core laboratory. RESULTS Twentyfour out of 27 STEMI patients were evaluable for angiographic analysis (0.075 mg/kg [n=7], 0.090 mg/kg [n=9], and 0.110 mg/kg [n=8]). TIMI flow grade 2 or 3 was seen in 1/7 patients receiving zalunfiban at 0.075 mg/kg, in 6/9 patients receiving 0.090 mg/kg, and in 7/8 patients receiving 0.110 mg/kg (ptrend = 0.004). A similar trend was observed based on TIMI flow grade 3. Myocardial perfusion was also related to zalunfiban dose (ptrend = 0.005) as reflected by more frequent TIMI myocardial perfusion grade 3. Consistent with the dose-dependent trends in greater coronary and myocardial perfusion, TIMI thrombus ≥4 grade was inversely related to zalunfiban dose (ptrend = 0.02). CONCLUSION This post hoc analysis found that higher doses of zalunfiban administered in the cardiac catheterization lab prior to vascular access were associated with greater coronary and myocardial perfusion, and lower thrombus burden at initial angiogram in patients with STEMI undergoing primary percutaneous coronary intervention.
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Affiliation(s)
- Sem A O F Rikken
- St. Antonius Hospital, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Willem L Bor
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Abi Selvarajah
- Department of Cardiology, Isala Heart Center, Zwolle, The Netherlands
| | - Kai L Zheng
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Amy P Hack
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Ohad S Bentur
- Rockefeller University, Allen and Frances Adler Laboratory of Blood and Vascular Biology, New York, NY
| | - Barry S Coller
- Rockefeller University, Allen and Frances Adler Laboratory of Blood and Vascular Biology, New York, NY
| | - Arnoud W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Department of Cardiology, MUMC+, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Jurriën M Ten Berg
- St. Antonius Hospital, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Department of Cardiology, MUMC+, Maastricht, The Netherlands
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Lechner I, Reindl M, Tiller C, Holzknecht M, Fink P, Troger F, Angerer G, Angerer S, Henninger B, Mayr A, Klug G, Bauer A, Metzler B, Reinstadler SJ. Temporal Trends in Infarct Severity Outcomes in ST-Segment-Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study. J Am Heart Assoc 2023; 12:e028932. [PMID: 37489726 PMCID: PMC10492996 DOI: 10.1161/jaha.122.028932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/10/2023] [Indexed: 07/26/2023]
Abstract
Background Severity of myocardial tissue injury is a main determinant of morbidity and death related to ST-segment-elevation myocardial infarction (STEMI). Temporal trends of infarct characteristics at the myocardial tissue level have not been described. This study sought to assess temporal trends in infarct characteristics through a comprehensive assessment by cardiac magnetic resonance imaging at a standardized time point early after STEMI. Methods and Results We analyzed patients with STEMI treated with percutaneous coronary intervention at the University Hospital of Innsbruck who underwent cardiac magnetic resonance imaging between 2005 and 2021. The study period was divided into terciles. Myocardial damage characteristics were assessed using a multiparametric cardiac magnetic resonance imaging protocol within the first week after STEMI and compared between groups. A total of 843 patients with STEMI (17% women) with a median age of 57 (interquartile range, 51-66) years were analyzed. While age, sex, and the clinical risk profile expressed as thrombolysis in myocardial infarction risk score were comparable across the study period, there were differences in guideline-recommended therapies. At the same time, there was no significant change in infarct size (P=0.25), microvascular obstruction (P=0.50), and intramyocardial hemorrhage (P=0.34). Left ventricular remodeling indices and left ventricular ejection fraction remained virtually unchanged (all P>0.05). Major adverse cardiovascular events at 4 (interquartile range, 4-5) months were similar between groups (P=0.36). Conclusions In this magnetic resonance imaging study investigating patients with STEMI treated with primary percutaneous coronary intervention over the past 15 years, no change in infarct severity at the myocardial level has been observed. Clinical research on novel therapeutic approaches to reduce myocardial tissue injury should be a priority.
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Affiliation(s)
- Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Felix Troger
- University Clinic of RadiologyMedical University of InnsbruckInnsbruckAustria
| | - Georg Angerer
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Simon Angerer
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Benjamin Henninger
- University Clinic of RadiologyMedical University of InnsbruckInnsbruckAustria
| | - Agnes Mayr
- University Clinic of RadiologyMedical University of InnsbruckInnsbruckAustria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
| | - Sebastian J. Reinstadler
- University Clinic of Internal Medicine III, Cardiology and AngiologyMedical University of InnsbruckInnsbruckAustria
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