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Bay B, Goßling A, Remmel M, Becher PM, Schrage B, Rimmele DL, Thomalla G, Blankenberg S, Clemmensen P, Brunner FJ, Waldeyer C. Temporal trends and outcomes of acute ischaemic strokes in patients hospitalised for percutaneous coronary intervention. EUROINTERVENTION 2024; 20:e1098-e1106. [PMID: 39219362 DOI: 10.4244/eij-d-24-00189] [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] [Indexed: 09/04/2024]
Abstract
BACKGROUND Acute ischaemic stroke (AIS) after percutaneous coronary intervention (PCI) is a rare, but debilitating, complication. However, contemporary data from real-world unselected patients are scarce. AIMS We aimed to explore the temporal trends, outcomes and variables associated with AIS as well as in-hospital all-cause mortality in a nationwide cohort. METHODS A retrospective analysis of healthcare records from 2006-2021 was implemented. Patients were stratified according to the occurrence of AIS in the setting of PCI. The temporal trends of AIS were analysed. A stepwise regression model was used to identify variables associated with AIS and in-hospital all-cause mortality. RESULTS A total of 4,910,430 PCIs were included for the current analysis. AIS occurred in 4,098 cases (0.08%). An incremental increase in the incidence of AIS after PCI from 0.03% to 0.14% per year was observed from 2006-2021. The strongest associations with AIS after PCI included carotid artery disease, medical history of stroke, atrial fibrillation, presentation with an ST-segment elevation myocardial infarction (STEMI) or non-STEMI and coronary thrombectomy. For patients with AIS, a higher in-hospital all-cause mortality (18.11% vs 3.29%; p<0.001) was documented. With regard to all-cause mortality, the strongest correlations in the stroke cohort were found for cardiogenic shock, dialysis and clinical presentation with a STEMI. CONCLUSIONS In an unselected nationwide cohort of patients hospitalised for PCI, a gradual increase in AIS incidence was noted. We identified several variables associated with AIS as well as with in-hospital mortality. Hereby, clinicians might identify the patient population at risk for a peri-interventional AIS as well as those at risk for an adverse in-hospital outcome after PCI.
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Affiliation(s)
- Benjamin Bay
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Centre for Population Health Innovation (POINT Institute), University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Centre for Population Health Innovation (POINT Institute), University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marko Remmel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter M Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Centre for Population Health Innovation (POINT Institute), University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Centre for Population Health Innovation (POINT Institute), University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David L Rimmele
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Centre for Population Health Innovation (POINT Institute), University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Clemmensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Centre for Population Health Innovation (POINT Institute), University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian J Brunner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Centre for Population Health Innovation (POINT Institute), University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Waldeyer
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Kara A, Soylu K, Yildirim U, Uyanik M, Coksevim M, Avci B. Comparative Analysis of Right vs. Left Radial Access in Percutaneous Coronary Intervention: Impact on Silent Cerebral Ischemia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1193. [PMID: 39202475 PMCID: PMC11356614 DOI: 10.3390/medicina60081193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/10/2024] [Accepted: 07/22/2024] [Indexed: 09/03/2024]
Abstract
Background and Objectives: Silent cerebral ischemia (SCI) is defined as a condition that can be detected by biochemical markers or cranial imaging methods but does not produce clinical symptom. This study aims both to compare the frequency of SCI in PCIs performed with right transradial access and left transradial access and to evaluate the influencing factors. Materials and Methods: A prospective, single-center study included 197 patients undergoing PCI via transradial access between November 2020 and July 2022. The patients were categorized into right radial and left radial groups. Neuron-specific enolase (NSE) values were measured and recorded before and 18 h after the procedure. A post-procedure NSE level higher than 20 ng/dL was defined as SCI. Results: SCI occurred in 60 of the 197 patients. NSE elevation was observed in 37.4% (n = 37) of the right radial group and in 23.5% (n = 23) of the left radial group (p = 0.032). Patients with SCI had higher rates of smoking (p = 0.043), presence of subclavian tortuosity (p = 0.027), and HbA1c (p = 0.031). In the multivariate logistic regression analysis, the level of EF (ejection fraction) (OR: 0.958 95% CI 0.920-0.998, p = 0.039), right radial preference (OR: 2.104 95% CI 1.102-3.995 p = 0.023), and smoking (OR: 2.088 95% CI 1.105-3.944, p = 0.023) were observed as independent variables of NSE elevation. Conclusions: Our findings suggest that PCI via right radial access poses a greater risk of SCI compared to left radial access. Anatomical considerations and technical challenges associated with right radial procedures and factors such as smoking and low ejection fraction contribute to this elevated risk.
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Affiliation(s)
- Abdulkadir Kara
- Department of Cardiology, Elbistan State Hospital, 46300 Kahramanmaraş, Turkey
| | - Korhan Soylu
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, 55270 Samsun, Turkey; (K.S.); (U.Y.); (M.C.)
| | - Ufuk Yildirim
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, 55270 Samsun, Turkey; (K.S.); (U.Y.); (M.C.)
| | - Muhammet Uyanik
- Department of Cardiology, Carsamba State Hospital, 55500 Samsun, Turkey;
| | - Metin Coksevim
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, 55270 Samsun, Turkey; (K.S.); (U.Y.); (M.C.)
| | - Bahattin Avci
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, 55270 Samsun, Turkey;
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3
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Fanning JP, Roberts S, Anstey C, Yerkovich S, Lu LY, Poon K, Incani A, Natani S, McCullough J, Winearls J, Fraser JF. Hemostatic Profiles of Patients Who Underwent Transcatheter Versus Surgical Aortic Valve Replacement Versus Percutaneous Coronary Intervention. Am J Cardiol 2023; 207:260-270. [PMID: 37769569 DOI: 10.1016/j.amjcard.2023.08.100] [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: 07/18/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 10/03/2023]
Abstract
Guidelines for transcatheter aortic valve replacement (TAVR) antithrombotic prophylaxis are extrapolated predominantly from percutaneous coronary intervention (PCI) data. Here, we examined temporal coagulation changes occurring in the early perioperative period to determine the pathobiologic validity of this supposition. This was a prospective observational study of consecutive patients who underwent transfemoral TAVR (n = 27), PCI (n = 12), or surgical aortic valve replacement (SAVR) requiring cardiopulmonary bypass and cross-clamping (n = 12). Blood samples were taken at 4 time points: T1 (baseline), after general anesthesia or sedation; T2, after heparin administration; T3, at the end of the procedure; and T4, 6 hours after the procedure. The samples were assessed concurrently using standard laboratory coagulation tests and viscoelastic tests of whole blood clotting, including the latest generation thromboelastometry (ROTEM sigma) and thromboelastometry (TEG 6s). Patients in the TAVR cohort were older and a had lower baseline hemoglobin level than patients in the PCI and SAVR cohorts. The baseline platelet function was similar between the TAVR and PCI cohorts and impaired in the SAVR cohort Figure S1. The baseline hemostatic measures were comparable among cohorts. Regarding the per-patient change from baseline, the TAVR cohort showed an overall more prothrombotic state than the other cohorts, with the most marked differences from the SAVR cohort after intraoperative heparin administration and from the PCI cohorts 6 hours after the procedure. In addition, the ROTEM and TEG parameters were well correlated but not interchangeable. In conclusion, patients who underwent TAVR have a more prothrombotic hemostatic profile than PCI and SAVR patients. These findings question the current guidelines that extrapolate antithrombotic regimens from PCI to TAVR settings.
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Affiliation(s)
- Jonathon Paul Fanning
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia.
| | - Shaun Roberts
- Faculty of Medicine, The University of Queensland, Queensland, Australia; Department of Anaesthesia and Perioperative Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Chris Anstey
- Faculty of Medicine, The University of Queensland, Queensland, Australia; School of Medicine, Griffith University, Queensland, Australia
| | - Stephanie Yerkovich
- Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
| | - Lawrence Yanxi Lu
- Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; Department of Anaesthesia and Perioperative Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Karl Poon
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - Alexander Incani
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - Sarvesh Natani
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - James McCullough
- School of Medicine, Griffith University, Queensland, Australia; Department of Intensive Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Winearls
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia; Department of Intensive Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - John Francis Fraser
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; School of Medicine, Griffith University, Queensland, Australia
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4
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Gin J, Yeoh J, Thijs V, Clark D, Ho JK, Horrigan M, Farouque O, Al-Fiadh A. Coronary Angiography Complicated by Acute Ischaemic Stroke and the Use of Thrombolysis: a Cardiology Perspective and Narrative Review of Current Literature. Curr Cardiol Rep 2023; 25:1499-1512. [PMID: 37847358 DOI: 10.1007/s11886-023-01962-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] [Accepted: 09/11/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE OF REVIEW Coronary angiography-associated acute ischaemic stroke (CAAIS) is an uncommon event but is associated with significant mortality and morbidity. The incidence of CAAIS has increased with a rise in the volume of coronary angiography (CA) and percutaneous coronary intervention (PCI) performed. Intravenous thrombolysis (IVT) is utilized in the general management of acute ischaemic stroke; however, it is associated with a higher risk of intracranial hemorrhage (ICH). As CA or PCI is performed more often in an aging population or high-risk patients that also carry an increased risk of ICH, it is vital to minimize additional complications from the treatment of CAAIS. This article aims to review the pathophysiological mechanisms for CAAIS, clarify the current evidence regarding IVT use in this setting, and thus assist cardiologists in the management of CAAIS. RECENT FINDINGS The pathophysiology for CAAIS may be different from acute ischaemic stroke in the general population. Embolic phenomena from dislodgement of calcium or other debris during manipulation of instrumentation during CA or PCI are likely mechanisms. This may contribute to altered thrombus composition, which affects the efficacy of IVT as suggested in recent studies. Furthermore, IVT in the management of CAAIS has not been evaluated specifically. The utilization of IVT should be carefully considered in CAAIS given a paucity of evidence demonstrating safety and efficacy in this setting. A multidisciplinary pathway that emphasizes the involvement of cardiologists in the treatment decision-making process would aid in thoughtful risk-benefit evaluation for IVT use in CAAIS and reduce adverse patient outcomes. Future studies to assess the impact of this pathway on CAAIS outcomes would be beneficial.
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Affiliation(s)
- Julian Gin
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia.
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Vincent Thijs
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
- Department of Neurology, Austin Health, Melbourne, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Jan Kee Ho
- Department of Neurology, Austin Health, Melbourne, VIC, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
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5
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Desai AM, Desai D, Gan A, Mehta D, Ding K, Gan F, Riangwiwat T, Sethi PS, Mukherjee A, Pai RG, Prasitlumkum N. Stroke risk in radial versus femoral approach in coronary intervention: an updated systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2023; 24:642-650. [PMID: 37409665 DOI: 10.2459/jcm.0000000000001485] [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: 07/07/2023]
Abstract
AIM Peri-cardiac catheterization (CC) stroke is associated with increased morbidity and mortality. Little is known about any potential difference in stroke risk between transradial (TR) and transfemoral (TF) approaches. We explored this question through a systematic review and meta-analysis. METHODS MEDLINE, EMBASE, and PubMed were searched from 1980 to June 2022. Randomized trials and observational studies comparing radial versus femoral access CC or intervention that reported stroke events were included. A random-effects model was used for analysis. RESULTS The total population in our 41 pooled studies comprised 1 112 136 patients - average age 65 years, women averaging 27% in TR and 31% in TF approaches. Primary analysis of 18 randomized-controlled trials (RCTs) that included a total of 45 844 patients showed that there was no statistical significance in stroke outcomes between the TR approach and the TF approach [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.48-1.06, P -value = 0.013, I2 = 47.7%]. Furthermore, meta-regression analysis of RCTs including procedural duration between those two access sites showed no significance in stroke outcomes (OR 1.08, 95% CI 0.86-1.34, P -value = 0.921, I2 = 0.0%). CONCLUSIONS There was no significant difference in stroke outcomes between the TR approach and the TF approach.
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Affiliation(s)
- Aditya M Desai
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside
| | - Darshi Desai
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside
| | - Arnold Gan
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside
| | - Devanshi Mehta
- Osteopathic Medicine, Western University of Health Sciences, Pomona
| | - Kimberly Ding
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside
| | - Frances Gan
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside
| | - Tanawan Riangwiwat
- Division of Cardiology, University of California, Riverside School of Medicine, Riverside, California, USA
| | - Prabhdeep S Sethi
- Division of Cardiology, University of California, Riverside School of Medicine, Riverside, California, USA
| | - Ashis Mukherjee
- Division of Cardiology, University of California, Riverside School of Medicine, Riverside, California, USA
| | - Ramdas G Pai
- Division of Cardiology, University of California, Riverside School of Medicine, Riverside, California, USA
| | - Narut Prasitlumkum
- Division of Cardiology, University of California, Riverside School of Medicine, Riverside, California, USA
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6
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Yang C, Sui YG, Wang BC, Xu YL, Wu NQ, Wu YJ, Li JJ, Qian J. Intracranial Hemorrhage in Hospitalized Patients Following Percutaneous Coronary Intervention: A Large Cohort Analysis from a Single Center. Diagnostics (Basel) 2023; 13:2422. [PMID: 37510165 PMCID: PMC10378240 DOI: 10.3390/diagnostics13142422] [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: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND There are several reports on the prevalence and characteristics of intracranial hemorrhage (ICH) following percutaneous coronary intervention (PCI), which is a rare but severe complication with high mortality. However, the clinical landscapes of computed tomography (CT)-confirmed, symptomatic ICH in hospitalized patients are not fully characterized. METHODS Among 121,066 patients receiving PCI treatment in the Fu Wai Hospital between 2013 and 2022, there were 18 CT-defined, symptomatic patients with ICH occurring during post-PCI hospitalization. Symptomatic ICH was defined as clinical suspicion of hemorrhage and/or new focal neurological signs. We analyzed ICH timing, clinical and imaging features, and subsequent outcomes. RESULTS Overall, in this retrospective analysis, the incidence of CT-defined, symptomatic ICH was 0.015% (18/121,066). More than half of the cases (55.6%) occurred within the first 12 h following PCI. The most common initial manifestation of ICH patients was disturbance of consciousness. Thirteen patients (72.2%) had a hematoma volume ≥ 30 cm3. Additionally, the ICH was observed in the cerebral lobe (66.7%), cerebellum (22.2%), and the basal ganglia and thalamus (11.1%). The 90-day mortality of ICH patients undergoing PCI was very high (72.2%). Consciousness disturbance (p = 0.036), intracerebral hemorrhage volume > 30 mm3 (p = 0.001), and intracerebral hemorrhage originating from the infratentorial origin (p = 0.044) were significantly higher in patients who died. CONCLUSIONS Symptomatic ICH events occur with a rate of around 0.015%, with significantly higher short-term mortality risk in our cohort receiving PCI, which has not yet been demonstrated in other cohorts.
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Affiliation(s)
- Cheng Yang
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yong-Gang Sui
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bin-Cheng Wang
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yan-Lu Xu
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Na-Qiong Wu
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yong-Jian Wu
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jian-Jun Li
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jie Qian
- Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Gaudino M, Andreotti F, Kimura T. Current concepts in coronary artery revascularisation. Lancet 2023; 401:1611-1628. [PMID: 37121245 DOI: 10.1016/s0140-6736(23)00459-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 05/02/2023]
Abstract
Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Osaka, Japan
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Tužil J, Matějka J, Mamas MA, Doležal T. Short-term risk of periprocedural stroke relative to radial vs. femoral access: systematic review, meta-analysis, study sequential analysis and meta-regression of 2,188,047 real-world cardiac catheterizations. Expert Rev Cardiovasc Ther 2023; 21:293-304. [PMID: 36877129 DOI: 10.1080/14779072.2023.2187378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVES To verify whether transradial (TRA) compared to transfemoral (TFA) cardiac catheterization reduces the risk of periprocedural stroke (PS). METHODS We reviewed (CRD42021277918) published real-world cohorts reporting the incidence of PS within 3 days following diagnostic or interventional catheterization. Meta-analyses and meta-regressions of odds ratios (OR) performed using the DerSimonian and Laird method were checked for publication bias (Egger test) and adjusted for false-positive results (study sequential analysis SSA). RESULTS The pooled incidence of PS from 2,188,047 catheterizations (14 cohorts), was 193 (105 to 355) per 100,000. Meta-analyses of adjusted estimates (OR = 0.66 (0.49 to 0.89); p = 0.007; I2 = 90%), unadjusted estimates (OR = 0.63 (0.51 to 0.77; I2 = 74%; p = 0.000)), and a sub-group of prospective cohorts (OR = 0.67 (0.48 to 0.94; p = 0.022; I2 = 16%)) had a lower risk of PS in TRA (without indication of publication bias). SSA confirmed the pooled sample size was sufficient to support these conclusions. Meta-regression decreased the unexplained heterogeneity but did not identify any independent predictor of PS nor any effect modifier. CONCLUSION Periprocedural stroke remains a rare and hard-to-predict adverse event associated with cardiac catheterization. TRA is associated with a 20% to 30% lower risk of PS in real-world/common practice settings. Future studies are unlikely to change our conclusion.
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Affiliation(s)
- Jan Tužil
- Value Outcomes s.r.o., Prague, Czech Republic.,Biomedical informatics, First Medical Faculty, Charles University, Prague, Czech Republic
| | - Jan Matějka
- Department of Cardiology, Hospital of Pardubice, Pardubice, Czech Republic.,Faculty of Health Studies, University of Pardubice, Pardubice, Czech Republic.,Academic Department of Internal Medicine, Charles University Faculty of Medicine, Hradec Králové, Czech Republic
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, University of Keele, StokeonTrent, UK
| | - Tomáš Doležal
- Value Outcomes s.r.o., Prague, Czech Republic.,Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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9
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Wang S, Ran Y, Cheng S, Lyu Y, Liu J. Determinants and clinical outcomes of stroke following revascularization among patients with reduced ejection fraction. Brain Behav 2023; 13:e2927. [PMID: 36860139 PMCID: PMC10097158 DOI: 10.1002/brb3.2927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 11/15/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023] Open
Abstract
OBJECTIVE Stoke after revascularization including both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is an uncommon but devastating complication. Patients with reduced ejection fraction (EF) had an increased risk of stroke after revascularization. However, little is known about the determinants and outcomes of stroke among patients with reduced EF following revascularization. MATERIALS AND METHODS A cohort study of patients with preoperative reduced EF (≤40%) who received revascularization by either PCI or CABG between January 1, 2005 and December 31, 2014 was performed. Multivariate logistic regression was used to identify independent correlates of stroke. Logistic regression models were applied to evaluate the association of stroke with clinical outcomes. RESULTS A total of 1937 patients were enrolled in this study. Of these, 111 (5.7%) patients suffered from stroke during the median 3.5-year follow-up. Older age (odds ratio [OR], 1.03; 95% CI, 1.01-1.05; p = .009), history of hypertension (OR, 1.79; 95% CI, 1.18-2.73; p = .007), and history of stroke (OR, 2.00; 95% CI, 1.19-3.36; p = .008) were found to be independent predictors for stroke. Patients with and without stroke had similar risk of all-cause death (OR, 0.91; 95% CI, 0.59-1.41; p = .670). However, stroke was associated with higher odds ratio of heart failure (HF) hospitalization (OR, 2.77; 95% CI, 1.74-4.40; p < .001) and composite end point (OR, 1.61; 95% CI, 1.07-2.42; p = .021). CONCLUSIONS Further research appears warranted to minimize the complication of stroke and improve long-term outcomes among patients with reduced EF who underwent such high risk revascularization procedural.
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Affiliation(s)
- Shaoping Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yuhua Ran
- Department of Neuropsychopharmacology, Beijing Institute of Toxicology and Pharmacology, Beijing, China
| | - Shujuan Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yi Lyu
- Department of Anesthesiology, Minhang Hospital, Fudan University, Shanghai, China
| | - Jinghua Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
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10
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Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update. Can J Cardiol 2023; 39:200-209. [PMID: 36435326 DOI: 10.1016/j.cjca.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural iatrogenic stroke an important concern. These strokes can occur intraoperatively or within 30 days of a procedure and can be categorised as either overt or covert, occurring without obvious acute neurologic symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing periprocedural morbidity and mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurologic standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include previous stroke, atherosclerotic disease, carotid stenosis, female sex, and African race, as well as other patient- and procedure-level factors. While the impact of covert brain infarctions is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures include screening and vascular risk factor control, premedicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurologic field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.
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11
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Wexler NZ, Vogrin S, Brennan AL, Noaman S, Al-Mukhtar O, Haji K, Bloom JE, Dinh DT, Zheng WC, Shaw JA, Duffy SJ, Lefkovits J, Reid CM, Stub D, Kaye DM, Cox N, Chan W. Adverse Impact of Peri-Procedural Stroke in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2022; 181:18-24. [PMID: 35999069 DOI: 10.1016/j.amjcard.2022.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 11/01/2022]
Abstract
Peri-procedural stroke (PPS) is an important complication in patients who underwent percutaneous coronary intervention (PCI). The extent to which PPS impacts mortality and outcomes remains to be defined. Consecutive patients who underwent PCI enrolled in the Victorian Cardiac Outcomes Registry (2014 to 2018) were categorized into PPS and no PPS groups. The primary outcome was 30-day major adverse cardiovascular events (MACEs) (composite of mortality, myocardial infarction, stent thrombosis, and unplanned revascularization). Of 50,300 patients, PPS occurred in 0.26% patients (n = 133) (71% ischemic, and 29% hemorrhagic etiology). Patients who developed PPS were older (69 vs 66 years) compared with patients with no PPS, and more likely to have pre-existing heart failure (59% vs 29%), chronic kidney disease (33% vs 20%), and previous cerebrovascular disease (13% vs 3.6%), p <0.01. Among those with PPS, there was a higher frequency of presentation with ST-elevation myocardial infarction (49% vs 18%) and out-of-hospital cardiac arrest (14% vs 2.2%), PCI by way of femoral access (59% vs 46%), and adjunctive thrombus aspiration (12% vs 3.6%), all p = <0.001. PPS was associated with incident 30-day MACE (odds ratio [OR] 2.97, 95% confidence intervals [CIs] 1.86 to 4.74, p <0.001) after multivariable adjustment. Utilizing inverse probability of treatment weighting analysis, PPS remained predictive of 30-day MACE (OR 1.91, 95% CI 1.31 to 2.80, p = 0.001) driven by higher 30-day mortality (OR 2.0, 95% CI 1.35 to 2.96, p = 0.001). In conclusion, in this large, multi-center registry, the incidence of PPS was low; however, its clinical sequelae were significant, with a twofold increased risk of 30-day MACE and all-cause death.
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Affiliation(s)
- Noah Z Wexler
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Omar Al-Mukhtar
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - James A Shaw
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Curtain School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.
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12
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Zhao X, Liu C, Zhou P, Sheng Z, Li J, Zhou J, Chen R, Wang Y, Chen Y, Song L, Zhao H, Yan H. Development and Validation of a Prediction Rule for Major Adverse Cardiac and Cerebrovascular Events in High-Risk Myocardial Infarction Patients After Primary Percutaneous Coronary Intervention. Clin Interv Aging 2022; 17:1099-1111. [PMID: 35880211 PMCID: PMC9307870 DOI: 10.2147/cia.s358761] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Aims We aimed to develop a clinical prediction tool to improve the prognosis of major adverse cardiac and cerebrovascular events (MACCE) among high-risk myocardial infarction (MI) patients undergoing primary percutaneous coronary intervention (PCI). Methods The present study was a prospective and observational study. A total of 4151 consecutive MI patients who underwent primary PCI at Fuwai Hospital in Beijing, China (January 2010 and June 2017) were enrolled. Forty-eight patients without follow-up data were excluded from the study. The pre-specified criteria (Supplementary Information 1) were chosen to enroll MI patients at high risk for MACCE complications after PCI. Results The full model included seven variables, with a risk score of 160 points. Derivation and validation cohort models predicting MACCE had C-statistics of 0.695 and 0.673. The area under the curve (AUC) of the survival receiver operating characteristic curve (ROC) for predicting MACCE was 0.991 and 0.883 in the derivation and validation cohorts, respectively. Conclusion The predicted model was internally validated and calibrated in large cohorts of patients with high-risk MI receiving primary PCI to predict MACCE and showed modest accuracy in the derivation and validation cohorts.
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Affiliation(s)
- Xiaoxiao Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Chen Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Peng Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Zhaoxue Sheng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Jiannan Li
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Jinying Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Runzhen Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Ying Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Yi Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Li Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Hanjun Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, BeiJing, People's Republic of China
| | - Hongbing Yan
- Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, People's Republic of China
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13
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Shoaib A, Spratt JC, Curzen N, Wilson S, Rashid M, Ahmad F, Ludman P, Kinnaird T, Mamas MA. Clinical outcomes of percutaneous coronary intervention for chronic total occlusion by treated segment length. Catheter Cardiovasc Interv 2021; 99:234-244. [PMID: 34797596 DOI: 10.1002/ccd.30015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/16/2021] [Accepted: 10/27/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Long lesions are known to have worse outcomes following percutaneous coronary intervention (PCI), but there are limited data assessing the association between lesion length and clinical outcomes in PCI procedures undertaken in chronic total occlusions (CTO). METHODS AND RESULTS We formed a longitudinal cohort (2006-2018, n = 27,205) of stable angina patients who underwent PCI to CTO in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographical, procedural, and outcome data were analyzed in three groups by treated segment length, < 30 mm (n = 11,782), 30-59 mm (n = 10,415), ≥ 60 mm (n = 5008). Prevalence of previous myocardial infarction and PCI were higher in patients in 30-59 mm group or ≥ 60 mm group compared with < 30 mm group. Following multivariable analysis, no significant difference was observed in in-patient death (OR = 30-59 mm group = 1.10, CI:0.55-2.19, p = 0.78) (OR ≥ 60 mm group = 0.82, CI: 0.33-2.05, p = 0.67), and 1-year death (OR = 30-59 mm group = 1.06, CI: 0.81-1.37, p = 0.69) (OR ≥ 60 mm group =1.01, CI: 0.70-1.43, p = 0.99) (< 30 mm group = reference) but in-patient MACE was higher in > = 60 mm group (OR: 1.52, CI: 1.15-2.01, p = 0.06) but similar in 30-59 mm group (OR: 1.16, CI: 0.91-1.48, p = 0.22) compared with < 30 mm group. The adjusted rates of procedural complications were higher in ≥ 60 mm group (OR: 1.61, CI: 1.40-1.85, p < 0.001) but were similar in 30-59 mm group (OR: 1.06, CI: 0.94-1.20, p < 0.31) compared with < 30 mm group. For every 10 mm increase, there was an increased adjusted risk of in-patient procedural complications and coronary perforation but not in-patient MACE or death. CONCLUSION Patients with very long CTO lesions have higher risk of procedural complications and in-patient MACE but similar risk of short or long-term mortality compared with short CTO lesions.
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Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK.,Victoria Heart Institute Foundation, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | | | - Nick Curzen
- University of Southampton, Southampton, & University Hospital Southampton NHS Trust, Southampton, UK
| | - Simon Wilson
- St Georges' Hospitals, NHS Foundation trust, London, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Fatima Ahmad
- Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, UK
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
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14
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Kayani WT, Jneid H. Increasing stroke events in patients with ST elevation myocardial infraction and cardiogenic shock: A cause for concern. Catheter Cardiovasc Interv 2021; 97:226-227. [PMID: 33587808 DOI: 10.1002/ccd.29473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/10/2022]
Abstract
The incidence of stroke in patients with STEMI complicated by cardiogenic shock (CS) is much higher than in those without CS. Use of percutaneous Mechanical Circulatory Support (MCS) is associated with a higher incidence of stroke in these patients; however, a causal relationship cannot be inferred. Careful attention should be given to stroke mitigation and management strategies in this cohort and judicious use of MCS is warranted. Future prospective clinical studies are needed to examine the impact of MCS on stroke incidence in these patients and further validate these clinically important findings.
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Affiliation(s)
- Waleed T Kayani
- Baylor College of Medicine, The Michael E. DeBakey VA Medical Center, Houston, TX
| | - Hani Jneid
- Baylor College of Medicine, The Michael E. DeBakey VA Medical Center, Houston, TX
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15
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Abstract
Neurological complications after cardiac surgery and percutaneous cardiac interventions are not uncommon. These include periprocedural stroke, postoperative cognitive dysfunction after cardiac surgery, contrast-induced encephalopathy after percutaneous interventions, and seizures. In this article, we review the incidence, pathophysiology, diagnosis, and management of these complications. Improved understanding of these complications could lead to their prevention, faster detection, and facilitation of diagnostic workup and appropriate treatment.
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Affiliation(s)
| | - Jeffrey Wang
- Division of Neurology, Department of Medicine, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Magdy Selim
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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16
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Ho JS, Sia CH, Djohan AH, Soh RYH, Tan BY, Yeo LL, Sim HW, Yeo TC, Tan HC, Chan MYY, Loh JPY. Long-Term Outcomes of Stroke or Transient Ischemic Attack after Non-Emergency Percutaneous Coronary Intervention. J Stroke Cerebrovasc Dis 2021; 30:105786. [PMID: 33865231 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105786] [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: 01/04/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Non-emergency percutaneous coronary intervention (PCI) has lower risk of stroke than emergency PCI. With increasing elective PCI and increasing risk of stroke after PCI, risk factors for stroke or transient ischaemic attack (TIA) in non-emergency PCI and long-term outcomes needs to be better characterised. We aim to identify risk factors for cerebrovascular accidents in patients undergoing non-emergency PCI and long-term outcomes after stroke or TIA. MATERIALS AND METHODS A retrospective cohort study was performed on 1724 consecutive patients who underwent non-emergency PCI for non-ST-segment elevation myocardial infarction (NSTEMI), unstable and stable angina. The primary outcomes measured were stroke or TIA, myocardial infarction (MI) and all-cause death. RESULTS Upon mean follow-up of 3.71 (SD 0.97) years, 70 (4.1%) had subsequent ischaemic stroke or TIA, and they were more likely to present with NSTEMI (50 [71.4%] vs 892 [54.0%], OR 2.13 [1.26-3.62], p = 0.004) and not stable angina (19 [27.1%] vs 648 [39.2%], OR 0.58 [0.34-0.99]). Femoral access was associated with subsequent stroke or TIA compared to radial access (OR 2.10 [1.30-3.39], p < 0.002). Previous stroke/TIA was associated with subsequent stroke/TIA (p < 0.001), death (p < 0.001) and MI (p = 0.002). Furthermore, subsequent stroke/TIA was significantly associated with subsequent MI (p = 0.006), congestive cardiac failure (CCF) (p = 0.008) and death (p < 0.001). CONCLUSIONS In patients undergoing non-emergency PCI, previous stroke/TIA predicted post-PCI ischaemic stroke/TIA, which was associated with death, MI, CCF.
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Affiliation(s)
- Jamie Sy Ho
- Academic Foundation Programme, North Middlesex University Hospital NHS Trust, United Kingdom
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | | | - Rodney Yu-Hang Soh
- Internal Medicine Residency, National University Health System, Singapore
| | - Benjamin Yq Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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17
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Patil S, Gonuguntla K, Rojulpote C, Kumar M, Nadadur S, Nardino RJ, Pickett C. Prevalence and Determinants of Atrial Fibrillation-Associated In-Hospital Ischemic Stroke in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2021; 144:1-7. [PMID: 33385356 DOI: 10.1016/j.amjcard.2020.12.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 01/19/2023]
Abstract
Atrial fibrillation (AF) is an established risk factor ischemic stroke (IS) and is commonly encountered in patient hospitalized with acute myocardial infarction (AMI). Uncommonly, IS can occur as a complication resulting from percutaneous coronary intervention (PCI). There is limited real world data regarding AF-associated in-hospital IS (IH-IS) in patients admitted with AMI undergoing PCI. We queried the National Inpatient Sample database from January 2010 to December 2014 to identify patients admitted with AMI who underwent PCI. In this cohort, we determined the prevalence of AF associated IH-IS and compared risk factors for IH-IS between patients with AF and without AF using multivariable logistic regression models. IH-IS was present in 0.46% (n = 5,938) of the patients with AMI undergoing PCI (n = 1,282,829). Prevalence of IH-IS in patients with AF was higher compared with patients without AF (1.05% vs 0.4%; adjusted odds ratio: 1.634, 95% confidence interval: 1.527 to 1.748, p <0.001). Regardless of AF status, prevalence and risk of IH-IS was higher in females and increased with advancing age. There was significant overlap among risk-factors associated with increased risk of IH-IS in AF and non-AF cohorts, except for obesity in AF patients (adjusted odds ratio: 1.268, 95% confidence interval: 1.023 to 1.572, p = 0.03) in contrast to renal disease, malignancy, and peripheral vascular disease in non-AF patients. In conclusion, IH-IS is a rare complication affecting patients undergoing PCI for AMI and is more likely to occur in AF patients, females, and older adults, with heterogeneity among risk factors in patients with and without AF.
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Affiliation(s)
- Shivaraj Patil
- Department of Internal Medicine, University of Connecticut, Farmington, Connecticut.
| | - Karthik Gonuguntla
- Department of Internal Medicine, University of Connecticut, Farmington, Connecticut
| | - Chaitanya Rojulpote
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Manish Kumar
- Department of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Srinivas Nadadur
- Department of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Robert J Nardino
- Department of Internal Medicine, University of Connecticut, Farmington, Connecticut
| | - Christopher Pickett
- Department of Cardiology, University of Connecticut, Farmington, Connecticut
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18
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Zykov MV, Butsev VV, Suleymanov RR. Myocardial Infarction Complicated by Ischemic Stroke: Risk Factors, Prognosis, Unresolved Problems and Possible Methods of Prevention. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-02-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present work is devoted to the analysis of modern publications on various aspects of the development and course of ischemic stroke in the presence of acute myocardial infarction. A literature search was conducted on the websites of cardiological and neurological societies, as well as on the PubMed, EMBASE, eLibrary databases using the keywords: myocardial infarction, acute coronary syndrome, stroke, acute cerebrovascular accident, myocardial infarction, acute coronary syndrome, stroke. The authors of this review found that although stroke is a relatively rare complication of myocardial infarction, its prevention is an extremely significant task, since it is associated with high mortality, disability and a significant increase in the cost of treatment. So, it is extremely important to detect thrombosis of the left ventricular cavity in a timely manner, to register preexisting atrial fibrillation that occurs earlier or for the first time, followed by the appointment of anticoagulant therapy. Timely reperfusion treatment, the use of statins and modern dual antithrombotic therapy can reduce the risk of developing cerebrovascular accident in patients with myocardial infarction. It is likely that a decrease in the activity of subclinical inflammation after myocardial infarction will also reduce the risk of stroke, as was recently shown in the COLCOT study. Currently, it remains relevant to search for new knowledge about the risk factors for stroke, which complicated the course of myocardial infarction, which will allow developing more effective and personalized preventive measures in a patient with acute coronary syndrome.
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Affiliation(s)
- M. V. Zykov
- Research Institute for Complex Issues of Cardiovascular Diseases;
Sochi City Hospital №4
| | | | - R. R. Suleymanov
- District Cardiology Dispensary, Center for Diagnosis and Cardiovascular Surgery
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19
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Bay B, Waldeyer C, Rimmele L, Blankenberg S, Clemmensen P. Myocardial rupture after percutaneous coronary intervention of an unstable RCA lesion in myocardial infarction and concomitant stroke treated with intravenous fibrinolytic agents: A case report. Clin Case Rep 2021; 9:1223-1227. [PMID: 33768816 PMCID: PMC7981751 DOI: 10.1002/ccr3.3736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 12/03/2022] Open
Abstract
Myocardial rupture after thrombolysis is an often fatal consequence. For patients with myocardial infarction and ischemic stroke within a short timeframe, a catheter-based therapy to retrieve emboli poses a valid therapeutic option in case of a treatment target in CT-Angiography.
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Affiliation(s)
- Benjamin Bay
- Department of CardiologyUniversity Heart & Vascular CenterUniversity Medical Center HamburgHamburgGermany
| | - Christoph Waldeyer
- Department of CardiologyUniversity Heart & Vascular CenterUniversity Medical Center HamburgHamburgGermany
| | - Leander Rimmele
- Department of NeurologyUniversity Medical Center HamburgHamburgGermany
| | - Stefan Blankenberg
- Department of CardiologyUniversity Heart & Vascular CenterUniversity Medical Center HamburgHamburgGermany
| | - Peter Clemmensen
- Department of CardiologyUniversity Heart & Vascular CenterUniversity Medical Center HamburgHamburgGermany
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20
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Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, Matsumura-Nakano Y, Nakatsuma K, Watanabe H, Yamamoto E, Kato E, Fuki M, Yamaji K, Nishikawa R, Nagao K, Takeji Y, Watanabe H, Tazaki J, Watanabe S, Saito N, Yamazaki K, Soga Y, Komiya T, Ando K, Minatoya K, Furukawa Y, Nakagawa Y, Kadota K, Kimura T. Periprocedural Stroke After Coronary Revascularization (from the CREDO-Kyoto PCI/CABG Registry Cohort-3). Am J Cardiol 2021; 142:35-43. [PMID: 33279479 DOI: 10.1016/j.amjcard.2020.11.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022]
Abstract
There is a scarcity of data on incidence, risk factors, especially clinical severity, and long-term prognostic impact of periprocedural stroke after coronary revascularization in contemporary real-world practice. Among 14,867 consecutive patients undergoing first coronary revascularization between January 2011 and December 2013 (percutaneous coronary intervention [PCI]: N = 13258, and coronary artery bypass grafting [CABG]: N = 1609) in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG registry Cohort-3, we evaluated the details on periprocedural stroke. Periprocedural stroke was defined as stroke within 30 days after the index procedure. Incidence of periprocedural stroke was 0.96% after PCI and 2.13% after CABG (log-rank p <0.001). Proportions of major stroke defined by modified Rankin Scale ≥2 at hospital discharge were 68% after PCI, and 77% after CABG. Independent risk factors of periprocedural stroke were acute coronary syndrome (ACS), carotid artery disease, advanced age, heart failure, and end-stage renal disease after PCI, whereas they were ACS, carotid artery disease, atrial fibrillation, chronic obstructive pulmonary disease, malignancy, and frailty after CABG. There was excess long-term mortality risk of patients with periprocedural stroke relative to those without after both PCI and CABG (hazard ratio 1.71 [1.25 to 2.33], and hazard ratio 4.55 [2.79 to 7.43]). In conclusion, incidence of periprocedural stroke was not negligible not only after CABG, but also after PCI in contemporary real-world practice. Majority of patients with periprocedural stroke had at least mild disability at hospital discharge. ACS and carotid artery disease were independent strong risk factors of periprocedural stroke after both PCI and CABG. Periprocedural stroke was associated with significant long-term mortality risk after both PCI and CABG.
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Affiliation(s)
- Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yukiko Matsumura-Nakano
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Nakatsuma
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Hiroki Watanabe
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Erika Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Eri Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masayuki Fuki
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyohei Yamaji
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Ryusuke Nishikawa
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Yasuaki Takeji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Junichi Tazaki
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shin Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuhiro Yamazaki
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiharu Soga
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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21
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Waqar A, Lopez JJ. Neurological complications of coronary heart disease and their management. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:57-63. [PMID: 33632457 DOI: 10.1016/b978-0-12-819814-8.00024-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
While risk factors for the development of neurovascular and coronary heart disease (CHD) are similar, it is important to consider neurologic complications of CHD separately, as many of these complications are a direct result of the underlying condition or procedures performed to treat atherosclerotic coronary disease. Stroke after myocardial infarction (MI) and acute coronary syndromes (ACSs) is not infrequent, occurring in 0.7%-2.5% of patients within 6 months of the coronary event. The etiology of these events can be frequently traced to the development of left ventricular thrombus (LVT) formation after large MI episodes. Often, however, these events are directly related to catheter-based procedures or anticoagulation strategies utilized to treat the ACS. Ischemic strokes outnumber hemorrhagic strokes in this population. While there is a modest evidence base for use of anticoagulation to treat LVT, catheterization-related ischemic stroke and anticoagulation-related hemorrhagic stroke are typically managed via standard approaches.
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Affiliation(s)
- Aneeq Waqar
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States; Department of Medicine, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - John J Lopez
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States; Department of Medicine, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States.
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22
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Shivashankarappa A, Mahadevappa N, Palakshachar A, Bhat P, Barthur A, Bangalore S, Chikkaswamy S, Katheria R, Nanjappa M. Cerebrovascular events complicating cardiac catheterization - A tertiary care cardiac centre experience. Heart Views 2021; 22:264-270. [PMID: 35330653 PMCID: PMC8939382 DOI: 10.4103/heartviews.heartviews_42_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 12/27/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Cerebrovascular events (CVEs) are one of the rare complications of cardiac catheterization. This prospective single-center study was conducted to assess the incidence, presentations, and outcomes of CVEs in patients undergoing cardiac catheterization. Methods: Patients undergoing cardiac catheterization who developed CVEs within 48 h of procedure were analyzed prospectively with clinical assessment and neuroimaging. Results: Out of 55,664 patients, 35 had periprocedural CVEs (0.063%). The incidence of periprocedural CVEs with balloon mitral valvotomy, percutaneous coronary intervention, and coronary angiography was 0.127%, 0.112%, and 0.043%, respectively. A larger proportion of periprocedural CVEs occurred in patients with acute coronary syndrome (ACS, 77.1%) than in patients with stable coronary artery disease (CAD). The majority of CVEs were ischemic type (33 patients, 94.3%). It was most commonly seen in the left middle cerebral artery (MCA) territory. Hemorrhagic CVEs were very rare (2 patients, 5.7%). The majority of the CVEs manifested during or within 24 h of the procedure (31 patients, 88.6%). Neurodeficits persisted during the hospital stay in 20 patients (57.2%), who had longer duration of procedure compared to those with recovered deficits (P = 0.0125). In-hospital mortality occurred in three patients (8.5%) and post-discharge mortality in another 3 (8.5%). Conclusions: Periprocedural CVEs are rare and have decreased over time. They occur in a greater proportion in patients with ACS than in patients with stable CAD, more with interventional than diagnostic procedures. Ischemic event in the left MCA territory is the most common manifestation, commonly seen within 24 h of the procedure. Longer duration of procedure was a risk factor for larger infarcts and hence persistent neurodeficit at discharge. Although a substantial number of patients recover the neurodeficits, periprocedural CVEs are associated with adverse outcomes.
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23
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Taxiarchi P, Kontopantelis E, Kinnaird T, Curzen N, Banning A, Ludman P, Shoaib A, Rashid M, Martin GP, Mamas MA. Adoption of same day discharge following elective left main stem percutaneous coronary intervention. Int J Cardiol 2020; 321:38-47. [PMID: 32739446 PMCID: PMC7392050 DOI: 10.1016/j.ijcard.2020.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/04/2020] [Accepted: 07/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI. METHODS We analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality. RESULTS SDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30-1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17-1.41) and those requiring ON stay (OR 0.58 95%CI 0.25-1.34). CONCLUSIONS We did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.
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Affiliation(s)
- Paraskevi Taxiarchi
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Nick Curzen
- Coronary Research Group, University Hospital Southampton, Faculty of Medicine, University of Southampton, UK
| | | | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK
| | - Glen P Martin
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Mamas A Mamas
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK.
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24
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Albaeni A, Harris CM, Nasser H, Sifontes S, Hasan S, Guduru S, Abusaada K, Chatila K, Gilani S, Khalife WI. In-Hospital acute ischemic stroke following ST-elevation myocardial infarction. IJC HEART & VASCULATURE 2020; 31:100684. [PMID: 33344755 PMCID: PMC7736913 DOI: 10.1016/j.ijcha.2020.100684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/15/2020] [Accepted: 11/23/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND In-hospital ischemic stroke following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale in the United States. METHODS We used 2003 to 2014 Nationwide Inpatient Sample data to identify adults with a principal diagnosis of STEMI. Patients were divided into two groups defined by presence or absence of ischemic stroke. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models identified factors associated with ischemic stroke, national trend of in-hospital stroke incidence and in-hospital mortality. RESULTS Of 1,842,529 STEMI patients hospitalized from 2003 to 2014, 22,268 (1.2%) developed acute in-hospital ischemic stroke. Those with acute strokes were older (age ≥ 65 years: 70% vs 46%), more likely female (51% vs 33%), and had higher rates of atrial fibrillation (28.9% vs 12.2%) and heart failure (40.5% vs 21.1%). Age and gender adjusted incidence of in-hospital ischemic stroke following STEMI remained stable; 1.4% in 2003 and 1.5% in 2014 (P trend = 0.50). However, age and gender adjusted in-hospital mortality declined in STEMI patients with and without in-hospital ischemic stroke [AOR 0.97 (0.95-0.99) P trend = 0.03, and AOR 0.98 (0.98-0.99) P trend < 0.001, respectively]. Patients with ischemic strokes had higher in-hospital mortality (25.7% Vs 7.2%, p < 0.001), [AOR 2.11, 95% CI (1.92-2.32)]. CONCLUSION In the United States, the incidence of acute in-hospital stroke remained stable from 2003 to 2014 following STEMI with significant decrease of in-hospital mortality trends. Despite slight improvement in mortality trends, in-hospital mortality rates remained elevated calling for interventions to optimize health care delivery.
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Affiliation(s)
- Aiham Albaeni
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Ché Matthew Harris
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Division of Hospital Medicine Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Hesham Nasser
- Department of Medicine, University of Central Florida, Ocala, FL, USA
| | - Sirhley Sifontes
- Department of Medicine, University of Central Florida, Ocala, FL, USA
| | - S.Mustajab Hasan
- Department of Medicine, University of Central Florida, Ocala, FL, USA
| | - Sai Guduru
- Department of Medicine, University of Central Florida, Ocala, FL, USA
| | - Khalid Abusaada
- Department of Medicine, University of Central Florida, Ocala, FL, USA
| | - Khaled Chatila
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Syed Gilani
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Wissam I. Khalife
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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25
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Dislodged Clot During Percutaneous Coronary Intervention: From the Heart to the Brain. Can J Neurol Sci 2020; 48:547-549. [PMID: 32981551 DOI: 10.1017/cjn.2020.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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26
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Stress cardiomyopathy misinterpreted as ST-segment elevation myocardial infarction in a patient with aneurysmal subarachnoid hemorrhage: a case report. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2020; 58:173-177. [PMID: 32364523 DOI: 10.2478/rjim-2020-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Indexed: 12/15/2022]
Abstract
Cardiac abnormalities are frequently reported in acute subarachnoid hemorrhage (SAH) patients. However, frank ST-elevation and myocardial dysfunction mimicking acute coronary syndrome is a rare occurrence. Systemic and local catecholamine release mediate myocardial injury and may explain raised troponin levels, concordant regional wall motion abnormalities and systolic dysfunction. These findings can pose a significant problem in the acute setting where "time-is-muscle" paradigm can rush clinicians towards a "rule-in" diagnosis of acute myocardial infarction. We present the case of a 60-year-old male who arrived at a regional emergency department with loss of consciousness, chest pain and headache. His ECG showed ST-elevation in precordial leads with corresponding region wall motion abnormalities and dynamically elevated troponin levels which supported a diagnosis of acute myocardial infarction. Percutaneous coronary intervention was attempted but found no hemodynamically significant lesions and the patient was managed conservatively with antithrombotic treatment. Further work-up for his headache led to the diagnosis of aneurysmal SAH and subsequent endovascular coiling. The patient was discharged with a good clinical outcome. We discuss the potential catastrophic consequences of interpreting neurologic myocardial stunning as STEMI. Use of potent antithrombotic therapies, like bridging thrombolysis, in this setting can lead to dismal consequences. Clinical history should still be carefully obtained in the acute setting in this era of sensitive biomarkers.
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27
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Rashid M, Ludman PF, Mamas MA. British Cardiovascular Intervention Society registry framework: a quality improvement initiative on behalf of the National Institute of Cardiovascular Outcomes Research (NICOR). EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 5:292-297. [PMID: 31050720 DOI: 10.1093/ehjqcco/qcz023] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/15/2019] [Accepted: 04/23/2019] [Indexed: 11/14/2022]
Abstract
The British Cardiovascular Intervention Society (BCIS) percutaneous coronary intervention (PCI) registry is hosted by the National Institute of Cardiovascular Outcomes Research (NICOR) at Bart's Heart Centre and collects clinical characteristics, indications, procedural details, and outcomes of all patients undergoing PCI in the UK. The data are used for audit and research to monitor and improve PCI practices and patient outcomes. Bespoke live data analysis and structured monthly reports are used to provide real-time feedback to all participating hospitals about the provision of care. Risk-adjusted analyses are used as a quality metric and benchmarking PCI practices. The consecutive patients undergoing PCI in all PCI performing hospitals in the UK from 1994 to present. One hundred and thirteen variables encompassing patient demographics, indication, procedural details, complications, and in-hospital outcomes are recorded. Prospective data are collected electronically and encrypted before transfer to central database servers. Data are validated locally and further range checks, sense checks, and assessments of internal consistency are applied during data uploads. Analyses of uploaded data including an assessment of data completeness are provided to all hospitals for validation, with repeat validation rounds prior to public reporting. Endpoints are in-hospital PCI complications, bleeding and mortality. All-cause mortality is obtained via linkage to the Office of National Statistics. No other linkages are available at present. Available for research by application to NICOR at http://www.nicor.org.uk/ using a data sharing agreement.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Peter F Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, UK
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28
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Kwok CS, Kinnaird T, Ludman P, Mohamed M, Borovac JA, Sirker A, Mamas MA. Evaluation of the DAPT Score in Patients Who Undergo Percutaneous Coronary Intervention in England and Wales. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1509-1514. [PMID: 32553851 DOI: 10.1016/j.carrev.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 11/24/2022]
Abstract
This study aims to evaluate the temporal changes in DAPT score and determine whether there is an association between DAPT score and mortality. We analyzed all patients who underwent PCI in England and Wales 2007-2014. Statistical analyses were performed evaluating the DAPT score according to ≥2 and <2 cutoffs. Trends in DAPT score and logistic regressions were used to determine the association between DAPT score and 30 day, 1 year and 3 year mortality. A total of 243,440 patients were included in the analysis and the proportion of patients with DAPT score ≥ 2 was 35.6% (n = 86,550). The trend in DAPT score ≥ 2 showed an overall decline over time from 38.5% in 2007 to 34.5% in 2014. In more recent years, patients were older and a greater proportion were diabetic and had myocardial infarction on presentation and there was a significant decline in patients receiving paclitaxel stent (23.7% in 2007 to 0.2% in 2014). Patients with DAPT score ≥ 2 were more likely to be male, have previous CABG and have glycoprotein IIB/IIIa inhibitors. At 3 year follow up there was a significant difference in death compared DAPT ≥ 2 vs <2 (5.2% vs 5.5%, p < 0.001). DAPT score ≥ 2 was associated with reduced mortality at 1 year (OR 0.87 95%CI 0.82-0.92, p < 0.001) and 3 years (OR 0.82 95%CI 0.79-0.86, p < 0.001) after adjustments. These findings suggest that the DAPT score classifies 1 in 3 patients as having scores ≥2 and these patients have reduced odds of long-term mortality.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Josip Andelo Borovac
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, United Kingdom; Department of Pathophysiology, University of Split School of Medicine and University Hospital of Split, Split, Croatia; Institute of Emergency Medicine of Split-Dalmatia County (ZHM SDZ), Split, Croatia
| | - Alex Sirker
- Department of Cardiology, University College London Hospitals and Barts Heart Centre, London, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom. https://twitter.com/MMamas1973
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29
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Gilchrist IC, Lall SK. Risk of Stroke during Cardiac Catheterization: A Function of Access Site or Still a Question to Be Answered? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:888-889. [PMID: 32505487 DOI: 10.1016/j.carrev.2020.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ian C Gilchrist
- Penn State University, College of Medicine, Heart & Vascular Institute, 500 University Drive, C1517, MS Hershey Medical Center, Hershey, PA 17033, United States of America.
| | - Sumeet K Lall
- Penn State University, College of Medicine, Heart & Vascular Institute, 500 University Drive, C1517, MS Hershey Medical Center, Hershey, PA 17033, United States of America
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30
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Châteauneuf G, Nazif TM, Beaupré F, Kodali S, Rodés-Cabau J, Paradis JM. Cerebrovascular events after transcatheter mitral valve interventions: a systematic review and meta-analysis. Heart 2020; 106:1759-1768. [DOI: 10.1136/heartjnl-2019-316331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 03/13/2020] [Accepted: 03/17/2020] [Indexed: 12/29/2022] Open
Abstract
ObjectiveCurrent guidelines support the use of transcatheter mitral valve interventions to treat some selected high-risk patients with significant mitral valvulopathy. As with any other interventional cardiac procedure, concerns have been raised about cerebrovascular event. The aim of this systematic review and meta-analysis was to determine the incidence of cerebrovascular events following (1) transcatheter mitral valve edge-to-edge repair with mitral valve clip and (2) transcatheter mitral valve replacement (TMVR).MethodsWe conducted a systematic review of studies reporting the cerebrovascular adverse events after transcatheter mitral valve edge-to-edge repair and TMVR procedures. The primary endpoint was the incidence of cerebrovascular events as defined by the Mitral Valve Academic Research Consortium. An event that occurred within 30 days or during index hospitalisation was defined as periprocedural; otherwise it was defined as non-periprocedural. This study was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Aggregated study-level data were pooled using a random effect model. The quality of each study was appraised with the Hawker checklist, a method of systematically reviewing research from different paradigms.ResultsSixty studies totalling 28 155 patients undergoing edge-to-edge repair with mitral valve clip were included in the analysis. Periprocedural stroke and non-periprocedural stroke rates were 0.9% (95% CI 0.6 to 1.1) and 2.4% (95% CI 1.6 to 3.2), respectively. For TMVR procedures, 26 studies including 1910 patients were analysed. The estimated periprocedural stroke incidence was 1% (95% CI 0.5 to 1.8) compared with 7% (95% CI 0.8 to 18.5) for non-periprocedural stroke.ConclusionsTranscatheter mitral valve interventions are associated with low rates of cerebrovascular events. The exact mechanisms of these complications are still poorly understood given the relative paucity of good quality data.Trial registration numberCRD42019117257.
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31
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Dawson LP, Cole JA, Lancefield TF, Ajani AE, Andrianopoulos N, Thrift AG, Clark DJ, Brennan AL, Freeman M, O'Brien J, Sebastian M, Chan W, Shaw JA, Dinh D, Reid CM, Duffy SJ. Incidence and risk factors for stroke following percutaneous coronary intervention. Int J Stroke 2020; 15:909-922. [PMID: 32248767 DOI: 10.1177/1747493020912607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stroke rates and risk factors may change as percutaneous coronary intervention practice evolves and no data are available comparing stroke incidence after percutaneous coronary intervention to the general population. AIMS This study aimed to identify the incidence and risk factors for inpatient and subsequent stroke following percutaneous coronary intervention with comparison to age-matched controls. METHODS Data were prospectively collected from 22,618 patients undergoing percutaneous coronary intervention in the Melbourne Interventional Group registry (2005-2015). The cohort was compared to the North-East Melbourne Stroke Incidence Study population-based cohort (1997-1999) and predefined variables assessed for association with inpatient or outpatient stroke. RESULTS Inpatient stroke occurred in 0.33% (65.3% ischemic, 28.0% haemorrhagic, and 6.7% cause unknown), while outpatient stroke occurred in 0.55%. Inpatient and outpatient stroke were associated with higher rates of in-hospital major adverse cardiovascular outcomes (p < 0.0001) and mortality (p < 0.0001), as well as 12-month mortality (p < 0.0001). Factors independently associated with inpatient stroke were renal impairment, ST-elevation myocardial infarction, previous stroke, left ventricular ejection fraction 30-45%, and female sex, while those associated with outpatient stroke were previous stroke, chronic lung disease, previous myocardial infarction, rheumatoid arthritis, female sex, and older age. Compared to the age-standardized population-based cohort, stroke rates in the 12 months following discharge were higher for percutaneous coronary intervention patients <65 years old, but lower for percutaneous coronary intervention patients ≥65 years old. CONCLUSIONS Risk of inpatient stroke following percutaneous coronary intervention appears to be largely associated with clinical status at presentation, while outpatient stroke relates more to age and chronic disease. Compared to the general population, outpatient stroke rates following percutaneous coronary intervention are higher for younger, but not older, patients.
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Affiliation(s)
- Luke P Dawson
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Justin A Cole
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | | | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Jessica O'Brien
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia
| | - Martin Sebastian
- Department of Cardiology, University Hospital Geelong, Geelong, Australia
| | - William Chan
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - James A Shaw
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Perth, Australia
| | - Stephen J Duffy
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Kataruka A, Dean LS. Uncommon but devastating: Stroke after percutaneous coronary intervention. Catheter Cardiovasc Interv 2020; 95:893-894. [PMID: 32294326 DOI: 10.1002/ccd.28881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 11/06/2022]
Abstract
Stroke occurs infrequently following percutaneous coronary intervention (PCI) with 30-day and 1-year cumulative incidence of 0.4 and 1.5%, respectively. Patient comorbidities, acute presentations, and complex coronary lesions are more prevalent among patients who sustain a stroke. The occurrence of stroke is associated with higher short-term and overall mortality compared with bleeding or myocardial infarction.
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Affiliation(s)
- Akash Kataruka
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Larry S Dean
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
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D'Rosario D, Currey J, Considine J, Cameron J. Clinical deterioration in patients with ST-elevation myocardial infarction during and for 24 h after percutaneous coronary intervention: An observational study. Aust Crit Care 2020; 33:458-462. [PMID: 32094016 DOI: 10.1016/j.aucc.2019.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/20/2019] [Accepted: 12/31/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In-hospital adverse events such as cardiac arrest are preceded by abnormalities in physiological data and are associated with high mortality. Healthcare institutions have implemented rapid response systems such as the medical emergency team for early recognition and response to clinical deterioration. Yet, most cardiac catheterisation laboratories, have yet to formally implement a rapid response system, so the nature and frequency of clinical deterioration is unclear and no published data exist. OBJECTIVES To explore the nature and frequency of clinical deterioration in ST- elevation myocardial infarction patients in a cardiac catheterisation laboratory without a Medical emergency team, and 24 hours after percutaneous coronary intervention and the immediate nursing responses to clinical deterioration. METHOD An exploratory descriptive study using retrospective medical audit was conducted in a public tertiary teaching hospital in Melbourne, Australia. In 2014, there were 327 ST- elevation myocardial infarction presentations of which 75 were randomly selected. Descriptive statistics were used to analyse the data. RESULTS In the cardiac catheterisation laboratory, 82.6% of patients fulfilled medical emergency team activation criteria and deterioration was predominantly cardiovascular. Respiratory rate was not documented for all patients in cardiac catheterisation laboratory. Post percutaneous coronary intervention, 31% of patients fulfilled medical emergency team activation criteria and this deterioration occurred secondary to hypoxia. There were no documented abnormalities in respiratory rate. CONCLUSION The ST- elevation myocardial infarction patients admitted to the cardiac catheterisation laboratory are critically ill patients. Failure to monitor for signs of respiratory dysfunction such as respiratory rate in cardiac catheterisation laboratory may delay recognition of clinical deterioration and timely escalation of care. Further research is required to inform changes in the system to improve patient safety.
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Affiliation(s)
- Dianne D'Rosario
- Monash Heart, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, 3168, Australia; School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Victoria, 3220, Australia.
| | - Judy Currey
- Deakin Learning Futures, Deakin University, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Victoria, 3220, Australia. https://twitter.com/Judy_Currey
| | - Julie Considine
- Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Victoria, 3220, Australia; School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research, Eastern Health Partnership, Box Hill, Victoria, 3128, Australia. https://twitter.com/Julie_Considine
| | - James Cameron
- Monash Cardiovascular Research Centre, Monash Heart Monash Health and Department of Medicine School of Clinical Sciences at Monash Health, Monash University, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
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Meertens MM, Lemmens CC, Oderich GS, Schurink GWH, Mees BME. Cerebrovascular Complications After Upper Extremity Access for Complex Aortic Interventions: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2020; 43:186-195. [PMID: 31591688 PMCID: PMC6965343 DOI: 10.1007/s00270-019-02330-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/26/2019] [Indexed: 01/16/2023]
Abstract
PURPOSE The purpose of this study was to review the risk of developing cerebrovascular complications from upper extremity access during endovascular treatment of complex aortic aneurysms. METHODS A systematic review and meta-analysis were conducted according to the PRISMA guideline. An electronic search of the public domains Medline (PubMed), Embase (Ovid), Web of Science and Cochrane Library was performed to identify studies related to the treatment of aortic aneurysms involving upper extremity access. Meta-analysis was used to compare the rate of cerebrovascular event after left, right and bilateral upper extremity access. Results are presented as relative risk (RR) and 95% confidence intervals (CIs). RESULTS Thirteen studies including 1276 patients with complex endovascular treatment of aortic aneurysms using upper extremity access were included in the systematic review. Left upper extremity access (UEA) was used in 1028 procedures, right access in 148 and bilateral access in 100 procedures. The rate of cerebrovascular complications for patients treated through left UEA was 1.7%, through right UEA 4% and through bilateral UEA 5%. In the meta-analysis, we included seven studies involving 645 patients treated with a left upper extremity access, 87 patients through a right and 100 patients through a bilateral upper extremity access. Patients, who underwent right-sided (RR 5.01, 95% CI 1.51-16.58, P = 0.008) or bilateral UEA (RR 4.57, 95% CI 1.23-17.04, P = 0.02), had a significantly increased risk of cerebrovascular events compared to those who had a left-sided approach. CONCLUSION Left upper extremity access is associated with a significantly lower rate of cerebrovascular complications as compared to right or bilateral upper extremity access.
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Affiliation(s)
- Max M Meertens
- Department of Vascular Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Charlotte C Lemmens
- Department of Vascular Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Geert W H Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
- European Vascular Center Aachen-Maastricht, Maastricht, The Netherlands
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
- European Vascular Center Aachen-Maastricht, Aachen, Germany.
- European Vascular Center Aachen-Maastricht, Maastricht, The Netherlands.
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35
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Marchese N, Copetti M, Inchingolo V, Popolizio T, Fontana A, Simeone A, Vigna C. Cerebral Infarcts After Coronary Angiography and Percutaneous Coronary Intervention: A Prospective Propensity-Score-Adjusted Comparison of Right Radial, Left Radial, and Femoral Approaches. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:882-887. [PMID: 31761638 DOI: 10.1016/j.carrev.2019.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND New cerebral infarcts (CIs) detected at magnetic resonance imaging (MRI) are reported after cardiac procedures. Clinical and procedural aspects are implicated as potential causal factors. The aim of this study was to evaluate the incidence of new CIs after coronary angiography and percutaneous coronary intervention according to the arterial access site. METHODS 180 patients undergoing elective coronary angiography were studied with cerebral MRI the day before and the day after the procedure. Unadjusted and propensity score (PS) analyses were performed comparing the occurrence of CIs in right radial (RR), left radial (LR) and transfemoral (TF) access groups. RESULTS New CIs were observed in 14 patients (7.8% of the total sample, one with neurological sequelae). CIs were detected in 15.5% vs 4.9% vs 3.3% of RR, LR and TF groups, respectively (p = .026). In PS adjusted analyses, the RR approach was associated with more CIs compared with the TF approach (odds ratio [OR] estimate from logistic regression adjusted by PS quartiles: 0.158; 95% confidence interval: 0.031 to 0.814; p = .027) and the LR approach (OR: 0.266; 95% confidence interval: 0.066 to 1.080; p = .064). In a secondary analysis, a comparison of RR vs non-RR approach (TF + LR) was performed, showing that post-procedural CIs were more frequent in the RR group (OR: 0.170; 95% confidence interval: 0.050 to 0.574; p = .004). CONCLUSIONS Our study suggests that the RR approach may be associated with a higher rate of new CIs after coronary angiography compared with LR and TF approaches.
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Affiliation(s)
- Nicola Marchese
- Unit of Cardiology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.
| | - Massimiliano Copetti
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Vincenzo Inchingolo
- Unit of Neurology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Teresa Popolizio
- Unit of Radiology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Annalisa Simeone
- Unit of Neurology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Carlo Vigna
- Unit of Cardiology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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36
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Kodaira M, Sawano M, Kuno T, Numasawa Y, Noma S, Suzuki M, Imaeda S, Ueda I, Fukuda K, Kohsaka S. Outcomes of acute coronary syndrome patients with concurrent extra-cardiac vascular disease in the era of transradial coronary intervention: A retrospective multicenter cohort study. PLoS One 2019; 14:e0223215. [PMID: 31618228 PMCID: PMC6795465 DOI: 10.1371/journal.pone.0223215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/16/2019] [Indexed: 11/18/2022] Open
Abstract
Background Extra-cardiac vascular diseases (ECVDs), such as cerebrovascular disease (CVD) or peripheral arterial disease (PAD), are frequently observed among patients with acute coronary syndrome (ACS). However, it is not clear how these conditions affect patient outcomes in the era of transradial coronary intervention (TRI). Methods and results Among 7,980 patients with ACS whose data were extracted from the multicenter Japanese percutaneous coronary intervention (PCI) registry between August 2008 and March 2017, 888 (11.1%) had one concurrent ECVD (either PAD [345 patients: 4.3%] or CVD [543 patients; 6.8%]), while 87 patients (1.1%) had both PAD and CVD. Overall, the presence of ECVD was associated with a higher risk of mortality (odds ratio [OR]: 1.728; 95% confidence interval [CI]: 1.183–2.524) and bleeding complications (OR: 1.430; 95% CI: 1.028–2.004). There was evidence of interaction between ECVD severity and procedural access site on bleeding complication on the additive scale (relative excess risk due to interaction: 0.669, 95% CI: -0.563–1.900) and on the multiplicative scale (OR: 2.105; 95% CI: 1.075–4.122). While the incidence of death among patients with ECVD remained constant during the study period, bleeding complications among patients with ECVD rapidly decreased from 2015 to 2017, in association with the increasing number of TRI. Conclusions Overall, the presence of ECVD was a risk factor for adverse outcomes after PCI for ACS, both mortality and bleeding complications. In the most recent years, the incidence of bleeding complications among patients with ECVD decreased significantly coinciding with the rapid increase of TRI.
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Affiliation(s)
- Masaki Kodaira
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
- * E-mail:
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshiki Kuno
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, United States of America
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Shigetaka Noma
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Masahiro Suzuki
- Department of Cardiology, National Hospital Organization Saitama Hospital, Saitama, Japan
| | - Shohei Imaeda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Abdel-Latif A, Misumida N. Ischemic Stroke After Percutaneous Coronary Intervention: Rare, But Devastating. JACC Cardiovasc Interv 2019; 12:1507-1509. [PMID: 31395221 DOI: 10.1016/j.jcin.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 05/14/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmed Abdel-Latif
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
| | - Naoki Misumida
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
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38
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Same-Day Discharge After Elective Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 12:1479-1494. [DOI: 10.1016/j.jcin.2019.03.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022]
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Kwok CS, Kontopantelis E, Kinnaird T, Potts J, Rashid M, Shoaib A, Nolan J, Bagur R, de Belder MA, Ludman P, Mamas MA. Retroperitoneal Hemorrhage After Percutaneous Coronary Intervention: Incidence, Determinants, and Outcomes as Recorded by the British Cardiovascular Intervention Society. Circ Cardiovasc Interv 2019; 11:e005866. [PMID: 29445000 DOI: 10.1161/circinterventions.117.005866] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/14/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Retroperitoneal hemorrhage (RH) is a rare bleeding complication of percutaneous coronary intervention, which can result as a consequence of femoral access or can occur spontaneously. This study aims to evaluate temporal changes in RH, its predictors, and clinical outcomes in a national cohort of patients undergoing percutaneous coronary intervention in the United Kingdom. METHODS AND RESULTS We analyzed RH events in patients who underwent percutaneous coronary intervention between 2007 and 2014. Multiple logistic regression models were used to identify factors associated with RH and to quantify the association between RH and 30-day mortality and major adverse cardiovascular events. A total of 511 106 participants were included, and 291 in hospital RH events were recorded (0.06%). Overall, rates of RH declined from 0.09% to 0.03% between 2007 and 2014. The strongest independent predictors of RH events were femoral access (odds ratio [OR], 19.66; 95% confidence interval [CI], 11.22-34.43), glycoprotein IIb/IIIa inhibitor (OR, 2.63; 95% CI, 1.99-3.47), and warfarin use (OR, 2.53; 95% CI, 1.07-5.99). RH was associated with a significant increase in 30-day mortality (OR, 3.59; 95% CI, 2.19-5.90) and in-hospital major adverse cardiovascular events (OR, 5.76; 95% CI, 3.71-8.95). A legacy effect was not observed; patients with RH who survived 30 days did not have higher 1-year mortality compared with those without this complication (hazard ratio, 0.97; 95% CI, 0.49-1.91). CONCLUSIONS Our results suggest that RH is a rare event that is declining in the United Kingdom, related to transition to transradial access site utilization, but remains a clinically important event associated with increased 30-day mortality but no long-term legacy effect.
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Affiliation(s)
- Chun Shing Kwok
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Evangelos Kontopantelis
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Tim Kinnaird
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Jessica Potts
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Muhammad Rashid
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Ahmad Shoaib
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - James Nolan
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Rodrigo Bagur
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Mark A de Belder
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Peter Ludman
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Mamas A Mamas
- From the Keele Cardiovascular Research Group, Institute for Applied Clinical Sciences and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., J.P., M.R., A.S., J.N., R.B., M.A.M.); Academic Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom (C.S.K., A.S., J.N., M.A.M.); Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom (E.K.); Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); and Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.).
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Gaudino M, Angiolillo DJ, Di Franco A, Capodanno D, Bakaeen F, Farkouh ME, Fremes SE, Holmes D, Girardi LN, Nakamura S, Head SJ, Park S, Mack M, Serruys PW, Ruel M, Stone GW, Tam DY, Vallely M, Taggart DP. Stroke After Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention: Incidence, Pathogenesis, and Outcomes. J Am Heart Assoc 2019; 8:e013032. [PMID: 31242821 PMCID: PMC6662343 DOI: 10.1161/jaha.119.013032] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNY
| | | | | | - Davide Capodanno
- Division of CardiologyC.A.S.T., P.O. “Rodolico”Azienda Ospedaliero‐Universitaria “Policlinico‐Vittorio Emanuele”University of CataniaItaly
| | | | - Michael E. Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar CentreUniversity of TorontoOntarioCanada
| | - Stephen E. Fremes
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | | | | | | | - Stuart J. Head
- Department of Cardiothoracic SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | - Seung‐Jung Park
- Department of CardiologyHeart InstituteUniversity of Ulsan College of MedicineAsian Medical CenterSeoulKorea
| | | | | | - Marc Ruel
- Division of Cardiac SurgeryUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | | | - Derrick Y. Tam
- Schulich Heart CentreSunnybrook Health ScienceUniversity of TorontoCanada
| | - Michael Vallely
- Sydney Medical SchoolThe University of SydneyNew South WalesAustralia
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41
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Whitehead N, Williams T, Brienesse S, Ferreira D, Murray N, Inder K, Beautement S, Spratt N, Boyle AJ, Collins N. Contemporary trends in stroke complicating cardiac catheterisation. Intern Med J 2019; 50:859-865. [PMID: 31211489 DOI: 10.1111/imj.14405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 06/08/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stroke remains an important complication of diagnostic cardiac catheterisation and percutaneous coronary intervention and is associated with high rates of in-hospital mortality. AIMS To evaluate the incidence of stroke over a 10-year period and assess the long-term influence of stroke following cardiac catheterisation and PCI on functional outcomes, based on modified Rankin score and mortality. METHODS The study was performed using a case-control design in a single tertiary referral centre. Patients were identified by correlating those patients undergoing cardiac catheterisation between October 2006 and December 2016 with patients who underwent neuroimaging within 7 days to identify possible cases of suspected stroke or transient ischaemic attack. RESULTS A total of 21 510 patients underwent cardiac catheterisation during the study period. Sixty (0.28%) patients experienced stroke or transient ischaemic attack. Compared to control patients, those who did experience cerebral ischaemic events were older (70.5 vs 64 years; P < 0.001), with higher rates of atrial fibrillation, hypertension and diabetes mellitus. Stroke complicating cardiac catheterisation was associated with an increased risk of readmission, with a significantly higher hazard of readmission for stroke noted. Despite minimal functional impairment based on modified Rankin score, stroke was associated with a significant risk of early and cumulative mortality. Stroke incidence remained stable over the study period despite changes in procedural practice. CONCLUSIONS The incidence and functional severity of stroke remains low despite evolving procedural practice with a stable incidence over time despite changes in procedural practice; however, post-procedural stroke confirms an increased mortality hazard.
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Affiliation(s)
- Nicholas Whitehead
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Trent Williams
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Health and Biomedical Sciences, University of Newcastle, Newcastle, New South Wales, Australia
| | - Stephen Brienesse
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - David Ferreira
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Natalia Murray
- School of Health and Biomedical Sciences, University of Newcastle, Newcastle, New South Wales, Australia
| | - Kerry Inder
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,Neurology Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Stephen Beautement
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Neil Spratt
- School of Health and Biomedical Sciences, University of Newcastle, Newcastle, New South Wales, Australia.,Neurology Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Andrew J Boyle
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,Neurology Department, John Hunter Hospital, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Nicholas Collins
- Cardiovascular Department, John Hunter Hospital, Newcastle, New South Wales, Australia
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42
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Chandiramani R, Chen H, Aoi S, Giustino G, Claessen B, Sartori S, Aquino M, Sorrentino S, Cao D, Goel R, Kini A, Rao S, Weintraub W, Henry TD, Kapadia S, DeFranco A, Muhlestein JB, Toma C, Effron MB, Keller S, Baker BA, Pocock S, Baber U, Mehran R. Incidence, predictors and impact of stroke on mortality among patients with acute coronary syndromes following percutaneous coronary intervention—Results from the PROMETHEUS registry. Catheter Cardiovasc Interv 2019; 95:885-892. [DOI: 10.1002/ccd.28369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/02/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Huazhen Chen
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Shunsuke Aoi
- Division of CardiologyMount Sinai Beth Israel New York New York
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Bimmer Claessen
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Melissa Aquino
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Sabato Sorrentino
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Sunil Rao
- Division of CardiologyDuke University Durham North Carolina
| | | | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital Cincinnati Ohio
| | - Samir Kapadia
- Division of CardiologyCleveland Clinic Cleveland Ohio
| | - Anthony DeFranco
- Division of CardiologyAurora Cardiovascular Services Milwaukee Wisconsin
| | | | - Catalin Toma
- Division of CardiologyUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Mark B. Effron
- Eli Lilly and Company Indianapolis Indiana
- John Ochsner Heart and Vascular CenterOchsner Clinical School—University of Queensland (Australia) School of Medicine New Orleans Louisiana
| | | | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine London UK
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount Sinai New York New York
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43
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Kwok CS, Sirker A, Farmer AD, Kontopantelis E, Potts J, Ayyaz Ul Haq M, Ludman P, Belder M, Townend J, Zaman A, Large A, Kinnaird T, Mamas MA. In‐hospital gastrointestinal bleeding following percutaneous coronary intervention. Catheter Cardiovasc Interv 2019; 95:109-117. [DOI: 10.1002/ccd.28222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/26/2019] [Accepted: 03/23/2019] [Indexed: 01/07/2023]
Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University Stoke‐on‐Trent UK
- Department of CardiologyRoyal Stoke University Hospital Stoke‐on‐Trent UK
| | - Alex Sirker
- Department of CardiologyUniversity College London Hospitals and St. Bartholomew's Hospital London UK
| | - Adam D. Farmer
- Department of Gastroenterology and Institute of Applied Clinical SciencesRoyal Stoke University Hospital Stoke‐on‐Trent UK
| | | | - Jessica Potts
- Department of CardiologyQueen Elizabeth Hospital Birmingham UK
| | - Muhammad Ayyaz Ul Haq
- Keele Cardiovascular Research Group, Keele University Stoke‐on‐Trent UK
- Department of CardiologyRoyal Stoke University Hospital Stoke‐on‐Trent UK
| | - Peter Ludman
- Department of CardiologyThe James Cook University Hospital Middlesbrough UK
| | - Mark Belder
- Department of CardiologyFreeman Hospital and Institute of Cellular Medicine, Newcastle University Newcastle Upon Tyne UK
| | - John Townend
- Department of CardiologyThe James Cook University Hospital Middlesbrough UK
| | - Azfar Zaman
- Department of CardiologyFreeman Hospital and Institute of Cellular Medicine, Newcastle University Newcastle Upon Tyne UK
| | - Adrian Large
- Department of CardiologyRoyal Stoke University Hospital Stoke‐on‐Trent UK
| | - Tim Kinnaird
- Department of CardiologyUniversity Hospital of Wales Cardiff UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University Stoke‐on‐Trent UK
- Department of CardiologyRoyal Stoke University Hospital Stoke‐on‐Trent UK
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44
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Kwok CS, Shah B, Al-Suwaidi J, Fischman DL, Holmvang L, Alraies C, Bagur R, Nagaraja V, Rashid M, Mohamed M, Martin GP, Kontopantelis E, Kinnaird T, Mamas M. Timing and Causes of Unplanned Readmissions After Percutaneous Coronary Intervention: Insights From the Nationwide Readmission Database. JACC Cardiovasc Interv 2019; 12:734-748. [PMID: 30928446 DOI: 10.1016/j.jcin.2019.02.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/23/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The aim of this study was to describe the rates and causes of unplanned readmissions at different time periods following percutaneous coronary intervention (PCI). BACKGROUND The rates and causes of readmission at different time periods after PCI remain incompletely elucidated. METHODS Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for the rates, causes, predictors, and costs of unplanned readmission between 0 and 7 days, 8 and 30 days, 31 and 90 days, and 91 and 180 days after index discharge. RESULTS This analysis included 2,412,000 patients; 2.5% were readmitted between 0 and 7 days, 7.6% between 8 and 30 days, 8.9% between 31 and 90 days, and 8.0% between 91 and 180 days (cumulative rates 2.5%, 9.9%, 18.0%, and 24.8%, respectively). The majority of readmissions during each time period were due to noncardiac causes (53.1% to 59.6%). Nonspecific chest pain was the most common identifiable noncardiac cause for readmission during each time period (14.2% to 22.7% of noncardiac readmissions). Coronary artery disease including angina was the most common cardiac cause for readmission during each time period (37.4% to 39.3% of cardiac readmissions). The second most common cardiac cause for readmission was acute myocardial infarction between 0 and 7 days (27.6% of cardiac readmissions) and heart failure during all subsequent time periods (22.2% to 23.7% of cardiac readmissions). CONCLUSIONS Approximately 25% of patients following PCI have unplanned readmissions within 6 months. Causes of readmission depend on the timing at which they are assessed, with noncardiovascular causes becoming more important at longer time points.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Binita Shah
- VA New York Harbor Healthcare System, New York University School of Medicine, New York, New York
| | - Jassim Al-Suwaidi
- Heart Hospital, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar
| | - David L Fischman
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chadi Alraies
- Wayne State University School of Medicine, Detroit Heart Hospital, Detroit, Michigan
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Vinayak Nagaraja
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Evan Kontopantelis
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom.
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45
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Cerebrovascular Events With Transcatheter Aortic Valve Replacement: Can We Identify Those Who Are at Risk? J Am Coll Cardiol 2018; 68:685-7. [PMID: 27515326 DOI: 10.1016/j.jacc.2016.05.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/29/2016] [Indexed: 11/21/2022]
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Rashid M, Lawson C, Potts J, Kontopantelis E, Kwok CS, Bertrand OF, Shoaib A, Ludman P, Kinnaird T, de Belder M, Nolan J, Mamas MA. Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset. JACC Cardiovasc Interv 2018; 11:1021-1033. [PMID: 29778726 DOI: 10.1016/j.jcin.2018.01.252] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/28/2017] [Accepted: 01/09/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The authors sought to determine the relationships between left radial access (LRA) or right radial access (RRA) and clinical outcomes using the British Cardiovascular Intervention Society (BCIS) database. BACKGROUND LRA has been shown to offer procedural advantages over RRA in percutaneous coronary intervention (PCI) although few data exist from a national perspective around its use and association with clinical outcomes. METHODS The authors investigated the relationship between use of LRA or RRA and clinical outcomes of in-hospital or 30-day mortality, major adverse cardiovascular events (MACE), in-hospital stroke, and major bleeding complications in patients undergoing PCI between 2007 and 2014. RESULTS Of 342,806 cases identified, 328,495 (96%) were RRA and 14,311 (4%) were LRA. Use of LRA increased from 3.2% to 4.6% from 2007 to 2014. In patients undergoing a repeat PCI procedure, the use of RRA dropped to 72% at the second procedure and was even lower in females (65%) and patients >75 years of age (70%). Use of LRA (compared with RRA) was not associated with significant differences in in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 0.90 to 1.57; p = 0.20), 30-day mortality (OR: 1.17, 95% CI: 0.93 to 1.74; p = 0.16), MACE (OR: 1.06, 95% CI: 0.86 to 1.32; p = 0.56), or major bleeding (OR: 1.22, 95% CI: 0.87 to 1.77; p = 0.24). In propensity match analysis, LRA was associated with a significant decrease in in-hospital stroke (OR: 0.52, 95% CI: 0.37 to 0.82; p = 0.005). CONCLUSIONS In this large PCI database, use of LRA is limited compared with RRA but conveys no increased risk of adverse outcomes, but may be associated with a reduction in PCI-related stroke complications.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom.
| | - Claire Lawson
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Jessica Potts
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Evangelos Kontopantelis
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Academic Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom
| | | | - Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Academic Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Mark de Belder
- The James Cook University Hospital, Middlesbrough, United Kingdom
| | - James Nolan
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Academic Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Academic Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom
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Incidence and prognostic factors related to major adverse cerebrovascular events in patients with complex aortic diseases treated by the chimney technique. J Vasc Surg 2018; 67:1372-1379. [DOI: 10.1016/j.jvs.2017.08.079] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/16/2017] [Indexed: 11/15/2022]
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Tokushige A, Miyata M, Sonoda T, Kosedo I, Kanda D, Takumi T, Kumagae Y, Fukukura Y, Ohishi M. Prospective Study on the Incidence of Cerebrovascular Disease After Coronary Angiography. J Atheroscler Thromb 2018; 25:224-232. [PMID: 28855432 PMCID: PMC5868508 DOI: 10.5551/jat.41012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/09/2017] [Indexed: 11/11/2022] Open
Abstract
AIM Previous studies have reported a 10.2%-22% rate of silent cerebral infarction and a 0.1%-1% rate of symptomatic cerebral infarction after coronary angiography (CAG). However, the risk factors of cerebral infarction after CAG have not been fully elucidated. For this reason, we investigated the incidence and risk factors of CVD complications within 48 h after CAG using magnetic resonance imaging (MRI) (Diffusion-weighted MRI) at Kagoshima University Hospital. METHODS From September 2013 to April 2015, we examined the incidence and risk factors, including procedural data and patients characteristics, of cerebrovascular disease after CAG in consecutive 61 patients who underwent CAG and MRI in our hospital. RESULTS Silent cerebral infarction after CAG was observed in 6 cases (9.8%), and they should not show any neurological symptoms of cerebral infarction. Only prior coronary artery bypass grafting (CABG) was more frequently found in the stroke group (n=6) than that in the non-stroke group (n=55); however, no significant difference was observed (P=0.07). After adjusting for confounders, prior CABG was a significant independent risk factor for the incidence of stroke after CAG (odds ratio: 11.7, 95% confidence interval: 1.14-129.8, P=0.04). CONCLUSIONS We suggested that the incidence of cerebral infarction after CAG was not related to the catheterization procedure per se but may be caused by atherosclerosis with CABG.
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Affiliation(s)
- Akihiro Tokushige
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masaaki Miyata
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takeshi Sonoda
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Ippei Kosedo
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Daisuke Kanda
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takuro Takumi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yuichi Kumagae
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yoshihiko Fukukura
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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Sawlani NN, Harrington RA, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Prats J, Deliargyris EN, Mahaffey KW, White HD, Bhatt DL. Impact of Cerebrovascular Events Older Than One Year on Ischemic and Bleeding Outcomes With Cangrelor in Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004380. [PMID: 28039321 DOI: 10.1161/circinterventions.116.004380] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cangrelor is a potent intravenous adenosine diphosphate-receptor antagonist that in the CHAMPION trials reduced the 48-hour and 30-day rates of ischemic events during percutaneous coronary intervention without an increase in severe bleeding. METHODS AND RESULTS CHAMPION PCI (A Clinical Trial to Demonstrate the Efficacy of Cangrelor), CHAMPION PLATFORM (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), and CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) were 3 randomized, double-blind, double-dummy trials in which cangrelor was compared with clopidogrel during percutaneous coronary intervention. The effect of cangrelor on ischemic events and bleeding was analyzed in the subgroup of patients with a history of cerebrovascular events at least 1 year prior to randomization; the Breslow-Day test was used to test for interaction of treatment effect in subgroups with and without such a history. The primary efficacy end point was a composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours. Among 24 910 randomized patients, 1270 patients (5.1%) had a cerebrovascular event >1 year old, including 650 assigned to cangrelor and 620 assigned to clopidogrel. Consistent with the overall trial results, the rate of the primary efficacy end point was 4.3% in the cangrelor group versus 5.3% in the clopidogrel group (odds ratio 0.80; 95% confidence interval 0.48-1.34; P=0.40; P for interaction =0.97), and the rate of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) severe bleeding was 0.3% in both groups (P=0.97; P for interaction =0.81). CONCLUSIONS Among patients in the CHAMPION trials with a prior cerebrovascular event at least 1 year before the percutaneous coronary intervention, the efficacy and bleeding profile of cangrelor compared with clopidogrel was similar to that in the overall trial.
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Affiliation(s)
- Neal N Sawlani
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Robert A Harrington
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Gregg W Stone
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Ph Gabriel Steg
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - C Michael Gibson
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Christian W Hamm
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Matthew J Price
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Jayne Prats
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Efthymios N Deliargyris
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Kenneth W Mahaffey
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Harvey D White
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Deepak L Bhatt
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.).
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Hulme W, Sperrin M, Kontopantelis E, Ratib K, Ludman P, Sirker A, Kinnaird T, Curzen N, Kwok CS, De Belder M, Nolan J, Mamas MA. Increased Radial Access Is Not Associated With Worse Femoral Outcomes for Percutaneous Coronary Intervention in the United Kingdom. Circ Cardiovasc Interv 2017; 10:e004279. [PMID: 28196898 DOI: 10.1161/circinterventions.116.004279] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 12/08/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The radial artery is increasingly adopted as the primary access site for cardiac catheterization because of patient preference, lower bleeding rates, cost effectiveness, and reduced risk of mortality in high-risk patient groups. Concerns have been expressed that operators/centers have become increasingly unfamiliar with transfemoral access. The aim of this study was to assess whether a change in access site practice toward transradial access nationally has led to worse outcomes in percutaneous coronary intervention procedures performed through the transfemoral access approach. METHODS AND RESULTS Using the British Cardiovascular Intervention Society (BCIS) database, a retrospective analysis of 235 250 transfemoral access percutaneous coronary intervention procedures was undertaken in all 92 centers in England and Wales between 2007 and 2013. Recent femoral proportion and recent femoral volume were determined, and in-hospital vascular complications and 30-day mortality were evaluated. After case-mix adjustment, no independent association was observed between 30-day mortality for cases undertaken through the transfemoral access and center femoral proportion, the risk-adjusted odds ratio for recent femoral proportion was nonsignificant (odds ratio, 0.99; 95% confidence interval, 0.97-1.02; P=0.472 per 0.1 increase in proportion), and similarly recent femoral volume (per 100 procedures) was not found to be significant (odds ratio, 1.00; 95% confidence interval, 0.98-1.01; P=0.869). The in-hospital vascular complication rate was 1.0%, and this outcome was not significantly associated with recent femoral proportion after risk-adjustment (odds ratio, 0.97; 95% confidence interval, 0.94-1.00; P=0.060 per 0.1 increase in proportion). CONCLUSIONS The outcome gains achieved by the national adoption of radial access are not associated with a loss of femoral proficiency, and centers should be encouraged to continue to adopt radial access as the default access site for percutaneous coronary intervention wherever possible in line with current best evidence.
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Affiliation(s)
- William Hulme
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Matthew Sperrin
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Evangelos Kontopantelis
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Karim Ratib
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Peter Ludman
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Alex Sirker
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Tim Kinnaird
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Nick Curzen
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Chun Shing Kwok
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Mark De Belder
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - James Nolan
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Mamas A Mamas
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.).
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