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Wu J, Biswas D, Ryan M, Bernstein BS, Rizvi M, Fairhurst N, Kaye G, Baral R, Searle T, Melikian N, Sado D, Lüscher TF, Grocott-Mason R, Carr-White G, Teo J, Dobson R, Bromage DI, McDonagh TA, Shah AM, O'Gallagher K. Artificial intelligence methods for improved detection of undiagnosed heart failure with preserved ejection fraction. Eur J Heart Fail 2024; 26:302-310. [PMID: 38152863 DOI: 10.1002/ejhf.3115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/20/2023] [Accepted: 12/07/2023] [Indexed: 12/29/2023] Open
Abstract
AIM Heart failure with preserved ejection fraction (HFpEF) remains under-diagnosed in clinical practice despite accounting for nearly half of all heart failure (HF) cases. Accurate and timely diagnosis of HFpEF is crucial for proper patient management and treatment. In this study, we explored the potential of natural language processing (NLP) to improve the detection and diagnosis of HFpEF according to the European Society of Cardiology (ESC) diagnostic criteria. METHODS AND RESULTS In a retrospective cohort study, we used an NLP pipeline applied to the electronic health record (EHR) to identify patients with a clinical diagnosis of HF between 2010 and 2022. We collected demographic, clinical, echocardiographic and outcome data from the EHR. Patients were categorized according to the left ventricular ejection fraction (LVEF). Those with LVEF ≥50% were further categorized based on whether they had a clinician-assigned diagnosis of HFpEF and if not, whether they met the ESC diagnostic criteria. Results were validated in a second, independent centre. We identified 8606 patients with HF. Of 3727 consecutive patients with HF and LVEF ≥50% on echocardiogram, only 8.3% had a clinician-assigned diagnosis of HFpEF, while 75.4% met ESC criteria but did not have a formal diagnosis of HFpEF. Patients with confirmed HFpEF were hospitalized more frequently; however the ESC criteria group had a higher 5-year mortality, despite being less comorbid and experiencing fewer acute cardiovascular events. CONCLUSIONS This study demonstrates that patients with undiagnosed HFpEF are an at-risk group with high mortality. It is possible to use NLP methods to identify likely HFpEF patients from EHR data who would likely then benefit from expert clinical review and complement the use of diagnostic algorithms.
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Affiliation(s)
- Jack Wu
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
| | - Dhruva Biswas
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Matthew Ryan
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Brett S Bernstein
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Maleeha Rizvi
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- Guy's and St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - George Kaye
- King's College Hospital NHS Foundation Trust, London, UK
| | - Ranu Baral
- King's College Hospital NHS Foundation Trust, London, UK
| | - Tom Searle
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Narbeh Melikian
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Daniel Sado
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Richard Grocott-Mason
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gerald Carr-White
- Guy's and St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - James Teo
- King's College Hospital NHS Foundation Trust, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Richard Dobson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Daniel I Bromage
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Theresa A McDonagh
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Ajay M Shah
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Kevin O'Gallagher
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
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2
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Aldous R, Roy R, Cannata A, Abdrazak M, Mohanan S, Beckley-Hoelscher N, Stahl D, Kanyal R, Kordis P, Sunderland N, Parczewska A, Kirresh A, Nevett J, Fothergill R, Webb I, Dworakowski R, Melikian N, Kalra S, Johnson TW, Sinagra G, Rakar S, Noc M, Patel S, Auzinger G, Gruchala M, Shah AM, Byrne J, MacCarthy P, Pareek N. MIRACLE 2 Score Compared With Downtime and Current Selection Criterion for Invasive Cardiovascular Therapies After OHCA. JACC Cardiovasc Interv 2023; 16:2439-2450. [PMID: 37609699 DOI: 10.1016/j.jcin.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND The MIRACLE2 score is the only risk score that does not incorporate and can be used for selection of therapies after out-of-hospital cardiac arrest (OHCA). OBJECTIVES This study sought to compare the discrimination performance of the MIRACLE2 score, downtime, and current randomized controlled trial (RCT) recruitment criteria in predicting poor neurologic outcome after out-of-hospital cardiac arrest (OHCA). METHODS We used the EUCAR (European Cardiac Arrest Registry), a retrospective cohort from 6 centers (May 2012-September 2022). The primary outcome was poor neurologic outcome on hospital discharge (cerebral performance category 3-5). RESULTS A total of 1,259 patients (total downtime = 25 minutes; IQR: 15-36 minutes) were included in the study. Poor outcome occurred in 41.8% with downtime <30 minutes and in 79.3% for those with downtime >30 minutes. In a multivariable logistic regression analysis, MIRACLE2 had a stronger association with outcome (OR: 2.23; 95% CI: 1.98-2.51; P < 0.0001) than zero flow (OR: 1.07; 95% CI: 1.01-1.13; P = 0.013), low flow (OR: 1.04; 95% CI: 0.99-1.09; P = 0.054), and total downtime (OR: 0.99; 95% CI: 0.95-1.03; P = 0.52). MIRACLE2 had substantially superior discrimination for the primary endpoint (AUC: 0.877; 95% CI: 0.854-0.897) than zero flow (AUC: 0.610; 95% CI: 0.577-0.642), low flow (AUC: 0.725; 95% CI: 0.695-0.754), and total downtime (AUC: 0.732; 95% CI: 0.701-0.760). For those modeled for exclusion from study recruitment, the positive predictive value of MIRACLE2 ≥5 for poor outcome was significantly higher (0.92) than the CULPRIT-SHOCK (Culprit lesion only PCI Versus Multivessel PCI in Cardiogenic Shock) (0.80), EUROSHOCK (Testing the value of Novel Strategy and Its Cost Efficacy In Order to Improve the Poor Outcomes in Cardiogenic Shock) (0.74) and ECLS-SHOCK (Extra-corporeal life support in Cardiogenic shock) criteria (0.81) (P < 0.001). CONCLUSIONS The MIRACLE2 score has superior prediction of outcome after OHCA than downtime and higher discrimination of poor outcome than the current RCT recruitment criteria. The potential for the MIRACLE2 score to improve the selection of OHCA patients should be evaluated formally in future RCTs.
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Affiliation(s)
- Robert Aldous
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Roman Roy
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Antonio Cannata
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Muhamad Abdrazak
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Shamika Mohanan
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Daniel Stahl
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Ritesh Kanyal
- School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Peter Kordis
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Nicholas Sunderland
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Ali Kirresh
- Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joanne Nevett
- London Ambulance Service NHS Trust, London, United Kingdom
| | | | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Rafal Dworakowski
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Narbeh Melikian
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Sundeep Kalra
- Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas W Johnson
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Serena Rakar
- Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Marko Noc
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Sameer Patel
- Faculty of Life Science and Medicine, King's College London, London, United Kingdom
| | - Georg Auzinger
- Faculty of Life Science and Medicine, King's College London, London, United Kingdom
| | - Marcin Gruchala
- Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Philip MacCarthy
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom.
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Roy R, Kanyal R, Abd Razak M, To-Dang B, Chotai S, Abu-Own H, Cannata A, Dworakowski R, Webb I, Pareek M, Shah AM, MacCarthy P, Byrne J, Melikian N, Pareek N. The effect of ethnicity and socioeconomic status on outcomes after resuscitated out-of-hospital cardiac arrest - Findings from a tertiary centre in South London. Resusc Plus 2023; 14:100388. [PMID: 37125005 PMCID: PMC10130337 DOI: 10.1016/j.resplu.2023.100388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background Out-of-hospital cardiac arrest is a common cause of morbidity and mortality, and ethnic variation in outcomes is recognised. We investigated ethnic and socioeconomic differences in arrest circumstances, rates of coronary artery disease, treatment, and outcomes in resuscitated OOHCA. Methods Patients with resuscitated OOHCA of suspected cardiac aetiology were included in the King's Out-of-Hospital Cardiac Arrest Registry between 1-May-2012 and 31-December-2020. Results Of 526 patients (median age 62.0 years, IQR 21.1, 74.1% male), 414 patients (78.7%) were White, 35 (6.7%) were Asian, and 77 (14.6%) were Black. Black patients had more co-existent hypertension (p = 0.007) and cardiomyopathy (p = 0.003), but less prior coronary revascularisation (p = 0.026) compared with White/Asian patients. There were no ethnic differences in location, witnesses, or bystander CPR, but Black patients had more non-shockable rhythms (p < 0.001). Black patients received less immediate coronary angiography (p < 0.001) and percutaneous coronary intervention (p < 0.001) but had lower rates of CAD (p = 0.004) than White/Asian patients. All-cause mortality at 12 months was highest amongst Black patients, followed by Asian and then White patients (57.1% vs 48.6% vs 41.3%, p = 0.032). In Black patients, excess mortality was driven by higher rates of multi-organ dysfunction but lower cardiac death than White/Asian patients, with cardiac death highest amongst Asian patients (p = 0.009). Socioeconomic status had no effect on mortality, and in a multivariable logistic regression, age, location, witnesses, and Black compared to White ethnicity were independent predictors of mortality, whilst social deprivation was not. Conclusion In this single-centre study, Black patients had higher mortality after resuscitated OOHCA than White/Asian patients. This may be in part due to differing underlying aetiology rather than differences in arrest circumstances or social deprivation.
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Affiliation(s)
- Roman Roy
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Ritesh Kanyal
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Muhamad Abd Razak
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Brian To-Dang
- King’s College Hospital NHS Foundation Trust, London, UK
| | - Shayna Chotai
- King’s College Hospital NHS Foundation Trust, London, UK
| | - Huda Abu-Own
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Antonio Cannata
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Rafal Dworakowski
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Ian Webb
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Department of Infection and HIV Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ajay M Shah
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Philip MacCarthy
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Jonathan Byrne
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Narbeh Melikian
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
| | - Nilesh Pareek
- King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King’s College London, UK
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4
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Tam To B, Roy R, Melikian N, Gaughran FP, O’Gallagher K. Coronary Artery Disease in Patients with Severe Mental Illness. Interv Cardiol 2023; 18:e16. [PMID: 37398869 PMCID: PMC10311395 DOI: 10.15420/icr.2022.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/23/2022] [Indexed: 07/04/2023] Open
Abstract
Severe mental illnesses (SMI), such as schizophrenia and bipolar disorder, are associated with a decrease in life expectancy of up to two decades compared with the general population, with cardiovascular disease as the leading cause of death. SMI is associated with increased cardiovascular risk profile and early onset of incident cardiovascular disease. Following an acute coronary syndrome, patients with SMI have a worse prognosis, but are less likely to receive invasive treatment. In this narrative review, the management of coronary artery disease in patients with SMI is discussed, and avenues for future research are highlighted.
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Affiliation(s)
- Brian Tam To
- Cardiovascular Department, King’s College Hospital NHS Foundation TrustLondon, UK
| | - Roman Roy
- Cardiovascular Department, King’s College Hospital NHS Foundation TrustLondon, UK
| | - Narbeh Melikian
- Cardiovascular Department, King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King’s College LondonLondon, UK
| | - Fiona P Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College LondonLondon, UK
- National Psychosis Service, South London and Maudsley NHS Foundation TrustLondon, UK
| | - Kevin O’Gallagher
- Cardiovascular Department, King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular and Metabolic Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King’s College LondonLondon, UK
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5
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Yeoh J, Kanyal R, Pareek N, Macaya F, Cannata S, Tzalamouras V, Webb I, Dworakowski R, Melikian N, Shah AM, MacCarthy P, Hill J, Byrne J. Intravascular lithotripsy in the treatment of coronary artery calcification in a high-risk real world population. Catheter Cardiovasc Interv 2023; 101:233-242. [PMID: 36617393 DOI: 10.1002/ccd.30546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/03/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The DISRUPT-CAD study series demonstrated feasibility and safety of intravascular lithotripsy (IVL) in selected patients, but applicability across a broad range of clinical scenarios remains unclear. AIMS This study aims to evaluate the procedural and clinical outcomes of IVL in a high-risk real-world cohort, compared to a regulatory approval cohort. METHODS Consecutive patients treated with IVL and percutaneous coronary intervention at our center from May 2016 to April 2020 were included. Comparison was made between those enrolled in the DISRUPT-CAD series of studies to those with calcified lesions but an exclusion criteria. RESULTS Among 177 patients treated with IVL, 142 were excluded from regulatory trials due to acute coronary syndrome presentation (47.2%), left ventricular ejection fraction <40% (22.5%), chronic renal failure (12.0%), or use of mechanical circulatory support (8.5%). This clinical cohort had a higher SYNTAX score (22.6 ± 12.1 vs. 17.4 ± 9.9, p = 0.019), and more treated ACC/AHA C lesions (56.3% vs. 37.1%, p = 0.042). Rates of device success (93.7% vs. 100.0%, p = 0.208), procedural success (96.5% vs. 100.0%, p = 0.585), and minimal lumen area gain (221.2 ± 93.7% vs. 198.6 ± 152.0%, p = 0.807) were similar in both groups. The DISRUPT-CAD cohort had no in-hospital mortality, 30-day major adverse cardiac events (MACE), or 30-day target vessel revascularization (TVR). The clinical cohort had an in-hospital mortality of 4.2%, 30-day MACE of 7.8%, and 30-day TVR of 1.5%. There was no difference in 12-month TVR (2.9% vs. 2.2%; p = 0.825). Twelve-month MACE was higher in the clinical cohort (21.1% vs. 8.6%, p = 0.03). CONCLUSION IVL use remains associated with high clinical efficacy, procedural success, and low complication rates in a real-world population previously excluded from regulatory approving trials.
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Affiliation(s)
- Julian Yeoh
- King's College Hospital NHS Foundation Trust, London, UK
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Ritesh Kanyal
- King's College Hospital NHS Foundation Trust, London, UK
| | - Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, UK
| | | | | | | | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Jonathan Hill
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, UK
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6
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Ryan M, De Silva K, Morgan H, O’Gallagher K, Demir OM, Rahman H, Ellis H, Dancy L, Sado D, Strange J, Melikian N, Marber M, Shah AM, Chiribiri A, Perera D. Coronary Wave Intensity Analysis as an Invasive and Vessel-Specific Index of Myocardial Viability. Circ Cardiovasc Interv 2022; 15:e012394. [PMID: 36538582 PMCID: PMC9760472 DOI: 10.1161/circinterventions.122.012394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/28/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coronary angiography and viability testing are the cornerstones of diagnosing and managing ischemic cardiomyopathy. At present, no single test serves both needs. Coronary wave intensity analysis interrogates both contractility and microvascular physiology of the subtended myocardium and therefore has the potential to fulfil the goal of completely assessing coronary physiology and myocardial viability in a single procedure. We hypothesized that coronary wave intensity analysis measured during coronary angiography would predict viability with a similar accuracy to late-gadolinium-enhanced cardiac magnetic resonance imaging. METHODS Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. Coronary wave intensity analysis was assessed during cardiac catheterization at rest, during adenosine-induced hyperemia, and during low-dose dobutamine stress using a dual pressure-Doppler sensing coronary guidewire. Scar burden was assessed with cardiac magnetic resonance imaging. Regional left ventricular function was assessed at baseline and 6-month follow-up after optimization of medical-therapy±revascularization, using transthoracic echocardiography. The primary outcome was myocardial viability, determined by the retrospective observation of functional recovery. RESULTS Forty participants underwent baseline physiology, cardiac magnetic resonance imaging, and echocardiography, and 30 had echocardiography at 6 months; 21/42 territories were viable on follow-up echocardiography. Resting backward compression wave energy was significantly greater in viable than in nonviable territories (-5240±3772 versus -1873±1605 W m-2 s-1, P<0.001), and had comparable accuracy to cardiac magnetic resonance imaging for predicting viability (area under the curve 0.812 versus 0.757, P=0.649); a threshold of -2500 W m-2 s-1 had 86% sensitivity and 76% specificity. CONCLUSIONS Backward compression wave energy has accuracy similar to that of late-gadolinium-enhanced cardiac magnetic resonance imaging in the prediction of viability. Coronary wave intensity analysis has the potential to streamline the management of ischemic cardiomyopathy, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.
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Affiliation(s)
- Matthew Ryan
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Kalpa De Silva
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Holly Morgan
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Kevin O’Gallagher
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Ozan M. Demir
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Haseeb Rahman
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Howard Ellis
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Luke Dancy
- Cardiology Department, King’s College Hospital, London, UK (L.D., D.S., N.M.)
| | - Daniel Sado
- Cardiology Department, King’s College Hospital, London, UK (L.D., D.S., N.M.)
| | | | | | - Michael Marber
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Ajay M. Shah
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
- Imaging Sciences Division, King’s College London, UK (A.C.)
| | - Divaka Perera
- Cardiovascular Division, King’s College London, UK (M.R., K.D.S., H.M., K.O., O.M.D., H.R., H.E., M.M., A.M.S., D.P.)
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7
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Ryan M, Morgan H, O'Gallagher K, Demir O, Rahman H, Ellis H, Dancy L, Sado D, Strange J, Melikian N, Marber M, Shah A, De Silva K, Chiribiri A, Perera D. Coronary wave energy to predict functional recovery in patients with ischemic left ventricular dysfunction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Invasive coronary angiography and non-invasive viability testing are the cornerstones of diagnosing and managing ischemic left ventricular dysfunction. At present there is no single test which serves both needs but, if developed, could revolutionise investigation of this condition. Coronary wave intensity analysis (cWIA) interrogates both contractility and microvascular physiology of the subtended myocardium [1,2] and therefore has the potential to fulfil this goal.
Objectives
We hypothesized that cWIA measured during coronary angiography would predict functional recovery with a similar accuracy to late gadolinium enhanced cardiac magnetic resonance imaging (LGE-CMR).
Methods
Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. cWIA, fractional flow reserve and microvascular resistance were assessed with a simultaneous coronary Doppler and pressure-sensing guidewire during cardiac catheterization at rest, during hyperaemia and during low-dose dobutamine stress. Viability was assessed using LGE-CMR. Regional left ventricular function was assessed at baseline and 6-month follow up after optimization of medical therapy +/− revascularization, using transthoracic echocardiography. The primary outcome was regional functional recovery.
Results
Forty participants underwent baseline physiology, LGE-CMR and thirty had echocardiography at baseline and 6 months; 21/42 territories demonstrated functional recovery. Resting backward compression wave energy was significantly greater in recovering than non-recovering territories (−5240±3772 vs. −1873±1605 W m–2 s–1, p=0.099, Figure 1), and had comparable diagnostic accuracy to CMR (area under the curve 0.812 vs. 0.757, p=0.649, Figure 2); a threshold of −2500 W mm–2 s–1 had 86% sensitivity and 76% specificity at predicting recovery. Backward expansion wave energy did not predict recovery. FFR was numerically higher in recovering territories (0.81±0.17 vs. 0.71±0.16, p=0.058), whilst hyperaemic microvascular resistance did not differentiate recovering from non-recovering territories (1.97±0.73 vs. 2.29±1.00, p=0.287). The likelihood of functional recovery was similar in revascularised and non-revascularised territories (15/29 vs. 6/13 respectively, p=0.739). Low-dose dobutamine stress increased the energy of all waves, but did not improve the accuracy of cWIA in predicting recovery. In a regression model, resting backward compression wave energy and optimization of medical therapy predicted functional recovery; fractional flow reserve and hyperemic microvascular resistance did not.
Conclusions
Backward compression wave energy has similar accuracy to LGE-CMR in the prediction of functional recovery. cWIA has the potential to revolutionise the management of ischaemic left ventricular dysfunction, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The British Heart Foundation Clinical Research Training Fellowship
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Affiliation(s)
- M Ryan
- King's College London , London , United Kingdom
| | - H Morgan
- King's College London , London , United Kingdom
| | | | - O Demir
- King's College London , London , United Kingdom
| | - H Rahman
- King's College London , London , United Kingdom
| | - H Ellis
- King's College London , London , United Kingdom
| | - L Dancy
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - D Sado
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - J Strange
- Bristol Heart Institute , Bristol , United Kingdom
| | - N Melikian
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - M Marber
- King's College London , London , United Kingdom
| | - A Shah
- King's College London , London , United Kingdom
| | - K De Silva
- King's College London , London , United Kingdom
| | - A Chiribiri
- King's College London , London , United Kingdom
| | - D Perera
- King's College London , London , United Kingdom
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8
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Benedetto U, Sinha S, Mulla A, Glampson B, Davies J, Panoulas V, Gautama S, Papadimitriou D, Woods K, Elliott P, Hemingway H, Williams B, Asselbergs FW, Melikian N, Krasopoulos G, Sayeed R, Wendler O, Baig K, Chukwuemeka A, Angelini GD, Sterne JAC, Johnson T, Shah AM, Perera D, Patel RS, Kharbanda R, Channon KM, Mayet J, Kaura A. Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative: TROP-CABG study). Int J Cardiol 2022; 362:14-19. [PMID: 35487318 DOI: 10.1016/j.ijcard.2022.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 11/05/2022]
Abstract
Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. BACKGROUND: The optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a) the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b) the interaction between troponin and time-to-surgery. METHODS AND RESULTS: Our cohort consisted of 1746 patients (1684 NSTEMI; 62 unstable angina) (mean age 69 ± 11 years,21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early (within 30 days) and late (beyond 30 days) survival. Average interval from peak troponin to surgery was 9 ± 15 days, with 1466 (84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4 ± 2 years (30-day survival 0.97 ± 0.004 and 5-year survival 0.83 ± 0.01). Peak troponin was a strong predictor of early survival (adjusted P = 0.002) with a significant interaction with time-to-surgery (P interaction = 0.007). For peak troponin levels <100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days (adjusted P = 0.64). CONCLUSIONS: Peak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.
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Affiliation(s)
- Umberto Benedetto
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK; University Gabriele D'Annunzio Chieti Pescara, Italy
| | - Shubhra Sinha
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Abdulrahim Mulla
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Benjamin Glampson
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Jim Davies
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vasileios Panoulas
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Sanjay Gautama
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Dimitri Papadimitriou
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Kerrie Woods
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Elliott
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK; Health Data Research UK, London, UK
| | - Harry Hemingway
- Health Data Research UK, London, UK; NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Bryan Williams
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Folkert W Asselbergs
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Narbeh Melikian
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - George Krasopoulos
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rana Sayeed
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Olaf Wendler
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - Kamran Baig
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Andrew Chukwuemeka
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Gianni D Angelini
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
| | - Jonathan A C Sterne
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tom Johnson
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ajay M Shah
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - Divaka Perera
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Riyaz S Patel
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Rajesh Kharbanda
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Keith M Channon
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jamil Mayet
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Amit Kaura
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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9
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Pareek N, Beckley-Hoelscher N, Kanyal R, Cannata A, Kordis P, Sunderland N, Kirresh A, Nevett J, Fothergill R, Webb I, Dworakowski R, Melikian N, Kalra S, Johnson TW, Sinagra G, Rakar S, Noc M, Shah AM, Byrne J, MacCarthy P. MIRACLE 2 Score and SCAI Grade to Identify Patients With Out-of-Hospital Cardiac Arrest for Immediate Coronary Angiography. JACC Cardiovasc Interv 2022; 15:1074-1084. [PMID: 35589238 DOI: 10.1016/j.jcin.2022.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/15/2022] [Accepted: 03/22/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the impact of performing immediate coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) with stratification of predicted neurologic injury and cardiogenic shock on arrival to a center. BACKGROUND The role of immediate CAG for patients with OHCA is unclear, which may in part be explained by the majority of patients dying of hypoxic brain injury. METHODS Between May 2012 and July 2020, patients from 5 European centers were included in the EUCAR (European Cardiac Arrest Registry). Patients were retrospectively classified into low vs high neurologic risk (MIRACLE2 score 0-3 vs ≥4) and degree of cardiogenic shock on arrival (Society for Cardiovascular Angiography and Interventions [SCAI] grade A vs B-E). A multivariable logistic regression analysis including immediate CAG was performed for the primary outcome of survival with good neurologic outcome (Cerebral Performance Category 1 or 2) at hospital discharge. RESULTS Nine hundred twenty-six patients were included in the registry, with 405 (43.7%) in the low-risk group and 521 (56.3%) in the high-risk group. Immediate CAG was independently associated with improved survival with good neurologic outcome in the low MIRACLE2 risk group with ST-segment elevation myocardial infarction (OR: 11.80; 95% CI: 2.24-76.74; P = 0.048) and with SCAI grade B to E shock (OR: 3.23; 95% CI: 1.10-9.50; P = 0.031). No subgroups, including those with ST-segment elevation myocardial infarction and with SCAI grade B to E shock, achieved any benefit from early CAG in the high MIRACLE2 group. CONCLUSIONS Combined classification of patients with OHCA with 12-lead electrocardiography, MIRACLE2 score 0 to 3, and SCAI grade B to E identifies a potential cohort of patients at low risk for neurologic injury who benefit most from immediate CAG.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom.
| | | | - Ritesh Kanyal
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Antonio Cannata
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Peter Kordis
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Nicholas Sunderland
- Bristol Heart Institute, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Ali Kirresh
- Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joanne Nevett
- London Ambulance Service NHS Trust, London, United Kingdom
| | | | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Rafal Dworakowski
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Narbeh Melikian
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Sundeep Kalra
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Thomas W Johnson
- Bristol Heart Institute, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Serena Rakar
- Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Marko Noc
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Philip MacCarthy
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
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10
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Nayagam JS, Norton BC, Belete S, Rosinhas J, Ramos K, Cramp ME, O'Kane R, Cash WJ, Milan Z, Nicholson C, Menon K, Prachalias A, Srinivasan P, Auzinger G, Byrne J, MacCarthy PA, Melikian N, Agarwal K, Aluvihare VR, Joshi D, Heneghan MA. Invasive coronary angiography as a tool in cardiac evaluation for liver transplant candidates. Journal of Liver Transplantation 2022. [DOI: 10.1016/j.liver.2022.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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11
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Sau A, Kaura A, Ahmed A, Patel KHK, Li X, Mulla A, Glampson B, Panoulas V, Davies J, Woods K, Gautama S, Shah AD, Elliott P, Hemingway H, Williams B, Asselbergs FW, Melikian N, Peters NS, Shah AM, Perera D, Kharbanda R, Patel RS, Channon KM, Mayet J, Ng FS. Prognostic Significance of Ventricular Arrhythmias in 13 444 Patients With Acute Coronary Syndrome: A Retrospective Cohort Study Based on Routine Clinical Data (NIHR Health Informatics Collaborative VA-ACS Study). J Am Heart Assoc 2022; 11:e024260. [PMID: 35258317 PMCID: PMC9075290 DOI: 10.1161/jaha.121.024260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/07/2021] [Accepted: 01/06/2022] [Indexed: 12/19/2022]
Abstract
Background A minority of acute coronary syndrome (ACS) cases are associated with ventricular arrhythmias (VA) and/or cardiac arrest (CA). We investigated the effect of VA/CA at the time of ACS on long-term outcomes. Methods and Results We analyzed routine clinical data from 5 National Health Service trusts in the United Kingdom, collected between 2010 and 2017 by the National Institute for Health Research Health Informatics Collaborative. A total of 13 444 patients with ACS, 376 (2.8%) of whom had concurrent VA, survived to hospital discharge and were followed up for a median of 3.42 years. Patients with VA or CA at index presentation had significantly increased risks of subsequent VA during follow-up (VA group: adjusted hazard ratio [HR], 4.15 [95% CI, 2.42-7.09]; CA group: adjusted HR, 2.60 [95% CI, 1.23-5.48]). Patients who suffered a CA in the context of ACS and survived to discharge also had a 36% increase in long-term mortality (adjusted HR, 1.36 [95% CI, 1.04-1.78]), although the concurrent diagnosis of VA alone during ACS did not affect all-cause mortality (adjusted HR, 1.03 [95% CI, 0.80-1.33]). Conclusions Patients who develop VA or CA during ACS who survive to discharge have increased risks of subsequent VA, whereas those who have CA during ACS also have an increase in long-term mortality. These individuals may represent a subgroup at greater risk of subsequent arrhythmic events as a result of intrinsically lower thresholds for developing VA.
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Affiliation(s)
- Arunashis Sau
- National Heart and Lung InstituteImperial College LondonLondonUK
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
| | - Amit Kaura
- National Heart and Lung InstituteImperial College LondonLondonUK
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
| | - Amar Ahmed
- National Heart and Lung InstituteImperial College LondonLondonUK
| | | | - Xinyang Li
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Abdulrahim Mulla
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
| | - Benjamin Glampson
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
| | | | - Jim Davies
- National Institute for Health Research Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Kerrie Woods
- National Institute for Health Research Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Sanjay Gautama
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
| | - Anoop D. Shah
- National Institute for Health Research University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUK
| | - Paul Elliott
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
- Health Data Research UKLondon Substantive SiteLondonUK
| | - Harry Hemingway
- National Institute for Health Research University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUK
- Health Data Research UKLondon Substantive SiteLondonUK
| | - Bryan Williams
- National Institute for Health Research University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUK
| | - Folkert W. Asselbergs
- National Institute for Health Research University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUK
| | - Narbeh Melikian
- National Institute for Health Research King’s Biomedical Research CentreKing’s College London and King’s College Hospital NHS Foundation TrustLondonUK
| | | | - Ajay M. Shah
- National Institute for Health Research King’s Biomedical Research CentreKing’s College London and King’s College Hospital NHS Foundation TrustLondonUK
| | - Divaka Perera
- National Institute for Health Research King’s Biomedical Research CentreKing’s College London and Guy’s and St Thomas' NHS Foundation TrustLondonUK
| | - Rajesh Kharbanda
- National Institute for Health Research Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Riyaz S. Patel
- National Institute for Health Research University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUK
| | - Keith M. Channon
- National Institute for Health Research Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Jamil Mayet
- National Heart and Lung InstituteImperial College LondonLondonUK
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
| | - Fu Siong Ng
- National Heart and Lung InstituteImperial College LondonLondonUK
- National Institute for Health Research Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUK
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12
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Kaura A, Hartley A, Panoulas V, Glampson B, Shah ASV, Davies J, Mulla A, Woods K, Omigie J, Shah AD, Thursz MR, Elliott P, Hemmingway H, Williams B, Asselbergs FW, O'Sullivan M, Lord GM, Trickey A, Sterne JA, Haskard DO, Melikian N, Francis DP, Koenig W, Shah AM, Kharbanda R, Perera D, Patel RS, Channon KM, Mayet J, Khamis R. Mortality risk prediction of high-sensitivity C-reactive protein in suspected acute coronary syndrome: A cohort study. PLoS Med 2022; 19:e1003911. [PMID: 35192610 PMCID: PMC8863282 DOI: 10.1371/journal.pmed.1003911] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/11/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There is limited evidence on the use of high-sensitivity C-reactive protein (hsCRP) as a biomarker for selecting patients for advanced cardiovascular (CV) therapies in the modern era. The prognostic value of mildly elevated hsCRP beyond troponin in a large real-world cohort of unselected patients presenting with suspected acute coronary syndrome (ACS) is unknown. We evaluated whether a mildly elevated hsCRP (up to 15 mg/L) was associated with mortality risk, beyond troponin level, in patients with suspected ACS. METHODS AND FINDINGS We conducted a retrospective cohort study based on the National Institute for Health Research Health Informatics Collaborative data of 257,948 patients with suspected ACS who had a troponin measured at 5 cardiac centres in the United Kingdom between 2010 and 2017. Patients were divided into 4 hsCRP groups (<2, 2 to 4.9, 5 to 9.9, and 10 to 15 mg/L). The main outcome measure was mortality within 3 years of index presentation. The association between hsCRP levels and all-cause mortality was assessed using multivariable Cox regression analysis adjusted for age, sex, haemoglobin, white cell count (WCC), platelet count, creatinine, and troponin. Following the exclusion criteria, there were 102,337 patients included in the analysis (hsCRP <2 mg/L (n = 38,390), 2 to 4.9 mg/L (n = 27,397), 5 to 9.9 mg/L (n = 26,957), and 10 to 15 mg/L (n = 9,593)). On multivariable Cox regression analysis, there was a positive and graded relationship between hsCRP level and mortality at baseline, which remained at 3 years (hazard ratio (HR) (95% CI) of 1.32 (1.18 to 1.48) for those with hsCRP 2.0 to 4.9 mg/L and 1.40 (1.26 to 1.57) and 2.00 (1.75 to 2.28) for those with hsCRP 5 to 9.9 mg/L and 10 to 15 mg/L, respectively. This relationship was independent of troponin in all suspected ACS patients and was further verified in those who were confirmed to have an ACS diagnosis by clinical coding. The main limitation of our study is that we did not have data on underlying cause of death; however, the exclusion of those with abnormal WCC or hsCRP levels >15 mg/L makes it unlikely that sepsis was a major contributor. CONCLUSIONS These multicentre, real-world data from a large cohort of patients with suspected ACS suggest that mildly elevated hsCRP (up to 15 mg/L) may be a clinically meaningful prognostic marker beyond troponin and point to its potential utility in selecting patients for novel treatments targeting inflammation. TRIAL REGISTRATION ClinicalTrials.gov - NCT03507309.
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Affiliation(s)
- Amit Kaura
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Adam Hartley
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Vasileios Panoulas
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ben Glampson
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Anoop S V Shah
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
- London School of Hygiene Tropical Medicine, London, United Kingdom
| | - Jim Davies
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Abdulrahim Mulla
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kerrie Woods
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Joe Omigie
- NIHR King's Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anoop D Shah
- NIHR University College London Hospitals Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mark R Thursz
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Paul Elliott
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
- Health Data Research, London Substantive Site, United Kingdom
| | - Harry Hemmingway
- NIHR University College London Hospitals Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Health Data Research, London Substantive Site, United Kingdom
| | - Bryan Williams
- NIHR University College London Hospitals Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Folkert W Asselbergs
- NIHR University College London Hospitals Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Michael O'Sullivan
- NIHR Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Graham M Lord
- NIHR Manchester Biomedical Research Centre, University of Manchester and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Adam Trickey
- NIHR Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, London, United Kingdom
| | - Jonathan Ac Sterne
- NIHR King's Biomedical Research Centre, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dorian O Haskard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Narbeh Melikian
- NIHR King's Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany and DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Ajay M Shah
- NIHR King's Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Rajesh Kharbanda
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Divaka Perera
- NIHR Manchester Biomedical Research Centre, University of Manchester and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Riyaz S Patel
- NIHR University College London Hospitals Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Keith M Channon
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jamil Mayet
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ramzi Khamis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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13
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Sarma D, Pareek N, Kanyal R, Cannata A, Dworakowski R, Webb I, Barash J, Emezu G, Melikian N, Hill J, Shah AM, MacCarthy P, Byrne J. Clinical Significance of Early Echocardiographic Changes after Resuscitated Out-of-Hospital Cardiac Arrest. Resuscitation 2021; 172:117-126. [PMID: 34923035 DOI: 10.1016/j.resuscitation.2021.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/26/2021] [Accepted: 12/12/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Left Ventricular Systolic Dysfunction (LVSD) is common after out-of-hospital cardiac arrest (OOHCA) and can manifest globally or regionally, although its clinical significance has not been robustly studied. This study evaluates the association between LVSD, extent of coronary artery disease (CAD) and outcome in those undergoing early echocardiography and coronary angiography after OOHCA. METHODS Trans-thoracic echocardiography (TTE) was performed in OOHCA patients on arrival to our centre between May 2012 and December 2017. Rates of cardiogenic shock and extent of CAD, respectively classified by SCAI grade and the SYNTAX score, were measured. The primary end-point was 12-month mortality. RESULTS From 398 patients in the King's Out of Hospital Cardiac Arrest Registry (KOCAR), 266 patients (median age 61 [53-71], 76% male) underwent both TTE and coronary angiography on arrival. 96 patients (36%) had significant LVSD (Left Ventricular Ejection Fraction [LVEF]<40%) and 139 (52.2%) patients had regional wall motion abnormalities (RWMAs). Patients with LVEF<40% had more SCAI grade C-E shock (65.3% vs. 34.5%, p<0.001) and higher 12-month mortality (55.2% vs 31.8%, p<0.001) which was more likely to be due to a cardiac aetiology (27.3% vs 5.3%, p<0.001). Patients with RWMAs had higher median SYNTAX scores (14.75 vs 7, p=0.001), culprit coronary lesions (83.5% vs. 45.3%, p <0.001) and lower 12-month mortality (29.5% vs 52%, p<0.001). CONCLUSIONS Patients with LVEF <40% at presentation have an increased mortality, driven by cardiac aetiology death, while the presence of RWMAs is associated with a higher rate of culprit coronary lesions, representing a potentially reversible cause of the arrest, and improved survival at 1 year.
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Affiliation(s)
- Dhruv Sarma
- King's College Hospital NHS Foundation Trust, London, U.K
| | - Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K.
| | - Ritesh Kanyal
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Antonio Cannata
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Rafal Dworakowski
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Jemma Barash
- King's College Hospital NHS Foundation Trust, London, U.K
| | - Gift Emezu
- King's College Hospital NHS Foundation Trust, London, U.K
| | - Narbeh Melikian
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Jonathan Hill
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Philip MacCarthy
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, U.K; School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, U.K
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14
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Kanyal R, Pareek N, Sarma D, Bharucha A, Dworakowski R, Melikian N, Webb I, Shah A, MacCarthy P, Byrne J. Complete Revascularisation is associated with Improved Survival after Out of Hospital Cardiac Arrest. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Coronary artery disease (CAD) is common in patients with Out of Hospital Cardiac Arrest (OOHCA) but the clinical relevance of burden of CAD and evidence for revascularisation strategies in relation to outcomes and modes of death remains unclear.
Purpose
This study sought to assess the extent of CAD as defined by the SYNTAX score and prognostic value of complete compared with incomplete revascularisation by evaluating the SYNTAX revascularisation index (SRI) in patients with OOHCA.
Methods
619 patients with OOHCA were admitted at our centre between 1st May 2012 and 31st December 2017. 237 were excluded for having a non-cardiac aetiology or prior neurological disability. 398 patients were included into the study and of these 272 (68.3%) had early coronary angiography (CAG) and were included in the final analysis.
The baseline SYNTAX score (bSS) and residual SYNTAX score (rSS) were determined from the coronary angiograms by a cardiologist blinded to the outcome. Patients were subdivided into 4 subgroups according to quartiles of the baseline syntax score (bSS) of 0, Group A: 1–10, Group B: 11–20 and Group C: ≥21. Complete revascularisation (CR) was defined as SRI of 1 and incomplete (IR) as SRI <1 where the SRI=(1-[rSS/bSS]) ×100 (Figure 1).
Results
Patients with a bSS of 0 were younger, had less shockable initial arrest rhythms and worse lactate and pH on arrival.Patients with bSS>0 (i.e., those with coronary artery disease) had similar cardiac arrest circumstances in terms of rates of witnessed, bystander CPR and shockable rhythms. Admission metabolic status reflected by pH and lactate and rates of ST elevation/LBBB were also identical for all three groups. However, LVEF on admission decreased significantly as coronary complexity increased (P<0.0001). While early angiography was more preferentially performed in those with higher coronary complexity, paradoxically, those with bSS 1–4 had highest rates of culprit lesions which was reflected in higher rates of PCI (Figure 1).
124 (45.4%) had CR compared with 54.2% with IR. CR was most likely to be achieved as the coronary complexity reduced (Group A – 71.7%, Group B – 41.1%, Group C - 23.3%). There was no difference in rates of cardiogenic shock between both groups (CR 61.1% vs. IR 69% p=ns), but patients with complete revascularisation were younger (58.8 vs 67.8, p<0.0001), lower rates of hypertension and previous CABG (16.2% vs 3.2%, p≤0.0001)
CR was associated with decreased mortality at 30 days (45.9% vs 34.6%, p=0.046) and 12 months (49.3% vs 35.4%, p=0.022). The lower mortality rate in CR appeared to partly be driven by lower cardiac deaths though this was not statistically significant (22% vs 7%, p=0.1) (Figure 2).
Conclusions
CR in a primary coronary aetiology OOHCA group is associated with reduced early and long-term mortality, which may be driven by a reduction in cardiac deaths. Prospective randomised trials in this population are warranted.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Affiliation(s)
- R Kanyal
- King's College Hospital, London, United Kingdom
| | - N Pareek
- King's College Hospital, London, United Kingdom
| | - D Sarma
- King's College Hospital, London, United Kingdom
| | - A Bharucha
- King's College Hospital, London, United Kingdom
| | | | - N Melikian
- King's College Hospital, London, United Kingdom
| | - I Webb
- King's College Hospital, London, United Kingdom
| | - A Shah
- King's College Hospital, London, United Kingdom
| | - P MacCarthy
- King's College Hospital, London, United Kingdom
| | - J Byrne
- King's College Hospital, London, United Kingdom
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15
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Kanyal R, Sarma D, Pareek N, Dworakowski R, Melikian N, Webb I, Shah A, MacCarthy P, Byrne J. Clinical significance of early echocardiography after out-of-hospital cardiac arrest on arrival to a heart attack centre. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Left ventricular systolic dysfunction (LVSD) is common after out of hospital cardiac arrest (OOHCA) and can manifest as global or regional change.
Purpose
We evaluated the extent of global and regional LVSD and its association with coronary artery disease (CAD) and outcome in those undergoing coronary angiography after OOHCA.
Methods
619 patients with OOHCA were admitted at our centre between 1st May 2012 and 31st December 2017. 398 patients were included. Rates of cardiogenic shock and extent of CAD, as classified by the SYNTAX score were measured. The primary endpoint was 12-month mortality. Patients with incomplete data were excluded from the analysis.
Results
Two hundred and sixty-six patients (median age 62 [53–71] 76.3% male) underwent both trans-thoracic echocardiography andcoronary angiography on arrival and were included in the final analysis. 81.6% had ventricular fibrillation, 83.5% were witnessed and 51.9% occurred at residence.
Ninety-six patients (36%) had significant LVSD (Left Ventricular Ejection Fraction [LVEF] <40%) and 139 (52.2%) patients had regional wall motion abnormalities (RWMAs) on arrival. Patients were classified into 4 groups (Group A: LVEF <40%/Global, Group B: LVEF <40%/RWMA, Group C: LVEF ≥40%/Global and Group D: LVEF ≥40%/RWMA) with frequencies of 10.9%, 25.2%, 41.4% and 22.6%).
Patients in Group D had the shortest low-flow times and lowest rates of epinephrine administration, with most favourable metabolic status on arrival, based on lactate and creatinine values. In Groups B and D (RWMAs), patients were significantly more likely to have a post-ROSC ECG demonstrating ST elevation/LBBB and absence of epinephrine administration during resuscitation with shorter low flow times. Extent of CAD was similar between the four groups. From patients with LVEF ≥40%, patients in Group C had substantially lower SYNTAX scores than compared with Group D (0.5 vs 13.5, p<0.001). However, both Group B and C (RWMA) groups had highest rates of culprit lesions compared with matched global groups which was reflected in higher PCI rates (Figure 1).
The primary endpoint of 12-month mortality was lowest in Group D and highest in the Group A group. A similar effect was observed for poor neurological outcome and 30-day mortality. Patients with regional LVSD had significantly improved survival at 12 months compared with those with global LVSD (70.5% vs 48.3%, p<0.001) vs 51). Those in Group D had highest survival at 12 months, while this was similar for Groups B and C and lowest in Group A (Figure 2). Cardiac aetiology death was significantly higher in those with LVEF <40% compared to those with LVEF ≥40% (70.5% vs 48.3%, p<0.001).
Conclusions
Patients with significant LVEF <40% have higher rates of cardiogenic shock and mortality which was driven by cardiac aetiology death, while presence of RWMAs are associated with a higher rate of culprit coronary lesions and improved outcome
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Affiliation(s)
- R Kanyal
- King's College Hospital, London, United Kingdom
| | - D Sarma
- King's College Hospital, London, United Kingdom
| | - N Pareek
- King's College Hospital, London, United Kingdom
| | | | - N Melikian
- King's College Hospital, London, United Kingdom
| | - I Webb
- King's College Hospital, London, United Kingdom
| | - A Shah
- King's College Hospital, London, United Kingdom
| | - P MacCarthy
- King's College Hospital, London, United Kingdom
| | - J Byrne
- King's College Hospital, London, United Kingdom
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16
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O'Gallagher K, Cabaco AR, Ryan M, Roomi A, Gu H, Dancy L, Melikian N, Chowienczyk PJ, Webb AJ, Shah AM. Direct cardiac versus systemic effects of inorganic nitrite on human left ventricular function. Am J Physiol Heart Circ Physiol 2021; 321:H175-H184. [PMID: 34018850 PMCID: PMC8505166 DOI: 10.1152/ajpheart.00081.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Inorganic nitrite is a source of nitric oxide (NO) and is considered as a potential therapy in settings where endogenous NO bioactivity is reduced and left ventricular (LV) function impaired. However, the effects of nitrite on human cardiac contractile function, and the extent to which these are direct or indirect, are unclear. We studied 40 patients undergoing diagnostic cardiac catheterization who had normal LV systolic function and were not found to have obstructive coronary disease. They received either an intracoronary sodium nitrite infusion (8.7–26 µmol/min, n = 20) or an intravenous sodium nitrite infusion (50 µg/kg/min, n = 20). LV pressure-volume relations were recorded. The primary end point was LV end-diastolic pressure (LVEDP). Secondary end points included indices of LV systolic and diastolic function. Intracoronary nitrite infusion induced a significant reduction in LVEDP, LV end-diastolic pressure-volume relationship (EDPVR), and the time to LV end-systole (LVEST) but had no significant effect on LV systolic function or systemic hemodynamics. Intravenous nitrite infusion induced greater effects, with significant decreases in LVEDP, EDPVR, LVEST, LV dP/dtmin, tau, and mean arterial pressure. Inorganic nitrite has modest direct effects on human LV diastolic function, independent of LV loading conditions and without affecting LV systolic properties. However, the systemic administration of nitrite has larger effects on LV diastolic function, which are related to reduction in both preload and afterload. These contractile effects of inorganic nitrite may indicate a favorable profile for conditions characterized by LV diastolic dysfunction. NEW & NOTEWORTHY This is the first study to assess the direct and indirect effects of inorganic nitrite on invasive measures of left ventricular function in humans in vivo. Inorganic nitrite has a modest direct myocardial effect, improving diastolic function. Systemic administration of nitrite has larger effects related to alterations in cardiac preload and afterload. The changes induced by nitrite appear favorable for potential use in conditions characterized by LV diastolic dysfunction.
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Affiliation(s)
- Kevin O'Gallagher
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom.,Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Ana R Cabaco
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Matthew Ryan
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Ali Roomi
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Haotian Gu
- Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Luke Dancy
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Narbeh Melikian
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Andrew J Webb
- Department of Clinical Pharmacology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Ajay M Shah
- Department of Cardiology, School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Research Excellence, London, United Kingdom
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17
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Kaura A, Sterne JAC, Trickey A, Abbott S, Mulla A, Glampson B, Panoulas V, Davies J, Woods K, Omigie J, Shah AD, Channon KM, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, O'Sullivan M, Lord GM, Melikian N, Johnson T, Francis DP, Shah AM, Perera D, Kharbanda R, Patel RS, Mayet J. Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data. Lancet 2020; 396:623-634. [PMID: 32861307 PMCID: PMC7456783 DOI: 10.1016/s0140-6736(20)30930-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI. METHODS Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure. FINDINGS Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82-89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2-4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55-0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48-0·93). INTERPRETATION The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older. FUNDING NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative.
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Affiliation(s)
- Amit Kaura
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan A C Sterne
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Adam Trickey
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Sam Abbott
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Abdulrahim Mulla
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Benjamin Glampson
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Vasileios Panoulas
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Jim Davies
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kerrie Woods
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joe Omigie
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Anoop D Shah
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Keith M Channon
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan N Weber
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Mark R Thursz
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Paul Elliott
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Harry Hemingway
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Bryan Williams
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Folkert W Asselbergs
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael O'Sullivan
- National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graham M Lord
- National Institute for Health Research Manchester Biomedical Research Centre, University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Narbeh Melikian
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas Johnson
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Darrel P Francis
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Ajay M Shah
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Divaka Perera
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Rajesh Kharbanda
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Riyaz S Patel
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Jamil Mayet
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK.
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18
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Pareek N, Dworakowski R, Webb I, Barash J, Emezu G, Melikian N, Hill J, Shah A, MacCarthy P, Byrne J. SCAI cardiogenic shock classification after out of hospital cardiac arrest and association with outcome. Catheter Cardiovasc Interv 2020; 97:E288-E297. [PMID: 32445610 DOI: 10.1002/ccd.28984] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/06/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We aimed to validate the Society for Cardiovascular Angiography and Interventions (SCAI) classification to evaluate association with outcome in a real-world population and effect of invasive therapies. BACKGROUND Cardiogenic shock is common after Out of Hospital Cardiac Arrest (OOHCA) but is often multifactorial and challenging to stratify. METHODS The SCAI shock grade was applied to an observational registry of OOHCA patients on admission to our center between 2012 and 2017. The primary end-point was 30-day mortality and secondary end-points were mode of death and 12-month mortality. Provision of early CAG and mechanical circulatory support (MCS) was evaluated by SCAI shock grade using logistic regression. RESULTS Three hundred and ninety-three patients (median age 64.3 years (24.9% females) were included. One hundred and seven patients (27.2%) were in Grade A, 94 (23.9%) in Grade B, 66 (16.8%) in Grade C, 91 (23.2%) in Grade D, and 35 (8.9%) in Grade E. There was a step-wise significant increase in 30-day mortality with increasing shock grade (A 28.9% vs. B 33.0% vs. C 54.5% vs. D 59.3% vs. E 82.9%; p < .0001). With worsening shock grade, requirement for renal replacement therapy and mortality from multiorgan dysfunction syndrome and cardiogenic causes increased. Early CAG was performed equally in all groups but was significantly associated with reduced mortality in SCAI grade D only (OR 0.26 [CI 0.08-0.91], p = .036). CONCLUSIONS Increasing SCAI shock grade after OOHCA is associated with 30-day mortality, requirement for renal replacement therapy and mortality attributed to multiorgan dysfunction syndrome and cardiac etiology death.
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Affiliation(s)
- Nilesh Pareek
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Rafal Dworakowski
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Ian Webb
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Jemma Barash
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Gift Emezu
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Narbeh Melikian
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Jonathan Hill
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Ajay Shah
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Philip MacCarthy
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
| | - Jonathan Byrne
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, London, UK
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Kaura A, Arnold AD, Panoulas V, Glampson B, Davies J, Mulla A, Woods K, Omigie J, Shah AD, Channon KM, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, O'Sullivan M, Lord GM, Melikian N, Lefroy DC, Francis DP, Shah AM, Kharbanda R, Perera D, Patel RS, Mayet J. Prognostic significance of troponin level in 3121 patients presenting with atrial fibrillation (The NIHR Health Informatics Collaborative TROP-AF study). J Am Heart Assoc 2020; 9:e013684. [PMID: 32212911 PMCID: PMC7428631 DOI: 10.1161/jaha.119.013684] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/13/2019] [Indexed: 11/16/2022]
Abstract
Background Patients presenting with atrial fibrillation (AF) often undergo a blood test to measure troponin, but interpretation of the result is impeded by uncertainty about its clinical importance. We investigated the relationship between troponin level, coronary angiography, and all-cause mortality in real-world patients presenting with AF. Methods and Results We used National Institute of Health Research Health Informatics Collaborative data to identify patients admitted between 2010 and 2017 at 5 tertiary centers in the United Kingdom with a primary diagnosis of AF. Peak troponin results were scaled as multiples of the upper limit of normal. A total of 3121 patients were included in the analysis. Over a median follow-up of 1462 (interquartile range, 929-1975) days, there were 586 deaths (18.8%). The adjusted hazard ratio for mortality associated with a positive troponin (value above upper limit of normal) was 1.20 (95% CI, 1.01-1.43; P<0.05). Higher troponin levels were associated with higher risk of mortality, reaching a maximum hazard ratio of 2.6 (95% CI, 1.9-3.4) at ≈250 multiples of the upper limit of normal. There was an exponential relationship between higher troponin levels and increased odds of coronary angiography. The mortality risk was 36% lower in patients undergoing coronary angiography than in those who did not (adjusted hazard ratio, 0.61; 95% CI, 0.42-0.89; P=0.01). Conclusions Increased troponin was associated with increased risk of mortality in patients presenting with AF. The lower hazard ratio in patients undergoing invasive management raises the possibility that the clinical importance of troponin release in AF may be mediated by coronary artery disease, which may be responsive to revascularization.
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Affiliation(s)
- Amit Kaura
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Ahran D. Arnold
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Vasileios Panoulas
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Benjamin Glampson
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Jim Davies
- NIHR Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Abdulrahim Mulla
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Kerrie Woods
- NIHR Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Joe Omigie
- NIHR King's Biomedical Research CentreKing's College London and King's College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Anoop D. Shah
- NIHR University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Keith M. Channon
- NIHR Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Jonathan N. Weber
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Mark R. Thursz
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Paul Elliott
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
- Health Data Research UKUniversity College LondonLondonUnited Kingdom
| | - Harry Hemingway
- NIHR University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Health Data Research UKUniversity College LondonLondonUnited Kingdom
| | - Bryan Williams
- NIHR University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Folkert W. Asselbergs
- NIHR University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Michael O'Sullivan
- NIHR Cambridge Biomedical Research CentreUniversity of Cambridge and Cambridge University Hospitals NHS Foundation TrustCambridgeUnited Kingdom
| | - Graham M. Lord
- NIHR King's Biomedical Research CentreKing's College London and Guy's and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Institute of Epidemiology and BiostatisticsUniversity of UlmGermany
- Faculty of Biology Medicine and HealthUniversity of ManchesterUnited Kingdom
| | - Narbeh Melikian
- NIHR King's Biomedical Research CentreKing's College London and King's College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - David C. Lefroy
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Darrel P. Francis
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | - Ajay M. Shah
- NIHR King's Biomedical Research CentreKing's College London and King's College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Rajesh Kharbanda
- NIHR Oxford Biomedical Research CentreUniversity of Oxford and Oxford University Hospitals NHS Foundation TrustOxfordUnited Kingdom
| | - Divaka Perera
- NIHR King's Biomedical Research CentreKing's College London and Guy's and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Riyaz S. Patel
- NIHR University College London Biomedical Research CentreUniversity College London and University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Jamil Mayet
- NIHR Imperial Biomedical Research CentreImperial College London and Imperial College Healthcare NHS TrustLondonUnited Kingdom
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Kaura A, Panoulas V, Glampson B, Davies J, Mulla A, Woods K, Omigie J, Shah AD, Channon KM, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, O'Sullivan M, Kharbanda R, Lord GM, Melikian N, Patel RS, Perera D, Shah AM, Francis DP, Mayet J. Association of troponin level and age with mortality in 250 000 patients: cohort study across five UK acute care centres. BMJ 2019; 367:l6055. [PMID: 31748235 PMCID: PMC6865859 DOI: 10.1136/bmj.l6055] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the relation between age and troponin level and its prognostic implication. DESIGN Retrospective cohort study. SETTING Five cardiovascular centres in the UK National Institute for Health Research Health Informatics Collaborative (UK-NIHR HIC). PARTICIPANTS 257 948 consecutive patients undergoing troponin testing for any clinical reason between 2010 and 2017. MAIN OUTCOME MEASURE All cause mortality. RESULTS 257 948 patients had troponin measured during the study period. Analyses on troponin were performed using the peak troponin level, which was the highest troponin level measured during the patient's hospital stay. Troponin levels were standardised as a multiple of each laboratory's 99th centile of the upper limit of normal (ULN). During a median follow-up of 1198 days (interquartile range 514-1866 days), 55 850 (21.7%) deaths occurred. A positive troponin result (that is, higher than the upper limit of normal) signified a 3.2 higher mortality hazard (95% confidence interval 3.1 to 3.2) over three years. Mortality varied noticeably with age, with a hazard ratio of 10.6 (8.5 to 13.3) in 18-29 year olds and 1.5 (1.4 to 1.6) in those older than 90. A positive troponin result was associated with an approximately 15 percentage points higher absolute three year mortality across all age groups. The excess mortality with a positive troponin result was heavily concentrated in the first few weeks. Results were analysed using multivariable adjusted restricted cubic spline Cox regression. A direct relation was seen between troponin level and mortality in patients without acute coronary syndrome (ACS, n=120 049), whereas an inverted U shaped relation was found in patients with ACS (n=14 468), with a paradoxical decline in mortality at peak troponin levels >70×ULN. In the group with ACS, the inverted U shaped relation persisted after multivariable adjustment in those who were managed invasively; however, a direct positive relation was found between troponin level and mortality in patients managed non-invasively. CONCLUSIONS A positive troponin result was associated with a clinically important increased mortality, regardless of age, even if the level was only slightly above normal. The excess mortality with a raised troponin was heavily concentrated in the first few weeks. STUDY REGISTRATION ClinicalTrials.gov NCT03507309.
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Affiliation(s)
- Amit Kaura
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Vasileios Panoulas
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Benjamin Glampson
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Jim Davies
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Abdulrahim Mulla
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Kerrie Woods
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joe Omigie
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - Anoop D Shah
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Keith M Channon
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan N Weber
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Mark R Thursz
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Paul Elliott
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
- Health Data Research UK, London, UK
| | - Harry Hemingway
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
- Health Data Research UK, London, UK
| | - Bryan Williams
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Folkert W Asselbergs
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael O'Sullivan
- NIHR Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rajesh Kharbanda
- NIHR Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Graham M Lord
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Narbeh Melikian
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - Riyaz S Patel
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Divaka Perera
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ajay M Shah
- NIHR Guy's and St Thomas' Biomedical Research Centre, King's College London and King's College Hospital NHS Foundation Trust, London, UK
| | - Darrel P Francis
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Jamil Mayet
- NIHR Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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Kaura A, Sterne J, Mulla A, Panoulas V, Glampson B, Davies J, Woods K, Omigie J, Melikian N, Francis DP, Kharbanda R, Shah AM, Perera D, Patel RS, Mayet J. 6029Invasive versus medical management for non-ST elevation myocardial infarction in the elderly (SENIOR-NSTEMI study). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Trials and registry studies suggest lower long-term mortality after invasive than medical management among patients with non-ST elevated myocardial infarction (NSTEMI), but elderly patients were underrepresented.
Purpose
To estimate the effect of invasive compared with medical management on survival in patients with NSTEMI aged ≥80 years, using routine clinical data.
Methods
We used National Institute for Health Research Health Informatics Collaborative data to identify eligible patients admitted during 2010–2017 at five tertiary centres. We compared patients who did and did not have invasive management within 3 days of their peak troponin level. To limit the effect of immortal time bias, follow-up started 3 days after peak troponin: deaths within three days were excluded. We conducted intention-to-treat analyses.
Propensity scores were derived from a logistic regression model based on pre-treatment variables: patient demographics, blood test results, cardiovascular risk factors, history of cardiovascular disease and other comorbidities. We modelled non-linear relationships using splines. Patients with high probability (based on propensity score) of medical or invasive intervention were excluded. We used Cox models to estimate hazard ratios (HR) comparing invasive with medical management. Three methods were used to control confounding; multivariable-adjusted, multivariable-adjusted additionally for continuous propensity score (primary analysis), and inverse-probability-of-treatment (IPT) weighting. Kaplan-Meier survival curves were plotted. The robustness of the results to unmeasured confounding was assessed in sensitivity analyses.
Results
The 2,239 patients (61.3% medical management) included in analyses had a median age of 85 (IQR 82–89) years. During a median follow-up of 32.1 (IQR 11.1–54.3) months, there were 1,015 (45.3%) deaths. At 3-years, cumulative survival was 78.9% and 50.3% in the invasive and medical management groups, respectively (Figure 1).
The crude HR comparing invasive with medical management was 0.34 (95% CI 0.29–0.40). The multivariable-adjusted HR was 0.44 (95% CI 0.36–0.53), was unchanged with additional adjustment for propensity score, and was 0.46 (95% CI 0.39–0.56) in the IPT-weighted model (all p<0.0001). The E-value for the point estimate was 2.91: this implies that residual confounding could explain the association if there is an unmeasured covariate with a relative risk of at least 2.91 for both mortality and undergoing invasive management. The highest mortality HR for comorbidities included in our model were aortic stenosis 1.66 (95% CI 1.28–2.14) and obstructive lung disease 1.50 (95% CI 1.16–1.94).
Figure 1. Kaplan-Meier survival curves
Conclusion
This study provides evidence that the survival advantage from invasive management may extend to elderly patients with NSTEMI. Future research should address the possibility of unmeasured confounding, including by post-admission prognostic factors that affect choice of invasive or medical management.
Acknowledgement/Funding
Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs
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Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Sterne
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre, University of Bristol, Bristol, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - J Omigie
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - N Melikian
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - D P Francis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - A M Shah
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - D Perera
- St Thomas' Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R S Patel
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
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Kaura A, Davies J, Panoulas V, Glampson B, Mulla A, Woods K, Omigie J, Shah AD, Melikian N, Francis DP, Kharbanda R, Perera D, Shah AM, Patel RS, Mayet J. P4345Supporting big data research in cardiovascular medicine using routinely-collected data. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Many of the data points required to support translational research are collected as a matter of routine, and should be available within electronic patient records. Variations in clinical and data recording practice can mean that the extraction and standardisation of this data, with the aim of producing a large-scale, research-ready dataset, presents a number of challenges.
Purpose
We set out to create a large-scale, research-ready dataset to support translational research in cardiovascular medicine, using routinely-collected data from five large university-hospital partnerships. As an initial focus, we selected those data points that would support an investigation of the relationship between test results and outcomes in acute coronary syndrome (ACS).
Methods
The National Institute of Health Research (NIHR) Health Informatics Collaborative (HIC) is a programme of infrastructure development aimed at increasing the quality and availability of routinely-collected data for collaborative, translational research. Eighteen university-hospital partnerships signed the data sharing agreement, and are working to facilitate the sharing and re-use of data across centres, for approved research purposes.
With support from the Directors of the NIHR Biomedical Research Centres (BRCs) within five of the largest partnerships, we established a clinical data collaboration, specifying a dataset and selecting an initial research question (Figure 1). The NIHR HIC team worked to extract data against this specification. With approval from an ethics committee, and from the information governance teams at each contributing centre, data was processed by one of the centres for standardisation and analysis.
Results
The specified dataset represented a longitudinal record for patients presenting with a suspected ACS, characterised by a request for a troponin test (Figure 1). The dataset included 156 data points, grouped into demographics, cardiovascular risk factor profile, emergency department attendance and inpatient episodes, blood tests, echocardiography and mortality. Data was extracted from the records of patients for whom a troponin test was requested between 2010 and 2017. A total of 257,948 records were standardised and analysed.
The collaboration has been successful, and an initial version of the combined dataset has been created. The size of the dataset has yielded new insights into the relationship between test results and outcomes, and publications are in preparation. An expanded dataset of over 800 data points has been agreed for the next phase of the collaboration, and three other centres have joined.
Figure 1. NIHR HIC dataset generation
Conclusion
It is perfectly feasible – in terms of governance and technology – to re-use routinely-collected data for collaborative, translational research in cardiovascular medicine. The resulting dataset will be large and complex enough to require big data tools and techniques, and will yield the kind of insights afforded only by big data in medicine.
Acknowledgement/Funding
Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs
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Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - J Omigie
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A D Shah
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - N Melikian
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - D P Francis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - D Perera
- St Thomas' Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A M Shah
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R S Patel
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
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Kaura A, Panoulas V, Glampson B, Davies J, Mulla A, Woods K, Omigie J, Shah AD, Melikian N, Kharbanda R, Perera D, Shah AM, Patel RS, Francis DP, Mayet J. P3592Troponin level and mortality risk in an unselected population of over 250,000 patients (TROP-RISK study). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Current evidence suggests a direct relationship between the magnitude of troponin elevation and mortality, albeit over a limited range of troponin levels, and clinicians generally work under the impression that higher troponins signify higher mortality in all age groups.
Purpose
The objective was to use big data to determine the relationship between the full spectrum of troponin level and mortality in patients in whom troponin testing has been performed for clinical purposes.
Methods
As part of the National Institute for Health Research Health Informatics Collaborative project, all troponin values measured during the study period (2010 to 2017) were assembled from five cardiovascular centres. Troponin concentrations were standardised as a multiple of each laboratory's 99th-percentile of the upper limit of normal (ULN). All patients were followed up until death or censoring on 1st April 2017. To model the relation between peak troponin level and all-cause mortality we used restricted cubic spline Cox regression analysis. Splines were adjusted for patient age, gender, haemoglobin, creatinine, white cell count and C-reactive protein.
Results
257,948 patients underwent troponin assessment. During a median follow-up of 1,198 (IQR, 514–1,866) days, there were 55,850 (21.7%) deaths. Using multivariable-adjusted restricted cubic spline Cox regression analysis, an inverted-U shaped relationship was observed between peak troponin level and mortality in all patients (Figure 1A). Among patients who were admitted to hospital, the recorded diagnostic code was acute coronary syndrome (ACS) in 14,468 patients and non-ACS in 120,049 patients.
The revascularisation rate within 3 months was 61.0% (n=8,820) in ACS versus 4.0% (n=4,793) in non-ACS patients. There was a very different rate of revascularisation across the spectrum of troponin. The rate was only 1.4% for troponins below 1 xULN, and 6.1% between 1 and 10 xULN. Beyond 10 xULN, rate of revascularisation rose rapidly to over 85% for greater than 10,000 xULN (Figure 1B). Stratifying patients by revascularisation, the restricted cubic spline Cox regression curve showed a progressive increase in mortality within both the revascularised and non-revascularised strata, even to very high peak troponin levels (Figure 1C). Overall, revascularisation was associated with lower hazard ratios across all troponin levels. A similar pattern was seen when patients were stratified by the presence or absence of ACS diagnosis.
Figure 1. Troponin level and mortality
Conclusions
An elevated troponin, even slightly above the ULN should be taken seriously. The inverted-U shaped mortality relationship with troponin occurred because patients with the highest troponin formed a different clinical subgroup who underwent different clinical management with a high revascularisation rate. These data on troponin level and mortality may help to inform clinical practice decisions and guide future risk stratification algorithms for patients with elevated troponin.
Acknowledgement/Funding
Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs
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Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - J Omigie
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A D Shah
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - N Melikian
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - D Perera
- St Thomas' Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A M Shah
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R S Patel
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - D P Francis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
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Kaura A, Panoulas V, Glampson B, Davies J, Mulla A, Woods K, Omigie J, Shah AD, Channon K, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs F, O’Sullivan M, Lord G, Melikian N, Kharbanda R, Shah A, Perera D, Patel R, Francis D, Mayet J. 69 The relationship between troponin level and mortality in an unselected population of over 250,000 patients with suspected acute coronary syndrome (NIHR Health Informatics Collaborative Trop-risk study). Interv Cardiol 2019. [DOI: 10.1136/heartjnl-2019-bcs.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Kaura A, Sterne J, Mulla A, Panoulas V, Glampson B, Davies J, Woods K, Omigie J, Shah AD, Channon K, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs F, O’Sullivan M, Lord G, Melikian N, Francis D, Perera D, Shah A, Kharbanda R, Patel R, Mayet J. 57 Invasive versus medical management of elderly patients with non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative Senior-NSTEMI study). Interv Cardiol 2019. [DOI: 10.1136/heartjnl-2019-bcs.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Kaura A, Arnold A, Panoulas V, Glampson B, Davies J, Woods K, Mulla A, Omigie J, Shah AD, Channon K, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, Kharbanda R, Lord GM, Melikian N, Patel R, Perera D, Shah A, Lefroy D, Francis D, Mayet J. CLINICAL IMPORTANCE OF TROPONIN LEVEL IN 3,121 PATIENTS PRESENTING WITH ATRIAL FIBRILLATION (AF-TROP STUDY). J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31018-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kaura A, Panoulas V, Glampson B, Davies J, Woods K, Mulla A, Omigie J, Shah AD, Channon K, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, O'Sullivan M, Kharbanda R, Lord GM, Melikian N, Patel R, Perera D, Shah A, Francis D, Mayet J. UNEXPECTED INVERTED U-SHAPED RELATIONSHIP BETWEEN TROPONIN LEVEL AND MORTALITY EXPLAINED BY REVASCULARIZATION IN BOTH PATIENTS WITH AND WITHOUT ACUTE CORONARY SYNDROME (TROP-RISK STUDY). J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kaura A, Hartley A, Panoulas V, Benjamin G, Davies J, Woods K, Mulla A, Shah AD, Channon K, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, Kharbanda R, Lord GM, Melikian N, Patel R, Perera D, Shah A, Francis D, Koenig W, Mayet J, Khamis R. HSCRP PREDICTS MORTALITY BEYOND TROPONIN IN 102,337 PATIENTS WITH SUSPECTED ACUTE CORONARY SYNDROME IN THE UK NATIONAL INSTITUTE FOR HEALTH RESEARCH CRP-RISK STUDY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30619-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kaura A, Panoulas V, Glampson B, Mulla A, Shah AD, Channon K, Kharbanda R, Melikian N, Patel R, Perera D, Shah A, Francis D, Mayet J. P2703Inverted-U-shaped relationship between troponin level and mortality in over 250,000 patients across five centres (NHIC Troponin Study). Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, Department of Cardiology, London, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, Department of Cardiology, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, Department of of Health Informatics, London, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, Department of of Health Informatics, London, United Kingdom
| | - A D Shah
- University College London, Department of of Health Informatics, London, United Kingdom
| | - K Channon
- Oxford University Hospitals NHS Trust, Department of Cardiology, Oxford, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, Department of Cardiology, Oxford, United Kingdom
| | - N Melikian
- King's College Hospital, Department of Cardiology, London, United Kingdom
| | - R Patel
- University College London Hospitals, Department of Cardiology, London, United Kingdom
| | - D Perera
- St Thomas' Hospital, Department of Cardiology, London, United Kingdom
| | - A Shah
- King's College Hospital, Department of Cardiology, London, United Kingdom
| | - D Francis
- Imperial College Healthcare NHS Trust, Department of Cardiology, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, Department of Cardiology, London, United Kingdom
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Ekmejian A, Lee A, Firoozi S, Sapontis J, Bhindi R, Hansen P, Ward M, Kaura A, Hill J, Dwokarowski R, MacCarthy P, Melikian N, Webb I, Shah A, Byrne J. P3585Comparison of 3 year outcomes between medical therapy and percutaneous revascularisation for surgically ineligible patients. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Ekmejian
- Wollongong Hospital, Cardiology, Wollongong, Australia
| | - A Lee
- Wollongong Hospital, Cardiology, Wollongong, Australia
| | - S Firoozi
- St Georges Hospital, London, United Kingdom
| | | | - R Bhindi
- Royal North Shore Hospital, Sydney, Australia
| | - P Hansen
- Royal North Shore Hospital, Sydney, Australia
| | - M Ward
- Royal North Shore Hospital, Sydney, Australia
| | - A Kaura
- King's College London, London, United Kingdom
| | - J Hill
- King's College London, London, United Kingdom
| | | | - P MacCarthy
- King's College London, London, United Kingdom
| | - N Melikian
- King's College London, London, United Kingdom
| | - I Webb
- King's College London, London, United Kingdom
| | - A Shah
- King's College London, London, United Kingdom
| | - J Byrne
- King's College London, London, United Kingdom
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Hildick-Smith D, Williams T, MacCarthy P, Melikian N, Monaghan M, Spence M, MacDonald ST, Duke A, Kovac J, McGregor A, Hilling-Smith R, Gomes A, Thomson C, Mullen M, Morrison L. Occlutech percutaneous patent foramen ovale closure: Safety and efficacy registry (OPPOSE). Int J Cardiol 2017; 245:99-104. [DOI: 10.1016/j.ijcard.2017.07.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 06/19/2017] [Accepted: 07/17/2017] [Indexed: 01/14/2023]
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Khan SG, Melikian N, Shabeeh H, Cabaco AR, Martin K, Khan F, O'Gallagher K, Chowienczyk PJ, Shah AM. The human coronary vasodilatory response to acute mental stress is mediated by neuronal nitric oxide synthase. Am J Physiol Heart Circ Physiol 2017. [PMID: 28646032 PMCID: PMC5625168 DOI: 10.1152/ajpheart.00745.2016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute mental stress induces vasodilation of the coronary microvasculature. Here, we show that this response involves neuronal nitric oxide synthase in the human coronary circulation. Mental stress-induced ischemia approximately doubles the risk of cardiac events in patients with coronary artery disease, yet the mechanisms underlying changes in coronary blood flow in response to mental stress are poorly characterized. Neuronal nitric oxide synthase (nNOS) regulates basal coronary blood flow in healthy humans and mediates mental stress-induced vasodilation in the forearm. However, its possible role in mental stress-induced increases in coronary blood flow is unknown. We studied 11 patients (6 men and 5 women, mean age: 58 ± 14 yr) undergoing elective diagnostic cardiac catheterization and assessed the vasodilator response to mental stress elicited by the Stroop color-word test. Intracoronary substance P (20 pmol/min) and isosorbide dinitrate (1 mg) were used to assess endothelium-dependent and -independent vasodilation, respectively. Coronary blood flow was estimated using intracoronary Doppler recordings and quantitative coronary angiography to measure coronary artery diameter. Mental stress increased coronary flow by 34 ± 7.0% over the preceding baseline during saline infusion (P < 0.01), and this was reduced to 26 ± 7.0% in the presence of the selective nNOS inhibitor S-methyl-l-thiocitrulline (0.625 µmol/min, P < 0.001). Mental stress increased coronary artery diameter by 6.9 ± 3.7% (P = 0.02) and 0.5 ± 2.8% (P = 0.51) in the presence of S-methyl-l-thiocitrulline. The response to substance P did not predict the response to mental stress (r2 = −0.22, P = 0.83). nNOS mediates the human coronary vasodilator response to mental stress, predominantly through actions at the level of coronary resistance vessels. NEW & NOTEWORTHY Acute mental stress induces vasodilation of the coronary microvasculature. Here, we show that this response involves neuronal nitric oxide synthase in the human coronary circulation. Listen to this article’s corresponding podcast at http://ajpheart.podbean.com/e/nnos-and-coronary-flow-during-mental-stress/.
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Affiliation(s)
- Sitara G Khan
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and.,Department of Clinical Pharmacology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Narbeh Melikian
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and
| | - Husain Shabeeh
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and.,Department of Clinical Pharmacology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Ana R Cabaco
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and
| | - Katherine Martin
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and
| | - Faisal Khan
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and.,Department of Clinical Pharmacology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Kevin O'Gallagher
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Ajay M Shah
- Department of Cardiology, Faculty of Life Sciences & Medicine, British Heart Foundation Centre, King's College London, London, United Kingdom; and
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Shabeeh H, Khan S, Jiang B, Brett S, Melikian N, Casadei B, Chowienczyk PJ, Shah AM. Blood Pressure in Healthy Humans Is Regulated by Neuronal NO Synthase. Hypertension 2017; 69:970-976. [PMID: 28264923 PMCID: PMC5389591 DOI: 10.1161/hypertensionaha.116.08792] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 12/27/2016] [Accepted: 01/10/2017] [Indexed: 01/22/2023]
Abstract
NO is physiologically generated by endothelial and neuronal NO synthase (nNOS) isoforms. Although nNOS was first identified in brain, it is expressed in other tissues, including perivascular nerves, cardiac and skeletal muscle. Increasing experimental evidence suggests that nNOS has important effects on cardiovascular function, but its composite effects on systemic hemodynamics in humans are unknown. We undertook the first human study to assess the physiological effects of systemic nNOS inhibition on basal hemodynamics. Seventeen healthy normotensive men aged 24±4 years received acute intravenous infusions of an nNOS-selective inhibitor, S-methyl-l-thiocitrulline, and placebo on separate occasions. An initial dose-escalation study showed that S-methyl-l-thiocitrulline (0.1–3.0 µmol/kg) induced dose-dependent changes in systemic hemodynamics. The highest dose of S-methyl-l-thiocitrulline (3.0 µmol/kg over 10 minutes) significantly increased systemic vascular resistance (+42±6%) and diastolic blood pressure (67±1 to 77±3 mm Hg) when compared with placebo (both P<0.01). There were significant decreases in heart rate (60±4 to 51±3 bpm; P<0.01) and left ventricular stroke volume (59±6 to 51±6 mL; P<0.01) but ejection fraction was unaltered. S-methyl-l-thiocitrulline had no effect on radial artery flow-mediated dilatation, an index of endothelial NOS activity. These results suggest that nNOS-derived NO has an important role in the physiological regulation of basal systemic vascular resistance and blood pressure in healthy humans.
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Affiliation(s)
- Husain Shabeeh
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.)
| | - Sitara Khan
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.)
| | - Benyu Jiang
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.)
| | - Sally Brett
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.)
| | - Narbeh Melikian
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.)
| | - Barbara Casadei
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.)
| | - Philip J Chowienczyk
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.)
| | - Ajay M Shah
- From the King's College London British Heart Foundation Centre, Cardiovascular Division, United Kingdom (H.S., S.K., B.J., S.B., N.M., P.J.C., A.M.S.); and Department of Cardiovascular Medicine, University of Oxford, United Kingdom (B.C.).
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Khan SG, Melikian N, Mushemi-Blake S, Dennes W, Jouhra F, Monaghan M, Shah AM. Physiological Reduction in Left Ventricular Contractile Function in Healthy Postpartum Women: Potential Overlap with Peripartum Cardiomyopathy. PLoS One 2016; 11:e0147074. [PMID: 26859567 PMCID: PMC4747599 DOI: 10.1371/journal.pone.0147074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/27/2015] [Indexed: 01/04/2023] Open
Abstract
Aims Peripartum cardiomyopathy is a potentially life-threatening cause of heart failure, commoner in Afro-Caribbean than Caucasian women. Its diagnosis can be challenging due to physiological changes in cardiac function that also occur in healthy women during the early postpartum period. This study aimed to (i) establish the overlap between normal cardiac physiology in the immediate postpartum period and pathological changes in peripartum cardiomyopathy ii) identify any ethnicity-specific changes in cardiac function and cardiac biomarkers in healthy postpartum women. Methods and Results We conducted a cross-sectional study of 58 healthy postpartum women within 48 hours of delivery and 18 matched non-pregnant controls. Participants underwent cardiac assessment by echocardiography and strain analysis, including 3D echocardiography in 40 postpartum women. Results were compared with 12 retrospectively studied peripartum cardiomyopathy patients. Healthy postpartum women had significantly higher left ventricular volumes and mass, and lower ejection fraction and global longitudinal strain than non-pregnant controls. These parameters were significantly more impaired in peripartum cardiomyopathy patients but with overlapping ranges of values. Healthy postpartum women had higher levels of adrenomedullin, placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt1) compared to controls. The postpartum state, adrenomedullin, sFlt1 and the sFlt1:PlGF ratio were independent predictors of LV remodelling and function in healthy postpartum women. Conclusion Healthy postpartum women demonstrate several echocardiographic indicators of left ventricular remodelling and reduced function, which are associated with altered levels of angiogenic and cardiac biomarkers.
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MESH Headings
- Adult
- Biomarkers/metabolism
- Cardiomyopathy, Dilated/diagnostic imaging
- Cardiomyopathy, Dilated/metabolism
- Cardiomyopathy, Dilated/pathology
- Cardiomyopathy, Dilated/physiopathology
- Female
- Humans
- Myocardial Contraction
- Peripartum Period/metabolism
- Peripartum Period/physiology
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnostic imaging
- Pregnancy Complications, Cardiovascular/metabolism
- Pregnancy Complications, Cardiovascular/pathology
- Pregnancy Complications, Cardiovascular/physiopathology
- Retrospective Studies
- Stroke Volume
- Ultrasonography
- Ventricular Dysfunction, Left
- Ventricular Function, Left
- Ventricular Remodeling
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Affiliation(s)
- Sitara G. Khan
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Narbeh Melikian
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Sitali Mushemi-Blake
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - William Dennes
- Department of Obstetrics and Gynaecology, King’s College Hospital, London, United Kingdom
| | - Fadi Jouhra
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Mark Monaghan
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Ajay M. Shah
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
- * E-mail:
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Mushemi-Blake S, Melikian N, Drasar E, Bhan A, Lunt A, Desai SR, Greenough A, Monaghan MJ, Thein SL, Shah AM. Pulmonary Haemodynamics in Sickle Cell Disease Are Driven Predominantly by a High-Output State Rather Than Elevated Pulmonary Vascular Resistance: A Prospective 3-Dimensional Echocardiography/Doppler Study. PLoS One 2015; 10:e0135472. [PMID: 26270484 PMCID: PMC4535955 DOI: 10.1371/journal.pone.0135472] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/22/2015] [Indexed: 01/07/2023] Open
Abstract
AIMS Patients with sickle cell disease have significant morbidity and mortality. Pulmonary hypertension is suggested to be an important contributor but its nature and severity in these patients and how best to non-invasively assess it are controversial. We hypothesised that a high-output state rather than primary pulmonary vascular pathology may be the major abnormality in sickle cell disease. This study aimed to evaluate the characteristics and severity of pulmonary hypertension in patients with sickle cell disease using detailed echocardiography. METHODS AND RESULTS We undertook a prospective study in 122 consecutive stable outpatients with sickle cell disease and 30 age, gender and ethnicity-matched healthy controls. Echocardiographic evaluation included 3D ventricular volumes, sphericity, tissue Doppler, and non-invasive estimation of pulmonary vascular resistance. 36% of patients had a tricuspid regurgitant velocity ≥2.5 m.s(-1) but only 2% had elevated pulmonary vascular resistance and the prevalence of right ventricular dysfunction was very low. Patients with raised tricuspid regurgitant velocity had significantly elevated biventricular volumes and globular left ventricular remodelling, related primarily to anaemia. In a subgroup of patients who underwent cardiac catheterization, invasive pulmonary haemodynamics confirmed the echocardiographic findings. CONCLUSIONS Elevated cardiac output and left ventricular volume overload secondary to chronic anaemia may be the dominant factor responsible for abnormal cardiopulmonary haemodynamics in patients with sickle cell disease. 3D echocardiography with non-invasive estimation of pulmonary vascular resistance represents a valuable approach for initial evaluation of cardiopulmonary haemodynamics in sickle cell disease.
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Affiliation(s)
- Sitali Mushemi-Blake
- King’s College London British Heart Foundation Centre, Cardiovascular Division, London, United Kingdom
- Department of Cardiology, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Narbeh Melikian
- King’s College London British Heart Foundation Centre, Cardiovascular Division, London, United Kingdom
- Department of Cardiology, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Emma Drasar
- Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Amit Bhan
- Department of Cardiology, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Alan Lunt
- Department of Paediatrics, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Sujal R. Desai
- Department of Radiology, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Anne Greenough
- Department of Paediatrics, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Mark J. Monaghan
- King’s College London British Heart Foundation Centre, Cardiovascular Division, London, United Kingdom
- Department of Cardiology, King’s College Hospital, Denmark Hill, London, United Kingdom
| | - Swee Lay Thein
- Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London, United Kingdom
- NIH / National Institute of Heart, Lung and Blood Diseases, Sickle Cell Branch, Bethesda, Maryland, United States of America
| | - Ajay M. Shah
- King’s College London British Heart Foundation Centre, Cardiovascular Division, London, United Kingdom
- Department of Cardiology, King’s College Hospital, Denmark Hill, London, United Kingdom
- * E-mail:
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Scott P, Sirker A, Dworakowski R, Paul G, Candilio L, Jahagirdar N, Melikian N, Byrne J. Fractional Flow Reserve in the Transradial Era: Will Hand Vein Adenosine Infusion Suffice? JACC Cardiovasc Interv 2015; 8:527-35. [DOI: 10.1016/j.jcin.2014.10.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/26/2014] [Accepted: 10/23/2014] [Indexed: 10/23/2022]
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Lally J, Brook J, Dixon T, Gaughran F, Shergill S, Melikian N, MacCabe JH. Ivabradine, a novel treatment for clozapine-induced sinus tachycardia: a case series. Ther Adv Psychopharmacol 2014; 4:117-22. [PMID: 25057344 PMCID: PMC4107704 DOI: 10.1177/2045125313512325] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Clozapine is the most efficacious treatment for treatment-resistant schizophrenia; however its use can be limited by intolerability. Sinus tachycardia is a common adverse event associated with clozapine use, which may lead to the premature discontinuation of clozapine. Traditionally, β blockers are used to treat clozapine-associated tachycardia, though problems with intolerability and ineffectiveness can limit their utility. METHODS In this article, we present two cases of patients with treatment-resistant schizophrenia who developed symptomatic tachycardia associated with clozapine therapy. RESULTS We demonstrate that the novel heart rate controlling agent ivabradine can be effectively and safely used to control the heart rate and to allow for continued treatment with clozapine. CONCLUSION This is the first report in the literature demonstrating that ivabradine appears to be a well tolerated agent, which should be considered as a symptomatic treatment of clozapine-induced tachycardia if the use of a β blocker fails due to a lack of response or intolerability.
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Affiliation(s)
- John Lally
- Department of Psychosis Studies, King's College London and National Psychosis Service, South London and Maudsley NHS Foundation Trust, London SE5 8AF, UK
| | - Jennifer Brook
- National Psychosis Services, South London and Maudsley NHS Foundation Trust, London, UK
| | - Thomas Dixon
- National Psychosis Services, South London and Maudsley NHS Foundation Trust, London, UK
| | - Fiona Gaughran
- National Psychosis Services, South London and Maudsley NHS Foundation Trust, and Department of Psychosis Studies, Institute of Psychiatry, Kings College London, London, UK
| | - Sukhi Shergill
- National Psychosis Services, South London and Maudsley NHS Foundation Trust, and Department of Psychosis Studies, Institute of Psychiatry, Kings College London, London, UK
| | | | - James H MacCabe
- National Psychosis Services, South London and Maudsley NHS Foundation Trust, and Department of Psychosis Studies, Institute of Psychiatry, Kings College London, London, UK
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Khan S, Melikian N, Mushemi-Blake S, Jouhra F, Dennes W, Monaghan M, Shah A. 106 Echocardiographic Evaluation Of Post-partum Ventricular Remodelling – Implications For The Detection Of Cardiac Disease. Heart 2014. [DOI: 10.1136/heartjnl-2014-306118.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Lunt A, Desai SR, Wells AU, Hansell DM, Mushemi S, Melikian N, Shah AM, Thein SL, Greenough A. Pulmonary function, CT and echocardiographic abnormalities in sickle cell disease. Thorax 2014; 69:746-51. [PMID: 24682519 DOI: 10.1136/thoraxjnl-2013-204809] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To test the hypothesis that vascular abnormalities on high-resolution CT (HRCT) would be associated with echocardiographic changes and lung function abnormalities in patients with sickle cell disease (SCD) and the decline in lung function seen in SCD patients. METHODS HRCT, echocardiography and lung function assessments were made in 35 adults, 20 of whom had previously been assessed a median of 6.6 years prior to this study. The pulmonary arterial dimensions on HRCT were quantified as the mean segmental pulmonary artery/bronchus (A/B) ratio and the summated cross-sectional area of all pulmonary vessels <5 mm in diameter (cross-sectional area (CSA)<5 mm%). RESULTS The segmental A/B ratio was negatively correlated with FEV1, vital capacity (VC), forced expiratory flow between 25% and 75% of VC (FEF25/75) and arterial oxygen saturation (SpO2) and positively with the residual volume: total lung capacity ratio (RV:TLC) and respiratory system resistance (Rrs). CSA<5 mm% was negatively correlated with FEV1, FEF25/75 and SpO2 and positively with RV, RV:TLC and respiratory system resistance (Rrs). There were significant correlations between cardiac output assessed by echocardiography and the segmental A/B ratio and CSA<5 mm%. Lung function (FEV1 p=0.0004, VC p=0.0347, FEF25/75 p=0.0033) and the segmental A/B ratio (p=0.0347) and CSA<5 mm% (p<0.0001) significantly deteriorated over the follow-up period. CONCLUSIONS Abnormalities in pulmonary vascular volumes may explain some of the lung function abnormalities and the decline in lung function seen in adults with SCD.
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Affiliation(s)
- Alan Lunt
- Division of Asthma, Allergy and Lung Biology, MCR Centre for Allergic Mechanisms in Asthma, King's College London, London, UK National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Sujal R Desai
- Department of Radiology and Interstitial Lung Unit, King's College London, London, UK
| | - Athol U Wells
- Department of Radiology, Royal Brompton Hospital, London, UK
| | - David M Hansell
- Department of Radiology, Royal Brompton Hospital, London, UK
| | - Sitali Mushemi
- Department of Radiology and Interstitial Lung Unit, King's College London, London, UK
| | - Narbeh Melikian
- Department of Radiology and Interstitial Lung Unit, King's College London, London, UK
| | - Ajay M Shah
- National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK Cardiovascular Division, King's College London British Heart Foundation Centre, London, UK
| | - Swee Lay Thein
- National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK Division of Cancer Studies, King's College London and Dept Haematological Medicine, King's College Hospital, London, UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MCR Centre for Allergic Mechanisms in Asthma, King's College London, London, UK National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Muraru D, Addetia K, Veronesi F, Corsi C, Mor-Avi V, Yamat M, Weinert L, Lang R, Badano L, Faita F, Di Lascio N, Bruno R, Bianchini E, Ghiadoni L, Sicari R, Gemignani V, Angelis A, Ageli K, Ioakimidis N, Chrysohoou C, Agelakas A, Felekos I, Vaina S, Aznaourides K, Vlachopoulos C, Stefanadis C, Nemes A, Szolnoky G, Gavaller H, Gonczy A, Kemeny L, Forster T, Ramalho A, Placido R, Marta L, Menezes M, Magalhaes A, Cortez Dias N, Martins S, Almeida A, Pinto F, Nunes Diogo A, Botezatu CD, Enache R, Popescu B, Nastase O, Coman M, Ghiorghiu I, Calin A, Rosca M, Beladan C, Ginghina C, Grapsa J, Cabrita I, Durighel G, O'regan D, Dawson D, Nihoyannopoulos P, Pellicori P, Kallvikbacka-Bennett A, Zhang J, Lukaschuk E, Joseph A, Bourantas C, Loh H, Bragadeesh T, Clark A, Cleland J, Kallvikbacka-Bennett A, Pellicori P, Lomax S, Putzu P, Diercx R, Parsons S, Dicken B, Zhang J, Clark A, Cleland J, Vered Z, Adirevitz L, Dragu R, Blatt A, Karev E, Malca Y, Roytvarf A, Marek D, Sovova E, Berkova M, Cihalik C, Taborsky M, Lindqvist P, Tossavainen E, Soderberg S, Gonzales M, Gustavsson S, Henein M, Sonne C, Bott-Fluegel L, Hauck S, Lesevic H, Hadamitzky M, Wolf P, Kolb C, Bandera F, Pellegrino M, Generati G, Donghi V, Alfonzetti E, Castelvecchio S, Menicanti L, Guazzi M, Buchyte S, Rinkuniene D, Jurkevicius R, Smarz K, Zaborska B, Jaxa-Chamiec T, Maciejewski P, Budaj A, Santoro A, Federico Alvino F, Giovanni Antonelli G, Roberta Molle R, Matteo Bertini M, Stefano Lunghetti S, Sergio Mondillo S, Henri C, Magne J, Dulgheru R, Laaraibi S, Voilliot D, Kou S, Pierard L, Lancellotti P, Szulik M, Stabryla-Deska J, Kalinowski M, Sliwinska A, Szymala M, Lenarczyk R, Kalarus Z, Kukulski T, Yiangou K, Azina C, Yiangou A, Ioannides M, Chimonides S, Baysal S, Pirat B, Okyay K, Bal U, Muderrisoglu H, Popovic D, Ostojic M, Petrovic M, Vujisic-Tesic B, Arandjelovic A, Petrovic I, Banovic M, Popovic B, Vukcevic V, Damjanovic S, Velasco Del Castillo S, Onaindia Gandarias J, Arana Achaga X, Laraudogoitia Zaldumbide E, Rodriguez Sanchez I, Cacicedo De Bobadilla A, Romero Pereiro A, Aguirre Larracoechea U, Salinas T, Subinas A, Elzbieciak M, Wita K, Grabka M, Chmurawa J, Doruchowska A, Turski M, Filipecki A, Wybraniec M, Mizia-Stec K, Varho V, Karjalainen P, Lehtinen T, Airaksinen J, Ylitalo A, Kiviniemi T, Gargiulo P, Galderisi M, D' Amore C, Lo Iudice F, Savarese G, Casaretti L, Pellegrino A, Fabiani I, La Mura L, Perrone Filardi P, Kim JY, Chung W, Yu J, Choi Y, Park C, Youn H, Lee M, Nagy A, Manouras A, Gunyeli E, Gustafsson U, Shahgaldi K, Winter R, Johnsson J, Zagatina A, Krylova L, Zhuravskaya N, Vareldzyan Y, Tyurina T, Clitsenko O, Khalifa EA, Ashour Z, Elnagar W, Jung I, Seo H, Lee S, Lim D, Mizariene V, Verseckaite R, Janenaite J, Jonkaitiene R, Jurkevicius R, Sanchez Espino A, Bonaque Gonzalez J, Merchan Ortega G, Bolivar Herrera N, Ikuta I, Macancela Quinones J, Gomez Recio M, Silva Fazendas Adame PR, Caldeira D, Stuart B, Almeida S, Cruz I, Ferreira A, Freire G, Lopes L, Cotrim C, Pereira H, Mediratta A, Addetia K, Moss J, Nayak H, Yamat M, Weinert L, Mor-Avi V, Lang R, Al Amri I, Debonnaire P, Van Der Kley F, Schalij M, Bax J, Ajmone Marsan N, Delgado V, Schmidt FP, Gniewosz T, Jabs A, Munzel T, Jansen T, Kaempfner D, Hink U, Von Bardeleben R, Jose J, George O, Joseph G, Jose J, Adawi S, Najjar R, Ahronson D, Shiran A, Van Riel A, Boerlage - Van Dijk K, De Bruin - Bon H, Araki M, Meregalli P, Koch K, Vis M, Mulder B, Baan J, Bouma B, Marciniak A, Elton D, Glover K, Campbell I, Sharma R, Batalha S, Lourenco C, Oliveira Da Silva C, Manouras A, Shahgaldi K, Caballero L, Garcia-Lara J, Gonzalez-Carrillo J, Oliva M, Saura D, Garcia-Navarro M, Espinosa M, Pinar E, Valdes M, De La Morena G, Barreiro Perez M, Lopez Perez M, Roy D, Brecker S, Sharma R, Venkateshvaran A, Dash PK, Sola S, Barooah B, Govind SC, Winter R, Shahgaldi K, Brodin LA, Manouras A, Saura Espin D, Caballero Jimenez L, Gonzalez Carrillo J, Oliva Sandoval M, Lopez Ruiz M, Garcia Navarro M, Espinosa Garcia M, Valdes Chavarri M, De La Morena Valenzuela G, Gatti G, Dell'angela L, Pinamonti B, Benussi B, Sinagra G, Pappalardo A, Hernandez V, Saavedra J, Gonzalez A, Iglesias P, Civantos S, Guijarro G, Monereo S, Ikeda M, Toh N, Oe H, Tanabe Y, Watanabe N, Ito H, Ciampi Q, Cortigiani L, Pratali L, Rigo F, Villari B, Picano E, Sicari R, Yoon J, Sohn J, Kim Y, Chang H, Hong G, Kim T, Ha J, Choi B, Rim S, Choi E, Tibazarwa K, Sliwa K, Wonkam A, Mayosi B, Oryshchyn N, Ivaniv Y, Pavlyk S, Lourenco MR, Azevedo O, Moutinho J, Nogueira I, Fernandes M, Pereira V, Quelhas I, Lourenco A, Sunbul M, Tigen K, Karaahmet T, Dundar C, Ozben B, Guler A, Cincin A, Bulut M, Sari I, Basaran Y, Baydar O, Kadriye Kilickesmez K, Ugur Coskun U, Polat Canbolat P, Veysel Oktay V, Umit Yasar Sinan U, Okay Abaci O, Cuneyt Kocas C, Sinan Uner S, Serdar Kucukoglu S, Zaroui A, Mourali M, Ben Said R, Asmi M, Aloui H, Kaabachi N, Mechmeche R, Saberniak J, Hasselberg N, Borgquist R, Platonov P, Holst A, Edvardsen T, Haugaa K, Lourenco MR, Azevedo O, Nogueira I, Moutinho J, Fernandes M, Pereira V, Quelhas I, Lourenco A, Eran A, Yueksel D, Er F, Gassanov N, Rosenkranz S, Baldus S, Guedelhoefer H, Faust M, Caglayan E, Matveeva N, Nartsissova G, Chernjavskij A, Ippolito R, De Palma D, Muscariello R, Santoro C, Raia R, Schiano-Lomoriello V, Gargiulo F, Galderisi M, Lipari P, Bonapace S, Zenari L, Valbusa F, Rossi A, Lanzoni L, Canali G, Molon G, Campopiano E, Barbieri E, Ikonomidis I, Varoudi M, Papadavid E, Theodoropoulos K, Papadakis I, Pavlidis G, Triantafyllidi H, Anastasiou - Nana M, Rigopoulos D, Lekakis J, Sunbul M, Tigen K, Ozen G, Durmus E, Kivrak T, Cincin A, Ozben B, Atas H, Direskeneli H, Basaran Y, Stevanovic A, Dekleva M, Trajic S, Paunovic N, Simic A, Khan S, Mushemi-Blake S, Jouhra F, Dennes W, Monaghan M, Melikian N, Shah A, Maceira Gonzalez AM, Lopez-Lereu M, Monmeneu J, Igual B, Estornell J, Boraita A, Kosmala W, Rojek A, Bialy D, Mysiak A, Przewlocka-Kosmala M, Popescu I, Mancas S, Mornos C, Serbescu I, Ionescu G, Ionac A, Gaudron P, Niemann M, Herrmann S, Hu K, Liu D, Wojciech K, Frantz S, Bijnens B, Ertl G, Weidemann F, Maceira Gonzalez AM, Cosin-Sales J, Ruvira J, Diago J, Aguilar J, Igual B, Lopez-Lereu M, Monmeneu J, Estornell J, Cruz C, Pinho T, Madureira A, Lebreiro A, Dias C, Ramos I, Silva Cardoso J, Julia Maciel M, De Meester P, Van De Bruaene A, Herijgers P, Voigt JU, Budts W, Franzoso F, Voser E, Wohlmut C, Kellenberger C, Valsangiacomo Buechel E, Carrero C, Benger J, Parcerisa M, Falconi M, Oberti P, Granja M, Cagide A, Del Pasqua A, Secinaro A, Antonelli G, Iacomino M, Toscano A, Chinali M, Esposito C, Carotti A, Pongiglione G, Rinelli G, Youssef Moustafa A, Al Murayeh M, Al Masswary A, Al Sheikh K, Moselhy M, Dardir M, Deising J, Butz T, Suermeci G, Liebeton J, Wennemann R, Tzikas S, Van Bracht M, Prull M, Trappe HJ, Martin Hidalgo M, Delgado Ortega M, Ruiz Ortiz M, Mesa Rubio D, Carrasco Avalos F, Seoane Garcia T, Pan Alvarez-Ossorio M, Lopez Aguilera J, Puentes Chiachio M, Suarez De Lezo Cruz Conde J, Petrovic MT, Giga V, Stepanovic J, Tesic M, Jovanovic I, Djordjevic-Dikic A, Generati G, Pellegrino M, Bandera F, Donghi V, Alfonzetti E, Guazzi M, Piatkowski R, Kochanowski J, Scislo P, Opolski G, Zagatina A, Zhuravskaya N, Krylova L, Vareldzhyan Y, Tyurina T, Clitsenko O, Bombardini T, Gherardi S, Leone O, Picano E, Michelotto E, Ciccarone A, Tarantino N, Ostuni V, Rubino M, Genco W, Santoro G, Carretta D, Romito R, Colonna P, Cameli M, Lunghetti S, Lisi M, Curci V, Cameli P, Focardi M, Favilli R, Galderisi M, Mondillo S, Hoffmann R, Barletta G, Von Bardeleben S, Kasprzak J, Greis C, Vanoverschelde J, Becher H, Machida T, Izumo M, Suzuki K, Kaimijima R, Mizukoshi K, Manabe-Uematsu M, Takai M, Harada T, Akashi Y, Martin Garcia A, Arribas-Jimenez A, Cruz-Gonzalez I, Nieto F, Iscar A, Merchan S, Martin-Luengo C, Brecht A, Theres L, Spethmann S, Dreger H, Baumann G, Knebel F, Jasaityte R, Heyde B, Rademakers F, Claus P, D'hooge J, Lervik Nilsen LC, Lund J, Brekke B, Stoylen A, Giraldeau G, Duchateau N, Gabrielli L, Penela D, Evertz R, Mont L, Brugada J, Berruezo A, Bijnens B, Sitges M, Kordybach M, Kowalski M, Hoffman P, Pilichowska E, Zaborska B, Baran J, Kulakowski P, Budaj A, Wahi S, Vollbon W, Leano R, Thomas A, Bricknell K, Holland D, Napier S, Stanton T, Teferici D, Qirko S, Petrela E, Dibra A, Bajraktari G, Bara P, Sanchis Ruiz L, Gabrielli L, Andrea R, Falces C, Duchateau N, Perez-Villa F, Bijnens B, Sitges M, Sulemane S, Panoulas V, Bratsas A, Tam F, Nihoyannopoulos P, Abduch M, Alencar A, Coracin F, Barban A, Saboya R, Dulley F, Mathias W, Vieira M, Buccheri S, Mangiafico S, Arcidiacono A, Bottari V, Leggio S, Tamburino C, Monte IP, Cruz C, Lebreiro A, Pinho T, Dias C, Silva Cardoso J, Julia Maciel M, Spitzer E, Beitzke D, Kaneider A, Pavo N, Gottsauner-Wolf M, Wolf F, Loewe C, Mushtaq S, Andreini D, Pontone G, Bertella E, Conte E, Baggiano A, Annoni A, Cortinovis S, Fiorentini C, Pepi M, Gustafsson M, Alehagen U, Dahlstrom U, Johansson P, Faden G, Faggiano P, Albertini L, Reverberi C, Gaibazzi N, Taylor RJ, Moody W, Umar F, Edwards N, Townend J, Steeds R, Leyva F, Mihaila S, Muraru D, Piasentini E, Peluso D, Casablanca S, Naso P, Puma L, Iliceto S, Vinereanu D, Badano L, Ciciarello FL, Agati L, Cimino S, De Luca L, Petronilli V, Fedele F, Tsverava M. Poster Session Saturday 14 December - AM: 14/12/2013, 08:30-12:30 * Location: Poster area. Eur Heart J Cardiovasc Imaging 2013. [DOI: 10.1093/ehjci/jet207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sirker AA, Scott P, Melikian N. Rare insight into the rapid evolution of a coronary aneurysm and fistula. J Am Coll Cardiol 2013; 62:2023. [PMID: 24076292 DOI: 10.1016/j.jacc.2013.06.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 06/25/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Alexander A Sirker
- Department of Cardiology, The Heart Hospital, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter Scott
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Narbeh Melikian
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Scott PJ, Alexander S, Jahagirdar N, Melikian N, Byrne J. TCT-635 Comparison of Fractional Flow Reserve (FFR) Measurements Obtained Using Central versus Distal Peripheral Intravenous Adenosine to Induce Hyperemia. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.08.1383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sirker A, Melikian N, Kenny C, Deshpande R. A rare indication for surgery in acute myocardial infarction: spontaneous aortic thrombus causing left main stem occlusion. Eur J Cardiothorac Surg 2013; 45:948. [DOI: 10.1093/ejcts/ezt441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Jouhra F, Sapontis J, Leonard S, Melikian N, Byrne J, Dworakowski R, Shah A, Hill J, Whitbread M, MacCarthy P. 057 MANAGEMENT AND OUTCOME OF OUT-OF-HOSPITAL CARDIAC ARREST AT A MAJOR UK TERTIARY CENTRE. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Shabeeh H, Melikian N, Dworakowski R, Casadei B, Chowienczyk P, Shah AM. Differential role of endothelial versus neuronal nitric oxide synthase in the regulation of coronary blood flow during pacing-induced increases in cardiac workload. Am J Physiol Heart Circ Physiol 2013; 304:H1277-82. [PMID: 23479261 DOI: 10.1152/ajpheart.00927.2012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Endothelial nitric oxide synthase (eNOS) was assumed to be the only source of nitric oxide (NO) involved in the regulation of human coronary blood flow (CBF). However, our recent first-in-human study using the neuronal NOS (nNOS)-selective inhibitor S-methyl-L-thiocitrulline (SMTC) showed that nNOS-derived NO also plays a role. In this study, we investigated the relative contribution of nNOS and eNOS to the CBF response to a pacing-induced increase in cardiac workload. Incremental right atrial pacing was undertaken in patients with angiographically normal coronary arteries during intracoronary infusion of saline vehicle and then either SMTC or N(G)-monomethyl-l-arginine (l-NMMA; which inhibits both eNOS and nNOS). Intracoronary SMTC (0.625 μmol/min) and l-NMMA (25 μmol/min) reduced basal CBF to a similar extent (-19.2 ± 3.2% and 25.0 ± 2.7%, respectively; n = 10 per group). Pacing-induced increases in CBF were significantly blunted by l-NMMA (maximum CBF: 83.5 ± 14.2 ml/min during saline vs. 61.6 ± 9.5 ml/min during l-NMMA; P < 0.01). By contrast, intracoronary SMTC had no effect on the maximum CBF during pacing (98.5 ± 12.9 ml/min during saline vs. 102.1 ± 16.6 ml/min during SMTC; P = not significant). l-NMMA also blunted the pacing-induced increase in coronary artery diameter (P < 0.001 vs. saline), whereas SMTC had no effect. Our results confirm a role of nNOS in the regulation of basal CBF in humans but show that coronary vasodilation in response to a pacing-induced increase in cardiac workload is exclusively mediated by eNOS-derived NO.
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Affiliation(s)
- Husain Shabeeh
- King's College London British Heart Foundation Centre, Cardiovascular Division, London, United Kingdom
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Shabeeh H, Seddon M, Brett S, Melikian N, Casadei B, Shah AM, Chowienczyk P. Sympathetic activation increases NO release from eNOS but neither eNOS nor nNOS play an essential role in exercise hyperemia in the human forearm. Am J Physiol Heart Circ Physiol 2013; 304:H1225-30. [PMID: 23436331 DOI: 10.1152/ajpheart.00783.2012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Nitric oxide (NO) release from endothelial NO synthase (eNOS) and/or neuronal NO synthase (nNOS) could be modulated by sympathetic nerve activity and contribute to increased blood flow after exercise. We examined the effects of brachial-arterial infusion of the nNOS selective inhibitor S-methyl-l-thiocitrulline (SMTC) and the nonselective NOS inhibitor N(G)-monomethyl-l-arginine (l-NMMA) on forearm arm blood flow at rest, during sympathetic activation by lower body negative pressure, and during lower body negative pressure immediately after handgrip exercise. Reduction in forearm blood flow by lower body negative pressure during infusion of SMTC was not significantly different from that during vehicle (-28.5 ± 4.02 vs. -34.1 ± 2.96%, respectively; P = 0.32; n = 8). However, l-NMMA augmented the reduction in forearm blood flow by lower body negative pressure (-44.2 ± 3.53 vs. -23.4 ± 5.71%; n = 8; P < 0.01). When lower body negative pressure was continued after handgrip exercise, there was no significant effect of either l-NMMA or SMTC on forearm blood flow immediately after low-intensity exercise (P = 0.91 and P = 0.44 for l-NMMA vs. saline and SMTC vs. saline, respectively; each n = 10) or high-intensity exercise (P = 0.46 and P = 0.68 for l-NMMA vs. saline and SMTC vs. saline, respectively; each n = 10). These results suggest that sympathetic activation increases NO release from eNOS, attenuating vasoconstriction. Dysfunction of eNOS could augment vasoconstrictor and blood pressure responses to sympathetic activation. However, neither eNOS nor nNOS plays an essential role in postexercise hyperaemia, even in the presence of increased sympathetic activation.
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Affiliation(s)
- Husain Shabeeh
- King's College London British Heart Foundation Centre, London, United Kingdom
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Campbell LJ, Desai M, Hegazi A, Ibrahim F, Melikian N, Hay P, Fox JM, Post FA. Renal impairment is associated with coronary heart disease in HIV-positive men. HIV Clin Trials 2013. [PMID: 23195672 DOI: 10.1310/hct1306-343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronic kidney disease is a risk factor for coronary heart disease (CHD). The association between renal impairment and CHD in HIV-positive patients remains poorly described. OBJECTIVE To describe the CHD incidence in a cohort of HIV-positive patients and to examine the relationship between reduced estimated glomerular filtration rate (eGFR) and incident CHD. METHODS We studied 7,828 HIV-positive patients who were followed up at 3 South London clinics between January 2004 and December 2009. CHD events were identified from electronic records and through elevated troponin levels. Multivariate Poisson regression analysis was used to identify factors associated with CHD among HIV-positive men. RESULTS The incidence of CHD among men was 1.2 (95% CI, 0.8-1.8) per 1,000 person-years of follow-up, with 28 patients (0.4%) having experienced 32 CHD events. In adjusted analyses, older age (incidence rate ratios [IRR], 2.81; 95% CI, 1.51-5.25) and hepatitis C virus (HCV) status (IRR, 3.94; 95% CI, 1.00-15.5) were significantly associated with CHD. Although eGFR as a continuous variable was not associated with CHD, an eGFR <75 mL/min remained associated with incident CHD (IRR, 4.30; 95% CI, 1.33-14.5) after adjustment for age. No association between CHD and abacavir exposure was observed (IRR, 0.94; 95% CI, 0.30-2.99). CONCLUSIONS The incidence of CHD in this ethnically diverse cohort was low. Our data suggest that impaired renal function identifies patients at increased risk of CHD events in whom management of traditional CHD risk factors should be prioritized.
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Mangiacapra F, De Bruyne B, Peace AJ, Melikian N, Wijns W, Barbato E. High cholesterol levels are associated with coronary microvascular dysfunction. J Cardiovasc Med (Hagerstown) 2012; 13:439-42. [DOI: 10.2459/jcm.0b013e328351725a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sirker A, Paul G, Dworakowski R, Melikian N, Byrne J. 020 Comparison of fractional flow reserve measurements obtained using central vs distal peripheral intravenous adenosine infusion to induce hyperaemia. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877b.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Shabeeh H, Melikian N, Dworakowski R, Casadei B, Chowienczyk P, Shah AM. 106 Role of neuronal vs endothelial nitric oxide synthase in the coronary blood flow response to pacing. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877b.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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