Background Longer ischemia time is known to be related to adverse outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI). Delay in time from symptom onset to emergency department (ED) has been studied less. The aim of this study was to define the clinical, transportation and residential factors associated with longer pre-hospital delay in STEMI events. Methods Total 308 successive patients presenting to Poriya Medical Center with STEMI between Feb 2015 and Dec 2017 were retrospectively identified. The final cohort included 266 patients after excluding inpatient STEMI, files missing time of pain onset and patients in cardiac arrest. Clinical and transport data were retrieved from the cardiology department database. Our primary clinical outcome was 1-year all-cause mortality. Univariable and multivariable logistic regression analyses were performed to define factors associated with prehospital delay. Results In the total cohort, the patients' mean age was 61 ± 11 years old, 81% were male, and patients lived 21 ± 12 km from our medical center. On multivariable logistic regression analysis, a stop at the community clinic and diabetes were associated with increased risk of a delay. Longer delays were associated with reduced ejection fraction at discharge, higher rates of readmissions and higher all-cause 1-year mortality. Conclusion The strongest determinant of prehospital delay in STEMI events was seeking first medical care at a community clinic, which was associated with the worst outcomes. This highlights the importance of education of both patients and primary clinic staff regarding the identification and prioritization of STEMI patients and immediate evacuation by emergency medical service.
Background Routine addition of an atrial lead during an implantable cardioverter‐defibrillator (ICD) implantation for primary prevention of sudden cardiac death, in patients without pacing indications, was not shown beneficial in contemporary studies. We aimed to investigate the use and safety of single‐ versus dual‐chamber ICD implantations in these patients. Methods and Results Using the National Inpatient Sample database, we identified patients with no pacing indications who underwent primary‐prevention ICD implantation in the United States between 2015 and 2019. Sociodemographic and clinical characteristics, as well as in‐hospital complications, were analyzed. Multivariable logistic regression was used to identify predictors of in‐hospital complications. An estimated total of 15 940 patients, underwent ICD implantation for primary prevention of sudden cardiac death during the study period, 8860 (55.6%) received a dual‐chamber ICD. The mean age was 64 years, and 66% were men. In‐hospital complication rates in the dual‐chamber ICD and single‐chamber ICD group were 12.8% and 10.7%, respectively ( P <0.001), driven by increased rates of pneumothorax/hemothorax (4.6% versus 3.4%; P <0.001) and lead dislodgement (3.6% versus 2.3%; P <0.001) in the dual‐chamber ICD group. Multivariable analyses confirmed atrial lead addition as an independent predictor for “any complications” (odds ratio [OR], 1.1 [95% CI, 1.0–1.2]), for pneumo/hemothorax (odds ratio, 1.1 [95% CI, 1.0–1.4]), and for lead dislodgement (odds ratio, 1.3 [95% CI, 1.1–1.6]). Conclusions Despite lack of evidence for clinical benefit, dual‐chamber ICDs are implanted for primary prevention of sudden cardiac death in a majority of patients who do not have pacing indication. This practice is associated with increased risk of periprocedural complications. Avoidance of routine implantation of atrial leads will likely improve safety outcomes.
Background: Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). Objectives: We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. Methods: This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. Results: In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43–2.45), p < 0.001), evening or night shifts (OR 1.31 (95% CI 1.11–1.55), p < 0.001; OR 1.68 (95% CI 1.32–2.15), p < 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26–0.37), p < 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46–0.67), p < 0.001), beta blockers (OR 0.63 (95% CI 0.52–0.76), p < 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48–0.69), p < 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. Conclusions: The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.
Empagliflozin improves cardiovascular outcomes in patients with heart failure, patients with type 2 diabetes who are at high cardiovascular risk, and patients with chronic kidney disease. The safety and efficacy of empagliflozin in patients who have had acute myocardial infarction are unknown.
Abstract Background Recent technological developments enable non-invasive monitoring of advanced hemodynamic parameters, allowing big data-driven insights on diurnal changes for the first time. This study aimed to describe the trends of multiple advanced cardiovascular parameters among ambulatory individuals using a medical grade wearable monitor. Methods Common and advanced cardio-respiratory parameters were monitored for 24 hours in ambulatory volunteers using a photoplethysmography-based wearable monitor. The multi vital ambulatory monitoring (MVAM) included stroke volume (SV), cardiac index (CI), systemic vascular resistance (SVR), blood oxygen saturation (SpO2), respiratory rate (RR), systolic (SBP) and diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), and heart rate (HR). Diurnal variations were evaluated among all participants, and analyses were stratified based on sex, age, and body-mass index (BMI). Results A total of 256 participants were included in the analysis. All measured parameters showed significant (p<0.001) diurnal changes. Nighttime values were lower excluding RR and SVR, reaching the nadir at 5 am, and then increasing to a maximum at 10 am, plateauing, and then gradually declining from 7 to 8 pm. CI demonstrated a reduction of 0.6 L/min/m2 (20%), while SVR demonstrated the opposite trend and was higher during the night increasing by up to 212 dynes/sec/cm5 (16%). Females demonstrated higher HR and CI with lower SVR during daytime and nighttime. Obese participants (BMI >30 kg/m2) had a higher SBP and DBP, and lower SV and CI. SVR was higher among the elderly. Conclusions Diurnal changes using MVAM corresponding with awake-sleep hours were noticed in the monitored parameters and differed between sex, age, and BMI groups. This suggests that wearable monitoring platforms could shed more light on hemodynamic changes in subgroups, and might help with future efforts to provide tailored personalized medicine and pre-symptomatic diagnosis and prevention. Funding Acknowledgement Type of funding sources: None.
We evaluated left ventricular contractility during upright isometric exercise, in heart transplant recipients (HTRs) and in healthy controls, using ejection fraction and end-systolic pressure/volume ratio indexes.Fifteen healthy men (40 +/- 13 years) and 10 HTRs (42 +/- 12 years) underwent dead lift (DL) test at 30% of maximal effort for 3 minutes. Echocardiographic variables were measured during the final 45 seconds.During DL test, HTRs were significantly different (P < .01) from controls in all parameters except end-diastolic volume. DL test had lower mean values of ejection fraction (49.9% +/- 8.3% vs 67.0% +/- 4.3%, respectively) and left ventricular end-systolic pressure/volume ratio (3.5 +/- 0.7 vs 5.5 +/- 1.2, respectively) whereas higher values of end-systolic volume (51.0 +/- 9.4 mL vs 34.1 +/- 5.3 mL, respectively). Importantly, an intergroup effect was found in end-systolic pressure/volume ratio, further signifying differential response of HTRs. End-systolic pressure/volume ratio increased consistently (P < .001) in both groups, whereas the overall main effect of ejection fraction response was not significant.Left ventricular function during upright isometric exercise displays differential pattern of response in HTRs in comparison with healthy controls. However, cardiac contractility in HTRs remained stable at peak systolic blood pressure produced by the isometric DL exercise. Results suggest that both ejection fraction and end-systolic pressure/volume ratio indexes can be used for assessment of ventricular function in patients after heart transplantation.
The relationship between body mass index (BMI) and clinical outcomes in patients with cardiovascular disease, including acute heart failure (AHF) and acute myocardial infarction (AMI), remains debated. This study investigates the association between BMI and clinical outcomes within the PARADISE-MI cohort, while also evaluating the impact of angiotensin receptor-neprilysin inhibitor (ARNI) versus angiotensin-converting enzyme inhibitor (ACE-I) treatment on this relationship.
Abstract Background P2Y12 receptor inhibitors are highly effective treatment options following ACS. However, premature discontinuation compromises their effectiveness. Although extensive literature exists, the clinical assessment of their adherence remains controversial, requiring definitive investigation. Purpose To evaluate treatment discontinuation and non-bleeding adverse effects associatedwith platelet P2Y12 receptor inhibitors in individuals post-ACS through network meta-analysis. Methods Data Sources: MEDLINE, Embase, Cochrane, and clinicaltrials.gov to May 2021 and later updated to October 2022. Study Selection and Outcomes: Reviewers identified RCTs that enrolled patients post-ACS taking Clopidogrel, Ticagrelor, and Prasugrel. Exclusions included non-ACS indications, anticoagulation therapy, observational studies, and crossover designs. The primary outcomesincludedoverall treatment discontinuation, treatment discontinuation attributed to side effects, and dyspnea. Secondary outcomes included bradycardia and atrial fibrillation. Data Extraction and Synthesis:This network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, employing frequentist random-effects models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework was utilized to assess the certainty of evidence. Results With 139,343 participants in 32 RCTs, the overall treatment discontinuation rate across all studies was 16.57% out of a total of 137,897 participants. Ticagrelor was associated with increased risk for overall treatment discontinuation compared to Clopidogrel (RR, 1.34; 95% CI, 1.19 to 1.49; P<0.0001), Prasugrel (RR, 1.23; 95% CI, 1.07 to 1.41; P=0.0031) and placebo (RR, 1,40; 95% CI, 1.19 to 1.65; P<0.0001). In compatibility to overall treatment discontinuation, Ticagrelor was associated with increased risk for treatment discontinuation due to side effects compared to Clopidogrel (RR, 1.80; 95% CI, 1.36 to 2.38; P<0.0001), Prasugrel (RR, 1.49; 95% CI, 1.06 to 2.10; P=0.0216) and placebo (RR, 1.85; 95% CI, 1.21 to 2.83; P=0.0044). Ticagrelor, Prasugrel and Clopidogrel were associated with an increased risk for dyspnea in comparison to placebo (RR, 2.86; 95% CI, 2.57 to 3.17; P<0.0001; RR, 1.61; 95% CI, 1.35 to 1.91; P<0.0001; RR, 1.60; 95% CI, 1.41 to 1.82; P<0.0001) respectively. Ticagrelor was associated with increased risk for dyspnea compared to Clopidogrel (RR, 1.78; 95% CI, 1.65 to 1.92; P<0.0001) and prasugrel (RR, 1.78; 95% CI, 1.55 to 2.05; P<0.0001). Conclusions The findings of this study suggest that Ticagrelor presents the highest risk for premature discontinuation compared to Clopidogrel and Prasugrel. Additionally, P2Y12 receptor inhibitors, in general, are notably associated with dyspnea, with Ticagrelor showing the highest risk. These results provide health professionals with valuable information for making treatment decisions in patients post-ACS.NMA netgraphsNMA of Overall treatment discontinuation
