Δευτέρα, 5 Αυγούστου 2019

Cardiovascular Medicine

Routine cardiac troponin assessment after percutaneous coronary intervention: useful or hype?
imageAlthough the angiographic and procedural success of percutaneous coronary intervention (PCI) is now very high, some severe complications may still develop, including periprocedural myocardial infarction (MI). An accurate diagnosis of this condition is essential for guiding the clinical management, as these patients may need a tailored management. The current recommendations for diagnosing periprocedural myocardial infarction based on the fourth universal definition appear at first sight straightforward, but the clinical and prognostic significance of routine periprocedural cardiac troponin (cTn) assessment remains uncertain. The current scientific evidence suggests that the likelihood of observing increased periprocedural values of cTn is high, comprising between 30 and 90%. Moreover, cTn values after PCI do not straightforwardly predict major adverse cardiovascular events or all-cause mortality. Although it seems still premature to classify many cases as 'false positive' periprocedural MIs, it is now clear that an isolate 'biochemical diagnosis' of myocardial injury during or immediately after PCI does not translate into early unfavourable clinical consequences. At this point in time, it seems reasonable to suggest that serial cTn assessment should not be routinely performed, but should be reserved for a high-risk subset of PCI patients who have also developed new ECG changes or symptoms suggestive of myocardial ischemia.

Cost-effectiveness of direct acting oral anticoagulants in the prevention of thromboembolic complications: limits and concerns of economic evaluations
imageEconomic evaluations have a widespread application in many areas of clinical research and play a key role in the clinical decision-making process. However, economic analyses have been sometimes used to produce new 'evidence' that is not adequately tested in the target population. This is the case of data arising from a systematic review of clinical trials evaluating the use of direct acting oral anticoagulants for the prevention of stroke in patients with atrial fibrillation. Taking into account this example, here we discuss the concerns raised by the improper interpretation of the results. Our conclusions are three-fold. Data from economic analyses should not be shifted to a clinical recommendation. Simulation models should not be used to generate new 'evidence' that is not supported by experimental data and is misleading. Clinical judgment is therefore pivotal to interpret results emerging from economic analyses.

High-sensitivity cardiac troponin assays and acute coronary syndrome: a matter of sex?
imageAdvances in technology have led to an improvement in the ability to detect and quantify acute cardiomyocyte injury with the measurement of high-sensitivity cardiac troponin as compared with conventional assays. The upper reference limit for the high-sensitivity cardiac troponin assays is defined as the 99th percentile cutoff value in a healthy reference population. Since sex-related threshold levels of high-sensitivity cardiac troponin assays have been proposed, this review will focus on the diagnostic and prognostic implications of adopting sex-specific threshold troponin values in patients with a suspected acute coronary syndrome.

Type 2 myocardial infarction: a grim diagnosis with different shades of gray
imageType 2 myocardial infarction (MI) is commonly encountered in daily practice. Its incidence can range between 5 and 35% among all cases of MI. It is caused by disorders that result in supply–demand mismatch, which leads to myocardial ischemia and necrosis. Therefore, unsurprisingly, it is frequently diagnosed in critically ill patients and those with severe coronary artery disease (CAD) and multiple comorbidities. Though it can occur in the absence of CAD, the presence of coronary blood flow-limiting stenoses can allow even minor insults to disturb the already fine supply–demand balance. Generally, type 2 MI may be associated with higher mortality; however, some data suggest it may have different severities, and outcome is better in patients with type 2 MI of milder severity. Nonetheless, regardless of the causes (ischemic or nonischemic), troponin elevation is associated with worse outcome. Differentiating type 2 MI from other causes of myocardial necrosis, mainly type 1 MI and myocardial injury, remains a clinical challenge. Different diagnostic tools can be utilized to aid in reaching an accurate diagnosis. These can include contrast echocardiography, computed tomography, MRI, radionuclide imaging, coronary angiography, and intracoronary imaging. However, each comes with its own limitations and results should be interpreted with caution and in clinical context. Management of type 2 MI is uncertain because of paucity of data. Evidence-based therapies of type 1 MI are frequently used, though this may be harmful sometimes. Therefore, clinical judgment should be used, and management and therapies should be tailored to each individual case.

Shrinkage as a potential mechanism of recurrent clinical events in patients with a large vulnerable plaque
imageAims This study aimed to investigate the progression and vascular shrinkage of vulnerable plaque lesions with a plaque burden at least 70% among patients with coronary artery disease by optical coherence tomography (OCT) and intravascular ultrasound (IVUS). Methods Fifty-six OCT-identified vulnerable plaques from 47 patients were included among coronary angiography-identified nonculprit/nontarget lesions. Serial IVUS images were used to assess plaque progression and vascular shrinkage. Results Thirty-five small vulnerable plaques (plaque burden <70%, group A) and 21 large vulnerable plaques (plaque burden ≥70%, group B) were identified. The IVUS results at baseline show that mean plaque areas (P < 0.001) and the percentage atheroma volume (PAV) (P < 0.0001) were greater and the minimal lumen area (P < 0.0001) was smaller in group B. The absolute and relative changes in the PAV and mean plaque area from baseline to follow-up were not significantly different. However, the lesions exhibited vessel shrinkage [the mean external elastic membrane (EEM) area (P = 0.02) and mean lumen area (P = 0.03) were significantly smaller in group B] from baseline to follow-up. Patients in group B also exhibited clinical events (recurrent angina symptoms) during the follow-up period. Positive correlations were found between changes in the mean plaque area and the mean EEM area in large vulnerable plaques (r = 0.61, P < 0.0001) and between changes in the mean EEM area and the mean lumen area in large vulnerable plaques (r = 0.61, P < 0.0001). Conclusion Vulnerable plaque progression was not different between small and large vulnerable plaques. However, large vulnerable plaque lesions tended to exhibit vascular shrinkage, which is possible a cause of coronary artery lumen loss in patients with large vulnerable plaques.

Contemporary differences between men and women with acute coronary syndromes: CIAM multicenter registry
imageAim Differences exist in the diagnosis and treatment of acute coronary syndrome (ACS) between men and women. However, recent advancements in the management of ACSs might have attenuated this sex gap. We evaluated the status of ACS management in a multicenter registry in 10 tertiary Spanish hospitals. Methods We enrolled 1056 patients in our study, including only those with type 1 myocardial infarctions or unstable angina presumably not related to a secondary cause in an 'all-comers' design. Results The women enrolled (29%) were older than men (71.0 ± 12.8 vs. 64.0 ± 12.3, P = 0.001), with a higher prevalence of hypertension (71.0 vs. 56.5%, P < 0.001), insulin-treated diabetes (13.7 vs. 7.9%, P = 0.003), dyslipidemia (62.2 vs. 55.3%, P = 0.038), and chronic kidney disease (16.9 vs. 9.1%, P = 0.001). Women presented more frequently with back or arm pain radiation (57.3 vs. 49.7%, P = 0.025), palpitations (5.9 vs. 2.0%, P = 0.001), or dyspnea (33.0 vs. 19.4%, P = 0.001). ACS without significant coronary stenosis was more prevalent in women (16.8 vs. 8.1%, P = 0.001). There were no differences in percutaneous revascularization rates, but drug-eluting stents were less frequently employed in women (75.4 vs. 67.8%, P = 0.024); women were less often referred to a cardiac rehabilitation program (19.9 vs. 33.9%, P = 0.001). There were no significant differences in in-hospital complications such as thrombosis or bleeding. Conclusion ACS presenting with atypical symptoms and without significant coronary artery stenosis is more frequent in women. Selection of either an invasive procedure or conservative management is not influenced by sex. Cardiac rehabilitation referral on discharge is underused, especially in women.

Clinical and organizational management of cardiac implantable electronic device replacements: an Italian Survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)
imageAims The aim of this survey was to assess the management and organization of cardiac implantable electronic device (CIED) replacement in Italy. Methods A questionnaire consisting of 24 questions on organizational aspects and on the peri-procedural management of anticoagulant therapies and antibiotic prophylaxis was sent via the Internet to 154 Italian arrhythmia centers. Results A total of 103 out of 154 centers completed the questionnaire (67% response rate). In 43% of the centers, the procedures were performed under day-case admission, in 40% under ordinary admission, and in 17% under either day-case or ordinary admission. The most frequent reason (66%) for choosing ordinary admission rather than day-case admission was to obtain full reimbursement. Although warfarin therapy was continued in 73% of the centers, nonvitamin K oral anticoagulants were discontinued, without bridging, 24 h or less prior to replacement procedures in 88%. Prophylactic antibiotic therapy was systematically administered in all centers; in 97%, the first antibiotic dose was administered 1–2 h prior to procedures. Local antibacterial envelopes were also used in 43% of the centers in patients with a higher risk of device infection. Conclusion This survey provides a representative picture of how CIED replacements are organized and managed in current Italian clinical practice. The choice of the type of hospitalization (short versus ordinary) was more often motivated by economic reasons (reimbursement of the procedure) than by clinical and organizational factors. Peri-procedural management of anticoagulation and prophylactic antibiotic therapy was consistent with current scientific evidence.

Long-term patient satisfaction with implanted device remote monitoring: a comparison among different systems
imageAims Remote monitoring is an effective strategy to improve patients' outcomes and reduce hospitalization in patients with cardiac implantable electronic devices. However, data on patients' satisfaction are scarce. The aim of the current study was to assess patients' satisfaction, ease of use and impact on daily activities of the remote monitoring and to investigate whether there are differences among different devices and different manufacturers. Methods A modified Home Monitoring Acceptance and Satisfaction Questionnaire telephone survey on the perceived quality of the different systems was performed with all patients followed with remote monitoring for at least 3 months. Results Among 604 patients with remote monitoring screened by telephone, 466 patients (77%) answered the questionnaire [142 patients (30.5%) had a pacemaker, 317 patients (68%) had an implantable cardioverter defibrillator, and seven patients (1.5%) had an implantable loop recorder]. Ninety-seven percent of patients were satisfied by the remote monitoring system during the entire follow-up and found it easy to use. Similarly, 85% of patients did not experience any restriction in daily activities, and for 99% of patients it did not affect their privacy. Importantly, for the vast majority of patients, remote monitoring gave a great (56.7%) or moderate (33.4%) sense of security. Conclusion Daily impact of cardiac implantable electronic devices still remains a challenging issue for caregivers. The introduction of remote monitoring allowed closer follow-up and improved outcomes. Our results highlighted patients' satisfaction, who also felt safer, with the remote monitoring, its ease of use, and the absence of any disturbances in patients' everyday activities or in their privacy.

Effects of remote monitoring of cardiac implantable electronic devices after stroke or transient ischemic attack
imageAims Cardiac implantable electronic device (CIED) recipients who experienced an ischemic cerebral event may particularly benefit from continuous remote monitoring. We aimed to assess the effect of remote monitoring on the occurrence of 1-year serious adverse events in CIED recipients after ischemic stroke or transient ischemic attack (TIA). Methods Patients were eligible if they suffered a TIA/stroke. Study endpoints were all-cause mortality, all-cause hospitalization, and TIA/stroke recurrence. Patients were retrospectively divided according to the presence of remote monitoring for CIED follow-up. Results From January 2011 to December 2017, 71 CIED recipients were hospitalized in our institution for TIA/stroke: pacemaker (76%), cardiac resynchronization therapy device (17%), or implantable cardioverter defibrillator (7%). Among them, 26 (37%) were remotely monitored (RM-ON), whereas 45 (63%) were followed with conventional in-hospital visits (RM-OFF). No significant differences were found in baseline characteristics between groups. The all-cause mortality and hospitalization rates were significantly lower in the RM-ON group [2.2; 95% confidence interval (CI) 0.8–4.8, and 5.8; 95% CI 3.3–9.4 per 100 patient-months] as compared with the RM-OFF group (8.1; 95% CI 5.2–11.9, and 9.7; 95% CI 6.5–13.9 per 100 patient-months). Despite a similar incidence of new diagnosis of atrial fibrillation, the median time from the arrhythmic episode to the physician evaluation was dramatically lower in the RM-ON as compared with the RM-OFF group [2 (1–3) vs. 78 (64–92) days; P = 0.002]. Conclusion We found that remote monitoring as compared with conventional in-hospital visits may contribute to a better outcome in CIED recipients who had suffered from an ischemic cerebral event.

Hypogastric artery coverage during endovascular aneurysm repair in octogenarian and younger patients
imageAim To report our experience about hypogastric artery coverage during endovascular aneurysm repair (EVAR) for aortoiliac aneurysms in patients younger than 80 years (group A) compared with octogenarian patients (group B). Methods Data of consecutive EVAR with hypogastric artery coverage from 01/1998 to 12/2016 were retrospectively analyzed. Primary outcomes were the occurrence of ischemic colitis, type II endoleak and buttock claudication both at 30 days and in the long term. P values less than 0.05 were considered statistically significant. Results The hypogastric artery was covered in 107 patients. Twenty-three (21.5%) were octogenarian (group B). At 30 days, one type II endoleak occurred in group B, whereas 16 patients of group A experienced buttock claudication. There were no cases of ischemic colitis. During follow-up (median 63.5 months), no cases of ischemic colitis occurred. Six new type II endoleaks were recorded (five in group B and one in group A, P = 0.0001). Buttock claudication persisted in four patients of group A. No new cases of buttock claudication were observed. Conclusion Unilateral hypogastric artery coverage during EVAR for aortoiliac aneurysms can be performed with an acceptable rate of postoperative complication. Postoperative buttock claudication was more frequent in younger patients, whereas a type II endoleak occurred mostly in octogenarian patients during follow-up.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos

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