Inclusion criteria included age >18 years, coronary artery disease, and ≥2 cardiovascular risk factors. Exclusion criteria included heart block, bleeding, stroke, dyspnea, oral anticoagulants, ...valvular heart disease, treatment with strong cytochrome P450 isoenzyme CYP3A4 inhibitors, drug or alcohol abuse, severe liver disease, hypersensitivity to the study drugs, pregnancy, and latex allergy. Clopidogrel also has been shown to increase nitric oxide bioavailability, a finding that may explain the observed positive effects of clopidogrel on vascular reactivity.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors and ...clinical impact of CIED dysfunction (CIED-D) following radiotherapy for cancer treatment. Clinical characteristics, cancer and different types of CIEDs as well as radiation-dose were evaluated. The investigation identified 230 patients; mean age 78±8 years and 70% were male. A total of 199 (86%) patients had pacemakers (59% dual-chamber), 21 (9%) cardioverter-defibrillators and 10 (4%) resynchronizators/defibrillators. The left pectoral (n=192, 83%) was the most common CIED location. Sixteen (7%) patients experienced 18 events of CIED-D after radiotherapy. Reset to back-up pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrio-ventricular dys-synchrony. Those who had CIED-D had a shorter device-age at the time of radiotherapy compared to those who did not (2.5±1.5 vs. 3.8±3.4 years, P =0.005). The total dose prescribed to the tumor (66±30 vs. 42±23 Gy) was significantly higher among those who had CIED-D (P<0.0001). Multivariable logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio: 1.19 for each increase in 5 Gy, 95% confidence interval: 1.08-1.31, P=0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to back-up pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias or conduction disorders.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background A major limitation of primary percutaneous coronary intervention (PPCI) for the treatment of ST-elevation myocardial infarction (STEMI) is impaired microvascular perfusion due to ...embolization and obstruction of microcirculation with thrombus. Manual thrombectomy has the potential to reduce distal embolization and improve microvascular perfusion. Clinical trials have shown mixed results regarding thrombectomy. Objective The objective of this study is to evaluate the efficacy of routine upfront manual aspiration thrombectomy during PPCI compared with percutaneous coronary intervention alone in patients with STEMI. Design This is a multicenter, prospective, open, international, randomized trial with blinded assessment of outcomes. Patients with STEMI undergoing PPCI are randomized to upfront routine manual aspiration thrombectomy with the Export catheter (Medtronic CardioVascular, Santa Rosa, CA) or to percutaneous coronary intervention alone. The primary outcome is the composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or new or worsening New York Heart Association class IV heart failure up to 180 days. The trial uses an event-driven design and will recruit 10,700 patients. Summary The TOTAL trial will determine the effect of routine manual aspiration thrombectomy during PPCI on clinically important outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background There is a paucity of data regarding the type of anaesthesia used and the perception toward anaesthesia among cardiologists, anaesthesiologists, and nurses. Our objective was to ...describe the use of sedation during nonsurgical cardiac procedures. Methods We designed a Web-based survey to assess anaesthesia practices during cardiac procedures. The survey was distributed to cardiologists, anaesthesiologists, and nurses through national societies and international investigator networks. The questions addressed the type of practice, type of anaesthesia used during procedures, and perceptions regarding anaesthesia. Results The survey was completed by 497 participants. Sedation during cardiac catheterization was used by 77/84 (92%) of cardiologists in North America, but only by 46/121 (38%) in other countries ( P < 0.0001). Use of general anaesthesia for complex procedures such as transaortic valve replacement is also more common in North America (92%) compared with other countries (76%; P = 0.004). Specific sedation-related training was provided to less than a third of nonanaesthesiologists. Although more than half of the nurses received training regarding procedural sedation, such training is provided to less than a quarter of the cardiologists. The lack of training was noted in all geographic regions. Conclusions Anaesthesia and especially sedation is frequently used during percutaneous cardiac procedures. The rate of use and perceptions regarding sedation differs among professionals and might be influenced by culture, training, and geography. There is a lack of adequate formal training in the use of sedation and analgesia for nonanaesthesia professionals.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Experimental evidence suggests that the inhalational anesthetic sevoflurane has a cardioprotective effect. Our objective was to determine if sedation with sevoflurane will reduce infarct ...size in patients with acute myocardial infarction (MI) who are treated with primary percutaneous coronary intervention (PCI). Methods We randomized 50 patients presenting with a first acute ST-elevation MI treated by primary PCI within 6 hours from symptom onset to sedation with sevoflurane inhalation or standard sedation (control). Coronary flow at the end of PCI was assessed by corrected Thrombolysis In Myocardial Infarction frame count. Myocardial reperfusion was assessed by ST-segment resolution 60 minutes post-PCI. Infarct size was assessed by release of creatinine kinase (CK) and troponin T. Results There was no difference in the primary end point: troponin T or CK release adjusted to the area at risk, between groups. However, among patients with anterior MI, there was a trend toward lower CK ( P = .05) and nonsignificant decrease in troponin ( P = .11) levels in the sevoflurane group. Corrected Thrombolysis In Myocardial Infarction frame count was 12.3 ± 1.5 in the sevoflurane group and 15.6 ± 9.1 in the control group ( P = .16). There was more ST resolution in patients treated by sevoflurane 80.7% ± 25.8% versus 56.6% ± 35.7% ( P = .01). Sevoflurane had no significant adverse effect during administration. Conclusions Sevoflurane administration during primary PCI did not reduce infarct size. There was a trend toward a reduction in infarct size among patients with anterior MI. Sevoflurane administration was associated with improvement in ST-segment resolution.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Since the introduction of newer, more potent P2Y12 receptor inhibitors (P2Y12 ris), practice patterns and associated clinical outcomes in patients with myocardial infarction (MI) ...undergoing percutaneous coronary intervention (PCI) and also requiring oral anticoagulation (OAC) have not been fully characterized. Methods The Canadian Observational Antiplatelet Study was a prospective, multicenter, longitudinal, observational study (26 hospitals, Dec/11-May/13) describing P2Y12 ri treatment patterns and outcomes in patients with ST-elevation and non-ST-elevation MI undergoing PCI. We describe the clinical characteristics, treatment patterns, bleeding and ischemic outcomes over the 15-month follow-up within and between the subgroups of patients discharged on either dual antiplatelet therapy (DAPT; ASA + P2Y12 ri) or triple therapy (ASA + P2Y12 ri + OAC). Results Of the 2034 patients at discharge, 86% (n = 1757) were on DAPT, while 14% (n = 277) were on triple therapy (50% warfarin, 50% non-vitamin K oral anticoagulant NOAC). The frequency of newer P2Y12 ri use (prasugrel or ticagrelor) was similar in the DAPT and triple therapy groups (28% vs 26%, respectively). In the triple therapy group, NOAC use was higher in those receiving a new P2Y12 ri compared to those receiving clopidogrel (75% vs 41%, respectively, P < .0001). The unadjusted and adjusted events of MACE and bleeding were higher in the triple therapy group. For patients on triple therapy, the bleeding or MACE events were not significantly different between those on clopidogrel versus those on ticagrelor or prasugrel. Conclusion In this observational study of MI patients requiring PCI, 1 in 8 were discharged on triple antithrombotic therapy, of whom 26% were on newer P2Y12 ris. Patients on triple therapy had higher risk at baseline, with higher unadjusted and adjusted MACE and bleeding events compared to those on DAPT alone. Amongst triple therapy-treated patients, there was no difference in the MACE and bleeding events regardless of the P2Y12 ri used.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Abstract Background The duration of red blood cell (RBC) storage may have a negative impact on endothelial nitric oxide bioavailability. We tested the hypothesis that transfused fresh blood will have ...a more favourable effect on microvascular endothelial function as compared to older standard issue blood. Methods Participants requiring chronic RBC transfusions were enrolled in a crossover-design study to receive fresh (less than 7 days storage) or standard (up to 42 days storage) blood on two separate visits. Endothelial function was assessed by Reactive Hyperaemia Peripheral Arterial Tonometry (Rh-PAT) that was measured prior to and following transfusions. For each participant, the difference between endothelial function pre and post transfusion was assessed in relation to blood storage time. Results Twenty one patients (71 ± 16 years, 52% females) were enrolled. Mean age of fresh blood was 5.5 days ±1.0 and of standard blood was 24.5 days ±7.9 days. The pre-transfusion haemoglobin was 83.1 ± 2.5 g/L and post-transfusion 98.9 ± 2.6 g/L. An average of 2 units of packed Red Blood Cells ( pRBCs) were transfused. Microvascular endothelial function decreased more frequently after transfusion of standard blood compared to fresh blood. Standard issue blood transfusion was associated with decrease in Rh-PAT index (−0.25 ± 0.63) compared to fresh blood (+0.03 ± 0.49), P = .026. Conclusion Transfusions of standard issue blood is associated with less favourable effect on microvascular endothelial function as compared to fresh blood.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Contemporary use of dual antiplatelet therapy and consistency with guideline recommendations in acute coronary syndrome (ACS) patients undergoing percutaneous coronary ...intervention (PCI) has not been well characterized. Methods The Canadian Observational AntiPlatelet sTudy (COAPT) was a prospective, observational, multicenter, longitudinal study of patients with myocardial infarction (MI) undergoing PCI. Baseline characteristics, treatment patterns, processes of care, factors associated with switching to and from novel adenosine diphosphate receptor inhibitors (ADPris), and in-hospital outcomes are described. Results Among 2179 MI patients undergoing PCI during their index hospitalisation, 1328 (60.9%) had ST elevation. Initial ADPri use included clopidogrel in 1812 (83.2%), prasugrel in 125 (5.7%), and ticagrelor in 242 (11.1%). At discharge, 1597 patients (73.4%) were prescribed clopidogrel, 220 (10.1%) prasugrel and 358 (16.5%) ticagrelor. Switching between ADPri therapies during the index hospitalisation occurred in 15.3%, 22.4%, and 25.2% of patients initially started on clopidogrel, prasugrel, and ticagrelor, respectively. The majority of switches over the 15 month study period occurred during the index admission (16.8% of patients vs. 4.4% switches post-discharge). Major adverse cardiovascular events (MACE) occurred in 7.5% of patients during the index hospitalisation. In-hospital bleeding events occurred in 6.0% of patients and the majority were mild. Conclusions Despite randomized trial evidence and guideline recommendations, only a minority of Canadian MI patients undergoing PCI initially received or were discharged on one of the newer ADPri agents. These findings suggest an opportunity to improve upon the appropriate selection of the ADPris at index hospitalisation and discharge in Canadian MI patients undergoing PCI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Abstract Out-of-hospital cardiac arrest (OHCA) carries an enormous global burden of mortality and morbidity. The post-cardiac arrest syndrome consists of complex pathophysiological changes that ...result in hypoxic brain injury, myocardial and peripheral organ dysfunction, and the systemic ischemia-reperfusion response. We review common cardiac arrest cases to highlight key management issues and recommendations in post-resuscitation care, including therapeutic hypothermia, coronary angiography and revascularization, and circulatory support. Guidelines still suggest mild therapeutic hypothermia be administered for OHCA over targeted temperature management preventing pyrexia. Similarly, early invasive coronary angiography is particularly beneficial when there is ST-elevation on the post-resuscitation electrocardiogram, but might be considered in the absence of ST-elevation if there is no noncardiac cause to explain the OHCA. However, there remain a large number of unanswered questions that require ongoing research.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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