Atrial fibrillation (AF) is a common arrhythmia in patients with aortic stenosis. When these patients are treated medically or by surgical aortic valve replacement, AF is associated with increased ...risk of adverse events including death. Growing evidence suggests a significant impact of AF on outcomes also in patients with aortic valve stenosis undergoing transcatheter aortic valve implantation (TAVI). Conversely, limited evidence is available regarding the optimal management of this condition. This review aims to summarize prevalence, pathophysiology, prognosis, and treatment of AF in patients undergoing TAVI.
Radionuclide bone scintigraphy is the cornerstone of an imaging-based algorithm for accurate non-invasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CA). In patients with heart failure and ...suggestive echocardiographic and/or cardiac magnetic resonance imaging findings, the positive predictive value of Perugini grade 2 or 3 myocardial uptake on a radionuclide bone scan approaches 100% for the diagnosis of ATTR-CA as long as there is no biochemical evidence of a clonal dyscrasia. The technetium-labelled tracers that are currently validated for non-invasive diagnosis of ATTR-CA include pyrophosphate (
Tc-PYP); hydroxymethylene diphosphonate (
Tc-HMDP); and 3,3-diphosphono-1,2-propanodicarboxylate (
Tc-DPD). Although nuclear scintigraphy has transformed the contemporary diagnostic approach to ATTR-CA, a number of grey areas remains, including the mechanism for binding tracers to the infiltrated heart, differences in the kinetics and distribution of these radiotracers, differences in protocols of image acquisition worldwide, the clinical significance of extra-cardiac uptake, and the use of this technique for prognostic stratification, monitoring disease progression and assessing the response to disease-modifying treatments. This review will deal with the most relevant unmet needs and clinical questions concerning scintigraphy with bone tracers in ATTR-CA, providing expert opinions on possible future developments in the clinical application of these radiotracers in order to offer practical information for the interpretation of nuclear images by physicians involved in the care of patients with this ATTR-CA.
Recent studies have reported that patients with end-stage heart disease can have cognitive deficits ranging from mild to severe. Little is known, however, about the relationship between cognitive ...performance, neurophysiological characteristics and relevant clinical and instrumental indexes for an extensive evaluation of patients with heart failure, such as: left ventricular ejection fraction (LVEF) and other haemodynamic measures, maximum oxygen uptake during cardiopulmonary exercise testing, comorbidities, major cardiovascular risk factors and disease duration. Our purpose was to outline the cognitive profiles of end-stage heart disease patients in order to identify the cognitive deficits that could compromise the quality of life and the therapeutic adherence in end-stage heart disease patients, and to identify the variables associated with an increased risk of cognitive deficits in these patients.
207 patients with end-stage cardiac disease, candidates for heart transplant, were assessed by complete neuropsychological evaluation and by electroencephalographic recording with EEG spectral analysis.
Pathological scores in one or more of the cognitive tests were obtained by 86% of the patients, while 36% performed within the impaired range on five or more tests, indicating poor performance across a broad range of cognitive domains. The executive functions were the cognitive domain most impaired (70%). Poor performances were not related to the aetiology of heart disease, but rather to cerebral dysfunction secondary to haemodynamic impairment and to comorbidities.
Severe heart failure induces significant neurophysiological and neuropsychological alterations, which may produce an impairment of cognitive functioning and possibly compromise the quality of life of patients and the therapeutic adherence.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Aims
Whether early or delayed dual antiplatelet therapy initiation is better in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is unclear. We assessed the evidence for ...comparing the efficacy and safety of early vs. delayed P2Y
12
inhibitor initiation in NSTE-ACS.
Methods
The randomized controlled trials with available comparisons between early and delayed initiation of P2Y
12
inhibitors (clopidogrel, prasugrel, and ticagrelor) in patients with NSTE-ACS until January 2021 were reviewed. The primary outcomes were trial-defined major adverse cardiovascular events (MACEs) and bleeding. Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis, urgent coronary revascularization, and stroke. Frequentist random-effects network meta-analyses were conducted, ranking best treatments per outcome with
p
-scores.
Results
A total of nine trials with intervention arms including early and delayed initiation of clopidogrel (
n
= 5), prasugrel (
n
= 8), or ticagrelor (
n
= 6) involving 40,096 patients were included. Early prasugrel (hazard ratio HR, 0.59; 95% confidence interval 95%CI, 0.40–0.87), delayed prasugrel (HR, 0.60; 95%CI 0.43–0.84), and early ticagrelor (HR, 0.84; 95%CI, 0.74–0.96) significantly reduced MACE compared with early clopidogrel, but increased bleeding risk. Delayed prasugrel ranked as the best treatment to reduce MACE (
p
-score=0.80), early prasugrel to reduce all-cause mortality, cardiovascular mortality, stent thrombosis, and stroke, and delayed clopidogrel to reduce bleeding (
p
-score = 0.84). The risk of bias was low for all trials.
Conclusion
In patients with NSTE-ACS, delayed prasugrel initiation was the most effective strategy to reduce MACE. Although early prasugrel was the best option to reduce most secondary cardiovascular outcomes, it was associated with the highest bleeding risk. The opposite was found for delayed clopidogrel.
Abstract Background Post-procedure non-access site related bleedings have a significant impact on mortality in patients treated by transcatheter aortic valve replacement (TAVR). Notwithstanding, the ...source of these bleedings is frequently indeterminate, with potentially serious clinical implications related to lack of diagnosis and treatment. Methods Out of 513 TAVR performed between June 2007 and January 2016 in the Interventional Cardiology Laboratory of the Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, we identified few proven cases of concealed bleeding after TAVR due to blood oozing. Results We report three cases of angiographically-confirmed post-TAVR non-access bleedings related to spontaneous blood oozing, a life-threatening condition consisting in diffuse capillary hemorrhage developing from vessels not directly involved by the procedure. We hypothesize that spontaneous post-procedural blood oozing may account for a substantial proportion of non-overt, non-access site related bleeding after TAVR. Conclusion The possibility of post-TAVR blood oozing is largely neglected in literature, and comprehensive categorization of non-access site bleedings in current standardized endpoints of TAVR studies is missing. Early assessment with arterial and venous contrast phase angio-MDCT scan in case of post-TAVR unexplained and persistent anemia may allow diagnosis and treatment of this subtle condition.
Abstract Objectives The authors conducted a systematic pairwise and network meta-analysis to assess optimal treatment strategies in patients with ST-segment elevation myocardial infarction (STEMI) ...and multivessel coronary artery disease (MV-CAD) undergoing primary percutaneous coronary intervention (PCI). Background Patients with STEMI and MV-CAD have a worse prognosis than those with single-vessel CAD. The optimal revascularization strategy for these patients is uncertain. Methods Studies of revascularization strategies for MV-CAD in STEMI patients undergoing primary PCI published between 2001 and 2015 were identified using an electronic search. Pairwise and network meta-analyses were performed for 3 PCI strategies in prospective and retrospective studies: 1) infarct-related artery (IRA)-only PCI; 2) single procedure MV-PCI; and 3) staged MV-PCI. Information on study design, inclusion and exclusion criteria, and clinical outcomes was extracted. The outcomes of interest were short-term and long-term mortality. Results Thirty-two studies (13 prospective and 19 retrospective) with 54,148 patients (IRA-only PCI n = 42,112, single procedure MV-PCI n = 8,138, and staged MV-PCI n = 3,898) were included in the analysis. Pairwise meta-analyses showed that staged MV-PCI was associated with lower short-term and long-term mortality compared with both IRA-only PCI and single stage MV-PCI, whereas IRA-only PCI was associated with lower mortality compared with single stage MV-PCI. Staged MV-PCI was also associated consistently with improved survival in network analyses. Conclusions The present systematic review and meta-analysis supports the hypothesis that in patients with MV-CAD presenting with STEMI undergoing primary PCI, a staged multivessel revascularization strategy may improve early and late survival.
A relevant proportion of patients, classified as severe aortic stenosis on the basis of valve area ≤1 cm2 , have a mean transvalvular gradient ≤40 mm Hg, despite a preserved left ventricular ejection ...fraction (LGSAS). We assessed the clinical and hemodynamic impact of transcatheter aortic valve implantation in patients with symptomatic LGSAS at high risk for surgery or inoperable, according to the type of percutaneous valve implanted. Ninety-five patients received an Edwards SAPIEN valve (Edwards Lifesciences, Irvine, California) and 51 received a Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota). The hemodynamic performance of the 2 valves was similar in term of final transvalvular gradients (10 mm Hg, p = 0.069). Early mortality rate was 7% and was not different between the 2 valves (p = 0.73). During follow-up, cardiovascular mortality rate was similar between groups, and valve type was not a predictor of outcome (p = 0.72). Estimated survival by Kaplan–Meier at 2 years was 70%. At multivariate analysis, life-threatening or major bleeding, postprocedural aortic insufficiency, and acute kidney injury were the major predictors of an adverse outcome. In patients with LGSAS treated by transcatheter aortic valve implantation, the use of balloon-expandable versus self-expandable valves resulted in similar hemodynamic, early, and long-term clinical outcomes.
PDF
