We report the case study of a 70-year-old gentleman who presented with isolated, slowly progressive dizziness after prolonged standing and was eventually diagnosed with pure autonomic failure. ...Initially, his symptoms improved with the use of midodrine and fludrocortisone, but gradually became refractory and disabling. Despite multiple therapeutic interventions, his symptoms persisted along with worsening supine hypertension. We discuss the challenges faced in the treatment of an uncommon condition and discuss the clinical utility of performing serial 24-h ambulatory monitoring to detect subclinical blood pressure fluctuations.
The prognostic impact of hyperglycemia (HG) in acute heart failure (AHF) is controversial. Our aim is to examine the impact of HG on short- and long-term survival in AHF patients.
Data from the Heart ...Function Assessment Registry Trial in Saudi Arabia (HEARTS) for patients who had available random blood sugar (RBS) were analyzed. The enrollment period was from October 2009 to December 2010. Comparisons were performed according to the RBS levels on admission as either <11.1 mmol/L or ≥11.1 mmol/L. Primary outcomes were hospital adverse events and short- and long-term mortality rates.
A total of 2511 patients were analyzed. Of those, 728 (29%) had HG. Compared to non-HG patients, hyperglycemics had higher rates of hospital, 30-day, and 1-year mortality rates (8.8% vs. 5.6%; p = 0.003, 10.4% vs. 7.2%; p = 0.007, and 21.8% vs. 18.4%; p = 0.04, respectively). There were no differences between the two groups in 2- or 3-year mortality rates. After adjustment for relevant confounders, HG remained an independent predictor for hospital and 30-day mortality odds ratio (OR) = 1.6; 95% confidence interval (CI) 1.07–2.42; p = 0.021, and OR = 1.55; 95% CI 1.07–2.25; p = 0.02, respectively.
HG on admission is independently associated with hospital and short-term mortality in AHF patients. Future research should focus on examining the impact of tight glycemic control on outcomes of AHF patients.
High Red Cell Distribution Width (RDW) is linked to poor outcomes in advanced Heart Failure (HF). Whether or not RDW levels predict response to Cardiac Resynchronization Therapy (CRT) remains ...unclear. We examined the role of RDW in predicting clinical outcomes of HF following CRT insertion. Further, we examined if follow-up RDW levels correlated with response and mortality.
A retrospective chart review was carried out for all patients undergoing CRT insertion from April 2009 to April 2015. RDW was measured at baseline and three different time points after CRT insertion (3 months, 6 months, and 1 year). Comparisons were done according to the median RDW value (RDW >14.1 vs. RDW ⩽14.1). Our primary endpoints were significant reduction (⩾15%) in Left Ventricular End Systolic Diameter (LVESD), HF readmissions, and all-cause mortality. The outcomes were examined over a median follow-up duration of 36 months.
One-hundred and eighty-nine patients were eligible for the present analysis. Of which, the majority were males (72.5%) with a mean age of 59.5. Elevated baseline RDW was significantly associated with HF readmissions (29.3% vs. 9.5%; P = 0.001) but not with significant reduction in LVESD (30.4% vs. 46.9%; P = 0.064) or all-cause mortality (11.1% vs. 10.0%; P = 0.808). Multivariate analysis showed no independent role of RDW in predicting HF readmissions (OR = 2.86, 95% CI 0.79–10.29, P = 0.108). Follow-up RDW levels remained persistently elevated in patients with poor reverse ventricular remodeling, HF readmissions, and all-cause mortality (Figure).
Baseline RDW had no independent role in predicting outcomes of advanced HF after CRT insertion. During follow-up, persistently elevated RDW correlated with HF morbidity and mortality.
Low Pulse Pressure (PP) predicts mortality in chronic symptomatic Heart Failure (HF). Data in Acute HF (AHF) are lacking. Our aim was to examine the prognostic value of PP in AHF for short- and ...long-term outcomes.
Data from the Heart Function Assessment Registry Trial (HEARTS) were analyzed. AHF patients were prospectively enrolled from October 2009 to December 2010, with a mortality follow-up until January 2013. Comparisons were done according to PP median value (50 mmHg). Primary outcomes were hospital adverse events and short and long-term mortality rates.
2609 patients were included. In crude comparisons, patients with low PP had higher rates of recurrence of HF (35.4% vs. 26.5%; P < 0.001), and greater risk of hospital and 30-day mortality (7.8% vs. 5.1%; P 0.006 and 9.5% vs. 6.6%; P = 0.006, respectively). There were no differences observed in long-term mortality rates. Multiple regression analyses showed no independent role for PP on all studied outcomes. However, a subgroup analysis revealed that hospital mortality was greater in HF with reduced Ejection Fraction (HFrEF).
Low PP was not predictive of mortality in the overall AHF population. However, it still remains an important prognostic marker in the HFrEF phenotype.
The optimal stenting strategy for unprotected left main coronary artery (ULMCA) disease remains debated. This retrospective observational study (Gulf Left Main Registry) analyzed the outcomes of 1 vs ...2 stents in patients with unprotected left main percutaneous coronary intervention (PCI). Overall, 1222 patients were evaluated; 173 had 1 stent and 1049 had 2 stents. The 2-stent group was older with more comorbidities, higher mean SYNTAX scores, and more distal bifurcation lesions. In the 1-stent group, in-hospital events were significant for major bleeding, and better mean creatinine clearance. At median follow-up of 20 months, the 1-stent group was more likely to have target lesion revascularization (TLR). Total mortality was numerically lower in the 1-stent group (.00% vs 2.10%); however, this was not statistically significant (P=.068). Our analysis demonstrates the benefits of a 2-stent approach for ULMCA patients with high SYNTAX scores and lesions in both major side branches, while the potential benefit of a 1-stent approach for less complex ULMCA was also observed. Further studies with longer follow-up are needed to definitively demonstrate the optimal approach.
STEMI and COVID-19 Pandemic in Saudi Arabia Daoulah, Amin; Hersi, Ahmad S.; Al-Faifi, Salem M. ...
Current problems in cardiology,
03/2021, Volume:
46, Issue:
3
Journal Article
Peer reviewed
Open access
The COVID-19 pandemic had significant impact on health care worldwide which has led to a reduction in all elective admissions and management of patients through virtual care. The purpose of this ...study is to assess changes in STEMI volumes, door to reperfusion, and the time from the onset of symptoms until reperfusion therapy, and in-hospital events between the pre-COVID-19 (PC) and after COVID-19 (AC) period. All acute ST-segment elevation myocardial infarction (STEMI) cases were retrospectively identified from 16 centers in the Kingdom of Saudi Arabia during the COVID-19 period from January 01 to April 30, 2020. These cases were compared to a pre-COVID period from January 01 to April 30, 2018 and 2019. One thousand seven hundred and eighty-five patients with a mean age 56.3 (SD ± 12.4) years, 88.3% were male. During COVID-19 Pandemic the total STEMI volumes was reduced (28%, n = 500), STEMI volumes for those treated with reperfusion therapy was reduced too (27.6%, n= 450). Door to balloon time < 90 minutes was achieved in (73.1%, no = 307) during 2020. Timing from the onset of symptoms to the balloon of more than 12 hours was higher during 2020 comparing to pre-COVID 19 years (17.2% vs <3%, respectively). There were no differences between the AC and PC period with respect to in-hospital events and the length of hospital stay. There was a reduction in the STEMI volumes during 2020. Our data reflected the standard of care for STEMI patients continued during the COVID-19 pandemic while demonstrating patients delayed presenting to the hospital.
The optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of ...percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease.
This retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n = 264) to patients who underwent CABG (n = 196) and patients with non-emergent LMCA revascularization with PCI (n = 958) to those who underwent CABG (n = 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE).
Emergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P = 0.017) and in-hospital mortality (P = 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P = 0.015) and intermediate (P < 0.001) EuroSCORE. PCI was associated with lower MACCE in patients with low (P = 0.002) and intermediate (P = 0.008) SYNTAX scores. In non-emergent revascularization, PCI was associated with reduced hospital mortality in patients with intermediate (P = 0.001) and high (P = 0.002) EuroSCORE compared to CABG. PCI was associated with lower hospital mortality in patients with low (P = 0.031) and intermediate (P = 0.001) SYNTAX scores. At a median follow-up time of 20 months (IQR: 10-37), emergency PCI had lower MACCE compared to CABG HR: 0.30 (95% CI 0.14-0.66), P < 0.003, with no significant difference in all-cause mortality between emergency PCI and CABG HR: 1.18 (95% CI 0.23-6.08), P = 0.845.
PCI could be advantageous over CABG in revascularizing LMCA disease in emergencies. PCI could be preferred for revascularization of non-emergent LMCA in patients with intermediate EuroSCORE and low and intermediate SYNTAX scores.
The impact of left ventricular dysfunction on clinical outcomes following revascularization is not well established in patients with unprotected left main coronary artery disease (ULMCA). In this ...study, we evaluated the impact of left ventricular ejection fraction (LVEF) on clinical outcomes of patients with ULMCA requiring revascularization with percutaneous coronary intervention (PCI) compared with coronary artery bypass graft (CABG).
The details of the design, methods, end points, and relevant definitions are outlined in the Gulf Left Main Registry: a retrospective, observational study conducted between January 2015 and December 2019 across 14 centres in 3 Gulf countries. In this study, the data on patients with ULMCA who underwent revascularization through PCI or CABG were stratified by LVEF into three main subgroups; low (l-LVEF <40%), mid-range (m-LVEF 40-49%), and preserved (p-LVEF ≥50%). Primary outcomes were hospital major adverse cardiovascular and cerebrovascular events (MACCE) and mortality and follow-up MACCE and mortality.
A total of 2137 patients were included; 1221 underwent PCI and 916 had CABG. During hospitalization, MACCE was significantly higher in patients with l-LVEF (10.10%), P = 0.005 and m-LVEF (10.80%), P = 0.009, whereas total mortality was higher in patients with m-LVEF (7.40%), P = 0.009 and p-LVEF (7.10%), P = 0.045 who underwent CABG. There was no mortality difference between groups in patients with l-LVEF. At a median follow-up of 15 months, there was no difference in MACCE and total mortality between patients who underwent CABG or PCI with p-LVEF and m-LVEF.
CABG was associated with higher in-hospital events. Hospital mortality in patients with l-LVEF was comparable between CABG and PCI. At 15 months' follow-up, PCI could have an advantage in decreasing MACCE in patients with l-LVEF.
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