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1.
Eur Heart J Cardiovasc Pharmacother ; 8(5): 511-518, 2022 08 11.
Article in English | MEDLINE | ID: mdl-34849686

ABSTRACT

AIMS: The PRECISE-DAPT (Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) score identifies patients at high risk of bleeding complications following percutaneous coronary intervention (PCI). International guidelines recommend the PRECISE-DAPT score to identify patients at high risk for bleeding, who may benefit from shortened dual antiplatelet therapy. The association of the PRECISE-DAPT score with ischaemic outcomes remains unclear. We performed a meta-analysis investigating the association between a high PRECISE-DAPT score and ischaemic outcomes. METHODS AND RESULTS: A comprehensive literature search was conducted on articles published between 11 March 2017 and 5 June 2021. Two reviewers independently screened articles for inclusion using pre-defined criteria. The outcome measures extracted included composite ischaemic events, major bleeding events, and all-cause mortality. A random effects model was applied to obtain combined risk estimates for outcomes. From 12 included studies, there were 39 459 patients with PRECISE-DAPT <25 and 14 761 patients with PRECISE-DAPT ≥25. PRECISE-DAPT score ≥25 was associated with increased risk of composite ischaemic events [odds ratio (OR) 2.16; 95% confidence interval (CI) 1.77-2.65], myocardial infarction (OR 2.06; 95% CI 1.38-3.08), and ischaemic stroke (OR 2.90; 95% CI 1.76-4.78). Patients with a PRECISE-DAPT score ≥25 had increased risk of major bleeding (OR 3.62; 95% CI 2.62-4.99). Patients with a PRECISE-DAPT score ≥25 had higher risk of all-cause mortality (OR 5.83; 95% CI 5.37-6.33). CONCLUSION: Patients with a PRECISE-DAPT score ≥25 are at increased risk for ischaemic events, bleeding, and all-cause mortality. Prospective evaluation of a PRECISE-DAPT guided approach to antiplatelet therapy is required to demonstrate benefit in this high-risk population.


Subject(s)
Brain Ischemia , Percutaneous Coronary Intervention , Stroke , Brain Ischemia/etiology , Hemorrhage/chemically induced , Hemorrhage/epidemiology , Humans , Ischemia/etiology , Percutaneous Coronary Intervention/adverse effects , Platelet Aggregation Inhibitors/adverse effects , Stroke/etiology
2.
Am J Cardiol ; 161: 19-25, 2021 12 15.
Article in English | MEDLINE | ID: mdl-34794614

ABSTRACT

The optimal length of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains debated. Current guidelines recommend individualized treatment with consideration of risk scores. We sought to evaluate the degree of agreement in treatment recommendations and the ability to predict ischemic and bleeding complications of the PRECISE-DAPT (predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy) and DAPT scores. Consecutive patients receiving 12 months of DAPT were grouped based on score treatment recommendation at the time of PCI: PRECISE-DAPT prolonged or shortened (PRECISE DAPT <25 vs ≥25) and DAPT prolonged or shortened (DAPT ≥2 vs <2). One-year ischemic and bleeding outcomes were compared for each group. In 451 patients, the PRECISE-DAPT and DAPT score recommendations were concordant in 56.7% of patients (Cohen's kappa for agreement of k = 0.139, 95% confidence interval 0.065 to 0.212). There was no difference in composite major adverse cardiovascular and cerebrovascular events between patients with high versus low PRECISE-DAPT or DAPT scores. In patients with a high PRECISE-DAPT score versus a low score, there was an increased incidence of 1-year all-cause mortality (2.13% vs 0%, p = 0.04) and an increase in bleeding (Bleeding Academic Research Consortium ≥3a: 17.0% vs 2.8%; p <0.001; Bleeding Academic Research Consortium 3b/c and 5: 8.5% vs 1.4%; p = 0.001). There were no differences in rates of mortality or bleeding for patients with high versus low DAPT scores. In conclusion, when applied at the baseline, the PRECISE-DAPT and DAPT scores frequently make discordant DAPT duration recommendations. The PRECISE-DAPT, but not the DAPT score, demonstrated associations with all-cause mortality and bleeding in patients prescribed 12 months of DAPT after PCI.


Subject(s)
Acute Coronary Syndrome/therapy , Dual Anti-Platelet Therapy/methods , Percutaneous Coronary Intervention , Postoperative Care/methods , Postoperative Complications/epidemiology , Registries , Risk Assessment/methods , Aged , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Ontario/epidemiology , Platelet Aggregation Inhibitors/administration & dosage , Retrospective Studies , Risk Factors , Time Factors
3.
CJC Open ; 2020 Dec 15.
Article in English | MEDLINE | ID: mdl-33521615

ABSTRACT

BACKGROUND: Management of ST-elevated myocardial infarction (STEMI) necessitates rapid reperfusion. Delays prolong myocardial ischemia and increase the risk of complications, including death. The COVID-19 pandemic may have impacted STEMI management. We evaluated the relative volume of hospitalizations and clinical time intervals within a regional STEMI system. METHODS: 494 patients with STEMI were grouped into pre-lockdown, lockdown and re-opening cohorts. Clinical, temporal and outcome data were collected and compared between groups for both urban and rural patients, receiving primary percutaneous coronary intervention (PCI) and pharmacoinvasive revascularization, respectively. Data was compared to a 10-year historical comparator. RESULTS: During pre-lockdown there was 238 cases versus 193 in lockdown; a 19.0% reduction in volume. When lockdown was compared to the median caseload from a 10-year historical cohort, a 19.8% reduction was observed. For patients treated with primary PCI during lockdown, median symptom-to-balloon time increased by 44-minutes [217 (IQR 157-387) vs. 261 (160-659) minutes; p=0.03]; driven by an increase in median symptom-to-door time of 41-minutes [136 (IQR 80-267) vs. 177 (IQR 90-569) minutes; p<0.01]. Only patients transferred from non-PCI facilities demonstrated an increase in door-to-reperfusion time [116 (IQR 93-150) vs. 139 (IQR 100-199) minutes; p<0.01]. More patients had left ventricular dysfunction during the lockdown [35% vs. 44%; p=0.04], but there was no difference in mortality. CONCLUSION: During the COVID-19 lockdown, fewer patients presented with STEMI. Time-to-reperfusion was significantly prolonged and appeared driven predominantly by patient-level and transfer delays. Public education and systems-level changes will be integral to STEMI care during the second wave of COVID-19.

4.
PLoS One ; 13(8): e0201694, 2018.
Article in English | MEDLINE | ID: mdl-30086148

ABSTRACT

INTRODUCTION: Radiologists and other specialty consultants play a role in diagnosing patients with acute abdominal conditions. Numerous Computed Tomography (CT) protocols are available and radiologists' choices are influenced by the clinical history provided. We hypothesize that the quality of the initial communication between referring physicians and radiologists greatly affects the utilization of health resources and subsequent patient care. The purpose of this pilot study was to employ a grading system to quantitatively evaluate a provided history. We also sought to evaluate inter-rater reliability by having radiologists evaluate sample histories and finally, to assess whether the quality of history has an impact on the number of CT protocols radiologists choose as potentially appropriate, with less potential protocols being seen as a positive outcome. METHODS: Four reviewers, (2 attendings and 2 residents) evaluated 350 consecutive clinical histories provided for patients presenting to a tertiary care Emergency Department (ED) between September-October, 2012. Reviewers graded histories on a 5-point scale using 4 categories of criteria. This includes a) presenting complaint, b) relevant past medical history or symptom evolution, c) objective laboratory or prior examination results and d) differential diagnosis. RESULTS: There was substantial agreement among all four reviewers when evaluating the quality of history, ICC 0.61, (95% CI 0.48-0.71). In particular, agreement amongst attending radiologists was substantial, with ICC 0.69 (0.48-0.80). Significant negative correlation was observed between history grade and number of potentially appropriate protocols in 3 of 4 reviewers (Spearman's rho: -0.394, -0.639, -0.864, p <0.0001 for these reviewers). This correlation was significantly stronger for attending radiologists (Spearman's rho: -0.763, 95% CI -0.7933 to -0.731; p<0.0001). Agreement was poor among reviewers when asked exactly how many protocols could potentially be used to answer the clinical question based on provided history, ICC 0.08, (95% -0.03-0.13). CONCLUSION: Although there is still variability in radiologists' approach to protocoling urgent studies, a more comprehensive requisition history narrowed the number of protocols considered.


Subject(s)
Abdomen/diagnostic imaging , Choice Behavior , Emergency Service, Hospital/statistics & numerical data , Pelvis/diagnostic imaging , Tomography, X-Ray Computed/statistics & numerical data , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Observer Variation , Pilot Projects , Radiologists , Retrospective Studies , Young Adult
5.
J Am Coll Radiol ; 12(3): 277-83, 2015 Mar.
Article in English | MEDLINE | ID: mdl-25640574

ABSTRACT

PURPOSE: To evaluate whether presence of a CT scanner in the emergency department (ED) improves ED workflow by decreasing time between imaging requisition and completion, and time to final patient disposition. METHODS: Institutional review board approval was obtained for this retrospective study conducted on 2,142 consecutive, acute thoracic, abdomino- pelvic imaging requests from 2 ED hospital campuses affiliated with the same academic institution, August 1 to October 31, 2012. Of these patients, only 1,696 had complete records and were used for analysis. One hospital had a CT scanner in the ED; the other was in the radiology department, 300 meters from the ED. Patients were stratified based on acuity of CT indication, interpreting radiologist training level, and time of day. Time points were compared between hospitals: (1) time of CT requisition receipt to time of scan initiation (2) time from scan initiation to time of preliminary report by resident or fellow, or verbally by staff to the ED; and (3) time of CT requisition receipt to time of final patient disposition. RESULTS: Decreases in time, favoring the institution with the ED CT scanner, are 16 min (P < .0001); 15 minutes (P < .0001); and 19 minutes (P < .04) for the 3 times, respectively. Significant differences were seen in morning and overnight shifts and for CT reporting times with higher radiology levels of training (20 min, P = .04; and 18 min, P < .0001 for staff and postgraduate year-5 residents, respectively). CONCLUSIONS: Presence of an ED CT scanner is associated with decreases in time to CT scan completion, radiologic interpretation, and patient disposition.


Subject(s)
Efficiency, Organizational/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Patient Discharge Summaries/statistics & numerical data , Referral and Consultation/statistics & numerical data , Tomography, X-Ray Computed/statistics & numerical data , Workflow , Documentation/statistics & numerical data , Medical Records Systems, Computerized/statistics & numerical data , Ontario/epidemiology , Time Factors
6.
Drug Metab Dispos ; 40(8): 1508-14, 2012 Aug.
Article in English | MEDLINE | ID: mdl-22573661

ABSTRACT

Expression and activity of drug-metabolizing enzymes are decreased in severe kidney disease; however, only a small percentage of patients with chronic kidney disease (CKD) are at the final stage of the disease. This study aimed to determine the changes in drug-metabolizing enzyme function and expression in rats with varying degrees of kidney disease. Sprague-Dawley rats were subjected to surgical procedures that allowed the generation of three distinct models of kidney function: normal kidney function, moderate kidney function, and severe kidney disease. Forty-two days after surgery, rats were sacrificed and hepatic CYP3A and CYP2C expression was determined. In addition, enzymatic activity was determined in liver microsomes by evaluating midazolam (CYP3A), testosterone (CYP3A and CYP2C), and tolbutamide (CYP2C) enzyme kinetics. Both moderate and severe kidney disease were associated with a reduction in CYP3A2 and CYP2C11 expression (p < 0.05). Likewise, moderate kidney disease resulted in more than a 60% decrease in enzyme activity (V(max)) for CYP2C11 and CYP3A, compared with controls (p < 0.05). When the degree of kidney disease was correlated with metabolic activity, an exponential decline in CYP2C- and CYP3A-mediated metabolism was observed. Our results demonstrate that CYP3A and CYP2C expression and activity are decreased in both moderate and severe CKD. Our data suggest that drug metabolism is significantly decreased in the earlier stages of CKD and imply that patients with moderate CKD may be subject to unpredictable pharmacokinetics.


Subject(s)
Cytochrome P-450 Enzyme System/metabolism , Down-Regulation , Isoenzymes/metabolism , Kidney Failure, Chronic/metabolism , Liver/enzymology , Animals , Base Sequence , Blotting, Western , Body Weight , Cytochrome P-450 Enzyme System/genetics , DNA Primers , Kidney Failure, Chronic/enzymology , RNA, Messenger/genetics , Rats , Real-Time Polymerase Chain Reaction
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