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1.
J Invasive Cardiol ; 34(3): E156-E163, 2022 03.
Article in English | MEDLINE | ID: mdl-35157607

ABSTRACT

BACKGROUND: Patients presenting with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) are at high risk for impaired antiplatelet activity secondary to malabsorption, systemic hypoperfusion, hypothermia, need for mechanical ventilation, and high use of analgesics. The use of antiplatelet therapy in these high-risk patients is not well studied. METHODS: Using the National Cardiogenic Shock Initiative database, we analyzed patients who presented with AMI-CS at 60 hospitals from March 2018 to December 2020. All patients were treated using a standard shock protocol. Herein, the patterns of antiplatelet use are described. RESULTS: A total of 204 patients were included in the analysis, of which 174 (85.3%) presented with ST-segment elevation myocardial infarction (STEMI). The majority (84.3%) received antiplatelet therapy before percutaneous coronary intervention (PCI); of those who received antiplatelets, 77.9% received aspirin, 55.2% received an oral P2Y12 inhibitor, and 19.2% received intravenous (IV) antiplatelet therapy. Ticagrelor was the most common P2Y12 inhibitor administered (41.9%), followed by clopidogrel (12.2%) and prasugrel (1.2%). Only 18.6% of oral antiplatelet agents were crushed. Baseline characteristics of patients who received IV vs non-IV antiplatelet agents were similar. Thrombolysis in Myocardial Infarction (TIMI) 0 flow was present in 69.6% of patients before PCI and aspiration thrombectomy was performed in 24.5% of patients. The presence of STEMI, cardiac arrest, cardiopulmonary resuscitation, hypothermia, vasopressor use, elevated lactate levels, or number of vessels treated did not influence the use of IV antiplatelet agents. CONCLUSIONS: The use of crushed and IV antiplatelet agents in AMI-CS is low. Further studies are needed in this high-risk population to assess whether more potent antiplatelet inhibition will improve outcomes.


Subject(s)
Hypothermia , Myocardial Infarction , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Humans , Hypothermia/chemically induced , Hypothermia/complications , Myocardial Infarction/complications , Myocardial Infarction/diagnosis , Myocardial Infarction/therapy , Percutaneous Coronary Intervention/adverse effects , Platelet Aggregation Inhibitors , Prasugrel Hydrochloride/adverse effects , ST Elevation Myocardial Infarction/complications , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/drug therapy , Shock, Cardiogenic/drug therapy , Shock, Cardiogenic/etiology , Treatment Outcome
2.
Catheter Cardiovasc Interv ; 99(3): 650-657, 2022 02.
Article in English | MEDLINE | ID: mdl-34343409

ABSTRACT

BACKGROUND: Increasing vasopressor dose is associated with increasing mortality in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS). It is unknown whether the use of vasopressors is independently harmful or if their use is secondary to decreasing intrinsic cardiac power output (CPO). Mechanical circulatory support (MCS) devices enhance CPO. We sought to evaluate the independent impact of increasing vasopressor dose on survival in the National Cardiogenic Shock Initiative (NCSI). METHODS: The NCSI is a single arm prospective trial evaluating outcomes associated with the use of MCS using Impella in patients with AMICS. Early initiation of MCS placement before percutaneous coronary intervention (PCI) and rapid de-escalation of vasopressors guided by systematic use of invasive hemodynamic measures led to 70% in-hospital survival for the first 300 patients enrolled from July 2016 to December 2019 in 57 U.S. sites. RESULTS: Hemodynamic measures were obtained immediately after MCS and PCI. Survival curves were constructed based on CPO and use of vasopressors. For patients with CPO ≤0.6 W, survival was 77.3%, 45.0%, and 35.3% when 0, 1, or ≥ 2 vasopressors were used (p = 0.02). Similarly, for patients with CPO >0.6 W survival was 81.7%, 72.6%, and 56.8%, respectively (p = 0.01). Logistic regression analysis demonstrated that increasing vasopressor requirements were independently associated with increasing mortality (p = 0.02). CONCLUSION: Increasing vasopressor requirement is associated with increased mortality in AMICS independent of underlying CPO. Methods to decrease the need for vasopressors may enhance survival in AMICS.


Subject(s)
Heart-Assist Devices , Myocardial Infarction , Percutaneous Coronary Intervention , Heart-Assist Devices/adverse effects , Humans , Myocardial Infarction/complications , Myocardial Infarction/diagnosis , Myocardial Infarction/therapy , Percutaneous Coronary Intervention/adverse effects , Prospective Studies , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/therapy , Treatment Outcome
3.
Crit Pathw Cardiol ; 20(3): 163-167, 2021 09 01.
Article in English | MEDLINE | ID: mdl-33606413

ABSTRACT

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with high mortality. Patients ≥75 years old represent an increasing proportion of those who present with AMICS and are at high risk for adverse outcomes. METHODS: The National Cardiogenic Shock Initiative includes patients with AMICS treated using a standard shock protocol with early invasive hemodynamic monitoring, mechanical circulatory support (MCS), and percutaneous coronary intervention (PCI). We evaluated the outcomes of patients based on their age group, dividing them into <75 and ≥75 years old. RESULTS: We included 300 consecutive patients: 238 were <75 years old (79.3%) and 62 patients ≥75 years old. There were significant differences in survival; patients <75 years old had a 75.6% survival, while those ≥75 years old had a 50% survival (adjusted OR: 10.4, P = 0.001). SCAI shock classification impacted survival as well; those <75 years old with class C or D shock had a survival of 84%, compared with 57% in those ≥75 years old. Patients ≥75 years old requiring 1 or 2 vasopressors had significantly lower survival rates (36% and 25%, respectively) when compared with patients <75 years old (76.7% with 1 and 60.5% with >1 vasopressor). CONCLUSIONS: Age is inversely proportional to survival; patients <75 years old have high rates of survival if treated using best practices with invasive hemodynamic monitoring, early MCS, and PCI. However, using a standardized protocol can improve survival in the elderly; therefore, age on its own should not be a reason to withhold PCI or MCS use.


Subject(s)
Heart-Assist Devices , Myocardial Infarction , Percutaneous Coronary Intervention , Aged , Humans , Myocardial Infarction/complications , Myocardial Infarction/epidemiology , Myocardial Infarction/therapy , Shock, Cardiogenic/epidemiology , Shock, Cardiogenic/therapy , Treatment Outcome
4.
Am Heart J ; 229: 61-69, 2020 11.
Article in English | MEDLINE | ID: mdl-32916609

ABSTRACT

Cardiovascular disease (CVD) is a major cause of morbidity and mortality. Although it has been widely appreciated that obesity is a major risk factor for CVD, treatments that produce effective, durable weight loss and the impact of weight reduction in reducing cardiovascular risk have been elusive. Instead, progress in CVD risk reduction has been achieved through medications indicated for controlling lipids, hyperglycemia, blood pressure, heart failure, inflammation, and/or thrombosis. Obesity has been implicated as promoting all these issues, suggesting that sustained, effective weight loss may have independent cardiovascular benefit. GLP-1 receptor agonists (RAs) reduce weight, improve glycemia, decrease cardiovascular events in those with diabetes, and may have additional cardioprotective effects. The GLP-1 RA semaglutide is in phase 3 studies as a medication for obesity treatment at a dose of 2.4 mg subcutaneously (s.c.) once weekly. Semaglutide Effects on Heart Disease and Stroke in Patients with Overweight or Obesity (SELECT) is a randomized, double-blind, parallel-group trial testing if semaglutide 2.4 mg subcutaneously once weekly is superior to placebo when added to standard of care for preventing major adverse cardiovascular events in patients with established CVD and overweight or obesity but without diabetes. SELECT is the first cardiovascular outcomes trial to evaluate superiority in major adverse cardiovascular events reduction for an antiobesity medication in such a population. As such, SELECT has the potential for advancing new approaches to CVD risk reduction while targeting obesity.


Subject(s)
Cardiovascular Diseases/prevention & control , Glucagon-Like Peptides , Obesity , Overweight , Weight Loss/drug effects , Cardiotonic Agents/administration & dosage , Cardiotonic Agents/adverse effects , Cardiovascular Diseases/epidemiology , Clinical Trials, Phase III as Topic , Double-Blind Method , Female , Glucagon-Like Peptide 1/agonists , Glucagon-Like Peptides/administration & dosage , Glucagon-Like Peptides/adverse effects , Heart Disease Risk Factors , Humans , Hypoglycemic Agents/administration & dosage , Hypoglycemic Agents/adverse effects , Male , Middle Aged , Obesity/diagnosis , Obesity/drug therapy , Obesity/metabolism , Outcome Assessment, Health Care , Overweight/diagnosis , Overweight/drug therapy , Overweight/metabolism , Randomized Controlled Trials as Topic
6.
Am Heart J ; 187: 1-9, 2017 May.
Article in English | MEDLINE | ID: mdl-28454792

ABSTRACT

BACKGROUND: EXSCEL is a randomized, double-blind, placebo-controlled trial examining the effect of exenatide once-weekly (EQW) versus placebo on time to the primary composite outcome (cardiovascular death, nonfatal myocardial infarction or nonfatal stroke) in patients with type 2 diabetes mellitus (DM) and a wide range of cardiovascular (CV) risk. METHODS: Patients were enrolled at 688 sites in 35 countries. We describe their baseline characteristics according to prior CV event status and compare patients with those enrolled in prior glucagon-like peptide-1 receptor agonist (GLP-1RA) outcomes trials. RESULTS: Of a total of 14,752 participants randomized between June 2010 and September 2015, 6,788 (46.0%) patients were enrolled in Europe; 3,708 (25.1%), North America; 2,727 (18.5%), Latin America; and 1,529 (10.4%), Asia Pacific. Overall, 73% had at least one prior CV event (70% coronary artery disease, 24% peripheral arterial disease, 22% cerebrovascular disease). The median (IQR) age was 63 years (56, 69), 38% were female, median baseline HbA1c was 8.0% (7.3, 8.9) and 16% had a prior history of heart failure. Those without a prior CV event were younger with a shorter duration of diabetes and better renal function than those with at least one prior CV event. Compared with prior GLP-1RA trials, EXSCEL has a larger percentage of patients without a prior CV event and a notable percentage who were taking a dipeptidyl peptidase-4 inhibitor at baseline (15%). CONCLUSIONS: EXSCEL is one of the largest global GLP-1RA trials, evaluating the safety and efficacy of EQW with a broad patient population that may extend generalizability compared to prior GLP-1RA trials (ClinicalTrials.gov number, NCT01144338).


Subject(s)
Cardiovascular Diseases/prevention & control , Diabetes Mellitus, Type 2/drug therapy , Glucagon-Like Peptide-1 Receptor/antagonists & inhibitors , Hypoglycemic Agents/administration & dosage , Peptides/administration & dosage , Venoms/administration & dosage , Aged , Cardiovascular Diseases/mortality , Double-Blind Method , Exenatide , Female , Humans , Hypoglycemic Agents/adverse effects , Male , Middle Aged , Myocardial Infarction/prevention & control , Peptides/adverse effects , Risk Factors , Stroke/prevention & control , Venoms/adverse effects
7.
Coron Artery Dis ; 20(5): 309-16, 2009 Aug.
Article in English | MEDLINE | ID: mdl-19543087

ABSTRACT

AIMS: We hypothesized that the plaque composition and plaque type classification differs between acute coronary syndrome (ACS) and stable angina (SA) patients. METHODS AND RESULTS: We analyzed culprit lesion (CL) and nonculprit lesion (NCL) of ACS patients compared with target lesion (TL) and nontarget lesion (NTL) of SA patients by intravascular ultrasound radio frequency analysis in 874 lesion segments of 424 patients (ACS: 193 patients/SA: 231 patients). Comparing all lesion segments in ACS and SA patients did not show significant differences in absolute or relative plaque composition. However, necrotic core area was larger in CL versus TL (0.9+/-0.7 vs. 0.7+/-0.5 mm, P=0.005) and all plaque components were significantly higher in CL compared with NCL and TL compared with NTL, respectively. A higher amount of thin cap fibroatheroma lesions (15.2 vs. 5.1%, P<0.0001) was detected in ACS compared with SA patients. Fibrocalcific lesions were lower in ACS patients (3 vs. 10.5%, P<0.0001). CONCLUSION: The differentiation in CL/NCL of ACS and TL/NTL of SA patients revealed significant differences in plaque composition and plaque types when examined by intravascular ultrasound radiofrequency analysis. However, considerable overlap between plaque characteristics exists for ACS and SA patients.


Subject(s)
Acute Coronary Syndrome/diagnostic imaging , Angina Pectoris/diagnostic imaging , Angina, Unstable/diagnostic imaging , Coronary Artery Disease/diagnostic imaging , Image Interpretation, Computer-Assisted , Ultrasonography, Interventional , Acute Coronary Syndrome/etiology , Aged , Angina Pectoris/etiology , Angina, Unstable/etiology , Calcinosis/diagnostic imaging , Coronary Artery Disease/complications , Cross-Sectional Studies , Europe , Female , Fibrosis , Humans , Male , Middle Aged , Necrosis , Predictive Value of Tests , Registries , Regression Analysis , United States
8.
Circulation ; 111(6): 768-73, 2005 Feb 15.
Article in English | MEDLINE | ID: mdl-15699258

ABSTRACT

BACKGROUND: Previous comparisons of percutaneous coronary interventions (PCIs) and coronary artery bypass graft (CABG) surgery have demonstrated similar survival but have also generally found better health status outcomes (symptoms, function, and quality of life) with CABG. The principal limitation of PCI has been the occurrence of restenosis. No previous studies comparing the health status outcomes of PCI and CABG have examined differences in these outcomes as a function of patients' preprocedural risk for restenosis. METHODS AND RESULTS: We examined the health status outcomes, using the Seattle Angina Questionnaire (SAQ), among 1459 consecutive patients (1027 treated with PCI and 432, with CABG), stratified by their risk for restenosis. In multivariable-adjusted, linear regression analyses, no differences in 1-year angina or quality of life were observed among the 37.4% of patients at low risk for restenosis. However, among the 46.7% at intermediate risk for restenosis, 1-year health status scores were moderately better after CABG surgery compared with PCI (difference in SAQ angina frequency scores favoring CABG=6.1+/-1.7 points, P=0.0003; difference in SAQ quality of life=5.8+/-1.6 points, P=0.0004). Even larger differences in 1-year outcomes favoring CABG surgery were observed in patients at high risk for restenosis (SAQ angina frequency difference=10.8+/-4.2, P=0.01; SAQ quality of life difference=10.8+/-3.9, P=0.006). CONCLUSIONS: The relative health status benefits of CABG surgery compared with PCI increase as the risk of restenosis increases. Although selecting CABG or PCI is complex, preprocedural restenosis risk should be considered. It should also be tested as a means for considering drug-eluting as opposed to bare metal stents in PCI.


Subject(s)
Angioplasty, Balloon, Coronary/trends , Coronary Artery Bypass/trends , Coronary Restenosis/epidemiology , Health Status Indicators , Aged , Female , Humans , Male , Multivariate Analysis , Quality of Life , Risk Factors , Surveys and Questionnaires
9.
Am J Med ; 114(2): 106-11, 2003 Feb 01.
Article in English | MEDLINE | ID: mdl-12586229

ABSTRACT

There has been much debate concerning an invasive versus a conservative strategy for patients with acute coronary syndromes. The purpose of this study was to determine whether early in-hospital catheterization reduced mortality in patients with unstable angina and non-ST-elevation myocardial infarction. We performed a retrospective analysis of data collected in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb trial, which compared hirudin and heparin in patients with acute coronary syndromes. We identified 8011 patients with non-ST-segment elevation myocardial infarction and unstable angina who were enrolled in the trial. The primary endpoints were all-cause mortality at 30 days and 1 year. Data were analyzed with multivariate hazards models and propensity scores.After accounting for inception time bias, there were 7897 patients identified, of whom 4536 patients (57%) underwent invasive therapy and 3361 (43%) underwent conservative therapy. Adjusting for propensity scores, the adjusted 30-day mortality for the invasive group was 2.5% compared with 2.7% in the conservative group (P = 0.92); at 1 year, the invasive group had a 6.2% mortality, versus 8.6% in the conservative group (P = 0.005). In a multivariate analysis that adjusted for other clinical factors, an invasive strategy was associated with lower 1-year mortality (hazard ratio = 0.46; 95% confidence interval: 0.10 to 0.84). In patients presenting with acute coronary syndromes, an invasive strategy is associated with improved survival at 1 year even after adjusting for baseline differences.


Subject(s)
Angina, Unstable/mortality , Cardiac Catheterization , Heart Conduction System/physiopathology , Myocardial Infarction/mortality , Aged , Angina, Unstable/physiopathology , Clinical Trials as Topic , Female , Humans , Male , Middle Aged , Myocardial Infarction/physiopathology , Retrospective Studies , Risk Factors
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