Accession Site Does Not Influence the Risk of Stroke after Diagnostic Coronary Angiography or Intervention: Results from a Large Prospective Registry.

INTRODUCTION: Periprocedural stroke represents a rare but serious complication of cardiac catheterization. Pooled data from randomized trials evaluating the risk of stroke following cardiac catheterization via transradial versus transfemoral access showed no difference. On the other hand, a significant difference in stroke rates favoring transradial access was found in a recent meta-analysis of observational studies. Our aim was to determine if there is a difference in stroke risk after transradial versus transfemoral catheterization within a contemporary real-world registry. METHODS: Data from 14,139 patients included in a single-center prospective registry between 2009 and 2016 were used to determine the odds of periprocedural transient ischemic attack (TIA) and stroke for radial versus femoral catheterization via multivariate logistic regression with Firth's correction. RESULTS: A total of 10,931 patients underwent transradial and 3,208 underwent transfemoral catheterization. Periprocedural TIA/stroke occurred in 41 (0.29%) patients. Age was the only significant predictor of TIA/stroke in multivariate analysis, with each additional year representing an odds ratio (OR) = 1.09 (CI 1.05-1.13, p < 0.000). The choice of accession site had no impact on the risk of periprocedural TIA/stroke (OR = 0.81; CI 0.38-1.72, p = 0.577). CONCLUSION: Observational data from a large prospective registry indicate that accession site has no influence on the risk of periprocedural TIA/stroke after cardiac catheterization.

Two different techniques of ultrasound-guided peripheral venous catheter placement versus the traditional approach in the pre-hospital emergency setting: a randomized study.

We performed a randomized pre-hospital clinical study to compare two different techniques of ultrasound-guided peripheral venous catheter (PVC) insertion and the conventional cannulation technique in the pre-hospital emergency setting, with a specific focus on the procedural success rate and the time required to introduce PVC. This pre-hospital prospective controlled randomized clinical trial allocated patients treated by emergency medical service to undergo PVC insertion fully controlled by ultrasound (ultrasound guidance of the PVC tip until it penetrates the lumen, group A), PVC insertion partially controlled by ultrasound (target vein identification only, group B) or to receive PVC without any ultrasound guidance (group C). The study outcomes were monitored until the patient was admitted to the hospital. A total of 300 adult patients were enrolled. The success of the first attempt (group A: 88%, group B: 94%, group C: 76%, p < 0.001) and overall success rate (A: 99%, B: 99%, C: 90%, p < 0.001) were significantly higher in the group A, followed by group B when compared to group C. The number of attempts was significantly lower (A: 1.18 ± 0.54, B: 1.05 ± 0.22, C: 1.22 ± 0.57, p < 0.001) and the time required for the procedure shorter (A: 75.3 ± 60.6, B: 43.5 ± 26.0, C: 82.3 ± 100.9 s, p < 0.001) in group B compared to groups A and C. Both techniques of ultrasound-guided PVC placement were associated with higher success rates than the conventional method. However, PVC insertion partially controlled by ultrasound was superior to full ultrasound guidance in terms of time and number of cannulation attempts required.

Correlation between end-tidal carbon dioxide and the degree of compression of heart cavities measured by transthoracic echocardiography during cardiopulmonary resuscitation for out-of-hospital cardiac arrest.

BACKGROUND: The concept of personalized cardiopulmonary resuscitation (CPR) requires a parameter that reflects its hemodynamic efficiency. While intra-arrest ultrasound is increasingly implemented into the advanced life support, we realized a pre-hospital clinical study to evaluate whether the degree of compression of the right ventricle (RV) and left ventricle (LV) induced by chest compressions during CPR for out-of-hospital cardiac arrest (OHCA) and measured by transthoracic echocardiography correlates with the levels of end-tidal carbon dioxide (EtCO2) measured at the time of echocardiographic investigation. METHODS: Thirty consecutive patients resuscitated for OHCA were included in the study. Transthoracic echocardiography was performed from a subcostal view during ongoing chest compressions in all of them. This was repeated three times during CPR in each patient, and EtCO2 levels were registered. From each investigation, a video loop was recorded. Afterwards, maximal and minimal diameters of LV and RV were obtained from the recorded loops and the compression index of LV (LVCI) and RV (RVCI) was calculated as (maximal - minimal/maximal diameter) × 100. Maximal compression index (CImax) defined as the value of LVCI or RVCI, whichever was greater was also assessed. Correlations between EtCO2 and LVCI, RVCI, and CImax were expressed as Spearman's correlation coefficient (r). RESULTS: Evaluable echocardiographic records were found in 18 patients, and a total of 52 measurements of all parameters were obtained. Chest compressions induced significant compressions of all observed cardiac cavities (LVCI = 20.6 ± 13.8%, RVCI = 34.5 ± 21.6%, CImax = 37.4 ± 20.2%). We identified positive correlation of EtCO2 with LVCI (r = 0.672, p < 0.001) and RVCI (r = 0.778, p < 0.001). The strongest correlation was between EtCO2 and CImax (r = 0.859, p < 0.001). We identified that a CImax cut-off level of 17.35% predicted to reach an EtCO2 level > 20 mmHg with 100% sensitivity and specificity. CONCLUSIONS: Evaluable echocardiographic records were reached in most of the patients. EtCO2 positively correlated with all parameters under consideration, while the strongest correlation was found between CImax and EtCO2. Therefore, CImax is a candidate parameter for the guidance of hemodynamic-directed CPR. TRIAL REGISTRATION: ClinicalTrial.gov, NCT03852225 . Registered 21 February 2019 - Retrospectively registered.

Heart failure is the strongest predictor of acute kidney injury in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: ST elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PCI) are at higher risk of acute kidney injury (AKI) than patients undergoing PCI in stable clinical conditions. This fact suggests that mechanisms other than contrast nephrotoxicity are involved. AIM: To evaluate the incidence, risk factors, and consequences of AKI in patients undergoing primary PCI for STEMI in current daily practice. METHODS: Analysis of all consecutive patients who underwent primary PCI over a one-year period. AKI was defined as an increase in serum creatinine ≥ 50% or 26.5 µmol/L (AKIN criteria) from the baseline within 48 h. RESULTS: A total of 202 patients were included. AKI occurred in 25 (12.4%) subjects. Baseline characteristics and in-hospital complications of the patients with and without AKI did not differ significantly except for age (69 ± 13 vs. 62 ± 12; p = 0.003), female gender (48.0% vs. 26.6%; p = 0.035), hypertension (88.0% vs. 62.7%; p = 0.013), left ventricular ejection fraction (40% ± 12% vs. 49% ± 14%; p = 0.002), cardiogenic shock (44.0% vs. 5.1%; p < 0.0001), use of intravenous diuretics (76.0% vs. 26.0%; p < 0.0001), ventricular arrhythmias (24.0% vs. 3.4%; p = 0.001), and in-hospital mortality (24.0% vs. 3.4%; p = 0.001). In multivariate analysis heart failure remained the only independent correlate of AKI. CONCLUSIONS: AKI was an frequent and serious complication of STEMI in patients treated by primary PCI. Heart failure was the strongest predictor of AKI. Other risk factors including contrast medium volume, baseline renal function, diabetes, and age failed to predict AKI.

Trends in cardiovascular mortality and hospitalisations, and potential contribution of inhospital case-fatality rates to changes in national mortality in the Czech Republic 1994-2009.

OBJECTIVES: To analyse trends in cardiovascular disease (CVD) mortality and hospitalisations in the Czech Republic in 1994-2009 and to assess the contribution of inhospital case-fatality rates (CFR) to changes in national CVD mortality. DESIGN: National hospitalisation and mortality registers were used to estimate rates of hospital admissions and mortality for hypertension, angina pectoris, acute myocardial infarction (AMI), chronic ischaemic heart disease chronic (IHD), heart failure and stroke. PATIENTS: All hospitalisations and deaths from CVD during 1994-2009. MAIN OUTCOME MEASURES: Average annual relative changes in age-standardised mortality, hospital admission and inhospital CFR. RESULTS: Between 1994 and 2009, 5 409 407 hospital admissions and 930 659 deaths from CVD were recorded. The age-standardised CVD mortality rate fell from 561 to 357 per 100 000 population (mean annual decline 3.1%) but hospitalisation rates remained relatively stable, with 2800 admissions per 100 000 per year (annual decline 0.7%). Inhospital CFR decreased significantly in all examined diagnoses but most rapidly for AMI (by 5.5% per year) and stroke (4.2% per year). The improvements were larger in the younger population than in elderly persons. Calculations based on unlinked mortality and hospitalisation data suggest that a decline in inhospital CFR may explain approximately 24%, 41% and 61% of the decline in national deaths from IHD, AMI and stroke, respectively. CONCLUSIONS: During the study period, the overall CVD hospitalisation rates remained high but inhospital CFR declined considerably. The improved case-fatality seems to have made a substantial contribution to the decline in the national CVD mortality, particularly for AMI and stroke.

Prevention of contrast-induced acute kidney injury by theophylline in elderly patients with chronic kidney disease.

Although the optimal strategy for preventing contrast-induced acute kidney injury (CI-AKI) has not yet been established, the current strategy focuses on adequate periprocedural hydration, the use of a low amount of low or iso-osmolar contrast medium, and the application of adjunctive therapies, including hemofiltration, hemodialysis and drugs. Previous trials and meta-analyses concerning the use of the adenosine antagonist theophylline have revealed contradictory results. We sought to evaluate the effect of theophylline in CI-AKI prevention in well-hydrated elderly patients with chronic kidney disease. We therefore conducted a randomized, double-blind, placebo-controlled trial involving 56 patients who had been referred for cardiac coronary angiography and/or angioplasty. 31 of these patients were randomly assigned to 200 mg theophylline IV before the procedure, and 25 to a placebo. The iso-osmolar contrast medium iodixanol was used. The primary endpoint was an increase in serum creatinine at study termination 48 h after contrast medium administration. Baseline characteristics in the placebo and theophylline groups were similar in terms of median age (75 years), estimated glomerular filtration rate (33 ± 10 vs. 33 ± 10 ml/min/1.73 m²; p = 0.87), diabetes mellitus (80 vs. 71%; p = 0.54), and amount of contrast used (94 ± 35 vs. 95 ± 38 ml; p = 0.89). There was no difference in serum creatinine at baseline (2.06 ± 0.59 vs. 2.02 ± 0.45 mg/dl; p = 0.62) or study termination (2.06 ± 0.68 vs. 2.10 ± 0.53; p = 0.79). A prophylactic effect of theophylline was not observed. The incidence of renal impairment following exposure to the contrast medium was low. This fact can be attributed to adequate parenteral hydratation and the use of the minimum amount of contrast medium necessary.

Inverse correlation between plasma Beta-carotene and interleukin-6 in patients with advanced coronary artery disease.

The interrelationships between plasma beta-carotene, alpha-tocopherol, and the level of systemic inflammation and oxidative stress were investigated in patients with advanced coronary artery disease (CAD). Plasma beta-carotene, alpha-tocopherol, malondialdehyde, free radicals, interleukin-6, high sensitive C-reactive protein levels, and other risk factors of CAD were determined in a group of patients with advanced CAD [significant stenosis according to coronarographic examination (n=91) and a control group of examined patients with coronary arteries with no stenosis (n=49)]. Between-group differences in continuous variables were analyzed with the Hotelling T2-test (software NCSS2000), analyses of correlation matrix with the software STATISTICA. Advanced CAD coincided with significantly lower plasma concentrations of high-density lipoprotein (HDL)-cholesterol and beta-carotene as well as with elevated levels of all inflammatory markers, but only with mild increase of oxidative stress. Beta-carotene significantly inversely correlated with interleukin-6. This inverse correlation could suggest potential protective effect of beta-carotene on atherosclerosis due to the inhibition of inflammatory processes.

Ubiquinol-10/lipids ratios in consecutive patients with different angiographic findings.

OBJECTIVE: Information concerning un-supplemented plasma concentrations of ubiquinol-10 in coronary artery disease patients is still controversial. The aim of this study is to determine the levels of plasma ubiquinol-10 and ratios of ubiquinol-10 to plasma lipids in consecutive patients with different angiographic findings. SUBJECTS AND METHODS: Thirty-six consecutive patients who underwent coronary angiography were split in two groups with different atherosclerotic changes. These patients were un-supplemented with antioxidants and were not treated by lipid-lowering medication. We have measured a plasma level of ubiquinol-10 using high-performance liquid chromatography with coulometric detection. Conventional plasma lipids, markers of oxidative stress and other widely accepted risk factors of atherosclerosis have been determined too. RESULTS: Plasma ubiquinol-10 to low-density lipoprotein cholesterol (LDL-C) ratios in patients with different angiographic findings have been found as 180+/-69 and 132+/-43, respectively (p=0.020). The ubiquinol-10/LDL-C ratio was significantly lower in angiographically positive patients. There were also significant differences in ubiquinol-10 per total cholesterol (109+/-47 and 80+/-26, respectively; p=0.031), per triglycerides (426+/-191 and 237+/-86, respectively; p=0.002) and per the sum of triglycerides and total cholesterol (86+/-35 and 61+/-20, respectively; p=0.013). CONCLUSIONS: There have not been found any significant differences between levels of widely accepted risk factors for genesis and progress of atherosclerotic changes in these two groups of patients. Only the level of triglycerides and the total cholesterol minus high-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio were significantly higher in patients with stenosis. This ratio correlated with the ubiquinol-10/LDL-C ratio, which was significantly lower in patients with stenosis. Our results indicate that the ratio of ubiquinol-10/LDL-C is likely to be a risk factor for atherogenesis.