RESUMEN
We examined behavioural risk factors and quality of life (QoL) in women and men, younger and older adults 12 months after a Rapid Access Cardiology Clinic (RACC) visit. Routine clinical care data were collected in person from three Sydney hospitals between 2017 and 2018 and followed up by questionnaire at 365 days. 1491 completed the baseline survey, at 1 year, 1092 provided follow-up data on lifestyle changes, and 811 completed the EQ-5D-5L (QoL) survey. 666 (44.7%) were women, and 416 (27.9%) were older than 60 years of age. Almost 50% of participants reported improving physical activity and diet a year after their RACC visit. These changes were less likely in women and older participants.
Asunto(s)
Instituciones de Atención Ambulatoria , Cardiopatías , Calidad de Vida , Anciano , Femenino , Humanos , Masculino , Estilo de Vida , Factores de Riesgo , Encuestas y CuestionariosAsunto(s)
Síndrome Coronario Agudo , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Infarto del Miocardio , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Síndrome Coronario Agudo/tratamiento farmacológico , Alta del Paciente , Hospitales , Cumplimiento de la MedicaciónRESUMEN
BACKGROUND: Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery. METHODS: In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined. RESULTS: One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630 mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life-threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death. CONCLUSION: This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.
Asunto(s)
Intervención Coronaria Percutánea , Anciano , Estudios de Cohortes , Puente de Arteria Coronaria , Femenino , Hospitales , Humanos , Masculino , Stents , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: Chest pain is a large health care burden in Australia and around the world. Its management requires specialist assessment and diagnostic tests, which can be costly and often lead to unnecessary hospital admissions. There is a growing unmet clinical need to improve the efficiency and management of chest pain. This study aims to show the cost-benefit of rapid access chest pain clinics (RACC) as an alternative to hospital admission. DESIGN: Retrospective cost-benefit analysis for 12 months. SETTING: RACCs in three Sydney tertiary referral hospitals. MAIN OUTCOME MEASURES: Cost per patient. RESULTS: Hospitals A, B and C implemented RACCs but each operating with slightly different staffing, referral patterns, and diagnostic services. All RACCs had similar costs per patient of AUD$455.25, AUD$427.12 and AUD$474.45, hospitals A, B and C respectively, and similar cost benefits per patient of AUD$1,168.75, AUD$1,196.88 and AUD$1,149.55, respectively. At least 28%, 26% and 29% of these RACC patients for hospitals A, B, and C, respectively, would have otherwise had to have been admitted to hospital for the model to be cost-beneficial. CONCLUSION: This study shows that a RACC model of care is cost-beneficial in the state of NSW as an alternative strategy to inpatient care for managing chest pain. Scaling up to a national level could represent an even larger benefit for the Australian health system.
Asunto(s)
Dolor en el Pecho , Clínicas de Dolor , Australia/epidemiología , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/epidemiología , Dolor en el Pecho/terapia , Análisis Costo-Beneficio , Humanos , Estudios RetrospectivosRESUMEN
Australian guidelines recommend prompt evaluation of patients presenting to emergency departments with chest pain, found to be low risk for acute coronary syndromes, and cardiologist-led Rapid Access Chest Pain Clinics (RACPC) have been proposed as a model to provide such care. Initial Australian experience of RACPCs suggests excellent short-term outcomes, and that they are cost-beneficial, though little data exists examining longer-term outcomes. The present study therefore examines such longer-term outcomes to beyond 5 years following presentation to an RACPC in an Australian tertiary metropolitan centre.
Asunto(s)
Dolor en el Pecho , Clínicas de Dolor , Instituciones de Atención Ambulatoria , Australia/epidemiología , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/epidemiología , Dolor en el Pecho/etiología , Servicio de Urgencia en Hospital , HumanosRESUMEN
THE CHALLENGES: Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. MAIN RECOMMENDATIONS: Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include.
Asunto(s)
Cardiología , Enfermedades Cardiovasculares , Control de Enfermedades Transmisibles , Infecciones por Coronavirus , Pandemias , Manejo de Atención al Paciente/métodos , Neumonía Viral , Servicios de Salud Rural , Telemedicina/métodos , Australia/epidemiología , Betacoronavirus , COVID-19 , Cardiología/métodos , Cardiología/organización & administración , Cardiología/tendencias , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/terapia , Control de Enfermedades Transmisibles/métodos , Control de Enfermedades Transmisibles/organización & administración , Consenso , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/prevención & control , Humanos , Área sin Atención Médica , Nueva Zelanda/epidemiología , Pandemias/prevención & control , Neumonía Viral/epidemiología , Neumonía Viral/prevención & control , Servicios de Salud Rural/organización & administración , Servicios de Salud Rural/tendencias , SARS-CoV-2 , Sociedades MédicasRESUMEN
Background Remote ischemic preconditioning (RIPC) attenuates myocardial damage during elective and primary percutaneous coronary intervention. Recent studies suggest that coronary microcirculatory function is an important determinant of clinical outcome. The aim of this study was to assess the effect of RIPC on markers of microcirculatory function. Methods and Results Patients referred for cardiac catheterization and fractional flow reserve measurement were randomized to RIPC or sham. Operators and patients were blinded to treatment allocation. Comprehensive physiological assessments were performed before and after RIPC/sham including the index of microcirculatory resistance and coronary flow reserve after intracoronary glyceryl trinitrate and during the infusion of intravenous adenosine. Thirty patients were included (87% male; mean age: 63.1±10.0 years). RIPC and sham groups were similar with respect to baseline characteristics. RIPC decreased the calculated index of microcirculatory resistance (median, before RIPC: 22.6 [interquartile range [IQR]: 17.9-25.6]; after RIPC: 17.5 [IQR: 14.5-21.3]; P=0.007) and increased coronary flow reserve (2.6±0.9 versus 3.8±1.7, P=0.001). These RIPC-mediated changes were associated with a reduction in hyperemic transit time (median: 0.33 [IQR: 0.26-0.40] versus 0.25 [IQR: 0.20-0.30]; P=0.010). RIPC resulted in a significant decrease in the calculated index of microcirculatory resistance compared with sham (relative change with treatment [mean±SD] was -18.1±24.8% versus +6.1±37.5; P=0.047) and a significant increase in coronary flow reserve (+41.2% [IQR: 20.0-61.7] versus -7.8% [IQR: -19.1 to 10.3]; P<0.001). Conclusions The index of microcirculatory resistance and coronary flow reserve are acutely improved by remote ischemic preconditioning. This raises the possibility that RIPC confers cardioprotection during percutaneous coronary intervention as a result of an improvement in coronary microcirculatory function. Clinical Trial Registration URL: www.anzctr.org.au/ . Unique identifier: CTRN12616000486426.
Asunto(s)
Enfermedad de la Arteria Coronaria/terapia , Circulación Coronaria/fisiología , Vasos Coronarios/fisiopatología , Precondicionamiento Isquémico Miocárdico/métodos , Microcirculación/fisiología , Resistencia Vascular/fisiología , Enfermedad de la Arteria Coronaria/fisiopatología , Procedimientos Quirúrgicos Electivos , Electrocardiografía , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Intervención Coronaria PercutáneaRESUMEN
Dual antiplatelet therapy, consisting of aspirin and a P2Y12 receptor antagonist, has been the cornerstone of management in those undergoing percutaneous coronary intervention, reducing stent thromboses and cardiovascular events. Given the pivotal role of aspirin in cardiovascular disease management, patients with aspirin hypersensitivity pose complex clinical challenges. Allergy to aspirin is reported in 1.5-2.6% of patients presenting with cardiac disease. Identification of the subtype of aspirin hypersensitivity will determine suitability for aspirin desensitization, dictate choice of desensitization protocol and inform risk management. Aspirin desensitization is an effective and viable clinical strategy, although it remains underutilised in clinical practice. Collaboration between cardiologists and immunologists should be strongly encouraged to facilitate optimal management of such patients. This review describes the complexity of managing patients with aspirin hypersensitivity in cardiac disease, the indications and risks of aspirin desensitization, and the approach to management of the minority of patients who are unsuitable for desensitization.
Asunto(s)
Aspirina/uso terapéutico , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Desensibilización Inmunológica/métodos , Hipersensibilidad a las Drogas , Tolerancia a Medicamentos , Hipersensibilidad a las Drogas/epidemiología , Hipersensibilidad a las Drogas/etiología , Hipersensibilidad a las Drogas/terapia , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéuticoRESUMEN
BACKGROUND: Chest pain is the second most common presenting symptom to emergency departments (ED) in Australia, although up to 85% of these patients do not have an acute coronary syndrome (ACS). Cardiologist-led rapid access chest pain clinics (RACPC) have been proposed overseas to assist in the management of such patients, with prompt outpatient assessment if patients are deemed low risk and discharged from the ED. The use of RACPCs in Australia has been only recently proposed; we therefore sought to examine one such RACPC in an Australian context. METHODS AND RESULTS: 1133 consecutive patients were seen at a metropolitan RACPC, between August 2008 and February 2017. There was a high preponderance of cardiovascular risk factors. Exercise stress testing (EST) was the default investigation upon discharge from ED, with a total of 1038 ESTs performed in 1113 patients (93%), with low numbers of other functional tests, and a small, but increasing number of coronary computed tomography (CT) scans performed over this period. Eighteen patients subsequently underwent revascularisation (1.6% of the total cohort), and none of these patients were readmitted at any time with an ACS between the interval of their index ED presentation to these investigations or treatments. Five (0.4%) patients represented to ED within 48hours, none due to a cardiovascular cause. A total of 24 (2.1%) patients represented between 2 and 28 days, with none of these due to an ACS. CONCLUSIONS: Following ED assessment of acute chest pain as low risk-with direct ED referral for exercising testing followed by RACPC review-results in very low readmission rates at 48hours and at 28 days. Moreover, these readmissions were almost always not of cardiovascular aetiology, and occurred despite relatively longer waiting periods for both EST (8 days) and between EST and RACPC review (11 days), than the prespecified 72 to 96hours as defined by the clinic protocol. Further investigation into this model of care in Australia is suggested.
Asunto(s)
Dolor en el Pecho/diagnóstico , Servicio Ambulatorio en Hospital/estadística & datos numéricos , Clínicas de Dolor/estadística & datos numéricos , Medición de Riesgo/métodos , Dolor en el Pecho/epidemiología , Dolor en el Pecho/etiología , Diagnóstico Diferencial , Electrocardiografía , Prueba de Esfuerzo , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/epidemiología , Nueva Gales del Sur/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
AIMS: Biodegradable polymer drug-eluting stents (BP-DES) were developed in hopes of reducing the risk of stent thrombosis. The comparison of this new stent platform with second-generation durable polymer drug-eluting stents (DP-DES) has not been well described. We, therefore, performed a meta-analysis to evaluate the safety and efficacy profiles of BP-DES versus second-generation DP-DES in patients with coronary artery disease. METHODS AND RESULTS: Electronic database searches were conducted, from their dates of inception to June 2018, to identify randomized controlled trials (RCTs) comparing patients with either BP-DES or second-generation DP-DES. Risk estimates were expressed as risk ratios (RRs) with 95% confidence intervals (CIs). We also performed a landmark analysis beyond 1 year and sensitivity analyses based on different variables. A total of 24,406 patients from 19 RCTs were included in the present meta-analysis. There were no significant differences between BP-DES and second-generation DP-DES for the risks of definite or probable stent thrombosis (RR 0.88; 95% CI, 0.69-1.12; P = 0.29), myocardial infarction (RR 0.97; 95% CI, 0.86-1.09; P = 0.59), cardiac death (RR 1.08; 95% CI, 0.92-1.28; P = 0.34), all-cause death (RR 1.02; 95% CI, 0.91-1.13; P = 0.77), target lesion revascularization (RR 1.05; 95% CI, 0.94-1.17; P = 0.38), and target vessel revascularization (RR 1.05; 95% CI, 0.95-1.16; P = 0.36). Similar outcomes were observed regardless of anti-proliferative drug and duration of dual antiplatelet therapy (all P > 0.05). CONCLUSION: Our findings demonstrate similar safety and efficacy profiles between BP-DES and second-generation BP-DES, with comparable rates of stent thrombosis.
RESUMEN
A case of left-main stem STEMI presenting "out of hours" is discussed, wherein an excellent result was achieved with acute thrombolysis.
Asunto(s)
Fibrinolíticos/uso terapéutico , Intervención Coronaria Percutánea , Cuidados Posoperatorios/métodos , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Terapia Trombolítica/métodos , Angiografía Coronaria , Vasos Coronarios/diagnóstico por imagen , Electrocardiografía , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/cirugía , Factores de TiempoRESUMEN
In this case, prompt stenting of the dissection entry flap allowed for stabilization and eventual healing of a severe catheter-induced aortic dissection, without resort to surgical intervention.
Asunto(s)
Aneurisma de la Aorta Torácica/terapia , Disección Aórtica/terapia , Catéteres/efectos adversos , Aneurisma Coronario/terapia , Intervención Coronaria Percutánea/efectos adversos , Stents , Espera Vigilante/métodos , Anciano , Disección Aórtica/diagnóstico , Disección Aórtica/etiología , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/etiología , Angiografía por Tomografía Computarizada , Aneurisma Coronario/diagnóstico , Aneurisma Coronario/etiología , Angiografía Coronaria , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Estudios de Seguimiento , Humanos , Masculino , Intervención Coronaria Percutánea/instrumentación , Reoperación , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
OBJECTIVE: Whether revascularisation is superior to medical therapy in older populations presenting with non-ST-elevation acute coronary syndromes (NSTEACS) remains contentious, with inconclusive evidence from randomised trials. We aimed to compare routine invasive therapy with initial medical management in the elderly presenting with NSTEACS. METHODS: MEDLINE, EMBASE and Cochrane Controlled Trial Register were searched for studies comparing routine invasive therapy with initial medical management in patients ≥75 years old presenting with NSTEACS. Endpoints included long-term mortality, myocardial infarction (MI), revascularisation, rehospitalisation, stroke and major bleeding reported as ORs. RESULTS: Four randomised trials and three observational studies met inclusion criteria, enrolling a total of 20 540 patients followed up from 6 months to 5 years. Routine invasive therapy reduced mortality (OR 0.67, CI 0.61 to 0.74), MI (OR 0.56, CI 0.45 to 0.70) and stroke (OR 0.53, CI 0.30 to 0.95). Analyses restricted to randomised controlled trials (RCTs) confirmed a reduction in MI (OR 0.51, CI 0.40 to 0.66), revascularisation (OR 0.27, CI 0.13 to 0.56) and a trend to reduced mortality (OR 0.84, CI 0.66 to 1.06) at the expense of major bleeding (OR 2.19, CI 1.12 to 4.28). Differences in major bleeding were unapparent in more recent studies. CONCLUSION: Routine invasive therapy reduces MI and repeat revascularisation and may reduce mortality at the expense of major bleeding in elderly patients with NSTEACS. Our findings highlight the need for further RCTs to better determine the effect on mortality and contemporary bleeding risk.
Asunto(s)
Fármacos Cardiovasculares/uso terapéutico , Puente de Arteria Coronaria , Infarto del Miocardio sin Elevación del ST/terapia , Intervención Coronaria Percutánea , Factores de Edad , Anciano , Anciano de 80 o más Años , Fármacos Cardiovasculares/efectos adversos , Distribución de Chi-Cuadrado , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Femenino , Hemorragia/etiología , Humanos , Masculino , Infarto del Miocardio sin Elevación del ST/diagnóstico , Infarto del Miocardio sin Elevación del ST/mortalidad , Oportunidad Relativa , Readmisión del Paciente , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Recurrencia , Factores de Riesgo , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Lipid-rich plaque (LRP) is thought to be a precursor to cardiac events. However, its clinical significance in coronary arteries has never been systematically investigated. OBJECTIVES: This study investigated the prevalence and clinical significance of LRP in the nonculprit region of the target vessel in patients undergoing percutaneous coronary intervention (PCI). METHODS: The study included 1,474 patients from 20 sites across 6 countries undergoing PCI, who had optical coherence tomography (OCT) imaging of the target vessel. Major adverse cardiac events (MACE) were defined as a composite of cardiac death, acute myocardial infarction, and ischemia-driven revascularization. Patients were followed for up to 4 years (median of 2 years). RESULTS: Lipid-rich plaque was detected in nonculprit regions of the target vessel in 33.6% of patients. The cumulative rate of nonculprit lesion-related MACE (NC-MACE) over 48 months in patients with LRP was higher than in those without LRP (7.2% vs. 2.6%, respectively; p = 0.033). Acute coronary syndrome at index presentation (risk ratio: 2.538; 95% confidence interval [CI]: 1.246 to 5.173; p = 0.010), interruption of statin use ≥1 year (risk ratio: 4.517; 95% CI: 1.923 to 10.610; p = 0.001), and LRP in nonculprit regions (risk ratio: 2.061; 95% CI: 1.050 to 4.044; p = 0.036) were independently associated with increased NC-MACE. Optical coherence tomography findings revealed that LRP in patients with NC-MACE had longer lipid lengths (p < 0.001), wider maximal lipid arcs (p = 0.023), and smaller minimal lumen areas (p = 0.003) than LRPs in patients without MACE. CONCLUSIONS: Presence of LRP in the nonculprit regions of the target vessel by OCT predicts increased risk for future NC-MACE, which is primarily driven by revascularization for recurrent ischemia. Lipid-rich plaque with longer lipid length, wider lipid arc, and higher degree of stenosis identified patients at higher risk of future cardiac events. (The Massachusetts General Hospital Optical Coherence Tomography Registry; NCT01110538).
Asunto(s)
Síndrome Coronario Agudo , Vasos Coronarios , Lípidos , Efectos Adversos a Largo Plazo , Infarto del Miocardio , Placa Aterosclerótica , Tomografía de Coherencia Óptica/métodos , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/fisiopatología , Síndrome Coronario Agudo/terapia , Anciano , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patología , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Efectos Adversos a Largo Plazo/diagnóstico , Efectos Adversos a Largo Plazo/epidemiología , Efectos Adversos a Largo Plazo/fisiopatología , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Infarto del Miocardio/fisiopatología , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/estadística & datos numéricos , Placa Aterosclerótica/diagnóstico por imagen , Placa Aterosclerótica/patología , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Recurrencia , Medición de Riesgo/métodos , Índice de Severidad de la EnfermedadRESUMEN
Chest pain is common and places a significant burden on hospital resources. Many patients with undifferentiated low- to intermediate-risk chest pain are admitted to hospital. Rapid-access cardiology (RAC) services are hospital co-located, cardiologist-led outpatient clinics that provide rapid assessment and immediate management but not long-term management. This service model is described as part of chest pain management and the National Service Framework for coronary heart disease in the United Kingdom (UK). We review the evidence on the effectiveness, safety and acceptability of RAC services. Our review finds that early assessment in RAC outpatient services of patients with suspected angina, without high-risk features suspicious of an acute coronary syndrome, is safe, can reduce hospitalisations, is cost effective and has good medical practitioner and patient acceptability. However, the literature is limited in that the evaluation of this model of care has been only in the UK. It is potentially suited to other settings and needs further evaluation in other settings to assess its utility.