The American journal of cardiology
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Randomized Controlled Trial Comparative Study
Preventive strategies of renal insufficiency in patients with diabetes undergoing intervention or arteriography (the PREVENT Trial).
Few studies have compared the ability of sodium bicarbonate plus N-acetylcysteine (NAC) and sodium chloride plus NAC to prevent contrast-induced nephropathy (CIN) in diabetic patients with impaired renal function undergoing coronary or endovascular angiography or intervention. Diabetic patients (n = 382) with renal disease (serum creatinine ≥1.1 mg/dl and estimated glomerular filtration rate <60 ml/min/1.73 m(2)) were randomly assigned to receive prophylactic sodium chloride (saline group, n = 189) or sodium bicarbonate (bicarbonate group, n = 193) before elective coronary or endovascular angiography or intervention. All patients received oral NAC 1,200 mg 2 times/day for 2 days. ⋯ The primary end point was met in 10 patients (5.3%) in the saline group and 17 (9.0%) in the bicarbonate group (p = 0.17), with 2 (1.1%) and 4 (2.1%), respectively, requiring hemodialysis (p = 0.69). Rates of death, myocardial infarction, and stroke did not differ significantly at 1 month and 6 months after contrast exposure. In conclusion, hydration with sodium bicarbonate is not superior to hydration with sodium chloride in preventing CIN in patients with diabetic nephropathy undergoing coronary or endovascular angiography or intervention.
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Current guidelines recommend that >75% of patients with ST-elevation myocardial infarction (STEMI) receive primary percutaneous coronary intervention (PPCI) within 90 minutes. The goal has been hardly achievable, so we conducted a 2-year before-and-after study to determine the impact of emergency department (ED) tele-electrocardiographic (tele-ECG) triage and interventional cardiologist activation of the infarct team at door-to-balloon time (D2BT) and the proportion of patients undergoing PPCI within 90 minutes since arrival. In total 105 consecutive patients with acute STEMI (mean age 62 ± 13 years, 82% men) were studied, 54 before and 51 after the change in protocol. ⋯ Median D2BT of the tele-ECG group was 86 minutes, significantly shorter than the median time of 125 minutes of the control group (p <0.0001). The proportion of patients who achieved a D2BT <90 minutes increased from 44% in the control group to 76% in the tele-ECG group (p = 0.0001). In conclusion, implementation of ED tele-ECG triage and interventional cardiologist activation of the infarct team can significantly shorten D2BT and result in a larger proportion of patients achieving guideline recommendations.
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Our aim was to evaluate the effectiveness of oral anticoagulation (OAC) in patients aged ≥80 years with nonvalvular atrial fibrillation in daily clinical practice. From February 1, 2000 to June 30, 2009, we enrolled all patients aged ≥80 years with nonvalvular atrial fibrillation attended at 2 outpatient cardiology clinics of a tertiary care university hospital. The patients received antithrombotic treatment according to the recommendations from scientific societies and were prospectively followed, with major events (i.e., all-cause death, stroke, transient ischemic attack, peripheral embolism, severe bleeding) analyzed according to the treatment group (OAC vs no OAC). ⋯ After adjustment for age, gender, coronary heart disease, and embolic risk, evaluated using the CHADS(2) score (congestive heart failure, 1 point; hypertension [blood pressure consistently >140/90 mm Hg or hypertension medication], 1 point; age ≥75 years, 1 point; diabetes mellitus, 1 point; previous stroke or transient ischemic attack, 2 points), only OAC was an independent predictor of embolic events (hazard ratio 0.17, 95% confidence interval 0.07 to 0.41, p <0.001). The CHADS(2) score (hazard ratio 1.32, 95% confidence interval 1.01 to 1.73, p = 0.04) and OAC (hazard ratio 0.52, 95% confidence interval 0.31 to 0.88, p = 0.01) were independent predictors of mortality. In conclusion, OAC according to the scientific societies' recommendations is effective and safe in daily clinical practice, even in patients aged ≥80 years.
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Meta Analysis Comparative Study
Meta-analysis of multivessel coronary artery revascularization versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease.
American College of Cardiology/American Heart Association guidelines for management of patients with ST-segment elevation myocardial infarction (STEMI) recommend culprit artery-only revascularization (CULPRIT) based on safety concerns during noninfarct-related artery intervention. However, the data to support this safety concern are scant. Searches were performed in PubMed/EMBASE/CENTRAL for studies evaluating multivessel revascularization versus CULPRIT in patients with STEMI and multivessel disease (MVD). ⋯ Similarly, for long-term outcomes (follow-up 2.0 ± 1.1 years), there was no difference for outcomes of MI, target vessel revascularization, and stent thrombosis, with 33%, 43%, and 53% decreases in risk of mortality, repeat percutaneous coronary intervention, coronary artery bypass grafting, respectively, and major adverse cardiovascular events (odds ratio 0.60, 95% confidence interval 0.50 to 0.72) with multivessel revascularization compared to CULPRIT. In conclusion, in patients with STEMI and MVD, multivessel revascularization appears to be safe compared to culprit artery-only revascularization. These findings support the need for a large-scale randomized trial to evaluate revascularization strategies in patients with STEMI and MVD.
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Comparative Study
Real-time three-dimensional transesophageal echocardiography for assessment of mitral valve functional anatomy in patients with prolapse-related regurgitation.
The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) for surgically recognized mitral valve (MV) prolapse anatomy compared to 2-dimensional transthoracic echocardiography (2D-TTE), 2D-transesophageal echocardiography (2D-TEE), and real-time 3D-transthoracic echocardiography (RT3D-TTE). We preoperatively analyzed 222 consecutive patients undergoing repair for prolapse-related mitral regurgitation using RT3D-TEE, 2D-TEE, RT3D-TTE, and 2D-TTE. Multiplanar reconstruction was added to volume-rendered RT3D-TEE for quantitative prolapse recognition. ⋯ Multiplanar reconstruction enabled RT3D-TEE to differentiate dominant (≥5-mm displacement) and secondary (2 to <5-mm displacement) prolapsed segments in agreement with surgically recognized dominant lesions (100%), but with a low predictive value (34%) for secondary lesions. In addition, owing to the identification of clefts and subclefts (indentations of MV tissue that extended ≥50% or <50% of the total leaflet height, respectively), RT3D-TEE accurately characterized the MV anatomy, including that which deviated from the standard nomenclature. In conclusion, RT3D-TEE provided more accurate mapping of MV prolapse than 2D imaging and RT3D-TTE, adding quantitative recognition of dominant and secondary lesions and MV anatomy details.