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Frontiers in Cardiovascular Medicine 2024Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary... (Review)
Review
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
PubMed: 38545346
DOI: 10.3389/fcvm.2024.1354158 -
JAMA Internal Medicine Aug 2023The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care; however, whether rates of IMV vary among countries is unclear.
IMPORTANCE
The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care; however, whether rates of IMV vary among countries is unclear.
OBJECTIVE
To estimate the per capita rates of IMV in adults across 3 high-income countries with large variation in per capita intensive care unit (ICU) bed availability.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study examined 2018 data of patients aged 20 years or older who received IMV in England, Canada, and the US.
EXPOSURE
The country in which IMV was received.
MAIN OUTCOMES AND MEASURES
The main outcome was the age-standardized rate of IMV and ICU admissions in each country. Rates were stratified by age, specific diagnoses (acute myocardial infarction, pulmonary embolus, upper gastrointestinal bleed), and comorbidities (dementia, dialysis dependence). Data analyses were conducted between January 1, 2021, and December 1, 2022.
RESULTS
The study included 59 873 hospital admissions with IMV in England (median [IQR] patient age, 61 [47-72] years; 59% men, 41% women), 70 250 in Canada (median [IQR] patient age, 65 [54-74] years; 64% men, 36% women), and 1 614 768 in the US (median [IQR] patient age, 65 [54-74] years; 57% men, 43% women). The age-standardized rate per 100 000 population of IMV was the lowest in England (131; 95% CI, 130-132) compared with Canada (290; 95% CI, 288-292) and the US (614; 95% CI, 614-615). Stratified by age, per capita rates of IMV were more similar across countries among younger patients and diverged markedly in older patients. Among patients aged 80 years or older, the crude rate of IMV per 100 000 population was highest in the US (1788; 95% CI, 1781-1796) compared with Canada (694; 95% CI, 679-709) and England (209; 95% CI, 203-214). Concerning measured comorbidities, 6.3% of admitted patients who received IMV in the US had a diagnosis of dementia (vs 1.4% in England and 1.3% in Canada). Similarly, 5.6% of admitted patients in the US were dependent on dialysis prior to receiving IMV (vs 1.3% in England and 0.3% in Canada).
CONCLUSIONS AND RELEVANCE
This cohort study found that patients in the US received IMV at a rate 4 times higher than in England and twice that in Canada in 2018. The greatest divergence was in the use of IMV among older adults, and patient characteristics among those who received IMV varied markedly. The differences in overall use of IMV among these countries highlight the need to better understand patient-, clinician-, and systems-level choices associated with the varied use of a limited and expensive resource.
Topics: Male; Humans; Female; Aged; Middle Aged; Respiration, Artificial; Cohort Studies; Renal Dialysis; Hospitalization; Dementia; Retrospective Studies
PubMed: 37358834
DOI: 10.1001/jamainternmed.2023.2371 -
Clinical Nutrition (Edinburgh, Scotland) Nov 2023Both during and after hospitalization, nutritional care with daily intake of oral nutritional supplements (ONS) improves health outcomes and decreases risk of mortality... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND & AIMS
Both during and after hospitalization, nutritional care with daily intake of oral nutritional supplements (ONS) improves health outcomes and decreases risk of mortality in malnourished older adults. In a post-hoc analysis of data from hospitalized older adults with malnutrition risk, we sought to determine whether consuming a specialized ONS (S-ONS) containing high protein and beta-hydroxy-beta-methylbutyrate (HMB) can also improve Quality of Life (QoL).
METHODS
We analyzed data from the NOURISH trial-a randomized, placebo-controlled, multi-center, double-blind study conducted in patients with congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. Patients received standard care + S-ONS or placebo beverage (target 2 servings/day) during hospitalization and for 90 days post-discharge. SF-36 and EQ-5D QoL outcomes were assessed at 0-, 30-, 60-, and 90-days post-discharge. To account for the missing QoL observations (27.7%) due to patient dropout, we used multiple imputation. Data represent differences between least squares mean (LSM) values with 95% Confidence Intervals for groups receiving S-ONS or placebo treatments.
RESULTS
The study population consisted of 622 patients of mean age ±standard deviation: 77.9 ± 8.4 years and of whom 52.1% were females. Patients consuming placebo had lower (worse) QoL domain scores than did those consuming S-ONS. Specifically for the SF-36 health domain scores, group differences (placebo vs S-ONS) in LSM were significant for the mental component summary at day 90 (-4.23 [-7.75, -0.71]; p = 0.019), the domains of mental health at days 60 (-3.76 [-7.40, -0.12]; p = 0.043) and 90 (-4.88 [-8.41, -1.34]; p = 0.007), vitality at day 90 (-3.33 [-6.65, -0.01]; p = 0.049) and social functioning at day 90 (-4.02 [-7.48,-0.55]; p = 0.023). Compared to placebo, differences in LSM values for the SF-36 general health domain were significant with improvement in the S-ONS group at hospital discharge and beyond: day 0 (-2.72 [-5.33, -0.11]; p = 0.041), day 30 (-3.08 [-6.09, -0.08]; p = 0.044), day 60 (-3.95 [-7.13, -0.76]; p = 0.015), and day 90 (-4.56 [-7.74, -1.38]; p = 0.005).
CONCLUSIONS
In hospitalized older adults with cardiopulmonary diseases and evidence of poor nutritional status, daily intake of S-ONS compared to placebo improved post-discharge QoL scores for mental health/cognition, vitality, social functioning, and general health. These QoL benefits complement survival benefits found in the original NOURISH trial analysis.
CLINICAL TRIAL REGISTRATION
NCT01626742.
Topics: Female; Humans; Aged; Male; Quality of Life; Aftercare; Patient Discharge; Dietary Supplements; Hospitalization; Malnutrition; Nutritional Status
PubMed: 37757502
DOI: 10.1016/j.clnu.2023.09.004 -
Asian Journal of Andrology Oct 2023To evaluate the relationship between testosterone replacement therapy (TRT) and arterial and/or venous thrombosis in patients with pre-treatment total testosterone (TT)...
To evaluate the relationship between testosterone replacement therapy (TRT) and arterial and/or venous thrombosis in patients with pre-treatment total testosterone (TT) <12 nmol l-1, we performed a meta-analysis following the Population Intervention Comparison Outcome model. Population: men with TT <12 nmol l-1 or clear mention of hypogonadism in the inclusion criteria of patients; intervention: TRT; comparison: placebo or no therapy; outcomes: arterial thrombotic events (stroke, myocardial infarction [MI], upper limbs, and lower limbs), VTE (deep vein thrombosis [DVT], portal vein thrombosis, splenic thrombosis, and pulmonary embolism), and mortality. A total of 2423 abstracts were assessed for eligibility. Twenty-four studies, including 14 randomized controlled trials (RCTs), were finally included, with a total of 4027 and 310 288 hypotestosteronemic male patients, from RCTs and from observational studies, respectively. Based on RCT-derived data, TRT did not influence the risk of arterial thrombosis (odds ratio [OR] = 1.27, 95% confidence interval [CI]: 0.47-3.43, P = 0.64), stroke (OR = 1.34, 95% CI: 0.09-18.97, P = 0.83), MI (OR = 0.51, 95% CI: 0.11-2.31, P = 0.39), VTE (OR = 1.42, 95% CI: 0.22-9.03, P = 0.71), pulmonary embolism (OR = 1.38, 95% CI: 0.27-7.04, P = 0.70), and mortality (OR = 0.70, 95% CI: 0.20-2.38, P = 0.56). Meanwhile, when only observational studies are considered, a significant reduction in the risk of developing arterial thrombotic events, MI, venous thromboembolism, and mortality was observed. The risk for DVT remains uncertain, due to the paucity of RCT-based data. TRT in men with TT <12 nmol l-1 is safe from the risk of adverse cardiovascular events. Further studies specifically assessing the risk of DVT in men on TRT are needed.
PubMed: 37921515
DOI: 10.4103/aja202352 -
Clinical Cardiology Jul 2023To investigate the efficacy and safety of percutaneous closure of ventricular septal rupture (VSR) after acute myocardial infarction (AMI).
OBJECTIVE
To investigate the efficacy and safety of percutaneous closure of ventricular septal rupture (VSR) after acute myocardial infarction (AMI).
METHODS
This retrospective study included 81 patients who underwent transcatheter closure for postinfarction VSR. We analyzed clinical data from hospitalization and the 30-day follow-up, compared clinical data from the survival and death groups, and explored the best closure time and the safety and efficacy of occlusion. The risk factors for death at 30 days were analyzed by logistic regression.
RESULTS
C-reactive protein (CRP), white blood cell counts, N-terminal pro brain natriuretic peptide (NT-ProBNP), and aspartate aminotransferase were higher in the death group than in the survival group (p < .01), with a higher rate of application of vasoactive drugs, and a shorter time from AMI to operation (p < .05). At 30 days postocclusion, 19 patients (23.5%) had died. The mortality rate was significantly lower for operation performed 3 weeks after AMI than for operation performed within 3 weeks of AMI (12.5% vs. 48%, p < .001). Devices were successfully implanted in 76 patients, with 16 (21.1%) operation-related complications and 12 (15.8%) valve injuries. Cardiac function improved significantly (p < .001) at discharge (N = 66) and 30 days after procedure (N = 62). Qp/Qs and pulmonary artery systolic pressure decreased significantly, while aortic systolic pressure increased significantly (p < .001). Additionally, EF and LVDd improved (p < .05) after occlusion. Increases in CRP and NT-ProBNP were risk factors for death at 30 days after closure (p < .05).
CONCLUSION
Percutaneous VSR closure can be a valuable treatment option for suitable patients with VSR.
Topics: Humans; Ventricular Septal Rupture; Retrospective Studies; Myocardial Infarction; Risk Factors; Logistic Models
PubMed: 37190920
DOI: 10.1002/clc.24027 -
JAMA Network Open Sep 2023American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited.
IMPORTANCE
American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited.
OBJECTIVE
To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance.
DESIGN, SETTING, AND PARTICIPANTS
This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023.
MAIN OUTCOMES AND MEASURES
The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]).
RESULTS
Among 220 598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127 402 were female (57.8%), 78 438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98 833) were diagnosed with diabetes, 61.3% (135 124) were diagnosed with hyperlipidemia, and 72.2% (159 365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61 125 patients) in 2015 and 36.7% (68 130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36 288 patients) in 2015 and 21.4% (39 857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14 899 patients] vs 2019: 9.3% [25 175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110 244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43 589 patients).
CONCLUSIONS AND RELEVANCE
In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.
Topics: Aged; Female; Humans; Male; American Indian or Alaska Native; Atrial Flutter; Cardiovascular Diseases; Cohort Studies; Coronary Artery Disease; Heart Failure; Ischemic Attack, Transient; Medicare; Stroke; United States; Insurance Benefits; Cost of Illness; Incidence; Prevalence; Comorbidity; Risk Factors; Cardiometabolic Risk Factors; Social Determinants of Health; Poverty
PubMed: 37738051
DOI: 10.1001/jamanetworkopen.2023.34923 -
ELife Nov 2023Compelling evidence has accumulated on the role of oxidative stress on the endothelial cell (EC) dysfunction in acute coronary syndrome. Unveiling the underlying...
Compelling evidence has accumulated on the role of oxidative stress on the endothelial cell (EC) dysfunction in acute coronary syndrome. Unveiling the underlying metabolic determinants has been hampered by the scarcity of appropriate cell models to address cell-autonomous mechanisms of EC dysfunction. We have generated endothelial cells derived from thrombectomy specimens from patients affected with acute myocardial infarction (AMI) and conducted phenotypical and metabolic characterizations. AMI-derived endothelial cells (AMIECs) display impaired growth, migration, and tubulogenesis. Metabolically, AMIECs displayed augmented ROS and glutathione intracellular content, with a diminished glucose consumption coupled to high lactate production. In AMIECs, while PFKFB3 protein levels of were downregulated, PFKFB4 levels were upregulated, suggesting a shunting of glycolysis towards the pentose phosphate pathway, supported by upregulation of G6PD. Furthermore, the glutaminolytic enzyme GLS was upregulated in AMIECs, providing an explanation for the increase in glutathione content. Finally, AMIECs displayed a significantly higher mitochondrial membrane potential than control ECs, which, together with high ROS levels, suggests a coupled mitochondrial activity. We suggest that high mitochondrial proton coupling underlies the high production of ROS, balanced by PPP- and glutaminolysis-driven synthesis of glutathione, as a primary, cell-autonomous abnormality driving EC dysfunction in AMI.
Topics: Humans; Reactive Oxygen Species; Endothelial Cells; Metabolic Reprogramming; Oxidative Stress; Glycolysis; Glutathione; Myocardial Infarction; Phosphofructokinase-2
PubMed: 38014932
DOI: 10.7554/eLife.86260 -
American Journal of Cardiovascular... 2023Takotsubo syndrome is comparable to microvascular acute coronary syndrome. It may partly share the same pathophysiology debated during scorpion envenomation (SE), with... (Review)
Review
BACKGROUND
Takotsubo syndrome is comparable to microvascular acute coronary syndrome. It may partly share the same pathophysiology debated during scorpion envenomation (SE), with an adrenergic storm, without myocardial infarction due to the absence of coronary artery stenosis. Takotsubo cardiomyopathy can help to better understand the pathophysiology of cardiac involvement during scorpion envenomation. However, Takotsubo syndrome seems to be underestimated in the literature in patients suffering from cardiac failure following SE.
METHODS
In this review, we aimed to detail all described cases, the mechanism, and outcomes of scorpion envenomation complicated by Takotsubo cardiomyopathy. We used the PubMed database by using the following keywords in MeSH research: scorpion envenomation, Takotsubo cardiomyopathy, and Takotsubo syndrome.
RESULTS
The literature analysis showed the existence of only four cases of confirmed Takotsubo cardiomyopathy following severe SE. All four patients developed a transient reversible left ventricular systolic dysfunction in the absence of coronary artery disease, following a positive history of scorpion envenomation. A cardiac MRI was performed in all cases, showing a ballooning in the left ventricle associated with a left ventricular ejection fraction in all cases. All patients were improved under symptomatic treatment, and complete recovery of the wall motion was observed.
CONCLUSION
Takotsubo syndrome, although not often reported in the literature in severe SE, can represent an effective hypothesis explaining the pathophysiology of cardiac involvement during SE. In severe scorpion envenomation, multiple mechanisms exist and can explain the development of Takotsubo syndrome. Its management is based on oxygen, with invasive or non-invasive ventilator support in patients with respiratory failure and/or cardiogenic shock. Beta-blockers, mineralocorticoid receptor antagonists, and diuretics are usually used in Takotsubo syndrome. However, in severe scorpion envenomation, all reported cases of Takotsubo cardiomyopathy are associated with cardiogenic shock and acute pulmonary edema. As a consequence, we advise the use of Dobutamine since it has already been confirmed that cardiac dysfunction following scorpion envenomation improves well and safely under Dobutamine infusion.
PubMed: 38205067
DOI: No ID Found -
European Journal of Epidemiology Oct 2023Previous research on the potential chemoprotective effect of aspirin for colorectal cancer (CRC) shows conflicting results. We aimed to emulate a trial of aspirin...
BACKGOUND AND AIMS
Previous research on the potential chemoprotective effect of aspirin for colorectal cancer (CRC) shows conflicting results. We aimed to emulate a trial of aspirin intiation in individuals with incident polyps.
METHODS
We identified individuals registered with their first colorectal polyp in the nationwide gastrointestinal ESPRESSO histopathology cohort in Sweden. Individuals aged 45-79 years diagnosed with colorectal polyps 2006-2016 in Sweden without CRC or contraindications for preventive aspirin (cerebrovascular disease, heart failure, aortic aneurysms, pulmonary emboli, myocardial infarction, gastric ulcer, dementia, liver cirrhosis, or any other metastatic cancer) registered until the month of first polyp detection were eligible. Using duplication and inverse probability weighting, we emulated a target trial of aspirin initiation within 2 years of initial polyp detection. The main outcome measures were incident CRC, CRC mortality and all-cause mortality registered until 2019.
RESULTS
Of 31,633 individuals meeting our inclusion criteria, 1716 (5%) initiated aspirin within 2 years of colon polyp diagnosis. Median follow-up was 8.07 years. The 10-year cumulative incidence in initiators versus non-initiators was 6% versus 8% for CRC incidence, 1% versus 1% for CRC mortality and 21% versus 18% for all-cause mortality. The corresponding hazard ratios were 0.88 (95% confidence interval, 95%CI = 0.86-0.90), 0.90 (95%CI = 0.75-1.06) and 1.18 (95%CI = 1.12-1.24).
CONCLUSION
Aspirin initiation in individuals with polyp removal was linked to 2% lower cumulative incidence of CRC after 10 years but did not alter CRC mortality. We also observed a 4% increased risk difference of all-cause mortality at 10 years after the initiation of aspirin.
PubMed: 37322135
DOI: 10.1007/s10654-023-01024-1 -
PloS One 2023Myocardial infarction (MI) is diagnosed when there is a rise in cardiac biomarkers along with supportive evidence in the form of typical symptoms, suggestive...
Electrocardiogram and echocardiography findings and the outcomes of patients with myocardial infarction: Retrospective study in tertiary care hospitals in Northwest Ethiopia.
BACKGROUND
Myocardial infarction (MI) is diagnosed when there is a rise in cardiac biomarkers along with supportive evidence in the form of typical symptoms, suggestive electrocardiographic (ECG) changes, or imaging evidence of a new loss of viable myocardium or a new regional wall motion abnormality. The data regarding the use of ECG and echocardiography (Echo) findings and their impact on mortality are still lacking in Ethiopia. This study assessed the utilization of ECG and Echo findings and outcomes of patients with MI in tertiary care hospitals in Northwest Ethiopia.
METHODS
A retrospective chart review was conducted on patients with MI who were admitted to the adult intensive care units (ICUs) of two selected hospitals between January 2018 and July 30, 2021. Data was entered and analyzed using the SPSS 25 software. Logistic regression analysis was used to assess the association between in-hospital mortality and other variables. A P-value < 0.05 was considered significant.
RESULTS
Among the 203 participants, 67.5% were male, and the mean age of the participants was 59 (13.8). Around two-thirds (66.5%) of patients had STEMI and a regional all-motion abnormality. More than half (54.1%) of the cases were in the anteroapical region. For MI, there was a 23.2% inconsistency between ECG and Echo findings. The rate of in-hospital mortality for patients with MI was 23%. Pulmonary hypertension [AOR = 7.8, 95% CI: 1.72-34.93], inferobasal regional wall motion abnormality [AOR = 7.9, 95% CI: 1.340-46.093], Killip's classes III and IV [AOR = 2.7, 95% CI: 1.103-6.314], infection [AOR = 3.2, 95% CI: 1.108-10.65], and ischemic stroke [AOR = 1.9, 95% CI: 1.091-5.222] were significantly associated with in-hospital mortality compared with their counterparts.
CONCLUSIONS
The mortality of patients with MI in this study was higher than in other reports. Killip's class, pulmonary hypertension, infection, ischemic stroke, and inferobasal regional wall motion abnormalities were significantly associated with the in-hospital mortality of the patients with MI. There was a higher degree of inconsistency between ECG and Echo findings. The treatment of patients with MI should be tailored to their specific risk factors and causes.
Topics: Adult; Humans; Male; Female; Retrospective Studies; Hypertension, Pulmonary; Ethiopia; Tertiary Care Centers; Myocardial Infarction; Electrocardiography; Echocardiography
PubMed: 37540698
DOI: 10.1371/journal.pone.0288698