RESUMEN
Diabetes is an independent risk factor for development of heart failure and has been associated with poor outcomes in these patients. The prevalence of diabetes continues to rise. Using routine HbA1c measurements on inpatients at a tertiary hospital, we aimed to investigate the prevalence of diabetes amongst patients hospitalised with decompensated heart failure and the association of dysglycaemia with hospital outcomes and mortality. 1191 heart failure admissions were identified and of these, 49% had diabetes (HbA1c ≥ 6.5%) and 34% had pre-diabetes (HbA1c 5.7-6.4%). Using a multivariable analysis adjusting for age, Charlson comorbidity score (excluding diabetes and age) and estimated glomerular filtration rate, diabetes was not associated with length of stay (LOS), Intensive Care Unit (ICU) admission or 28-day readmission. However, diabetes was associated with a lower risk of 6-month mortality. This finding was also supported using HbA1c as a continuous variable. The diabetes group were more likely to have diastolic dysfunction and to be on evidence-based cardiac medications. These observational data are hypothesis generating and possible explanations include that more diabetic patients were on medications that have proven mortality benefit or prevent cardiac remodelling, such as renin-angiotensin system antagonists, which may modulate the severity of heart failure and its consequences.
Asunto(s)
Diabetes Mellitus/epidemiología , Hemoglobina Glucada/análisis , Insuficiencia Cardíaca/sangre , Anciano , Anciano de 80 o más Años , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Diabetes Mellitus/sangre , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/tratamiento farmacológico , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Humanos , Pacientes Internos , Tiempo de Internación/estadística & datos numéricos , Masculino , Readmisión del Paciente/estadística & datos numéricos , Prevalencia , Factores de Riesgo , Índice de Severidad de la Enfermedad , Análisis de SupervivenciaRESUMEN
Radiological interventions play an increasingly relevant role in cardiology. Due to the inherent risks of ionizing radiation, proper care must be taken with monitoring and optimizing the dose delivered in angiograms to pose as low risk as possible to staff and patients. Dose optimization is particularly pertinent in teaching hospitals, where longer procedure times are at times necessary to accommodate the teaching needs of junior staff, and thus impart a more significant radiation dose. This study aims to analyze the effects of different protocol settings in routine coronary angiograms, from the perspective of a large tertiary center implementing a rapid dose reduction program. Routine coronary angiograms were chosen to compare baseline levels of radiation, and the dose imparted before and after dose optimization techniques was measured. Such methods included lowering dose per pulse, fluoroscopic pulse rates, and cine acquisition frame rates. The results showed up to 63% reduction in radiation dose without adverse impact on clinical or teaching outcomes. A 10 fps/low and 5 pps/low setting was found to achieve maximum dose optimization, with the caveat that settings require incremental changes to accommodate for patient complexities.
RESUMEN
BACKGROUND: Guidelines recommend prasugrel or ticagrelor instead of clopidogrel in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary interventions (PCI). AIM: We sought to describe the trends in uptake of the newer agents and analyse the clinical characteristics and short-term outcomes of patients treated with clopidogrel, prasugrel or ticagrelor. METHODS: We analysed the temporal trends of antiplatelet use since the availability of prasugrel (2009-2013) in patients with ACS from the Melbourne Interventional Group registry. To assess clinical characteristics and outcomes, we included 1850 patients from 2012 to 2013, corresponding to the time all three agents were available. The primary outcome was major adverse cardiovascular events (MACE). The safety end-point was in-hospital bleeding. RESULTS: For the period of 2009-2013, the majority of patients were treated with clopidogrel (72%) compared with prasugrel (14%) or ticagrelor (14%). There was a clear trend towards ticagrelor by the end of 2013. Patients treated with clopidogrel were more likely to present with non-ST-elevation ACS, be older, and have more comorbidities. There was no difference in unadjusted 30-day mortality (0.9 vs 0.5 vs 1.0%, P = 0.76), myocardial infarction (2 vs 1 vs 2%, P = 0.52) or MACE (3 vs 3 vs 4%, P = 0.57) between the three agents. There was no difference in in-hospital bleeding (3 vs 2 vs 2%, P = 0.64). CONCLUSION: Prasugrel and ticagrelor are increasingly used in ACS patients treated with PCI, predominantly in a younger cohort with less comorbidity. Although antiplatelet therapy should still be individualised based on the thrombotic and bleeding risk, our study highlights the safety of the new P2Y12 inhibitors in contemporary Australian practice.
Asunto(s)
Síndrome Coronario Agudo/terapia , Adenosina/análogos & derivados , Clorhidrato de Prasugrel/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Ticlopidina/análogos & derivados , Síndrome Coronario Agudo/mortalidad , Adenosina/efectos adversos , Adenosina/uso terapéutico , Anciano , Anciano de 80 o más Años , Australia/epidemiología , Clopidogrel , Comorbilidad , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/inducido químicamente , Intervención Coronaria Percutánea , Clorhidrato de Prasugrel/efectos adversos , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , Sistema de Registros , Ticagrelor , Ticlopidina/efectos adversos , Ticlopidina/uso terapéutico , Resultado del TratamientoRESUMEN
BACKGROUND: The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. When applied in multiple centres overseas, the rate of inappropriate referrals was as high as 22%. AIM: To assess the applicability of, and the level of adherence to the 2011 AUC in an Australian regional hospital where the AUC have not been tested systematically. METHODS: A retrospective analysis of 1000 inpatient and outpatient TTE referrals was conducted between January 2014 and June 2014 at Bendigo Hospital, a major regional referral hospital. RESULTS: Ninety-eight percent of the TTE referrals were classifiable. The most common indication for ordering TTE was to evaluate symptoms potentially related to a cardiac aetiology. Of the classifiable referrals, 77% were appropriate, 20.3% were inappropriate and 2.7% were uncertain. The most common inappropriate indications were routine surveillance of the left ventricular (LV) function in stable chronic cardiac conditions and routine perioperative evaluation of the LV function with no symptoms or signs of cardiovascular disease. Inappropriate referrals were significantly more frequent in outpatients compared with inpatients (24.4% vs 9.6%, P < 0.001). CONCLUSION: This study provides a novel insight into the ordering of TTEs in regional Australia. In this study, one in five referrals had an inappropriate indication and could be avoided. This may have significant implications for healthcare resources in regional centres, and strategies to reduce inappropriate echocardiography ordering need to be implemented.
Asunto(s)
Ecocardiografía/estadística & datos numéricos , Ecocardiografía/normas , Hospitales Generales/normas , Evaluación de Programas y Proyectos de Salud/normas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Australia/epidemiología , Enfermedades Cardiovasculares/diagnóstico por imagen , Enfermedades Cardiovasculares/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Victoria/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Although dual antiplatelet therapy is the standard of care in non-ST-segment elevation acute coronary syndromes (NSTEACS), it remains unclear when a second antiplatelet agent should be initiated. We sought to assess the safety and efficacy of pre-treatment with clopidogrel in patients with NSTEACS undergoing percutaneous coronary intervention (PCI). METHODS: We analysed baseline clinical and procedural characteristics of 6817 patients with NSTEACS who underwent PCI from the Melbourne Interventional Group registry from 2005 to 2012. Patients were included in the pre-treatment group if clopidogrel was administered prior to cardiac catheterisation. We assessed 30-day mortality, myocardial infarction (MI) and major adverse cardiovascular events. The safety endpoint was in-hospital bleeding. RESULTS: Of the 6817 patients, only 2951 (43%) received pre-treatment with clopidogrel. Patients in the pre-treatment group were more likely to present with unstable angina (70.8% vs 68.2%, P = 0.02) and have a history of MI (35.6% vs 23.6%, P < 0.01) but were less likely to have PCI within 24 h of admission (17.2% vs 25.2%, P < 0.01). There was no difference between the groups in 30-day mortality (0.9% vs 1.4%, P = 0.06), MI (2.0% vs 2.2%, P = 0.52) or major adverse cardiovascular event (3.7% vs 4.2%, P = 0.25). There was no difference in bleeding complications (1.9% vs 1.9%, P = 0.94). CONCLUSIONS: Pre-treatment with dual antiplatelet therapy in NSTEACS is not routine clinical practice in Australia. Pre-treatment appears safe but is not associated with improved short-term clinical outcomes.
Asunto(s)
Síndrome Coronario Agudo/cirugía , Infarto del Miocardio/epidemiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Complicaciones Posoperatorias , Ticlopidina/análogos & derivados , Anciano , Aspirina/uso terapéutico , Australia , Clopidogrel , Femenino , Hemorragia/etiología , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/etiología , Inhibidores de Agregación Plaquetaria/efectos adversos , Sistema de Registros , Ticlopidina/administración & dosificación , Ticlopidina/efectos adversos , Resultado del TratamientoRESUMEN
Coronary angiographies that are performed via the radial artery generally have lower bleeding complications, however, patients are at risk of radial artery occlusion, with resultant digital ischaemia. This report describes a case of digital ischaemia after transradial coronary angiography in a patient with essential thrombocytosis. Risk factors for thrombo-occlusive complications, and potential prevention strategies are also explored.
Asunto(s)
Arteriopatías Oclusivas/etiología , Angiografía Coronaria/efectos adversos , Arteria Radial , Trombocitemia Esencial/diagnóstico por imagen , Femenino , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: This study aimed to evaluate the feasibility and accuracy of 16-slice computed tomography (CT) in the assessment of coronary stent patency. CT coronary angiography (CA) has a high degree of accuracy in the assessment of coronary artery disease compared with invasive selective CA. However, its accuracy in the evaluation of stent patency is not well investigated. METHODS: We conducted a retrospective observational study of paired CT coronary angiography (CT-CA) and invasive fluoroscopic coronary angiography (FCA) in 37 patients with 47 coronary stents. CT-CA was carried out with an electrocardiogram-gated 16-slice CT (LightSpeed-16, General Electric (GE), WI, USA). Two CT reporters, blinded to the FCA findings, assessed CT images for stent patency. A cardiologist blinded to CT findings reported FCA. FCA was regarded as the reference standard. RESULTS: A CT-CA could assess 45 of 47 coronary stents (96%). Non-assessable stents on CT-CA were due to motion artefacts and stent-blooming effects. Of those 45 assessable stents, CT-CA correctly identified five out of seven stents with binary in-stent restenosis (ISR) and 37 of 38 stents without binary ISR. The sensitivity and specificity of 16-slice CT in the evaluation of coronary stents for binary ISR were 71% (95% confidence interval (CI) (29%, 96%)) and 97% (95%CI (86%, 100%)), respectively, exclusive of non-assessable stents. The positive and negative predictive values of 16-slice CT were 83% (95%CI (36%, 100%)) and 95% (95%CI (83%, 99%)), respectively. CONCLUSION: Sixteen-slice CT has a low sensitivity, but very a high specificity when compared with FCA in the evaluation of coronary stents for ISR.