RESUMEN
BACKGROUND: Although telemedicine has been proven to have significant potential for improving care for patients with cardiac problems, there remains a substantial risk of introducing disparities linked to the use of digital technology, especially for older or socially vulnerable subgroups. OBJECTIVE: We investigated factors influencing adherence to a telemedicine-delivered health education intervention in patients with ischemia, emphasizing demographic and socioeconomic considerations. METHODS: We conducted a descriptive, observational, prospective cohort study in consecutive patients referred to our cardiology center for acute coronary syndrome, from February 2022 to January 2023. Patients were invited to join a web-based health educational meeting (WHEM) after hospital discharge, as part of a secondary prevention program. The WHEM sessions were scheduled monthly and used a teleconference software program for remote synchronous videoconferencing, accessible through a standard computer, tablet, or smartphone based on patient preference or availability. RESULTS: Out of the 252 patients (median age 70, IQR 61.0-77.3 years; n=189, 75% male), 98 (38.8%) declined the invitation to participate in the WHEM. The reasons for nonacceptance were mainly challenges in handling digital technology (70/98, 71.4%), followed by a lack of confidence in telemedicine as an integrative tool for managing their medical condition (45/98, 45.9%), and a lack of internet-connected devices (43/98, 43.8%). Out of the 154 patients who agreed to participate in the WHEM, 40 (25.9%) were unable to attend. Univariable logistic regression analysis showed that the presence of a caregiver with digital proficiency and a higher education level was associated with an increased likelihood of attendance to the WHEM, while the converse was true for increasing age and female sex. After multivariable adjustment, higher education level (odds ratio [OR] 2.26, 95% CI 1.53-3.32; P<.001) and caregiver with digital proficiency (OR 12.83, 95% CI 5.93-27.75; P<.001) remained independently associated with the outcome. The model discrimination was good even when corrected for optimism (optimism-corrected C-index=0.812), as was the agreement between observed and predicted probability of participation (optimism-corrected calibration intercept=0.010 and slope=0.948). CONCLUSIONS: This study identifies a notable lack of suitability for a specific cohort of patients with ischemia to participate in our telemedicine intervention, emphasizing the risk of digital marginalization for a significant portion of the population. Addressing low digital literacy rates among patients or their informal caregivers and overcoming cultural bias against remote care were identified as critical issues in our study findings to facilitate the broader adoption of telemedicine as an inclusive tool in health care.
RESUMEN
Left ventricular (LV) dyssynchrony (LVdys) is a necessary condition for successful cardiac resynchronization therapy (CRT). Despite left bundle branch block (LBBB) representing a reliable surrogate of LVdys, not all LBBB patients will respond to CRT. Our aim was to investigate the relation between QRS duration and LVdys in patients with LBBB who underwent CRT. We retrospectively studied 165 patients with LBBB who underwent CRT implantation according to the current guidelines. A 6-month reduction of LV end-systolic volume ≥15% identified responders to CRT. Baseline LVdys was defined as the delay between peak systolic velocities of the interventricular septum and lateral wall assessed by color-coded tissue Doppler imaging. Baseline characteristics of responders (61%) and nonresponders (39%) were comparable except for larger QRS complex (172 ± 24 vs 160 ± 16 ms, p <0.001) and lower degree of LVdys (46 ± 42 vs 72 ± 31 ms, p <0.001) in nonresponders. Receiver-operating characteristic curve analysis demonstrated that an optimal cut-off value of 3 for the ratio of QRS duration and LVdys (QRS/LVdys) yielded a sensitivity of 66% and specificity of 80% to predict nonresponsiveness to CRT; QRS/LVdys >3 remained an independent predictor at multivariate analysis. In patients with nonischemic origin of cardiomyopathy, the linear regression analysis documented a significant inverse relation between QRS duration and LVdys, as dyssynchrony progressively decreased as QRS widening increased (p = 0.006). This was not evident in patients with ischemic origin. In conclusion, in LBBB patients with nonischemic origin and marked QRS widening, the absence of LVdys may account for a lower response to CRT compared with patients with intermediate QRS widening.
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Bloqueo de Rama/fisiopatología , Terapia de Resincronización Cardíaca/métodos , Desfibriladores Implantables , Electrocardiografía , Ventrículos Cardíacos/fisiopatología , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Anciano , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/terapia , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Sistema de Conducción Cardíaco/fisiopatología , Frecuencia Cardíaca/fisiología , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Left bundle branch block (LBBB) is the most reliable electrocardiographic predictor of responsiveness to cardiac resynchronization therapy (CRT). However, not all patients with LBBB will respond to CRT. Our aim was to investigate the interaction between QRS duration, LBBB-type morphology, and the responsiveness to CRT. We retrospectively analyzed electrocardiograms of 243 patients who underwent CRT implantation according to current clinical indications. A 6-month reduction of left ventricular end-systolic volume >15% was used to identify CRT responders. The clinical end point consisted of death, hospitalization for heart failure and sustained rapid ventricular tachyarrhythmias. An LBBB morphology was present in 169 patients (70%) and 101 of these (60%) were responders to CRT. Analyzing the interaction between QRS duration and CRT responsiveness in patients with LBBB, a "U shaped" distribution resulted, with nonresponders clustered between 120 and 130 ms and above 180 ms. The receiver operating characteristic curve analysis identified 178 ms as the optimal cut-off value of QRS to predict a nonresponsiveness to CRT (area under the curve = 0.67 [95% confidence interval 0.57 to 0.76]). At multivariate analysis, only an ischemic cause and a QRS ≥178 ms were independent predictors of nonresponsiveness to CRT (area under the curve = 0.75). Patients with LBBB with QRS ≥178 ms had greater likelihood of adverse clinical events during a mean follow-up of 32 months (p = 0.049). In conclusion, in patients with LBBB undergoing CRT, a marked QRS widening (i.e., ≥178 ms) is related to worse echocardiographic responsiveness and lower event free survival rate compared with patients with an intermediate QRS widening.
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Terapia de Resincronización Cardíaca/métodos , Electrocardiografía , Insuficiencia Cardíaca/terapia , Función Ventricular Izquierda/fisiología , Remodelación Ventricular/fisiología , Anciano , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Myocarditis is associated with a broad spectrum of clinical and electrocardiographic manifestations, ranging from completely asymptomatic courses to signs of myocardial infarction or cardiogenic shock. Endomyocardial biopsy is considered the gold standard for the diagnosis of myocarditis; however, in clinical practice, cardiovascular magnetic resonance (CMR) plays a leading role, being the most accurate noninvasive method for tissue characterization. We report the case of a 22-year-old patient hospitalized for acute precordial pain associated with ST-segment elevation in leads DI and aVL, mimicking acute myocardial infarction, in whom CMR led to the correct diagnosis of acute focal myocarditis.
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Imagen por Resonancia Magnética/métodos , Infarto del Miocardio/diagnóstico , Miocarditis/diagnóstico , Enfermedad Aguda , Biopsia , Dolor en el Pecho/etiología , Electrocardiografía , Humanos , Masculino , Infarto del Miocardio/fisiopatología , Miocarditis/fisiopatología , Adulto JovenRESUMEN
BACKGROUND: The optimal duration of dual-antiplatelet therapy and the risk-benefit ratio for long-term dual-antiplatelet therapy after coronary stenting remain poorly defined. We evaluated the impact of up to 6 versus 24 months of dual-antiplatelet therapy in a broad all-comers patient population receiving a balanced proportion of Food and Drug Administration-approved drug-eluting or bare-metal stents. METHODS AND RESULTS: We randomly assigned 2013 patients to receive bare-metal, zotarolimus-eluting, paclitaxel-eluting, or everolimus-eluting stent implantation. At 30 days, patients in each stent group were randomly allocated to receive up to 6 or 24 months of clopidogrel therapy in addition to aspirin. The primary end point was a composite of death of any cause, myocardial infarction, or cerebrovascular accident. The cumulative risk of the primary outcome at 2 years was 10.1% with 24-month dual-antiplatelet therapy compared with 10.0% with 6-month dual-antiplatelet therapy (hazard ratio, 0.98; 95% confidence interval, 0.74-1.29; P=0.91). The individual risks of death, myocardial infarction, cerebrovascular accident, or stent thrombosis did not differ between the study groups; however, there was a consistently greater risk of hemorrhage in the 24-month clopidogrel group according to all prespecified bleeding definitions, including the recently proposed Bleeding Academic Research Consortium classification. CONCLUSIONS: A regimen of 24 months of clopidogrel therapy in patients who had received a balanced mixture of drug-eluting or bare-metal stents was not significantly more effective than a 6-month clopidogrel regimen in reducing the composite of death due to any cause, myocardial infarction, or cerebrovascular accident. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00611286.
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Vasos Coronarios/cirugía , Stents Liberadores de Fármacos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Anciano , Anciano de 80 o más Años , Aspirina/uso terapéutico , Causas de Muerte , Clopidogrel , Reestenosis Coronaria/mortalidad , Reestenosis Coronaria/prevención & control , Quimioterapia Combinada , Everolimus , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/prevención & control , Paclitaxel/uso terapéutico , Riesgo , Sirolimus/análogos & derivados , Sirolimus/uso terapéutico , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Trombosis/mortalidad , Trombosis/prevención & control , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico , Resultado del TratamientoRESUMEN
BACKGROUND: Detection of markers of incipient syncope in patients with vasovagal syncope (VVS), without prodromal symptom, is still an open issue. The aim of this study was to assess the behavior of heart rate (HR) and ejection time, expressed as the percentage of the corresponding cardiac cycle (ET%), in patients with bradycardic VVS with a view to providing an alarm before the event. METHODS: In 33 patients with syncope and positive tilt testing and in 33 control patients, we collected beat-to-beat data on HR, ET%, stroke volume (SV), and blood pressure (BP). The trends of HR and ET% were analyzed. A set of combined changes of HR and ET% were tested in order to select the most appropriate algorithm for detecting the incipient syncope within the 3 minutes preceding the event. RESULTS: In patients with positive tilt testing, BP significantly decreased at 3 minutes before and at the time of syncope (P < 0.0001). HR slowly rose at 3 minutes before syncope and then suddenly decreased at the time of syncope (P < 0.0001). The correlation between SV and ET% was r = 0.79 (P < 0.0001). SV and ET% significantly decreased throughout tilt testing (P < 0.0001). The selected setting for the algorithm provided sensitivity of 97% and specificity of 73%. The theoretical alarm was generated at least 9 and 5 seconds before syncope, respectively, in 76% and 85% of the subjects. CONCLUSION: The combined trends in HR and ET% may provide a marker of incipient bradycardic VVS in the majority of patients.
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Bradicardia/diagnóstico , Hemodinámica/fisiología , Síncope Vasovagal/diagnóstico , Adolescente , Adulto , Anciano , Algoritmos , Biomarcadores , Presión Sanguínea/fisiología , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Sensibilidad y Especificidad , Volumen Sistólico/fisiología , Pruebas de Mesa Inclinada , Adulto JovenRESUMEN
AIMS: There are conflicting reports on the presence of subtle haemodynamic alterations during orthostatic stress in subjects with vasovagal syncope (VVS). The aim of the present study was to investigate whether young/middle-aged subjects with VVS show abnormal responses to orthostatic stress. METHODS AND RESULTS: Four groups of subjects underwent tilt testing (TT) during the passive phase and, if negative, after nitroglycerin administration: Group I, 20 subjects with a history of syncope and positive passive TT; Group II, 23 subjects with a history of syncope and TT positive after nitroglycerin; Group III, 23 subjects with a history of syncope and negative TT; and Group IV, 20 normal control subjects. Heart rate, systolic, diastolic, and mean blood pressure, stroke volume, cardiac output, and total peripheral resistance were computed from pressure pulsations (Modelflow). The demographic data and the values of the haemodynamic variables in the supine position did not differ significantly among the four groups. The per cent changes in these variables did not differ significantly among the four groups after 2 and 5 min of TT and among Groups II, III, and IV, 2 min after nitroglycerin administration. CONCLUSION: Young/middle-aged subjects with VVS have a normal measured haemodynamic response to orthostatic stress; therefore, the vasovagal reflex is not secondary to an impairment of the primary vasoconstrictive mechanism.
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Velocidad del Flujo Sanguíneo , Presión Sanguínea , Mareo/fisiopatología , Síncope Vasovagal/fisiopatología , Pruebas de Mesa Inclinada/métodos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
AIMS: In patients with vasovagal syncope (VVS), a neural reflex appears the main determinant of hypotension leading to loss of consciousness; whether hypotension is mainly due to involvement of the arterial system or the venous system remains a debated issue. The aim of the present study was to assess which of these two systems is responsible for the fall in blood pressure (BP) in patients with VVS; to this end, a haemodynamic study was carried out not only before and during loss of consciousness but also during the recovery phase. METHODS AND RESULTS: Beat-to-beat recordings of heart rate (HR), BP (volume-clamp method) and stroke volume (SV) (modelflow method), cardiac output (CO), and total peripheral resistance (TPR) were made at rest, during unmedicated tilt testing (TT) and recovery from loss of consciousness in 18 patients with a history of syncope (age 45+/-23 years) and positive response to TT. Blood pressure showed a significant fall during prodromal symptoms and a further fall at the beginning of loss of consciousness, together with a fall in SV, CO, and HR, and a slight, but significant, increase in TPR. At the beginning of recovery, BP showed a significant increase and a further increase 5 min later, together with an increase in SV, CO, and HR without significant changes in TPR. CONCLUSION: These results suggest that in VVS the fall in BP is mainly caused by reduced venous return to the heart. The arterial system does not appear to be the main determinant of the fall of BP; however, the system appears unable to make the appropriate compensatory changes.
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Hipotensión/fisiopatología , Síncope Vasovagal/complicaciones , Venas/fisiopatología , Presión Sanguínea , Gasto Cardíaco , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Volumen Sistólico , Pruebas de Mesa Inclinada , Resistencia VascularRESUMEN
The data in the literature on the relationship between sexual activity, with and without the use of sildenafil, and the occurrence of cardiovascular events (ventricular arrhythmias, nonfatal myocardial infarction, stroke and death) have been reviewed in patients with heart disease. To date, only patients with ischemic heart disease (IHD) have been investigated. The prevalence of premature ventricular beats during sexual intercourse is similar to that observed during other daily activities. Therefore, sexual activity does not seem to have a relevant arrhythmogenic effect. The incidence of sustained ventricular tachycardia during sexual intercourse in unknown. The relative risk of nonfatal myocardial infarction is 2.7 in males and 1.3 in females; however, the absolute risk appears extremely low and is similar in normal subjects and in patients with and without IHD. The risk appears to be restricted to the 2-hour time period after sexual intercourse. The incidence of stroke during sexual intercourse appears very low, but clear data are lacking. The incidence of death during sexual activity is unknown; the few available data suggest that it is very low. Extramarital sexual intercourse seems to increase the risk of death. The incidence of cardiovascular events after sildenafil administration has been investigated in placebo-controlled studies in patients with IHD. The incidence of nonfatal myocardial infarction, stroke and death did not significantly differ between sildenafil-treated and placebo-treated patients; therefore, sildenafil does not appear contraindicated in subjects with IHD. However, the drug should be administered with caution in patients with recent myocardial infarction or stroke, in those with active coronary ischemia and in patients with episodes of heart failure. The drug is absolutely contraindicated in patients using nitrates.