RESUMO
BACKGROUND-OBJECTIVE: Prior studies have suggested a higher prevalence of simple renal cysts (SRC) among patients with aortic disease, including abdominal aortic aneurysms (AAA). Thus, the aim of this study was to systematically review all currently available literature and investigate whether patients with AAA are more likely to have SRC. METHODS: This study was performed according to the PRISMA guidelines. A meta-analysis was conducted with the use of random effects modeling and the I-square was used to assess heterogeneity. Odds ratios (OR) and the corresponding 95% confidence intervals (CI) were synthesized to compare the prevalence of several patients' characteristics between AAA vs. no-AAA cases. RESULTS: Eleven retrospective studies, 9 comparative (AAA vs. no-AAA groups) and 3 single-arm (AAA group), were included in this meta-analysis, enrolling patients (AAA: Nâ¯=â¯2,297 vs. no-AAA: Nâ¯=â¯35,873) who underwent computed tomography angiography as part of screening or preoperative evaluation for reasons other than AAA. The cumulative incidence of SRC among patients with AAA and no-AAA was 55% (95% CI: 49%-61%) and 32% (95% CI: 22%-42%) respectively, with a statistically higher odds of SRC among patients with AAA (OR: 3.02; 95% CI: 2.01-4.56; P< 0.001). The difference in SRC prevalence remained statistically significant in a sensitivity analysis, after excluding the study with the largest sample size (OR: 2.71; 95% CI: 1.91-3.84; P< 0.001). CONCLUSIONS: Our meta-analysis demonstrated a 3-fold increased prevalence of SRC in patients with AAA compared to no-AAA cases, indicating that the pathogenic processes underlying SRC and AAA could share a common pathophysiologic mechanism. Thus, patients with SRC could be considered at high risk for AAA formation, potentially warranting an earlier AAA screening.
Assuntos
Aneurisma da Aorta Abdominal/complicações , Doenças Renais Císticas/complicações , Comorbidade , Intervalos de Confiança , Dislipidemias/complicações , Feminino , Humanos , Doenças Renais Císticas/epidemiologia , Masculino , Razão de Chances , PrevalênciaRESUMO
BACKGROUND: The relative benefit of higher statin dosing in patients with peripheral artery disease has not been reported previously. We compared the effectiveness of low- or moderate-intensity (LMI) versus high-intensity (HI) statin dose on clinical outcomes in patients with peripheral artery disease. METHODS AND RESULTS: We reviewed patients with symptomatic peripheral artery disease who underwent peripheral angiography and/or endovascular intervention from 2006 to 2013 who were not taking other lipid-lowering medications. HI statin use was defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg. Baseline demographics, procedural data, and outcomes were retrospectively analyzed. Among 909 patients, 629 (69%) were prescribed statins, and 124 (13.6%) were treated with HI statin therapy. Mean low-density lipoprotein level was similar in patients on LMI versus HI (80±30 versus 87±44 mg/dL, P=0.14). Demographics including age (68±12 versus 67±10 years, P=0.25), smoking history (76% versus 80%, P=0.42), diabetes mellitus (54% versus 48%, P=0.17), and hypertension (88% versus 89%, P=0.78) were similar between groups (LMI versus HI). There was a higher prevalence of coronary artery disease (56% versus 75%, P=0.0001) among patients on HI statin (versus LMI). After propensity weighting, HI statin therapy was associated with improved survival (hazard ratio for mortality: 0.52; 95% confidence interval, 0.33-0.81; P=0.004) and decreased major adverse cardiovascular events (hazard ratio: 0.58; 95% confidence interval 0.37-0.92, P=0.02). CONCLUSIONS: In patients with peripheral artery disease who were referred for peripheral angiography or endovascular intervention, HI statin therapy was associated with improved survival and fewer major adverse cardiovascular events compared with LMI statin therapy.
Assuntos
Atorvastatina/administração & dosagem , Dislipidemias/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Claudicação Intermitente/tratamento farmacológico , Isquemia/tratamento farmacológico , Doença Arterial Periférica/tratamento farmacológico , Rosuvastatina Cálcica/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Angiografia , Atorvastatina/efeitos adversos , Biomarcadores/sangue , Estado Terminal , Progressão da Doença , Intervalo Livre de Doença , Prescrições de Medicamentos , Dislipidemias/sangue , Dislipidemias/diagnóstico por imagem , Dislipidemias/mortalidade , Procedimentos Endovasculares , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Claudicação Intermitente/sangue , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/mortalidade , Isquemia/sangue , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Estimativa de Kaplan-Meier , Lipídeos/sangue , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Padrões de Prática Médica/tendências , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Rosuvastatina Cálcica/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The relationship between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness remains unclear. We examined the association between neuromuscular blocking agents and ICU-acquired weakness, critical illness polyneuropathy, and critical illness myopathy. DATA SOURCES: PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature, and bibliographies of included studies were searched from database inception until September 24, 2015. STUDY SELECTION: Randomized controlled trials and prospective observational studies examining the association between neuromuscular blocking agents and ICU-acquired weakness, critical illness polyneuropathy, or critical illness myopathy. DATA EXTRACTION: One author screened titles/abstracts. Two authors independently reviewed full text and extracted data from included studies. Meta-analysis was performed using the DerSimonian-Laird random effects model (OpenMetaAnalyst 10.10 for OS.X). We assessed reporting bias with funnel plots and heterogeneity with the I statistic. DATA SYNTHESIS: Of 2,170 titles/abstracts screened, 99 full texts were selected for review, yielding one randomized controlled trial and 18 prospective observational studies, for a total of 2,254 patients. The randomized controlled trial did not show an association between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness (odds ratio, 1.21; 95% CI, 0.67-2.19), but pooled data from all included studies suggested a modest association (odds ratio, 1.25; 95% CI, 1.06-1.48; I = 16%). Funnel plots suggested reporting bias, and sensitivity analyses showed a disproportionate contribution from critical illness polyneuropathy/critical illness myopathy and severe sepsis/septic shock studies. CONCLUSIONS: This meta-analysis suggests a modest association between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness; limitations include studies with a high risk of bias and a disproportionate contribution from studies examining patients for critical illness polyneuropathy/critical illness myopathy and those with severe sepsis/septic shock.
Assuntos
Estado Terminal , Debilidade Muscular/induzido quimicamente , Doenças Musculares/induzido quimicamente , Bloqueadores Neuromusculares/efeitos adversos , Polineuropatias/induzido quimicamente , Humanos , Unidades de Terapia IntensivaRESUMO
BACKGROUND: Stigma against the obese is well described in health care and may contribute to disparities in medical decision-making. It is unknown whether similar disparity exists for obese patients in cardiovascular care. We evaluated the association between body mass index (BMI) and prescription of guideline-recommended medications in patients undergoing elective percutaneous coronary intervention. METHODS AND RESULTS: Using data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified patients undergoing elective percutaneous coronary intervention from 2007 to 2012, stratifying them by category of BMI. We described rates of prescription for class I guideline recommended medications for each BMI category (normal, overweight, and obese). Multivariable logistic regression assessed the association between BMI category and medication prescription. Seventeen thousand thirty-seven patients were identified, with 35.3% having overweight BMI, and 50.8% obese BMI. Obese patients were more likely than normal BMI patients to be prescribed ß-blockers (OR 1.34), statins (OR 1.39), or ACE/ARB (odds ratio [OR] 1.52; all significant) when indicated. Overweight patients were more likely than normal BMI patients to be prescribed statins (OR 1.29) and angiotensin-converting enzymes/angiotensin II receptor blockers (OR 1.41) when indicated. There was no association between BMI category and prescription of anticoagulants. CONCLUSIONS: Over 85% of patients undergoing elective percutaneous coronary intervention in the Veterans Affairs are overweight or obese. Rates of guideline-indicated medication prescription were <70% among all patients, and across BMI categories, with an association between increased BMI and greater use of guideline-recommended medications. Our findings offer a possible contribution to the obesity paradox seen in many cardiovascular conditions.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/uso terapêutico , Doença da Artéria Coronariana/terapia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Obesidade/epidemiologia , Idoso , Índice de Massa Corporal , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Tomada de Decisão Clínica , Comorbidade , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Sobrepeso/epidemiologia , Intervenção Coronária Percutânea , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans AffairsRESUMO
BACKGROUND: Current guidelines recommend that patients with peripheral arterial disease (PAD) cease smoking and be treated with aspirin, statin medications, and angiotensin-converting enzyme (ACE) inhibitors. The combined effects of multiple guideline-recommended therapies in patients with symptomatic PAD have not been well characterized. METHODS AND RESULTS: We analyzed a comprehensive database of all patients with claudication or critical limb ischemia (CLI) who underwent diagnostic or interventional lower-extremity angiography between June 1, 2006 and May 1, 2013 at a multidisciplinary vascular center. Baseline demographics, clinical data, and long-term outcomes were obtained. Inverse probability of treatment propensity weighting was used to determine the 3-year risk of major adverse cardiovascular or cerebrovascular events (MACE; myocardial infarction, stroke, or death) and major adverse limb events (MALE; major amputation, thrombolysis, or surgical bypass). Among 739 patients with PAD, 325 (44%) had claudication and 414 (56%) had CLI. Guideline-recommended therapies at baseline included use of aspirin in 651 (88%), statin medications in 496 (67%), ACE inhibitors in 445 (60%), and smoking abstention in 528 (71%) patients. A total of 237 (32%) patients met all four guideline-recommended therapies. After adjustment for baseline covariates, patients adhering to all four guideline-recommended therapies had decreased MACE (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.89; P=0.009), MALE (HR, 0.55; 95% CI, 0.37 to 0.83; P=0.005), and mortality (HR, 0.56; 95% CI, 0.38 to 0.82; P=0.003), compared to patients receiving less than four of the recommended therapies. CONCLUSIONS: In patients with claudication or CLI, combination treatment with four guideline-recommended therapies is associated with significant reductions in MACE, MALE, and mortality.
Assuntos
Fidelidade a Diretrizes/normas , Infarto do Miocárdio/prevenção & controle , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Cooperação do Paciente , Doença Arterial Periférica/terapia , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Serviços Preventivos de Saúde/normas , Acidente Vascular Cerebral/prevenção & controle , Idoso , Amputação Cirúrgica , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Inibidores da Agregação Plaquetária/uso terapêutico , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Abandono do Hábito de Fumar , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: With adoption of telemedicine, physicians are increasingly asked to diagnose ST-segment elevation myocardial infarctions (STEMIs) based on electrocardiograms (ECGs) with minimal associated clinical information. We sought to determine physicians' diagnostic agreement and accuracy when interpreting potential STEMI ECGs. METHODS AND RESULTS: A cross-sectional survey was performed consisting of 36 deidentified ECGs that had previously resulted in putative STEMI diagnoses. Emergency physicians, cardiologists, and interventional cardiologists participated in the survey. For each ECG, physicians were asked, "based on the ECG above, is there a blocked coronary artery present causing a STEMI?" The reference standard for ascertaining the STEMI diagnosis was subsequent emergent coronary arteriography. Responses were analyzed with generalized estimating equations to account for nested and repeated measures. One hundred twenty-four physicians interpreted a total of 4392 ECGs. Among all physicians, interreader agreement (kappa) for ECG interpretation was 0.33, reflecting poor agreement. The sensitivity to identify "true" STEMIs was 65% (95% CI: 63 to 67) and the specificity was 79% (95% CI: 77 to 81). There was a 6% increase in the odds of accurate ECG interpretation for every 5 years of experience since medical school graduation (OR 1.06, 95% CI: 1.02 to 1.10, P = 0.01). After adjusting for experience, there was no significant difference in the odds of accurate interpretation by specialty-Emergency Medicine (reference), General Cardiology (AOR 0.97, 95% CI: 0.79 to 1.2, P = 0.80), or Interventional Cardiology physicians (AOR 1.24, 95% CI: 0.93 to 1.7, P = 0.15). CONCLUSIONS: There is significant physician disagreement in interpreting ECGs with features concerning for STEMI. Such ECGs lack the necessary sensitivity and specificity to act as a suitable "stand-alone" diagnostic test.