RESUMO
INTRODUCTION: There is no consensus on the impact of coronary artery disease in patients undergoing transcatheter aortic valve implantation. Therefore, the objective of this study was, in a single-center setting, to evaluate the five-year outcome of transcatheter aortic valve implantation patients with or without coronary artery disease. METHODS: All transcatheter aortic valve implantation patients between 2009 and 2019 were included and grouped according to the presence or absence of coronary artery disease. The primary endpoint, five-year all-cause mortality, was evaluated using Cox regression adjusted for age, sex, procedure years, and comorbidities. Comorbidities interacting with coronary artery disease were evaluated with interaction tests. In-hospital complications was the secondary endpoint. RESULTS: In total, 176 patients had aortic stenosis and concomitant coronary artery disease, while 170 patients had aortic stenosis only. Mean follow-up was 2.2±1.6 years. There was no difference in the adjusted five-year all-cause mortality between transcatheter aortic valve implantation patients with and without coronary artery disease (hazard ratio 1.00, 95% confidence interval 0.59-1.70, P=0.99). In coronary artery disease patients, impaired renal function, peripheral arterial disease, or ejection fraction < 50% showed a significant interaction effect with higher five-year all-cause mortality. No significant differences in complications between the groups were found. CONCLUSION: Five-year mortality did not differ between transcatheter aortic valve implantation patients with or without coronary artery disease. However, in patients with coronary artery disease and impaired renal function, peripheral arterial disease, or ejection fraction < 50%, we found significantly higher five-year all-cause mortality.
Assuntos
Estenose da Valva Aórtica , Doença da Artéria Coronariana , Doença Arterial Periférica , Substituição da Valva Aórtica Transcateter , Humanos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/cirurgia , Substituição da Valva Aórtica Transcateter/métodos , Seguimentos , Resultado do Tratamento , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/cirurgia , Doença Arterial Periférica/complicações , Valva Aórtica/cirurgia , Fatores de RiscoRESUMO
OBJECTIVE: To describe the incidence and predictors of acute limb ischemia (ALI) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). METHODS: Patients with index hospitalizations for AMI complicated by cardiogenic shock from 2016 to 2019 in the US National Readmission Database were identified. We evaluated the incidence of ALI and its associated mortality, length of stay, and cost of hospitalization. We used multivariable logistic regression to determine independent predictors of ALI in this population. RESULTS: A total of 84,615 patients had AMI complicated by cardiogenic shock and 1302 (1.54%) developed ALI. The rates of ALI increased from 1.29% in 2016 to 1.66% in 2019 (P ≤ .002). The use of microaxial mechanical circulatory support increased from 2.25% in 2016 to 13.36% in 2019 (P = .0001). The major predictors of ALI included peripheral arterial disease (odds ratio [OR], 7.34; 95% confidence interval [CI], 6.12-8.81), venoarterial extracorporeal membrane oxygenation (OR, 4.40; 95% CI, 3.19-6.07), and microaxial mechanical circulatory support (OR, 3.12; 95% CI, 2.74-3.55). ALI in patients with cardiogenic shock was associated higher mortality (39.20% vs 33.53%; P ≤ .0001). CONCLUSIONS: This nationwide observational study shows that ALI is an important complication of AMI with cardiogenic shock. This complication is associated with higher mortality. In addition to peripheral artery disease, the use of mechanical circulatory devices was associated with significantly higher rates of ALI.
Assuntos
Coração Auxiliar , Infarto do Miocárdio , Doença Arterial Periférica , Humanos , Choque Cardiogênico , Incidência , Resultado do Tratamento , Mortalidade Hospitalar , Doença Arterial Periférica/complicações , Coração Auxiliar/efeitos adversos , Estudos RetrospectivosRESUMO
La enfermedad arterial periférica se considera la mayor causa de hospitalización, con riesgo de amputación de la extremidad afectada y muerte debido a la enfermedad per se o sus complicaciones. Se reporta la experiencia del tratamiento a un paciente con macroangiopatía diabética, estenosis del 64 por ciento de la arteria ilíaca izquierda y afectación de los segmentos fémoro-poplíteos bilaterales, al cual, a través de un acceso percutáneo vía arteria braquial izquierda, se le realizó revascularización mediante la implantación de stent de cromo-cobalto liberado por balón catéter. El objetivo de este estudio fue describir la utilidad del 2D-ASD y su valor como herramienta para determinar el transproceder y la repercusión en el flujo sanguíneo de la revascularización realizada, y establecer un pronóstico funcional para el paciente. Se utilizó la angiografía por perfusión bidimensional como herramienta para evaluar el éxito técnico del proceder y la repercusión inmediata en la perfusión distal de la extremidad afecta, y describir la utilidad de la escala paramétrica de colores y las curvas de densidad en función del tiempo obtenidos en el estudio(AU)
Peripheral artery disease is considered the leading cause of hospitalization, with risk of amputation of the affected limb and death due to the disease per se or its complications. It is reported the experience of treatment in a patient with diabetic macroangiopathy, stenosis of 64 precent of the left iliac artery and involvement of the bilateral femoro-popliteal segments, to which, through a percutaneous access via the left brachial artery, revascularization was performed through the implantation of cobalt-chromium stent released by balloon catheter. The objective of this study was to describe the usefulness of 2D-ASD and its value as a tool to determine the trans-procedure and the impact on blood flow of the revascularization performed, and to establish a functional prognosis for the patient. Two-dimensional perfusion angiography was used as a tool to evaluate the technical success of the procedure and the immediate impact on distal perfusion of the affected limb, and to describe the usefulness of the parametric color scale and density curves as a function of the time obtained in the study(AU)
Assuntos
Angiografia/efeitos adversos , Doença Arterial Periférica/complicações , Amputação Cirúrgica/métodos , HospitalizaçãoRESUMO
BACKGROUND: Patients undergoing lower extremity bypasses (LEB) are at a high risk of developing post-discharge complications requiring readmission. Health systems have developed several strategies to mitigate this risk. One such measure is developing comprehensive Transitional Care Program (TCP), which includes phone calls to patients after being discharged from the hospital. Our study aimed to assess short-term readmission, mortality, and amputation rates of patients who participated in TCP by completing at least one post-discharge follow-up phone call after undergoing LEB for revascularization of peripheral arterial disease (PAD). METHODS: A retrospective review was completed for patients who underwent LEB surgery between January 2010 and January 2020 to treat PAD at Penn State Hershey Medical Center. Immediate discharge follow-up was done via telephone calls using a standardized script. Patients were then divided into two groups, those who did not have a successful follow-up call (Group I) and those who had at least one successful follow-up call within seven days after discharge (Group II). Univariate analysis was used to compare preoperative demographics, intraoperative variables, and postoperative outcomes. The probability of readmission and risk factors contributing to it were computed using multiple stepwise forward regression analyses. Epidemiological analysis was done to evaluate the risk of readmission in the group receiving post-discharge follow-up calls. RESULTS: A total of 457 patients underwent LEB from 2010 to 2020 and qualified for inclusion in the study. Among these patients, 126 (27.6%) did not have a successful post-discharge follow-up call (Group I), whereas, 331 (72.4%) patients did complete a successful call (Group II). The mean age of patients was 66.7 years. There were no significant differences in preoperative baseline patient characteristics or intraoperative factors. Patients who completed a successful call had lower readmission rates within thirty days of the operation (8.8 vs. 17.5%, P = 0.008), and this was sustained in multivariate analysis (adjusted odds ratio AOR: 0.18, [confidence interval CI: 0.05-0.66], P = 0.009). However, no differences were observed for thirty-day mortality (Group-I: 3.2% versus Group-II: 1.2%, P = 0.152) or amputation (Group-I: 9.6% versus Group II 5.9%, P = 0.162). Among those who had a successful call, patients with a history of smoking (AOR: 4.05 [CI: 1.21, 17.12] P = 0.025), diabetes mellitus (AOR: 3.42 [CI: 1.35, 8.7] P = 0.01) and myocardial infarction (AOR: 7.15 [CI: 1.76, 20.1] P = 0.006) had a much higher chances of readmission. Risk analysis using epidemiological methods showed that by receiving a call, the risk of readmission could be dropped to half (RR: 0.50 [CI: 0.30, 0.84]), with an attributable risk reduction of -8.7% (CI: -15.9%, -1.4%). CONCLUSIONS: This single-institution retrospective study demonstrates the importance of immediate discharge follow-up phone calls in patients who undergo open lower extremity revascularization to reduce thirty-day readmissions. Our analysis showed patients who received immediate follow-up phone calls were less likely to be readmitted to the hospital. The development of reliable and efficient systems to enhance immediate discharge follow-up in vascular surgery patients is pivotal to improving quality of care, preventing readmissions, and reducing healthcare costs.
Assuntos
Doença Arterial Periférica , Cuidado Transicional , Assistência ao Convalescente , Idoso , Humanos , Modelos Logísticos , Extremidade Inferior/irrigação sanguínea , Alta do Paciente , Readmissão do Paciente , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: The COMPASS trial demonstrated that in patients with peripheral arterial disease, the combination of rivaroxaban and aspirin compared with aspirin reduces the risk of major adverse limb events, but it is not known whether this combination can also improve symptoms in patients with intermittent claudication. The primary objective of this study is to evaluate the effect of the combination on claudication distance. STUDY DESIGN: Eighty-eight patients with intermittent claudication will be randomized to receive rivaroxaban 2.5â mg twice daily plus aspirin 100â mg once daily or aspirin 100â mg once daily for 24 weeks. The primary outcome is the change in claudication distance from the baseline to 24 weeks, measured by 6â min walking test and treadmill test. The primary safety outcome is the incidence of major bleeding and clinically relevant non-major bleeding according to the International Society on Thrombosis and Hemostasis criteria. SUMMARY: The COMPASS CLAUDICATION trial will provide high-quality evidence regarding the effect of the combination of rivaroxaban and aspirin on claudication distance in patients with peripheral arterial disease.
Assuntos
Aspirina/uso terapêutico , Claudicação Intermitente/tratamento farmacológico , Doença Arterial Periférica/tratamento farmacológico , Método Duplo-Cego , Quimioterapia Combinada , Teste de Esforço , Inibidores do Fator Xa/uso terapêutico , Feminino , Seguimentos , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/etiologia , Masculino , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico , Inibidores da Agregação Plaquetária/uso terapêutico , Estudos Prospectivos , Rivaroxabana/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVE: Prior studies have demonstrated an increased risk of developing cardiovascular and peripheral arterial disease (PAD) in patients with human immunodeficiency virus (HIV). However, the effect of chronic HIV infection in patients with preexisting PAD and requiring vascular intervention is unclear. In the present study, we assessed the differences in clinical presentation and perioperative outcomes for patients with PAD who had undergone revascularization or amputation with and without HIV infection. METHODS: International Classification of Diseases, 9th and 10th Revisions, Clinical Modification, codes were used to identify patients with a prior diagnosis of PAD who had undergone lower extremity revascularization or amputation in the National Inpatient Sample (2003-2017). From this group, the patients were divided for analysis into those with and without HIV infection. Of the patients with HIV infection (PWHs), we identified additional subsets of patients: those with any prior or current diagnosis of an HIV-related illness, including acquired immunodeficiency syndrome, designated as symptomatic HIV, and those without such a diagnosis, designated as asymptomatic HIV infection. Propensity score matching was performed to create matched cohorts. Population-based comparative analyses were performed of the clinical characteristics of the HIV-infected and HIV-uninfected groups. Univariate and multivariate logistic regression analyses of the perioperative in-hospital outcomes were performed on the matched cohorts. RESULTS: A total of 224,912 patients aged 18 to 85 years were identified who had been admitted with an established diagnosis of PAD and had undergone a lower extremity procedure. Of these patients, 1264 (0.56%) also had a diagnosis of HIV infection. Symptomatic PWHs were more likely to present with critical limb ischemia than were the HIV-uninfected patients or asymptomatic PWHs (66.2% vs 46.3% and 43.6%; P < .01). However, both asymptomatic and symptomatic PWHs were more likely to have required minor (7.5% and 6.7% vs 2.6%; P < .01) and major (12.9% and 27.4% vs 7.0%; P < .01) amputations than were matched HIV-uninfected controls. Although adjusted multivariate logistic regression analysis demonstrated symptomatic HIV infection to be a significant, independent predictor of in-hospital mortality (odds ratio, 2.46; 95% confidence interval, 1.37-4.40; P = .003), the perioperative mortality for the asymptomatic PWH was comparable to that of matched HIV-uninfected controls. CONCLUSIONS: Symptomatic PWHs, including patients living with acquired immunodeficiency syndrome, who had required a PAD-related procedure had presented with more advanced vascular disease and were most at risk of early perioperative mortality. However, the presentation and mortality between asymptomatic PWHs with well-controlled disease and HIV-uninfected patients were comparable. All PWHs with PAD were more likely to undergo lower extremity amputations than were HIV-uninfected matched controls. Asymptomatic, well-controlled HIV infection should not be a contraindication to elective PAD-related procedures because the mortality was similar to that of HIV-uninfected controls. However, the limb salvage rates might be lower for all PWHs with PAD, regardless of HIV disease severity. Taken together, these findings can improve perioperative risk stratification and surgical management of PAD in this high-risk population.
Assuntos
Amputação Cirúrgica , Infecções por HIV/complicações , Extremidade Inferior , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos de Coortes , Infecções por HIV/diagnóstico , Humanos , Isquemia , Salvamento de Membro , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/cirurgia , Pessoa de Meia-Idade , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
O diabetes melito é o maior fator de risco para doença arterial coronariana. Além da longa duração de diabetes, outros fatores, como presença de doença arterial periférica e tabagismo são fortes preditores para anormalidades na cintilografia de perfusão do miocárdio. O objetivo deste estudo foi avaliar o impacto dos fatores de risco de pacientes diabéticos nos resultados da cintilografia de perfusão do miocárdio e comparar com os resultados de pacientes não diabéticos em uma clínica de medicina nuclear. Foi realizado um estudo transversal retrospectivo por meio da análise de prontuários de pacientes que realizaram cintilografia miocárdica no período de 2010 a 2019. Foram avaliados 34.736 prontuários. Analisando a fase de estresse da cintilografia de perfusão do miocárdio, os portadores de diabetes melito precisaram receber estímulo farmacológico duas vezes mais que os não diabéticos para sua realização. Também foram avaliados fatores que tivessem impacto negativo no resultado da cintilografia de perfusão do miocárdio, e foi visto que o diabetes melito (33,6%), a insulinoterapia (18,1%), a hipertensão arterial sistêmica (69,9%), a dislipidemia (53%), o sedentarismo (83,1%), o uso de estresse farmacológico (50,6%), a dor torácica típica (8,5%) e a angina limitante durante o teste (1,7%) estiveram associados significativamente (p<0,001) a anormalidades neste exame. (AU)
Diabetes mellitus (DM) is the greatest risk factor for coronary artery disease. In addition to a long duration of diabetes, the presence of peripheral arterial disease and smoking are strong predictors of abnormalities on myocardial perfusion scintigraphy (MPS). This study aimed to assess the impact of risk factors in diabetic patients on MPS results and compare them with those of non-diabetic patients in a nuclear medicine clinic. A retrospective cross-sectional study was performed through the analysis of the medical records of patients who underwent MPS in 20102019. A total of 34,736 medical records were evaluated. Analyzing the stress phase of MPS, DM patients required two-fold more pharmacological stimulation than non-diabetic patients for MPS. Factors that negatively impact the MPS results were also evaluated, and DM (33.6%), insulin therapy (18.1%), systemic arterial hypertension (69.9%), dyslipidemia (53%), sedentary lifestyle (83.1%), use of pharmacological stress (50.6%), typical chest pain (8.5%), and limiting angina during the test (1.7%) were significantly associated (p < 0.001) with test abnormalities. (AU)
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Tabagismo/complicações , Diabetes Mellitus Tipo 2/patologia , Doença Arterial Periférica/complicações , Cintilografia de Ventilação/Perfusão/métodos , Miocárdio/patologia , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Fatores de Risco , Isquemia Miocárdica/diagnóstico , Convulsoterapia/métodos , Dislipidemias/complicações , Comportamento Sedentário , Hipertensão/complicações , Serviço Hospitalar de Medicina NuclearRESUMO
OBJECTIVE: To examine the impact of hypertension on cardiovascular health in patients with symptomatic peripheral artery disease and to identify factors associated with uncontrolled hypertension. METHODS: A cross-sectional study including 251 patients with symptomatic peripheral artery disease (63.9% males, mean age 67±10 years). Following hypertension diagnosis, blood pressure was measured to determine control of hypertension. Arterial stiffness (carotid-femoral pulse wave velocity) and cardiac autonomic modulation (sympathovagal balance) were assessed. RESULTS: Hypertension was associated with higher carotid-femoral pulse wave velocity, regardless of sex, age, ankle-brachial index, body mass index, walking capacity, heart rate, or comorbidities (ß=2.59±0.76m/s, b=0.318, p=0.003). Patients with systolic blood pressure ≥120mmHg had higher carotid-femoral pulse wave velocity values than normotensive individuals, and hypertensive patients with systolic blood pressure of ≤119mmHg (normotensive: 7.6±2.4m/s=≤119mmHg: 8.1±2.2m/s 120-129mmHg:9.8±2.6m/s=≥130mmHg: 9.9±2.9m/s, p<0.005). Sympathovagal balance was not associated with hypertension (p>0.05). CONCLUSION: Hypertensive patients with symptomatic peripheral artery disease have increased arterial stiffness. Arterial stiffness is even greater in patients with uncontrolled high blood pressure.
Assuntos
Hipertensão , Doença Arterial Periférica , Rigidez Vascular , Idoso , Pressão Sanguínea , Estudos Transversais , Feminino , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/complicações , Análise de Onda de PulsoRESUMO
Introducción: La diabetes mellitus modifica la historia natural de la aterosclerosis. Por ello, la repercusión de este proceso en los diferentes lechos vasculares constituye la principal causa de morbimortalidad en estos pacientes. Objetivos: Determinar la frecuencia de enfermedad arterial periférica asintomática en personas con diabetes mellitus tipo 2, su relación con otras variables clínicas de la diabetes y las complicaciones de la enfermedad. Métodos: Se realizó un estudio descriptivo transversal en el policlínico Cerro con un total de 100 pacientes diabéticos tipo 2 en edades comprendidas entre 40 y 70 años en el período de un año (2019), sin diagnóstico previo de enfermedad arterial periférica ni lesiones en los pies. Se examinaron los pulsos periféricos de miembros inferiores y se calculó el índice de presiones tobillo-brazo. Resultados: Se identificaron 36 pacientes con índices bajos, lo que fue consistente con una enfermedad arterial periférica asintomática (36 por ciento). El tabaquismo se relacionó de forma significativa con la presencia de índices bajos (p = 0,02), pero no hubo diferencias significativas con respecto a la edad, el sexo, el color de la piel, el tiempo de evolución de la diabetes, el consumo de bebidas alcohólicas, la actividad física, la hipertensión arterial y la obesidad. La mayoría de los pacientes tuvo una afectación ligera en cuanto a la severidad. Conclusiones: La enfermedad arterial periférica asintomática es una complicación frecuente en las personas con diabetes de tipo 2(AU)
Introduction: Diabetes mellitus modifies the natural history of atherosclerosis. Therefore, the impact of this process on the different vascular beds is the main cause of morbidity and mortality in these patients. Objectives: Determine the frequency of asymptomatic peripheral artery disease in people with type 2 diabetes mellitus, its relationship with other clinical variables of diabetes and complications of the disease. Methods: A cross-sectional descriptive study was conducted at Cerro polyclinic with a total of 100 type 2 diabetic patients aged between 40 and 70 years in a period of one year (2019), without prior diagnosis of peripheral arterial disease or foot injuries. Peripheral pulses of the lower limbs were examined and the ankle-brachial pressure index was calculated. Results: 36 patients with low rates were identified, which was consistent with asymptomatic peripheral arterial disease (36 percent). Smoking habit was significantly related to the presence of low rates (p = 0.02), but there were no significant differences with respect to age, sex, skin color, time of evolution of diabetes, consumption of alcoholic beverages, physical activity, high blood pressure and obesity. Most patients had a slight affectation regarding severity. Conclusions: Asymptomatic peripheral artery disease is a common complication in people with type 2 diabetes(AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Idoso , Diabetes Mellitus Tipo 2/etiologia , Doença Arterial Periférica/complicações , Epidemiologia Descritiva , Estudos TransversaisRESUMO
PURPOSE: This study aimed to determine the association between light-intensity physical activity and the incidence of all-cause and cardiovascular mortality in patients with peripheral artery disease (PAD) limited by claudication followed for up to 18.7 yr. METHODS: A total of 528 patients with PAD and claudication were screened in Baltimore between 1994 and 2002, and 386 were deemed eligible for the study. At baseline, patients were classified into three physical activity groups: 1) physically sedentary, 2) light intensity, and 3) moderate to vigorous intensity based on a questionnaire. All-cause and cardiovascular mortality of patients through December 2014 was determined using the National Death Index and the U.S. Department of Veterans Affairs and the U.S. Department of Defense Suicide Data Repository. RESULTS: Median survival time was 9.9 yr (interquartile range, 4.9-15.7 yr; range, 0.38-18.7 yr). During follow-up, 257 patients (66.6%) died, consisting of 40/48 (83.3%) from the sedentary group, 135/210 (64.3%) from the light-intensity group, and 82/128 (64.0%) from the moderate- to vigorous-intensity group. For all-cause mortality, light-intensity activity status (hazard ratio [HR] = 0.523, P = 0.0007) and moderate- to vigorous-intensity status (HR = 0.425, P < 0.0001) were significant predictors. During follow-up, 125 patients died because of cardiovascular causes (32.4%), in which light-intensity activity status (HR = 0.511, P = 0.0113) and moderate- to vigorous-intensity activity status (HR = 0.341, P = 0.0003) were significant predictors. CONCLUSIONS: Light-intensity physical activity is associated with nearly 50% lower risk of all-cause and cardiovascular mortality in high-risk patients with PAD and claudication. Furthermore, moderate- to vigorous-intensity physical activity performed regularly is associated with 58% and 66% lower risk of all-cause and cardiovascular mortality, respectively. The survival benefits associated with light-intensity physical activity make it a compelling behavioral intervention that extends beyond improving ambulation.