014 Risk score to predict serious bleeding in stable outpatients with atherothrombosis (original) (raw)
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European heart journal. Acute cardiovascular care, 2015
The scope of the problem The incidence of life-threatening ventricular arrhythmias (LT-VAs) among patients with non-ST elevation myocardial infarction (NSTEMI) is substantially lower (1.5-2.1%) than that among patients with ST-segment elevation myocardial infarction (STEMI) (10%). 1-3 In patients with NSTEMI, data on ventricular arrhythmias are scant and limited to sub-analysis of large multicentre trials or to highly selected patient groups. 2 In patients with STEMI, LT-VAs usually occur immediately after the onset of acute myocardial ischaemia or reperfusion. In contrast, LT-VAs are infrequent after NSTEMI as compared to STEMI but may occur within or after 48 h. 3 LT-VAs are associated with significantly increased mortality in NSTEMI. 2 Some observational studies reported that LT-VAs in the early setting of an acute coronary syndrome (ACS) might be due to reversible ischaemia. These patients seem to be at low risk for sudden death during follow-up if they are completely revascularised. 4,5 However, several trials have shown that implantation of a cardioverter defibrillators in the first 40 days after an acute myocardial infarction (MI) which resulted in low left ventricular ejection fraction (LV-EF) did not improve survival. 6,7 Thus, optimal therapy for patients with ventricular arrhythmias due to NSTEMI is uncertain, and strategies to improve survival are needed. 2
European Heart Journal: Acute Cardiovascular Care, 2014
Identification of patients with non-ST elevation acute myocardial infarction (NSTEMI) at higher risk of in-hospital life-threatening ventricular arrhythmias (LT-VA) and death is crucial for determining appropriate levels of care/monitoring during hospitalisation. We assessed predictors of in-hospital LT-VA and all-cause mortality in a consecutive series of NSTEMI patients. Methods and results: We prospectively studied 1325 consecutive patients (69.7% males, median age 70 (61-79) years) presenting with NSTEMI and undergoing continuous electrocardiographic monitoring. The primary study end-point was the occurrence of spontaneous (unrelated to coronary interventions) in-hospital LT-VA, including sustained ventricular tachycardia and ventricular fibrillation; the secondary end-point was in-hospital mortality from all causes. Of 1325 patients, 21 (1.5%) experienced LT-VA and 62 (4.7%) died from either arrhythmias (n=1) or other causes (n=61). Seven of the 20 patients who survived LT-VA subsequently died of heart failure. Independent predictors of in-hospital LT-VA were the Global Registry of Acute Coronary Events (GRACE) score >140 (odds ratio (OR)=7.5; 95% confidence interval (CI) 1.7-33.3; p=0.008) and left ventricular ejection fraction (LV-EF)<35% (OR=4.1; 95% CI 1.7-10.3; p=0.002). GRACE score >140 (OR=14.6; 95% CI 3.4-62) and LV-EF <35% (OR=4.4; 95% CI 1.9-10) also predicted in-hospital all-cause death. The cumulative probability of inhospital LT-VA and death was respectively 9.2% and 23% in the 98 (7.4%) patients with GRACE score >140 and LV-EF<35%, while it was respectively 0.2% and 0% among the 627 (47.3%) with GRACE score ≤140 and LV-EF ≥35%. Conclusions: Simple risk stratification at admission based on GRACE score and echocardiographic LV-EF allows early identification of NSTEMI patients at higher risk of both in-hospital LT-VA and all-cause mortality.
Use of ischemic ECG patterns for risk stratification in intermediate-risk patients with acute PE
The American Journal of Emergency Medicine, 2014
Available online xxxx 23 24 25 26 27 Background: European recommendations on the management of acute pulmonary embolism (APE) divide 28 patients into 3 risk categories: high, intermediate, and low. Mortality has previously been estimated at 3% to 29 15% in the intermediate group. The aim of this study was to use a new metric "ischemic electrocardiographic 30 (ECG) patterns" to more precisely estimate the risk (complications or death) of APE patients identified as 31 "intermediate risk" by current Q3 ESC criteria. 32 Methods: The study group consisted of 500 consecutive patients (290 females), with a mean age 66.3 ± 15.2 years, 33 and 245 (72.8%) patients were initially classified as intermediate risk. Four ischemic ECG patterns were studied: 34 (i) ST-segment ischemic pattern (STIP), (ii) global ischemic pattern (GIP), (iii) negative T wave pattern, and 35 (iv) control group consisting of patients with no ischemic changes. 36 Results: Predictors of death in univariate analysis included elevated troponin concentration (odds ratio [OR], 6.8; 95% 37 confidence interval [CI], 1.28-169; P = 0.02]) and ischemic ECG patterns: STIP (OR, 6.3; 95% CI, 1.6-46.0; P = 0.007).
PLoS ONE, 2012
Background: The presence of pre-infarction angina (PIA) has been shown to confer cardioprotection after ST-segment elevation myocardial infarction (STEMI). However, the clinical impact of PIA in non-ST-segment elevation myocardial infarction (NSTEMI) remains to be determined. Methods and Results: From the obseRvatoire des Infarctus de Cô te d'Or (RICO) survey, 1541 consecutive patients admitted in intensive care unit with a first NSTEMI were included. Patients who experienced chest pain ,7 days before the episode leading to admission were defined as having PIA and were compared with patients without PIA. Incidence of in-hospital ventricular arrhythmias (VAs), heart failure and 30-day mortality were collected. Among the 1541 patients included in the study, 693 (45%) patients presented PIA. PIA was associated with a lower creatine kinase peak, as a reflection of infarct size (231(109-520) vs. 322(148-844) IU/L, p,0.001) when compared with the group without PIA. Patients with PIA developed fewer VAs, by 3 fold (1.6% vs. 4.0%, p = 0.008) and heart failure (18.0% vs. 22.4%, p = 0.040) during the hospital stay. Overall, there was a decrease in early CV events by 26% in patients with PIA (19.2% vs. 25.9%, p = 0.002). By multivariate analysis, PIA remained independently associated with less VAs. Conclusion: From this large contemporary prospective study, our work showed that PIA is very frequent in patients admitted for a first NSTEMI, and is associated with a better prognosis, including reduced infarct size and in hospital VAs. Accordingly, protecting the myocardium by ischemic or pharmacological conditioning not only in STEMI, but in all type of MI merits further attention.
2021
Background: Non ST segment elevation myocardial infarction (NSTEMI) is a clinical condition characterized by typical symptoms of myocardial ischemia along with electrocardiographic changes and a positive value of troponin. After presentation in emergency department these patients have their troponin I value and electrocardiography done. The echocardiography should also be performed in these patients. This study was conducted to determine the relationship between ECG, Echo and troponin and how prognostically these are relevant to each other along with their prognostic significance.Results: This observational study was conducted at tertiary care cardiac hospital on 221 patients diagnosed with the NSTEMI. The most frequent finding on presenting ECG was ST depression in anterior leads (V1-V6) in 27.6%. Median troponin I at presentation was 3.2 ng/dl and median ejection fraction was 45%. Overall all-cause mortality rate at 6-months was observed to be 8.6%, re-infarction in 5%, re-hospita...
Cardiology News/Recent Literature Review/First Three Quarters 2013
Programming implantable cardioverter defibrillators (ICDs) to delay the time they take to treat ventricular arrhythmias cuts mortality by 23% and inappropriate shocks by more than one-half in a meta-analysis encompassing ~4900 patients. The included studies were prospective and multicenter and covered both primary and secondary prevention and patients with either ischemic or nonischemic cardiomyopathy. The risk of syncope did not rise significantly with longer detection times, despite traditional concerns that lots of patients would not tolerate prolonged arrhythmia exposure before their ICD is allowed to deliver therapy, either shocks or antitachycardia pacing (ATP). Instead, the extra time frequently gave devices a better chance to exclude non-life-threatening arrhythmias like atrial fibrillation and to let otherwise self-terminating ventricular arrhythmias play out on their own. Current nominal settings used by some ICD manufacturers are likely to be too aggressive, with arrhythmia detection times that in some cases may be as short as 1-3s. These results highlight the importance of setting longer default ICD detection times. The analysis included 4896 patients from the MADIT-RIT, ADVANCE 3, and PROVIDE randomized trials and the RELEVANT nonrandomized study. Overall, 264 patients received appropriate shocks and 253 experienced inappropriate shocks at follow-up (12 -17 months). The relative risk (RR) of death from any cause was 0.77 (p=0.02) in the prolonged-detection-time groups compared with controls; the risks of inappropriate shocks and appropriate and inappropriate ATP also fell significantly. Why there were fewer deaths with longer detection times is unclear but it may derive from less exposure to potential hazards of shocks and ATP; inappropriate shocks may up mortality, and ATP poses a small risk of inducing ventricular fibrillation; or it may be due to some other factor, e.g. avoidance of treatment for multiple ICD therapies (e.g., prescription of antiarrhythmic drugs) (Scott PA et al, Heart Rhythm 2014;
Incidence of ventricular arrhythmias in patients with severe
Revista Portuguesa de …, 2011
Introduction: Cardiac resynchronization therapy (CRT) has significant benefits in selected patients, but its impact on the incidence of ventricular tachyarrhythmias remains the subject of debate. We analyzed the occurrence of appropriate therapies in patients undergoing CRT combined with an implantable cardioverter-defibrillator (ICD). Methods: We studied 123 patients with left ventricular ejection fraction (LVEF) <35%, who underwent successful implantation of CRT-ICD or ICD alone (primary prevention). Results: Mean age was 63±12 years, LVEF 25±6%, and median follow-up 372 days. CRT-ICD devices were implanted in 63 patients (group A) and ICD alone in 60 (group B). In Group A 86% were clinical responders, with a lower prevalence of ischemic cardiomyopathy (30% vs. 72%), and more patients in NYHA class III before device implantation (90% vs. 7%) compared to those with ICD alone. There were no differences in the incidence of appropriate therapies (19% vs. 12%) or in the time to first therapy (305 days vs. 293 days). Overall mortality was 11% in group A and 12% in group B. Kaplan-Meier curves for arrhythmic events in patients with CRT showed no significant differences (HR 1.71, 95% CI 0.67-4.36, p=NS) compared to those without CRT. Conclusions: Despite a higher rate of responders in patients with CRT-ICD for primary prevention, the incidence of appropriate therapies was similar to those with an ICD alone.