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Carmen P. Lydell Yoko Mikami Kai Homer Mingkai Peng Aidan Cornhill Archa Rajagopalan Punitha Arasaratnam Karen Cowan Andrew Roberts Claire Sumner Bobak Heydari Andrew G. Howarth Derek Exner James A. White 《The Canadian journal of cardiology》2019,35(9):1149-1157
BackgroundIn this study we aimed to investigate left atrial (LA) function, measured from routine cine cardiovascular magnetic resonance imaging, to determine its value for the prediction of sudden cardiac death (SCD) or appropriate implantable cardioverter defibrillator (ICD) shock in patients who received primary prevention ICD implantation.MethodsWe studied 203 patients with ischemic or idiopathic nonischemic dilated cardiomyopathy who underwent cardiovascular magnetic resonance imaging before primary prevention ICD implantation. LA volumes were measured at end-diastole and end-systole from 4- and 2-chamber cine images, and LA emptying function (LAEF) calculated. Patients were followed for the primary composite end point of SCD or appropriate ICD shock.ResultsMean age was 61 ± 12 years with a mean left ventricular ejection fraction of 24 ± 7%. The mean LAEF was 27 ± 15% (range, 0.9%-73%). At a median follow-up of 1639 days, 35 patients (17%) experienced the primary composite outcome. LAEF was strongly associated with the primary outcome (P = 0.001); patients with an LAEF ≤ 30% experienced a cumulative event rate of 26.1% vs 5.7% (hazard ratio, 5.5; P < 0.001) in patients above this cutoff. This finding was maintained in multivariable analysis (hazard ratio, 4.7; P = 0.002) and was consistently shown in the ischemic and nonischemic dilated cardiomyopathy subgroups.ConclusionsLAEF is a simple, powerful, and independent predictor of SCD in patients being referred for primary prevention ICD implantation. 相似文献
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James E. Andruchow Peter A. Kavsak Andrew D. McRae 《The Canadian journal of cardiology》2018,34(2):98-108
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate “observation zone” even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS. 相似文献
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Ali Fatehi Hassanabad Vishnu Vasanthan William D.T. Kent 《The Canadian journal of cardiology》2019,35(2):225-228
Aortic valve replacement (AVR) is the only definitive treatment for severe aortic stenosis. Options for valve replacement include surgical AVR (SAVR) and percutaneous transcatheter AVR. Although transcatheter AVR has recently been shown to be the optimal approach for high-risk patients, SAVR is the gold standard for patients with low and intermediate surgical risk. Advances in technique and innovations in rapid-deployment and sutureless valves have facilitated the development of a third alternative. Accumulating evidence suggests that minimally invasive SAVR can be performed as safely as conventional SAVR, and perhaps with less morbidity, allowing patients a quicker return to their productive lives. The following discussion outlines the surgical technique, patient selection and advances in valve design. 相似文献
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Bishoy Deif Sally Kang Abid Ismail Thuva Vanniyasingam Juan C. Guzman Carlos A. Morillo 《The Canadian journal of cardiology》2018,34(9):1158-1164
Background
Low-risk syncope accounts for a large proportion of hospital admissions; however, inpatient investigations are often not necessary and are rarely diagnostic. Reducing the number of low-risk syncope admissions can likely lower health care resource consumption and overall expenditure. Application of syncope guidelines by physicians in the emergency department provides a standardized approach that may potentially reduce admissions and lead to health care resource utilization savings.Methods
A retrospective chart review of 1229 syncope presentations was conducted at 2 major academic centres spanning 1 year. Three major society guidelines and position statements were applied to determine the effect on admission rates.Results
A total of 1031 true syncope charts were included in the analysis; 407 (39%) were admitted and 624 (61%) were discharged by the treating physician (MD). There was a significant difference in the mean [standard deviation] age (75 [14] vs 55 [22]) and baseline cardiovascular disease, including congestive heart failure 51/407 (13%) vs 28/624 (5%), coronary artery disease 125/407 (31%) vs 91/624 (15%), and structural heart disease 36/407 (9%) vs 26/624 (4%), between admitted and not admitted patients, respectively (P < 0.01). All guidelines warranted more low-risk admissions when compared with 19% by the MD: Canadian Cardiovascular Society 34% (P < 0.01), American College of Emergency Physicians 22% (P = 0.03), and European Society of Cardiology 26% (P < 0.01).Conclusion
In conclusion, application of the current syncope guidelines to an emergency department population is unlikely to reduce low-risk hospital admissions. 相似文献5.
Charlotte Zerna Thomas Jeerakathil Michael D. Hill 《The Canadian journal of cardiology》2018,34(7):889-896
Stroke is a leading cause of adult disability and the fourth leading cause of death in Canada. Most strokes are ischemic and functional outcome is highly time-dependent, making fast diagnosis and treatment initiation crucial. This poses a challenge in vast geographical areas where stroke neurology expertise is only available in urban centres. In this article we review the rationale for telestroke networks and their current implementation in Canada. Telestroke networks enable stroke-specific procedures to be performed by less experienced physicians under the guidance of stroke neurology experts. We also present evidence that the safety and effectiveness of intravenous alteplase in community hospitals in a telestroke network seems to be comparable with that achieved in dedicated stroke centres. It is thus a viable option to guarantee an aging population access to stroke care across large geographic regions with faster treatment and access to more advanced treatment options by means of transfer to a comprehensive centre if necessary. Although telestroke networks have an upfront implementation cost, they can lead to reduced direct and indirect costs for the health care system by reducing days spent in the hospital as well as disability with the need for long-term care. Telestroke networks can also be used for identification and enrollment of patients into emergency stroke trials and thus provide a more representative sample of the population and increase recruitment. Standardization of regional telestroke networks could lead to collaborations with larger data acquisitions for research purposes and quality control in the future. 相似文献
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P. Timothy Pollak Gavin R. Sun Richard B. Kim 《The Canadian journal of cardiology》2018,34(3):342.e17-342.e19
A 45-year-old woman who required lifelong anticoagulation for recurrent thrombosis had her therapeutic choices limited by heparin-induced thrombocytopenia and abnormal pharmacokinetics (greatly reduced absorption) resulting from short gut syndrome from extensive gut resection after mesenteric thrombosis. As an alternative to inconvenient and expensive injections of fondaparinux, personalized dosing of a direct oral anticoagulant was sought using clinical pharmacology techniques. Enteral absorption was ascertained with small test doses of apixaban, and the ability of supraconventional doses to deliver effective concentrations was verified. 相似文献
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Yang Zhan Jacqueline Joza Mohamed Al Rawahi Rodrigo S. Barbosa Michelle Samuel Martin Bernier Thao Huynh George Thanassoulis Vidal Essebag 《The Canadian journal of cardiology》2018,34(3):252-261
Background
Intracardiac thrombi arising in the left atrial appendage (LAA) are the principal cause of stroke in nonvalvular atrial fibrillation (AF). Predicting the presence of LAA thrombi is of vital importance in stratifying patients that would need further LAA imaging prior to cardioversion or AF ablation.Methods
We comprehensively searched PubMed from its inception to November 2017 for randomized controlled trials, cohort and case control studies, as well as for case series on LAA thrombi risk factors, imaging, prevention, and anticoagulation management in atrial fibrillation.Results
A systematic review of the literature identified 106 articles that investigated the presence of LAA thrombi in AF patients. We classified the articles according to topic and reported on: (1) risk factors; (2) diagnostic imaging modalities; (3) prevention strategies before cardioversion; (4) prevention strategies before AF ablation; and (5) management of detected LAA thrombi.Conclusions
Integration of clinical, biomarker, and imaging risk factors can improve overall prediction for the presence of LAA thrombi, translating into improved patient selection for imaging. The gold standard for the diagnosis of LAA thrombi remains transesophageal echocardiography, although intracardiac ultrasound, cardiac computed tomography, and cardiovascular magnetic imaging are promising alternative modalities. When LAA thrombi are discovered, the treatment regimen remains variable, although direct oral anticoagulants might have efficacy similar to vitamin K antagonists. Future trials will help further elucidate direct oral anticoagulant use for the treatment of LAA thrombi. 相似文献10.
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Cardiovascular disease and chronic kidney disease (CKD) share several common risk factors, and CKD itself is an independent and graded risk factor for cardiovascular disease. Although control of vascular risk factors is associated with improved kidney outcomes, certain patients still show CKD progression, highlighting that examination of other factors is warranted. In this review we explore how blood pressure and glycemic targets appear to differ for macro- vs microvascular disease. Furthermore, factors such as obstructive sleep apnea and obesity are associated with CKD progression. There is increasing recognition of how sex, gender, ethnicity, and socioeconomic position all factor into CKD progression. Uncertainty exists as to what is the optimal diet to prevent loss of kidney function. Last, complications of CKD might directly or indirectly contribute to progression of kidney disease. In conclusion, control of vascular risk factors reduces the risk of CKD progression, and careful consideration of these additional factors might ultimately result in improved cardiovascular and CKD outcomes. 相似文献
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Michael Slawnych 《The Canadian journal of cardiology》2018,34(7):914-924
The landscape of patient care at the beginning of the 19th century was dramatically different than it is today. With few good treatment options, illness courses were generally brief. Near the end of life, patients were attended to by spiritual advisors, not health care professionals. Death typically occurred at home, surrounded by friends and family. Moving to the present time, decades of medical advances have significantly improved life expectancy. Cardiology has particularly benefited from many of these advances. Cardiac patients are initiated on optimal medication regimens. As disease burdens progress, interventions such as implantable defibrillators and cardiac resynchronization pacing systems become options for many patients. With further clinical deterioration, select patients might be candidates for ventricular assist devices and heart transplants. These advances have unquestionably improved the prognosis with advanced cardiovascular illnesses. However, they have also changed patient and family attitudes about death and dying, to the point where we have effectively “medicalized our mortality.” The importance of introducing palliative care to the cardiac patient population is now well recognized, with the major cardiovascular societies incorporating palliative care principles into their guideline and consensus statement documents. However, despite this recognition, few cardiac patients get access to palliative care and other resources such as hospice. In this article the existing literature on this topic is reviewed and opportunities for developing and fostering a more collaborative relationship between the disciplines of cardiology and palliative care are discussed. 相似文献
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Dong Huang Jing-bo Li Tarek Zghaib Esra Gucuk Ipek Muhammad Balouch David D. Spragg Hiroshi Ashikaga Harikrishna Tandri Sunil K. Sinha Joseph E. Marine Ronald D. Berger Hugh Calkins Saman Nazarian 《The Canadian journal of cardiology》2018,34(1):73-79
Background
The extent of left atrial (LA) baseline low-voltage areas (LVA-B), which may be a surrogate for fibrosis, is associated with recurrent atrial fibrillation (AF) after ablation. This study aimed to assess the relationship between the extent of LVA-B isolated by ablation (LVA-I) and AF recurrence.Methods
The study cohort included 159 consecutive patients with drug-refractory AF who underwent an initial AF ablation with LA voltage mapping during sinus rhythm. The extent of LVA-B was quantified while excluding the pulmonary veins, LA appendage, and mitral valve area. LVA-I was quantified as the percentage of LVA-B encircled by pulmonary vein isolation. Surveillance and symptom-prompted electrocardiograms, Holter monitors, and event monitors were used to document atrial arrhythmia recurrence for a median follow-up of 712 days (1.95 years).Results
Of 159 patients, 72% were men and 27% had persistent AF. The mean number of sampled bipolar voltage points was 119 ± 56. The mean LA surface area was 102.3 ± 37.3 cm2, and the mean LVA-B was 1.9 ± 3.8 cm2. The mean LVA-I was 51.05% ± 36.8% of LVA-B. In the multivariable Cox proportional hazards model adjusted for LA volume, CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age [≥ 75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female] score), LVA-B, and AF type, LVA-I was inversely associated with recurrent atrial arrhythmia after the blanking period (hazard ratio, 0.42/percent LVA isolated; P = 0.037).Conclusions
The extent of LVA-I is independently associated with freedom from atrial arrhythmias after AF ablation, supporting ongoing efforts to target low LA voltage areas and other fibrosis indicators to improve ablation outcomes. 相似文献17.
Malay Shukla Jae-Hyeong Park James D. Thomas Victoria Delgado Jeroen J. Bax Garvan C. Kane Jonathan G. Howlett James A. White Nowell M. Fine 《The Canadian journal of cardiology》2018,34(8):1069-1078
Background
Right ventricular (RV) strain imaging using speckle-tracking echocardiography (STE) is a quantitative method of assessing RV systolic function that has shown prognostic utility in patients with pulmonary hypertension (PH). However, its prognostic value for a large and mixed PH population remains poorly defined.Methods
A systematic review and meta-analysis was performed using the MedLine, Embase, and Cochrane Library databases for publications reporting the prognostic value of RV strain calculated using 2-dimensional STE in PH patients for the clinical end point of all-cause mortality.Results
Screening of 687 publications yielded 10 that were included in the meta-analysis, representing data for 1001 PH patients, among whom 76% had pulmonary arterial hypertension with the remainder having a range of PH etiologies. The pooled free wall RV strain was ?16.2% (95% confidence interval [CI], ?14.3 to ?18.1; I2 = 94.1%; Q = 102.8; P < 0.001), and the global (free wall and septum) RV strain was ?14.5% (95% CI, ?12.9 to ?16; I2 = 84.9%; Q = 20; P < 0.001). There were 193 (18%) deaths (follow-up period range, 7.4 months to 4.2 years). From 6 publications, the pooled unadjusted hazard ratio for a binary cut off RV strain value for the primary outcome was 3.67 (95% CI, 2.82-4.77; P < 0.001; I2 = 0; Q = 1.8; P = 0.87), whereas the pooled unadjusted hazard ratio of RV strain as a continuous variable (per 1% change) was 1.14 (95% CI, 1.11-1.8; P < 0.001; I2 = 0; Q = 2.0; P = 0.85), and were superior to corresponding values for tricuspid annular systolic plane excursion (1.45; P = 0.071, hazard ratio = 1.00, and P = 0.82, respectively).Conclusions
RV strain performed using 2-dimensional STE provides important prognostic value within a large and mixed population of PH patients. 相似文献18.
Alexsander K. Bressan Michael Wahba Elijah Dixon Chad G. Ball 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2018,20(1):20-27
Background
Pancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A variety of pancreas-preserving operations have been proposed, but completion pancreatectomy (CP) stands out in locally complicated cases as a universal approach. This study aims to provide a qualitative synthesis of the peer-reviewed literature regarding emergency CP for post-PD pancreatic fistula.Methods
A systematic search of PubMed and EMBASE for all studies reporting clinical outcomes for CP in the acute treatment of pancreatic fistula following PD from January 1975 until May 2016.Results
Eleven patient-series with a total of 5566 PD and 151 (3%) emergency CP were included. Median time from PD to CP ranged from 6 to 17 days (7 studies), and mean operative time and blood loss – reported in only two studies – were 197 min and 2173 mL respectively. Re-laparotomy following CP was required in 35% of patients. Median hospital length-of-stay varied from 21 to 64 days, and postoperative mortality was 42%.Conclusions
Emergency surgery for postoperative pancreatic fistula should only be considered after expert consultation. CP carries a high risk of mortality, and it is most commonly recommended for a selected subgroup of patients with locally complicated fistula. 相似文献19.
Michael H. Chiu Jonathan G. Howlett Vikas P. Kuriachan Nakul C. Sharma 《The Canadian journal of cardiology》2018,34(8):1089.e1-1089.e3
A 58-year-old man with previous mitral/aortic mechanical-valve replacement, aortic root repair, and coronary disease developed severe left-ventricular dysfunction following AV-node ablation/single-chamber pacemaker implantation for management of atrial fibrillation. He then underwent an upgrade to cardiac resynchronization therapy with a defibrillator. To manage his heart failure better, angiotensin-receptor blocker therapy was changed to sacubitril/valsartan, after which symptomatic palpitations with T-wave oversensing occurred. The resolved T-wave oversensing and palpitations stopped upon discontinuation of sacubitril/valsartan and recurred upon rechallenge, requiring a switch back to valsartan monotherapy. Our report presents the first known case of T-wave oversensing due to sacubitril/valsartan. 相似文献