Serum Polyclonal Immunoglobulin Free Light Chain Levels Predict Mortality in People With Chronic Kidney Disease

ObjectiveTo determine whether elevated serum polyclonal free light chain (FLC) levels predict mortality in a population of individuals with chronic kidney disease (CKD).Patients and MethodsFrom January 2, 2006, through July 31, 2007, we recruited a cohort of 848 people with CKD who were not receiving renal replacement therapy and did not have monoclonal gammopathy. We measured serum kappa FLC and lambda FLC isotype levels to determine combined FLC (cFLC) levels. The cohort was prospectively followed up for a median of 63 months (interquartile range, 0-93 months). Cox regression analysis was performed to determine variables predictive of mortality.ResultsHigh cFLC levels were an independent risk factor for death (hazard ratio [HR], 2.71; 95% CI, 1.98-3.70; P<.001). Other independent risk factors were age (HR, 1.79; 95% CI, 1.52-2.10; P<.001), South Asian ethnicity (HR, 0.33; 95% CI, 0.14-0.64; P=.02), preexisting cardiovascular disease (HR, 1.59; 95% CI, 1.09-2.31; P=.02), and high-sensitivity C-reactive protein (HR, 1.13; 95% CI, 1.00-1.28; P=.04). Neither estimated glomerular filtration rate nor albuminuria was an independent risk factor for death.ConclusionHigh cFLC levels independently predict mortality in people with CKD.     

Mid‐term outcome after carotid artery stenting depends on presence of coronary artery disease

BACKGROUND. Longer‐term outcome of patients following carotid artery revascularization depends predominantly on cardiac events rather than neurological events.

AIM. To assess the longer‐term outcomes of patients with known coronary artery morphology undergoing carotid artery stenting.

METHOD. In a prospective observational study including 549 consecutive patients undergoing carotid artery stenting, a coronary angiography was performed in a single session unless a recent angiogram was available. Following the intervention, patients were followed prospectively to determine neurological events as well as major adverse coronary events (MACE) during long‐term follow‐up.

RESULTS. Coronary artery disease was present in 378 patients including 92 patients without current significant stenosis. The MACE rate was 6.4% in patients without coronary artery disease compared to 28.3% in patients with coronary artery disease (P<0.00001). Cardiac and all‐cause mortality were statistically significantly higher in patients with a significant coronary stenosis than in patients without coronary artery disease (P<0.001 and P<0.01). Cardiac mortality and all‐cause mortality were 2.3% and 7.6% in patients without coronary artery disease (patient group I), 7.6% and 13.0% in patients with coronary artery disease but no current significant stenosis (patient group II), and 10.5% and 16.1% in patients with significant coronary stenosis (patient group III). Neurological events, however, were distributed equally among the three patient groups.

CONCLUSIONS<1/emph>. In the longer term, outcomes in patients undergoing carotid artery stenting depend on concomitant coronary artery disease rather than neurological events, cardiac mortality and even all‐cause mortality depending on a significant coronary artery stenosis.     

Estimated Glomerular Filtration Rate,Activation of Cardiac Biomarkers and Long-Term Cardiovascular Outcomes: A Population-Based Cohort

ObjectiveTo classify subjects in a general population per their renal function and characterize the cardiac biomarker levels, left ventricular function and cardiovascular outcomes over a 10.2 year follow-up period (interquartile range, 5.1–11.4 years).MethodsThis was a retrospective review of a population-based random sample of residents aged ≥45 years. Data were collected between January 1, 1997, and December 31, 2000. One thousand nine hundred eighty-one individuals were classified based on estimated glomerular filtration rate (eGFR) into group I (>90 mL/min/1.73 m²), group II (60 to 89 mL/min/1.73 m²) and group III (<60 mL/min/1.73 m²; chronic kidney disease [CKD]). Age/sex-adjusted baseline characteristics, tertiles of N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT) and their interactions with eGFR were examined. Outcomes measured included incident myocardial infarction (MI), congestive heart failure, stroke, and all-cause mortality.ResultsEight hundred nineteen patients were classified as group I, 1036 as group II, and 126 of 1981 (6.4%) as group III or CKD. Subjects in group III were older and had a higher incidence of hypertension, diabetes, and MI at baseline. Over a 10.2-year follow-up period, CKD was associated with an increased risk of MI (hazard ratio, 1.95; 95% CI, 1.2-3.14; P=.006) and composite cardiovascular outcomes including MI, congestive heart failure, stroke, and all-cause mortality (hazard ratio, 1.38; 95% CI, 1.05-1.83 ;P=.02). Subjects with NT-proBNP or hs-TnT in the third tertile were at greater risk of cardiovascular events without significant interactions between eGFR and levels of NT-proBNP and hs-TnT.ConclusionSubjects with CKD had significantly elevated cardiac biomarkers and were at an increased risk of MI and adverse cardiovascular events. This warrants future studies to investigate whether these cardiac biomarkers could identify high-risk CKD patients for aggressive management of cardiovascular risk factors.     

Mid-term outcome after carotid artery stenting depends on presence of coronary artery disease

BACKGROUND: Longer-term outcome of patients following carotid artery revascularization depends predominantly on cardiac events rather than neurological events. AIM: To assess the longer-term outcomes of patients with known coronary artery morphology undergoing carotid artery stenting. METHOD: In a prospective observational study including 549 consecutive patients undergoing carotid artery stenting, a coronary angiography was performed in a single session unless a recent angiogram was available. Following the intervention, patients were followed prospectively to determine neurological events as well as major adverse coronary events (MACE) during long-term follow-up. RESULTS: Coronary artery disease was present in 378 patients including 92 patients without current significant stenosis. The MACE rate was 6.4% in patients without coronary artery disease compared to 28.3% in patients with coronary artery disease (P<0.00001). Cardiac and all-cause mortality were statistically significantly higher in patients with a significant coronary stenosis than in patients without coronary artery disease (P<0.001 and P<0.01). Cardiac mortality and all-cause mortality were 2.3% and 7.6% in patients without coronary artery disease (patient group I), 7.6% and 13.0% in patients with coronary artery disease but no current significant stenosis (patient group II), and 10.5% and 16.1% in patients with significant coronary stenosis (patient group III). Neurological events, however, were distributed equally among the three patient groups. CONCLUSIONS: In the longer term, outcomes in patients undergoing carotid artery stenting depend on concomitant coronary artery disease rather than neurological events, cardiac mortality and even all-cause mortality depending on a significant coronary artery stenosis.     

Use of Nitrates and Risk of Cardiovascular Events in Patients With Heart Failure With Preserved Ejection Fraction

ObjectiveTo assess the association of nitrate use with cardiovascular events in patients with heart failure with preserved ejection fraction (HFpEF).Patients and MethodsPatient data were collected from the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist trial, which had been conducted at 233 sites in 6 countries from August 10, 2006, through January 31, 2012. The primary outcome was the occurrence of a major adverse cardiovascular event (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke) or heart failure hospitalization. The association between nitrate use and cardiovascular risk was evaluated using Cox proportional hazards analysis. In addition, we verified the results using propensity score–matched patients.ResultsA total of 3417 patients with HFpEF were evaluated over a mean follow-up of 3.1 years, and 778 experienced a primary outcome event. The risk of primary outcome events was significantly higher in patients taking nitrates than in those not taking nitrates (hazard ratio [HR], 1.21; 95% CI, 1.01-1.46, P=.04). The risk of major adverse cardiovascular events was significantly higher in patients taking nitrates than in those not taking nitrates (HR, 1.32; 95% CI, 1.05-1.66, P=.01). Furthermore, the risk of hospitalization for heart failure was higher in patients taking nitrates (HR, 1.25; 95% CI, 0.99-1.60, P=.06), with propensity score–matched analyses revealing similar findings. In addition, a similar association was observed in various subgroups.ConclusionThis study reported that nitrate use in patients with HFpEF was associated with a significantly increased risk of cardiovascular events.     

Carotid stents: is the gold standard ready for change?

Carotid artery stenting is emerging as an intervention for high-risk nonsurgical patients with high-grade symptomatic carotid artery stenosis. The purpose of this article is to inform advanced practice nurses about research findings related to carotid endarterectomy and carotid artery stenting. This overview of carotid angioplasty and stenting includes complications and guidelines for preprocedural, periprocedural, and postprocedural care. Standards of practice for managing carotid artery disease are highlighted with emphasis on primary and secondary prevention.     

Inability of Radioiodine Remnant Ablation to Improve Postoperative Outcome in Adult Patients with Low-Risk Papillary Thyroid Carcinoma

ObjectiveTo determine whether radioiodine remnant ablation (RRA) reduces cause-specific mortality (CSM) or tumor recurrence (TR) rate after bilateral lobar resection (BLR).Patients and MethodsThere were 2952 low-risk adult papillary thyroid cancer (LRAPTC) patients (with MACIS scores <6) who underwent potentially curative BLR during 1955-2014. During 1955-1974, 1975-1994, and 1995-2014, RRA was administered in 3%, 49%, and 28%. Statistical analyses were performed using SAS software.ResultsDuring 1955-1974, the 20-year CSM and TR rates after BLR alone were 1.0% and 6.8%; rates after BLR+RRA were 0% (P=.63) and 5.9% (P=.82). During 1975-1994, post-BLR 20-year rates for CSM and TR were 0.3% and 7.5%; after BLR+RRA, rates were higher at 0.9% (P=.31) and 12.8% (P=.01). When TR rates were examined separately for 448 node-negative and 317 node-positive patients, differences were nonsignificant. In 1995-2014, post-BLR 20-year CSM and TR rates were 0% and 9.2%; rates after BLR+RRA were higher at 1.4% (P=.19) and 21.0% (P<.001). In 890 pN0 cases, 15-year locoregional recurrence rates were 3.4% after BLR and 3.7% after BLR+RRA (P=.99). In 740 pN1 patients, 15-year locoregional recurrence rates were 10% higher after BLR+RRA compared with BLR alone (P=.01). However, this difference became nonsignificant when stratified by numbers of metastatic nodes.ConclusionRRA administered to LRAPTC patients during 1955-2014 did not reduce either the CSM or TR rate. We would therefore not recommend RRA in LRAPTC patients undergoing BLR with curative intent.     

Effectiveness and Safety of Clopidogrel vs Aspirin in Elderly Patients With Ischemic Stroke

ObjectiveTo evaluate the risks of recurrent stroke and major bleeding events with clopidogrel and aspirin use among patients aged 80 years or older.Patients and MethodsThis retrospective cohort study was conducted using the Full Population Data of the Health and Welfare Database in Taiwan. Patients aged 80 years or older who received monotherapy with clopidogrel or aspirin following hospitalization for primary acute ischemic stroke between January 1, 2009, and December 31, 2018, were included. Inverse probability of treatment weighting was used to balance measured covariates between clopidogrel and aspirin users. Measured outcomes included recurrent acute ischemic stroke, acute myocardial infarction, composite cardiovascular events (recurrent stroke or acute myocardial infarction), intracranial hemorrhage, major gastrointestinal tract bleeding, and composite major bleeding events (intracranial hemorrhage or major gastrointestinal tract bleeding).ResultsA total of 15,045 patients were included in the study, 1979 of whom used clopidogrel and 13,066 who used aspirin following hospitalization for primary acute ischemic stroke. Clopidogrel use was associated with significantly lower risk of recurrent acute ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.83 to 0.96; P=.002), composite cardiovascular events (HR, 0.88; 95% CI, 0.82 to 0.95; P<.001), intracranial hemorrhage (HR, 0.71; 95% CI, 0.56 to 0.90; P=.005), and composite major bleeding events (HR, 0.89; 95% CI, 0.80 to 0.99; P=.04) compared with aspirin use.ConclusionIn patients aged 80 years or older with primary acute ischemic stroke, clopidogrel users had lower risks of recurrent stroke and the composite cardiovascular events compared with aspirin users. Clopidogrel users also had lower risks of intracranial hemorrhage and the composite major bleeding events compared with aspirin users.     

Long-Term Risk of Major Adverse Cardiac Events in Atrial Fibrillation Patients on Direct Oral Anticoagulants

ObjectiveTo determine the association between direct oral anticoagulant (DOAC) use and risk of major adverse cardiac events (MACEs) in patients with atrial fibrillation (AF).Patients and MethodsThis study is a single-center prospective observational cohort study including 2366 outpatients with non-valvular AF on treatment with DOACs or vitamin K antagonists (VKAs) from February 2008 for patients on VKA and September 2013 for patients on novel oral anticoagulants. The primary endpoint was the incidence of MACE including fatal and non-fatal myocardial infarction (MI), cardiac revascularization, and cardiovascular death.ResultsThe mean age was 75.1±9.0 years; 44.7% were women. During a mean follow-up of 33.3±21.9 months (6567 patients/years) 133 MACEs occurred (2.03%/year): 79 MI/cardiac revascularization and 54 cardiovascular deaths. Of these, 101 were on VKAs (2.42%/year) and 32 on DOACs (1.34%/year; log-rank test P=.040). This difference was evident also considering MI alone (1.53%/year and 0.63%/year in the VKA and DOAC group, respectively, log-rank test P=.009). At multivariable Cox proportional hazard regression analysis, use of DOACs was associated with a lower risk of MACE (hazard ratio, 0.636; 95% CI, 0.417 to 0.970; P=.036) and MI (hazard ratio, 0.497; 95% CI, 0.276 to 0.896; p=.020). Sensitivity analysis showed that this association was consistent in younger patients (<75 years), in patients with anemia, and in those without chronic obstructive pulmonary disease and heart failure. We also found that both dabigatran and apixaban/rivaroxaban were associated with a lower rate of MACE, with similar efficacy between full and low doses.ConclusionDOACs are associated with a lower risk of MACE in patients with AF independently from dosage.     

BARI 2D: A Reanalysis Focusing on Cardiovascular Events

ObjectiveTo reanalyze the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial using a new composite cardiovascular disease (CVD) outcome to determine how best to treat patients with type 2 diabetes mellitus and stable coronary artery disease.Patients and MethodsFrom January 1, 2001, to November 30, 2008, 2368 patients with type 2 diabetes mellitus and angiographically proven coronary artery disease were randomly assigned to insulin-sensitizing (IS) or insulin-providing (IP) therapy and simultaneously to coronary revascularization (REV) or no or delayed REV (intensive medical therapy [MED]), with all patients receiving intensive medical treatment. The outcome of this analysis was a composite of 8 CVD events.ResultsFour-year Kaplan-Meier rates for the composite CVD outcome were 35.8% (95% CI, 33.1%-38.5%) with IS therapy and 41.6% (95% CI, 38.7%-44.5%) with IP therapy (P=.004). Much of this difference was associated with lower in-trial levels of fibrinogen, C-reactive protein, and hemoglobin A_1c with IS therapy. Four-year composite CVD rates were 32.7% (95% CI, 30.0%-35.4%) with REV and 44.7% (95% CI, 41.8%-47.6%) with MED (P<.001). A beneficial effect of IS vs IP therapy was present with REV (27.7%; 95% CI, 24.0%-31.4% vs 37.5%; 95% CI, 33.6%-41.4%; P<.001), but not with MED (43.6%; 95% CI, 39.5%-47.7% vs 45.7%; 95% CI, 41.6%-49.8%; P=.37) (homogeneity, P=.05). This interaction between IS therapy and REV was limited to participants preselected for coronary artery bypass grafting (CABG). The lowest composite CVD rates occurred in patients preselected for CABG and assigned to IS therapy and REV (17.3%; 95% CI, 11.8%-22.8%).ConclusionIn the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial, the IS treatment strategy and the REV treatment strategy each reduces cardiovascular events. The combination of IS drugs and CABG results in the lowest risk of subsequent CVD events.Trial Registrationclinicaltrials.gov Identifier: NCT00006305     

Comparison of the Effect of the Metabolic Syndrome and Multiple Traditional Cardiovascular Risk Factors on Vascular Function

ObjectiveTo assess the effect of the metabolic syndrome (MetS) on endothelial function and compare these findings to those in individuals with a similar burden of traditional cardiovascular (CV) risk factors (≥3) without MetS.Patients and MethodsBoth MetS and multiple CV risk factors were identified from 1103 individuals who underwent the evaluation of endothelial function at the Mayo Clinic, in Rochester, Minnesota, from July 1, 2000, through July 31, 2011. Endothelial function was measured using digital arterial tonometry by assessing reactive hyperemia–induced vasodilation in one arm and adjusting for changes in the contralateral arm (reactive hyperemia index [RHI]).ResultsA total of 316 individuals with MetS and 210 with multiple risk factors were assessed. Endothelial dysfunction was more pronounced in the MetS group compared with the multiple risk factor group (mean ± SD natural logarithmic RHI, 0.61±0.25 and 0.68±0.28, respectively; P=.006). Leukocyte count (7.00±1.89 × 10⁹/L vs 6.41±1.76 × 10⁹/L, respectively; P=.001) and high-sensitivity C-reactive protein level (1.78±1.53 mg/L vs 1.48±1.42 mg/L, respectively; P=.01) were higher in the MetS group compared with the multiple risk factor group. After adjustment for covariates and 6 traditional CV risk factors in a multivariate regression model, MetS had a significant and independent influence on natural logarithmic RHI (β=?.11; P=.01).ConclusionThe current study found that individuals with MetS have a higher degree of endothelial dysfunction and inflammation compared with individuals with multiple CV risk factors and may therefore have an increased CV risk beyond the contributions of multiple traditional risk factors.     

Efficacy and Safety of Lower Limb Progressive Resistance Exercise for Patients With Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials

ObjectiveTo evaluate the efficacy and safety of progressive resistance exercise (PRE) for patients with total knee arthroplasty (TKA) in a meta-analysis.Data SourcesPubMed, MEDLINE, Cochrane’s Library, and EMBASE databases.Study SelectionRandomized controlled trials evaluating the effect of PRE on mobility and function in patients with TKA.Data ExtractionA random-effects model was applied if significant heterogeneity was detected; otherwise, a fixed-effects model was applied.Data SynthesisSeven randomized controlled trials. Compared with a rehabilitation program without PRE, physiotherapy including PRE was associated with improvements in the 6-minute walking test (weighed mean difference [WMD], 19.22m; P=.04) with a wide confidence interval (CI, 0.48～37.95). However, sensitivity analysis by omitting 1 study with preoperative rehabilitation revealed nonsignificant results (WMD, 15.15m; P=.16). Moreover, PRE did not significantly improve the maximal walking speed (WMD, 0.05m/s, 95% CI, 0.00～0.11; P=.05). However, PRE was associated with improved knee strength of extension (standardized mean difference [SMD], 0.72; 95% CI, 0.47～0.96; P<.001) and flexion (SMD, 0.47; 95% CI, 0.19～0.74; P<.001) but not self-reported physical function (SMD, ?0.17; 95% CI, ?0.37～0.03; P=.10) or changes in pain score (SMD, 0.11; 95% CI, ?0.15～0.37; P=.40). PRE did not increase the risk of adverse events (risk ratio, 1.19; 95% CI, 0.52～2.71; P=.68).ConclusionsPRE may lead to improvements in physical function among patients receiving a TKA. PRE leads to higher ultimate strength in the surgical knee and is safe to perform.     

Left Ventricular Diastolic Dysfunction in Patients With Mitral Stenosis Undergoing Percutaneous Mitral Balloon Valvotomy

ObjectiveTo investigate the effect of left ventricular diastolic dysfunction on outcome in patients with mitral stenosis undergoing percutaneous mitral balloon valvotomy (PMBV).Patients and MethodsWe evaluated consecutive patients with mitral stenosis who underwent PMBV from November 1, 2002, through October 30, 2011, at our institution.ResultsOf 107 total patients, 35 (32.7%) had diastolic dysfunction, defined as a preprocedural elevation in left ventricular end-diastolic pressure (LVEDP) (>15 mm Hg). The LVEDP was normal in the remaining 72 patients (≤15 mm Hg). Clinical factors associated with diastolic dysfunction were body mass index (32±7 vs 28±5; P=.004) and diabetes mellitus (29% vs 6%; P=.002), but no differences were found in severity of pulmonary hypertension or degree of improvement in mitral valve hemodynamics after PMBV between the 2 groups. Survival free of recurrent severe symptoms, repeated PMBV, or mitral valve replacement was worse in patients with elevated LVEDP vs normal LVEDP (1-year estimate, 42% vs 81%; hazard ratio, 2.83; 95% CI, 1.62-4.96).ConclusionIn patients referred for treatment of symptomatic mitral stenosis, left ventricular diastolic dysfunction may contribute to elevated left atrial pressure, and its presence is associated with a greater risk of failure of PMBV to improve symptoms. These data have implications for counseling and patient selection for PMBV.     

Randomized Controlled Trial of a Telephone-Delivered Physical Activity and Fatigue Self-management Interventions in Adults With Multiple Sclerosis

ObjectiveTo compare the effectiveness of telephone-delivered interventions on fatigue, physical activity, and quality of life outcomes in adults with multiple sclerosis (MS).DesignA single-blinded, randomized controlled trial. Participants were randomized to contact-control intervention (CC), physical activity–only intervention (PA-only), and physical activity plus fatigue self-management intervention (FM+). Outcomes were measured at baseline (2wk prerandomization), posttest (14wk postrandomization), and follow-up (26wk postrandomization).SettingTelephone-delivered in Midwest and Northeast regions of the United States.ParticipantsInactive adults with MS (N=208) and moderate-to-severe fatigue.InterventionsThree or 6 group teleconferences followed by 4 individually tailored phone calls delivered during 12 weeks. An occupational therapist and research assistant delivered the teleconferences and tailored phone calls, respectively.Main Outcome MeasuresPrimary outcomes were self-report fatigue and physical activity measured with the Fatigue Impact Scale and Godin Leisure-Time Exercise Questionnaire, respectively. Secondary outcomes included quality of life measured with the Multiple Sclerosis Impact Scale and moderate-to-vigorous exercise and step count measured with an accelerometer.ResultsLinear mixed effects models showed FM+ significantly improved self-reported fatigue (β=−11.08; P=.03) and physical activity (β=0.54; P=.01) compared with CC at posttest. However, FM+ had nonsignificant differences compared with PA-only on self-report fatigue (β=−1.08, P=.84) and physical activity (β=0.09; P=.68) at posttest. PA–only had significant improvements compared with CC on moderate-to-vigorous exercise (β=0.38; P=.02) at posttest and step count at posttest (β=1.30; P<.01) and follow-up (β=1.31; P=.01) measured with an accelerometer. FM+ and PA-only had nonsignificant differences compared with CC on quality of life.ConclusionsGroup teleconferences followed by tailored phone calls have a small yet statistically significant effect in promoting physical activity and reducing fatigue impact in people with MS.     

C-Reactive Protein to Albumin Ratio in Patients Undergoing Transcatheter Aortic Valve Replacement

ObjectiveTo evaluate whether the serum C-reactive protein to albumin ratio (CAR) could be used for risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).Patients and MethodsFrailty is a predictor of poor outcomes in patients undergoing AS interventions. The CAR reflects key components of frailty (systemic inflammation and nutrition) and could potentially be implemented into assessment and management strategies for patients with AS. From March 1, 2010, through February 29, 2020, 1836 patients were prospectively enrolled in an observational TAVR database. Patients (prospective development cohort, n=763) were grouped into CAR quartiles to compare the upper quartile (CAR Q4) with the lower quartiles (CAR Q1-3). Primary end point was all-cause mortality. Results were verified in an independent retrospective cohort (n=1403).ResultsThe CAR Q4 had a higher prevalence of impaired left ventricular function, atrial fibrillation, diabetes, and cerebrovascular disease and a higher median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) vs CAR Q1-3. After median follow-up of 15.0 months, all-cause mortality was significantly higher in CAR Q4 vs CAR Q1-3 (P<.001). In multivariable analyses, risk factors for all-cause mortality were CAR Q4 (>0.1632; hazard ratio, 1.45; 95% confidence interval, 1.05 to 2.00; P=.03), N-terminal pro–B-type natriuretic peptide Q4 (>3230 pg/mL [to convert to ng/L, multiply by 1), high-sensitivity troponin T Q4 (>0.0395 ng/mL [to convert to μg/L, multiply by 1]), above-median logistic EuroSCORE (16.1%), myocardial infarction, Acute Kidney Injury Network stage 3, and life-threatening bleeding.ConclusionElevated CAR was associated with increased risk of all-cause mortality in patients undergoing transfemoral TAVR. The CAR, a simple, objective tool to assess frailty, could be incorporated into assessing patients with AS being considered for TAVR.     

Study on the value of small dense low‐density lipoprotein in predicting cardiovascular and cerebrovascular events in the high‐risk stroke population

BackgroundLipid management in people at high risk of stroke is an important measurement to prevent the occurrence of stroke. The study aims to investigate the association between sdLDL and cardiovascular and cerebrovascular events in high‐risk stroke populations.MethodsThis was a prospective study. Screened from 15,933 individuals aged >40 years in April 2013 and followed up at 3rd, 6th, 12th, and 24th months, 823 participants met the screening criteria and were investigated for clinical data and biochemical parameters.ResultsA total of 286 subjects had varying degrees of carotid stenosis, and 18 subjects experienced cardiovascular and cerebrovascular events during the two‐year follow‐up period. There was no positive correlation between sdLDL and carotid stenosis. Carotid stenosis and extent of carotid stenosis involvement did not predict cardiovascular and cerebrovascular events in patients with high‐risk stroke, while sdLDL did. The sdLDL level in the events group was significantly higher than those in the no event group (p = 0.002). In the events group, the risk of events in the fourth quartile of sdLDL was 10.136 times higher than in the first quartile (HR = 10.136, 95% CI: 1.298–79.180, p = 0.027).ConclusionssdLDL was positively correlated with the incidence of cardiovascular and cerebrovascular events, which can predict the occurrence of an event and provide a scientific basis for early prevention.     

Clinical Characteristics,Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting

ObjectiveTo investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI).Patients and MethodsWe undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004–September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]).ResultsPatients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P=.26).ConclusionsIn this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.     

Noninvasive Voice Biomarker Is Associated With Incident Coronary Artery Disease Events at Follow-up

ObjectiveTo evaluate the association between a preidentified voice biomarker and incident coronary artery disease (CAD) events.MethodsPatients referred for clinically indicated coronary angiography underwent a total of three 30-second voice recordings using the Vocalis Health smartphone application between January 1, 2015, and February 28, 2017. A pre-established voice biomarker was derived from each individual recording, and the mean biomarker value was calculated for each patient. Individuals were clinically observed through December 31, 2019. The prespecified primary outcome was a composite of presenting to the emergency department with chest pain, being admitted to the hospital with chest pain, or having an acute coronary syndrome; the prespecified secondary outcome was a composite of a positive stress test result at follow-up or the presence of CAD at follow-up coronary angiography.ResultsIn the final analysis, 108 patients were included (mean age, 59.47±11.44 years; male, 59 [54.6%]). The median follow-up time was 24 months (range, 1 to 60 months). In multivariable Cox proportional hazards models adjusting for CAD grade on baseline angiography, a high baseline mean voice biomarker was significantly associated with both the primary (hazard ratio, 2.61; 95% CI, 1.42 to 4.80; P=.002) and secondary (hazard ratio, 3.13; 95% CI, 1.13 to 8.68; P=.03) composite outcomes.ConclusionThis study found a significant association between a noninvasive voice biomarker and incident CAD events at follow-up. These results may have important clinical implications for the remote and noninvasive screening of patients to identify those at risk of coronary disease and its complications.     

Comparison of Carotid Artery Stenting and Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis: A Single Center Study

Introduction

Carotid artery stenting (CAS) is believed to be an alternative to carotid endarterectomy (CEA); however, recent studies have demonstrated an increase of complications with stenting that does not reflect our experience. We thus wanted to compare the periprocedural and 1-year follow-up outcomes of CAS with those of CEA among patients with symptomatic extracranial carotid stenosis in a population from eastern Turkey.

Methods

The hospital records of all patients who underwent carotid artery revascularization were retrospectively reviewed. Patients were divided into two groups based on the type of carotid revascularization performed, namely CEA or CAS. Comparisons were made with respect to 30-day and 1-year outcomes of transient ischemic attack (TIA), myocardial infarction (MI), stroke, and all-cause death rates. Composite endpoints for both groups were also analyzed.

Results

Thirty-two CEA and 33 CAS procedures were performed for symptomatic occlusive carotid disease. Baseline characteristics were similar between both groups except for the incidence of diabetes mellitus. No significant differences were found with respect to 30-day mortality, MI, and neurologic morbidity endpoints for CEA and CAS procedures. In the postprocedural 1-year follow-up, only TIA was observed to be significantly higher in the CAS group; the other endpoints did not differ significantly. One-year composite endpoints did not differ between both groups (log-rank P = 0.300).

Conclusion

In our trial of patients with symptomatic carotid artery stenosis, no significant difference could be shown in periprocedural outcomes, postprocedural outcomes except TIA, and in composite endpoints between the CEA and CAS groups. CAS is a safe and efficacious alternative for the treatment of symptomatic carotid artery stenosis.     

Different level, but a similar day pattern of physical activity in workers and sick-listed people with chronic nonspecific musculoskeletal pain

Reneman MF, de Vries HJ, van den Hengel EJ, Brouwer S, van der Woude LH. Different level, but a similar day pattern of physical activity in workers and sick-listed people with chronic nonspecific musculoskeletal pain.ObjectiveTo investigate whether physical activity (PA) levels and day patterns of sick-listed workers with chronic nonspecific musculoskeletal pain (CMP) admitted for multidisciplinary rehabilitation are different from those of workers with CMP.DesignCross-sectional.SettingOutpatient rehabilitation center and general community.ParticipantsA convenience sample of sick-listed patients with CMP (n=27) referred for multidisciplinary pain rehabilitation, and a volunteer sample of workers with CMP (n=107; <5% sick leave in year before participation).InterventionParticipants wore an accelerometer for 5 to 7 consecutive days.Main Outcome MeasurePA, expressed as activity counts. All analyses were corrected for confounders.ResultsPA levels of workers with CMP were higher than those of sick-listed patients (P=.01). After correction for confounders, work status explained 3.5% of the variance observed in activity counts (F_change=5.27, P=.024). In the mornings, group status significantly contributed to the variance in mean activity counts (F_change=5.32, P=.02). In afternoons (F_change=3.29, P=.07) and evenings (F_change=2.41, P=.12), the effect of group status on PA level was nonsignificant. No significant interaction was observed between time and group status (Wilks' λ=.92, F_14,104=.66, P=.80).ConclusionsWorkers with CMP have a higher PA level compared with sick-listed patients. The PA day pattern did not differ significantly between the 2 groups.