Unstable Coronary Syndromes Research Articles

How to Reduce the Cardiac Risk, One of the Most Common Perioperative Complications Following Invasive Surgery in Gynecology

The role of preoperative cardiac evaluation is to determine the medical condition of the patient's cardiovascular status .A history and cardiovascular examination are crucial to identify severe cardiac conditions such as unstable coronary syndromes, serious arrhythmias, decompensated HF, and valvular disease. These conditions would place the patient in a high surgical risk category. In some situations, an additional diagnostic cardiac evaluation is necessary on the basis of the results of the initial preoperative test. In an acute surgical emergency, preoperative evaluation might have to be limited to simple tests, such as a rapid assessment of cardiovascular vital signs, ECG, blood pressure, hematocrit, electrolytes, renal function, blood analysis. Only the most essential tests and interventions are appropriate until the acute surgical emergency is resolved. Under other, less urgent circumstances, the preoperative cardiac evaluation may lead to a variety of responses, including delay or cancellation of surgery until the cardiac problem has been clarified and treated appropriately. This ideally would include direct communication with the surgeon, anaesthesiologist, and other physicians, as well as discussion directly with the patient and, if appropriate, the family. Conclusion: Preoperative cardiac evaluation is very important for all the patients undergoing gynaecologic surgery because cardiac related perioperative complications are well-known in general practice.

Chronic troponin elevation assessed by myocardial T1 mapping in patients with stable coronary artery disease.

Cardiac troponin detected with sensitive assays can be chronically elevated, in the absence of unstable coronary syndromes. In patients with chronic coronary artery disease, clinically silent ischemic episodes may cause chronic troponin release. T1 mapping is a cardiovascular magnetic resonance technique useful in quantitative cardiac tissue characterization. We selected patients with anatomically and functionally normal hearts to investigate associations between chronic troponin release and myocardial tissue characteristics assessed by T1 mapping. We investigated the relationship between cardiac troponin I concentrations and cardiovascular magnetic resonance T1 mapping parameters in patients with stable coronary artery disease enrolled in MASS V study before elective revascularization. Participants had no previous myocardial infarction, negative late gadolinium enhancement, normal left ventricular function, chamber dimensions and wall thickness. A total of 56 patients were analyzed in troponin tertiles: nativeT1 and extracellular volume (ECV) values (expressed as means ± standard deviations) increased across tertiles: nativeT1 (1006 ± 27 ms vs 1016 ± 27 ms vs 1034 ± 37 ms, ptrend = 0.006) and ECV (22 ± 3% vs 23 ± 1.9% vs 25 ± 3%, ptrend = 0.007). Cardiac troponin I concentrations correlated with native T1(R = 0.33, P = .012) and ECV (R = 0.3, P = .025), and were independently associated with nativeT1 (P = .049) and ventricular mass index (P = .041) in multivariable analysis. In patients with chronic coronary artery disease and structurally normal hearts, troponin I concentrations correlated with T1 mapping parameters, suggesting that diffuse edema or fibrosis scattered in normal myocardium might be associated with chronic troponin release.

Serum matrix metalloproteinase type 9 in patients with coronary heart disease

BACKGROUND: The study sends to quantify type 9 matrix metalloproteinase in serum in patients with coronary heart disease, since this enzyme is able to provoke an immunoinflammatory process leading to destabilization of atherosclerotic plaque, the development of unstable angina and acute coronary syndrome.
 AIM: Is to conduct a comparative analysis of the quantitative content of MMR-9 in serum in patients with coronary heart disease (CHD) with a different course of angina and atherosclerosis and in relatively healthy individuals.
 MATERIALS AND METHODS: Blood serum samples of 66 CHD patients were examined. All patients based on clinical examination were divided into 3 groups, depending on the severity of the disease. Quantitative MMR-9 analysis was performed using the Thermo Fisher ELISA kits (BMS2016-2). Determination of the amount of MMR-9 in serum was recorded in the ELX 800 ELISA reader plate. Data processing was carried out using Statistica 6.0 statistical analysis (StatSof, USA). The results were presented as means and mean errors.
 RESULTS: The obtained results indicate a significant decrease in the concentration of MMR-9 in the serum of patients with an unstable course of the disease compared to the control group (relatively healthy people). This is probably due to the effect on the content and activity of its MMR-9 inhibitor TIMP-1. Further studies will investigate whether MMR-9 can be considered as a marker of destabilization of atherosclerotic plaque and act as an independent predictor of acute clinical complications in patients with cardiovascular pathology.
 CONCLUSIONS: The study made it possible to establish a significant decrease in the concentration of MMR-9 in the serum of patients with an unstable course of atherosclerosis compared to the control group (relatively healthy people). In addition, in patients with an unstable course of atherosclerosis, a tendency to reduce the concentration of this enzyme compared to persons with stable atherosclerosis was revealed.

Abbreviated versus Standard Duration of DAPT after PCI: A Systematic Review and Network Meta-analysis

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is typically continued for 6-12 months depending on clinical presentation. Recent studies have evaluated the safety of shorter durations of DAPT across stable and unstable coronary syndrome but are limited by smaller patient pools and varying indications. The present study performed a systematic review and network meta-analysis comparing abbreviated (1-3 months) with standard (6-12 months) duration of DAPT. Both conventional and frequentist network meta-analyses with a random-effects model were conducted. Seventeen randomized controlled trials, nine of which included 1-3 months of DAPT, were selected. The risks of any bleeding (RR 0.68, 95% CI 0.54-0.85), major bleeding (RR 0.66, 95% CI 0.50-0.86), and net adverse clinical events (NACE) (RR 0.87, 95% CI 0.76-0.99) were lower with abbreviated (1-3 months) than standard-term (6-12 months) DAPT. No significant differences in the risk of myocardial infarction (RR 1.02, 95% CI 0.87-1.18), definite or probable stent thrombosis (RR 1.11, 95% CI 0.83-1.50), and major adverse cardiac events (MACE) (RR 0.96, 95% CI 0.86-1.06) were observed. Network meta-analysis demonstrated lower risk of any bleeding, major bleeding, and NACE with shorter durations of DAPT compared with 12 months. Risks of definite or probable stent thrombosis, myocardial infarction, and MACE were not significantly different. The results support the growing body of evidence that abbreviated duration (1-3 months) of DAPT may be considered to reduce the risk of bleeding without any differences in myocardial infarction, stent thrombosis, or MACE.

Plasma PCSK9 levels increase following percutaneous coronary interventions

Abstract Background Beside its role in cholesterol homeostasis, Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) has been associated with the processes of vascular inflammation and atherosclerosis. The protein is expressed in endothelial cells, smooth muscle cells and macrophages and it is detected inside the human atherosclerotic plaque. Purpose We aimed to investigate the effect of acute inflammation associated with plaque rupture and vascular injury during elective percutaneous coronary intervention (PCI) on plasma levels of PCSK9 in patients with coronary artery disease (CAD). Methods We measured PCSK9, C-reactive protein (CRP), Interleukin-6 (IL-6) and high-sensitivity cardiac Troponin T (hs-cTnT) plasma levels immediately before and 18–24 hours after PCI via the radial approach, in 68 consecutive patients with stable CAD referred for elective PCI of a de novo lesion in a native coronary artery. Patients with unstable coronary syndrome <3 months old, baseline inflammatory condition, malignancy, auto-immune disease or intervention via the femoral access, were excluded. Results All patients were treated with balloon angioplasty and implantation of a second-generation drug eluting stent (DES). Baseline plasma levels of PCSK9 were higher in women and in patients treated with statins. At 18–24 hours after the procedure, plasma levels of PCSK9, CRP, IL-6 and hs-cTnT increased significantly compared to baseline (table). The change (elevation) in CRP plasma levels was statistically correlated with that of IL-6 (r=0.33; p=0.006) and with that of hs-cTnT (r=0.28; p=0.023). However, there was no correlation between the change (elevation) in plasma PCSK9 levels and those of IL-6 (r=−0.09; p=0.47), CRP (r=0.01; p=0.9), and hs-cTnT (r=0.1; p=0.41). Conclusions Plasma levels of PCSK9 increased by 26% following PCI with DES. That elevation was however, not correlated with the degree of myocardial injury (hs-cTnT) or of inflammation (IL-6 and CRP). The mechanism underlying PCK9 elevation post PCI requires further investigation. Funding Acknowledgement Type of funding sources: None.

Assessing the downstream value of first-line cardiac positron emission tomography (PET) imaging using real world Medicare fee-for-service claims data

BackgroundHigher imaging quality makes cardiac positron emission tomography (PET) desirable for evaluation of suspected coronary artery disease (CAD). High cost of PET imaging may be offset by reduced utilization and/or improved outcomes. MethodsThis retrospective observational study utilized Medicare fee-for-service dataset. Study participants had no CAD diagnosis within 1 year prior to initial imaging. The PET group (PET imaging) and propensity score matched comparison group (single photon emission computed tomography or stress echocardiography) underwent index imaging between January 2014 and December 2016. Outcomes were analyzed using generalized linear models. ResultsAmong 144,503 study subjects, 4619 (3.2%) had PET and 139,884 (96.8%) had conventional imaging. After matching, each group had 4619 patients (mean age 74 years, 59% female). The PET group had lower radiation exposure (3.8 milliSievert less per year, 95% CI − 3.96 to − 3.64, P < .0001) and unstable coronary syndrome (incidence rate ratio (IRR) 0.77, 95% CI 0.64-0.94, P = .008). The PET group experienced more hospital admissions (IRR 1.10, 95% CI 1.06-1.15, P < .0001), more use of percutaneous coronary intervention (IRR 1.24, 95% CI 1.02-1.50, P = 0.03), while similar mortality rate (hazard ratio 0.95, 95% CI 0.78-1.14, P = 0.55). The PET group had higher medical spending ($2358.2 vs $1774.3, difference = $583.9 per patient per month, P < .0001). ConclusionsFirst-line PET imaging was not associated with reduced levels of utilization and spending. Clinical outcomes were mostly similar.

Assessment Framework for Recognizing Clinical Deterioration in Patients With ACS Undergoing PCI.

Patients with acute coronary syndrome undergoing primary percutaneous coronary intervention are at risk of clinical deterioration that results in similar general signs and symptoms regardless of its cause. However, specific causes and forms of clinical deterioration are associated with key differences in assessment findings. Focused clinical assessments using a modified primary survey enable nurses to rapidly identify the cause and form of clinical deterioration, facilitating targeted treatment. Clinical deterioration during percutaneous coronary intervention is associated with increased mortality and morbidity. Previous studies identified nursing inconsistencies when recognizing clinical deterioration, with inconsistent collection of cues and prioritization of cues related to cardiac performance over more sensitive indicators of clinical deterioration. To describe a framework to help nurses optimize physiological cue collection to improve recognition of clinical deterioration during periprocedural care of patients undergoing percutaneous coronary intervention for unstable acute coronary syndrome. Literature analysis revealed 7 forms of clinical deterioration in patients undergoing percutaneous coronary intervention: coronary artery occlusion, stroke, ventricular rupture, valvular insufficiency, lethal cardiac arrhythmias, access-site and non-access-site bleeding, and anaphylaxis. Evidence for the pathophysiology, incidence, severity, and clinical features of each form of clinical deterioration is identified. A framework is proposed to help nurses conduct highly focused patient assessments, enabling prompt recognition of and response to the specific forms of clinical deterioration that occur in patients undergoing percutaneous coronary intervention.

CD38 Genetic Knockout Confers Marked Protection Against In Vivo Myocardial Ischemia/Reperfusion Injury

Background CD38 is a multifunctional membrane protein with the major NAD(P)ase activity in human tissues. It is highly expressed in endothelial cells and some inflammatory cells. Using ex vivo perfused hearts and cell models, we have shown that ischemia/reperfusion (I/R) in the heart leads to CD38 activation with subsequent NAD(P)H depletion and impaired endothelial nitric oxide synthase function, triggering diminished coronary flow and decreased contractile function. Here we test if genetic knockout (KO) of CD38 protects against in vivo myocardial I/R in mice. Methods Male CD38 KO (n=7) and wild type (WT) mice (n=11) in C57BL/6 background were subjected to I/R surgery at the age of 12–16 weeks. The mice were anesthetized, endotracheal intubated, and ventilated with a rodent ventilator. A left lateral thoracotomy was performed, and the left anterior descending coronary artery was visualized and ligated with a slip knot. Then, mice were subjected to 30 minutes of ischemia followed by 24 h of reperfusion. The left ventricular area at risk (AAR) and infarct areas were visualized by Evans blue and TTC staining, respectively. The hearts were sliced and digitally photographed. Left ventricular AAR and infarct area were contoured using Image J software. (P<0.05) was considered significant in statistical testing. Results In CD38 KO and WT mice the AAR/LV % was similar with values of 56.2±6.8 % and 54.6±4.4 %, respectively. However, CD38 KO mice exhibited marked protection against myocardial I/R injury with decreased infarction. Infarct area/AAR was only 10.3±3.2 % in CD38 KO mice compared to 36.7±6.8 % in WT, p=0.0097. Conclusions Thus, abrogation of CD38 expression was observed to be highly protective against in vivo myocardial I/R injury with major reduction in infarction. As new highly potent CD38 inhibitors have recently been developed, these may hold great promise as therapeutics in the treatment of unstable coronary syndromes and acute myocardial infarction.

PEGylated Serp-1 Markedly Reduces Pristane-Induced Experimental Diffuse Alveolar Hemorrhage, Altering uPAR Distribution, and Macrophage Invasion.

Diffuse alveolar hemorrhage (DAH) is one of the most serious clinical complications of systemic lupus erythematosus (SLE). The prevalence of DAH is reported to range from 1 to 5%, but while DAH is considered a rare complication there is a reported 50–80% mortality. There is at present no proven effective treatment for DAH and the therapeutics that have been tested have significant side effects. There is a clear necessity to discover new drugs to improve outcomes in DAH. Serine protease inhibitors, serpins, regulate thrombotic and thrombolytic protease cascades. We are investigating a Myxomavirus derived immune modulating serpin, Serp-1, as a new class of immune modulating therapeutics for vasculopathy and lung hemorrhage. Serp-1 has proven efficacy in models of herpes virus-induced arterial inflammation (vasculitis) and lung hemorrhage and has also proved safe in a clinical trial in patients with unstable coronary syndromes and stent implant. Here, we examine Serp-1, both as a native secreted protein expressed by CHO cells and as a polyethylene glycol modified (PEGylated) variant (Serp-1m5), for potential therapy in DAH. DAH was induced by intraperitoneal (IP) injection of pristane in C57BL/6J (B6) mice. Mice were treated with 100 ng/g bodyweight of either Serp-1 as native 55 kDa secreted glycoprotein, or as Serp-1m5, or saline controls after inducing DAH. Treatments were repeated daily for 14 days (6 mice/group). Serp-1 partially and Serp-1m5 significantly reduced pristane-induced DAH when compared with saline as assessed by gross pathology and H&E staining (Serp-1, p = 0.2172; Serp-1m5, p = 0.0252). Both Serp-1m5 and Serp-1 treatment reduced perivascular inflammation and reduced M1 macrophage (Serp-1, p = 0.0350; Serp-1m5, p = 0.0053), hemosiderin-laden macrophage (Serp-1, p = 0.0370; Serp-1m5, p = 0.0424) invasion, and complement C5b/9 staining. Extracellular urokinase-type plasminogen activator receptor positive (uPAR+) clusters were significantly reduced (Serp-1, p = 0.0172; Serp-1m5, p = 0.0025). Serp-1m5 also increased intact uPAR+ alveoli in the lung (p = 0.0091). In conclusion, Serp-1m5 significantly reduces lung damage and hemorrhage in a pristane model of SLE DAH, providing a new potential therapeutic approach.

Unstable Angina and Non-ST Segment Elevation Acute Coronary Syndrome

Unstable angina and non-ST-segment acute coronary syndrome represent a frequent and serious presentation to the emergency department. While most patients present with chest discomfort, atypical presentations warrant that clinicians maintain a high index of suspicion. This review summarizes the present nomenclature, definitions, and pathophysiology for this high morbidity disease process. The rapid acquisition of an electrocardiogram and serial cardiac troponins are mainstays of diagnosis. Also outlined is an approach for initial assessment, high-risk ECG findings, risk stratification, biomarker strategies, and subsequent stabilization. Once diagnosed, treatment options for these patients aim to halt continued ischemia and resultant necrosis. These therapies may include agents such as supplemental oxygen, nitrates, anti-platelet agents, beta blockers, anti-coagulation, anti-thrombin and statin therapies in appropriate settings. Caution should be exercised when dosing high-risk patients for bleeding such as those who are elderly or who weigh less than 60kg. Emergent angiography is reserved for patients who develop hemodynamic instability, cardiogenic shock, pulmonary edema, persistent angina refractory to medical therapy, and sustained arrhythmia. This review contains 2 figures, 12 tables, and 64 references. Keywords: acute coronary syndrome, unstable angina, myocardial infarction, troponin, electrocardiogram

Two-year outcomes after percutaneous coronary intervention with drug-eluting stents or bare-metal stents in elderly patients with coronary artery disease.

Report the results at 2 years of the patients included in the SENIOR trial. Patients above 75 years of age represent a fast-growing population in the cathlab. In the SENIOR trial, patients treated by percutaneous coronary intervention (PCI) with drug eluting stent (DES) and a short duration of P2Y12 inhibitor (1 and 6 months for stable and unstable coronary syndromes, respectively) compared with bare metal stents (BMS) was associated with a 29% reduction in the rate of all-cause mortality, myocardial infarction (MI), stroke, and ischaemia-driven target lesion revascularization (ID-TLR) at 1 year. The results at 2 years are reported here. We randomly assigned 1,200 patients (596[50%] to the DES group and 604[50%] to the BMS group). At 2 years, the composite endpoint of all-cause mortality, MI, stroke and ID-TLR had occurred in 116 (20%) patients in the DES group and 131 (22%) patients in the BMS group (RR 0.90 [95%CI 0.72-1.13], p = .37). IDTLR occurred in 14 (2%) patients in the DES group and 41 (7%) patients in the BMS group (RR 0.35 [95%CI 0.16-0.60], p = .0002). Major bleedings (BARC 3-5) occurred in 27(5%) patients in both groups (RR 1.00, [95%CI 0.58-1.75], p = .99). Stent thrombosis rates were low and similar between DES and BMS (0.8 vs 1.3%, (RR 0.52 [95%CI 0.01-1.95], p = .27). Among elderly PCI patients, a strategy combining a DES together with a short duration of DAPT is associated with a reduction in revascularization up to 2 years compared with BMS with very few late events and without any increased in bleeding complications or stent thrombosis.

A comparative study of Terumo radial Band® and PreludeSYNC hemostasis compression device after transradial coronary catheterization.

Novel hemostasis strategies, including PreludeSYNC DISTAL, Merit Medical Systems, Inc. South Jordan, UT, USA (PSD) radial compression device for distal radial artery (DRA) access, have been described for radial access protocols. This study aimed to compare the safety profile of PSD and Terumo radial (TR) Band®. This prospective interventional study was conducted on patients who underwent coronary interventions via either the DRA or forearm radial artery (FRA). Patients with an arterial diameter of <2 mm, requiring dialysis, with unstable acute coronary syndrome, failed radial cannulation, and sheath insertion were excluded. PSD and TR Band® were used for hemostasis after DRA and FRA access, respectively. The time to hemostasis and complications, including minor/major hematoma, radial artery occlusion (RAO), and neurological symptoms (after 20 days) were recorded. The mean and standard deviation were calculated for age and hemostasis duration. Frequency and percentages were calculated for categorical variables. Independent t-test and Chi-squared test were performed to determine the significance of the differences between the two groups. A p-value of <0.05 was significant. Of 139 participants, TR Band® and PSD were used in 76 and 63 patients, respectively. The mean age of the participants was 58.70±10.00 years, and the majority of the patients were men (67.60%). The hemostasis time of both devices was similar (p>0.490). Compared with PSD, TR Band® had more complications (52.63% vs. 23.81%; p=0.020), particularly RAO [odds ratio (OR), 3.17; p=0.018] and neurological problems (OR, 5.33; p=0.005). Although, PSD seems safer in patients with coronary interventions, the device should further be explored in crossover trials for the two access types to determine the overall safety profile.

Detection of positively remodeled coronary artery lesions by multislice CT and its impact on cardiovascular future events

BackgroundPositive arterial remodeling may be a characteristic of early proliferative lesions. The study was done to identify the different morphological characteristics of the positively remodeled coronary lesions, and causing non-significant arterial stenosis, as detected by multislice computed tomography coronary angiography (MSCT CA) and its predictors of cardiovascular clinical events at 90-day follow-up. The study included 55 patients who were candidate for MSCT CA and found to have a single-vessel disease with less than 70% stenosis positively remodeled lesions. The most expansive or solitary lesion was selected for each patient. Positive remodeling defined as remodeling index (RI) > 1.05. We followed the patients clinically for 90 days.ResultsTwenty-four patients had a history of acute coronary syndrome at initial presentation with normal LV systolic function for all studied patients. Dyslipidemia was found in 37 patients (67.3%) while diabetes was found in 29 patients (52.7%). The majority of the lesions were found in the proximal LAD (43.6%). The mean calculated remodeling index was 1.41 ± 0.25. At the end of 90 days, 25 patients had clinical events in the form of unstable coronary syndromes, coronary interventions, or coronary angiography related to the index lesion. The predictors of clinical events were duration of DM, higher degree of luminal narrowing, calculated wall/lumen area percentage, plaque burden, plaque-specific calcification, and total calcium score at remodeling site as well as a lower percentage of low-attenuation plaque area. The mean calculated wall/lumen area percentage was 263.72 ± 122.71%. A cut-off value of > 226% was found a predictor for clinical events. The mean plaque burden percentage was 69.72 ± 9.71%, a value of > 69% was found a predictor for clinical events. Both values had a sensitivity of 68% and specificity of 86.6% and PPV of 81%. Positively remodeled lesions with a high RI > 1.4 were correlated with patients who had acute coronary syndrome on their initial presentation.ConclusionDifferent morphological characteristics of positively remodeled non-occlusive atherosclerotic plaques as detected by multislice CT coronary angiography may be good potential predictors of future cardiovascular events.

P6263Results of percutaneous coronary intervention of unprotected left main coronary disease in octogenarian patients

Abstract Introduction Conservative treatment unprotected left main coronary (uLMCA) disease has a high mortality rate (50% at 3 years). Since octogenarian patients are often dismissed for surgical treatment, they tend to adopt a more conservative attitude in this population. Purpose We report medium and long-term outcomes of percutaneous coronary intervention (PCI) for uLCMA stenosis in elderly patients. Methods Retrospective cohort study of consecutive patients ≥80 years with uLMCA stenosis, treated with PCI at a single center between June 2005 and February 2017. Results A total of 100 patients were included in the study. 58% were male, with a mean age of 83.8±3 years. There were 86% hypertensive, 63% diabetic and 68% dyslipidemic. 14% of the patients had an LVEF ≤35%. Unstable angina (45%) and acute coronary syndromes withouth ST-segment elevation (44%) were the most common presentation. In 9% of the cases, cardiogenic shock was the initial presentation form. The distal left main coronary was the most frequent localitation of the lesion (46%) followed by the ostium (33%). In 63% of the cases, a multivessel coronary disease was detected and in 47% the revascularization was incomplete. The survival rate after a year follow up was 79% and after three years follow up was 65%. However, in most of the cases the cause of death was due to other comorbidities, with cardiac death being 10% per year and 13% at 3 years of follow-up. The rate of non-fatal acute myocardial infarction was 13% per year, increasing to 20% at 3 years of follow-up. There was a 9% stent restenosis implanted at 3 years. The presence of severe left ventricular systolic dysfunction was the main predictor of mortality in long-term follow-up (OR 1.39 [95% CI 1.10–1.752], p&lt;0.001). Incomplete revascularization was not associated with a higher mortality rate. Conclusion PCI is a safety option for revascularization in uLMCA stenosis in elderly patientes with excellent short-term results, as well as acceptable long-term results. Age should not be a handicap to consider uLMCA revascularization in this population.

SCARF: SAXAGLIPTIN AND CARDIAC STRUCTURE AND FUNCTION

Large cardiovascular (CV) outcome trials in patients with type 2 diabetes have demonstrated excess heart failure hospitalization with saxagliptin that has not been observed with other dipeptidyl peptidase-4 inhibitors (DPP-4i). The aim of this study was to provide detailed analysis of the effect of saxagliptin on cardiac structure and function by Cardiac MRI (CMR), the reference imaging standard, in order to identify cardiac remodeling as a result of treatment with saxagliptin. Patients with type 2 diabetes receiving background therapy with at least Metformin and a clinical indication to start DPP-4i therapy without a pre-existing history of heart failure with reduced ejection fraction (HFrEF) were considered eligible for inclusion. Those previously treated with a GLP-1 receptor agonist or DPP-4i were excluded, as were patients with known histories of heart failure (recent hospitalizations or NYHA Class III-IV), or with active or recent unstable coronary syndromes. Clinical assessment, CMR imaging with gadolinium and biomarkers were obtained and compared before initiating therapy and following 6 months of continued treatment. Our primary outcome was the change in left ventricular ejection fraction (LVEF) pre-and post 6 months of saxagliptin therapy. Key secondary outcomes included the changes in left and right ventricular end diastolic volume (LV and RVEDV indexed to body surface area), indexed left and right ventricular mass, and biomarkers. Our cohort (n=16) had a mean age of 60.7 years and was 69% male (11/16). CMR measurements and serum blood work results are summarized in the Table. Mean baseline creatinine was 76 umol/L, and HbA1C was 8.3%. Mean pre- and post-treatment LVEF were 57.3%, showing no significant change in LV function (p = 0.98). Indexed LVEDV (67 mL/m2 pre-treatment versus 65 mL/m2 post-treatment [p = 0.25]), indexed LV mass (46 g/m2versus 45 g/m2 [p = 0.14]) and all other CMR measurements assessed showed no significant change. Serum biomarkers (NT-pro BNP, hsCRP) and creatinine were also evaluated, showing no statistically significant changes after 6 months of treatment. In our clinically stable and focused cohort, we observed no significant difference in ventricular function when measuring for ejection fraction, end diastolic volume, and mass using the gold standard of assessment of cardiac structure and function. Additionally, these structural findings were mirrored by serum biomarkers, including NT-pro BNP and hsCRP, demonstrating no significant changes in any of the measured biomarkers in patients treated with saxagliptin for 6 months in addition to their background antihyperglycemic regimen.

A Patient-Centered Mobile Intervention to Promote Self-Management and Improve Patient Outcomes in Chronic Heart Failure: The ManageHF Trial

Introduction Heart failure (HF) is the most common hospital discharge diagnosis among older adults. As a result, the management of HF is moving toward a proactive real-time technological model of assisting patients with monitoring and self-management. Hypothesis Our hypothesis was that a patient-centered mobile application, ManageHF, would reduce Minnesota Living with Heart Failure Questionnaire (MLHFQ) at 6 and 12 weeks post-hospital discharge compared to usual care. Methods A single-center randomized controlled trial was performed. Patients were included if they were greater than 45 years of age, had a left ventricular ejection fraction (LVEF) 40% (with LA size >40 mm or BNP > 200 pg/ml or NT-proBNP > 800 pg/ml) and were currently admitted or recently discharged for acute on chronic decompensated HF. Patients were excluded for any of the following: unstable coronary syndromes within 8 weeks, primary valvular heart disease, constrictive pericardial disease, uncorrected thyroid disease, dialysis or creatinine >4.0 mg/dL, a hospice candidate, active cancer, pulmonary fibrosis, discharged to a setting other than home, or required a chronic inotrope. The intervention group used a mobile application, ManageHF, along with a Fitbit wearable and scale. The mobile application prompted active self-monitoring and provided a health status indicator to promote self-management. The control group received usual care. The primary outcome was the change in MLHFQ from baseline to 6 and 12 weeks using mixed models. Secondary outcomes were the Self-Care Heart Failure Index (SCHFI) questionnaire and HF admissions. Results Eighty-two patients were enrolled and completed all baseline assessments. Baseline characteristics were similar between groups with the exception of HF type. The intervention group had a reduced MLHFQ at 6 weeks (p=0.026) but not at 12 weeks (p=0.61) compared to control (Figure). There was no effect of the intervention on the SCHFI or any of its subcomponents at 6 or 12 weeks. The time to first HF admission was not statistically different between the two groups (HR 0.85, 95% CI 0.36-2.0, p=0.71). Median number of days the intervention group performed self-monitoring was 63 days. Conclusion ManageHF improved MLHFQ at 6 weeks, but did not sustain its effects at 12 weeks. No effect was seen on self-care measured by SCHFI. Further research is needed to enhance engagement in the app for a longer period of time and to determine if the app can reduce HF admissions in a larger study.

Unstable Angina and Other Acute Coronary Syndromes

Patients with coronary artery disease (CAD) present clinically when their disease enters an unstable phase known as an acute coronary syndrome (ACS), in which the cap of a previously stable atheromatous coronary plaque ruptures or erodes, which in turn activates a thrombotic cascade that may lead to coronary artery occlusion, myocardial infarction (MI), cardiogenic shock, and patient death. There are nearly 2 million episodes of ACS in the United States annually; it is the most common reason for hospitalization with CAD and is the leading cause of death in the developed world. This review contains 2 figures, 16 tables, and 70 references. Key Words: coronary artery disease, myocardial infarction, cardiogenic shock

Unstable Angina and Other Acute Coronary Syndromes

Patients with coronary artery disease (CAD) present clinically when their disease enters an unstable phase known as an acute coronary syndrome (ACS), in which the cap of a previously stable atheromatous coronary plaque ruptures or erodes, which in turn activates a thrombotic cascade that may lead to coronary artery occlusion, myocardial infarction (MI), cardiogenic shock, and patient death. There are nearly 2 million episodes of ACS in the United States annually; it is the most common reason for hospitalization with CAD and is the leading cause of death in the developed world. This review contains 2 figures, 16 tables, and 70 references. Key Words: coronary artery disease, myocardial infarction, cardiogenic shock

Unstable Angina and Other Acute Coronary Syndromes

Patients with coronary artery disease (CAD) present clinically when their disease enters an unstable phase known as an acute coronary syndrome (ACS), in which the cap of a previously stable atheromatous coronary plaque ruptures or erodes, which in turn activates a thrombotic cascade that may lead to coronary artery occlusion, myocardial infarction (MI), cardiogenic shock, and patient death. There are nearly 2 million episodes of ACS in the United States annually; it is the most common reason for hospitalization with CAD and is the leading cause of death in the developed world. This review contains 2 figures, 16 tables, and 70 references. Key Words: coronary artery disease, myocardial infarction, cardiogenic shock

Nurses' recognition and response to clinical deterioration in the cardiac catheterisation laboratory

BackgroundPatients presenting to the cardiac catheter laboratory for treatment of unstable acute coronary syndromes (ACS) experience a mismatch in myocardial oxygen supply and demand, causing vital sign abnormalities prior to neurological, cardiac and respiratory deterioration. Delays in detecting clinical deterioration and escalating care increases risk of adverse events, unplanned intensive care (ICU) admission, cardiac arrest, and in-hospital mortality. ObjectivesThe objective of the study was to explore how nurses in the cardiac catheter laboratory (CCL) recognise and respond to clinical deterioration in patients with unstable ACS undergoing primary percutaneous coronary intervention (PCI). MethodsA prospective exploratory descriptive design was used with 30 participants completing 10 written clinical scenarios. Participants scored their level of concern for each physiological cue and then then ranked their preferred immediate response based on the deterioration identified. ResultsHypotension and the presence of pain were the physiological cues of highest concern. The most common responses to clinical deterioration were to increase vital sign assessment to 5-minutely intervals, administer pain relief or provide reassurance. Despite the presence of clinical deterioration fulfilling organisational escalation of care criteria, calling cardiac arrest or rapid response team (RRT) were not commonly selected responses. ConclusionNurses most commonly use hypotension and the presence of pain to recognise clinical deterioration in patients presenting to the CCL with an unstable ACS. Once clinical deterioration is identified, interventional cardiac nurses delay the escalation of care to the RRT or cardiac arrest team, preferring to implement local nurse initiated interventions.