scholarly journals Incidence, characteristics, determinants and prognostic impact of recurrent syncope

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T Zimmermann ◽  
J Du Fay De Lavallaz ◽  
T Nestelberger ◽  
D Gualandro ◽  
P Badertscher ◽  
...  
Keyword(s):  
Patient Characteristics ◽  
Coronary Intervention ◽  
Final Diagnosis ◽  
Major Adverse Cardiovascular Events ◽  
Unknown Etiology ◽  
Funding Source ◽  
Prognostic Impact ◽  
Lasso Regression ◽  
Recurrence Rates ◽  
Increased Risk

Abstract Background The incidence, characteristics, determinants, and prognostic impact of recurrent syncope are largely unknown, causing uncertainty for both patients and physicians. Methods We characterized recurrent syncope including sex-specific aspects and its impact on death and major adverse cardiovascular events (MACE) in a large prospective international multicenter study enrolling patients ≥40 years presenting with syncope to the emergency department (ED). Syncope etiology was centrally adjudicated by two independent and blinded cardiologists using all information becoming available during syncope work-up and 12-month follow-up. MACE were defined as a composite of all-cause death, acute myocardial infarction, surgical or percutaneous coronary intervention, life-threatening arrhythmia including cardiac arrest, pacemaker or implantable cardioverter defibrillator implantation, valve intervention, heart-failure, gastrointestinal bleeding or other bleeding requiring transfusion, intracranial hemorrhage, ischemic stroke or transient ischemic attack, sepsis and pulmonary embolism. Results Incidence of recurrent syncope among 1790 patients was 20% (95%-confidence interval (CI) 18% to 22%) within 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95%-CI 1.11 to 2.01) or syncope of unknown etiology even after central adjudication (HR 2.11, 95%-CI 1.54 to 2.89) had an increased risk for syncope recurrence (Figure). LASSO regression fit on all patient information available early in the ED identified more than three previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95%-CI 1.64 to 2.75). Recurrent syncope within the first 12 months after the index event carried an increased risk for all-cause death (HR 1.59, 95%-CI 1.06 to 2.38) and MACE (HR 2.24, 95%-CI 1.67 to 3.01), whereas recurrences after 12 months did not have a significant impact on outcome measures. Conclusion Recurrence rates of syncope are substantial and vary depending on syncope etiology. There seem to be no reliable patient characteristics available early on the ED that allow for the prediction of recurrent syncope with only a history of more than three previous syncope being associated with a higher risk for future recurrences. Importantly, recurrent syncope within the first 12 months carries an increased risk for death and MACE. Figure 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation

scholarly journals Incidence, characteristics, determinants, and prognostic impact of recurrent syncope

EP Europace ◽  
2020 ◽  
Vol 22 (12) ◽  
pp. 1885-1895
Author(s):  
Tobias Zimmermann ◽  
Jeanne du Fay de Lavallaz ◽  
Thomas Nestelberger ◽  
Danielle M Gualandro ◽  
Ivo Strebel ◽  
...  
Keyword(s):  
Final Diagnosis ◽  
Time Dependent ◽  
Major Adverse Cardiovascular Events ◽  
Prognostic Impact ◽  
Recurrence Rates ◽  
Cardiac Syncope ◽  
Increased Risk ◽  
Long Term Follow Up ◽  
Selection Operator

Abstract Aims  The aim of this study is to characterize recurrent syncope, including sex-specific aspects, and its impact on death and major adverse cardiovascular events (MACE). Methods and results We characterized recurrent syncope in a large international multicentre study, enrolling patients ≥40 years presenting to the emergency department (ED) with a syncopal event within the last 12 h. Syncope aetiology was centrally adjudicated by two independent cardiologists using all information becoming available during syncope work-up and long-term follow-up. Overall, 1790 patients were eligible for this analysis. Incidence of recurrent syncope was 20% [95% confidence interval (CI) 18–22%] within the first 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95% CI 1.11–2.01) or syncope with an unknown aetiology even after central adjudication (HR 2.11, 95% CI 1.54–2.89) had an increased risk for syncope recurrence. Least Absolute Shrinkage and Selection Operator regression fit on all patient information available early in the ED identified >3 previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95% CI 1.64–2.75). Recurrent syncope carried an increased risk for death (HR 1.87, 95% CI 1.26–2.77) and MACE (HR 2.69, 95% CI 2.02–3.59) over 24 months of follow-up, however, with a time-dependent effect. These findings were confirmed in a sensitivity analysis excluding patients with syncope recurrence or MACE before or during ED evaluation. Conclusion  Recurrence rates of syncope are substantial and vary depending on syncope aetiology. Importantly, recurrent syncope carries a time-dependent increased risk for death and MACE. Trial registration BAsel Syncope EvaLuation (BASEL IX, ClinicalTrials.gov registry number NCT01548352).

scholarly journals CYP2C19 genotype-guided antiplatelet therapy: promises and pitfalls

2020 ◽  
Vol 21 (12) ◽  
pp. 889-897
Author(s):  
Moataz Ellithi ◽  
Jordan Baye ◽  
Russell A Wilke
Keyword(s):  
Cytochromes P450 ◽  
Coronary Intervention ◽  
Antiplatelet Drug ◽  
Major Adverse Cardiovascular Events ◽  
Gene Variants ◽  
Loss Of Function ◽  
Increased Risk ◽  
Percutaneous Coronary ◽  
Genes Encoding ◽  
Cyp2c19 Gene

Pharmacogenetic variants can alter the mechanism of action (pharmacodynamic gene variants) or kinetic processes such as absorption, distribution, metabolism and elimination (pharmacokinetic gene variants). Many initial successes in precision medicine occurred in the context of genes encoding the cytochromes P450 (CYP enzymes). CYP2C19 activates the antiplatelet drug clopidogrel, and polymorphisms in the CYP2C19 gene are known to alter the outcome for patients taking clopidogrel in the context of cardiovascular disease. CYP2C19 loss-of-function alleles are specifically associated with increased risk for coronary stent thrombosis and major adverse cardiovascular events in patients taking clopidogrel following percutaneous coronary intervention. We explore successes and challenges encountered as the clinical and scientific communities advance CYP2C19 genotyping in the context of routine patient care.

Resolution of Clostridium difficile–Associated Diarrhea in Patients With Cancer Treated With Fidaxomicin or Vancomycin

2013 ◽  
Vol 31 (19) ◽  
pp. 2493-2499 ◽  
Author(s):  
Oliver A. Cornely ◽  
Mark A. Miller ◽  
Bruno Fantin ◽  
Kathleen Mullane ◽  
Yin Kean ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Cancer Recurrence ◽  
Patient Characteristics ◽  
Sustained Response ◽  
Recurrence Rates ◽  
Double Blind ◽  
Patients With Cancer ◽  
Increased Risk ◽  
Intent To Treat ◽  
Clostridium Difficile Associated Diarrhea

Purpose Patients with cancer are at increased risk for Clostridium difficile–associated diarrhea (CDAD). Little is known about treatment response. Patients and Methods Two double-blind trials randomly allocated 1,105 patients with CDAD to fidaxomicin or vancomycin treatment (modified intent-to-treat [mITT]), and 183 of these had cancer. Univariate and multivariate post hoc analyses compared effects of treatment and patient characteristics on cure, recurrence, and sustained response after 4 weeks. Time to resolution of diarrhea (TTROD) was also evaluated. Results Patients with cancer had a lower cure rate and longer TTROD than patients without cancer. Recurrence rates were similar. Cure was more likely with fidaxomicin than vancomycin (odds ratio [OR] 2.0; P = .065), recurrence was less likely (OR = 0.37; P = .018), and sustained response more frequent (OR = 2.56; P = .003). Under vancomycin, median TTROD was longer in patients with cancer than in those without (123 v 58 hours; log-rank P < .001). With fidaxomicin, median TTROD was not significantly affected by presence of cancer (74 v 54 hours; log-rank P = .145). In the full mITT population, age, hypoalbuminemia, and cancer were inversely associated with clinical cure by multivariate analysis. Study treatment with vancomycin was a significant predictor of recurrence (P < .001). Within the cancer population, low albumin was negatively and fidaxomicin was positively associated with improved cure. Conclusion For patients with cancer, fidaxomicin treatment was superior to vancomycin, resulting in higher cure and sustained response rates, shorter TTROD, and fewer recurrences.

Abstract 17283: De-Escalation of Antiplatelet Therapy in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Clinical Trials

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Babikir Kheiri ◽  
Mohammed Osman ◽  
Ahmed Abdalla ◽  
Sahar Ahmed ◽  
Khansa Osman ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Percutaneous Coronary Intervention ◽  
Randomized Clinical Trials ◽  
Maintenance Phase ◽  
Coronary Intervention ◽  
Major Adverse Cardiovascular Events ◽  
Safety And Efficacy ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Percutaneous Coronary

Introduction: Potent P2Y 12 -receptor inhibitors are recommended in the management of acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). As the risk of thrombotic complications from an ACS event is highest in the early “ischemic phase,” the greatest benefit of potent P2Y 12 blockade occurs early. However, the risk of bleeding from such therapy tends to occur with chronic treatment during the “maintenance phase.” Therefore, a stage-adapted strategy with the early use of potent P2Y 12 blockade in acute treatment, followed by de-escalation to clopidogrel during the maintenance phase is common. Nevertheless, clinical outcomes supporting this strategy are lacking. Hypothesis: This study aimed to evaluate the safety and efficacy of antiplatelet de-escalation compared with continuation in patients with ACS treated with PCI. Methods: Electronic databases search were conducted for all randomized clinical trials (RCTs) that evaluated the safety and efficacy of antiplatelet de-escalation compared with continuation in patients with ACS treated with PCI. A random-effects model was used to calculate the pooled summary estimates. Results: We included 3 RCTs with 3,391 total patients (median follow-up 12 months). The net clinical outcome (composite of thrombotic or bleeding events) was significantly reduced in the switched group compared with the continued group (8.7% vs 12.1%; risk ratio (RR): 0.64; 95% confidence interval (CI): 0.43-0.97; P=0.03). However, there were no significant differences between groups in major adverse cardiovascular events (RR: 0.78; 95% CI: 0.55-1.11; P=0.17), all BARC (Bleeding Academic Research Consortium) types bleeding (RR: 0.61; 95% CI: 0.33-1.11; P=0.10), or BARC types ≥2 bleeding (RR: 0.49; 95% CI: 0.19-1.26; P=0.14). Conclusions: Our results suggest a net clinical benefit of de-escalation therapy shortly after PCI in ACS patients, without increased risk of MACE or bleeding, though further adequately powered trials are needed to confirm this finding.

scholarly journals Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction

2021 ◽  
Vol 10 (2) ◽  
pp. 258
Author(s):  
Seung-Hyun Kim ◽  
Michael Behnes ◽  
Kambis Mashayekhi ◽  
Alexander Bufe ◽  
Markus Meyer-Gessner ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Prognostic Impact ◽  
Total Occlusion ◽  
Increased Risk ◽  
Percutaneous Coronary ◽  
Periprocedural Myocardial Infarction

Coronary chronic total occlusion (CTO) has gained increasing clinical attention as the most advanced form of coronary artery disease. Prior studies already indicated a clear association of CTO with adverse clinical outcomes, especially in patients with acute myocardial infarction (AMI) and concomitant CTO of the non-infarct-related coronary artery (non-IRA). Nevertheless, the prognostic impact of percutaneous coronary intervention (PCI) of CTO in the acute setting during AMI is still controversial. Due to the complexity of the CTO lesion, CTO-PCI leads to an increased risk of complications compared to non-occlusive coronary lesions. Therefore, this review outlines the prognostic impact of CTO-PCI in patients with AMI. In addition, the prognostic impact of periprocedural myocardial infarction caused by CTO-PCI will be discussed.

Association between hypercoagulability and microvascular dysfunction in patients with acute myocardial infarction

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M.G Kang ◽  
K.H Kim ◽  
J.S Bae ◽  
J.H Ahn ◽  
H.W Park ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Confidence Interval ◽  
Microvascular Dysfunction ◽  
Coronary Intervention ◽  
Fibrin Clot ◽  
Hazard Ratio ◽  
Major Adverse Cardiovascular Events ◽  
Increased Risk ◽  
Index Of Microcirculatory Resistance

Abstract Background Microvascular dysfunction (MVD) following percutaneous coronary intervention (PCI) can increase the risk of adverse clinical outcomes, which partly may be related with thromboembolic microvascular obstruction. This study was sought to determine whether hypercoagulability is linked with MVD post-PCI in patients with acute myocardial infarction (AMI). Methods Hypercoagulability was determined with thrombin-induced platelet-fibrin clot strength (maximal amplitude [MAthrombin] ≥68 mm evaluated by thromboelastography). Microvascular function was assessed by invasive physiological index after PCI (MVD: index of microcirculatory resistance [IMR] ≥40 U). Major adverse cardiovascular events (MACE) was defined as the incidence of death or rehospitalization for heart failure post-PCI. Results Among AMI patients (n=116), 46 patients (39.7%) met the criteria of hypercoagulability and 27 patients (23.3%) had a MVD. Level of IMR showed a significant correlation with MAthrombin value (r=0.313; p=0.001). Prevalence of MVD was increased proportionally according to the quartile scale of MAthrombin (3.6% vs. 21.9% vs. 25.9% vs. 41.4%; p for trend = 0.009). Hypercoagulability significantly increased the predictive value for MVD occurrence (odds ratio: 4.35; 95% confidence interval: 1.74 to 10.89; p=0.001). During the follow-up post-PCI of 40.9 months (IQR: 19.8 to 59.4 months), MVD and hypercoagulability were both associated with MACE (hazard ratio: 5.86 and 2.28 respectively). Patients with both MVD and hypercoagulability showed an increased risk for MACE compared with the others (18.2% vs. 5.3%; adjusted hazard ratio: 4.50; 95% confidence interval: 1.26 to 16.12; Log rank p=0.011) (Figure). Conclusion This is the first analysis to demonstrate that baseline hypercoagulability is an independent determinant of post-PCI MVD in AMI patients. Combining the measurements of hypercoagulability and MVD may enhance risk stratification and deserves further study. Long-term outcomes Funding Acknowledgement Type of funding source: None

scholarly journals Venous thromboembolism and bleeding in a community setting

2009 ◽  
Vol 101 (05) ◽  
pp. 878-885 ◽  
Author(s):  
Joel Gore ◽  
George Reed ◽  
Darleen Lessard ◽  
Luigi Pacifico ◽  
Cathy Emery ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Total Mortality ◽  
Community Setting ◽  
Patient Characteristics ◽  
Recurrence Rates ◽  
Increased Risk ◽  
History Of ◽  
Recurrent Vte ◽  
The Impact

SummaryBleeding is the most frequent complication of antithrombotic therapy for venous thromboembolism (VTE). However, little attention has been paid to the impact of bleeding after VTE in the community setting. The purpose of this investigation was to describe the incidence rate of bleeding after VTE, to characterize patients most at risk for bleeding, and to assess the impact of bleeding on rates of recurrent VTE and all-cause mortality. The medical records of residents of the Worcester (MA, USA) metropolitan area diagnosed with ICD-9 codes consistent with potential VTE during 1999, 2001, and 2003 were individually validated and reviewed by trained data abstracters. Clinical characteristics, acute treatment, and outcomes (including VTE recurrence rates, bleeding rates, and mortality) over follow-up (up to 3 years maximum) were evaluated. Bleeding occurred in 228 (12%) of 1,897 patients with VTE during our follow-up. Of these, 115 (58.8%) had evidence of early bleeding occurring within 30 days of VTE diagnosis. Patient characteristics associated with bleeding included impaired renal function and recent trauma. Other than a history of prior VTE, the occurrence of bleeding was the strongest predictor of recurrent VTE (hazard ratio [HR] 2.18; 95% confidence interval [CI] 1.54–3.09) and was also a predictor of total mortality (HR 1.97; 95%CI 1.57–2.47). The occur-rence of bleeding following VTE is associated with an increased risk of recurrent VTE and mortality. Future study of antithrombotic strategies for VTE should be informed by this finding. Advances that result in decreased bleeding rates may paradoxically decrease the risk of VTE recurrence.

scholarly journals The Safety and Efficacy of Aspirin Discontinuation on a Background of a P2Y 12 Inhibitor in Patients After Percutaneous Coronary Intervention

Circulation ◽  
2020 ◽  
Vol 142 (6) ◽  
pp. 538-545 ◽  
Author(s):  
Michelle L. O’Donoghue ◽  
Sabina A. Murphy ◽  
Marc S. Sabatine
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Coronary Intervention ◽  
Major Adverse Cardiovascular Events ◽  
Coronary Syndrome ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Percutaneous Coronary

Background: Dual antiplatelet therapy with aspirin and a P2Y 12 inhibitor has been shown to reduce the risk of major adverse cardiovascular events (MACE) compared with aspirin alone after percutaneous coronary intervention (PCI) or acute coronary syndrome but with increased risk of bleeding. The safety of discontinuing aspirin in favor of P2Y 12 inhibitor monotherapy remains disputed. Methods: A meta-analysis was conducted from randomized trials (2001–2020) that studied discontinuation of aspirin 1 to 3 months after PCI with continued P2Y 12 inhibitor monotherapy compared with traditional dual antiplatelet therapy. Five trials were included; follow-up duration ranged from 12 to 15 months after PCI. Primary bleeding and MACE outcomes were the prespecified definitions in each trial. Results: The study population included 32 145 patients: 14 095 (43.8%) with stable coronary artery disease and 18 046 (56.1%) with acute coronary syndrome. In the experimental arm, background use of a P2Y 12 inhibitor included clopidogrel in 2649 (16.5%) and prasugrel or ticagrelor in 13 408 (83.5%) patients. In total, 820 patients experienced a primary bleeding outcome and 937 experienced MACE. Discontinuation of aspirin therapy 1 to 3 months after PCI significantly reduced the risk of major bleeding by 40% compared with dual antiplatelet therapy (1.97% versus 3.13%; hazard ratio [HR], 0.60 [95% CI, 0.45–0.79]), with no increase observed in the risk of MACE (2.73% versus 3.11%; HR, 0.88 [95% CI, 0.77–1.02]), myocardial infarction (1.08% versus 1.27%; HR, 0.85 [95% CI, 0.69–1.06]), or death (1.25% versus 1.47%; HR, 0.85 [95% CI, 0.70–1.03]). Findings were consistent among patients who underwent PCI for an acute coronary syndrome, in whom discontinuation of aspirin after 1 to 3 months reduced bleeding by 50% (1.78% versus 3.58%; HR, 0.50 [95% CI, 0.41–0.61]) and did not appear to increase the risk of MACE (2.51% versus 2.98%; HR, 0.85 [95% CI, 0.70–1.03]). Conclusions: Discontinuation of aspirin with continued P2Y 12 inhibitor monotherapy reduces risk of bleeding when stopped 1 to 3 months after PCI. An increased risk of MACE was not observed after discontinuation of aspirin, including in patients with acute coronary syndrome.

Assessing the relationship between serum potassium variability and the risk of hyperkalaemia and adverse clinical outcomes

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
P McEwan ◽  
K Badora ◽  
D Sugrue ◽  
G James ◽  
M Hurst ◽  
...  
Keyword(s):  
Serum Potassium ◽  
Index Date ◽  
Adverse Outcomes ◽  
Practice Research ◽  
Major Adverse Cardiovascular Events ◽  
Clinical Practice Research Datalink ◽  
Funding Source ◽  
Private Company ◽  
Increased Risk

Abstract Background Serum potassium (SK+) is a vital electrolyte, which level is maintained by adjusting renal K+ excretion. Variability in SK+ has been linked to increased risk of mortality and other adverse clinical events in patients in intensive care and/or receiving haemodialysis, prompting a similar investigation in cardiovascular patients. Purpose To examine the effect of SK+ variability on all-cause mortality (ACM) and the incidence of major adverse cardiovascular events (MACE), comprising arrhythmia, [subsequent records of] HF, myocardial infarction, or stroke, in patients with heart failure (HF) or resistant hypertension (RHTN). Methods Patients aged ≥18 years with HF or RHTN were identified from the UK Clinical Practice Research Datalink (CPRD, primary care data) and linked Hospital Episode Statistics (HES, secondary care data). HF and RHTN were defined through READ codes recorded during the study period (2008-June 2018) or the five-year look-back period (2003–2007). Index date was set to 1st January 2008 or initial diagnosis; whichever occurred later. Mean SK+ and variability of measurements (quantified as standard deviation [SD] and each patient categorised as low or highly variable based on the median SD of the cohort), and crude incidence rates of ACM and MACE were estimated over a follow-up period from index date to event or end of follow-up (death, loss to follow-up or end of study, whichever was earlier). Results The eligible population included 317,135 RHTN patients and 84,210 HF patients with a mean follow-up of 6.37 (SD 3.06) and 5.01 (SD 3.20) years, respectively. In both cohorts, higher mean SK+ ≥5.0 mmol/L was associated with increased rates of ACM and MACE relative to a mean SK+ of 3.5–5 mmol/L (Table 1). High SK+ variability was associated with increased incidence of adverse outcomes, with rates consistently higher in the high SK+ variability group compared to low-variability patients with the same diagnosis and mean SK+ category (Table 1); all comparisons were statistically significant except for ACM in HF patients with mean SK+ ≥5 mmol/L. Conclusion Independently of mean SK+, increased variability in SK+ levels was associated with an increased rate of mortality and MACE in patients with RHTN or HF. Careful SK+ monitoring and management to maintain SK+ concentrations may improve the outcomes of patients with RHTN and HF. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): AstraZeneca

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