Bronchial artery embolization being the therapy of choice for massive hemoptyses in bronchiectases

Introduction. Hemoptyses may be very often due to bronchiectases. Although these bleedings are usually spontaneously resolved recurrent and massive hemoptyses may vitally endanger a patient. Therefore, an urgent diagnosis and treatment of hemoptyses is required. Case report. A 56- year old patient was admitted to the hospital due to massive hemoptyses, presented with a non-homogenous shadowing, paracardially on the left. The chest Computerized Tomography finding delineated atelectasis of the lower left lobe and bronchiectases. Bronchoscopy sampling of the left lung airways provided the fresh blood. The multislice angiography and embolization of the bronchial arteries was carried out, entirely ceasing hemoptyses so the patient was discharged with no symptoms. On the control examination one month later, he was well, with normal radiological finding and inflammation markers. Conclusion. In our patient, the life-threatening bleeding due to inflamed bronchiectases was successfully resolved by bronchial arterial embolization, thus avoiding surgery

Low arterial pressure on admission as a predictor of mortality in operated patients with type A aortic dissection

Background/Aim. Hypertension is a known predictor of proximal aortic dissection, but it is not commonly present in these patients on presentation. The associations between ascending aorta with left ventricular hypertrophy, cardiovascular risk factors and coronary atherosclerosis, and outcome of these patients are not fully elucidated. Methods. This retrospective study included 55 consecutive patients with acute type A aortic dissection treated surgically in our institution during the last 2 years. The diagnosis was based on imaging studies. Diameter of ascending aorta was measured with echocardiography. Results. The mean age of the patients was 55.4 ± 12.19 years, and 72.7% were men. A history of arterial hypertension was present in 76.4% of the patients. Maximal ascending aorta diameter was 4.09 ± 0.59 cm, while patients with frank aneurysm accounted for 5.5%. Systolic blood pressure on admission was < 150 mmHg in 58.2% of the patients. Diastolic blood pressure on admission was < 90 mmHg in 54.5% of the patients. Mean arterial pressure on admission was 104.9 ± 24.6 mmHg. No correlations were demonstrated between maximal ascending aorta diameter and diameter of the left ventricular wall, any obtained risk factor and with coronary artery atherosclerosis (p > 0.05). After six months 11 (20%) patients died, while intrahospital mortality was 72%. According to logistic regression analysis which included traditional risk factors, echo parameters, coronary artery disease and logistic euro scor, mean arterial blood pressure was the independent predictor of a six-month mortality [RR 0.956; CI (0.918-0.994 ); p = 0.024]. Conclusion. In our population the acute type A aortic dissection occurred rarely in the setting of frank ascending aortic aneurysms > 5.0 cm. The majority of patients had a history of arterial hypertension. A history of arterial hypertension was not associated with maximal ascending aorta diameter. Mean arterial blood pressure was the independent predictor of a six-months mortality

The impact of obesity on early mortality after coronary artery bypass grafting

Background/Aim. It had been suggested that elevated body mass index (BMI) is a beneficial and preventive factor when it comes to the outcome for patients undergoing coronary artery bypass grafting (CABG). At the same time, obesity is strongly associated with coronary artery disease development. The aim of this study was to determine the significance of the obesity paradox in patients referred for CABG and to examine if a relationship exists between obesity and early coronary surgery outcome. Methods. This study comparised 791 patients who had undergone isolated CABG over one year period (year 2010). The average age of patients was 62.33 ± 8.12 years and involved 568 (71.8%) male and 223 (28.2%) female patients, while the mean logistic EuroSCORE was 3.42%. The patients were categorized into three distinct groups based on their BMI: I - BMI 30 kg/m2. Regression analysis was conducted to determine whether BMI was an independent predictor of early mortality after CABG. Results. The majority of the cohort could be categorized as overweight (49%) or obese (30%). There was no association between BMI and gender (p = 0.398). The overall early mortality was 2.15% (1.85% in the group I, 2.06% in the group II and 2.51% in the group III; p = 0.869). Univariate analysis showed that obesity cannot be regarded as an independent risk factor for early mortality following CABG (odds ratio 1.021, 95% confidence interval 0.910-1.145, p = 0.724). Duration of in-hospital period following the surgery was comparable within the BMI groups (p = 0.502). Conclusion. Compared to non-obese patients, overweight and obese individuals have similar early mortality rate following CABG. This study can substantiate the presence of obesity paradox only in terms that elevated BMI patients have comparable outcome with non-obese. Further research is needed to delineate potential underlying mechanisms that set off obesity to protective factor for coronary surgery

Trends of risk factors in coronary surgery

Introduction. In current era of widespread use of percutaneous coronary interventions (PCI), it is debatable whether coronary artery by-pass graft (CABG) patients are at higher risk. Objective. The aim of the study was to evaluate trends in risk profile of isolated CABG patients. Methods. By analysing the EuroSCORE and its risk factors, we reviewed a consecutive group of 4675 isolated CABG patients, operated on during the last 8 years (2001-2008) at our Clinic. The number of PCI patients was compared to the number of CABG patients. For statistical analyses, Pearson’s chi-square and ANOVA tests were used. Results. The number of PCI increased from 159 to 1595 (p<0.001), and the number of CABG from 557 to 656 (p<0.001). The mean EuroSCORE increased from 2.74 to 2.92 (p=0.06). The frequency of the following risk factors did not change over years: female gender, previous cardiac surgery, serum creatinine >200μmol/l, left ventricular dysfunction and postinfarct ventricular septal rupture. Chronic pulmonary disease, neurological dysfunction, and unstable pectoral angina declined significantly (p<0.001). Critical preoperative care declined from 3.1% in 2001 to 0.5 % in 2005, than increased and during the last 3 years did not change (2.3%). The mean age increased from 56.8 to 60.7 (p<0.001) and extracardiac arteriopathy increased from 9.2% to 22.9% (p<0.001). Recent preoperative myocardial infarction increased from 11% to 15.1% (p=0.021), while emergency operations increased from 0.9% to 4.0% (p=0.001). Conclusion. The number of CABG increases despite the enlargement of PCI. The risk for isolated CABG given by EuroSCORE increases over years. The risk factors, significantly contributing to higher EuroSCORE are: older age, extracardiac arteriopathy, recent myocardial infarction and emergency operation

The variable "Jung" as a predictor of mortality in patients with pulmonary edema

Background/Aim. In our Intensive Coronary Care Unit (CCU) a specific scoring system named the AMIS_NS was developed both for prediction of mortality in patients with acute myocardial infarction and for evaluation of the quality of work. One of the most important variables of the AMIS_NS system is the variable Jung which stands for the interrelationship unified mortality predictors. The variable includes all the values of systolic blood pressure, heart rate and age, without limiting values for any of these. The cutoff value is 2.08. The patients with the lower variable value account for a significantly higher mortality. Data on the actual infarction are not necessitated now for this variable. The aim of this study was to assess the significance of the variable Jung in non-infarction patients with acute pulmonary edema. Methods. In a 24-month period out of 2,223 patients there were 1,087 and 1,136 patients with and without acute myocardial infarction, respectively. There was the subgroup without myocardial infarction of 312 (84.1%) patients admitted with the diagnosis of pulmonary edema. The subgroup with myocardial infarction consisted of 59 (15.9%) patients who were admitted for acute myocardial infarction and pulmonary edema which developed immediately after admission or during hospitalization in the CCU. For all the patients a uniform questionnaire was fulfilled on admission. Data were put into the personal computer. The variable “Jung” was used: (systolic bloog pressure/heart rate × age) × 100. Results. Regarding sex, there was no difference in mortality, so that males and females were regarded as a whole. Previous myocardial infarction was equally registered in both groups. The investigated persons had less percent of mortality and a significantly higher systemic pressure as well as higher value of the variable Jung. There was no statistically significant difference in the heart rate between the two groups. In both groups of deceased patients the variable Jung (1.5 vs 1.6) was significantly lower in respect to the survived patients (2.3 vs 2.1). Conclusion. The variable Jung is simple, highly reliable and can absolutely be used as a significant indicator of clinical status also in noninfarction patients with the acute pulmonary edema, no matter if it is caused by acute myocardial infarction or not

Age and computed tomography and invasive coronary angiography in stable chest pain: a prespecified secondary analysis of the discharge randomized clinical trial

Importance: The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown. Objective: To determine the association of age with outcomes of CT and ICA in patients with stable chest pain. Design, Setting, and Participants: The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023. Interventions: Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy. Main Outcomes and Measures: MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years. Results: Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients. Conclusions and Relevance: Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients

Effect of body mass index on effectiveness of CT versus invasive coronary angiography in stable chest pain: The DISCHARGE trial

Background Recent trials support the role of cardiac CT in the evaluation of symptomatic patients suspected of having coronary artery disease (CAD); however, body mass index (BMI) has been reported to negatively impact CT image quality. Purpose To compare initial use of CT versus invasive coronary angiography (ICA) on clinical outcomes in patients with stable chest pain stratified by BMI category. Materials and Methods This prospective study represents a prespecified BMI subgroup analysis of the multicenter Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial conducted between October 2015 and April 2019. Adult patients with stable chest pain and a CAD pretest probability of 10%–60% were randomly assigned to undergo initial CT or ICA. The primary end point was major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal myocardial infarction, or stroke. The secondary end point was an expanded MACE composite, including transient ischemic attack, and major procedure-related complications. Competing risk analyses were performed using the Fine and Gray subdistribution Cox proportional hazard model to assess the impact of the relationship between BMI and initial management with CT or ICA on the study outcomes, whereas noncardiovascular death and unknown causes of death were considered competing risk events. Results Among the 3457 participants included, 831 (24.0%), 1358 (39.3%), and 1268 (36.7%) had a BMI of less than 25, between 25 and 30, and greater than 30 kg/m2, respectively. No interaction was found between CT or ICA and BMI for MACE (P = .29), the expanded MACE composite (P = .38), or major procedure-related complications (P = .49). Across all BMI subgroups, expanded MACE composite events (CT, 10 of 409 [2.4%] to 23 of 697 [3.3%]; ICA, 26 of 661 [3.9%] to 21 of 422 [5.1%]) and major procedure-related complications during initial management (CT, one of 638 [0.2%] to five of 697 [0.7%]; ICA, nine of 630 [1.4%] to 12 of 422 [2.9%]) were less frequent in the CT versus ICA group. Participants with a BMI exceeding 30 kg/m² exhibited a higher nondiagnostic CT rate (7.1%, P = .044) compared to participants with lower BMI. Conclusion There was no evidence of a difference in outcomes between CT and ICA across the three BMI subgroups

CT or Invasive Coronary Angiography in Stable Chest Pain.

Background: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain. Methods: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris. Results: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). Conclusions: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.)