79 research outputs found
MITRACLIP IN THE SETTING OF CARDIOGENIC SHOCK: BEYOND COAPT
Title:
MITRACLIP IN THE SETTING OF CARDIOGENIC SHOCK: BEYOND COAPT
Authors:
Deen, James, MS., Lev, Tohar, BS., Ebinger, Joseph, MD.
Purpose of the study:
To assess the short- and long-term outcomes of patients undergoing MitraClip for severe MR in the setting of cardiogenic shock.
Methods:
This was a retrospective observational cohort study of patients who underwent MitraClip at large academic institution between 2013 and 2019. Charts were reviewed to identify patients with pre-procedure cardiogenic shock if at least 1 of the following was present: 1) documentation of ongoing cardiogenic shock by a provider, 2) cardiac index \u3c2.2 or 3) use of inotropes (Dobutamine, Milrinone or Dopamine) or vasopressors (Norepinephrine, Epinephrine or Vasopressin) within 24 hours of the procedure.
Results:
Out of 448 MitraClip patients, 29 (6.5%) were identified as having pre-procedure cardiogenic shock. Of those in cardiogenic shock prior to MitraClip, 26 (90%) were on inotropes and 16 (55%) were on vasopressors. This decreased to 22 (76%) and 15 (52%) post-procedure, respectively, though did not reach statistical significance (p=0.80). On pre-procedure echocardiography, MR severity was graded as severe or very severe in 21 (72.4%) of those with cardiogenic shock and 301 (71.8%) of those without shock. Of these patients, MR severity was reduced to moderate or less in 26 (89.7%) of those with shock and 400 (95.5%) of those without shock following the procedure (p=0.80).
Conclusion:
Use of MitralClip for the treatment of MR in the setting of cardiogenic shock is feasibility, with noted reductions in the severity of MR and inotropic requirements
High-Throughput Precision Phenotyping of Left Ventricular Hypertrophy with Cardiovascular Deep Learning
Left ventricular hypertrophy (LVH) results from chronic remodeling caused by
a broad range of systemic and cardiovascular disease including hypertension,
aortic stenosis, hypertrophic cardiomyopathy, and cardiac amyloidosis. Early
detection and characterization of LVH can significantly impact patient care but
is limited by under-recognition of hypertrophy, measurement error and
variability, and difficulty differentiating etiologies of LVH. To overcome this
challenge, we present EchoNet-LVH - a deep learning workflow that automatically
quantifies ventricular hypertrophy with precision equal to human experts and
predicts etiology of LVH. Trained on 28,201 echocardiogram videos, our model
accurately measures intraventricular wall thickness (mean absolute error [MAE]
1.4mm, 95% CI 1.2-1.5mm), left ventricular diameter (MAE 2.4mm, 95% CI
2.2-2.6mm), and posterior wall thickness (MAE 1.2mm, 95% CI 1.1-1.3mm) and
classifies cardiac amyloidosis (area under the curve of 0.83) and hypertrophic
cardiomyopathy (AUC 0.98) from other etiologies of LVH. In external datasets
from independent domestic and international healthcare systems, EchoNet-LVH
accurately quantified ventricular parameters (R2 of 0.96 and 0.90 respectively)
and detected cardiac amyloidosis (AUC 0.79) and hypertrophic cardiomyopathy
(AUC 0.89) on the domestic external validation site. Leveraging measurements
across multiple heart beats, our model can more accurately identify subtle
changes in LV geometry and its causal etiologies. Compared to human experts,
EchoNet-LVH is fully automated, allowing for reproducible, precise
measurements, and lays the foundation for precision diagnosis of cardiac
hypertrophy. As a resource to promote further innovation, we also make publicly
available a large dataset of 23,212 annotated echocardiogram videos
Electrocardiographic Deep Learning for Predicting Post-Procedural Mortality
Background. Pre-operative risk assessments used in clinical practice are
limited in their ability to identify risk for post-operative mortality. We
hypothesize that electrocardiograms contain hidden risk markers that can help
prognosticate post-operative mortality. Methods. In a derivation cohort of
45,969 pre-operative patients (age 59+- 19 years, 55 percent women), a deep
learning algorithm was developed to leverage waveform signals from
pre-operative ECGs to discriminate post-operative mortality. Model performance
was assessed in a holdout internal test dataset and in two external hospital
cohorts and compared with the Revised Cardiac Risk Index (RCRI) score. Results.
In the derivation cohort, there were 1,452 deaths. The algorithm discriminates
mortality with an AUC of 0.83 (95% CI 0.79-0.87) surpassing the discrimination
of the RCRI score with an AUC of 0.67 (CI 0.61-0.72) in the held out test
cohort. Patients determined to be high risk by the deep learning model's risk
prediction had an unadjusted odds ratio (OR) of 8.83 (5.57-13.20) for
post-operative mortality as compared to an unadjusted OR of 2.08 (CI 0.77-3.50)
for post-operative mortality for RCRI greater than 2. The deep learning
algorithm performed similarly for patients undergoing cardiac surgery with an
AUC of 0.85 (CI 0.77-0.92), non-cardiac surgery with an AUC of 0.83
(0.79-0.88), and catherization or endoscopy suite procedures with an AUC of
0.76 (0.72-0.81). The algorithm similarly discriminated risk for mortality in
two separate external validation cohorts from independent healthcare systems
with AUCs of 0.79 (0.75-0.83) and 0.75 (0.74-0.76) respectively. Conclusion.
The findings demonstrate how a novel deep learning algorithm, applied to
pre-operative ECGs, can improve discrimination of post-operative mortality
Variability independent of mean blood pressure as a real-world measure of cardiovascular risk
BackgroundIndividual-level blood pressure (BP) variability, independent of mean BP levels, has been associated with increased risk for cardiovascular events in cohort studies and clinical trials using standardized BP measurements. The extent to which BP variability relates to cardiovascular risk in the real-world clinical practice setting is unclear. We sought to determine if BP variability in clinical practice is associated with adverse cardiovascular outcomes using clinically generated data from the electronic health record (EHR).MethodsWe identified 42,482 patients followed continuously at a single academic medical center in Southern California between 2013 and 2019 and calculated their systolic and diastolic BP variability independent of the mean (VIM) over the first 3 years of the study period. We then performed multivariable Cox proportional hazards regression to examine the association between VIM and both composite and individual outcomes of interest (incident myocardial infarction, heart failure, stroke, and death).FindingsBoth systolic (HR, 95% CI 1.22, 1.17–1.28) and diastolic VIM (1.24, 1.19–1.30) were positively associated with the composite outcome, as well as all individual outcome measures. These findings were robust to stratification by age, sex and clinical comorbidities. In sensitivity analyses using a time-shifted follow-up period, VIM remained significantly associated with the composite outcome for both systolic (1.15, 1.11–1.20) and diastolic (1.18, 1.13–1.22) values.InterpretationVIM derived from clinically generated data remains associated with adverse cardiovascular outcomes and represents a risk marker beyond mean BP, including in important demographic and clinical subgroups. The demonstrated prognostic ability of VIM derived from non-standardized BP readings indicates the utility of this measure for risk stratification in a real-world practice setting, although residual confounding from unmeasured variables cannot be excluded.</p
Effect and safety of treatment with ACE-inhibitor Enalapril and β-blocker metoprolol on the onset of left ventricular dysfunction in Duchenne muscular dystrophy - a randomized, double-blind, placebo-controlled trial
Background: X-linked Duchenne muscular dystrophy (DMD), the most frequent human hereditary skeletal muscle myopathy, inevitably leads to progressive dilated cardiomyopathy. We assessed the effect and safety of a combined treatment with the ACE-inhibitor enalapril and the β-blocker metoprolol in a German cohort of infantile and juvenile DMD patients with preserved left ventricular function.
Methods, Trial design: Sixteen weeks single-arm open run-in therapy with enalapril and metoprolol followed by a two-arm 1:1 randomized double-blind placebo-controlled treatment in a multicenter setting. Inclusion criteria: DMD boys aged 10–14 years with left ventricular fractional shortening [LV-FS] ≥ 30% in echocardiography. Primary endpoint: time from randomization to first occurrence of LV-FS < 28%. Secondary: changes of a) LV-FS from baseline, b) blood pressure, c), heart rate and autonomic function in ECG and Holter-ECG, e) cardiac biomarkers and neurohumeral serum parameters, f) quality of life, and g) adverse events.
Results: From 3/2010 to 12/2013, 38 patients from 10 sites were centrally randomized after run-in, with 21 patients continuing enalapril and metoprolol medication and 17 patients receiving placebo. Until end of study 12/2015, LV-FS < 28% was reached in 6/21 versus 7/17 patients. Cox regression adjusted for LV-FS after run-in showed a statistically non-significant benefit for medication over placebo (hazard ratio: 0.38; 95% confidence interval: 0.12 to 1.22; p = 0.10). Analysis of secondary outcome measures revealed a time-dependent deterioration of LV-FS with no statistically significant differences between the two study arms. Blood pressure, maximal heart rate and mean-NN values were significantly lower at the end of open run-in treatment compared to baseline. Outcome analysis 19 months after randomization displayed significantly lower maximum heart rate and higher noradrenalin and renin values in the intervention group. No difference between treatments was seen for quality of life. As a single, yet important adverse event, the reversible deterioration of walking abilities of one DMD patient during the run-in period was observed.
Conclusions: Our analysis of enalapril and metoprolol treatment in DMD patients with preserved left ventricular function is suggestive to delay the progression of the intrinsic cardiomyopathy to left ventricular failure, but did not reach statistical significance, probably due to insufficient sample size.
Clinical trial registration: DRKS-number 00000115, EudraCT-number 2009–009871-36
The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2
Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age 6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score 652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701
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