In order to help older adults with cardiovascular disease navigate complex decisions, clinicians must know tenets of medical ethics and have good communication skills. The elements of decision making capacity and info...In order to help older adults with cardiovascular disease navigate complex decisions, clinicians must know tenets of medical ethics and have good communication skills. The elements of decision making capacity and informed consent are reviewed, using relevant clinical ex- amples to illustrate the basic concepts. The shared decision making model, by which clinician and patient work together to determine the plan of care, is described. Useful communication techniques to implement shared decision making are suggested.展开更多
While the elderly represent one of the highest-risk patient subsets among the growing population of patients undergoing percutaneous coronary intervention ( PCI ),elderly patients are often under-treated with revascul...While the elderly represent one of the highest-risk patient subsets among the growing population of patients undergoing percutaneous coronary intervention ( PCI ),elderly patients are often under-treated with revascularization therapies.展开更多
Positron emission tomography(PET)is a powerful noninvasive imaging tool for phenotyping patients at risk of or with known coronary artery disease(CAD).One of the key advantages over other imaging modalities is its uni...Positron emission tomography(PET)is a powerful noninvasive imaging tool for phenotyping patients at risk of or with known coronary artery disease(CAD).One of the key advantages over other imaging modalities is its unique ability to quantify physiologic processes,including myocardial blood fl ow(in milliliters per minute per gram of myocardium),metabolism,and cardiac receptors,and its high sensitivity for delineating and quantifying molecular targets in vivo using targeted imaging probes.Cardiac PET/CT offers opportunity for a comprehensive noninvasive evaluation of the consequences of atherosclerosis in the coronary arteries and the myocardium.展开更多
Background Prior studies have demonstrated that the achievement of faster coronary artery flow following reperfusion therapies is associated with improved outcomes among ST-elevation myocardial infarction (STEMI) pati...Background Prior studies have demonstrated that the achievement of faster coronary artery flow following reperfusion therapies is associated with improved outcomes among ST-elevation myocardial infarction (STEMI) patients. The association of patient age with angiographic characteristics of flow and perfusion after rescue/adjunctive percutaneous coronary intervention (PCI) following the administration of fibrinolytic therapy has not been previously investigated. Objectives and Methods We examined the association between age (≥ 70 years or ＜ 70years)and clinical and angiographic outcomes in 1472 STEMI patients who underwent rescue/adjunctive PCI following fibrinolytic therapy in 7 TIMI trials. We hypothesized that elderly patients would have slower post-PCI epicardial flow and worsened outcomes compared to younger patients. Results The 218 patients aged ≥ 70 years (14.8%) had more comorbidities than younger patients. Although these patients had significant angiographic improvement in TIMI frame counts and rates of TIMI Grade 3 flow following rescue/adjunctive PCI, elderly patients had higher (slower)post-PCI TIMI frame counts compared to the younger cohort (25 vs 22 frames, P = 0.039), and less often achieved post-PCI TIMI Grade 3 flow (80.1 vs 86.4%, P = 0.017). The association between age ( ≥70 years) and slower post-PCI flow was independent of gender, time to treatment, left anterior descending (LAD) lesion location, and pulse and blood pressure on admission. Elderly patients also had 4-fold higher mortality at 30 days (12.0 vs 2.7%,P = 0. 001 ). Conclusions This study suggests one possible mechanism underlying worsened outcomes among elderly STEMI patients insofar as advanced chronological age was associated with higher TIMI frame counts and less frequent TIMI Grade 3 flow after rescue/adjunctive PCI.展开更多
Objectives: We aimed to identify correlates of Thrombolysis In Mycocardial Infarction(TIMI) major/minor bleeding among eptifibatide-treated patients undergoing percutaneous coronary intervention(PCI). Background: Eval...Objectives: We aimed to identify correlates of Thrombolysis In Mycocardial Infarction(TIMI) major/minor bleeding among eptifibatide-treated patients undergoing percutaneous coronary intervention(PCI). Background: Evaluation of bleeding predictors among patients treated with glycoprotein IIb/IIIa receptor inhibition might aid in the identification of targets to reduce bleeding risk. Methods: Data were analyzed from 567 moderate-to high-risk PCI patients with non-ST-segment elevation acute coronary syndrome(NSTEACS) treated with eptifibatide/reduced-dose unfractionated heparin or eptifibatide/ reduced-dose enoxaparin enrolled in the Randomized Trial to Evaluate the Relative Protection Against Post-PCI Microvascular Dysfunction and Post-PCI Ischemia Among Anti-Platelet and Anti-Thrombotic Agents-Thrombolysis In Myocardial Infarction-30(PROTECT-TIMI-30). Results: The incidence of significant bleeding was 3.2%with a median time to event of 7.0 h after the first eptifibatide bolus. Increased age was the only independent correlate of bleeding events. Among patients with reduced creatinine clearance(CrCl), lack of adjustment of the maintenance infusion for CrCl ≤50 ml/min occurred frequently(15 of 33 patients, or 45%) and was associated with a high rate of bleeding(20%). The association of CrCl with bleeding appeared to be largely mediated by the incorporation of age in the estimation of CrCl. Patient gender, Cr, weight, and the peak activated clotting time were not associated with bleeding. Conclusions: Among NSTEACS PCI patients treated with eptifibatide, increased age was a significant correlate of bleeding events and appeared to explain the association between low CrCl and bleeding. The more widespread use of CrCl or other estimates of renal function over Cr may lead to more appropriate dose adjustments of eptifibatide.展开更多
Background: Despite advances in antithrombotic therapies and invasive technology, the risk of recurrent ischemic complications in patients with non-ST-elevation acute coronary syndromes(NSTE-ACSs) remains substantial....Background: Despite advances in antithrombotic therapies and invasive technology, the risk of recurrent ischemic complications in patients with non-ST-elevation acute coronary syndromes(NSTE-ACSs) remains substantial. Ranolazine is a novel agent that inhibits the late sodium current thereby reducing cellular sodium and calcium overload and has been shown to reduce ischemia in patients with chronic stable angina. Study Design: MERLIN-TIMI 36 is a phase III, randomized, double-blind, parallel-group, placebo-controlled, multinational clinical trial to evaluate the efficacy and safety of ranolazine during long-term treatment of patients with NSTE-ACS receiving standard therapy(N=6500). Eligible patients are randomized 1 ∶1 to ranolazine or matched placebo, initiated as 200 mg intravenously over 1 hour, followed by an 80-mg/h infusion(40 mg/h for patients with severe renal insufficiency) for up to 96 hours and oral ranolazine ER 1000 mg BID or matched placebo until the end of study. The primary end point is the time to first occurrence of any element of the composite of cardiovascular death, myocardial infarction, or recurrent ischemia. Secondary end points include ischemia on Holter monitoring, hospitalization for new or worsening heart failure, quality of life measures, and exercise performance. The evaluation of longterm safety will include death from any cause and symptomatic documented arrhythmia. Recruitment began in October 2004. The trial will continue until 730 major cardiovascular events and 310 deaths are recorded with expected completion in 24 to 28 months. Conclusions: MERLIN-TIMI 36 will evaluate the role of ranolazine in the acute and chronic management of patients presenting with NSTE-ACS.展开更多
We present a 37-year-old woman with drug refractory atrial fibrillati on refe rred for a pulmonary vein (PV) isolation procedure who manifested a tachycardia with 2:1 intra-PV block within a dissociated PV.During abla...We present a 37-year-old woman with drug refractory atrial fibrillati on refe rred for a pulmonary vein (PV) isolation procedure who manifested a tachycardia with 2:1 intra-PV block within a dissociated PV.During ablation in the right su perior PV, the surface rhythm became normal sinus, with persistent atrial fibril lation within the PV. Shortly thereafter, an atrial tachycardia with a cycle len gth of 190 ms and 2:1 distal to proximal exit block was observed within the isol ated PV. Conduction block within a PV electrically isolated from the left atrium is a newly observed phenomenon that may have imp lications to the electrophysiologic properties of the PV muscular sleeves.展开更多
The differential diagnosis for pediatric patients with apparent transient loss of consciousness(TLOC)is a frequent challenge.True TLOC refers to a state of unawareness of a short duration(usually less than 5 min)that ...The differential diagnosis for pediatric patients with apparent transient loss of consciousness(TLOC)is a frequent challenge.True TLOC refers to a state of unawareness of a short duration(usually less than 5 min)that terminates spontaneously,during which the patient is unresponsive to speech,touch or pain and may exhibit abnormal motor activity,including jerking movements of the extremities[1].In general,the patients cannot recall the complete course of the episode,and any physical findings during the episode can only be obtained through the description of witnesses.展开更多
文摘In order to help older adults with cardiovascular disease navigate complex decisions, clinicians must know tenets of medical ethics and have good communication skills. The elements of decision making capacity and informed consent are reviewed, using relevant clinical ex- amples to illustrate the basic concepts. The shared decision making model, by which clinician and patient work together to determine the plan of care, is described. Useful communication techniques to implement shared decision making are suggested.
文摘While the elderly represent one of the highest-risk patient subsets among the growing population of patients undergoing percutaneous coronary intervention ( PCI ),elderly patients are often under-treated with revascularization therapies.
文摘Positron emission tomography(PET)is a powerful noninvasive imaging tool for phenotyping patients at risk of or with known coronary artery disease(CAD).One of the key advantages over other imaging modalities is its unique ability to quantify physiologic processes,including myocardial blood fl ow(in milliliters per minute per gram of myocardium),metabolism,and cardiac receptors,and its high sensitivity for delineating and quantifying molecular targets in vivo using targeted imaging probes.Cardiac PET/CT offers opportunity for a comprehensive noninvasive evaluation of the consequences of atherosclerosis in the coronary arteries and the myocardium.
文摘Background Prior studies have demonstrated that the achievement of faster coronary artery flow following reperfusion therapies is associated with improved outcomes among ST-elevation myocardial infarction (STEMI) patients. The association of patient age with angiographic characteristics of flow and perfusion after rescue/adjunctive percutaneous coronary intervention (PCI) following the administration of fibrinolytic therapy has not been previously investigated. Objectives and Methods We examined the association between age (≥ 70 years or ＜ 70years)and clinical and angiographic outcomes in 1472 STEMI patients who underwent rescue/adjunctive PCI following fibrinolytic therapy in 7 TIMI trials. We hypothesized that elderly patients would have slower post-PCI epicardial flow and worsened outcomes compared to younger patients. Results The 218 patients aged ≥ 70 years (14.8%) had more comorbidities than younger patients. Although these patients had significant angiographic improvement in TIMI frame counts and rates of TIMI Grade 3 flow following rescue/adjunctive PCI, elderly patients had higher (slower)post-PCI TIMI frame counts compared to the younger cohort (25 vs 22 frames, P = 0.039), and less often achieved post-PCI TIMI Grade 3 flow (80.1 vs 86.4%, P = 0.017). The association between age ( ≥70 years) and slower post-PCI flow was independent of gender, time to treatment, left anterior descending (LAD) lesion location, and pulse and blood pressure on admission. Elderly patients also had 4-fold higher mortality at 30 days (12.0 vs 2.7%,P = 0. 001 ). Conclusions This study suggests one possible mechanism underlying worsened outcomes among elderly STEMI patients insofar as advanced chronological age was associated with higher TIMI frame counts and less frequent TIMI Grade 3 flow after rescue/adjunctive PCI.
文摘Objectives: We aimed to identify correlates of Thrombolysis In Mycocardial Infarction(TIMI) major/minor bleeding among eptifibatide-treated patients undergoing percutaneous coronary intervention(PCI). Background: Evaluation of bleeding predictors among patients treated with glycoprotein IIb/IIIa receptor inhibition might aid in the identification of targets to reduce bleeding risk. Methods: Data were analyzed from 567 moderate-to high-risk PCI patients with non-ST-segment elevation acute coronary syndrome(NSTEACS) treated with eptifibatide/reduced-dose unfractionated heparin or eptifibatide/ reduced-dose enoxaparin enrolled in the Randomized Trial to Evaluate the Relative Protection Against Post-PCI Microvascular Dysfunction and Post-PCI Ischemia Among Anti-Platelet and Anti-Thrombotic Agents-Thrombolysis In Myocardial Infarction-30(PROTECT-TIMI-30). Results: The incidence of significant bleeding was 3.2%with a median time to event of 7.0 h after the first eptifibatide bolus. Increased age was the only independent correlate of bleeding events. Among patients with reduced creatinine clearance(CrCl), lack of adjustment of the maintenance infusion for CrCl ≤50 ml/min occurred frequently(15 of 33 patients, or 45%) and was associated with a high rate of bleeding(20%). The association of CrCl with bleeding appeared to be largely mediated by the incorporation of age in the estimation of CrCl. Patient gender, Cr, weight, and the peak activated clotting time were not associated with bleeding. Conclusions: Among NSTEACS PCI patients treated with eptifibatide, increased age was a significant correlate of bleeding events and appeared to explain the association between low CrCl and bleeding. The more widespread use of CrCl or other estimates of renal function over Cr may lead to more appropriate dose adjustments of eptifibatide.
文摘Background: Despite advances in antithrombotic therapies and invasive technology, the risk of recurrent ischemic complications in patients with non-ST-elevation acute coronary syndromes(NSTE-ACSs) remains substantial. Ranolazine is a novel agent that inhibits the late sodium current thereby reducing cellular sodium and calcium overload and has been shown to reduce ischemia in patients with chronic stable angina. Study Design: MERLIN-TIMI 36 is a phase III, randomized, double-blind, parallel-group, placebo-controlled, multinational clinical trial to evaluate the efficacy and safety of ranolazine during long-term treatment of patients with NSTE-ACS receiving standard therapy(N=6500). Eligible patients are randomized 1 ∶1 to ranolazine or matched placebo, initiated as 200 mg intravenously over 1 hour, followed by an 80-mg/h infusion(40 mg/h for patients with severe renal insufficiency) for up to 96 hours and oral ranolazine ER 1000 mg BID or matched placebo until the end of study. The primary end point is the time to first occurrence of any element of the composite of cardiovascular death, myocardial infarction, or recurrent ischemia. Secondary end points include ischemia on Holter monitoring, hospitalization for new or worsening heart failure, quality of life measures, and exercise performance. The evaluation of longterm safety will include death from any cause and symptomatic documented arrhythmia. Recruitment began in October 2004. The trial will continue until 730 major cardiovascular events and 310 deaths are recorded with expected completion in 24 to 28 months. Conclusions: MERLIN-TIMI 36 will evaluate the role of ranolazine in the acute and chronic management of patients presenting with NSTE-ACS.
文摘We present a 37-year-old woman with drug refractory atrial fibrillati on refe rred for a pulmonary vein (PV) isolation procedure who manifested a tachycardia with 2:1 intra-PV block within a dissociated PV.During ablation in the right su perior PV, the surface rhythm became normal sinus, with persistent atrial fibril lation within the PV. Shortly thereafter, an atrial tachycardia with a cycle len gth of 190 ms and 2:1 distal to proximal exit block was observed within the isol ated PV. Conduction block within a PV electrically isolated from the left atrium is a newly observed phenomenon that may have imp lications to the electrophysiologic properties of the PV muscular sleeves.
基金supported by the Clinical Medicine Plus X-Young Scholars Project of Peking University,the Fundamental Research Funds for the Central Universities(PKU2022LCXQ028)the National High-Level Hospital Clinical Research Funding(Multicenter Clinical Research Project of Peking University First Hospital)(2022CR59).
文摘The differential diagnosis for pediatric patients with apparent transient loss of consciousness(TLOC)is a frequent challenge.True TLOC refers to a state of unawareness of a short duration(usually less than 5 min)that terminates spontaneously,during which the patient is unresponsive to speech,touch or pain and may exhibit abnormal motor activity,including jerking movements of the extremities[1].In general,the patients cannot recall the complete course of the episode,and any physical findings during the episode can only be obtained through the description of witnesses.
