Background Covid-19 is associated with an increased risk of pulmonary embolism (PE) therefore, should the cut off d-dimer value be adjusted for these patients? Material and methods Retrospective and observational study to understand if there is a d-dimer cut-off that could guide clinics to perform a thoracic computed tomography angiography (CTA) in patients with covid-19. The population was covid-19 patients admitted to covid-19 dedicated wards of a University Hospital Centre for one year. Results and conclusions 725 (52%) patients with covid-19 had a d-dimer value dosed during the first 5 days of the disease. Those, 63 (9%) did a CTA with a diagnosis of 16 (25%) PE. Gender was equally represented, median age was 70 years (ID = 3.49) and the majority (94%) survived. Thirteen (81%) patients with PE had a d-dimer value above 2500 ng/mL (OR = 9.244, 95% CI 2.248–9.837), with 7 (54%) with values over 10000 ng/mL, but in 3 (9%) it was under 1500 ng/mL. Seventy-three (63%) of patients with a d-dimer over 1500 ng/mL did not had a thoracic CTA performed. In our population PE was not a frequent outcome. The results are influenced by the low number of thoracic CTA performed because, even tough the cut-off d-dimer value used at our hospital to perform a thoracic CTA to exclude PE is 1500 ng/mL, most patients with that d-dimer value did not take the exam and so PE could not be excluded. Although in most PE cases the d-dimer value was above 2500 ng/mL, the results of our study cannot verify if that is a better cut-off value.
Background Despite being primarily a disease of older patients, acute myocardial infarction (AMI) has been increasingly recognized in young individuals. This study sought to characterize and determine the prognosis of AMI in patients aged ≤ 45 years old. Methods We retrospectively analyzed patients consecutively admitted to the coronary care unit with AMI. Two groups were identified: patients aged ≤ 45 and > 45 years old. Results and conclusions A total of 5696 AMI patients were included in the analysis: median age of 70 (IQR 19) years and 68.6% (n = 3906) were male; 5.6% (n = 318) of patients were aged ≤ 45 years old. In contrast to the older patients, those aged ≤ 45 years old were more likely to be male (P < 0.001), presented more often with a history of smoking (P < 0.001), and family history of premature coronary artery disease (P < 0.001), but less often hypertension, hyperlipidemia, and diabetes. In coronary angiography, most younger patients presented a single-vessel disease (57.1%), more commonly affecting the left anterior descending artery (51.7%); left main involvement was rare (0.8%); and 14.2% presented MINOCA (vs. 11.4% of older patients). Regarding prognosis, 6.4% (n = 366) of patients died in the hospital and 24.2% (n = 1380) died during the 5-year follow-up. Younger patients had a lower risk of in-hospital mortality (OR 0.22, 95% CI 0.09–541, P = 0.001) and 5-year mortality (OR 0.12, 95% CI 0.06–0.201, P < 0.001), compared to the older patients. In conclusion, patients with premature AMI have a different proportion of risk factors, less extensive coronary artery disease, and more commonly present MINOCA, compared to the older patients.
Background The optimal management of myocardial infarction with nonobstructive coronary arteries (MINOCA) is still uncertain. This study sought to determine the association between pharmacological therapies after hospital discharge and the long-term prognosis of MINOCA patients. Material and methods We analyzed patients consecutively admitted to the coronary care unit with myocardial infarction (MI). Multivariate analysis was performed to determine which drugs were implicated in the prognosis of MINOCA patients. The primary endpoint was all-cause mortality at 5 years. Results and conclusions From a total of 3721 MI patients, MINOCA was identified in 11.6% (n = 430), of whom 56 (13.0%) experienced the primary endpoint. Median age was 66 years (IQR 19), and 51.6% (n = 222) of patients were male. At discharge, 81.2% of MINOCA patients were prescribed aspirin, 87.4% a statin, 78.6% beta-blockers, and 66.7% angiotensin-converting enzyme inhibitors (ACEI). MINOCA patients were less likely to be prescribed these medications compared to patients with obstructive coronary artery disease (all P < 0.001). 1.4% (n = 6) of MINOCA patients died in the hospital, and the 5-year mortality rate was 13.0% (n = 56). In multivariate Cox regression, treatment with ACEI at discharge was found to be independently associated with a 5-year mortality benefit (HR = 0.29, 95% CI 0.12–0.67, adjusted P = 0.004) in MINOCA patients. In conclusion, compared with patients with obstructive CAD, patients with MINOCA are less likely to be treated with secondary prevention drugs and are at lower risk of all-cause mortality during long-term follow-up. Treatment with ACEI seems to provide an additional mortality benefit in MINOCA patients.
Background Progress in decreasing ischemic complications in acute coronary syndrome (ACS) has come at the expense of increased risk of bleeding. This study sought to determine the incidence, predictors, and prognosis of in-hospital bleeding (IHB) in ACS patients. Material and methods We retrospectively analyzed patients consecutively admitted to the coronary care unit (CCU) with ACS. Patients who suffered clinically significant IHB were compared to the remaining ACS patients. The primary endpoint was all-cause in-hospital death. Results and conclusions From a total of 1032 ACS patients, clinically significant IHB was identified in 5.6% (n = 58) of patients, of whom 13 patients presented serious bleeding. Patients with IHB were older (P = 0.003), more often female (P = 0.012), were more likely to have prior heart failure (P = 0.007) and chronic kidney disease (P = 0.001). At admission, they presented more often with Killip-Kimball class > I (P = 0.001), lower hemoglobin (P = 0.013), lower eGFR (P = 0.005), and a higher CRUSADE score (P < 0.001). In multivariate logistic regression, female sex (OR = 2.26, 1.17–4–38, P = 0.023), acute kidney injury (OR = 2.23, 1.12–4.45, P = 0.028), and non-radial access in coronary angiography (OR = 2.04, 1.08–3.87, P = 0.028), were identified as independent predictors of IHB. The primary endpoint occurred in 5.8% of ACS patients. Patients who suffered IHB were at higher risk of death during hospitalization (OR = 2.39, 95% CI 1.03–5.51, P = 0.042), but not during the 2-year follow-up (P = 0.429). In conclusion, IHB is not an uncommon complication in ACS patients and is associated with an increased risk of in-hospital mortality.
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