In patients presenting with acute coronary syndrome (ACS) and multivessel disease, it is unclear whether non-culprit lesions should be revascularized immediately or in a staged procedure. We performed a meta-analysis of randomized controlled trials that compared immediate versus staged revascularization strategies. Two authors independently screened records from the online databases PubMed, Embase, Web of Science, and the Cochrane Library to identify eligible trials up to November 2025. The primary outcome was all-cause mortality at 1year. Secondary outcomes included cardiovascular events at 1year. Meta-regressions were performed to explore the influence of study-level characteristics. This study was registered in PROSPERO (CRD42023446181). Ten trials with a total of 5651 patients were included in the final analysis. All-cause death at 1year occurred in 109 (3.9%) of 2809 patients in the immediate revascularization group and 100 (3.5%) of 2842 patients in the staged revascularization group (risk ratio, 1.10; 95% CI 0.79-1.52). Cardiovascular death at 1year occurred in 76 (2.8%) of 2749 patients in the immediate revascularization group and 66 (2.4%) of 2768 patients in the staged revascularization group. Meta-regression suggested that higher mean patient age was significantly associated with a lower risk ratio favoring the immediate revascularization group (regression coefficient -0.10; 95% CI -0.16 to -0.002; p = 0.047). All-cause mortality and cardiovascular deaths were similar in patients with ACS, predominantly with STEMI, and multivessel coronary disease undergoing immediate or staged revascularization. The available effect estimates do not exclude the possibility of clinically meaningful benefit or harm from immediate revascularization.

A prescribing cascade occurs when an adverse drug reaction (ADR) generated from an index drug (Drug A) is mistaken for a new medical condition that is in turn managed with a new drug prescription (Drug B). Prescribing cascades represent a factor influencing inappropriate prescribing and unnecessary polypharmacy, especially among older adults. Using the REPOSI registry, we conduct a retrospective observational study to examine the prevalence of potential prescribing cascades, as identified in the ThinkCascades framework, among patients aged ≥ 65years admitted to geriatric or internal medicine wards. Evaluation was made at (i) admission, (ii) discharge, and (iii) at the 3month follow-up. At admission the prescribing cascade was defined as "not-determined" owing to the unavailability of sequential prescription information, while at discharge or 3month follow-up the cascade was defined as "introduced" when the marker medication (Drug B) was prescribed after the index medication (Drug A). At admission, among the REPOSI population of 10,253 hospitalized patients, 13.0% of them (1,335 cases) showed at least one "not-determined" prescribing cascade, with major prevalence for calcium channel blockers (CCBs) combined with diuretics (n = 932, 65.6%). During hospitalization, a total of 305 potential prescribing cascades were introduced, but 474 not-determined cascades were deprescribed at discharge. Three months after discharge, 31 new cases of potential prescribing cascades were introduced. For four out of nine prescribing cascades, low or no cases were found in all three situations. The proportion of patients exposed to potentially inappropriate prescribing cascades was relatively low. However, these findings highlight the need for practical tools to support physicians in preventing inappropriate prescribing.

Sleep apnoea (SA) is a common condition associated with obesity, conferring significant cardiovascular and metabolic risks. This study investigates the causal effects of obesity phenotypes throughout the life course, from birth weight to adult obesity, on SA risk using Mendelian randomization (MR). A two-sample MR approach was utilized, employing genome-wide association study (GWAS) data from individuals of European ancestry. Exposures included birth weight, childhood obesity, adult obesity classifications (overweight and obesity classes 1-3), and fat distribution characteristics (waist/hip circumference and MRI-derived abdominal adipose tissue volumes). Outcome data were sourced from the FinnGen database. Analyses were conducted using inverse variance weighting (IVW), MR-Egger regression, and sensitivity analyses. A replication analysis using another GWAS dataset on SA was also performed. The analysis demonstrated a positive causal relationship between birth weight and SA risk (OR = 1.142, P < 0.001). Features of childhood obesity, including BMI (OR = 1.218, P < 0.001) and early life body size (OR = 1.533, P < 0.001), were associated with increased SA risk. In adulthood, BMI was strongly associated with SA risk (OR = 2.419, P < 0.001). Fat distribution measures, notably MRI-derived subcutaneous adipose tissue volume (OR = 1.119, P = 0.003) and waist circumference (OR = 1.953, P < 0.001), were also predictors of SA risk. Sensitivity analyses affirmed these findings, suggesting minimal horizontal pleiotropy. The replication analysis confirmed a positive correlation between obesity indicators and SA. This study supports the causal relationship of life-course obesity, including birth weight and obesity, in childhood and adulthood, on SA risk, highlighting the importance of fat distribution metrics in understanding SA determinants.

Atrial fibrillation (AF) is highly prevalent in internal medicine and often requires timely echocardiographic assessment. Limited availability of standard studies may delay management, particularly in acute or resource-limited settings. We conducted a multicenter, cross-sectional study across 35 Spanish hospitals, enrolling adults with new-onset or chronic AF without echocardiography in the previous 12months, comparing internist-performed point-of-care ultrasound (POCUS) with blinded cardiologist-performed transthoracic or transesophageal echocardiography (TTE/TEE) as the reference standard. The primary outcome was diagnostic accuracy for structural abnormalities. Secondary outcomes included comparison with auscultation and the clinical impact of POCUS findings. Among 441 patients (mean age 80.4 ± 9.9years; 51% women), POCUS showed good diagnostic accuracy for left ventricular (LV) dilation (sensitivity 83%, specificity 94%) and LV systolic dysfunction (sensitivity 81%, specificity 94%), and moderate accuracy for left atrial (LA) enlargement (sensitivity 91%, specificity 64%). Compared with auscultation, POCUS was significantly more accurate for detecting mitral and tricuspid disease. POCUS findings frequently prompted therapeutic adjustments, including anticoagulation in mitral stenosis, individualized rate-control strategies in LV dysfunction, diuretic titration in congestion, and referral for significant valvular disease. Pericardial effusion, though less common, strongly influenced management. Internist-performed POCUS demonstrated robust diagnostic performance in AF and directly informed bedside therapeutic decisions. Although it does not replace comprehensive echocardiography, particularly for detailed valvular assessment, it represents a valuable extension of the physical examination and may improve timely and equitable cardiac evaluation.

Heart failure (HF) with preserved ejection fraction (HFpEF) is increasingly suspected in older adults. However, diagnosis remains challenging due to nonspecific symptoms, age-related structural cardiac changes, and confounding comorbidities. Reliability of algorithms developed in younger populations may be limited in this population. This prospective study enrolled inpatients aged > 75years with at least one ESC-listed typical sign/symptom suggestive of HF and no prior HF diagnosis were evaluated for HFpEF using ESC 2021 criteria. Structural/functional transthoracic echocardiographic (TTE) abnormalities and age-adjusted NT-proBNP thresholds were recorded. Diagnostic accuracy of the H2FPEF and HFA-PEFF scores was evaluated. We also tested a modified HFA-PEFF score incorporating age-adjusted thresholds for NT-proBNP and for septal/lateral e' velocity. Among 200 inpatients (median age 86.6years, 58.0% women), 96.0% fulfilled ESC criteria, with TTE abnormalities almost universal (95.0%), mainly left atrial enlargement (70.0%) and increased wall thickness (66.5%). However, only 52.0% had elevated age-adjusted NT-proBNP. Notably, confounding comorbidities were very frequent (98.0%), particularly chronic kidney disease (60.0%) and infections (40.0%). Using rule-in cut-offs, H₂FPEF score identified few high-probability cases (7.0%) with very low sensitivity (0.07) and perfect specificity (1.00; AUROC 0.676). HFA-PEFF classified 67.5% of patients as high probability, with better accuracy (sensitivity 0.69, specificity 0.75; AUROC 0.856). The modified HFA-PEFF increased specificity (1.00) but reduced sensitivity (0.36), improving AUROC to 0.908 and lowering false positives. HFpEF diagnosis in older inpatients is complicated by overlapping comorbidities and age-related cardiac changes. Standard algorithms may misclassify patients and do not reflect true disease burden. Incorporating age-adjusted parameters in scores may improve specificity and support better clinical decision-making, but validation in larger studies is needed.

Cancer is associated with a prothrombotic state and venous thromboembolism (VTE) can be the first manifestation of occult cancer. However, no impact on survival of extensive cancer screening in VTE has been demonstrated. Limited data are available on the association between D-dimer (DD), a non-specific marker of activation of coagulation, at VTE diagnosis and occult cancer. The objective is to investigate whether high DD levels at VTE diagnosis are associated with subsequent cancer development. The study design is a retrospective cohort study conducted in a single tertiary care hospital from 2008 to 2018. The participants were consecutive patients diagnosed with symptomatic VTE and without known overt cancer who underwent routine clinical evaluation and laboratory tests. In case of abnormal findings, further targeted tests were performed. The primary outcome measures were cancer development within 12 months of VTE diagnosis. 843 patients (413 women-49%, median age 67.3 years; 10 lost to follow-up-1.2%) were included, of whom 567 (67%) had unprovoked VTE. Median DD was 2,750 ng/mL (range 30-45,320) and DD was above 8,000 ng/mL in 151 patients (18%). During follow-up, 37 patients (all above 60 years) developed new cancers (4.6 percent patient years; 95%CI 3.3-6.3). Multivariate regression showed that age above 60 years (Hazard Ratio-HR 11.7; 95%CI 1.58-86.6; p = 0.016) and DD above 8,000 ng/mL (HR: 2.5; 95%CI 1.22-5.24; p = 0.012) were independently associated with subsequent cancer development. Patients older than 60 years at VTE diagnosis may deserve extensive screening for occult cancer, and DD above 8000 ng/mL may be an index of occult cancer.