Management Of Patients Research Articles

Sex differences in in-hospital management and outcomes of patients with acute pulmonary embolism

Abstract Background Acute pulmonary embolism (PE) is a life-threatening disease with specific risk factors among women. Systematic evaluation of contemporary quality of care and outcomes in women hospitalized with acute PE is needed. Methods The COPE Registry (COntemporary management of acute Pulmonary Embolism) is a nationwide registry that was run in Internal Medicine, Cardiology and Emergency Departments in Italy. Using data from the COPE Registry, we evaluated sex differences in acute management, medical therapies, in-hospital and 30-day mortality and major bleeding in 5,213 patients admitted for acute PE at 182 hospitals in Italy from 2018 to 2020. Results Women (n=2,728) were older than men (71.2 versus 66.6 years, P<0.001) and had different distribution of comorbidities, with dementia and severe renal failure being more prevalent (13.6 vs 6.4% and 6.1 vs 3.0%, respectively) and cancer, COPD and recent bed-rest less prevalent (15.2 vs 18.5% and 11.1 vs 14.5% and 23.5 vs 20.2%) in women than men. At presentation, PE was more severe in women than men in terms of hemodynamic instability (4.1 vs 2.7%), prevalence of right ventricle overload at echocardiography (64.5 vs 57%) and prevalence of sPESI=0 (29.4 vs 38.5%). Concerning the likelihood to receive evidence-based acute treatments for PE, women were more likely than men to receive reperfusion in the case of hemodynamic compromise at presentation after adjusting for age and dementia (63.1 vs 50.0%; OR 1.934, 95% CI 1.01-3.71), and to receive direct oral anticoagulants during hospitalization after adjusting for age, dementia and severe renal failure (50.9 vs 48.6%; OR 1.14, 95% CI 1.01-1.28); similar proportions of low-risk women and men were managed as outpatients or by short hospital stay (1.4% vs 1.4% and 8.6 vs 6.0%, respectively). In-hospital and 30-day mortality rates were not different in women and in men (3.7% versus 3.1% and 5.5 vs 4.8%), but PE-related mortality was higher in women than in men (2.1 vs 1.3%). The sex difference in PE-related mortality was no longer observed in after adjusting for age, hemodynamic instability and dementia (adjusted HR 1.20; 95% CI 0.77-1.88; P=0.415). Similar rates of early and delayed major bleedings occurred in women and in men, both at univariate analysis and after adjusting for age, creatinine clearance and use of thrombolysis. None of 22 pregnant women and 1 out of 204 women with estro-progestin associated PE died or experienced major bleeding. Conclusions Women hospitalized for acute PE in Italy received evidence-based acute treatments more commonly than men. The observed sex differences in PE-related mortality were mainly attributable to worse clinical profiles and older age. Women with sex-related risk factor for PE had favorable prognosis.

Molecular Tumor Boards impact on patients’ health: towards a policy brief in the Can.Heal project

Abstract Background Molecular Tumor Boards (MTBs) are pivotal in the current management of oncological patients, integrating molecular diagnostics with clinical expertise to tailor precise treatments. Within the framework of EU-funded ‘Building EU Cancer and Public Health Genomics platform’ (Can.Heal) project that aims at streamlining genomics implementation in public health, we are developing a policy brief to promote MTBs’ adoption across the EU. Methods A two-step approach was employed to delineate strategies for MTB implementation. Firstly, we conducted a systematic review and meta-analyses (if feasible) up to November 2023, on studies assessing the MTBs’ clinical impact. Secondly, based on the results of the review, we conducted an expert consultation to identify key areas to improve MTBs implementation and impact. Results 48 studies were included, whose results were heterogeneous in terms of organizational aspects and number of experts involved (mean n: 6, range: 2-19). Average implementation rate of the recommendations issued by the MTB was 43.1% (3.2%-92%), with a turnaround time from testing to recommendation of 36 days (15-58). By pooling data from 12 studies (n = 1623), a favorable overall survival [HR = 0.63 (95% CI 0.53-0.76), I2 42.0%] was reported for patients managed in hospitals with MTBs versus not. Similar estimates were reported when the outcome was progression free survival [HR = 0.63 (95% CI 0.54-0.72), I2 = 0.0%], based on 8 studies (n = 1106). The subsequent expert consultation identified 5 key areas for MTB implementation: genetic data sharing, standards for results’ interpretation, equitable access to MTB, optimization of the testing process, and funding and reimbursement. Conclusions The policy brief underscores the significant clinical benefits of MTB-recommended therapy, improving patients’ outcomes. Nevertheless, addressing resource allocation and infrastructure development is essential to optimize MTB utilization and enhance patient outcomes. Key messages • Our results highlight that MTBs-recommended therapy translates into tangible clinical benefits. • More fundings and resources are needed to optimize and fully implement MTBs in clinical practice.

The prognostic value of contrast stress echocardiography in a real-world population of symptomatic patients without known coronary artery disease

Abstract Background Coronary artery disease (CAD) is the leading cause of mortality and morbidity worldwide. In addition to diagnosis, non-invasive tests may also provide prognostic information useful in the risk stratification and management of CAD patients. Stress echocardiography (SE) is an accurate, non-invasive method for the detection of obstructive CAD. However, in real-world clinical practice the test performance may vary among different centres, depending on availability, local protocols, and operator expertise. Purpose To evaluate the prognostic value of contrast SE in a real-world population of symptomatic patients without known CAD. Methods This was a cohort follow-up study of patients without known CAD and symptoms of atypical chest pain, unexplained dyspnoea or palpitations who were referred to the echocardiography lab of a tertiary hospital for SE between January 2020 and December 2021. Patients with resting regional wall motion abnormalities were excluded. All patients underwent treadmill exercise stress echocardiography (ESE) or dobutamine stress echocardiography (DSE) if unable to exercise. Contrast agents were used in almost all patients (99%). The study population was followed-up for at least 2 years after SE by phone and/or electronic hospital records. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, acute coronary syndrome (ACS), or cardiac-related death. Results The study comprised 266 patients (mean age 58±12 years, 63% male) who underwent either ESE (58%) or DSE (42%). The patients' details are reported in Table 1. The most common indication for the exam was atypical chest pain, with a prevalence of 73%. SE exams were positive for inducible ischaemia in 14 (5%) patients. Symptoms during the exam were present in 3 (21%) patients with positive SE and 4 patients (2%) with negative SE (p=0.004). No serious complications (sustained ventricular tachycardia, myocardial infarction, or death) were recorded. During the follow-up (median 30, IQR 23–38 months), 264 patients (99%) were successfully contacted. Cardiac outcome occurred in 10 patients. Among 14 patients with positive SE, 8 underwent revascularization due to significant coronary artery stenosis. Among 250 patients with negative SE, 1 underwent revascularization due to significant coronary artery stenosis and 1 presented with ACS 13 months after the test (both patients underwent DSE). Negative predictive value was 99% over a median follow-up of 30 months, corresponding to an annualized event rate of 0.32% per year. A positive SE was significantly associated with cardiac outcome (log-rank test p<0.0001, Figure 1). Conclusion Contrast SE carries significant prognostic implications in symptomatic patients without known CAD. A positive test is strongly associated with the need for revascularization, while a normal test result has an excellent negative predictive value regarding cardiovascular morbidity and mortality.Figure 1

Role of inflammation and cholesterol efflux in myocardial infarction patients without standard modifiable risk factors

Abstract Background A substantial proportion of ST-segment elevation myocardial infarction (STEMI) patients has no standard modifiable cardiovascular risk factors (SMuRF) at admission. Knowledge on pathogenesis and risk markers of mortality in these patients remain limited. Aims We described the characteristics and prognosis of SMuRF-less patients admitted for a first STEMI in the light of recent prognostic biomarkers. Methods Baseline characteristics including interleukin (IL)-1β, hs-CRP and serum cholesterol efflux capacity were compared between patients with and without SMuRF. Determinants of 1-year all-cause mortality were assessed using univariable and multivariable Cox regression analyses. Results Among the 1604 patients included, 178 (11.1%) were SMuRF-less. SMuRF-less patients were older (66.9 ± 15.3 vs 61.9 ± 13.9, p<0.001), less often men (66.9 vs 75.9%, p<0.001) and had lower body mass index (24.2 ± 3.9 vs 26.0 ± 4.4, p<0.001) compared to patients with ≥1 SMuRFs. SMuRF-less patients presented higher rates of altered LVEF<45% and killip≥2 at admission (31.8% vs 22.8%, p=0.014 and 19 vs 12.9%, respectively, p=0.027) without differences in proportions of late STEMI presenters (symptoms-to-balloon time >360 min) did not differ between groups. SMuRF-less patients had lower rates of revascularization (82 vs 92.3%, p<0.001) and received less guidelines recommended medications (statins, β-blockers or angiotensin-converting enzyme (ACE) inhibitors) at discharge; p<0.001 for all. Compared to patients with SMuRF, SMuRF-less patients had lower serum cholesterol efflux capacity (0.79 ± 0.16 vs 0.83 ± 0.16, respectively, p<0.001), were more often in the highest tertile of IL-1β (28.7% vs 18.9%, respectively, p=0.002) with a trend towards more patients within the highest hs-CRP level tertile (24.7% vs 19.1%, respectively, p=0.077). Crude rates of mortality were more than doubled in the SMuRF-less group (18.5% vs 7.7%, respectively, p<0.001). After multivariable adjustment SMuRF-less status was associated with a higher rate of mortality at one year aHR 1.87 [1.05-2.38], p=0.029) as well as inflammation biomarkers IL-1β (HR 1.81 [1.23-2.66], p=0.003) and high tertiles of hs-CRP (HR 1.87 [1.31-2.66], p<0.001) whereas having a high serum cholesterol efflux capacity was associated with a lower mortality (HR 0.27 [0.09-0.87], p=0.0208). Conclusion In STEMI patients, SMuRF-less patients have higher levels of inflammatory biomarkers and more frequent defective serum cholesterol efflux capacity, are undertreated, and have higher rate of mortality than patients with standard modifiable cardiovascular risk factors. Optimized management of such patients is needed.

The impact of a dedicated heart failure clinic on patients with heart failure with reduced ejection fraction

Abstract Introduction Heart failure (HF) is not a diagnosis but rather a syndrome with a variety of potential causes and once a patient has been diagnosed as having HF, the underlying etiology should be sought and treated. Thus, patients with HF should be engaged in a disease management program that includes a dedicated wider healthcare team which is critical for delivering the best care for patients. A dedicated HF clinic is one of the cornerstones of this ultimate management program. This clinic is specifically made to make sure of the proper management and follow-up of those patients. There is a scarce evidence of weather a dedicated HF clinic can alter the long-term outcomes of HF patients or not. Thus, the aim of this study is to search for the impact of a dedicated HF clinic on patients with HF with reduced ejection fraction (HFrEF) regarding the symptoms, management received according to latest guidelines, the patients’ quality of life and impact on health care resources. Patients and Methods This is a single center retrospective study that included patients presented to a dedicated heart failure clinic at a secondary care hospital through a one-year period. The study group included patients with diagnosis of HFrEF only who had one or more visit to the HF clinic. These patients served as their own control. Hospital admissions and emergency room visits in the 12-month period preceding enrollment was compared to the number in the following year after enrollment. Patients with incomplete data and those with ejection fraction >40% were excluded. Results The study included 48 patients with a mean age of 65 years, 70.8% of them were males. Most of the patients were hypertensive (77.1%), diabetic (75%) and with history of coronary artery disease (60.4%). Symptoms improved significantly in all patients, left ventricular volumes and ejection fraction improved (31±8.1% vs 40.7±10.5%) (P<0.0001). NT-ProBNP level improved significantly (5927 ng/L vs 3135 ng/L) (P = 0.03). The guideline directed medical therapy was used properly before and after the clinic. There was a significant improvement in the quality of life where the KCCQ-12 score improved from 71.25±13.2 to 83.3±13.3 (P<0.0001), six-minute walk test also improved significantly from 362±184 meters to 479±211 meters (P = 0.005). Regarding the economic impact, there was no significant difference in the number of unplanned visits (20.8% vs 10.4%) (P = 0.16) but there was a significant reduction in the number of HF hospitalizations within one year (20.8% vs 6.25%) (P = 0.038) Conclusion Dedicated HF clinics are very important now for the proper management of HF patients where it is proved that it can improve HF symptoms, improve the quality of life measurements, maintain the proper guideline directed therapy and reduce the economic burden of HF through reducing the number of HF hospitalizations.Clinical dataOutcomes

Efficacy of native T1 mapping for patients with non-ischemic cardiomyopathy and ventricular functional mitral regurgitation undergoing transcatheter edge-to-edge repair

Abstract Background The objectives of this study were to investigate the efficacy of LV myocardial damage assessment by native T1 mapping obtained with cardiac magnetic resonance (CMR) for symptomatic heart failure (HF) patients with non-ischemic cardiomyopathy (NICM) and ventricular functional mitral regurgitation (VFMR) undergoing transcatheter edge-to-edge repair (TEER). Methods We studied 40 symptomatic HF patients with NICM and VFMR undergoing TEER. LV myocardial damage was defined as the native T1 Z-score which was converted from native T1 value obtained with CMR before TEER. The primary endpoint was defined as first re-hospitalization for HF or cardiovascular death over a median follow-up period of 12 months after TEER. Results Multivariable Cox-proportional hazards analysis showed that a native T1 Z-score was the only independent parameter associated with cardiovascular events (hazard ratio: 3.40, 95% confidential interval: 1.51-7.67), and patients with native T1 Z-score < 2.41 experienced significantly fewer cardiovascular events than those with a native T1 Z-score ≥ 2.41 (log-rank P = 0.001). Moreover, such a low native T1 Z-score and more severe VFMR in an effective regurgitant orifice area (EROA) ≥ 0.30 cm2 was associated with fewer cardiovascular events than for a high native T1 Z-score of ≥ 2.41 and less severe VFMR of EROA < 0.30 cm2 (log-rank P = 0.002). Conclusion Assessment of baseline LV myocardial damage by means of native T1 Z-score obtained with CMR without the use of gadolinium-based contrast media is a valuable additional parameter for better management of symptomatic NICM patients with reduced LVEF and VFMR following TEER.

The effect of oral anticoagulants on the incidence of dementia in patients with atrial fibrillation: a systematic review and meta-analysis

Abstract Background Atrial fibrillation (AF) is a common cardiac arrhythmia, with dementia being an increasingly recognised complication of this. Treatment with oral anticoagulant (OAC) therapy may be protective in developing this complication. Purpose This meta-analysis aims to investigate the validity of this hypothesis, whilst additionally exploring the effect of specific OAC medication subtypes on the incidence of dementia. Methods A comprehensive search of MEDLINE and Embase for relevant studies reporting the efficacy of OAC therapy for the incidence of dementia in patients with AF was conducted from its inception until March 2023. This included observational studies that reported odds ratio, risk ratio and hazard ratio for adult AF patients. Studies including patients with prior OAC use or prior history of dementia were excluded. Statistical analysis was performed using a random-effects model to calculate the pooled hazard ratio and their corresponding 95% confidence interval for all outcomes. Subgroup analyses were also performed according to the study design, presence of observational window, and prior history of stroke in patients. Results A total of 13 studies were included in the study. Although the heterogeneity was high in all comparisons, we demonstrated that OAC usage lowered the risk of developing dementia in AF patients when compared to the non-OAC cohort. Looking more specifically at medication subtypes, direct oral anticoagulants (DOACs) and vitamin K agonists (VKA) were both effective in reducing the likelihood of AF patients developing dementia when compared to non-OAC treatments. Conclusion Our meta-analysis confirms that administration of OAC and its subtypes (VKA and DOAC) are effective pharmacotherapies in managing dementia in patients with AF. These findings have important clinical implications for the management of AF patients and highlight the need for further investigation of the protective effects of OAC therapy on cognitive decline. Future research should explore the long-term effects of OAC therapy on cognitive function in AF patients.

Successful management of infection and macrophage activation syndrome patient using low-dose etoposide: A case report

Successful management of infection and macrophage activation syndrome patient using low-dose etoposide: A case report

Single center experience of internal jugular vein as alternative access for implantation of a wireless pulmonary artery pressure sensor

Abstract This single-center study delves into the novel use of the internal jugular vein (IJ) as an alternative access pathway for the implantation of the CardioMEMS device, a wireless pulmonary artery pressure sensor. This approach is compared to the conventional femoral vein access in terms of procedural times, contrast volume, and patient outcomes. The study spans five years, from 2018 to 2023, evaluating the efficacy and safety of IJ access for CardioMEMS implantation. The analysis revealed a tendency towards shorter procedural times and reduced contrast volume with IJ access, although statistical significance was not reached due to the small sample size. Notably, IJ access provided a quicker needle-to-door time, suggesting benefits such as improved patient throughput and potentially shorter hospital stays, which are pivotal in a healthcare landscape that prioritizes efficiency and cost-effectiveness. In conclusion, this investigation offers initial evidence that IJ vein access is a feasible and potentially superior alternative for CardioMEMS device implantation. While the findings are preliminary due to the study's limited scale, they pave the way for future larger-scale, multicenter studies. Such research could confirm the benefits of IJ access and possibly influence clinical practices, enhancing the management of heart failure patients.

A deep learning model for syncope recognition in the emergency department

Abstract Introduction Syncope is a common presenting symptom in the emergency departments (EDs) and poses challenges in its recognition and differentiation from alternative causes of transient loss of consciousness. Natural Language Processing (NLP) is an artificial intelligence technique that enables the analysis of natural language, such as clinical notes and medical history within electronic medical records (EMRs). The application of NLP into the medical field is surging but its use for the recognition of syncope is still underexplored. Purpose We aimed to develop a NLP-based deep learning model for syncope recognition in the ED. Methods Two models, based on the Italian and Multilingual Bidirectional Encoder Representations from Transformers (BERT) language model, were developed and evaluated using consecutive EMRs from Humanitas Research Hospital ED. The first "triage" model was only based on textual data contained in the "triage" section of the EMR. The second "anamnesis" model also considered textual data contained in the "medical history" section. Performance metrics including area under the curve (AUC), Matthew’s correlation coefficient (MCC) and Brier’s score (BS) were used to compare the discriminative capabilities of different BERT models. Results The models were developed and tested on 15,098 and 15,222 EMRs, respectively. The Multilanguage BERT discriminated patients with syncope with an AUC of 0.85 in the triage model and of 0.92 in the anamnesis model. The Italian BERT identified patients with syncope with a MCC of 0.50 and a BS of 0.02 in the triage model and of 0.64 and 0.01, respectively, in the anamnesis model. Conclusions We propose two NLP-based models that identify syncope patients with a high discriminative capability. The presented algorithm may provide a starting point for the management of syncope patients using machine learning techniques.ROC and calibration curves of modelsFramework for model implementation

How preoperative upper gastrointestinal investigations affect the management of bariatric patients: results of a cohort study of 897 patients.

Preoperative diagnostic protocols vary worldwide, some prioritizing safety while others question routine procedures. Building on prior research, this study explores the impact of diverse preoperative findings on bariatric management and procedure selection. In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022 undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) were analyzed. Preoperative assessment included upper endoscopy, upper GI series, and esophageal manometry. Sonography data were excluded. The primary endpoint examined the influence of preoperative exams on procedure selection, the secondary endpoint evaluated their therapeutic impact. 897 patients (741 RYGB, 156 SG) were included. All underwent upper endoscopy, revealing common findings such as type C gastritis and reflux esophagitis. Upper endoscopy prompted a therapeutic consequence in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1. Upper GI series and manometry were more frequently performed before LSG. Upper GI series detected hiatal hernias and motility disorders but did not result in any change of procedures. Esophageal manometry found pathologies in 37 (25.3%) patients rising to 41.5% if symptoms were present. Overall, 16 (1.8%) patients experienced a change in the planned procedure, with 14 changes prompted by preoperative findings and two by technical difficulties. We advise routine upper endoscopies for all patients undergoing LRYGB or LSG, while reserving upper GI series only for selected cases. Manometry should be exclusively performed on symptomatic patients undergoing LSG, ensuring a balanced and individualized preoperative assessment.

Epidemiology of recurrent myocardial infarction in the reperfusion era

Abstract Introduction During the past decades, the incidence, management, and outcomes of myocardial infarction (MI) have improved considerably.(1-4) However, the characteristics and outcomes of patients who experience a recurrent MI are sparsely described. Purpose This study aimed to analyse the epidemiology and temporal trends of recurrent MI during the reperfusion era. Methods A nationwide registry-based cohort study was conducted, including all hospital admissions for recurrent MI in Denmark during 2000 to 2020. Descriptive statistics were used to analyse changes in patient characteristics and management. Survival analyses, taking competing risks into account when relevant, and multivariable Cox proportional hazards models adjusted for sex, age, comorbidities, and pre-recurrent MI pharmaceutical treatment were used to analyse the outcomes of interest: all-cause mortality, hospitalisation for heart failure (HHF), and additional recurrent MI. Results A total of n=55,722 admissions for recurrent MI between 2000 and 2020 were included. Median age at admission was 73 years, 68.0% were male, and 32.9% were patients with a 3rd or more recurrent MI. Between 2000-02 (n=9,490) and 2018-20 (n=5,520), patients admitted with a recurrent MI had an increased prevalence of comorbidities such as diabetes, chronic kidney disease, and cancer (Condensed Table 1). Likewise, the use of guideline directed management at the time of recurrent MI increased during the study period: percutaneous coronary intervention (PCI) from 12.8% to 47.2%, coronary angiography (CAG) from 21.8% to 68.0%, statins from 30.5% to 74.2%, and adenosine diphosphate (ADP) receptor inhibitors from 8.2% to 41.8%. Statistically significant linear calendar time trends were observed for all three outcomes (Figure 1). Between 2000-02 and 2018-20 (Figure 2), the absolute 1-year risk of mortality declined from 31.6% to 16.0% (adjusted hazard ratio [aHR]: 0.46 [95% CI: 0.43-0.50]). The absolute 1-year risk of an additional recurrent MI declined from 13.9% to 6.2% (aHR: 0.38 [0.34-0.43]). The absolute 1-year risk of HHF increased from 8.8% in 2000-02 to 10.5% in 2009-11 (aHR: 1.09 [0.99-1.21]), before declining to 7.4% in the final calendar year period (aHR: 0.75 [0.66-0.84]). Interpretation and conclusion Despite remarkable advances in the management and outcomes of patients experiencing recurrent MI during the reperfusion era, this remains a vulnerable, high-risk population. Special attention is warranted regarding the optimization of guideline directed care and prevention of heart failure following a recurrent MI.Figure 1Figure 2 & Condensed Table 1

Empagliflozin: unlocking new potentials in heart failure decongestion

Abstract Background Managing acute heart failure (AHF) remains a formidable challenge in cardiology, primarily due to the limitations of conventional decongestive therapies. This study explores the efficacy of Empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, in decongestion management for AHF. Methods Conducted in a tertiary care setting, this prospective cohort study involved 450 patients, divided equally into an Empagliflozin group and a control group receiving standard care. The study assessed changes in body weight, clinical congestion scores, hematocrit levels, and NT-proBNP levels as primary outcomes over a period of 90 days. Safety and adverse events related to Empagliflozin were also monitored. Results Empagliflozin led to a significant reduction in body weight (mean difference at Day 15: −1.95 kg, P<0.0001), and clinical congestion scores (mean difference at Day 15: −0.35, P=0.0050). Hematocrit levels increased significantly (mean increase at Day 15: 1.65%, P<0.0001), and NT-proBNP levels showed a more substantial decrease in the Empagliflozin group compared to the placebo. Safety profiles were consistent with previous studies, showing no significant increase in adverse events. Conclusion Empagliflozin demonstrates a substantial improvement in decongestion management in AHF patients, offering a promising alternative to traditional therapies. The findings indicate potential broader applications in heart failure management and support the need for updated clinical guidelines incorporating Empagliflozin as a therapeutic option in AHF.

Sex differences in management of LDL-cholesterol in patients with chronic coronary syndrome

Abstract Background Effective management of low-density lipoprotein cholesterol (LDL-C) is crucial for preventing recurrent cardiovascular (CV) events in patients with chronic coronary syndrome (CCS). Sex may impact the LDL-C management, by gender bias and/or sex-specific responses to pharmacological interventions. Purpose We examined sex-specific LDL-C management in CCS patients, assessing target achievement rates and their implications for CV outcomes. Methods In the international CLARIFY registry, we included 22,134 CCS patients with baseline LDL-C measurements. LDL-C levels were monitored annually over the 5-year follow-up period. Target LDL-C was set at 100 mg/dL, in line with prevailing recommendations at that time. Sex-specific differences in LDL-C were adjusted for age, geographical region and indication for lipid lowering drugs (stroke, MI, PAD). The primary endpoint was the incidence of MACE, defined as CV death or MI during the 5-year follow-up, evaluated using multivariable analysis adjusted for known predictors of recurrent CV events in CCS patients. Results Of 22,134 patients, 21.6% were women. Upon inclusion (6.5 ± 6.3 years after CCS diagnosis), women were more likely than men to have LDL-C levels above the recommended threshold (45.6% vs. 37.4%; aOR 1.47, 95%CI 1.38-1.58, p<0.001) and less likely to receive statin treatment (82.7% vs. 85.4%, p<0.001). Although women and men had comparable numbers of LDL-C measurements during follow-up, the discrepancies endured over the 5-year observation period, with women consistently showing lower likelihoods of achieving LDL-C targets at 1, 2, 3, 4, and 5 years post-inclusion (p<0.001 for all time points). Overall, women were less likely than men to have all available LDL-C concentrations within the target range (37.8% vs. 44.6%; aOR 0.70, 95% CI 0.64-0.76, p<0.001) and more likely to never reach the target LDL-C goal during follow-up (22.6% vs. 17.5%; aOR 1.43, 95% CI 1.32-1.55, p<0.001). Failing to achieve at least one LDL-C concentration below 100 mg/dL was associated with an increased risk of subsequent MACE (adjusted HR 1.57, 95%CI 1.38-1.77, p<0.001), with similar associations observed in both men (aHR 1.66, 95% CI 1.44-1.91, p<0.001) and women (aHR 1.31, 95% CI 1.01-1.70, p=0.05). Conclusion In patients with CCS, women consistently showed lower likelihood of reaching LDL-C targets throughout follow-up compared to men, even after adjusting for age, geographical region and other statin indications. Notably, women were more likely to have no LDL-C concentration within recommended range during follow-up, which is particularly concerning given its association with an increased risk of CV events. A contributing factor to this sex disparity in LDL-C control is women's lower likelihood of receiving lipid-lowering drugs than men. These results highlight the need for tailored interventions to address sex-related disparities in LDL-C management and improve cardiovascular outcomes in CCS patients.

The difference between guideline based lipid optimisation and real-world practice in a very high risk population

Abstract Background Elevated low-density lipoprotein cholesterol (LDL-C) is an important risk factor for the progression of cardiovascular disease and early optimisation of lipid lowering therapy following an acute coronary syndrome (ACS) or stroke is associated with improved outcomes. Recent guidelines have advocated the use of combination lipid-lowering therapy and achieving very low LDL-C concentrations.Purpose To identify if optimal lipid management in high risk patients has occurred. Methods A retrospective analysis of high-risk patients with a prior history of ACS or stroke presenting with a further subsequent ACS/stroke from January 2022 to December 2022 in a UK District General Hospital was performed. Lipid lowering therapy in primary care in the 18 months leading up admission, inpatient admission and subsequent 12 month post admission (delivered through the cardiac rehabilitation service post ACS and via primary care post stroke) was compared to our regional secondary prevention lipid lowering pathway. This patient group, with recurrent events, was selected as represents the "very high risk group" and had been through various clinicians multiple times increasing the opportunity to treat to guidance. Results 102 very high risk patients were admitted within the 12 month period. Only 79/102 patients had lipid profile in preceding 18 months and only 19% were compliant with the standard secondary prevention guidelines (20/102 patients high intensity statins), mainly due to reduced intensity statin doses (60%) and no lipid lowering medications (15%). A significant proportion of patients did not have any lipid blood tests during their index admission (no lipid profile 21% in stroke group vs 77% in ACS group) and whilst there was a significant inpatient escalation in lipid therapy this was mainly confined to high dose statins, and seen more clearly in the ACS group (ACS 65% vs stroke 21%). During the 12 months following admission a significant number of patients had no further lipid profiles (21% ACS vs 57% stroke) and minimal further optimisation of lipid management. Further escalation following high intensity statins were rare with only 5 / 102 patients receiving high intensity statin plus ezetimibe, 1 patient receiving statin/ ezetimibe/ PCSK9 inhibitor. Only 45% of patients achieved the guideline target of LDL < 1.8 mmol/L and only 18% achieved the ESC target of LDL <1.4 during 1 year follow up. Conclusion Although lipid guidelines have changed in recent year’s clinical real-world practice locally has not reflected these important developments, even in a very high-risk group patients are not benefiting from established evidence-based interventions. A majority of our ACS patients did not have a lipid profile blood test during their admission highlighting the fact that whilst guidelines have progressed significantly over the last few years the clinical importance of lipid optimisation in practice has not been appreciated by many of the cliniciansResults

Effect of remote monitoring on the management of heart failure patients with cardiac amyloidosis

Abstract Objective The primary objective was to assess the characteristics of heart failure (HF) patients with cardiac amyloidosis (CA) monitored remotely with our program. The secondary objective was to evaluate the discrimination of alerts by remote monitoring for HF in this specific population. Methods The entire multicentre cohort of HF patients monitored remotely with our program from August 2018 to December 2023 were included in the analysis. Results A total of 13,933 patients, including 346 (2.5%) with CA and 13,587 (97.5%) without cardiac amyloidosis (no-CA), had a median follow-up of 14 months. CA patients were more often male (78.6% vs 63.8%), over 80 years of age (69.9% vs 40.4%), with left ventricular ejection fraction >40% (78.6% vs 56.5%), more often NYHA class III-IV (26.6% vs 16.2%), more atrial fibrillation (54.0% vs 40.9%) but less myocardial infarction (8.4% vs 27.9%), diabetes (16.5% vs 28.1%), smoking (2.9% vs 13.4%), p<0.001 for all. There was no difference in the rate of renal failure (21.7% vs. 20.3%), obstructive sleep apnea (15.9% vs. 14.9%) or stroke (10.7% vs. 9.4%). Remote monitoring identified a total of 57,624 alerts, including 1240 in the CA group vs 56,384 in the no-CA group (i.e. 3.58 alerts per CA patient vs 4.15 alerts per no-CA patient). Of the alert resolutions in the CA group vs no-CA group, 22.4% vs 38.9% had a low probability of cardiac decompensation, 34.0% vs 35.4% had a moderate probability, 43.6% vs 25.7% had a high probability of cardiac decompensation (global Chi-square p<0.001). Conclusion Despite an elderly population with different comorbidities, remote monitoring with this program in CA patients identifies correct relevance for discrimination of cardiac decompensation.

Acute myocarditis presentation and intra-hospital prognosis: results of the multicenter prospective MYOCARDITIRM study

Abstract Background Acute myocarditis (AM) usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favorable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders and is considered the leading cause of sudden cardiac death in young apparently healthy adults. There is no recommendation for AM, only expert consensus, given the lack of important databases for a strong level of confidence. Methods We performed a multicenter prospective observational study of patients admitted for AM acknowledged by cardiac MRI to describe baseline characteristics, management, in-hospital and long-term outcomes of AM patients in France. Secondary objectives were to investigate determinants of prognosis, modalities of treatment and follow-up, and to identify gaps between expert consensus and real-life management. Results We enrolled 805 consecutive patients hospitalized for AM in 49 participating centers between May 2016 and February 2019. Median age was 31 (IQR 23-41) with 19% of female. Chest pain was the most frequent symptom (93%) and 112 (14%) had severity criteria upon admission (LVEF<50% or severe ventricular arrythmia or high-grade AV block or cardiogenic shock). ST elevation was observed in 49% of patients. One 26-years old patient died during initial hospital stay. Overall, 62 patients (8%) experienced intra-hospital complication of their AM, defined as a combined endpoint of death, LVEF<40% (MRI), sustained ventricular or supraventricular arrythmia, acute renal failure, cardiogenic shock, need for ventricular assistance device, need for inotropic drugs, temporary cardiac pacing, pace-maker or cardiac defibrillator implantation. Patients with initial severity criteria were 10 times more likely to present intra-hospital complication (33% vs 3.6%, p<0.001). Conclusion This prospective cohort represents the largest database on AM worldwide. Here we report baseline characteristics and in hospital events. Most patients had typical presentation with favorable outcomes but as much as 8% of patients did exhibit intra-hospital complication. The prospective follow up will provide valuable data to better identify subset of patients with poor prognosis that may be of interest to develop new therapeutic strategies.Acute myocarditis on cardiac MRI

Concomitant cardiac arrest on cardiogenic shock patients. Differences in clinical profile and outcomes with non-cardiac arrest patients. The Shock CAT Study

Abstract Background Mortality on cardiogenic shock (CS) remains undesirable, although CS patients with or without concomitant CA may have different prognoses and clinical profile. Purpose The aim is to analyse differences in clinical profile, management, in-hospital prognosis and mid-term mortality in CS patients with and without cardiac arrest on admission in a Mediterranean cohort. Method Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients of different aetiologies. Data on clinical presentation, biomarkers, management, including mechanical cardiac/circulatory support (MCS), in-hospital and 6 months mortality were analysed comparing patients with and without CA at admission. Results A total of 382 CS patients (p) were included: CA 34.8% (n=133 p) and non-CA 65.2% (n=249 p). CA patients were younger than non-CA (61.9 vs 67.4 years, p<0.001) with higher prevalence of men (82% vs 71.8%, p= 0.024). Acute coronary syndrome was the main CS cause (60.7%) and ST elevation myocardial infarction (STEMI) was higher in CA patients than non-CA (55.6% vs 42.6%, p<0.001). In CA group, time to recover of spontaneous circulation was 24 min (IQR: 14-40 min) and hypothermia was performed in 55% of cases. CA patients had less prevalence of cardiovascular risk factors (hypertension, diabetes and dyslipidaemia) and lower pH at admission (7.19 vs 7.31, p<0.001) and higher lactate peak (6.9 vs 5.0, p=0.001) than non-CA patients. MCS was implanted in 35.3% of all CS patients, with lower use in CA patients (23.3% vs 41.8%, p<0.001), mainly due to lower intraaortic balloon pump (19.5% vs 35.5%, p=0.001), without differences in the use of extracorporeal membrane oxygenation (ECMO) (11.4% vs 8.7%, p=0.40) or Impella (10.6% vs 12.8%. p=0.54). Cardshock score was higher in CA patients than non-CA (4.68 vs 4.2, p=0.038), without differences in IABP score (2.31 vs 2.20, p= 0.621) or SCAI D/E (42.1% vs 33.3%, p= 0.090). In-hospital mortality was higher in CA patients (42.9% vs 27.7%, p=0<0.001). Moreover, 6-months mortality remains higher in CA than non-CA patients, although without statistical significance (47.7% vs 38.3%, p=0.079). Conclusions In a Mediterranean CS cohort, concomitant CA patients were younger, with higher prevalence in men with STEMI. MCS had a lower used in CA patients, although without differences in ECMO or Impella. In-hospital mortality was 35% higher in CA patients than non-CA, although 6-months mortality only trend to be higher in CA group.

Sex-specific syncope characteristics in the early diagnosis of cardiac syncope

Abstract Background The Lancet women and cardiovascular disease commission requested evaluating sex-specific approaches in the diagnosis and management of acute cardiovascular disease. Purpose We aimed to explore 1) the utility of sex-specific syncope characteristics in the early diagnosis of cardiac syncope 2) sex-related differences in the management and outcomes of patients with a cardiac syncope. Methods Thirty-one syncope characteristics were prospectively assessed in women and men presenting with syncope to the emergency department (ED) in an international multicenter study. The final diagnosis of cardiac syncope was centrally adjudicated by two independent cardiologists. Sex-specific differences in the prevalence of syncope characteristics and their positive likelihood ratio (pLR) for cardiac syncope were the primary diagnostic endpoints. Sex-specific differences in hospital admission, diagnostic procedures performed in patients with a cardiac syncope and adverse events in patients directly discharged from the ED during one-year follow-up were secondary endpoints. Results Among 2661 patients (median age 71 years, 1099 women and 1562 men), 14.6% of women and 18.2% of men (p=0.02) were adjudicated to have a cardiac syncope. Eleven syncope characteristics showed diagnostic utility (statistically significant pLRs) in assessing cardiac syncope in the overall population. However, none of the syncope characteristics demonstrated significant sex interaction. Women adjudicated as having a cardiac syncope were as likely to be hospitalized as men (OR 1.12; 95% CI: 0.61-2.08, p=0.7) and to receive telemetry (40% vs 41%, p=0.9), ergometry (3.1% vs 6.3%, p=0.4), a holter (21% vs 17%, p=0.3), a loop recorder (0.6% vs 3.9%, p=0.06) and an echocardiogram (69% vs 65%, p=0.4). Among the 591 women and 796 men directly discharged from the ED, 18 women (3%) and 36 men (5%) were finally adjudicated as cardiac syncope. Noteworthy, within this cardiac syncope subgroup, 28% of women experienced major adverse cardiac events (MACE) during the 365-day follow-up period, in comparison to 67% men (OR 0.20; 95% CI: 0.06-0.68, p=0.011, Figure). Conclusion Syncope characteristics contributed to the early diagnosis of cardiac syncope, however, none had a significant sex interaction. Women with a cardiac syncope had a similar likelihood of being hospitalized and receiving diagnostic testing. Compard to men, women had a significantly decreased risk of MACE when not hospitalized after a cardiac syncope.Kaplan-Meier curves for 1 year MACE

Changes in heavy metal levels in the oral fluid of young patients with and without plaque-induced gingivitis undergoing treatment with braces

Relevance. Research into the effects of nickel-titanium alloys and heavy metal ions on the development of inflammatory oral diseases is becoming increasingly significant in orthodontics. The relationship between toxic elements and inflammatory responses remains under-researched and controversial. Data on the connection between heavy metals and inflammatory reactions could influence the choice of orthodontic appliance materials and guide the subsequent management and monitoring of patients with braces. The question of the safe use of nickel-titanium alloy braces continues to be a relevant concern.Purpose. To assess the levels of heavy metals in the oral fluid of young patients with braces, both in those who developed plaque-induced gingivitis and those who did not.Materials and Methods. The study involved 50 clinically healthy patients (Groups I and II health categories) with intact teeth, including patients with compensated dental caries (isolated carious lesions – Grade I) and no periodontal diseases (PMA index <20), presenting with dental crowding and malocclusion (K07.2, K07.3). The average age of the patients was 22.1 ± 2.7 years, all of whom were undergoing treatment with metal braces. Oral fluid samples were analyzed for 12 heavy metal elements using inductively coupled plasma mass spectrometry (ICP-MS) in a laboratory setting. Additionally, lysozyme activity and oral fluid pH were measured before appliance placement and six months into orthodontic treatment.Results. Adaptation to braces in young patients is frequently complicated by the development of gingivitis and periodontitis due to impaired oral hygiene and the mechanical pressure exerted on teeth and gums, leading to elemental imbalances. Patients with gingivitis during orthodontic treatment are particularly at risk of developing such imbalances and therefore require timely correction of their mineral metabolism.