Young Patients Research Articles

Venous thrombo-embolic events as the probable cause of arterial ischemic event in patients with patent foramen ovale

Abstract Introduction The origin of the emboli involved in patent foramen ovale (PFO)-related embolic events remains mostly unknown. Purpose To evaluate the venous thrombo-embolic (VTE) origin of patients with PFO-related embolic event. Methods Patients planned for PFO closure for secondary prevention of PFO-related arterial embolic event had a systematic venous thrombo-embolic (VTE) risk evaluation that included : an extensive questionnaire on past history of VTE events, clinical situations at high risk of VTE including complicated hemorrhoids, prior saphenectomy or venous sclerosis, varicocele, intrapelvic tumor, pregnancy, surgery or prolonged travel or presence of hyperthrombotic state (i.e., thrombophilia, active cancer or covid) and an abdominopelvic magnetic resonance venography (MRV) evaluation to identify any intrapelvic venous disease. Results From July 2020 to May 2023, 366 consecutive patients (Median age 51 [42-58] years, 42.9% female) were prospectively included. A past medical VTE events, a high risk VTE situation, a hyperthrombotic state and a pelvic venous abnormality on MRV were present in 8.5% (95%CI 6.0-11.8), 22.7% (95%CI 18.7-27.2), 7.1% (95%CI 4.9-10.2), and 36.3% (95%CI 31.6-41.4), respectively, and 58.5% (95%CI 53.4-63.4) of the patients presented at least one of the previous conditions. MRV identified various undiagnosed pelvic venous abnormalities with 20.0% of pelvic varices, 9.8% of May-Thurner-Cockett and 7.4% of Nutcracker phenomenons (Figure 1). Imaging abnormalities were more frequent among younger patients (aOR 1.02 95%CI:1.00-1.04) and women (aOR 1.94 ; 95%CI:1.25-3.02). Conclusion A majority of patients undergoing PFO closure for secondary prevention have a potential VTE source of paradoxical emboli suggesting that VTE events is the probable cause of arterial ischemic event in these patients.

The association between elevated systemic inflammation response index and long-term mortality in patients with triple-vessel coronary disease

Abstract Background Inflammation is a critical factor in the development of coronary artery disease. The systemic inflammatory response index (SIRI) is a novel biomarker of inflammation. Studies have shown that SIRI is associated with the severity of coronary artery disease. However, there is currently a lack of research on the relationship between SIRI and adverse outcomes in patients with multivessel coronary artery disease. Our study aimed to investigate the correlation between SIRI and long-term mortality risk in patients with triple-vessel coronary disease (TVD) and explore the interaction between SIRI and treatment strategies. Methods After excluding patients with missing data or loss to follow-up, a total of 8559 patients with TVD were included in our study. Based on their SIRI levels during hospitalization, patients were evenly divided into three groups (SIRI-L, SIRI-M, and SIRI-H). All patients received appropriate treatment, including medical therapy alone (MT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG). The primary endpoint was all-cause death. SIRI was calculated by the formula: neutrophil counts × monocyte counts / lymphocyte counts. Results During a median follow-up of 6.58 years, a total of 1264 all-cause deaths (14.8%) were recorded. Elevated SIRI was significantly associated with increased mortality rates (11.1%, 14.6%, and 18.6% in the SIRI-L, SIRI-M, and SIRI-H groups, respectively). The risk of all-cause mortality was significantly higher in the SIRI-M and SIRI-H groups compared to the SIRI-L group (adjusted HR: 1.203, 95% CI: 1.037-1.395, p=0.015; adjusted HR: 1.400, 95% CI: 1.212-1.617, p<0.001; respectively). In elderly patients, the relationship between elevated SIRI and the risk of all-cause mortality was more pronounced, while it attenuated in younger patients. Additionally, it is noteworthy that there was an interaction between SIRI and treatment strategy (p=0.037). In patients of the SIRI-L group, there was no significant difference between PCI and CABG treatment. However, in patients of the SIRI-M and SIRI-H groups, CABG shows a significant survival advantage over PCI. Conclusion Evaluating SIRI may help identify high-risk groups among patients with triple-vessel coronary disease and guide the selection of treatment strategies.Kaplan-Meier curves

Increased prevalence of coronary atherosclerosis in cancer survivors: a matched cross-sectional study with coronary CT angiography

Abstract Background Cancer and atherosclerosis share many risk factors. Although cardiovascular disease is highly prevalent among cancer survivors, it is unknown whether coronary atherosclerosis is present at a younger age in patients with a history of cancer. Purpose The purpose of this study is to evaluate the prevalence of coronary atherosclerosis in different age groups of patients with a history of cancer compared to matched controls. Methods Consecutive patients with a history of cancer aged >30 years who underwent evaluation for coronary artery disease with coronary computed tomography angiography (CCTA) between 2010 and 2023 were included in this cross-sectional study. Patients with a history of cancer were matched 1:2 to a control population without oncological history using propensity score matching. Patients were matched on age, gender, body mass index, hypercholesterolemia, hypertension, diabetes, use of statins and smoking status. The presence of atherosclerosis in the main coronary arteries was compared between the groups. Results The study population consisted of 313 patients with an oncological history and 626 matched control patients. The median age during CCTA scan was 59.4 [50.4-67.5] years and 66.1% of the patients were female. Coronary atherosclerosis was observed in 258 (82.4%) patients with a history of cancer compared to 461 (73.6%) control patients with a risk ratio of 1.12 [95% CI: 1.04-1.20], p<0.01. Mainly younger patients with a history of cancer aged between 30-59 years had a significant increased prevalence of coronary atherosclerosis with a risk ratio of 1.18 [1.04-1.33] compared to healthy controls (p=0.02). In our study population, thoracic radiotherapy was not associated with an increased prevalence of coronary atherosclerosis. Calcified plaques were observed more frequently in patients with a history of cancer (14.4% vs. 9.3% respectively, p=0.018). Conclusion Patients with a history cancer have a higher prevalence of coronary atherosclerosis as observed on CCTA compared to matched patients without cancer. This effect was most pronounced in younger patients aged 30-59 years. There is an unmet need to define strategies for cardiovascular disease monitoring and prevention in this growing patient population of patients with a history of cancer.Presence of coronary atherosclerosisRadiotherapy and atherosclerosis

Coronary artery disease screening in renal transplant candidates: insights from a large prospective cohort

Abstract Background There is currently no specific consensus regarding the screening strategy for CAD in renal transplant candidates. Purposes To describe in renal transplant candidates 1/ Strategies and results of CAD screening and 2/ renal and cardiovascular outcomes in this population Methods All patients registered on kidney transplant waiting list in our tertiary centre were classified into no screening for CAD (unscreened), screened, or with prior CAD. Unscreened was defined as no ischemia or anatomic testing while on waiting list or within the year prior to listing. Screening was considered as "positive" when it led to diagnostic of obstructive CAD (stenosis > 50%). Primary outcome was a composite outcome defined as [death or unplanned revascularization]. Primary outcome and renal transplant were analysed using multivariable Cox model. Results From 2005 to 2023, 3248 patients were registered as candidates for kidney transplantation, 228 (7.0%) patients had a history of CAD, 1987 (61.2%) patients were screened for CAD and 1033 (31.8%) were unscreened. Initial screening investigation were mainly stress cardiovascular MRI (33.7%), stress TTE (27.7%) or myocardial perfusion imaging (26.4%). Among screened patients, 133 (6.7%) patients had a positive screening for obstructive CAD. Within 4.7 [1.2 – 7.2] years, using patients with a negative screening as a reference, patients with positive screening and known CAD were less likely to receive renal transplant (aHR 0.70 [0.53 ; 0.93] and 0.64 [0.49 ; 0.84] respectively), while patients without screening were similarly transplanted (aHR 1.01 [0.89 ; 1.15]). Patients without screening or with a prior history of CAD were at higher risk of primary outcome compared with patients with negative screening (aHR 1.49 [1.16; 1.91]) and aHR 1.97 [1.48; 2.62] respectively), along with patients on dialysis at registration (1.37 [1.13; 1.66]), diabetic patients (1.79 [1.47; 2.18]) and smokers (1.25 [1.03; 1.53]). Age was an interaction factor between unscreening and primary outcome, as there was no association in younger patients (aHR 1.21 [0.81; 1.81]). Conclusion Among candidates for kidney transplantation, 2 out of 3 patients underwent non-invasive testing for obstructive CAD resulting in less than 10 % of positive cases. Positive testing and history of CAD were associated with a lower opportunity for kidney transplantation compared with negative testing or absence of screening. Nonetheless, absence of screening was associated with a higher risk of [death + unplanned revascularization], especially in older patients.Central illustration

Equal performance of the subcutaneous and transvenous implantable cardioverter defibrillator across all age groups in the PRAETORIAN trial

Abstract Introduction The subcutaneous ICD (S-ICD) is developed to overcome lead-related complications and systemic infections, inherent to transvenous ICD (TV-ICD) therapy. In the PRAETORIAN trial the S-ICD proved to be non-inferior to the TV-ICD with regard to inappropriate shocks (IAS) and complications. However, the S-ICD is still mainly the preferred choice in young patients with a long life expectancy and therefore higher risk for lead-related complications. We aimed to evaluate the impact of age on complications and IAS between the S-ICD and TV-ICD. Methods The PRAETORIAN trial is an investigator-initiated, international, multicenter, randomized, two-arm noninferiority trial that was conducted in the United States and Europe. In total 849 patients with a class I or IIa indication for ICD therapy and no pacing indication were randomized to receive an S-ICD (N=426) or TV-ICD (N=423) and followed for a median of 49 months. We compare the occurrence of complications and IAS between increasing quartiles of age. Results Quartile 1 (Q1) consisted of 203 patients aged <55 (109 S-ICD, 94 TV-ICD), Q2 of 199 patients aged 55-62 (100 S-ICD, 99 TV-ICD), Q3 of 232 patients aged 63-69 (111 S-ICD, 121 TV-ICD) and Q4 of 215 patients aged ≥70 (106 S-ICD, 109 TV-ICD). Between the quartiles, there were no significant differences in occurrence of device-related complications (P = 0.32) or IAS (P = 0.66). In Q1, there were 15 (7.4%) complications (5 S-ICD, 10 TV-ICD) and 13 (6.4%) IAS (7 S-ICD, 6 TV-ICD), compared to 20 (10.1%) complications (7 S-ICD, 13 TV-ICD) and 17 (8.5%) IAS (9 S-ICD, 8 TV-ICD) in Q2, 22 (9.5%) complications (12 S-ICD, 10 TV-ICD) and 19 (8.2%) IAS (11 S-ICD, 8 TV-ICD) in Q3 and 18 (8.4%) complications (7 S-ICD, 11 TV-ICD) and 21 (9.8%) IAS (14 S-ICD, 7 TV-ICD) in Q4 (Figure 1.). Figure 2. shows forest plots of the hazard ratios per quartile. Conclusions The S-ICD performed equal to the TV-ICD with regard to IAS and complications between quartiles of age, making the S-ICD a good alternative across all age groups.

Prevalence and characteristics of the catecholamine induced QT prolongation syndrome

Abstract Background We have recently described large families of idiopathic ventricular fibrillation characterised by catecholamine-induced QT interval prolongation (CIQTP). The patient presented with a normal QT duration at rest but an abnormal QT prolongation during a mental stress test (MST). Objective The aim of this study was to investigate the role of this new syndrome in inherited arrhythmic diseases. Methods Consecutive patients and their relatives, identified after unexplained familial sudden cardiac death or sudden cardiac arrest, were enrolled in the study in the presence of: - no other diagnosis after cardiac ultrasound, stress test, pharmacological test with adrenaline and ajmaline. - positive MST defined by a prolongation of the QT interval (>-11ms) during MST (as previously published). Results 134 families with unexplained SCD were examined. CIQTP was diagnosed in 15 families, representing a prevalence of 11.2%. Family screening of these 15 families identified a total of 43 individuals. Seven (16%) had symptoms prior to diagnosis, including sudden cardiac arrest in one. At baseline, the QTc interval was measured at 440+/-23 ms. MST increased the QTc interval by 49+/-33 ms. The identification of QT interval prolongation was less important in the exercise test (delta QTc 17+/-52 ms at 4 minutes after exercise) and the epinephrine test (delta QTc 19+/-36 at 1 minute according to the Krahn protocol). Treatment with beta-blockers was initiated in 19 patients (44%) on the basis of symptoms and major prolongation of the QT interval during the MST. After a mean follow-up of 7+/-2 years, only one patient developed ventricular fibrillation. This episode occurred during a short period when he was no observant for the treatment. Since then, there has been no recurrence of the arrhythmia on beta-blocker therapy. All other patients, including those who were previously symptomatic remained symptom-free on treatment. Conclusion CIQTP may explain a significant part of sudden cardiac arrest or syncope in young patients. Conventional screening using ECG, exercise test and epinephrine challenge may not be able to unmask CIQTP. Then MST may be systematically proposed for the screening of patient and their family. In CIQTP patients beta blocker therapy appears to be highly efficient to prevent symptoms.

Long-term outcomes in women diagnosed with heart failure in connection to delivery

Abstract Background Heart failure (HF) among young patients may be from various causes, often triggered by heightened physical demands like pregnancy. Data regarding outcomes of women diagnosed with HF in conjunction to pregnancy and delivery are varied. There remains a notable gap in understanding the outcomes observed in women diagnosed with heart failure in conjunction with delivery. Also, long-term follow-up studies are crucial to elucidate the impact of pregnancy-associated HF on future cardiovascular. Purpose To study the interplay between pregnancy, HF, and subsequent cardiovascular risk. Method Using the personal identification numbers (PINs) that all individuals in Sweden have enables linkage of data between different registers. Data from the National Patient Register (NPR), Swedish Medical Birth Register (MBR) and the Cause of Death Register were also used. All women 18 to 50 years of age registered in the in MBR in the period 1st January 1997 to 31st December 2019 were included. Women with first-time HF in relation to delivery were identified using the international classification code for diseases (ICD-10) I50, I42, I43 and 090.3 together with co-morbidities. Every patient was compared with 5 controls without HF from the Total Population Register matched on age at delivery and calendar year of delivery. Outcomes: all-cause mortality, and any cardiovascular disease (CVD) diagnosed during the observation time. Results A total of 286 cases and 1,430 controls were included. The prevalence of comorbidities at baseline for both patients and controls was low; congenital heart disease (1.4%, vs. 0%), pulmonary hypertension (1.0% vs. 0%), valvular heart disease (5.9% vs. 0%), myocardial infarction 0.7% vs. 0%), arrhythmia (5.9% vs. 0%), hypertension (6.3 % vs. 0.1%), (all p<0.05). Preeclampsia prior to HF diagnosis had 31% of patients vs. 0.2% of controls (p<0.001). Patients exhibited higher mortality rates at 4.9% during median follow up 9.0 (IQR 5.6-13.0) years vs. 0.3%, median follow up 9.4 (6.2-13.5) years and hazard ratios (HR) for all-cause mortality HR (95% CI) of 18.20 (5.99 - 55.31) (p<0.001) compared to controls. During median follow up of 3.2 (0.0-9.2) years 60.1% of patients were diagnosed with CVD both at in-/out-patient settings compared with 4.1% in controls during 9.4 (5.8-13.5) years of follow up. Comparing patients with controls the HR (95% CI) was 22.24 (16.50 - 29.96) p<0.0001 for CVD diagnosis during follow-up, see Figure 1. Conclusion In conjunction with delivery, and in the years thereafter, women with heart failure diagnosis had more than eighteen times higher risk of mortality than women without heart failure. The risk of CVD event in the heart failure group is highest in conjunction with delivery. Figure 1. Cumulative incidence functions for all-cause mortality, CVD in- or out-patient visit adjusted for death as competing risk, comparing cases with controls.

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.

Intention to use HIV pre-exposure prophylaxis (PrEP) in health sciences students

Abstract Introduction HIV is a public health issue, and as such, there are currently programs for the use of pre-exposure prophylaxis for HIV (PrEP) in various public institutions, with family physicians being one of the pillars to provide information and raise awareness among individuals at risk for HIV who wish to use these strategies. Objectives To determine the factors associated with the intention to use PrEP among university students in the healthcare field in the Veracruz-Boca del Río region. Methods A cross-sectional, prospective, and analytical study was conducted from August 2023 to March 2024, including students from healthcare-related majors at universities in the Veracruz region. An instrument was used to assess the level of knowledge about PrEP (Cronbach’s alpha of 0.8), with scores ranging from 0 to 10. Students were invited to participate in this research at different faculties of health sciences. Results 508 subjects participated, with 299 (58.9%) females and 386 (76.0%) heterosexual; 65.9% had never heard the term ‘PrEP,’ and 12% learned it from social media. The intention to use PrEP was positive in 81.5% of subjects in case of becoming a high-risk person for acquiring HIV. The level of knowledge about PrEP showed a score of 2.2 (SD ± 2.6), with 3.7% having high knowledge, 10.2% having a passing grade, and 55.9% scoring above the median (1.4) of the group’s scores. No association was identified between gender identity, sexual orientation, academic characteristics, and sources of information with the intention to use PrEP (p > 0.05). Knowledge level above the median of 6 points showed an odds ratio of 2.95 (95% CI 1.03-8.3) for the intention to use PrEP (p < 0.05). Conclusions The level of knowledge increases the probability of the intention to use PrEP in young people, making it essential for the primary care physician to carry out this training and awareness activity within their daily interactions with young patients. Key messages • It is essential to generate education programs on Prep for the population, as this will favor informed decision making on the use of these medicines in case they are required. • It is necessary to provide people with general information about Prep, since despite the existence of active programs for its distribution, most people have never heard anything about this drug scheme.

Prosthesis-patient mismatch is associated with long-term mortality following surgical aortic valve replacement

Abstract Background Prosthesis-patient mismatch (PPM) refers to a situation where the indexed effective orifice area (iEOA) of an implanted prosthetic valve is too small relative to the patient's body size, resulting in hemodynamic compromise. Studies examining the long-term consequences of PPM after surgical aortic valve replacement (SAVR) have yielded conflicting results. Purpose To evaluate the impact of PPM on long-term outcomes in patients undergoing primary isolated SAVR. Methods All patients who underwent isolated first-time SAVR from 1990-2014 were included in this observational, single-center study. PPM was defined as a predicted iEOA <0.85 cm2/m2 and severe PPM was defined as an iEOA <0.65 cm2/m2. Patient demographics, surgical details, and in-hospital outcomes were prospectively collected in our institutional database. Cases were linked to provincial administrative databases at an independent, non-profit research institute whose legal status allows it to collect and analyze health care and demographic data. The primary outcome of interest was all-cause mortality. Secondary outcomes were aortic valve reoperation (surgical or transcatheter) and post-operative hospitalization for heart failure. Multivariable Cox regression analysis identified risk factors for long-term mortality. Kaplan-Meier curves were generated for long-term survival and cumulative incidence functions for aortic valve reoperation and heart failure hospitalization. Results A total of 1,798 patients were included (no PPM: 770 [43%]; moderate PPM: 943 [52%]; and severe PPM: 85 [5%]). Mean age was 64±13 years, and 750 (42%) were female. 451 (25%) patients received a mechanical valve, and 1347 (75%) received a stented bioprosthetic valve. Concomitant aortic root enlargement was performed in 492 (27%) patients. At 20 years, survival was 47.8% (95% CI: 43.2%–52.2%) in the "no PPM group" compared with 29.5% (95% CI: 25.6%–33.5%) and 24.7% (95% CI: 12.7%–38.8%) in the moderate and severe PPM groups, respectively (p<0.001) (Figure 1). On multivariable analysis, iEOA was independently associated with long-term mortality (HR 0.95 per 0.10 increase in iEOA, 95% CI [0.91–0.98]; p=0.007). In a pre-specified subgroup analysis, iEOA was found to be associated with late mortality in patients younger than 65 years (p<0.001) but not in patients 65 years and older (p=0.23). Readmission for heart failure was more frequent among patients who had PPM than those who did not (Figure 2). There was no difference in aortic valve reintervention in patients with or without PPM (p=0.654). Conclusions Prosthesis-patient mismatch is common after SAVR and is associated with late mortality and hospitalization for heart failure. The deleterious impact of PPM on survival appears more pronounced in young patients. These findings may have important implications for the lifetime management of patients with aortic valve disease.Survival post SAVRHeart failure hospitalization post SAVR

Treatment approaches and survival outcomes in elderly colorectal cancer patients: a single-center comparative study.

Geriatric patients account for nearly half of new colorectal cancer (CRC) cases. This study compares clinicopathological features, treatments, outcomes, and frailty in elderly (≥ 70) and younger (< 70) CRC patients at our center. Patients diagnosed with non-metastatic or de novo metastatic CRC between January 2015 and April 2024 were included. Demographic, pathological, and survival data were retrospectively collected. Analyses were performed using SPSS version 25, with statistical significance set at P < 0.05. Of the 414 non-metastatic CRC patients, 26.6% were aged ≥ 70. Elderly patients received less perioperative chemotherapy (60% vs. 81.6%, P < 0.001) and had more dose reductions (41.6% vs. 19.2%, P < 0.001). Frailty reduced perioperative chemotherapy in elderly non-metastatic patients (54.5% vs. 92.1%, P < 0.001) but did not affect dose reduction (37.9% vs. 33.3%, P = 0.764) or treatment duration (median 24weeks for both groups, P = 0.909). In metastatic patients, frailty shortened chemotherapy duration (9.5 vs. 15.5weeks, P = 0.129). Elderly patients had lower 5- and 8-year overall survival (OS) rates (64.7%, 60.1% vs. 83.0%, 78.8%, P = 0.004). In the de novo metastatic cohort (135 patients), age did not affect OS (19.4 vs. 17.3months, P = 0.590) or PFS (9.8 vs. 7.5months, P = 0.209). Rectal cancer (HR: 2.751, P = 0.005) and early chemotherapy termination (HR: 4.138, P < 0.001) worsened OS in non-metastatic CRC, while absence of RAS (HR: 2.043, P = 0.047), BRAF mutations (HR: 8.263, P = 0.010), and metastasectomy (HR: 3.650, P = 0.036) improved OS in metastatic CRC. Age does not independently worsen CRC survival, though early chemotherapy discontinuation impacts outcomes. Reduced-dose chemotherapy or monotherapy can help minimize adverse effects in elderly patients.

Return to work after hip and knee arthroplasty: qualitative outcome from the Netherlands

Abstract Background Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) are performed daily worldwide. More younger working-age patients are receiving a THA and/or TKA. Outcomes, including Quality-of-Life (QOL), patient satisfaction and Return-to-Work (RTW) are becoming more important and have implications for healthcare budget and health workforce. Clinical recovery pathways should improve patient outcomes and cost-effective care. Insight in patient experiences and expectations regarding RTW remains behind. This study aims to gain insight into influenceable factors in the recovery pathway after THA or TKA that could lead to improved care and enhanced patient participation. Methods In this single-center qualitative study, performed at Zuyderland Medical Center (Sittard-Geleen, the Netherlands), 12 patients (n = 6 THA; n = 6 TKA) aged under 65 years were approached to participate. During interviews 6-weeks after arthroplasty, this research explored their RTW experiences in both pre-, and postoperative, in- and outpatient settings. Results In total, 12 employed patients who received a THA (n = 6, mean age 56 ± 7.4 years; female: n = 4, 66%) or a TKA (n = 6, mean age 61 ± 2.6 years; female n = 3, 50%) participated. Own control regarding RTW and a minimal recovery time after the operation was necessary for all patients. During this time, focus on physical therapy and strengthening was most important. RTW was not expected to be the primary goal during the clinical recovery pathway. The RTW topic was said to belong to the occupational physician (OP) and employer. Patients however knowledge that the type of work should gain importance in the consultation room. Patients missed accessible communication between the orthopedic surgeon and OP. Conclusions Overall, patients are satisfied with the current clinical recovery pathway. Intercollegiate communication should be made more accessible. Own control and strengthening self-management in the RTW remain important for all patients. Key messages • Own control and strengthening self-management should have importance in the guidance of working-age patients after THA or TKA. • Intercollegiate communication should be made more accessible.

Real world evidence of Sacubitril/Valsartan in octogenarian patients with heart failure. Results From the PARACHUTE-HF Study

Abstract Introduction The beneficial effects of Angiotensin Receptor Neprilysin Inhibitors (ARNI) on heart failure (HF) patients, particularly those with reduced left ventricular ejection fraction (LVEF), have been highlighted in several randomized controlled trials. Since 2020, ARNI has been available for HF treatment in Japan, a country known for its aging population. However, the inclusion of octogenarians in previous trials has been limited, leaving a gap in evidence regarding ARNI's effectiveness in the elderly. Objective This study aims to explore the real-world efficacy and safety of ARNI treatment among octogenarian HF patients in Japan, reflecting its status as a leading aging society. Methods The Prospective Area Registry of ARNI for Congestive Heart failUre in Tokyo East (PARACHUTE) trial, a multicenter registry, was conducted. It involved patients newly prescribed ARNI for chronic HF regardless of LVEF between 2020 and 2021. We compared patient backgrounds, changes in NT-proBNP levels at 6 months, and the rate of ARNI discontinuation between groups aged below and above 80 years. Results The study enrolled 105 patients, with an average age of 75 years. Forty-six patients (44%) were over 80 years old, and the majority (72%) were male. Among the younger group, 50% had preserved LVEF, compared to 32% in the octogenarian group (p=0.01). Median NT-proBNP levels across all patients decreased significantly from 2,540 pg/mL at baseline to 998 pg/mL at 6 months. The reduction in NT-proBNP was similar between the two age groups, with no significant interaction (p=0.46). Discontinuation rates due to any cause were not significantly different between younger and older patients (7% vs. 13%, p=0.28). Conclusion ARNI treatment resulted in significant reductions in NT-proBNP levels in HF patients, both under and over 80 years of age, with comparable discontinuation rates. These findings highlight the effectiveness and safety of ARNI in the management of chronic HF in the elderly, offering valuable real-world evidence from Japan's unique demographic context.

Cluster-specific risk factors for suboptimal thromboprophylaxis in contemporary European cohort of patients with atrial fibrillation: the EHRA-PATHS Project

Abstract Background Oral anticoagulation (OAC) is essential to optimal thromboprophylaxis in patients with atrial fibrillation (AF). Owing to bleeding risk concerns, OAC use may be challenging in clinically complex high-risk AF patients. Comorbidities might lead to suboptimal OAC use. We assessed cluster-specific risk factors for non-prescribing OAC in pre-defined AF clusters in contemporary European EHRA-PATHS AF cohort. Methods The EHRA-PATHS AF cohort was constructed using data from the three prospective EurObservational Research Programme (EORP) AF registries - General Pilot, General Long-term, and AF III registry. A two-step cluster analysis was performed. A hierarchical cluster analysis with 18 variables was used to identify the optimal number of clusters, followed by a K-means cluster analysis to determine variable cluster association. Cluster-specific risk factors for non-prescribing OAC were identified using univariate and multivariate logistic regression analyses. Results Of 18.799 patients, 2086 (11.1%) were not prescribed with OAC. Among the three clusters (see Table), OAC non-prescribing was significantly more prevalent in Cluster 1 (younger healthier AF patients) compared with Cluster 2 (Elderly with less comorbidity, mostly non-cardiovascular) or Cluster 3 (Elderly with more comorbidity, mostly cardiovascular), both P&amp;lt;0.001, with no significant difference between Clusters 2 and 3 (P=0.161). Cluster-specific multivariable risk factors for non-prescribing OAC are shown in Table. In all three clusters AF clinical type was significantly associated with OAC non-use. In Cluster 1, OAC non-use was less likely in the presence of CHA2DS2-VASc stroke risk factors, while bleeding risk factors were predominant multivariable predictors of OAC non-use among elderly (Clusters 2 and 3). Conclusion Our findings in a large contemporary European cohort suggest that different considerations prevail in treatment decision on OAC use in AF patients in clinical practice, depending on patient’s age and AF clinical type, as well as the presence and type of underlying comorbidities. Our findings could help in formulating targeted interventions to optimize stroke prevention in different subgroups of AF patients.

Phenotype groups in atrial cardiomyopathy and their prognosis

Abstract Background Atrial cardiomyopathy (ACM) includes patients with heterogenous demographic characteristics and comorbidities. Defining phenotype groups with similar clinical characteristics is important for the effective treatment of these patients, and for their prognosis and prevention of ACM. Purpose To conduct a cluster analysis that could help us in phenotyping ACM and exploring the clinical complexity of this entity. Methods We performed a hierarchical cluster analysis based on Ward’s Method using 10 clinical binary variables (hypertension, diabetes mellitus, heart failure, obesity, chronic obstructive pulmonary disease, cancer, coronary artery disease, sinus node dysfunction or atrio-ventricular block, implanted pacemaker, and ischemic stroke), identifying the optimal number of clusters. We investigated differences in demographic, laboratory and echocardiographic parameters, and treatment between defined clusters, and assessed the impact of these factors on prognosis. Results Of 724 evaluated consecutive patients with dilated left atrium only 200 met the criteria for advanced atrial cardiomyopathy, defined as severely dilated left atrium with volume index (LAVI) ≥ 48 ml/m2, preserved left ventricular systolic function - ejection fraction ≥ 50%, without an overt valvular or ventricular disease, and were included in the analysis. Mean age of the studied population was 73.91 ± 9.74 years, 58 % of them were women. We identified 4 clusters: cluster 1 (n = 73, 36%) were younger overweight patients with paroxysmal atrial fibrillation (AF); cluster 2 (n = 56, 28%) - old patients with congestive heart failure (CHF) and low body mass index (BMI); cluster 3 (n = 34, 17%)- diabetic patients with obesity and CHF; and cluster 4 (n = 37, 19%) old patients with tachycardia-bradycardia syndrome, implanted pacemakers, and long -standing AF. Over a mean follow up of 20.6 months cluster 2 had the highest mortality rate (28.6%), followed by cluster 3 (20.6%), compared to the lower mortality rate of cluster 1 and 4 (11% and 10.8%, respectively, p=0.047). The presence of heart failure (HR 4.4, CI 1.5 ÷12.7, p=0.006), cancer (HR 3.3, CI 1.6 ÷ 6.9, p=0.002) and greater than moderate tricuspid regurgitation (HR 5.4, CI 2.6 ÷ 11.3, p&amp;lt;0.001) were predictors of poor outcome. Conclusion In patients with advanced atrial cardiomyopathy, four main clusters were identified, differentiated by distinct comorbidities. Both clinical and echocardiographic parameters were found to be associated with an increased risk of mortality.Phenotype clusters of ACMKaplan-Meier curves of clusters

Outcomes of percutaneous coronary interventions after transcatheter aortic valve replacement

Abstract Background The number of percutaneous coronary interventions (PCI) after transcatheter aortic valve replacement (TAVR) is expected to increase with the extension of this treatment toward younger and lower-risk patients. However, little is known about the prognosis of this evolving subset of patients. Purpose This study aims to assess the clinical outcomes of patients undergoing PCI after TAVR. Methods Patients undergoing PCI after TAVR were retrospectively included from 20 centers across 7 European Countries from July 2008 to November 2023. The patients and procedural characteristics at the time of PCI, post-discharge antithrombotic regimen, and clinical outcomes were collected by each center. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, or stroke. Results A total of 464 patients underwent PCI at a median interval of 106 days (interquartile range: 40-502) after TAVR (45.4% balloon-expandable, 49.6% self-expandable, and 5.0% mechanically-expandable valve). The cohort had a mean age of 80.9±6.2 years, a mean Euroscore II of 5.5±6.2, and 48% had undergone prior PCI or coronary artery bypass graft. Indications for PCI included chronic coronary syndrome (64.6%), non-ST elevation myocardial infarction (20.5%), unstable angina (7.9%), ST elevation myocardial infarction (5.7%), and other acute reasons (1.2%). PCI was complex in approximately 20% of the cases and radial access was utilized only in about 47.4% of them. Still, PCI success rate was 96.7%, achieving complete revascularization in 70.5% of cases. There were 19 periprocedural myocardial infarctions (4.3%). The predominant antithrombotic regimen was 12-month dual antiplatelet therapy (49.1% of patients). MACE incidence over one year of follow-up was 11.8% (95% CI: 9.0%-15.4%), with no differences among TAVR valve types (p-value=0.260). The incidences of the individual component of MACE were 8.7% for cardiovascular deaths, 5.3% for myocardial infarctions, and 2.3% for strokes. Conclusion At present, patients undergoing PCI after TAVR represents a high-risk subgroup. Nonetheless, elucidating actionable factors could potentially improve their outcomes. This preliminary analysis did not reveal any association with the type of implanted valve.

Oncofertility in primary health care: the role of the Portuguese family doctor

Abstract Background The increasing number of cancer cases diagnosed at young ages and the impact of the disease and treatments on reproductive function have led to the development of Oncofertility. While oncologists typically lead these discussions, family doctors, as primary care providers, also play a crucial role. This study aims to assess family doctors’ knowledge, attitudes, and practices regarding fertility preservation in cancer patients. Methods This cross-sectional study, conducted between April 2023 and March 2024, surveyed 351 General and Family Medicine doctors from the Portuguese Northern Regional Health Administration. The questionnaire, consisting of 15 questions, assessed sociodemographic profiles, knowledge, attitudes, and practices. Data were analyzed using descriptive statistics and multivariate logistic regression. Results Most participants were female (80.5%) and under 40 years old. The majority (91.5%) had treated fewer than 10 cancer patients under 40 in the past two years. Key barriers included lack of knowledge (63.3%), time constraints (57.0%), and patient age (18.5%). Male physicians were more likely to address specific fertility concerns (OR 2.239) and less likely to view patient age as a barrier (OR 0.459). Physicians aged 31-35 were less likely to discuss fertility preservation (OR 0.553) but more likely to address it in the first consultation (OR 2.969). Urban-based physicians were less likely to discuss fertility preservation (OR 2.099). Only 9.1% always discussed fertility preservation before treatment, 27.6% did so sometimes, and 63.3% never discussed it. Conclusions There are significant gaps in the knowledge and practices of family doctors regarding fertility preservation for cancer patients. Targeted training and resources are urgently needed to support family doctors in effectively discussing fertility preservation, crucial for improving the quality of life of young cancer patients wishing to preserve their fertility. Key messages • Empowering Portuguese family doctors to address fertility concerns in cancer patients contributes to comprehensive oncofertility care, improving patient outcomes and quality of life. • Integrating oncofertility support with Portuguese family doctors strengthens primary care, ensuring discussion of fertility preservation is considered as part of cancer treatment planning.

The effects of fresh embryo transfer and frozen-thawed embryo transfer on the perinatal outcomes of single fetuses from mothers with PCOS.

To investigate the effects of fresh embryo transfer and frozen-thawed embryo transfer on perinatal outcomes among patients with PCOS. Patients who underwent in vitro fertilization and embryo transfer at the reproductive medicine center of the Affiliated Hospital of Guangdong Medical University from February 2013 to March 2021 were retrospectively analyzed. Patients were divided into the fresh embryo transfer group and frozen-thawed embryo transfer group according to whether fresh embryo transfer was performed. According to their conditions, patients were further classified into the ET-PCOS group (group A, n = 104), ET-non-PCOS group (group B, n = 212), FET-PCOS group (group C, n = 102), or FET-non-PCOS group (group D, n = 148); the general data, laboratory indicators and pregnancy outcomes of the patients were statistically analyzed, and the perinatal outcomes and related factors between the groups were compared and analyzed. The level of E2 on the HCG test day in the ET group was lower than that in the FET group. The natural birth rate of group D was lower than that of group A and group B, and the cesarean section rate was higher than that of group A and group B; the clinical pregnancy rate of group A was higher than that of group B and group D, and the difference was statistically significant (P < 0.05). There was no significant difference in the total abortion rate, early abortion rate or late abortion rate between the groups (P > 0.05). There was no significant difference in gestational age, neonatal sex or neonatal weight between the groups (P > 0.05). The incidence of placenta previa in Group B was significantly lower than that in Group D, and the difference was significant (P < 0.05). The incidence of fetal distress in Group B was significantly lower than that in Groups C and D, and the incidence of neonatal jaundice in Group D was significantly higher than that in Groups A and B (P < 0.05). In the multivariate analysis, the number of high-quality embryos was independent factors affecting clinical pregnancy, and the embryo transfer method was an independent factor affecting fetal distress and neonatal jaundice. Young PCOS patients without risk of OHSS have a high clinical pregnancy rate with fresh transplant cycles. PCOS disease itself has no significant effect on the perinatal outcomes of the mother or singleton infant. Frozen-thawed embryo transfer may increase the incidence of low placenta, fetal distress and neonatal jaundice.

A young male patient with cardiomyopathy associated with human immunodeficiency virus infection in the era of highly active antiretroviral therapy

Background: Cardiomyopathy in young people, especially those associated with HIV infection, has been reduced since the era of Highly Active Antiretroviral Therapy (HAART). In the era of post-HAART, manifestations of human immunodeficiency virus (HIV)-associated cardiomyopathy with impaired left ventricular (LV) systolic function are approximately about 1-3% of HIV-infected people. In this case, we presented how to diagnose and appropriately manage such a patient. Case Illustration: A 27-year-old male patient who works as a health worker came to the emergency room with complaints of shortness of breath; it worsened in the last 2 weeks. He got vital signs: blood pressure 97/60 mmHg, heart rate 118 bpm, respiratory rate 23 tpm, and oxygen saturation 99 % with oxygen supplementation of 8 lpm. Risk factors in patients such as smoking, family history, hypertension, diabetes mellitus, and dyslipidemia were denied. He was diagnosed with HIV on (antiretroviral therapy) ART 3 years ago with risk factors for free sex without protection. The last CD4 value was 796 cells/ul (normal value 637 – 1485). The echocardiography showed all chamber dilatation, global hypokinetic, and a significant decrease in LV systolic function (LVEF 16%). Laboratory examination showed an increase of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) into 6824 pg/mL (normal value &lt;85.8). It was then treated by optimizing HF therapy continue HIV therapy. Conclusion: In HIV patients who have fallen into heart failure, a proper diagnosis using relevant tools could be a reference for clinicians to make the right decision. Prompt treatment combination of optimal HF therapy and HIV therapy are becoming the keys to the treatment. Keyword: antiretroviral, cardiomyopathy, heart failure, human immunodeficiency virus

Sex differences in paediatric onset hypertrophic cardiomyopathy

Abstract Background Hypertrophic Cardiomyopathy (HCM) is a heterogeneous disease characterised by age related incomplete penetrance and variable long term outcomes. Sex differences have been described in both the clinical phenotype and natural history of adults with the disease, which have been attributed to both biological (eg sex hormone effect) and non-biological (eg societal and cultural effects) factors. It is unknown if similar sex differences exist in childhood-onset HCM. Purpose This study aimed to investigate the influence of biological sex on the clinical characteristics and outcomes of children with HCM. Methods Retrospective cohort study from an international registry of patients diagnosed under the age of 18 years with HCM. Patients with syndromic disease (RASopathy syndromes, inborn errors of metabolism, neuromuscular disease) were excluded. Sex differences in baseline characteristics and clinical outcomes were described. Primary outcomes were all-cause mortality or cardiac transplantation, Major Arrhythmic Cardiac Event (MACE) and heart failure event (defined as heart failure death or cardiac transplantation) Results Of 1262 patients, 851 (67.4%) were male (median age 11 yrs (IQR 7.4, 14.4) vs 11.1 (IQR 6.9, 14.0) in females, p=0.0312). Female patients were more likely to have a sarcomeric variant identified (n=208, 85.6% vs 388 (79.4%), p=0.041) despite equivalent genetic testing utilisation between sexes. Female patients were more likely to have severe heart failure symptoms (NYHA 3 or 4) (n=19, 6.1% vs n=20, 2.5% p value 0.030) but there was no difference in the proportion on medical therapy (male n=328, 39.7%, female n=167, 41.8, p value 0.476). The clinical phenotype in terms of degree of hypertrophy, left atrial size and left ventricular outflow tract gradient did not differ by sex. Over a median follow up of 5.2 years (IQR 2.4, 9.9) all-cause mortality or cardiac transplantation did not vary by sex but females were more likely to experience a heart failure event (females 0.6/100,000 pt years (95% CI 0.39-0.92) vs males 0.32/100,000 pt years (95% CI 0.21 – 0.50), hazard ratio 1.89, p value 0.0467). The incidence of MACE did not differ by sex but there was a trend towards higher implantable cardioverter defibrillator implantation in females (n=123, 30.7% vs n=210, 25.4%, p value 0.051). Conclusions For the first time, this study has shown sex differences in paediatric-onset hypertrophic cardiomyopathy. Despite no difference in baseline clinical phenotype, young female patients are more likely to experience heart failure symptoms and heart failure events over follow up. Further studies are required to explore the underlying mechanisms for these observed differences.Table summarising outcomes by sexSurvival free from heart failure