Risultati per: LBP (Low Back Pain): Cosa dicono le linee guida del mal di schiena

Circulation, Volume 146, Issue Suppl_1, Page A15009-A15009, November 8, 2022. Introduction:Patients with single ventricle physiology frequently demonstrate decreased exercise tolerance after the Fontan operation. The objective of this study was to investigate the contribution of ventricular stiffness to exercise function in these patients.Hypothesis:We hypothesized that ventricular stiffness, both extremes of high and low stiffness, would be associated with exercise tolerance in Fontan patients.Methods:We previously validated an echocardiographic measure of ventricular stiffness, lateral Doppler E: tissue Doppler e’/end-diastolic volume (lateral E:e’/EDV) in children. Core-lab echocardiograms and exercise test results were obtained from the publicly-available Pediatric Heart Network Fontan Cross-sectional Study database. Exercise function was quantified as % predicted VO2. Ejection fraction (EF) was considered abnormal if < 50%. Diastolic function was defined as high stiffness if the lateral E:e’/EDV was > 90th percentile or low stiffness if < 10th percentile. Patients were divided into four groups: 1 = normal EF and normal diastolic function, 2 = decreased EF with normal diastolic function, 3 = normal EF with high ventricular stiffness, and 4 = normal EF with low ventricular stiffness.Results:239 patients (61% left, 29% right, 10% mixed ventricular dominance) had EF, lateral E:e’/EDV, and VO2measured. Differences between groups are reported in the Table.Conclusion:Single ventricle patients with both high and low stiffness and preserved EF had worse exercise capacity than patients with both normal and abnormal EF. To our knowledge, this is the first study detecting a low stiffness heart failure phenotype in single ventricle physiology. Future studies should further investigate the pathophysiologic mechanisms that lead to these extremes of stiffness in Fontan patients.

Circulation, Volume 146, Issue Suppl_1, Page A15051-A15051, November 8, 2022. Case presentation:A 58-year-old gentleman presented to A&E with low back pain for a few days and lower limb weakness for 24 hours. His background history was not medically significant. On examination, GCS 14/15, lower limbs power 2/5, and palpable urinary bladder. DRE revealed poor anal tone. MRI spine showed epidural abscess at L3-L4 & L5-S1 level and urgent decompressive spinal surgery was performed. IV antibiotics were started and the patient was admitted to the general HDU for vasopressor support. Since the operation, he developed cold, pale, swollen right leg, with no palpable peripheral arteries. A CT aortogram showed occlusion of the right popliteal artery. Right popliteal artery exploration with anterior and posterior tibial embolectomy and fasciotomies were done. As the patient was slow to wake up post-surgery, he was transferred to ICU. MRI brain showed no pathology. Transthoracic echocardiogram revealed no vegetation. As clinical suspicion of infective endocarditis was high, transoesophageal echocardiogram and real-time 3D analysis was done which showed a large highly mobile echogenic mass attached to the left atrial surface of the anterior mitral leaflet (A1 and A2) causing moderate MR. Urgent surgical mitral valve repair and removal of a 2 cm vegetation were performed. Both the blood culture and the culture of the vegetation tissue confirmed the growth of Staphylococcus aureus (MSSA). After 8 weeks of hospital stay, the patient was discharged home.Discussion:The objective of this case presentation is to reemphasize that infective endocarditis is not a single organ disease and can present to different specialities. Transthoracic echocardiography has reduced sensitivity in the critical care setting. So, there should be a relatively low threshold for transoesophageal echocardiography. Although the mortality rate of infective endocarditis is relatively high in ICU patients, multidisciplinary team management may result in favourable outcomes.

Circulation, Volume 146, Issue Suppl_1, Page A11655-A11655, November 8, 2022. Objective:Low molecular weight heparin (LMWH) has been established for the treatment of cancer-associated thromboembolism (CAT). Recent guidelines suggest Direct Oral Anti-Coagulants (DOACs) may have a role in the management of CAT, however these recommendations were conditional. This study aims to compare DOACs with LMWH and Vitamin K Antagonists (VKAs) in CAT.Methods:We conducted a meta-analysis of studies through a systematic search of four electronic databases (PubMed, Scopus, Web of Science, and Cochrane) published before January 25, 2022. Our criteria included studies in patients with all cancer types who received DOACs, VKAs, or LMWH for prevention or treatment of CAT. We analyzed outcomes including recurrent venous thromboembolism, major bleeding, clinically relevant non-major bleeding (CRNMB), and all-cause mortality. The quality assessment of the included RCTs was conducted through Cochrane Tool, while the quality of the included cohort studies was assessed by the NIH tool. The network meta-analysis was performed using the netmeta package in R software.Results:A total of 55 studies were included; 18 RCTs, and 37 cohort studies. DOACs (RR= 0.72, 95% CI [0.63; 0.83]) and LMWH (RR= 0.78, 95% CI [0.64; 0.94]) had a significantly lower risk of major bleeding than VKAs. There was also a significantly decreased risk of clinically relevant non-major bleeding (CRNMB) with LMWH than DOACs (RR= 0.63, 95% CI [0.55; 0.73]) and DOACs compared to VKA (RR= 0.83, 95% CI [0.72; 0.95]). With regards to recurrent venous thromboembolism risk (VTE), DOACs showed a significantly lower risk compared with either LMWH (RR=0.70, 95% CI [0.59; 0.83]) or VKA (RR=0.66, 95% CI [0.54; 0.80]).Conclusion:We conclude that DOACs are more effective in the management of CAT when compared to LMWH and VKA. DOACs and LMWH have significantly lower risk of major bleeding when compared to VKA. More research is needed to determine the best anticoagulation strategy for distinct types of cancers.

Circulation, Volume 146, Issue Suppl_1, Page A14613-A14613, November 8, 2022. Introduction:Carpal tunnel syndrome, spinal stenosis, and biceps tendon rupture may precede cardiac transthyretin amyloidosis (ATTR-CA).Hypothesis:We tested the hypothesis that amyloidosis-related orthopedic events herald amyloidosis and cardiac events consistent with ATTR-CA through transthyretin destabilization.Methods:In observational analysis in the Copenhagen General Population Study (CGPS; n=93,637), we first tested whether amyloidosis-related orthopedic events at baseline were associated with amyloidosis and incident cardiac events consistent with ATTR-CA (heart failure, atrial fibrillation, myocardial infarction, or death), and whether a low plasma transthyretin was associated with a higher risk. In genetic analysis, in CGPS and the Copenhagen City Heart Study(CCHS) combined (n=102,496), we tested whetherTTRgenotypes associated with stepwise lower plasma transthyretin, marking lower transthyretin tetramer stability and higher amyloidogenic potential, was associated with both orthopedic and incident cardiac events, implying a common mechanistic background through transthyretin destabilization.Results:In individuals with versus without orthopedic events at baseline, hazard ratios (HRs) were 10.7 (95% CI: 3.9-29.3) for amyloidosis, and 1.3(1.1-1.4) for cardiac events. Furthermore, in individuals with orthopedic events at baseline, HRs for cardiac events were 3.8(1.9-7.6) in those with transthyretin

Circulation, Volume 146, Issue Suppl_1, Page A14524-A14524, November 8, 2022. Introduction:Low testosterone (LowT) has been suggested to be associated with increased ASCVD risk and mortality, but results are conflicting across studies. We evaluated the independent relationship between low testosterone levels in adult males and ASCVD using data from an EHR-based database. Methods Cross-sectional study using the Houston Methodist CVD Learning Health System Registry, which includes data from 1.1 million patients aged ≥18 years (June 2016-April 2022). Analyses were restricted to men, and those on testosterone replacement therapy were excluded. We evaluated the associations between total testosterone levels (categorized as quartiles [Q], lowest Q as exposure of interest and highest Q as reference) and ASCVD (CAD, PAD, stroke), using logistic regression. Conditions and risk factors were identified using ICD 10-CM codes.Results:We evaluated 30,150 men ≥18 years (mean age 55.3 years, 12% NHB, 15% Hispanics) with testosterone level data. Men in testosterone Q1 (lowest levels: ≤285 ng/dl) had higher prevalence of almost all risk factors and composite ASCVD compared to Q4 (highest levels: ≥515 ng/dl)(Panel A).In unadjusted analyses, men in testosterone Q1 vs Q4 had higher odds of ASCVD (OR 1.54, 95% CI 1.41-1.68). In multivariable adjusted logistic regression, the increased odds persisted adjusting for age, sex, and race OR 1.33 (CI 1.21 – 1.46), while it was fully attenuated (OR 1.04 CI 0.94 – 1.14) after adjusting for risk factors (DM, HTN, dyslipidemia, obesity)(Panel B).The attenuation in association with prevalent ASCVD was highest adjusting for DM (67%) and HTN (58%)(Panel C).Similar results were noted when cutoff of

Circulation, Volume 146, Issue Suppl_1, Page A11488-A11488, November 8, 2022. Introduction:The epidemiology of coronary artery disease (CAD) has shifted, with increasing cardiometabolic (CM) disease and decreasing obstructive CAD in patients referred for myocardial perfusion imaging (MPI). Coronary microvascular dysfunction, defined as impaired coronary flow reserve (CFR) by positron emission tomography (PET), has emerged as a key mediator of risk. Our objective was to assess whether CFR provides additive value to identify low-risk CM disease patients compared with single-photon emission computed tomography (SPECT) MPI.Methods:We retrospectively studied patients with CM disease (obesity, diabetes, or chronic kidney disease (CKD) stage ≥3) and without known CAD referred for PET or SPECT MPI at our center from 2006 to 2020. Annualized all-cause and cardiac mortality was determined from death certificates, and propensity-matched low-risk PET and SPECT patients were compared using Poisson and Cox regression.Results:CM disease was prevalent in consecutive MPI referrals without CAD including obesity (N=8869), diabetes (N=4896) and CKD (N=3555), and higher among PET MPI (p 3 reflecting obstructive CAD was low (12%, 15% and 16%). Conversely, prevalence of CFR

Circulation, Volume 146, Issue Suppl_1, Page A12136-A12136, November 8, 2022. Background and Objectives:Previous studies have shown that a multiple blood biomarker strategy prior to aortic valve replacement (AVR) may be useful for risk stratification in patients undergoing surgical AVR (SAVR). The usefulness of this approach in patients with low-flow low-gradient aortic stenosis (LF-LG AS) has not been examined. The objective of this study was to determine the prognostic value of combined measures of multiple blood biomarkers in patients with LF-LG AS treated conservatively or by AVR.Methods:168 patients were prospectively enrolled in the TOPAS (Truly or Pseudo-severe Aortic Stenosis) study at our institute. Clinical and echocardiographic data were collected for each patient. Eight biomarkers of myocardial stress, inflammation, renal function (brain natriuretic peptide, creatine kinase-mb, interleukin-6, alanine transaminase, lactate dehydrogenase, alkaline phosphatase, procalcitonin, ferritin) were measured from blood samples collected at baseline. The cohort was divided into 3 groups according to the number of elevated biomarkers. Uni- and multivariable survival analyses were performed to evaluate the association between the number of elevated biomarkers and all-cause mortality.Results:Mean age was 73 years (68% male). After a median follow-up of 3.41 years, 69 (35%) patients died. Patients with 0-3, 4-6, and >6 elevated biomarkers had 8 years survival estimates of 75%, 52%, and 19%, respectively (log-rank p6 elevated biomarkers had an increased risk of all-cause mortality as compared to the group of patients with 0-3 elevated biomarkers (referent group), HR=3.82, p

Circulation, Volume 146, Issue Suppl_1, Page A15024-A15024, November 8, 2022. Introduction:LDL transports dietary long chain fatty acids, constituents that may influence rates of lipid oxidation. Modified LDL promotes foam cell formation during atherosclerosis. The omega-3 fatty acid (n3-FA) eicosapentaenoic acid (EPA) administered as icosapent ethyl (IPE), reduced cardiovascular events in REDUCE-IT compared to mixed n3-FAs in similar high-risk patients (STRENGTH). Some have attributed these discordant outcomes, in part, to placebo choice (mineral versus corn oil) despite very limited oral absorption. We compared the effects of these oils and various FAs on rates of LDL oxidation at supra-pharmacologic doses.Methods:LDL was isolated from human plasma by isopycnic centrifugation, separated into test samples of 100 μg/mL before being incubated at 37°C for 30 min with pharmaceutical grade mineral or corn oil at high concentrations (100 μg/mL) that are comparable to treatment achieved n3-FAs (4 g/d) that have high oral absorption. We also tested FAs contained in these oils, including stearic acid (18:0), arachidic acid (20:0), and linoleic acid (18:2, n-6) as well as ascorbic acid (10 μM) and a water-soluble analog of vitamin E (Trolox, 10 μM) as controls. All samples then underwent copper-induced oxidation (20 μM) monitored by formation of malondialdehyde (MDA).Results:MDA formation increased from 0.28 ± 0.03 to 9.96 ± 0.58 μM (p

Circulation, Volume 146, Issue Suppl_1, Page A13331-A13331, November 8, 2022. Introduction:Statins are a cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), the leading cause of death in the US. Despite conclusive evidence to the efficacy and safety of statins, low adherence remains a public health challenge. Although patient, clinician, and health system barriers to statin adherence have been documented, the effect of national policies targeting prescription access remains largely understudied. This study sought to assess the effect of the 2016 US Preventive Services Task Force (USPSTF) recommendation of statins on racial/ethnic disparities in treatment adherence.Methods:Utilizing records of the novel All of Us Research Program, a dataset of historically underrepresented groups in health research, we compared statin use in adult ASCVD non-Hispanic White (NHW) patients before (2014-2016) and after (2017-2020) the USPSTF recommendation with Black and Hispanic patients. Statin use was measured as percent days covered (PDC). Trends were compared using a regression model with demographics and an indicator variable for the change in recommendation as covariates. Regression coefficients and p-values were analyzed to assess the effect of the policy.Results:The study included 94,883 unique statin prescription records belonging to a patient cohort of which 52% were female, 21% Black and 12% Hispanic, with a mean age of 61.93 years. There was poor statin adherence across all racial/ethinic subgroups (PDC < 0.80). Following the policy, PDC increased 3.1% overall (p

Circulation, Volume 146, Issue Suppl_1, Page A15106-A15106, November 8, 2022. Introduction:Inadequate ventricular sensing at implantable cardiac defibrillator (ICD) implantation in patients with arrhythmogenic cardiomyopathy (ACM) is troubling and might cause inappropriate ICD interventions and complications. We aimed to evaluate the value of ventricular mechanics features in predicting low sensing value by emerging cardiovascular magnetic resonance-feature tracking (CMR-FT) in ACM patients.Hypothesis:CMR-FT characteristics prior to ICD implantation might assist in predicting low R wave amplitude.Methods:We retrospectively enrolled ACM patients receiving CMR examinations prior to ICD implantation at our center from January 2011 to July 2021. The strain parameters of LV and RV were analyzed by CMR-FT. The R wave amplitude (RWA) was obtained within 24 hours of completion of the ICD implantation and its association with CMR strain parameters was analyzed.Results:We enrolled 83 ACM patients with a median RWA of 8.0 mV (Interquartile range IQR:5.4-12.1 mV) and impedance within the normal range. 18 (21.7%) patients were found with low RWA (

Circulation, Volume 146, Issue Suppl_1, Page A10438-A10438, November 8, 2022. Introduction:Increased levels of low-density lipoprotein cholesterol (LDL-C) and its constituent apolipoprotein B (ApoB) are associated with atherosclerotic coronary disease, a risk factor for heart failure (HF). However, among patients with established HF, increased LDL-C has been associated with a lower risk of death. The potential causality of this association is unclear.Hypothesis:This study investigated the relationship between ApoB/LDL-C and adverse outcomes in participants with HF.Methods:We measured ApoB levels using the SomaScan assay among participants in the Penn Heart Failure Study (PHFS, n=1268). We performed one-sample Mendelian Randomization (MR) for ApoB and two-sample MR for ApoB and LDL-C.Results:Measured ApoB levels were inversely associated with the risk of death (Fig 1A) or death and heart failure hospital admission (DHFA; Fig 1B). One-sample MR revealed no significant association between genetically determined ApoB and the risk of death (HR 0.497, [95% CI, 0.20-1.2], p=0.125) or DHFA (HR 0.653, [95% CI, 0.35-1.2], p=0.182). Two-sample MR analyses were also consistent with a non-significant association between ApoB (Fig 2) or LDL-C (Fig 3) and risk of death or DHFA.Conclusions:ApoB is associated with the risk of death or DHFA in established HF. However, MR does not support a causal link between ApoB/LDL-C and the risk of adverse outcomes in this population.

Circulation, Volume 146, Issue Suppl_1, Page A14607-A14607, November 8, 2022. Introduction:Heart failure (HF) is one of the most common causes of hospital readmission. Self-care is essential but challenging task in patients with HF, and self-care deficit is closely related to unplanned readmission and unnecessary health expenditure. Patient centered education using teach-back method (TBM) emerged as a key strategy to prevent patients’ adverse events by improving self-care. This study aims to evaluate the effects of TBM in patients with HF.Hypothesis:HEART program®, a TBM-based discharge education, will significantly improve self-care, symptom experience, caregiver dependency, and unplanned healthcare utilization.Methods:This was a randomized controlled trial in HF patients with left ventricular ejection fraction ≤50%. Before discharge, the experimental group (EG) received HEART program®by a trained nurse, while the control group (CG) received usual discharge education. Measures were self-care (self-care maintenance; symptom-perception; self-care management), symptom experience, caregiver dependency at 7-days after discharge, and healthcare utilization (readmission; emergency room visit; hospital contact, etc.) at 1-month after discharge. Outcomes were analyzed with ANCOVA and Chi-squared test using SPSS program 25.Results:A total of 86 patients (EG = 40, CG = 46) completed the study (mean age 61±12 years; mean left ventricular ejection fraction 30±9%; mean duration of illness 4 years; mean hospitalization day 8±7). Self-care (self-care maintenance,F=12.3; symptom perception,F=15.4; self-care management,F=6.0) in the EG significantly improved compared with the CG (allPs.05). For healthcare utilization, only hospital contact via telephone was significantly different between the EG and CG (N=1 vs. 8;P=.032).Conclusions:This result indicates that discharge education based on TBM is an effective strategy to improve self-care ability, which could lead to reducing unplanned health expenditure in patients with HF. We suggest that healthcare providers implement TBM education for patients with chronic HF.

Circulation, Volume 146, Issue Suppl_1, Page A10038-A10038, November 8, 2022. Introduction:Low endothelial shear stress (ESS) is a pro-atherogenic stimulus associated with coronary plaque development, while high plaque structural stress (PSS) and its heterogeneity is associated with plaque destabilization. Previous studies showed that combining ESS and PSS additively predicts plaque progression, but no studies have determined their ability to predict major adverse cardiovascular events (MACE). We examined whether combining ESS and PSS improves MACE prediction in patients with acute coronary syndrome.Methods:We examined baseline ESS, ESS gradient, PSS, and PSS heterogeneity index (HI) in 22 non-culprit lesions (NCL) leading to future MACE, and 64 randomly selected control NCLs without MACE from the PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) study. ESS was calculated by computational fluid dynamics and PSS by finite element analysis on co-registered lesions.Results:86 lesions (55 thin-cap and 31 thick-cap fibroatheromas) were analyzed from 67 patients. Lesions that caused future MACE showed baseline higher PSS HI (0.32 vs. 0.24, p

Circulation, Volume 146, Issue Suppl_1, Page A10369-A10369, November 8, 2022. Background:The coronary computed tomography angiography (CCTA) is a noninvasive alternative tool in diagnosis of coronary artery disease compared to invasive coronary angiography (ICA). However, there is uncertainty regarding its usefulness in reducing major adverse cardiovascular events in stable chest pain patients.Methods:We have searched EMBASE, PubMed, and Cochrane Library (inception through May 24th, 2022) for randomized controlled trials (RCTs) evaluating CCTA versus ICA in stable chest pain. The Mantel-Haenszel method was used with Paule-Mandel estimator of tau2and Hartung-Knapp-Sidik-Jonkman adjustment (given small number of the included studies) to calculate the risk ratio (RR) and 95% confidence interval (CI).Results:Three RCTs with a total of 5,393 patients were included in this study. There was no significant difference between CCTA and ICA in terms of myocardial infarction [RR: 1.12; 95%CI: 0.60; 2.09; I2:0%][Figure], stroke [RR: 0.52; 95%CI: 0.22; 1.24; I2:0%], all-cause mortality [RR: 1.83; 95%CI: 0.17; 20.18; I2:50%], or cardiovascular mortality [RR: 0.47; 95%CI: 0.02; 9.15; I2:0%].Conclusion:This meta-analysis suggests that there is no difference between CCTA and ICA for stable chest pain evaluation in terms of myocardial infarction, stroke, all-cause mortality, or cardiovascular mortality.

Circulation, Volume 146, Issue Suppl_1, Page A9618-A9618, November 8, 2022. Introduction:Many patients with acute coronary syndrome (ACS) presented with elevated troponin level and reversible changes in the thallium scan. When they patients underwent coronary angiogram, the results showed patent coronary arteries. WHY?Hypothesis:Could abnormal coronary flow explain ACS, abnormal thallium and patent coronary arteries?Methods:Patients with newly diagnosed ACS and abnormal Thallium scan underwent a new dynamic coronary angiogram. 10 patients without ACS, normal EF and no coronary artery disease served as control. In this new technique, the contrast and blood flow were recorded at 15 images per second. The first image was of the index artery completely filled with contrast. The subsequent images showed the blood in white color moving in over a background of black contrast. The arterial phase started when the blood began moving in and ended when the contrast disappeared from the distal arterial vasculature as the contrast was replaced by blood. The machine learning (ML) program had 2 models (built on Python). Model 1 was built based on U-net and Densenet-121 for vessel segmentation. Model 2 was used for classification of flow. The model 2 was trained based on the convolutional neural network. The data to be collected was the duration of the arterial phase and the recurrence of ACS within one year follow-upResults:45 patients with ACS (elevated troponin level (50-100mg), reversible stress thallium), underwent coronary angiogram. The angiograms of 10 control patients showed a normal arterial phase (AP) of 1.56 sec. It was prolonged at 2.5sec in 45 patients with ACS (p

Circulation, Volume 146, Issue Suppl_1, Page A15165-A15165, November 8, 2022. Introduction:Guidelines recommend the use of Dobutamine stress echocardiography (DSE) in case of low flow low gradient aortic stenosis (LFLG AS) when left ventricular ejection fraction (LVEF)