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

Circulation, Volume 146, Issue Suppl_1, Page A11151-A11151, November 8, 2022. Introduction:High energy requirements and poor feeding due to left-to-right shunting can lead to growth failure in patients with ventricular septal defect (VSD) but the effect of malnutrition on surgical outcomes is not well known, especially in low-resource settings. More data would inform decisions on whether nutritional repletion should occur pre-operatively or be deferred until after surgery.Methods:We analyzed cases of isolated VSD +/- ASD or PDA closure in children < 5 years old from 19 centers in 10 low- and middle-income countries with complete audited data collected as part of the International Quality Improvement Collaborative for Congenital Heart Disease from 2016 - 2020. Premature infants and those with known genetic/non-cardiac structural anomalies were excluded. We examined inter-center variation in weight-for-height z score (WHZ) and adjusted for age and major medical illness to calculate odds ratios (OR) of death and major infection (surgical site infection or bacterial sepsis) during hospitalization for changes in WHZ, and for patients with moderate acute malnutrition (-3 < WHZ ≤ -2; MAM) or severe acute malnutrition (WHZ ≤ -3; SAM) versus those without malnutrition (WHZ > -2).Results:Among 6441 VSD closures (5023 membranous, 160 muscular, 73 AV canal, 1046 infundibular, 139 DORV), median age was 8 months (1 day – 4.4 years). Median WHZ at time of surgery was -1.1 (-8.0 – 7.4); 949 patients (15%) had MAM and 1026 (16%) had SAM. Median WHZ (-3.52 – 0.35) and rates of MAM (19 – 80%) and SAM (6 – 63%) varied among centers. Overall, 0.5% died in hospital and 1.2% had major post-operative infection. Odds of major infection (OR 1.07, 95% CI 0.89-1.29) and mortality (OR 1.18, 0.93-1.49) increased for each one unit decrease in WHZ. For the MAM group, odds of major infection (OR 1.50, 0.67-3.37) and mortality (OR 1.32, 0.50-3.49) were increased compared to those without malnutrition. For SAM, odds were higher, and were significant for major infection (OR 2.15, 1.01-4.56) and nearly so for mortality (OR 1.93, 0.98-3.77).Conclusions:Malnutrition is common in children undergoing VSD closure in low-resource settings and increases risk of major infection and death, especially in cases of SAM. Pre-operative nutritional repletion may be considered to reduce risk.

Circulation, Volume 146, Issue Suppl_1, Page A12463-A12463, November 8, 2022. Introduction:Clinical uncertainty remains about the relationship between cholesterol levels and risk of death in older persons.Hypothesis:Lower low-density lipoprotein (LDL) cholesterol level was associated with a decreased mortality risk from cardiovascular disease (CVD) and an increased mortality risk due to non-CVD causes in primary prevention older populations.Methods:We examined the relationship between LDL cholesterol levels and mortality outcomes in a cohort of older individuals aged ≥65 years enrolled into a clinical trial. At baseline, participants had no diagnosed dementia, physical disability or CVD events, and were not taking lipid-lowering agents. Multivariable Cox proportional-hazards models were used to examine associations of LDL cholesterol with all-cause, CVD, cancer, and combined non-CVD/non-cancer mortality. Restricted cubic splines were used to depict non-linear relationships.Results:Among 12,334 participants included in this analysis [mean (SD) age: 75.2 (4.6) years; 54% females], who were followed for a median of 6.9 (5.7-8.0) years, 1250 (10%) died (24% due to CVD, 43% cancer, and 33% non-CVD/non-cancer). There was a U-shaped relation linking LDL cholesterol and all-cause mortality (nadir: 3.3mmol/L) and a curvilinear relation for other mortality outcomes. Each 1-mmol/L higher LDL cholesterol was associated with a lower risk of all-cause mortality (HR=0.91, 95% CI 0.85-0.98), cancer mortality (0.83, 0.74-0.94) and non-CVD/non-cancer mortality (0.81, 0.71-0.93), but a higher risk of CVD mortality (1.19, 1.03-1.38). Reduced risks of all-cause and non-CVD/non-cancer mortality were only significant in males and but not females (P values for sex interaction 0.10).Conclusions:Higher LDL cholesterol is associated with a greater risk of CVD mortality in older adults. Reduced risks for non-CVD mortality were likely driven by reverse causality, evidenced by the absence of associations after excluding deaths that occurred within the initial five years of follow-up.

Circulation, Volume 146, Issue Suppl_1, Page A14857-A14857, November 8, 2022. Background:Management of patients with paradoxical (ejection fraction > 50%) low gradient (< 40 mm Hg mean) severe (valve area < 1 cm2) aortic stenosis (PLAS) on ECHO is controversial. We studied the role of invasive hemodynamics (CATH) in evaluating these patients.Methods:In this single center retrospective cohort study, patients who underwent CATH for evaluation of PLAS on ECHO were divided into a “concordant” group (CG) when CATH aortic valve area (AVA) was < 1.0 cm2and a “discordant” group (DG) when CATH AVA was > 1.0 cm2. ECHO features, aortic valve replacement (AVR), and all-cause mortality were compared between the two groups. T-test, Chi-square test, and Kaplan-Meier analysis were performed. P-value of < 0.05 was considered statistically significant.Results:Among 76 PLAS patients who underwent CATH, the AVA was discordant in 21/76 (27.6%). DG patients were younger (72.2 vs. 78.7 y, p = 0.008). Other demographics including the Charlson comorbidity index (CCI) were similar. Dimensionless index (DI) was lower in CG than in DG (0.24 ±0.042 vs. 0.274 ± 0.041, p = 0.002) and % with DI < 0.25 was higher in CG (55.6% vs. 28.7%, p = 0.03). Other ECHO parameters including mean gradient, left ventricular outflow tract (LVOT) diameter, Vmax LVOT, AVAi, stroke volume index, and flow rate (AVA x mean velocity) were not different. More patients underwent AVR in CG (49/55, 89%) compared to DG (12/21, 57%, p = 0.001). Overall survival based on all-cause mortality was similar after AVR in both groups (p = 0.695, median follow up 1105.5 days). In DG, survival was better with AVR than with medical therapy alone (p = 0.049). CCI was not different in patients with AVR versus those without (p = 0.102).Conclusion:¼ of patients with PLAS on ECHO had discordant AVA on CATH. DI < 0.25 occurred more frequently in the CG cohort. Even in the DG, survival was better with AVR.Clinical Implication:AVR confers a survival advantage in patients with PLAS on ECHO, and should be considered regardless of AVA on CATH.

Circulation, Volume 146, Issue Suppl_1, Page A14001-A14001, November 8, 2022. Introduction:Patients with decreased LV ejection fraction (LVEF) presenting with elevated troponin incur high in-patient and follow-up mortality. Despite guidelines, testing for CAD and guideline-directed therapy in such patients has not been consistently utilized. To better understand this issue, we investigated hospital practice patterns in this vulnerable population.Methods:We conducted a tertiary single-center study of consecutive in-patients with abnormal troponin results on testing performed for clinical indications as requested by the treating physician. The study cohort included 432 patients, 67 +/- 14 years old with HTN in 75%, DM in 38%, smoking in 51%, dyslipidemia in 64%, family history of CAD in 28% and personal history of CAD or equivalent in 46%. Among them, 412 patients underwent echocardiographic LVEF assessment. Patients were then stratified according to the LVEF. The use of both ischemic evaluation and evidence-based medical therapy were compared. Hospital and long-term outcomes were analyzed.Results:Hospital mortality was 51/432 (11.8%) and during 28.1+/-13.8 months of follow-up additional 82/432 (18.9%) patients expired. Ischemia evaluation (both cardiac catheterization and non-invasive) was underutilized across all subgroups, including patients with decreased LVEF. Regarding guideline-directed medical therapy, only beta-blocker therapy was consistently utilized. Afterload reduction therapies such as angiotensin convertase enzyme inhibitors, angiotensin II receptor blockers, neprilysin inhibitors, hydralazine and nitrates were significantly underutilized. Statins and mineralocorticoid receptor blockers were also significantly underused (Table).Conclusions:Despite increased mortality, there continues to be room for improvement in the utilization of diagnostic evaluation and application of evidence-based therapy and in patients admitted with elevated cardiac biomarkers.

Circulation, Volume 146, Issue Suppl_1, Page A13829-A13829, November 8, 2022. Introduction:Atherosclerosis is the leading cause of cardiovascular diseases (CVDs). Over the past three decades, the clinical focus has been reducing plasma lipids and other traditional risk factors to reduce cardiovascular mortality. More recently, the CANTOS trial showed that inflammation is a significant additional risk factor for CVDs. Regulatory T cells (Tregs) are well known to protect the aorta from the inflammatory burden, but clinically how to induce these cells is not known.Hypothesis:LDLris expressed on various immune cells, including Tregs. Recently, our lab found that modulating the lipid metabolism throughLDLrin Tregs protects mice from colitis. Collectively, our data illustrate thatLDLrplays an essential role in T cell homeostasis and function that may impact atherosclerosis progression. Therefore, our goal in this study is to test whether the absence ofLDLrin immune cells alters the development of atherosclerosis.Methods:We used C57BL/6J male mice, which were lethally irradiated and transplanted with eitherLDLr-/-orWTbone marrow (BMT). To induce atherosclerosis, we blocked hepatic triglyceride clearance (antisense oligonucleotides) and fed mice with a high-fat diet for 12 weeks. We then collected blood and aorta to assess the extent of atherosclerosis.Results:Mice transplanted withLDLr-/-bone marrow have a lower percentage of T lymphocytes such as Th1 cells, Th1/Th2 hybrid cells, and pro-inflammatory M1 macrophages in the aorta compared toWTBMT aorta. Conversely,LDLr-/-BMT mice had a lower percentage of total Tregs but a significantly higher percentage of Tregs expressing the anti-inflammatory cytokine IL-10 and a lower percentage of Tregs co-expressing the pro-inflammatory marker T-bet compared toWTBMT aorta. Also,LDLr-/-BMT mice exhibited a 2-fold increase in plasma IL-10 compared toWTBMT plasma.Conclusion:Altogether, the current study’s finding suggests that the loss of theLDLrin the immune compartment (bone marrow) can induce a significant change in the aortic immune cells and may be a future target for augmenting the protective Tregs population in CVD patients.

Circulation, Volume 146, Issue Suppl_1, Page A10535-A10535, November 8, 2022. Introduction:The association of combined low-risk lifestyle behaviors (LRLBs) with cardiovascular disease (CVD) and all-cause mortality has not been systematically quantified.Objective:We undertook a systematic review and dose-response meta-analysis to assess the association of combined LRLBs with CVD and all-cause mortality.Methods:MEDLINE, EMBASE and Cochrane were searched up to December 29, 2021. Prospective cohort studies reporting the association between a minimum of 3 combined LRLBs (including healthy diet) with CVD, coronary heart disease (CHD) and stroke incidence and mortality were included. Independent reviewers extracted data and assessed study quality. Highest vs. lowest LRLB score was pooled using random effects. Heterogeneity was assessed (Cochran Q) and quantified (I2). Global dose response meta-analysis (DRM) for maximum adherence was estimated using one-stage linear mixed model. The certainty of the evidence was assessed using GRADE.Results:116 cohort comparisons (n=9,775,191) involving 382,922 cases were included. Comparing highest with lowest adherence LRLBs were associated with lower risk of CHD incidence (RR, 0.29 [95% CI, 0.21, 0.42]), stroke incidence (0.56 [0.50, 0.62]), CVD incidence (0.47 [0.37, 0.58]), CHD mortality (0.32 [0.25, 0.41]), stroke mortality (0.37 [0.30, 0.46]), CVD mortality (0.41 [0.34, 0.49]) and all-cause mortality (0.46 [0.41 to 0.52]). DRM analysis showed a linear association between LRLBs and all outcomes reaching a global DRM between 59-76% protection. LRLBs were defined with variable ranges as a healthy body weight (body mass index median), regular physical activity (1/week to >30 minutes/day), smoking cessation (never smoked or smoking cessation), light alcohol intake (≤30g/day) and adequate sleep (5.5-9 hours). The certainty of the evidence was graded as moderate to high owing to downgrades for inconsistency and/or upgrades for a large magnitude of effect and significant dose-response gradient.Conclusions:Pooled analyses show that the combination of LRLBs was associated with a substantial lower risk of CVD outcomes and all-cause mortality. The available evidence provides a very good indication of the benefit of combined LRLBs.

Circulation, Volume 146, Issue Suppl_1, Page A13688-A13688, November 8, 2022. Introduction:Insulin like growth factor binding proteins (IGFBPs) are a family of growth factor modifiers, some of which are known to be independently associated with PAH survival. IGFBP7 is a unique low-affinity IGFBP that, independent of IGF, stimulates prostacyclin production.Hypothesis:Elevated IGFBP7 is associated with worse disease severity and survival in PAH.Methods:Using enzyme-linked immunosorbent assays (ELISA), we evaluated serum IGFBP7 in a multicenter PAH cohort, the NHLBI PAHBiobank (N=2583), and healthy controls (N=99). Hemodynamic and functional measures were used to assess IGFBP7’s association to PAH severity and survival. Kruskal Wallis was used for comparison and Spearman’s rank correlation for correlations. Linear and logistic regressions performed for associations. IGFBP7 was dichotomized at the median and analyzed by Kaplan-Meier survival and Cox proportional Hazard regression.Results:Serum IGFBP7 levels were significantly elevated in patients with PAH compared to controls. After adjustment, logarithmic increases in IGFBP7 were associated with a 38 meter shorter six-minute walk distance (6MWD; -37.7, 95%CI -54 to -21, p=

Circulation, Volume 146, Issue Suppl_1, Page A13522-A13522, November 8, 2022. Introduction:Statin utilization for LDL-C lowering remains the cornerstone management strategy to reduce the risk of ASCVD. While lower statin utilization has been reported among women compared to men, contemporary studies evaluating sex disparities in LDL-C management across the spectrum of ASCVD are lacking, particularly across age and racial/ethnic subgroups. We aimed to provide detailed insights into this using data from a large US healthcare system.Methods:Cross-sectional study using data from ∼1.1 million patients aged 18+ years in the Houston Methodist Learning Health System Registry (2016-2022). Prevalent ASCVD including CAD, PAD, and stroke were identified using ICD 10-CM codes. Statin use and dose were identified in the database using ATC codes, and this information was recorded based on medication reconciliation reviews with patients at each clinical encounter. Individuals (n=973,720) without established ASCVD were excluded.Results:The study population consisted of 97,819 patients with prevalent ASCVD (55% men; 45% women, mean age: 69 years, 19% NHB, 12% Hispanic). Women with ASCVD reported lower statin use (64.3% vs 72.6%) and lower high-intensity statin use (29.8% vs 42.5%) compared with men. Women were also less likely to have on-treatment LDL-C

Circulation, Volume 146, Issue Suppl_1, Page A13934-A13934, November 8, 2022. Introduction:Although a higher protein intake has been related with lower mortality rates in general population, the association between protein intake and nutritional status/mortality in patients with acute heart failure has yet to be clarified.Methods and Results:We retrospectively analyzed 694 patients who were admitted due to acute heart failure in our hospital (mean age, 75±13 years; male 60%). The estimated protein intake was defined as a validated formula: [13.9 + 0.907*body mass index (kg/m2) + 0.0305*urinary urea nitrogen level (mg/dL)] using spot urine samples on admission. All patients were divided into three groups according to the estimated protein intake: low (≤43.6 g/day, n=232), middle (43.7 to 51.5 g/day, n=231), and high (≥51.6 g/day, n=231) group. The primary outcome of this study was regarded as all-cause mortality. Patients with low protein intake were older and had lower albumin compared with other two groups. A lower protein intake was associated with worse nutritional status evaluated using Geriatric Nutritional Risk Index (P

Circulation, Volume 146, Issue Suppl_1, Page A12237-A12237, November 8, 2022. Introduction:Transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement is recommended for symptomatic patients with high-gradient aortic stenosis (HGAS) and certain patients with low-flow, low-gradient aortic stenosis (LGAS). While TAVI may be beneficial in LGAS (mean pressure gradient (MPG)

Circulation, Volume 146, Issue Suppl_1, Page A13685-A13685, November 8, 2022. Introduction:Oxidized LDL triggers inflammation during the initiation and progression of atherosclerotic plaque. The omega-3 fatty acid (n3-FA) EPA administered as icosapent ethyl (IPE), reduced cardiovascular (CV) events in REDUCE-IT due, in part, to potential antioxidant and anti-thrombotic activity. By contrast, mixed n3-FA containing docosahexaenoic acid (DHA) have failed to reduce CV events in similar high-risk patients (STRENGTH). Some have raised concerns over the relationship between these discordant outcomes and placebo choice (mineral oil) as well as DHA content. We compared the effects of these compounds on oxidation of LDL where such ingested fatty acids are concentrated and transported.Methods:LDL was isolated from human plasma by isopycnic centrifugation, separated into test samples of 100 μg/mL, and incubated at 37°C for 30 min with pharmaceutical grade mineral oil, EPA, DHA or vehicle at equimolar levels (10 μM). All samples were then subjected to copper sulfate-induced oxidation (20 μM) monitored by formation of malondialdehyde (MDA). Ascorbic acid at equimolar levels served as a control.Results:LDL oxidation increased 30-fold (0.28±0.03 vs 8.72±0.54 μM;p

Circulation, Volume 146, Issue Suppl_1, Page A12333-A12333, November 8, 2022. Introduction:There are many reports on the effects of on-treatment platelet reactivity using P2Y12reaction units (PRU) on the ischemic or bleeding risk in patients who underwent percutaneous coronary intervention (PCI). However, there was little report including low-dose prasugrel (2.5mg).Hypothesis:We assumed that low-dose prasugrel use may contribute to the effectiveness and safety in the chronic phase of PCI in Japanese patients.Methods:This prospective observational study included 398 patients who underwent PCI between 2017 and 2018 (mean age: 68±11 years, male: 83%). Serial PRU measurements were performed; the baseline was at 6 to 12 months after PCI, and the follow-up was after 6 months later. The PRU was measured by the VerifyNow® P2Y12assay, and we assessed the distribution of PRU in each P2Y12inhibitor, after defined PRU 86 to 238 as therapeutic window.Results:Among 398 patients, the follow-up PRU was obtained in 360 patients (90%), and 80 patients (22%) were taking prasugrel 2.5mg. The baseline PRUs of clopidogrel 75mg, prasugrel 3.75mg, and prasugrel 2.5mg were 175±64, 147±55, and 154±66, respectively (p

Circulation, Volume 146, Issue Suppl_1, Page A15478-A15478, November 8, 2022. Introduction:We present a case of spontaneous retroperitoneal bleed that presented as back pain until it required multiple transfusions.Case presentation:A 66-year-old gentleman with past medical history of only dyslipidemia, presented with chest pain and was found to have an anterior wall ST-elevation myocardial infarction. He underwent stenting to proximal LAD and was found to be in cardiogenic shock with elevated biventricular filling pressures and ejection fraction of 5-10%. IABP was inserted, which had to be upgraded to axillary Impella 5.5 the next day, and LVAD workup was initiated. He gradually improved with decreasing Impella needs when he started complaining of back pain 5 days into his admission. At the same time, his Impella requirements started to go up. He went on to develop sweating, pallor & hemodynamic compromise. Since he was on anticoagulation due to Impella, a CT scan was obtained, which showed a spontaneous left-sided retroperitoneal bleed (F1) (IABP had been on the right side) and drop in hemoglobin from 15.8 mg/dl on admission to 7.2 mg/dl. He went on to develop hemorrhagic shock requiring massive blood product transfusion with subsequent vessel embolization by interventional radiology. Afterwards, he continued to improve, and Impella was eventually removed. Later in the course, he had another drop in hemoglobin & was taken back for CT, which showed expanding retroperitoneal hematoma (F2). Hematology team was consulted due to 2 spontaneous bleeds; however, no underlying bleeding disorder was suspected. He stabilized; was weaned off of Impella and, was subsequently discharged on milrinone infusion.Conclusions:We conclude that providers highly suspect retroperitoneal bleeds in the proper clinical setting for optimum patient care.

Circulation, Volume 146, Issue Suppl_1, Page A12386-A12386, November 8, 2022. Introduction:Coronary microvascular dysfunction (CMD) is an underdiagnosed cause of chest pain. The 2021 AHA/ACC guidelines do not advocate for testing in patients with chest pain and low pretest probability (PTP

Circulation, Volume 146, Issue Suppl_1, Page A14329-A14329, November 8, 2022. Background:Cardiac tamponade is a potentially fatal complication of catheter ablation for atrial fibrillation (AF). The risk of cardiac tamponade during AF ablation in underweight patients has never been investigated. This study aimed to evaluate the impact of body mass index (BMI) on the prediction of cardiac tamponade during AF ablation.Methods:Patients who underwent catheter ablation for AF between April 2016 and March 2018 were analyzed using a Japanese nationwide claims database, the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination (JROAD-DPC). Mixed-effects multivariable logistic regression analysis was performed to investigate the association between BMI and cardiac tamponade.Results:A total of 59,807 hospitalizations (median age: 67 [60-73], 29% women) with catheter ablation for AF were analyzed. Cardiac tamponade occurred in 657 patients (1.1%). Multivariable analysis revealed that being underweight (BMI

Circulation, Volume 146, Issue Suppl_1, Page A12585-A12585, November 8, 2022. Background:High-dose ionizing radiation is a well-established risk factor for childhood malignancies, including hematopoietic cancers (HC). However, data on the effect of low-dose ionizing radiation (LDIR) from medical imaging is conflicting and scant, especially in the pediatric population with congenital heart diseases (CHD). This study evaluated the association between cardiac LDIR exposure and hematopoietic cancers among children with CHD.Methods:A nationwide population-based cohort study was conducted using the Canadian Congenital Heart Disease (CanCHD) database. The study population included children born between 1999 and 2017 with at least one CHD diagnosis in their medical records. The cumulative dose of ionizing radiation corresponding to cardiac diagnostic and therapeutic procedures was quantified considering a 6-month exposure lag. The recency-weighted cumulative exposure (WCE) model, a flexible extension of Cox’s proportional hazards model, was used to assess the association.Results:We identified 139,975 children with CHD born between 1999 and 2017 and followed them for 1,388,681 person-years since birth. In this population, 718 hematopoietic cancer cases were observed. Children with HC were exposed to low-dose ionizing radiation earlier in life (median age at first exposure: 6 vs. 10 months; p=0.03) and had more procedures than those without cancer (mean number of procedures: 0.4 vs. 0.2; p