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

Circulation, Volume 146, Issue Suppl_1, Page A15317-A15317, November 8, 2022. Case Presentation:A 42-year-old male with a past medical history of recurrent myopericarditis treated with a combination of NSAIDs, colchicine, and steroids presented for left-sided chest pain. The pain first recurred when he attempted a prednisone taper and he was started on Anakinra. Upon presentation, physical examination and laboratory findings were within normal limits. Echocardiography and electrocardiogram were within normal limits. Cardiac magnetic resonance imaging (CMR) showed transmural enhancement of the basal-mid inferolateral segments and patchy mid-myocardial enhancement in the basal-mid anterolateral segments. Nuclear medicine PET showed FDG uptake in the basal anteroseptal, anterolateral, inferolateral, inferior, and apical segments suggestive of active inflammation. Initially, the diagnosis was thought to be recurrent myopericarditis of unknown etiology. Subsequent right heart catheterization with endomyocardial biopsy (EMB) showed mononuclear infiltrates in the interstitium associated with myocyte infiltration and focal moderate interstitial fibrosis. Due to his clinical, imaging, and pathologic findings, he was diagnosed with lymphocytic myocarditis. His anti-inflammatory therapy regimen was reinstated, and he was started on Mycophenolate Mofetil. On follow-up, the patient had significant symptomatic improvement.Discussion:Lymphocytic myocarditis is a pattern of myocardial inflammation that is typically associated with autoimmune and idiopathic causes. Myocarditis frequently manifests with signs and symptoms of heart failure, including chest pain, dyspnea, and arrhythmias. Diagnosis of myocarditis is often supported by CMR and FDG-PET findings, however, EMB is the gold standard for the diagnosis of myocarditis. Treatment is generally supportive, though immunomodulatory therapies have gained increased popularity due to benefits in treating symptoms and preventing complications of heart failure.

Circulation, Volume 146, Issue Suppl_1, Page A15587-A15587, November 8, 2022. Introduction:Spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy (TCM) are uncommon non-atherosclerotic causes of acute myocardial infarction (MI). These patients have fewer cardiovascular risk factors than those who have atherosclerotic MI. Clinical presentation in both subsets of MI is identical due to which diagnosis requires echocardiography and coronary angiography. The incidence of TCM and SCAD in the same patient is scarce and only documented in a few case reports and a case series.Case presentation:We present the case of a 50-year-old female with a past medical history of hypertension, hypothyroidism, and median arcuate ligament syndrome. She presented to the emergency department with intermittent chest pain radiating to her upper back, both arms, and her left jaw and it was associated with nausea. On examination, she was tachycardic, tachypneic, and anxious. She had normal heart sounds with no chest tenderness. Her EKG demonstrated ST-elevations in leads II, III, aVF, V4, V5, and V6. Laboratory results showed elevated high sensitivity troponin of 11,949 (pg/ml) and 30,256 (pg/ml) four hours later. The patient underwent emergent coronary angiography, which revealed diffuse tubular stenosis suggestive of type 2 SCAD in the second obtuse marginal artery but otherwise normal coronary anatomy with minimal stenosis. Left ventriculogram showed antero-apical, apical, and infero-apical hypokinesis and basal hyperkinesis, suggestive of Takotsubo cardiomyopathy. Transthoracic echocardiogram (TTE) completed 48 hours later demonstrated improved contractility with lateral wall hypokinesis. The patient was managed conservatively with medical management, and she was discharged on aspirin, plavix, carvedilol, isosorbide mononitrate, and losartan.Conclusions:SCAD and TCM are uncommon diagnoses that can rarely co-exist. TTE can help diagnose TCM in patients with chest pain and elevated cardiac biomarkers. Non-occlusive coronary vasculature is a diagnostic criterion per the proposed Mayo Clinic criteria. This case highlights the importance of coronary angiography in patients with TCM for assessment of potential co-existent coronary vascular pathology; SCAD in our case.

Circulation, Volume 146, Issue Suppl_1, Page A13076-A13076, November 8, 2022. Introduction:Mitochondrial respiration defects accompanied by low nitric oxide (NO) are associated with heart failure in congenital heart disease (CHD) patients with hypoplastic left heart syndrome (HLHS). Here we investigated the genetic etiology of low NO in patients with CHD.Hypothesis:Mutations in mitochondrial-related genes involved in NO metabolism contributes to the low NO associated risk for heart failure and need for heart transplantation in HLHS.Methods and Results:We performed a case-control association study among 588 white CHD cases including 41 with HLHS, and 24,143 white controls from the genome aggregation database (gnomAD). A rare conserved stopgain variant (rs562886845) inSLC25A2encoding mitochondrial ornithine transporter was significantly enriched among the HLHS patients with poor clinical outcome (Group II, Table 1), with 15.8% carrying this mutation, yielding odds ratio of 17.07 (p= 5.23 х 10-4) in comparison to CHD patients without left ventricular outflow tract obstruction or 7.63 (p=2.68 х 10–3) in comparison to gnomAD control cohort. Significantly,SLC25A2is the only mitochondrial transporter exporting asymmetric dimethylarginine, a natural NO synthase inhibitor. The three HLHS patients with thisSLC25A2variant showed very low nasal NO (nNO), a proxy for endogenous NO production capacity. All three patients had received heart transplant, with two being heterozygous and one homozygous for this variant. Significantly, the HLHS patient with the homozygous mutation had nNO at background levels (2.8 nl/min at 7 years of age as compared to >200 nl/min expected nNO).Conclusions:Our findings uncovered an essential role forSLC25A2in determining NO production capacity in patients with HLHS. As all three HLHS patients with this variant and very low nNO survived with heart transplant, this variant should be further investigated as a genetic marker for predicting the need for early heart transplant in HLHS.

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 A14235-A14235, November 8, 2022. Lower plasma tissue plasminogen activator (tPA), a key fibrinolytic enzyme, is associated with higher atherogenic cholesterol levels in humans, but the mechanism is unknown. Hepatocyte (HC) is the factory producing atherogenic apoB lipoproteins, also a major source of basal plasma tPA. Our hypothesis is that tPA limits apoB-VLDL production in HCs.Silencing tPA in HCs using AAV8-H1-sh-tPA inLdlr-/-mice leads to increased plasma cholesterol, triglyceride, apoB, and exacerbated atherosclerosis compared with scramble-silenced controls. Fractionation of plasma lipoproteins by FPLC or ultracentrifugation shows increased cholesterol and apoB in VLDL and LDL fractions. Inhibiting VLDL hydrolysis by P407 leads to a faster plasma triglyceride-rising rate in HC-tPA-silenced wild type mice, suggesting higher hepatic VLDL production. In a pulse-chase assay, tPA-silenced human primary HC has higher apoB-associated radioactivity in cell medium and lysate, suggesting increased apoB production.Adequate apoB lipidation is required for its secretion. By electronic microscopy, the distribution of VLDL shifts to a larger diameter in plasma VLDL isolated from HC-tPA-silencedLdlr-/-mice, suggesting higher lipid contents in VLDL. The endoplasmic reticulum (ER)-associated apoB is higher in tPA-silenced vs. control HCs, more prominent in the less denser density fractions. As density and lipidation are inversely related, these findings are consistent with the hypothesis that tPA limits apoB lipidation in ER. MTP is an ER chaperone incorporating neutral lipids onto apoB in HC. The tPA-silenced human primary HC has higher neutral lipid transfer activity than controls, despite similar MTP protein levels. Moreover, higher apoB is in the anti-MTP-precipitations from tPA-silenced vs. control HCs, suggesting that silencing tPA increases apoB-MTP interaction. Proximity ligation and immunoprecipitation assays show tPA interacts with apoB in HC. Solid-phase binding assay and native gel reveal purified human tPA binds to LDL, but not to MTP. tPA competes with MTP in binding to LDL. Moreover, tPA inhibits MTP-mediated neutral lipid transfer. These findings suggested tPA binds to apoB and inhibits MTP-dependent apoB lipidation and VLDL secretion.

Circulation, Volume 146, Issue Suppl_1, Page A9961-A9961, November 8, 2022. Introduction:Low left ventricular ejection fraction (LVEF) was commonly seen in chronic total occlusion (CTO) patients and was considered as an independent risk factor of poor prognosis of those patients. Yet, data regarding the clinical outcome, symptom and quality of life (QOL) of successful recanalization of CTO in low LVEF patients were scarcely reported.Objectives:This study set out to assess the clinical outcome, symptoms and QOL of CTO treated with percutaneous coronary intervention (CTO-PCI) in Chinese patients with low LVEF.Methods:Patients consecutively undergoing elective CTO-PCI were included and subdivided into 3 groups: LVEF≥50%, 50% >LVEF≥40%, and LVEF

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 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 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

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 A13682-A13682, November 8, 2022. Introduction:Cardiac lipomas are rare primary cardiac tumors. Depending on the location, they can present with vague symptoms such as chest pain, palpitations, dizziness, or arrhythmias.Case Presentation:A 58 y.o. female with a PMH of HLD and HTN presents for evaluation of chest pain and palpitations. An initial CvCTA was negative for significant CAD. A TTE showed a 1.6cm x 1.42 cm echolucent mobile mass attached to the lateral wall of the LV (Figure 1.A). Initially, there was a reasonable concern for an LV thrombus. However, it was unusual since the TTE revealed a normal EF and overall wall motion. Due to suspicions of a non-thrombus LV mass, a cardiac MRI was performed which showed a highly mobile mass attached to the mid anterior/anterolateral wall and a chordae within the LV cavity (Figure 1.B, Figure 1.C). The lesion was T2-hyperintense with loss of signal during fat suppression, highly suspicious for a lipoma. Given the mass mobility and strong patient preference, an elective robotic surgical resection was performed with a surgical biopsy confirming a lipoma (Figure 1.D).Discussion:Cardiac lipomas are often silent; however, symptoms can range from benign palpitations to life-threatening arrhythmias and outlet obstruction. TTE is typically the first-line imaging choice, followed by either cardiac CT or MRI imaging used for further diagnostic evaluation. Treatment options include conservative observation or prophylactic resection for asymptomatic patients, and therapeutic resection for symptomatic patients.Conclusion:Cardiac lipomas should be considered in the differential for any cardiac mass. TTE is the first-line imaging choice followed by a cardiac CT or MRI. Treatment remains a discussion between the patient and physician, varying from conservative management of symptoms to definitive treatment with surgical resection.

Circulation, Volume 146, Issue Suppl_1, Page A12348-A12348, November 8, 2022. HypothesisThe morphology of low-density non-calcified coronary plaque is associated with acute coronary syndrome (ACS) and culprit lesion precursorsMethods:This was a post-hoc analysis of the multicenter ICONIC study. A subset of 94 patients suspected of coronary artery disease (CAD) underwent coronary CT angiography imaging (CCTA) with subsequent follow-up for the occurrence of the first ACS event were selected. At the time of ACS, the culprit lesion was adjudicated by invasive coronary angiography cardiologists blinded to the CCTA.Quantitative CT was performed by a validated software as a service (Cleerly Labs, Cleerly, Inc., Denver, CO). A level-III reader used multiplanar reformation (MPR) images from this analysis to qualitatively assess individual collections of low-density non-calcified (LDNC) plaques (-189 to 30 HU).The degree of embedded LDNC plaque (DELP) was the amount a LDNC plaque was surrounded by non-calcified plaque. DELP was categorized as 90, 180, 270, and 360. LDNC plaque shape was categorized as crescent, round, lobular, or bean-shaped. DELP and shape were qualitatively assessed using the cross-sectional MPR image with the greatest LDNC plaque area. LDNC plaques with >270 DELP and round or bean-shaped were considered high-risk plaque (HRP) morphology.Results:ACS occurred in 64 patients. 247 LDNC plaques were analyzed. Patients without and with ACS had, on average 0.40±0.86 and 1.02±1.21 (p-value = 0.014) LDNC plaques with HRP morphology. The proportional hazard ratio associating the presence of one or more HRP morphology plaques with ACS was 2.03 (1.19, 3.48; p-value = 0.009), after controlling for diameter stenosis, age, sex, and family history of CAD. The odds ratio of the association of HRP morphology with culprit lesion precursors was 10.93 (3.77, 31.71; p-value

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 A11036-A11036, November 8, 2022. Introduction:Aortic Valve Calcification (AVC) measured by computed tomography (C-CT) and Dobutamine stress echocardiography (DSE) are both important when determining AS severity in low flow low gradient (LFLG) AS. It is generally accepted that AS is moderate if aortic mean gradient is

Circulation, Volume 146, Issue Suppl_1, Page A15388-A15388, November 8, 2022. Background:Patients with heart failure (HF) commonly remain symptomatic after medical treatment. Symptoms are associated with rehospitalizations and mortality. We developed a 6-month nutrition intervention targeting the 3 most common HF symptoms: edema, shortness of air, and fatigue. The intervention involves 3 nutrients that target the pathologic pathways underlying symptoms: sodium, omega-3 fatty acids, and lycopene.Hypothesis:Time to first event will be longer in the nutrition intervention group than in the placebo group at 1-year follow-up.Methods:This was a randomized controlled double-blind clinical trial where 118 patients (mean age 63±12 years; 40% female; 64% NYHA class III or IV) with HF were randomized to active intervention vs placebo groups. The active intervention included a skill-building strategy based on Theory of Planned Behavior using Motivational Interviewing. It included a low sodium (LS) diet (2500mg sodium/day), lycopene supplementation daily (8 ounces [oz] of LS sodium tomato juice or 11.5 oz of LS V8 juice), and omega-3 fatty acid capsules (350mg EPA, 50 mg DHA/capsule) 3/meal with each meal. Placebo patients received generic instructions to follow a LS diet, 8 oz/day of fruit juice with no lycopene (e.g. cranberry juice) and capsules that contained soybean oil, but that looked like intervention capsules. Cox proportional hazards modeling was done to determine time to event of cardiac hospitalization or death based on intervention group. Models were adjusted for age, gender, NYHA class and HF medications.Results:The two groups were similar at baseline. The active intervention group had better event-free survival (Figure, p = 0.03) independent of covariates. Placebo patients were 2.2 (95% CI 1.025 – 4.584) times more likely to experience an event.Conclusion:A diet-based intervention aimed at the pathologic pathways underlying the 3 most common HF symptoms is successful in reducing cardiac rehospitalizations and mortality.

Circulation, Volume 146, Issue Suppl_1, Page A11986-A11986, November 8, 2022. Introduction:Patients with peripheral artery disease (PAD) are at high risk for adverse cardiovascular events, including acute myocardial infarction (AMI). Though AMI care has improved, in-hospital outcomes for patients experiencing an AMI with comorbid PAD are not well described in recent practice. We hypothesized that patients with PAD would have higher rates of bleeding and mortality during AMI hospitalization.Methods:We assessed clinical characteristics and in-hospital major bleeding and mortality rates of patients admitted with AMI and comorbid PAD at 646 hospitals in the NCDR Chest Pain MI Registry from 1/2019 to 9/2021. Major bleeding and mortality were compared for patients with vs. without PAD using multivariable logistic regression.Results:Compared with patients admitted for AMI without PAD (n = 307,550), those with PAD (n = 24,585) were older, had more comorbidities including tobacco use, diabetes, prior AMI and heart failure, and more frequently presented with NSTEMI vs. STEMI. Patients with PAD had higher crude rates of in-hospital major bleeding (9.7% vs. 6.3%) and mortality (8.1% vs. 4.7%); in exploratory analyses, rates of other adverse in-hospital events were also higher (Figure). After multivariable adjustment, PAD was associated with an increased risk of major bleeding (adjusted OR [aOR] 1.23 [95% CI 1.17-1.30]). PAD was also associated with greater risk of in-hospital mortality (aOR 1.28 [95% CI 1.21-1.37]), particularly among patients over age 65 (aOR 1.32 [95% CI 1.23-1.42] for ≥65 years vs. 1.06 [95% CI 0.96-1.18] for patients