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

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 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 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 A9556-A9556, November 8, 2022. Introduction:Transvenous lead extraction (TLE) is associated with better outcomes in high-volume (HiV, >30 TLE/year) than low-volume centers. Little data exist regarding transitioning to a HiV TLE center. We examined the impact of strategic interventions at a tertiary care center transitioning to a HiV TLE center.Hypothesis:Systematic interventions to increase TLE volume and quality are expected to decrease the rate of major complications without adversely affecting procedural success rates.Methods:Consecutive patients undergoing TLE with leads >1 year post implantation from 2012-2021 were reviewed. The primary endpoints were TLE success and major complications including TLE-related mortality, vascular laceration, pericardial effusion, and emergent cardiothoracic surgery. Outcomes were compared between TLE completed in 2012-2018 prior to the intervention (n=125) and TLE after intervention 2019-2021 (n=127).Results:There were 252 consecutive TLE procedures included involving 398 leads. Strategic interventions were implemented in 2018 (Figure). Annual mean TLE volume increased from 19.5 TLE (29.7 leads) to 42.4 TLE (69.7 leads). Baseline characteristics including age (62.4±14.7 vs. 61.9±17.4), gender (52.4% vs. 47.7% male), and infectious indications (33.6% vs. 35.4%) were similar (P >0.05 for all). With the transition to a HiV center, there was no significant change in complete procedural success (84.0% vs. 85.8%, P=0.73) and clinical success (94.4% vs. 96.1%, P=0.57). Major complications significantly decreased from 10/125 (8.0%) to 3/127 (2.4%) after the interventions in 2018 (P=0.049).Conclusions:Multidisciplinary improvements in pre-procedural risk stratification, scheduling, and technique resulted in a successful transition to a HiV TLE center with a reduction in major complications and a high procedural success rate.

Circulation, Volume 146, Issue Suppl_1, Page A10088-A10088, November 8, 2022. Electronic cigarettes (e-cigarettes) are advertised as a healthier alternative for combustible cigarettes and have become the most commonly used smoking product. There is limited data regarding the association of e-cigarettes and risk of cardiovascular disease (CVD). We assessed the association of chest pain reports across tobacco product use groups. We used data from the Population Assessment of Tobacco and Health (PATH) study which is a nationally representative longitudinal study of tobacco use behavior and health effects. We categorized tobacco use patterns into 4 groups: cigarette use, dual use, e-cigarette use, and non-use. Participants were asked if they have ever had chest pain and if they have had chest pain in the past 30 days. Binominal regression models were used to examine the association between tobacco use categories and the 2 chest pain outcomes. We adjusted for covariates including age, sex, race, education, BMI, hypercholesterolemia, hypertension, current use of other combustible tobacco products, secondhand smoke exposure, marijuana use in the past 30 days, recreational drug use and history of respiratory diseases. The cohort included 9,284 participants after excluding those with established CVD and those with missing outcome or exposure data. The Mean age was 57 (SD±11) years and 54% of participants were female. Among the participants, 3,020 were exclusive cigarette users, 213 were dual users, 175 were exclusive e-cigarette users (94% were former smokers), and 5,876 were non-users. Compared to non-use, combustible cigarette use had 1.48 (95% CI, 1.27, 1.73) odds of ever having chest pain and 1.72 (95% CI, 1.4, 2.11) odds of having chest pain in the past 30 days. Dual use was associated with 1.52 (CI 95%, 1.05, 2.19) odds of chest pain ever and 1.82 (95% CI, 1.17, 2.83) odds of 30 days chest pain. Exclusive e-cigarette use had 0.78 (95% CI, 0.49, 1.26) odds of ever having chest pain and 0.75 (95% CI, 0.39, 1.42) odds of having chest pain in the past 30 days. Our findings suggest that compared to non-use, exclusive e-cigarette use has similar rates of chest pain; whereas dual use and combustible cigarette use have increased rates of chest pain outcomes.

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)

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 A13156-A13156, November 8, 2022. Introduction:The presence of multiple high-risk prognostic features enhances risk-stratification of plaques prone to destabilization and major adverse cardiac events (MACE). Spatial superimposition of high-risk features (concordance) likely amplifies local risk. Local endothelial shear stress (ESS) and plaque structural stress (PSS) metrics predict MACE, but their spatial concordance and their location relative to the minimal lumen area (MLA) is unknown. If the highest-risk plaque area is distant from the MLA, then PCI of the MLA alone will leave high-risk plaque areas untreated.Purpose:To identify the site of high-risk features of low ESS and high PSS heterogeneity (HI) along the course of a plaque in patients who develop MACE, and the site of their spatial concordance relative to the MLA.Methods:We examined ESS, PSS, and PSS HI in 22 non-culprit lesions (NCL) leading to MACE, and 64 randomly selected control NCLs without MACE from the PROSPECT study. ESS was calculated by computational fluid dynamics and PSS by finite element analysis on co-registered lesions. We examined high-risk plaques with empirically-derived (ROC curve) ESS < 1.3 Pa and PSS HI > 0.29 in 16 lesions leading to future MACE, and 11 control lesions without MACE.Results:MACE outcomes were significantly more frequent in plaques with combined low ESS+high PSS HI vs plaques with low ESS alone (72.7% vs 27.3%, p

Circulation, Volume 146, Issue Suppl_1, Page A9539-A9539, November 8, 2022. Background:The potential association between lower bone mineral density (BMD) and atherosclerotic cardiovascular disease (ASCVD) has been suggested in women. We investigated whether the association between low BMD and ASCVD differs according to the age of ASCVD occurrence.Methods:We retrospectively analyzed 7,932 women aged 50-65 years who underwent dual-energy X-ray absorptiometry to measure total hip BMD. The primary outcome of interest was ASCVD, defined as a composite of ASCVD death, myocardial infarction, and ischemic stroke. Participants were classified into no event (n=7,803), early ASCVD (occured before 70 years of age) (n=97), and late ASCVD (occured at or after 70 years of age) (n=32) groups. The association of low BMD with early and late ASCVD was estimated using multivariate Cox hazard modeling after adjustment for clinical risk factors (age, body mass index, hypertension, diabetes, hyperlipidemia, current smoking, and previous fracture).Results:The median age increased across no event, early ASCVD, and late ASCVD groups (58, 60, and 63 years, respectively). However, the estimated BMD T-score at the age of 65 years was lowest in the early ASCVD group (median -0.9, -1.1, and -0.5, respectively). Lower BMD was an independent predictor for early ASCVD (adjusted hazard ratio [HR]: 1.34 per 1-SD decrease in T-score, 95% confidence interval [CI] 1.08-1.67), but not late ASCVD (adjusted HR: 0.88, 95% CI 0.60-1.30) (Figure). The inverse trend between early ASCVD risk and BMD T-score was consistent regardless of the number of accompanied clinical risk factors.Conclusions:Low BMD is an independent predictor for earlier ASCVD occurrence in women. BMD evaluation can provide prognostic benefit for risk stratification for earlier ASCVD occurrence.

Circulation, Volume 146, Issue Suppl_1, Page A12725-A12725, November 8, 2022. Introduction:Low serum albumin is a marker of protein malnutrition and is commonly associated with worse outcomes in various clinical settings. Furthermore, significant overlap exists between malnutrition and sarcopenia, which can be an independent predictor of worse outcomes.Hypothesis:We assessed the hypothesis that the presence of sarcopenia with low albumin (SLA) would lead to synergistically worse outcomes in patients with acute decompensated heart failure (ADHF).Methods:Patients hospitalized for ADHF from 2017 to 2019 with computed tomography of the abdomen/pelvis within 30 days and albumin level within 24 hours before discharge were studied (n=181). Given the high prevalence of hypoalbuminemia, low albumin was defined as the lower fiftieth percentile. Semi-automatic measurements of skeletal muscle area were made at L3 (Figure 1A) and adjusted using height squared to obtain skeletal muscle index (SMI). Sarcopenia was defined as the lowest sex-stratified SMI tertile.Results:The prevalence of sarcopenia alone was 11.6%, low albumin alone 28.7%, and SLA 20.4%. The groups had similar demographics but differed in BMI (lowest in sarcopenia alone, p

Circulation, Volume 146, Issue Suppl_1, Page A10116-A10116, November 8, 2022. Introduction:The relationship between low body mass index (BMI) and prognostic factors for patients with coronary artery disease, commonly observed in elderly individuals in Japan, is important. Few studies have evaluated the prognosis for patients with low BMI after percutaneous coronary intervention (PCI). We analyzed the risk associated with low BMI for patients after PCI using a multivariable-adjusted model and data from a prospective cohort registry.Methods:This prospective, multicenter registry included 5965 consecutive patients with coronary artery disease who underwent successful PCI. The patients were followed-up clinically for up to 3 years or until the occurrence of major adverse cardiac events. The primary endpoint was defined as a composite of all-cause death and nonfatal myocardial infarction.Results:During the follow-up period, primary events occurred in 639 (10.7%) patients. A risk analysis of the primary endpoint adjusted for the multivariable model showed a significant increase in risk for elderly individuals, underweight individuals[HR 1.43 (95% CI, 1.10-1.85),P< 0.001], those with diabetes mellitus (DM), peripheral artery disease, low left ventricular ejection fraction or acute coronary syndrome (ACS), and smokers. A stratified adjusted risk analysis based on BMI levels showed that the risk associated with underweight status was significantly pronounced for male patients, those aged 60-74 years, those with DM or ACS.Conclusions:Underweight patients with several risk factors were at significantly increased risk after PCI. Furthermore, the risk associated with low BMI was significantly more pronounced for men, individuals aged 60-74 years, patients with DM or ACS.

Circulation, Volume 146, Issue Suppl_1, Page A12816-A12816, November 8, 2022. Introduction:High-sensitivity cardiac troponin (hs-cTn) laboratory assays are used to rule out myocardial infarction (MI) on presentation, but prolonged result turn-around times can delay patient management.Hypothesis:Our aim was to identify patients at low risk of index MI using a rapid, point of care (POC), whole blood hs-cTnI assay at presentation, with potential early patient discharge, with99% for index MI, was derived (SEIGE) and validated using plasma (SAMIE). Event adjudications were established using hs-cTnI assay results from usual clinical care. The primary outcome was MI at 30-days.Results:1086 patients (8.1% MI) were enrolled in a US derivation cohort (SEIGE) and 1486 (5.5% MI) in an Australian validation cohort (SAMIE). A derivation whole blood POC hs-cTnI concentration of

Circulation, Volume 146, Issue Suppl_1, Page A11734-A11734, November 8, 2022. Introduction:Chest pain is common in patients with Post-acute Sequelae of SARS-CoV-2 (PASC), also known as long COVID, but the mechanism is unknown.Hypothesis:We hypothesized that PASC patients with chest pain have impaired myocardial perfusion reserve (MPR) measured by stress perfusion cardiovascular magnetic resonance (CMR) imaging.Methods:We retrospectively identified the first 30 consecutive patients who underwent clinically ordered adenosine stress perfusion CMR for chest pain persisting >4 weeks after SARS-CoV-2 infection (PASC). Patients with a history of coronary artery disease (CAD) or left ventricular ejection fraction (LVEF) 2 SD below mean MPR for controls.Results:In 30 PASC (67% female, age 43±13) and 13 controls (54% female, age 50±12), with LVEF (61±6% vs 59±8%), native T1 (1001±49 vs 992±57 ms), T2 (49.5±3.7 vs 48.0±3.3 ms), and ECV (24.6±2.9 vs 24.6±2.6%) were similar (p >0.2 for all). Prior pericarditis (n=2) or prior myocarditis (n=3) were infrequent, with no acute disease by CMR. PASC patients had significantly lower global MPR than controls (1.54±0.25 vs. 2.20±0.36, p

Circulation, Volume 146, Issue Suppl_1, Page A13323-A13323, November 8, 2022. Introduction:Acute heart failure is associated with higher post-discharge mortality, especially in low-middle income countries (LMIC). There are limited studies on adherence to the recommended post-discharge care guidelines in these settings. The study assessed adherence to the 2020 ACC/AHA inpatient heart failure performance and quality measure in Gaza Strip, Palestine.Methods:The study was a cross-sectional survey study. We chose a stratified random sample from the three different geographical areas across Gaza Strip with numbers proportional to the size of each region. Patients selected were adults ( >18 years) admitted to the various hospitals for acute decompensated heart failure between 4/2021 and 12/2021. We collected data through chart review. Measures were β blockers, ACEi/ARB and MRA prescription, and outpatient follow-up. Results reported as proportion with 95% CI.Results:The sample size was 155 patients. The mean age was 64 years. 59% were males. The mean length of stay was 2.8 days. β blockers were prescribed to 85.1% [79.5,90.8] of patients. For ACEi/ARB use, it was 42.7% [34.9,50.5]. For MRA, after excluding ineligible patients, it was prescribed in 48.5% [39.9, 57.2]. None of the patients were prescribed hydralazine/nitrate. Only 30.1% [ 23.6, 38.1] of patients had an outpatient appointment. The median time between discharge and appointment date was 22 days. Only 9.7% [5.0,14.3] of patients were discharged with all quality measures fulfilled.Conclusions:There are considerable gaps in the post-discharge care of heart failure patients in the Gaza Strip. There is a need to develop local care guidelines to improve care.

Circulation, Volume 146, Issue Suppl_1, Page A11394-A11394, November 8, 2022. Introduction:Chest pain is a common presentation in the emergency department and physician office visits. Identifying coronary artery disease (CAD) as the cause of chest pain is essential for improving prognosis. The 2021 AHA/ACC guidelines do not advocate for testing in patients with low pretest probability (PTP