Risultati per: Malattia Arteriosa Periferica (PAD) - Indicazioni su diagnosi e gestione

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Endocrinologi, 16 anni di vita in meno senza gestione ottimale

Circulation, Volume 148, Issue Suppl_1, Page A16398-A16398, November 6, 2023. Background:Rivaroxaban 2.5 mg BID reduced major adverse limb events (MALE) and total vascular events in patients with symptomatic peripheral artery disease (PAD) after lower extremity revascularization (LER) in VOYAGER PAD. The safety and efficacy of rivaroxaban on MALE and total vascular events in fragile patients with PAD has not been described.Hypothesis and Methods:Patients were categorized as fragile based on prespecified criteria (age > 75 years or weight ≤ 50 kg or baseline eGFR < 50 mL/min). MALE was defined as composite of acute limb ischemia (ALI) and major amputation. Total vascular events include cardiovascular, MALE, peripheral revascularizations and venous thromboembolism events. Same-day vascular events are consolidated into a single event. The main safety outcome was TIMI major bleeding.Results:A total of 1,669 (25%) subjects of 6,564 randomized were categorized as fragile at baseline. Rivaroxaban reduced the risk of MALE particularly in fragile (HR 0.56; 95% CI 0.38 - 0.81) vs non-fragile patients (HR 0.82; 95% CI 0.67 - 1.00, p-interaction 0.07, figure upper panel) with the benefits in fragile patients driven by reduced ALI (HR 0.47; 95% CI 0.30 - 0.75). Rivaroxaban reduced the occurrence of total vascular events at 3 years in fragile patients with absolute rates of 82.1 events/100 patients on rivaroxaban vs 99.3 events/100 patients on placebo (HR 0.81; 95% CI 0.68 - 0.98). Similar benefit was seen in non-fragile patients 70.4 events/100 patients on rivaroxaban vs 81.6 events/100 patients on placebo, HR 0.90; 95% CI 0.81-1.00 (figure, lower panel). Rivaroxaban increased TIMI major bleeding similarly in fragile (HR 1.66; 95% CI 0.87 - 3.19) and non-fragile (HR 1.37; 95% CI 0.83 - 2.24, p-interaction 0.65).Conclusions:In a high-risk PAD population rivaroxaban reduces MALE and total vascular events and increases bleeding regardless of fragile status. These data may assist in personalization of antithrombotic therapy in this high-risk population.

Circulation, Volume 148, Issue Suppl_1, Page A14729-A14729, November 6, 2023. Introduction/Background:Acute limb ischemia (ALI) is a severe complication of peripheral artery disease. Lipid lowering and antithrombotic therapies reduce ALI but pathologic studies have described thrombus in distal arteries without plaque, suggesting that artery to artery embolism from proximal (aortic-iliac) athero-thrombosis may be a key driver.Research Questions/Hypothesis:We hypothesized that the burden and character of atherosclerosis in the iliac arteries of patients with PAD would be associated with long term risk of ALI.Methods:VOYAGER PAD enrolled 6,554 patients with PAD and collected 2,200 baseline angiograms in 1,664 patients including 400 CT angiograms enabling plaque characterization. A case-control of 9 who had ALI during follow up and 9 controls were matched on anatomic and patient characteristics, type of index revascularization and disease pattern. Images were read by a blinded, independent imaging core lab.Results/Data:Of the 9 ALI cases, 45% had iliac artery occlusion and 55% had distal artery occlusion. Plaque characteristics were different in cases relative to controls including significantly greater non-calcified plaque volume (OR 2.36, 95% CI 1.05 – 9.38, p=0.03) as well as similar trends for low attenuation plaque (OR 1.65, 95% CI 0.89 – 4.72, p=0.05), and plaque burden (OR 1.16, 95% CI 1.00 – 1.25, p=0.03, Figure). In patients who experienced ALI, there was a trend for greater non-calcified plaque in the limb that experienced the ALI relative to the contra-lateral limb (index 7.2 vs contra-lateral 5.4, p=0.08).Conclusions:In a case-control series, total non-calcified plaque volume and overall plaque burden in the iliac arteries were associated with future ALI over 3 years. Based on the observations in this case-control, we are now analyzing plaque and outcomes in the full cohort. These data are hypothesis generating and suggest that plaque characteristics may be associated with ALI and may serve a surrogate marker of risk.

Circulation, Volume 148, Issue Suppl_1, Page A16428-A16428, November 6, 2023. Background:Patients with peripheral artery disease (PAD) are at heightened risk of major adverse cardiovascular events (MACE). In VOYAGER PAD, rivaroxaban 2.5 mg BID reduced ischemic risk in PAD patients after lower extremity revascularization (LER). Whether the benefits for MACE and in particular for Myocardial Infarction (MI) differ in those with and without clinically known coronary artery disease (CAD) has not been described.Hypothesis and Methods:VOYAGER PAD randomized patients with symptomatic PAD undergoing LER to rivaroxaban 2.5 mg BID plus aspirin versus aspirin alone. MACE was defined as composite of MI, ischemic stroke, or cardiovascular death. Subtypes of MI were adjudicated according to the Universal Definition. Comorbid CAD was a prespecified subgroup.Results:Of 6,564 symptomatic PAD randomized, 2,083 (32%) had documented CAD at baseline. The benefit of rivaroxaban plus aspirin was greater for MACE in those with vs without CAD (HR 0.79, 95% CI 0.62 – 1.00 vs HR 1.12, 95% CI 0.92 – 1.36; p-interaction 0.03). Similarly, MI reduction with rivaroxaban plus aspirin was greater for those with vs without CAD (HR 0.78, 95% CI 0.56 – 1.10 vs HR 0.96, 95% CI 0.69 – 1.34; p-interaction 0.39). Considering MI subtypes, the effect of rivaroxaban plus aspirin on type 1 MI was consistent in patients with CAD (HR 0.91, 95% CI 0.58 – 1.42) and without CAD (HR 0.74, 95% CI 0.74 – 1.11, p-interaction 0.50). However, a trend towards benefit of rivaroxaban plus aspirin was seen for Type 2 MI in those with CAD (HR 0.71, 95% CI 0.41 – 1.24) but not in patients without CAD (HR 1.66, 95% CI 0.89 – 3.09, p-interaction 0.0475, figure). Type 4 MI was infrequent regardless of CAD.Conclusions:Rivaroxaban plus aspirin had consistent effects in MACE for PAD and CAD patients undergoing LER. Our analysis of MI subtype suggests that events adjudicated as MI due to supply demand mismatch (Type 2) may have a thrombotic component and are lowered with rivaroxaban and aspirin in PAD and CAD patients undergoing LER.

Circulation, Volume 148, Issue Suppl_1, Page A11450-A11450, November 6, 2023. Introduction:Several policies exist that incentivize improved care coordination. Reintervention care fragmentation (when a patient requires a reintervention at another facility that is different than the index facility) for peripheral artery disease (PAD) has not been well-characterized. The intent of this work is to explore the frequency, characteristics, and differences in outcomes for patients when a vascular reintervention occurs at a non-index facility.Methods:National cohort of adults over age 65 who underwent an endovascular procedure for PAD within the Vascular Quality Initiative between January 1, 2010 to December 31, 2018 and had subsequent vascular reintervention. Data was linked to Medicare claims and American Hospital Association. We excluded emergency procedures, those performed for aneurysm, and those performed in an office-based setting. The primary outcomes were 90-day and 180-day amputation. Covariates of interest included sociodemographic, anatomic, procedural, and facility-level characteristics. Mixed effect logistic regression models (clustered at the facility-level) were used to determine the association between reintervention at an index versus non-index facility and the outcomes of interest.Results:Among 4,470 patients who underwent a vascular reintervention after an index endovascular procedure for PAD, 18.1% had their reintervention performed at a non-index facility. There were no differences noted by sex or level of community distress among those who went to the index facility versus a non-index facility for their vascular reintervention. Compared to those who had their reintervention at an index facility, vascular reintervention at a non-index facility was associated with significantly higher likelihood of major amputation (90-d amputation: Odds Ratio (OR) 1.61 [95% Confidence Interval (CI) 1.08-2.39]; 180-day amputation: OR 1.75 [95% CI 1.14-2.70]).Conclusions:Care fragmentation for patients who require vascular reintervention after an index endovascular PAD procedure is associated with higher risk of amputation. Additional work is needed to better understand which patients are at greatest risk for care fragmentation and how to better coordinate care in the post-procedural setting.

Circulation, Volume 148, Issue Suppl_1, Page A17200-A17200, November 6, 2023. Introduction:Atherosclerotic peripheral artery disease (PAD) leads to a great burden of cardiovascular and limb-related morbidity and mortality in African Americans (AA) compared to White Americans. Medical center partnerships with churches may be an effective method to improve PAD awareness and detection in the AA community.Hypotheses:We hypothesized that implementing a medical educational program in partnership with churches would increase PAD familiarity and identify participants with undiagnosed PAD.Aims:To determine (1) PAD familiarity before and after a one-time educational intervention and (2) the prevalence of PAD in older, church-going Nashville residents.Methods:Using a community-engaged research (CER) model, we partnered with 5 churches to enroll participants ≥ 50 years of age. Participants were given a 16-point pre- and post-educational program assessment to determine baseline and post-intervention PAD knowledge. Pre- and post-intervention scores were compared using Wilcoxon signed-rank test. Ankle-brachial index (ABI) testing was used to screen for PAD (ABI < 0.9).Results:We enrolled 120 participants (mean age [SD]: 64.67 [8.33] years, 74% women, 80% AA). The prevalence of PAD was 10.83%. Pre-intervention PAD awareness was low (mean score (MS): 10.89 [4.24]) and improved significantly post-intervention in all participants (MS: 13.88 [2.76; p=2 x 10-12). Participants without PAD (ABI ≥ 0.9-1.39) (MS: 10.81 [4.28] vs. 13.91 [2.79]; p= p=4 x 10-11) and with indeterminate status (ABI >1.4) (MS [SD]: 10.00 [5.03] vs. 14.10 [1.73; p=0.01) showed significant improvement in PAD awareness pre vs post intervention. Participants with PAD (ABI

Circulation, Volume 148, Issue Suppl_1, Page A14010-A14010, November 6, 2023. Background:Cardiovascular benefits of 2.5 mg twice daily rivaroxaban plus aspirin therapy (RIV+ASA) has been demonstrated in patients with arterial diseases.Hypothesis:RIV+ASA is associated with reduced platelet activation and plasma inflammation and coagulation activation markers in patients with CAD and/or PAD who were on ASA.Methods:In this open-label biomarker study, patients on 81 mg/day ASA were randomized to continue ASA or RIV+ASA for 12 weeks. We assessed ADP-, α-thrombin-, and tissue factor-induced platelet aggregation (PA) using conventional aggregometry, platelet-fibrin clot strength (PFCS) by INTEM (intrinsic pathway activator) and EXTEM (extrinsic pathway activator) using thromboelastometry, shear-induced PA by platelet function analyzer-100, D-dimer and fibrinogen using coagulation analyzer, hs-CRP and interleukin-6 using ELISA method at baseline, and four weeks and 12 weeks post-randomization.Results:Data was available in 9 patients with RIV + ASA and ten patients with ASA-only therapy. Most patients were male, Caucasians, obese and older. There were no differences in baseline demographics, medications, and laboratory values between groups, except patients in RIV + ASA group had higher white blood cell counts (p=0.028) and lower baseline 2uM ADP-induced PA (p=0.03). There were no differences in other laboratory measurements between baseline and post-randomization time points within the group or at 4- and 12-week time points between groups, except D-dimer values were significantly lower at 12 weeks (p=0.038) in the RIV + ASA vs. ASA-only group. No significant adverse events were observed.Conclusions:Twelve weeks of rivaroxaban plus aspirin vs. aspirin was associated with similar levels of platelet aggregation, platelet fibrin clot strength, fibrinogen and inflammation markers, and lower d-dimer levels.

Circulation, Volume 148, Issue Suppl_1, Page A311-A311, November 6, 2023. Introduction:Out-of-hospital cardiac arrest (OHCA) victims receiving defibrillation from an automated external defibrillator (AED) placed early in the chain of survival are more likely to survive.Aim:We sought to explore the accuracy of AED pad placement for lay rescuers (LR) and first responders (FR).Methods:We conducted a secondary analysis of data collected during randomized OHCA simulation trials involving LR and FR. LR received hands-only CPR and AED guidance from a simulated 9-1-1 telecommunicator. FRs did not receive telecommunicator instruction. Participants were surveyed about medical training and experience. Correct AED pad placements (anterior: AP, lateral: LP) were individually determined from video abstraction based on manufacturer’s recommendations and distance to anatomical landmarks (mid, nipple, and naval lines). Incorrect AP placement was defined as more than 6 cm medial or 10 cm inferior. Incorrect LP placement was defined as more than 6 cm superior, 9 cm inferior, or 10 cm medial. We examined the association between correct pad placement and previous CPR training (current, expired, or never) for LR and correct pad placement and self-reported recent field experience (< 1 year) with AED application for FR using Chi-square tests.Results:LR correctly placed the AP in 30/38 (79%) and the LP 30/38 (79%) simulations. Application did not differ significantly based on previous CPR training (AP p= .187, LP p=.578). The most common incorrect placement was too low for both AP (5/8, 63%) and LP (4/8, 50%). FRs applied the AP correctly in 31/36 (86%) and the LP in 22/36 (61%) simulations. Among FRs, correct pad application did not differ significantly based on recent field experience (AP p=.29, LP p=.563). The most common incorrect placement was too low for both AP (5/5, 100%) and LP (12/14, 86%).Conclusion:Both LRs and FRs may not apply AEDs per manufacturer’s recommendations. Further research is needed to improve instructions and follow-up training to ensure appropriate placement of AEDs, and to understand how improper AED placement impacts the accuracy of rhythm analysis and defibrillation success.

Circulation, Volume 148, Issue Suppl_1, Page A16776-A16776, November 6, 2023. Introduction:Peripheral artery disease (PAD) and chronic kidney disease (CKD) are common comorbidities in patients with heart failure (HF). Importantly, CKD is associated with a greater risk of incident PAD and is a known risk factor for worse outcomes in HF patients. However, it is unclear whether the concomitant existence of PAD and CKD increases the risk of recurrent hospitalization for acute decompensated heart failure (ADHF).Methods:Since 2005, the Atherosclerosis Risk in Communities (ARIC) study has conducted hospital surveillance of ADHF with events verified by physician review. Demographics, comorbidities, laboratory data, and medications were abstracted from medical record by trained personnel. Hazard ratios of ADHF readmissions were analyzed using repeat-events Cox regression. Models were adjusted for age, race, sex, year and hospital of admission, coronary artery disease (CAD), COPD, and diabetes mellitus. CKD was defined by glomerular filtration rate [GFR] ≤60 mL/min/1.73m2.Results:From 2005-2018, there were 1049 index hospitalizations for ADHF (mean age 77 years, 66% white) with measured creatinine, who were discharged alive. Of these, 155 (15%) had a diagnosis of PAD and 66% had CKD stage 3a or worse (GFR ≤60 mL/min/1.73m2). Patients with PAD had a greater prevalence of smoking, CAD, myocardial infarction, and stroke. The 1-year ADHF readmission rate tended to be higher in patients with PAD, irrespective of CKD stage, compared to those without PAD (Figure 1). After adjustments, PAD was associated with greater hazards of 1-year ADHF readmissions, both in patients with CKD stage 3a or worse (HR, 1.71; 95% CI: 1.25 – 2.32) and without CKD (HR, 1.84; 95% CI: 1.07-3.15).Conclusion:Patients with ADHF and concomitant PAD have a higher prevalence of cardiovascular comorbidities and higher likelihood of 1-year ADHF readmission, irrespective of the CKD status. Focused strategies to prevent ADHF readmission in this high-risk group are warranted.

Circulation, Volume 148, Issue Suppl_1, Page A220-A220, November 6, 2023. Background:Ventricular fibrillation (VF) or ventricular tachycardia (VT) are the most treatable causes of out-of-hospital cardiac arrest (OHCA). Yet, it remains unknown if defibrillator pad position, placement in the anterior-posterior (AP) or anterior-lateral (AL) positions, impacts patient outcomes in VF/VT OHCA.Aim:Evaluate the association between initial defibrillator pad placement (AP vs. AL) and OHCA outcomes for patients presenting with VF/VT.Methods:This was a prospective observational study of non-traumatic OHCA patients with initial VF/VT on EMS rhythm analysis treated by a single EMS agency in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry) from July 1st, 2019 through October 15th, 2022. Our primary outcome was return of spontaneous circulation (ROSC) at any time and secondary outcomes were ROSC at emergency department (ED) arrival, survival to admission, survival to discharge, and functional survival (cerebral perfusion category score of ≤2). We performed t-tests, chi-squared tests, and multivariable logistic regressions adjusting for age, sex, witness status, bystander interventions, arrest location, 911 call to EMS arrival time, and year of arrest.Results:A total of 243 OHCA patients met inclusion criteria and 232 (95.5%) had initial pad positioning documented (133 AP and 99 AL). Patients with AP placement had higher rates of ROSC at any time (72.2% vs. 47.5%, p

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