Risultati per: Colite ulcerosa negli adulti: review

Circulation, Volume 146, Issue Suppl_1, Page A13952-A13952, November 8, 2022. Introduction:Studies evaluating trends in the incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease admitted to the intensive care unit (ICU) are rare. Additionally, there is limited information on factors associated with IHCA and mortality.Hypothesis:We hypothesized that the incidence of IHCA and the mortality rate in cardiac children admitted to the ICU has significantly decreased over time.Methods:We conducted a systematic review of PubMed, Web of Science, EMBASE, and CINAHL from inception to Sept 2021. Random effects meta-analysis was used to compute pooled-proportions and pooled-ORs. Meta-regression adjusted for type of study (registry vs cohort) and diagnostic category (surgical vs general cardiac) was used to evaluate trends in incidence and mortality.Results:Of the 2,574 studies identified, 25 were included in the systematic review (126,087 patients), 18 in the meta-analysis. Five percent (95% CI: 4-7%) of ICU children experienced IHCA and 35% (95% CI: 27-44%) did not achieve ROSC. In centers with ECMO, 21% (95% CI: 15-28%) underwent ECPR. The pooled in-hospital mortality was 54% (95% CI: 47-62%). Both incidence of IHCA and in-hospital mortality decreased significantly in the last 20 y (p

Circulation, Volume 146, Issue Suppl_1, Page A9736-A9736, November 8, 2022. Introduction:Catheter placement and stability are well-known challenges in atrial fibrillation (AF) ablation. As a result, steerable sheaths were developed to improve catheter stabilization and maintain proper catheter-tissue contact. The purpose of this systematic review and meta-analysis is to see if employing a steerable sheath influences procedure outcome.Method:We performed a comprehensive literature search for studies that evaluated the efficacy and safety of Steerable Sheaths (SS) compared to Non-Steerable Sheaths (NSS) in AF ablation. The primary outcome was the rate of atrial arrhythmia (AA) freedom by the time of the last follow-up. The secondary outcomes were the procedure-related complications and procedural characteristics. Risk ratio (RR) or the mean difference (MD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model.Results:A total of 10 studies, including 967 AF patients (mean age: 59.2±11.1 years, 516 patients managed with SS vs. 454 with NSS), were included. SS group showed a higher rate of freedom of AA compared to NSS (RR: 1.19; 95% CI 1.09, 1.29; P < 0.001). Both techniques had similar rate for procedural-related complication (RR: 1.09, 95% CI 0.50, 2.39; P = 0.83). The SS strategy had a shorter procedure time (MD -10.6 (min.), 95% CI -20.97, -0.20; P = 0.05) but comparable fluoroscopic and radiofrequency application times to the NSS group.Conclusions:The steerable sheaths for AF catheter ablation not only reduced the total procedure time but also significantly increased the rate of successful ablation while maintaining a similar safety profile when compared to the traditional non-steerable sheaths.

Circulation, Volume 146, Issue Suppl_1, Page A11139-A11139, November 8, 2022. Introduction:Trials evaluating the role of esophageal cooling in the prevention of esophageal injury in patients undergoing atrial fibrillation (AF) catheter ablation have yielded mixed results. The aim of our study is to evaluate the efficacy of esophageal cooling in the prevention of esophageal injury in patients undergoing AF catheter ablation.Methods:Comprehensive search of MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) evaluating the role of esophageal cooling compared with control in the prevention of esophageal injury during AF catheter ablation. The study’s primary outcome was the incidence of total esophageal injury. Secondary outcomes included the incidence of severe esophageal injury, the incidence of mild to moderate esophageal injury, procedural duration, posterior wall duration, total radiofrequency (RF) time, acute reconnection incidence, and ablation index.Results:The meta-analysis included 4 RCTs with total of 294 patients. There was no significant difference in the incidence of total esophageal injury between esophageal cooling and control (15% vs. 19%; Relative Risk [RR] 0.86; 95% confidence interval [CI] 0.31 – 2.41; I2= 63%). However, compared with control, esophageal cooling showed lower risk of severe esophageal injury (0.01% vs. 0.09%; RR 0.21; 95% CI 0.05 – 0.80). There were no significant differences among the two groups in mild to moderate esophageal injury (13.6% vs. 12.1%; RR 1.09; 95% CI 0.28 – 4.23), procedure duration (standardized mean difference [SMD] -0.03; 95% CI -0.36 – 0.30), posterior wall duration (SMD 0.27; 95% CI -0.04 – 0.58), total RF time (SMD -0.50; 95% CI -1.15 – 0.16), acute reconnection incidence (RR 0.93; 95% CI 0.02 – 36.34), and ablation index (SMD 0.16; 95% CI -0.33 – 0.66).Conclusions:Among patients undergoing AF catheter ablation, esophageal cooling did not show a significant difference in the incidence of total esophageal injury. However, it has shown a significant decrease in the risk of severe esophageal injury without affecting the ablation process. This can help decrease the progression to atrial-esophageal fistula. Further large RCTs are needed to better evaluate the role of esophageal cooling in the prevention of esophageal injury.

Circulation, Volume 146, Issue Suppl_1, Page A11823-A11823, November 8, 2022. Background:Besides hard medical outcomes in patients with inherited cardiac conditions (ICC). it is crucial to focus on the patient-reported outcomes (PRO) as well. These patients may have a disease-specific need due to ICC-related distress concerning family members and reproductive choices. We evaluated which PRO scales are currently used in cardiogenetics.Methods:From three datasets (PubMed, PsychINFO, and Web of Science), eligible studies published between 2008-2022 were selected as described in the review protocol (PROSPERO 2021 CRD42021271384). The quality of studies was assessed (https://pubmed.ncbi.nlm.nih.gov/27082055 ) and analyzed for the primary outcome variable of patient-reported outcomes.Results:Eighteen out of 232 articles were selected for data extraction; 9 studies used a cross-sectional design, and population characteristics and outcome measures varied. The risk of bias was high or unclear in 77% of the studies. All studies mainly used two questionnaires in combination or alone: the short form of medical outcomes survey (SF-36), a generic PROM that reports on health status and the Hospital Anxiety and Depression Scale (HADS), a standard measure of psychological well-being. Thirteen studies using SF-36 showed lower scores on the mental health component in patients with ICC versus population norms. Ten studies using HADS showed a prevalence of clinically significant anxiety (17-47%) and depression (8.3% to 28%) which are higher than the population norm (8.3% and 6.3%).Conclusion:Our results from only a few published studies indicate that although psychological morbidity in ICC patients is high, measurements are non-specific, variable, and generic and address overall health, instead of addressing factors specific to ICC, such as heritability. We propose to develop a disease-specific PROM for cardiogenetics to evaluate the heritability factor in patients with ICC to implement in the care pathway and optimize patient-centred care.

Circulation, Volume 146, Issue Suppl_1, Page A11195-A11195, November 8, 2022. Introduction:The safety and clinical outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among solid organ transplant patients are not well documented.Objective:This study aimed to evaluate the clinical outcomes of TAVR and SAVR among patients with a history of solid organ transplantation.Method:We performed a systematic literature search of databases for relevant articles from inception until April 20, 2022.Result:A total of 342 studies were identified, resulting in 7 studies with a total of 6,128 patients included in the final analysis. The odds of in-hospital mortality (OR 0.29, 95% CI 0.16-0.52, p < 0.0001), blood transfusion (OR 0.30, 95% CI 0.22-0.40 p < 0.00001), postoperative bleeding (OR 0.40, 95% CI 0.33-0.48 p < 0.00001), acute kidney injury (OR 0.50, 95% CI 0.38-0.67 p < 0.00001), and sepsis or infection (OR 0.37, 95% CI 0.25-0.56, p < 0.00001) were significantly lower in patients undergoing TAVR compared to SAVR. Permanent pacemaker implantation was significantly higher in patients who underwent SAVR (OR 2.96, 95% CI 1.98-4.44, p =

Circulation, Volume 146, Issue Suppl_1, Page A15459-A15459, November 8, 2022. Introduction:Heart failure with preserved ejection fraction (HFpEF) is a common condition with one of its characteristics being exercise intolerance, which contributes to poor quality of life and clinical outcomes. High-intensity interval training (HIIT) is an innovative training approach, but its impact on patients with HFpEF is uncertain. We pooled data from all relevant studies reporting results of HIIT versus moderate continuous training (MCT) on cardiopulmonary exercise outcomes in patients with HFpEF.Methods:PubMed and SCOPUS were queried until February, 2022 for all randomized controlled trials (RCT) comparing the effects of HIIT versus MCT on outcomes such as peak oxygen consumption (peak VO2), respiratory exchange ratio (RER), and minute ventilation / carbon dioxide production (VE/CO2) > slope. A random-effects model was used and weighted mean differences (WMDs) were reported with 95% confidence intervals (CI). Heterogeneity across studies was evaluated using the HigginsI2statistic.Results:Three RCTs (n = 150) were included in our analysis. The mean training duration was 23 weeks (range: 4 – 52 weeks). Pooled analysis demonstrated that HIIT significantly improved peak VO2(WMD = 1.46 mL.kg-1.min-1(0.88, 2.05);p

Circulation, Volume 146, Issue Suppl_1, Page A15605-A15605, November 8, 2022. Introduction:Cardiologists face an increased risk of medical professional liability (MPL) claims compared to physicians overall throughout their careers. Simultaneously, male physicians are over twice as likely to encounter medicolegal litigation than female physicians. Understanding the distribution of MPL claims across cardiologist demographics is vital to identify high risk areas and improve quality of patient care. Thus, we aimed to characterize current literature on the inclusion of demographic data in medicolegal cases against cardiologists.Methods:Searches were performed in the PubMed database. An initial search using a combination of the terms “cardiologist,” “cardiology,” “cardiac,” and “malpractice” yielded 802 results. Studies were screened by title and abstract for 1) relevance and 2) acquisition of data from a legal or insurance database. Data was manually extracted from eligible studies and categorized into 18 legal and demographic fields.Results:After applying eligibility criteria, 21 studies were analyzed. Comparison of key variables revealed an underrepresentation of cardiologist demographic data compared to patient data (Table 1). While two-thirds of medicolegal studies in cardiology described patient gender, no studies included gender of the defending cardiologist. Similarly, though two-thirds of studies mentioned patient age, none included cardiologist age. There was no mention of patient or cardiologist race in any of the 21 studies reviewed.Conclusion:In conclusion, knowledge of gender- and race-specific litigation patterns against cardiologists is absent from literature. Despite descriptions of patient characteristics, current studies on the medicolegal landscape of cardiology ignore key cardiologist variables. Incorporating demographics of prosecuted cardiologists could help elucidate the role of gender and race in medicolegal cases, minimize litigation risk, and enhance patient care outcomes.

Circulation, Volume 146, Issue Suppl_1, Page A15577-A15577, November 8, 2022. Introduction:Despite the increasing rate of hypertensive emergency (elevated blood pressure with acute target organ damage) presentations in the emergency department (ED), subsequent morbidity and mortality data to support clinical decision making remains scarce. We aim to study the prevalence and prognosis of hypertensive emergencies and hypertension mediated organ damage (HMOD) in patients presenting to the ED.Methods:PubMed and Scopus were queried from their inception through the mid of November 2021. Studies were included if they reported the prevalence or prognosis of hypertensive emergencies in patients presenting to the ED. Data from each study was arcsine-transformed and pooled using a random-effects model.Results:Fourteen studies (n = 4370 patients) were included in our analysis. Pooled analysis demonstrates that the prevalence of hypertensive emergencies was 0.5% (95% CI: 0.40 – 0.60) in patients presenting to ED. Ischemic stroke 28.1% (95% CI: 18.7 – 38.6), was the most prevalent HMOD, followed by pulmonary edema/acute heart failure 24.1%, (95% CI: 19.0 – 29.7, hemorrhagic stroke 14.6%, (95% CI: 9.9 – 20.0), acute coronary syndrome 10.8%, (95% CI: 7.3 – 14.8), renal failure 8.0%, (95% CI: 2.9 – 15.5), subarachnoid hemorrhage 6.9%, (95% CI: 3.9 – 10.7), encephalopathy 6.1%, (95% CI: 1.9 – 12.4), and the least prevalent was aortic dissection 1.8%, (95% CI: 1.1 – 2.8) (Figure). Mortality rate among patients admitted to the hospital due to hypertensive emergency was 9.9% (CI: 1.4 – 24.6).Conclusions:Our findings demonstrate substantial morbidity and mortality amongst patients presenting to the ED with hypertensive emergency. Results of studies may help clinicians identify organs at highest risk of damage in patients with hypertensive emergency, aiding the work-up and therefore helping curb the burden of this disease.

Circulation, Volume 146, Issue Suppl_1, Page A11962-A11962, November 8, 2022. Introduction:The cardiopulmonary exercise testing (CPET) has been proved to be a good tool in prognostic stratification of HFrEF and HFpEF, but its value in cardiac amyloidosis (CA) is uncertain. With the increasing knowledge and clinical suspicion toward CA, the growing prevalence of the disease, and the current availability of disease-modifying drugs, prognostic stratification is becoming fundamental to optimise the cost-effectiveness of treatment, patient follow-up and management.Hypothesis:We investigate the association of VO2max and VE/VCO2 slope with prognosis in patients with CA.Methods:We performed a systematic review following the PRISMA guidelines. Electronic databases (MEDLINE, Biomed Central, and Cochrane Library) were searched for clinical trials performing CPET for prognostication in transthyretin and light-chain CA patients. Studies reporting Hazard Ratio (HR) for mortality and VO2 max or VE/VCO2 slope (1-unit increase) were further selected for quantitative analysis. After logarithmic transformation, HRs were pooled using a random-effect model.Results:Five studies were selected for qualitative analysis and 3 for the quantitative analysis. A total of 233 patients were included in the meta-analysis, 127 (55%) with transthyretin and 106 (45%) with light-chain CA. Mean VO2 max in each trial was consistently depressed, ranging from a mean of 14.5 ± 4.5 mL/kg/min to 15.2 ± 10 mL/kg/min. On the other side, the VE/VCO2 slope ranged from a mean of 30 ± 3.0% to 41.3 ± 9.7%. Our pooled analysis shows that VO2 max (pooled HR 0.89, 95%CI 0.84-0.94) and VE/VCO2 slope (pooled HR 1.04, 95%CI 1.01-1.07) are significantly associated with the risk of death in CA patients, with no significant statistical heterogeneity for both analyses.Conclusions:CPET is a valuable tool for prognostic stratification in CA, identifying patients at increased risk of death. Large prospective clinical trials are needed to confirm this exploratory finding.

Circulation, Volume 146, Issue Suppl_1, Page A11149-A11149, November 8, 2022. Background:the practice of pretreatment with oral P2Y12inhibitors in ST-Elevation Myocardial Infarction (STEMI) remains common; however, its association with improved cardiovascular outcomes is unclear, since no large RCT has addressed this issue.Hypothesis:We aimed to evaluate the association of oral P2Y12 inhibitor pretreatment in STEMI patients with cardiovascular and bleeding outcomes.Methods:PubMed, MEDLINE, Embase, Cochrane, Scopus, Web of Science were systematically searched for studies that compared pretreatment with P2Y12versus no pretreatment in STEMI, and reported efficacy and safety outcomes. A meta-analysis using a fixed and random effects model was used to calculated outcomes of interest. Heterogeneity was assessed with I2statistics.Results:A total of 3 RCTs and 14 observational studies assigning 91,771 patients to either pretreatment (65,598 patients) or no pretreatment (26,171 patients) were included. Follow-up ranged from 7 days to 19 months. The P2Y12inhibitors included clopidogrel, prasugrel and ticagrelor. At 30 days, P2Y12pretreatment was associate with lower 30-day mortality (risk ratio [RR], 0.71; 95% CI, 0.56-0.91; p=0.006; I2=75%), stent thrombosis (RR, 0.33; 95% CI, 0.12-0.95; p=0.04; I2=83%), and major bleeding (RR, 0.81; 95% CI, 0.74-0.90; p

Circulation, Volume 146, Issue Suppl_1, Page A15314-A15314, November 8, 2022. Introduction:Mycobacterium chimaera is an emerging pathogen, recognized to cause prosthetic valve infective endocarditis (PVIE) and disseminated infection following open-chest cardiac surgery with certain contaminated heater-cooler systems. Diagnosis is challenging and requires a very high index of suspicion. Data regarding the optimal cardiac imaging evaluation of this condition is limited.Methods:Scopus, PubMed, EMBASE, Ovid and Cochrane were searched for published articles through October 2021, using keywords “Mycobacterium chimaera”, “Prosthetic valve” and “Endocarditis”. 169 articles were found and reviewed for study eligibility. Articles were included if they consisted of Mycobacterium chimaera causing IE, with imaging modalities used to establish diagnosisResults:Thirty-three articles were included, yielding twenty-two cases of Mycobacterium chimaera PVIE. The disease manifested on average thirty months after surgery, with an average patient age of 59 years (90% male). Imaging modalities to establish the diagnosis of prosthetic valve infective endocarditis included: transthoracic echocardiogram in 5 cases, transesophageal echocardiogram (TEE) in nine cases, 18F-FDG-PET/CT in seven cases. A combination of imaging modalities with TEE and 18F-FDG-PET/CT was reported once; TTE, TEE and 18F-FDG-PET/CT was also noted in one case. Lastly there was one instance each of combined use of TTE, TEE, and one of the following: CTA, Cardiac MRI, or standard CT. Nine cases did not specify the imaging modality used to achieve diagnosis. Ten patients died.Conclusions:PVIE due to Mycobacterium chimaera infection is a rare and challenging diagnosis, which requires a high index of suspicion. Accurate diagnosis should be aided by multimodality cardiac imaging, with 18F-FDG-PET/CT being a powerful adjunct imaging modality.

Circulation, Volume 146, Issue Suppl_1, Page A15477-A15477, November 8, 2022. Introduction:Approximately 8-40% of ST-elevation Myocardial Infarction (STEMI) present later than 12 hours after symptom onset. Current ACC/AHA guidelines recommend primary percutaneous coronary intervention (PCI) for STEMI after 12 hours of symptom onset only in the setting of cardiogenic shock or severe acute heart failure, (Class Ia, LOE B) or persistent ischemic symptoms (Class IIa, LOE B). There are limited data comparing long-term outcomes among patients with a late STEMI presentation managed with PCI versus medical therapy (MT).Objective:To compare long-term outcomes among patients treated with PCI versus MT who have late presentation of STEMIMethods:We followed Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to extract data from PubMed/Medline, Cochrane, Embase, and Clinicaltrials.gov databases by using the search terms “late” or “delayed” or “ >12 hours” presentation with STEMI from 01/2012 through 12/2022. Included studies reported at least one of the following outcomes: all-cause mortality, reinfarction, heart failure, major adverse cardiac events (MACE), and stroke. Studies reporting delays in PCI due to COVID-19 positive status or COVID-19 enforced protocols were excluded to prevent the impact of pragmatic barriers on treatment. Relative risk (RR) was calculated using random effects model if heterogeneity was >50%, otherwise, fixed effects model was usedResults:Seven studies (n=11,576, delayed PCI n=6,248, and medical therapy n=5,319) were included in our analysis. The median follow-up was 12 months (1-60 months). Overall, among patients with STEMI and PCI >12 hour after presentation had lower incidence of MACE (27% vs. 30%, RR 0.85, 95% CI 0.76-0.69, I2=30%, p=0.007) compared to MT alone, which was driven by a significantly reduced all-cause mortality with PCI (4.4% vs. 17%, RR 0.38, 95% CI 0.17-0.85, I2=95%, p=0.01). No significant differences were observed in the incidence of recurrent MI and heart failure hospitalizations.Conclusion:Our study suggests favorable outcomes of PCI in STEMI with presentation >12 hours compared with medical therapy. Further prospective studies are needed to validate our findings.

Circulation, Volume 146, Issue Suppl_1, Page A14060-A14060, November 8, 2022. Background:RCTs studying the effect of sodium-glucose co-transporter 2 inhibitors (SGLT2i) on cardiovascular (CV) risk factors and outcomes have been underpowered to assess patients with overweight or obesity, thus presenting the need for a meta-analysis.Methods:Electronic databases were queried up till February 2022 for RCTs comparing SGLT2i with placebo in patients with overweight (BMI ≥25 kg/m2) or obesity (BMI ≥30 kg/m2) – irrespective of diabetes status – with a follow-up of ≥24 weeks. Meta-analyses were performed using the generic inverse variance technique and a random-effects model. Results are presented as weighted mean differences (WMD) for continuous outcomes, and hazard ratios (HR) for dichotomous outcomes. Outcomes studied were: (i) weight; (ii) systolic BP; (iii) diastolic BP; (iv) heart rate; (v) HDL-C; (vi) LDL-C; (vii) major adverse cardiac events (MACE), i.e., composite of CV death, non-fatal myocardial infarction (MI) and non-fatal stroke; (viii) composite of heart failure hospitalization and CV death (HFH/CV death); (ix) mortality; (x) MI; and (xi) stroke.Results:Seventeen RCTs (47,649 patients) were included. Compared with placebo, SGLT2i significantly reduced weight (WMD: -2.32 kg [-2.77, -1.88]), HbA1c (WMD: -0.79 % [-0.98, – 0.61]) and systolic BP (WMD: -2.15 mm Hg [-3.08, – 1.22]). SGLT2i did not have a significant effect on diastolic BP (WMD: -0.55 mmHg [-1.51, 0.41]), heart rate (WMD: 0.08 bpm. [-0.21, 0.37]), HDL-C (WMD: 1.62 mmol l-1[-0.21, 3.45]) or LDL-C (WMD: 0.53 mmol l-1[-0.88, 1.94]). Amongst CV outcomes, SGLT2i reduced the risk of MACE (HR: 0.90 [0.81, 0.99]), HFH/CV death (HR: 0.82 [0.75, 0.90]), and mortality (HR: 0.85 [0.77, 0.94]). No effect was noted on stroke (HR: 0.99 [0.85, 1.26]) or MI (HR: 0.89 [0.77, 1.02]).Conclusions:In patients with overweight or obesity, SGLT2i produce a modest but significant reduction in weight, systolic BP and HbA1c. SGLT2i may also reduce the risk of MACE, HFH/CV death, and mortality.

Circulation, Volume 146, Issue Suppl_1, Page A11793-A11793, November 8, 2022. Background:The risk of fatal and recurrent cardiovascular complications in Hypertrophic Cardiomyopathy (HCM) warrant data to identify the rate, causes and predictors of readmission on a large scale. We conducted the first-ever meta-analysis to evaluate the pooled rate of short-term and long-term readmissions after index HCM admissions.Methods:PubMed/Medline, EMBASE and SCOPUS databases were systematically reviewed to find studies through May 2022 reporting rates and causes of readmission following index HCM admissions. Random effects models were used to estimate pooled rates and causes of readmissions and I2statistics were used to report inter-study heterogeneity.Results:This meta-analysis included 17860 index HCM admissions (Mean age: 46-67 years, median follow up duration: 321.6 days, Female 53.11%) from 17 studies, which revealed a 14.8% [95% CI 12.2%-17.4%, I2=96%] pooled rate of readmission(Fig. 1). Studies published from China (23.5% vs. 10.5%) had a higher readmission rate than the USA(Fig. 2). The long-term readmission rate was highest within 1-3 years (26.6%) and in patients who underwent alcohol septal ablation procedure (10% vs 7.6%) compared to those who underwent surgical myectomy(Fig. 3). The readmission rate was higher in cohorts with smaller sample sizes (19.2% vs 10.2%) (n1000). Among the readmission events, congestive heart failure, and acute decompensated heart failure were the leading causes of readmission, accounting for up to 66% of the readmission cases [95%CI 32.5%-100.4%, p

Circulation, Volume 146, Issue Suppl_1, Page A12256-A12256, November 8, 2022. Rivaroxaban is a direct oral anticoagulant that works by inhibiting factor Xa. Direct anticoagulants have largely replaced direct vitamin K inhibitors (VKAs) due to the increased risk of major hemorrhages and the need for regular monitoring and dose adjustments. However, there have been multiple reports of elevated international normalized ratio (INR) and incidents of bleeding in patients on rivaroxaban, which brings into question the potential need for monitoring. The purpose of this review is to differentiate the patients that may benefit from regular monitoring and to propose future directions for implementation of monitoring. Here we report a case of an INR of 4.8 in a patient who presented with a gastrointestinal bleed and a drop of five gm/dL in hemoglobin four days after starting rivaroxaban following right femoral popliteal bypass graft stenting. The patient had no liver or kidney abnormalities and was not taking any medication or consuming any foods that could introduce any significant drug interaction. Additionally, we conducted a systematic review of similar reports in the literature with the goal of identifying the factors that could influence rivaroxaban’s levels in the blood or its influence on the INR. We reviewed PubMed using keywords including; “rivaroxaban”, “anti-Xa”, “DOAC”, “elevated”, “INR”, “bleeding”, “hemorrhage”, “pharmacology”, and “pharmacokinetics”. The literature revealed reports of INRs up to 5.2. Reviewing the pharmacokinetics of rivaroxaban indicated possibly higher drug levels in Caucasians, patients with a low body mass index (BMI), and patients with polymorphisms in the genes coding for CYP3A4, CYP2J2, or p-glycoprotein, assuming no renal or liver disease and no significant drug-drug or drug-food interactions. INR can be falsely normal if the thromboplastin reagent used to monitor the INR on warfarin is not sensitive to the changes in INR due to rivaroxaban. We suggest finding a thromboplastin reagent that is sensitive to INR changes with rivaroxaban, which could yield clinically relevant INRs on rivaroxaban allowing for accurate monitoring. We then suggest conducting studies to evaluate the cost effectiveness of regular monitoring in at-risk patients.

Circulation, Volume 146, Issue Suppl_1, Page A13752-A13752, November 8, 2022. Introduction:Treating individuals with stable multivessel coronary artery disease (CAD) and retained ventricular function is still debatable. Percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG) are all options for treatment, and they are all employed in tandem with rigorous secondary prevention. One technique’s significant long-term mortality benefit over the other is still debatable for multivessel disease management.Hypothesis:To compare the long-term mortality and complications of coronary artery bypass graft (CABG) versus Percutaneous Coronary Intervention (PCI) among patients with multivessel disease.Methods:Pubmed/Medline, EMBASE, Cochrane, Web of Science, Scopus, and grey literature were searched in March 2022. We only included randomized clinical trials (RCTs) that reported the outcome differences between CABG and PCI. The primary outcome was long-term all-cause mortality. The secondary outcomes were re-intervention rate and major adverse cardiac events (MACE). The statistical analysis was performed using Comprehensive Meta-analysis software version 3.Results:A total of 6 Randomized Control Trails (RCTs) studies were included in the analysis comprising 7,126 patients (3558 PCI and 3568 CABG). The median follow up period was 6.33 years. Long-term mortality from any cause (after 2 years follow up or more) was significantly higher in PCI group compared to CABG group (HR: 1.44; 95% CI, 1.25-1.67; P < 0.01; I2= 18.78%). This trend was consistent among diabetic patients (HR: 1.39; 95% CI, 1.14-1.69; P < 0.01; I2= 23.73%). CABG procedure was associated with lower rate of additional or repeat intervention (RR: 0.25; 95% CI, 0.17-0.37; P < 0.01; I2= 74.4%). Cardiovascular-specific mortality and MACE were lower among CABG group compared to PCI (RR: 0.77; 95% CI, 0.58-0.95; P < 0.01; I2= 0%), (RR: 0.77; 95% CI, 0.64-0.93; P < 0.01; I2= 0%), respectively.Conclusions:The study shows that CABG provides lower long-term mortality rates, including diabetic patients, a lower rate of repeat intervention, and lower major adverse cardiac events. Therefore, CABG is an effective and safe approach for patients with multivessel diseases compared to PCI, especially in the long term.