Risultati per: Colite ulcerosa negli adulti: review

Circulation, Volume 146, Issue Suppl_1, Page A14285-A14285, November 8, 2022. Introduction:Contemporary literature reveals a range of cardiac complications in patients who receive the percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).Hypothesis:This study compared the adverse cardiac outcomes and procedural/technical success rates between the patients groups of in-stent (IS) CTO PCI and de novo CTO PCI.Methods:This systematic review and meta-analysis compared odds for primary (all-cause mortality, MACE, cardiac death post PCI, stroke) and secondary (bleeding requiring blood transfusion, ischemia-driven target-vessel revascularization, PCI procedural success, PCI technical success, and target-vessel MI) endpoints between 2,734 patients who received PCI for IS CTO and 17,808 for de novo CTO. Odds ratios for outcome variables were calculated within 95% confidence intervals (CIs) via the Mantel-Haenszel method. The pooled analysis was undertaken for observational (retrospective/prospective) single- and multi-centered studies published between January 2005 and December 2021.Results:We found 57% higher, 166% higher, 129% higher, and 57% lower odds for MACE (OR: 1.57, 95% CI 1.31, 1.89,p

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 A15618-A15618, November 8, 2022. Introduction:Several studies have described trends toward increasing complexity and illness-severity of patients admitted to the cardiac intensive care units (CICU). This has necessitated the development of training pathways in critical care cardiology (CCC). Hybrid training in combinations of interventional cardiology (IC), advanced heart failure and transplant cardiology (AHFTC), and CCC have also gained interest. This review sought to outline current and proposed pathways for hybrid training in acute cardiovascular care.Methods:We performed a systematic review of articles describing training pathways for dual certification in CCC, as well as hybrid models for training in a combination of IC, CCC, and AHFTC. PubMed, EMBASE, and CINAHL were searched from 01/01/2000 to 04/28/2022. Pathways through pediatric and adult non-internal medicine specialties were excluded.Results:Of 2,236 citations, 18 studies were included in the final analysis. Most pathways included sequential CCC training, i.e. traditional cardiovascular fellowship and 1-2 additional years of critical care medicine, although integrated 4-year programs were noted to be emerging. Hybrid models for advanced training in two or more complementary subspecialties, including CCM, AHFTC, and IC, have been described, each with their own strengths and limitations. Additional expertise in advanced therapies such as mechanical circulatory support, the longitudinal AHFTC practice, and the combination of procedural and intensivist skills for management of diseases such as acute coronary syndromes were the stated benefits of these combined models. Alternatively, some advocate for incorporating focused CC training into a single year of IC or AHFTC fellowship. However, this may limit the time required to gain expertise in all areas of advanced training and is insufficient for board certification in CCM.Conclusion:Despite the growing need, there are limited dedicated pathways to train the contemporary acute care cardiologists. Further study is needed to consolidate training to encourage the growth and development of this field.

Circulation, Volume 146, Issue Suppl_1, Page A310-A310, November 8, 2022. Purpose:Often emphasized as a best practice in prehospital airway management, first-pass intubation success (FPS) depends upon paramedic self-reports. We sought to determine the accuracy of paramedic reports of FPS in prehospital airway management.Methods:We analyzed adult (age >=18 years) prehospital airway management data from a ground EMS agency, including cases from 5/1/2020 to 2/28/2022. Paramedics performed all adult prehospital endotracheal intubations (ETI) using standard video laryngoscopy (Airtraq, Mountain View CA) with a hyperangulated blade. Paramedics did not use neuromuscular blocking agents for ETI. Real time video images were recorded for all cases. We excluded cases where the video was missing, data was not captured, or the video was of insufficient quality. Each video was reviewed by a single independent rater using the same objective definition of FPS as the paramedic. The primary outcome was FPS, defined as correct intratracheal placement on the first video laryngoscopy. We evaluated agreement between paramedic and reviewer-reported FPS using Cohen’s Kappa statistic.Results:There were a total of 514 ETI cases, including cardiac arrest, trauma, and non-arrest medical. Paramedic and reviewer reported FPS agreed in 429/514 (83.5%) and disagreed in 85 (16.5%). Of the discordant cases, the paramedic reported FPS but the reviewer disagreed in 78 (92%). Interrater agreement was strong; kappa 0.659 (95%CI 0.595 – 0.722). FPS discordance was not associated with patient age, sex, cardiac arrest status.Conclusions:Despite the computed Kappa statistic showing strong interrater reliability, the objective nature of the rating leaves very little room for discordance. The expected result would have been near compete agreement, however 15% of cases resulted in disagreement. Additionally, when there was disagreement, it overwhelmingly favored the clinician reporting FPS when the reviewer disagreed. Paramedics incorrectly reported FPS in 1 of 6 ETI. Independent review is essential in the assessment of prehospital ETI performance. Further study is needed to determine the reasons for the discordance that may include confusion about the FPS definition or incentivization (real or perceived) of reporting outcomes in a particular way.

Circulation, Volume 146, Issue Suppl_1, Page A12239-A12239, November 8, 2022. Introduction:Physical activity (PA) decreases the risk of cardiovascular events, but to what degree this is related to effects on surrogate markers of subclinical cardiovascular disease (CVD) is unclear. Clarifying the relationship between objectively measured PA and subclinical CVD would provide justification for using measures of subclinical CVD in clinical trials of PA interventions.Hypothesis:We hypothesized that higher levels of objectively measured PA are associated with less subclinical CVD.Methods:We performed a systematic review using Medline, Embase, CINAHL and Cochrane (January 1, 2000 – January 12, 2022). Studies of adult populations that examined the relationship between objectively measured PA (accelerometry) and subclinical CVD were included. Markers for subclinical CVD included: ankle brachial index (n=4 studies); arterial stiffness (n=31); carotid artery plaque/stenosis and intima media thickness (n=9); coronary artery atherosclerosis (n=4); endothelial function (n=8); measures of cardiac structure and function (n=4); and eight studies included multiple of the aforementioned outcomes. For those studies, we considered results on each outcome separately. Risk of bias was also assessed.Results:PA was inversely associated with subclinical CVD in 60 of 78 included analyses (76.9%). Of these, five studies (6.4%) found only an association with higher levels of PA. In six studies (7.7%), PA was no longer associated with subclinical CVD after adjustment for confounders. Seven analyses (9.0%) demonstrated mixed results but demonstrated an inverse relationship between PA and subclinical CVD in specific circumstances. Only 18 studies (23.1%) suggested that PA was not associated with decreased subclinical CVD.Conclusions:Increased PA is associated with less subclinical CVD across diverse populations. Interventions to increase PA have the potential to reduce the burden of subclinical CVD and, therefore, clinical CVD events.

Circulation, Volume 146, Issue Suppl_1, Page A323-A323, November 8, 2022. Global prevalence of cardiopulmonary resuscitation and automated external defibrillator training: a systematic review and meta-analysisAim:Sudden cardiac arrest exerts a large disease burden, which may be mitigated by bystander cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED). The global prevalence and distribution of laypersons trained in these skills are poorly understood. We aimed to estimate the global prevalence of CPR and AED training, and identify their determinants.Method:We searched Medline, Embase and Cochrane Library from inception to October 24th, 2021, for cross-sectional studies reporting the prevalence of CPR or AED training from representative samples of laypersons. Prevalences were pooled using random effects models. We examined varying definitions of being identified as CPR-trained, namely CPR-V (valid training within 2-years), CPR-E (ever been trained). Subgroup analysis and meta-regression were used to examine determinants of interest.Results:28 studies were included, representing 53,397 laypersons. Among national studies, the prevalence of CPR-V training was 10.02% (95% CI 6.60 to 14.05), prevalence of CPR-E training was 39.64% (95%CI 29.11 to 50.67), and prevalence of AED training was 15.70% (95% CI 10.17 to 22.18). Subgroup analysis revealed differences in prevalences between continents,with prevalence highest in Oceania and lowest in Asia (p

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 A14282-A14282, November 8, 2022. Introduction:While kidney transplant recipients (KTR) are high risk candidates for valve replacements, the safety of transcatheter aortic valve replacement (TAVR) is limited among this population as they are excluded from major trials. We aimed to compare the outcomes between TAVR and surgical aortic valve replacement (SAVR) among KTR by a systematic review and meta-analysis.Methods:We comprehensively searched PubMed, Embase, and Cochrane Library from its inception until April 20, 2022 for relevant studies. Outcomes were pooled using the DerSimonian and Laird random-effects model and reported as odd ratios (OR) or standardized mean difference (SMD) and 95% confidence intervals (CI).Results:6 studies involving 5,452 patients (1,956 TAVR, 3,496 SAVR) were included in the analysis. TAVR patients were older (69.4 years vs 62.8 years), were less likely to be male (66.7% vs 67.9%) and had a higher prevalence of most comorbidities including coronary artery diseases (78% vs 58%), heart failure (71% vs 42%) and diabetes mellitus (52% vs 45%). Compared with SAVR, KTR undergoing TAVR had significantly lower risk of in-hospital all-cause mortality (OR 0.51, 95% CI: 0.39 to 0.67, p

Circulation, Volume 146, Issue Suppl_1, Page A15681-A15681, November 8, 2022. Introduction:Although heart failure (HF) guidelines emphasized dietary sodium restriction, the recommendation was based on limited evidence. We analyzed the impact of dietary sodium restriction on HF outcomes and quality of life (QoL) by systematically reviewing the available literature to-date.Methods:MEDLINE and SCOPUS were queried from inception till April 2022 for randomized controlled trials (RCTs) and observational studies with sodium restriction (≤1500-3000mg) as an intervention/comparator and assessing its impact (or association) on HF outcomes. Data about HF-related hospitalizations, all-cause mortality and QoL (via the Kansas City Cardiomyopathy Questionnaire) was extracted, pooled and analyzed. Forest plots were created based on random effects model.Results:Twelve studies (n= 4637 patients) were included in our analysis with a median follow-up time of 6 months. The pooled analysis demonstrated no difference in HF hospitalizations between the sodium-restricted and unrestricted groups (OR = 1.30 [0.81-2.10] P

Circulation, Volume 146, Issue Suppl_1, Page A12442-A12442, November 8, 2022. Introduction:Heart failure with preserved ejection fraction (HFpEF) remains a highly prevalent condition with significant morbidity and mortality but limited treatment options. Sodium glucose cotransporter-2 inhibitors (SGLT2i), angiotensin-receptor neprilysin inhibitors (ARNi) and mineralocorticoid receptor antagonists (MRA) are moderately to weakly guideline supported. Yet, the potential gain with combination therapies has not been elucidated.Hypothesis:This study sought to estimate and compare the aggregate treatment benefit of medical therapies for HFpEF.Methods:We performed a systematic reviewed and network meta-analysis, using MEDLINE, Cochrane, and the Web of Science databases for randomized controlled studies from inception to May 2022. We included patients with heart failure and left ventricular ejection fraction >40%, treated with any of the following therapies: angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), beta-blockers (BB), MRA, digoxin, ARNi, SGLT2i, and vericiguat. Our analysis assumed additive benefits of each therapy. The primary outcome was a composite of cardiovascular (CV) death and hospitalization for heart failure (HHF); secondary outcome was all-cause mortality.Results:We identified 14 studies with a total of 26,556 patients, mean age 71 (±8.8), 49% females and mean ejection fraction of 57% (±8%). Mean follow-up time was 24 months. MRA and SGLT2i, were the individual components that reduced the primary outcome [HR =0.82 (95% CI 0.67-0.99 and 0.78 (95% CI 0.68 – 0.91), respectively], while the combination of ACE-i/ARB, BB, MRA and SGLT2i was the only beneficial [HR 0.53 (95% CI 0.30 – 0.95]. None of the explored combinations or individual components were associated with decreased all-cause mortality.Conclusions:In patients with HFpEF, MRA and SGLT2i alone as well as a combination of ACE-i/ARB, BB, MRA and SGLT2i were associated with decreased risk of CV mortality and HHF.

Circulation, Volume 146, Issue Suppl_1, Page A12596-A12596, November 8, 2022. Introduction:The efficacy and safety of direct oral anticoagulants (DOACs) as treatment alternatives for patients with thrombotic antiphospholipid syndrome (APS) remain controversial.Methods:We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the efficacy and safety of DOACs with vitamin-K antagonists (VKAs) in patients with thrombotic APS. We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials through April 9, 2022. Main efficacy outcomes were a composite of arterial thrombotic events, and a composite of venous thromboembolic events (VTE). The main safety outcome was major bleeding according to the International Society on Thrombosis and Hemostasis (ISTH) criteria. A random effects model with inverse variance was used for the primary analysis. Risk of bias was assessed using the Cochrane Collaboration criteria.Results:Our search retrieved 253 studies. Four RCTs involving 474 patients were included (Figure). All four RCTs were open-label but had proper random sequence generation and adequate allocation concealment. The DOACs used were rivaroxaban (3 trials) and apixaban (1 trial). The mean percent time in therapeutic range in the warfarin arm among the four studies was 60%. Overall, use of DOACs compared with VKAs was associated with increased odds of composite of arterial thrombotic events (OR 5.64, 95% confidence interval [CI] 1.96-16.27,p=0.001, I2= 0%). The odds of subsequent VTE events (OR 1.19, 95% CI 0.31-4.53,p=0.80, I2= 0%), or major bleeding (OR 1.02, 95% CI 0.42-2.47,p=0.97, I2= 0%) were not significantly different between the two groups.Conclusions:Patients with thrombotic APS randomized to DOACs compared to VKAs appear to have increased risk for arterial thrombosis. No significant differences were observed between patients randomized to DOACs vs VKAs in the risk of subsequent VTE or major bleeding.

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 A11096-A11096, November 8, 2022. Introduction:Many randomized controlled trials (RCTs) compared rate control vs rhythm control therapy in patients with atrial fibrillation (AF). In this study, we systematically reviewed these RCTs and performed a meta-analysis of the outcomes comparing the two therapies.Methods:We searched PubMed, Medline, EMBASE, and SCOPUS databases until April 30, 2022 for all RCTs investigating AF rate vs rhythm control. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for constructing and reporting this review. We assigned I2 >50% as an indicator of statistical heterogeneity among the RCTs. We analyzed all-cause mortality, stroke rate, heart failure (HF) hospitalization, and total hospitalization between the two groups. We estimated the risk ratios (RR) with a random-effects model using the Mantel-Haenszel technique and calculated the 95% confidence intervals (CI). A P-value

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 A12334-A12334, November 8, 2022. Introduction:Internal Medicine (IM) residents face major challenges in conducting original research due to inadequate instruction in research methodology and lack of mentorship during the traditional research electives offered during residency.Hypothesis:A novel systematic review curriculum (SRC) can improve resident satisfaction and research productivity.Methods:8 IM residents interested in cardiology were selected to participate in a 4-week elective focused on conducting systematic reviews and meta-analyses. Didactic lectures, online tutorials, and problem-based exercises were delivered by a multidisciplinary team of educators including a clinical researcher, librarian, and biostatistician.Results:Demographics are presented (Table 1). As compared to 16 residents that underwent traditional research electives, the SRC participants reported higher satisfaction, completed a mentored research project within 4 weeks, presented 4 posters at AHA annual meeting 2020, and finished manuscripts for publication (Figure 1).Conclusions:A focused research curriculum delivered by multidisciplinary educators is better than a traditional research elective and improves resident satisfaction.

Circulation, Volume 146, Issue Suppl_1, Page A12357-A12357, November 8, 2022. Introduction:The prevalence of obesity among patients with AF and its impact on catheter ablation outcomes remain controversial. We aimed to examine the proportion of obese participants enrolled in current AF ablation RCTs and outcomes of ablation among patients with obesity.Methods:We systematically searched PUBMED for RCTs examining catheter ablation for treatment of AF published between 01/2019 to 03/2022. When mean and standard deviation (SD) were available, normal distribution was assumed and a z-score was used to estimate the proportion of obese participants. A trial was classified as group A and B when conducted in countries where obesity is defined as BMI ≥30 and ≥25 kg/m2, respectively.Results:Of 26 RCTs comprising 1,582 participants, 19 (73.1%) trials reported the BMI of study participants, but only 2 (7.7%) specified the proportion of obesity (15.5% and 39.0%). Two trials excluded participants with BMI >35 kg/m2. In group A (N1=17), the mean BMI was 28.8±1.4 kg/m2with estimated obese participants of 39.7% (IQR 38-45 kg/m2). The mean BMI in group B (N2=9) was 24.9±1.1 kg/m2with estimated obese participants of 47.1% (IQR 37-50 kg/m2), Figure. Subgroup analysis examining the effect of catheter ablation according to the BMI status was not reported in any RCTs. Bivariate or multivariate analysis evaluating the effect of BMI or body weight were used in only 4 (15.4%) RCTs. The results suggested that BMI or body weight did not affect their main findings with risk ratio of 0.97-1.00.Conclusion:Current AF ablation RCTs underreport the actual proportion of participants with obesity. However, using the available mean BMI of the study subjects, concomitant obesity among AF patients was highly prevalent and identified in 40-50%. The impact of obesity on the main findings is not fully reported; thus, efficacy of AF ablation among obese patients could not be concluded.