Risultati per: ESH: nuove linee guida complete per la gestione dell’ipertensione arteriosa

Circulation, Volume 150, Issue Suppl_1, Page A4145488-A4145488, November 12, 2024. Description of Case:An 81-year-old man with left bundle branch block (LBBB) and recent inguinal hernia repair presented with 2 weeks of dizziness and shortness of breath. On presentation, sinus tachycardia was noted with a heart rate of 100 bpm. While in the emergency department, he acutely developed complete heart block, initially with a right bundle branch block (RBBB) pattern escape at a rate of 53 bpm. Gradually, the escape slowed to 20 bpm with vomiting and hypotension so an emergent transvenous pacer was placed; he was paced at VVI 80 bpm with improvement in status. Transthoracic echocardiogram exhibited McConnell’s sign (Figure 1) with severe RV enlargement, severely reduced RV systolic function and normal LV systolic function. Arterial line tracings fluctuated with inspiration/expiration consistent with a pulsus paradoxus pattern (Figure 2) without evidence of pericardial effusion. CT angiography of the chest showed emboli in the bilateral main pulmonary arteries. For treatment, the patient was started on a therapeutic heparin drip, transitioned later to therapeutic apixaban. He did continue to require intermittent pacing and so underwent dual-chamber permanent pacemaker placement on hospital day 3.Discussion:EKG findings in patients with pulmonary emboli can be variable. In one prospective cohort study of 246 consecutive patients suspected to have pulmonary embolism (PE), only tachycardia (p = 0.008) and incomplete right bundle branch block (p = 0.002) amongst 28 total EKG findings evaluated were associated with confirmed pulmonary embolism by imaging. Interestingly, new RBBB may be a sensitive and specific marker for massive PE. In 50 patients with proven pulmonary embolism, all 16 cases with new RBBB on EKG were noted to have massive trunk obstruction (no patients with peripheral PEs had new RBBB). In the several case reports we found of patients with prior/observed LBBB and PEs who subsequently developed CHB, PEs were notably large, described as either bilateral or saddle-shaped, suggesting an association of acquired RBBB with significant PE burden. The cause of new complete heart block should always be acutely sought; in patients with baseline LBBB, a new RBBB leading to complete heart block can occur with massive/submassive PE. Rapid identification and treatment are needed to limit mortality in this often hemodynamically unstable entity.

Circulation, Volume 150, Issue Suppl_1, Page A4139610-A4139610, November 12, 2024. Carfilizomib is a proteasome inhibitor used in the treatment of multiple myeloma. The incidence of arrhythmias according to one pooled analysis was 13.3%, mostly linked to mild supraventricular arrhythmias. We present a case of carfilzomib-induced complete heart block (CHB).A 66-year-old male with a history of restrictive lung disease on 2 liters (L) oxygen, moderate aortic stenosis and multiple myeloma presented with shortness of breath and mild chest discomfort that started earlier that day. His most recent chemotherapy with carfilzomib, cyclophosphamide, and dexamethasone was 3 days prior to arrival. Oxygen requirements increased to 15L. Laboratory findings showed elevated high sensitivity troponins (600s), elevated brain natriuretic peptide (800), creatinine of 1.86 above baseline of 0.9. Chest x-ray revealed pulmonary edema. Initial electrocardiogram (EKG 1) showed 2nd degree, type 1 atrioventricular block, which was new compared to a prior EKG. Subsequent EKGs showed alternating bundle branch blocks with LBBB and RBBB (EKG 2) that progressed to eventual complete heart block (EKG 3). Echocardiogram revealed an ejection fraction of 55-59% without wall motion abnormalities and unchanged valve pathologies.The patient was treated for acute heart failure with diuretics and fluid restriction. Cardiac catheterization was deferred as he did not have classic anginal symptoms. Oncology recommended discontinuation of carfilzomib. Electrophysiology recommended implantation of a permanent pacemaker (PPM) due to persistent complete heart block, which he successfully underwent, improving his symptoms.The general arrhythmogenic effects of carfilzomib are established, however there is limited data on the specific types of arrhythmias. This case suggests that carfilzomib can result in CHB. Additional monitoring or early discontinuation of carfilzomib should be considered to prevent severe conduction abnormalities resulting in morbidity and potential mortality. Further research is necessary to elucidate underlying mechanisms and risk factors associated with carfilzomib-induced conduction abnormalities and whether they resolve with discontinuation of the medication.

Circulation, Volume 150, Issue Suppl_1, Page A4141135-A4141135, November 12, 2024. BACKGROUND:Right atrial (RA) dysfunction related to right ventricular (RV) function has been reported in patients with repaired TOF. Increased liver stiffness in these patients has also been reported. Whether RA function worsens under exercise stress, and its relationship with worsened liver stiffness is unknown.HYPOTHESIS:In patients after TOF repair, RA functional reserve during exercise stress is reduced and correlated with raised liver stiffness and RV dysfunction.METHODS:19 patients (8 male) aged 17.92 ± 3.81 at 16.06 ± 3.98 years after repair and 25 controls (16 male, aged 19.99 ± 1.67 years) were studied. RA mechanics was assessed by speckle-tracking echocardiography (STE) at rest and during bicycle exercise, with quantification of positive, negative, and total strain, and strain rates at ventricular systole (aSRs), early diastole (aSRed), and atrial contraction (aSRac). RAFR is calculated as (Change in RA total strain x [1-1/ baseline RA total strain]). Biventricular (RV, LV) function were quantified using Doppler interrogation and STE. Hepatic shear wave velocity (c) and tissue elasticity (E) were measured using shear wave elastography.RESULTS:At rest, patients had lower RA positive, negative and total strain, aSRs and aSRed than control subjects (all p

Circulation, Volume 150, Issue Suppl_1, Page A4145652-A4145652, November 12, 2024. Background:Invasive management strategies for myocardial infarction (MI) and multivessel coronary artery disease (MV-CAD) include complete revascularization (successful revascularization of all coronary artery lesions or segments ≥1.5 mm in diameter with ≥50% diameter stenosis) and incomplete revascularization (including culprit-only revascularization). However, non-culprit lesion management strategy in elderly patients remains ambiguous due to a lack of representation of this cohort in randomized trials (RCTs) and higher cardiovascular complication risks.Methods:We performed a meta-analysis comparing clinical outcomes of elderly individuals (age ≥65 years) with MI and MV-CAD submitted to complete vs. incomplete (including culprit-only) percutaneous coronary intervention (PCI). The outcomes of interest were all-cause death, cardiovascular mortality, recurrent MI, and any revascularization. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model.Results:Thirteen studies (3 RCTs, 1 post hoc analysis of previous RCT, and 9 observational studies) with a total of 12,289 patients were included. Complete revascularization (CR) was performed in 5,232 patients, while 7,057 patients underwent incomplete revascularization (IR). The mean age was 80.46 years for CR and 80.73 years for IR and the mean durations of follow-ups ranged from 12-78 months. As compared to IR, the CR group was associated with significantly lower risk of all-cause mortality (OR 0.59, 95% CI 0.49 to 0.71, p

Circulation, Volume 150, Issue Suppl_1, Page A4135984-A4135984, November 12, 2024. Background:Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) frequently present with multivessel coronary artery disease (CAD) at the time of primary percutaneous coronary intervention (PCI). The optimal timing of complete revascularization (CR) in these cases remains a subject of ongoing debate.Objective:To assess major cardiovascular outcomes and procedural complications in STEMI patients with multivessel CAD undergoing immediate versus staged CR post index procedure.Methods:We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing immediate to staged CR in STEMI and multivessel CAD. Trials were identified via a systematic search of MEDLINE, Embase, and Cochrane Libraries from database inception to March 6, 2024. The data were analyzed using RevMan software.Results:Among five RCTs (n=1,415) the majority of participants were male, the weighted mean follow-up duration across studies was 15.6 months. Immediate versus staged CR showed no significant differences in MACE (13.3% vs 9.8%; RR: 1.07, 95% CI [0.62, 1.83]), all-cause mortality (3% vs 4.55%; RR: 0.70, 95% CI [0.41, 1.21]), or MI (4.5% vs 2.6%; RR: 1.43, 95% CI [0.58, 3.55]). However, the staged group had higher unplanned revascularization incidence (8.6% vs 4.4%; RR: 1.92, 95% CI [1.21, 3.04]).Conclusion:Staged revascularization in STEMI patients with multivessel CAD demonstrates comparable effectiveness to immediate revascularization but leads to a greater number of unplanned revascularization procedures, likely due to delayed intervention. The early implementation of staged PCI during the initial hospitalization phase may provide equivalent efficacy to immediate complete revascularization. Nonetheless, further research is necessary to corroborate these findings.

Circulation, Volume 150, Issue Suppl_1, Page A4142244-A4142244, November 12, 2024. Background:Multivessel coronary artery disease has a higher risk of adverse cardiovascular outcomes. Although patients presenting with STEMI usually undergo revascularization of the infarct-related artery only (i.e. cuplrit only percutaneous coronary intervention or CO-PCI), recent trials suggest improved outcomes with complete PCI of all arteries with chronic total occlusion (CTO).Aim:To meta-analyze data from randomized controlled trials comparing the impact of complete versus CO-PCI in STEMI patients with CTO in the non-infarct related artery (non-IRA).Methods:We conducted a comprehensive search of Medline, EMBASE, and Scopus up till May 2024, to identify studies comparing the clinical outcomes between CO-PCI versus complete PCI in patients with STEMI accompanied by CTO in the non-IRA. Effect estimates were pooled using a random-effects model and reported as risk ratios (RR) along with corresponding 95% confidence intervals (CIs), with a significant p value < 0.05. Outcomes of interest include all-cause and cardiac mortality, myocardial infarction and stroke.Results:Our search strategy yielded 16 eligible studies (complete PCI, n= 7,982; CO-PCI, n= 7,753). Complete PCI significantly reduced all-cause mortality in comparison to CO-PCI (RR=0.64 [0.49, 0.84]; p=0.002). Complete PCI was also associated with a significant reduction in cardiac death (RR: 0.54 [0.41 - 0.72]; p

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