Risultati per: Low Back Pain: raccomandazioni

Circulation, Volume 150, Issue Suppl_1, Page A4140066-A4140066, November 12, 2024. Background:The no-reflow has been reported to be associated with larger infarct size and mortality after acute myocardial infarction (AMI). A pathological classification of no-reflow was proposed: structural no-reflow—microvessels within the necrotic myocardium exhibit loss of capillary integrity (it is usually irreversible)—and functional no reflow—patency of microvasculature is compromised due to distal embolization, spasm, ischemic injury, reperfusion injury. It may be reversible. After about 6 hours of AMI, myocardial necrosis occurs, which leads to the coronary microcirculation to injury which contribute to no-reflow. The rate of no-reflow was lower in patients presented with AMI, who had reperfusion in less than 4 hours. In AMI within 4 hours of pain-to-balloon time, the proportion of reversible causes of no-reflow may be higher compared to irreversible causes. The incidence of no-reflow was higher in patients with attenuated plaque ≥5 mm in length as evaluated by intravascular ultrasound (IVUS).Objective:The aim of this study was to evaluate the effects of no-reflow after PCI and the association between attenuation plaque as detected by IVUS and no-reflow in ACS patients within 4 hours of pain-to-balloon time.Methods and Results:We retrospectively evaluated 77 ACS patients within 4 hours of pain-to-balloon time between December 2020 and March 2022. Patients were divided into the reflow group (final TIMI 3) (n = 58) and the no-reflow group (final TIMI < 3) (n = 19). The median peak creatine kinase (CK) level was significantly higher in the no-reflow group compared to the reflow group (3754 IU/L [IQR: 4155] vs. 1712 IU/L [IQR: 2849]). Blood pressure decrease during PCI was significantly more pronounced in the no-reflow group (47.4% vs. 8.6%, p < 0.001). The proportion of low attenuation plaque observed by IVUS with a length of ≥5 mm was significantly higher in the no-reflow group compared to the reflow group (52.6% vs. 25.5%, p = 0.032). The proportion of low attenuation plaque with an angle of ≥180 degrees was significantly higher in the no-reflow group compared to the reflow group (68.4% vs. 41.2%, p=0.043).Conclusion:In ACS patients within 4 hours of pain-to-balloon time, the peak CK and the decrease in blood pressure during PCI were significantly greater and the proportion of low attenuation plaque with a length of ≥5 mm and an angle of ≥180 degrees were significantly higher in the no-reflow group.

Circulation, Volume 150, Issue Suppl_1, Page A4140003-A4140003, November 12, 2024. Background:Hypertension is a major preventable risk factor for cardiovascular (CV) disease. Emerging evidence suggests that in addition to blood pressure (BP) levels, controlling the consistency of BP is a key determinant of clinical outcomes. We aimed to assess the effects of consistency of BP control on adverse CV and renal outcomes using two metrics: long-term variability of systolic BP (LT-BPV) and the degree at which BP control is achieved, known as cumulative systolic BP load (CBPL).Methods:We collected clinic systolic BP (SBP) measurements from UK Biobank primary care records in those diagnosed with hypertension (N=39,816), chronic kidney disease (CKD, N=8,062), and neither of these (N=17,702), including a per-participant mean of 21 SBP values over 6 years. Instances of the primary outcome, 4-point major adverse cardiovascular events (MACE; stroke, acute myocardial infarction, heart failure hospitalization, and cardiovascular-related death), were collected from hospital records. Per-standard deviation (SD) and per-quartile hazard ratios (HR) were used to estimate LT-BPV, CBPL, and mean SBP separately using adjusted Cox regression. Sensitivity analyses were used to determine the independence of BP consistency effects from mean BP levels.Results:In those with hypertension, each per-SD increase in LT-BPV was associated with increased risk for MACE (HR=1.12, p=4.4E-11), specifically CV-related death, stroke, and HF hospitalization. LT-BPV effect estimates were strongest in those with controlled SBP and the strongest predictors for all events in those without high-risk comorbidities (coronary artery disease, CKD, peripheral vascular disease, and diabetes). CBPL was similarly associated with MACE (HR=1.13, p=8.1E-13), specifically stroke and acute myocardial infarction, but not with fatal events or HF. In those with CKD, both LT-BPV and CBPL were associated with progression to renal failure (HR=1.31-1.33, p

Circulation, Volume 150, Issue Suppl_1, Page A4135082-A4135082, November 12, 2024. Background:High levels of small dense low-density lipoprotein (sdLDL) is a hallmark of dyslipidemia; however, studies on sdLDL cholesterol levels and risk of peripheral artery disease are sparse and results inconclusive.Hypothesis:We tested the hypothesis that higher levels of sdLDL cholesterol are associated with increased risk of peripheral artery disease in a primary prevention setting.Methods:We studied 31,036 individuals free of lipid-lowering therapy, ischemic stroke, and myocardial infarction at study entry in 2013-2017. All had fresh sample measurements of sdLDL cholesterol. During a median follow-up on 6.2 years, 155 were diagnosed with peripheral artery disease. The association was confirmed using ankle-brachial index (ABI) ≤ 0.9 as endpoint. Lastly, as comparison across different vascular beds risk estimates for myocardial infarction and ischemic stroke were calculated.Results:Higher levels of sdLDL cholesterol were associated with higher risk of peripheral artery disease and an ABI ≤ 0.9 illustrated by cubic splines multivariable adjusted for sex, systolic blood pressure, education, body mass index (BMI), diabetes, large buoyant LDL cholesterol, and age. Per 1 mmol/L (37 mg/dL) higher sdLDL cholesterol hazard ratio for peripheral artery disease was 2.01 (95% CI: 1.41-2.85) and odds ratio for an ABI ≤ 0.9 was 1.51 (95% CI: 1.07-2.14) in multivariable adjusted models. The cumulative incidence of peripheral artery disease was respectively 1.5%, 2.5%, and 3.5% for individuals having a sdLDL cholesterol in the 1st-50th, 51st-90th, and the 91st-100thpercentiles at age 80. For the 91st-100thversus the 1st-50thpercentile a hazard ratio on 2.51 (95% CI: 1.50-4.20) for peripheral artery disease, 2.18 (95% CI: 1.58-3.01) for myocardial infarction, and 1.85 (95% CI: 1.37-2.49) for ischemic stroke was found. Furthermore, the association of higher sdLDL cholesterol with increased risk of peripheral artery disease was robust in sensitivity analyses.Conclusion:Higher levels of sdLDL cholesterol were robustly associated with increased risk of peripheral artery disease in a primary prevention setting.

Circulation, Volume 150, Issue Suppl_1, Page A4144944-A4144944, November 12, 2024. Background:The American Heart Association’s (AHA) Life’s Essential 8 (LE8) concept serves as a quantitative framework for assessing cardiovascular health (CVH). Post-operative coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) patients are at high-risk for subsequent cardiovascular events (CVE). However, LE8 scores for post-procedural CABG or PCI patients remain unknown.Methods:Isolated post-operative CABG (n=208) or PCI (n=739) non-institutionalized patients from the National Institutes of Health’s (NIH) All of Us (AoU) Research Program (2017-2022) were included. LE8 scores (range 0-100, higher = better CVH; excluding diet metric) were calculated using methods recommended by the AHA. Physical activity and sleep metrics were derived from patients’ Fitbit data, while all other metrics were sourced from electronic health records (EHR).Results:Overall LE8 scores for post-operative CABG (57.9 [95% CI: 56.6-59.2]) and PCI patients (55.3 [54.4-56.1]) were significantly lower than that of the general population (65.9 [65.1-66.7] (p

Circulation, Volume 150, Issue Suppl_1, Page A4124369-A4124369, November 12, 2024. Background:Several clinical trials have demonstrated non-inferiority of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) and low to intermediate surgical risk. However, mid-term results are still contentious.Question:Is TAVR superior to SAVR in the mid-term in terms of mortality outcomes or adverse cardiovascular events?Methods:We searched Embase, Pubmed and Cochrane databases for RCTs that compared TAVR with SAVR in patients with symptomatic severe AS with a follow-up of at least 4 years. Outcomes of interest were all-cause mortality and disabling stroke.Results:We included six RCTs involving 6,444 patients with severe AS, of whom 3,282 (50.9%) underwent TAVR. There was no difference in mortality from all causes (RR 1.08; 95%CI 0.94-1.25; p=0.30; I2=45%) and disabling stroke (RR 0.95; 95%CI 0.75-1.21; p=0.67; I2=9%) between groups. In the subgroup analysis, 5-year mortality (RR 1.28; 95%CI 1.10-1.49; I2=0%) was higher in the TAVI group. The new pacemaker implantation rate was higher in the TAVI group (RR 2.22; 95%CI 1.42-3.45; p=0.0004 ; I2=91%). However, new atrial fibrillation rate was higher in the SAVR group (RR 0.42; 95%CI 0.37-0.49; p=0.00001; I2=62%).Conclusion:Mid-term mortality and disabling stroke of patients with severe AS treated with TAVR or SAVR were similar.

Circulation, Volume 150, Issue Suppl_1, Page A4134796-A4134796, November 12, 2024. Introduction:Over 6 million patients (pts) present to US emergency departments annually with chest pain (CP), of which the majority are found to have no serious disease. Evaluation of these pts results in substantial costs for unnecessary hospitalization and extensive testing. We evaluated the utility of early discharge of selected low-risk (LR) CP pts from a chest pain unit (CPU) in which no predischarge testing or risk scores were used.Methods:This retrospective study analyzed 1,037 consecutive LR CP pts from a prospectively recorded database. LR was based on normal examination, stable hemodynamics, normal electrocardiograms (ECG), and negative cardiac troponin I, without pre-discharge functional or anatomic cardiac testing or risk scores. We assessed demographics, comorbidities, medications, and major cardiac events at 30 d and 6 mos post-discharge.Results:The study group of 1037 pts comprised 26% of the 4010 pts admitted to the CPU during the study interval from May 2005 to March 2015. Mean patient age was 55 yrs, 56% (n=575) were women, and comorbid conditions were frequent: hypertension (64.1%), dyslipidemia (46.1%), diabetes (25.7%), documented coronary artery disease (19.3%), previous revascularization (20.6%), previous myocardial infarction (10.1%). Length of stay (LOS) in the CPU to discharge was 10.4 hrs. Women received more discharge cardiac medications than men: antiplatelet agents, statins, beta blockers, ACE inhibitors, angiotensin II blockers, calcium channel blockers, and nitrates (p=0.0002 – 0.04).Follow-up (F/U) at 30 d was 91% (n=948) complete and revealed 0.3% (n=3) cardiac deaths, 0.6% (n=6) acute coronary syndromes (ACS), and 6.2% (n= 64) receiving revascularization. F/U at 6 mos was 90% (n=936) complete and total cumulative cardiac deaths were 0.9% (n=9), 0.7% (n=7) ACS and 6.3% (n=65) revascularization.Discussion:Cardiac events at both 30 d and 6 mos were very low and did not differ in men and women (P=0.8). LOS in CPU was minimized and patient safety was maintained. These selected LR pts remained at reduced risk for cardiac events despite a high rate of comorbidities. Early discharge of selected LR CP pts based on history, examination, ECG, and biomarker evaluation was safe and effective.Conclusion:This approach in selected LR pts has the potential to reduce unnecessary diagnostic testing and CPU LOS. This strategy could lead to substantial savings in healthcare costs without compromising patient safety.

Circulation, Volume 150, Issue Suppl_1, Page A4134273-A4134273, November 12, 2024. Background:Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome and its pathophysiology is not fully understood. A monoamine, 5-hydroxytryptamine (5-HT), is involved in diverse biological functions and suggested to play a role in cardiovascular diseases. However, the clinical relevance of 5-HT in HFpEF remains unclear.Aims:This study aimed to elucidate the clinical significance and prognostic value of 5- HT in patients with HFpEF.Methods:We conducted a prospective study involving 240 consecutive hospitalized patients with HFpEF (mean age 72 years, 52% male). We measured circulating blood 5-HT levels using the enzyme-linked immunosorbent assay method. Clinical and outcome data were collected.Results:Correlation analysis revealed that 5-HT levels were negatively correlated with blood B-type natriuretic peptide concentration and tricuspid regurgitation pressure gradient. When patients were stratified into two groups based on the median 5-HT levels (90.5 ng/mL), Kaplan-Meier analysis showed that HFpEF patients with low blood 5-HT levels had lower event-free survival rates from the composite event of cardiac death and worsening heart failure over a median follow-up period of 725 days (Figure). In a multivariable Cox proportional hazard model adjusting for confounding variables, low levels of 5-HT were independently associated with increased risks of the composite of cardiac events (hazard ratio, 3.25; P < 0.01).Conclusion:Low 5-HT levels are associated with adverse outcomes in patients with HFpEF and 5-HT may serve as a useful biomarker for predicting prognosis in such patients.

Circulation, Volume 150, Issue Suppl_1, Page A4134364-A4134364, November 12, 2024. Introduction:Inclisiran, an siRNA, targeting PCSK9 mRNA, reduces LDL-c levels. In SIRIUS in silico trial (NCT05974345), inclisiran was predicted to lower cardiovascular (CV) events in virtual patients with atherosclerotic cardiovascular disease (ASCVD).Research question:This analysis predicted the potential efficacy of inclisiran on CV outcomes in virtual patients with or without prior ischemic stroke (IS).Methods:The SIRIUS trial was conducted using a calibrated and validated knowledge-based mechanistic computational model of ASCVD applied to a virtual population with LDL-C ≥ 70 mg/dL. Each virtual patient was its own control. SIRIUS compared the efficacy of inclisiran vs placebo on top of High Intensity (HI) statin with or without ezetimibe on 3-Point-MACE defined as a composite of time to first occurrence of CV death, nonfatal myocardial infarction (MI) or nonfatal IS over 5 years in patients with or without prior IS. Occurrence of fatal and non-fatal (IS) was also individually assessed in time-to-first-event analyses.Results:Among 204,691 virtual SIRIUS ASCVD patients, 39 371 (19%) had prior IS. At 5 years, the predicted mean percentage reduction in LDL-C with inclisiran as compared to placebo was –49.17% and –49.88% in patients with or without prior IS respectively. Patients with prior IS were at higher risk of 3P-MACE than patients without IS both with placebo and inclisiran (17.01% vs 14.41% with placebo and 13.44% vs 10.83% with inclisiran). However, the predicted rate of 3P-MACE in the inclisiran arm was consistently lower than in the placebo arm for both prior IS and no prior IS (HR 0.78 medium uncertainty and 0.74 low uncertainty respectively). Compared to placebo, inclisiran was also predicted to consistently reduce fatal and non-fatal IS in patients with or without prior IS (5.45% vs 7.22%; HR: 0.75 medium uncertainty and 1.87% vs 2.54%; HR: 0.73 medium uncertainty respectively).Conclusion:SIRIUS provides insights into the potential efficacy of inclisiran on CV events suggesting a substantial 3P-MACE and fatal and non-fatal IS reduction in ASCVD patients including those with prior IS, several years before the availability of results from ongoing outcomes trials (ORION-4, VICTORION-2P).

Circulation, Volume 150, Issue Suppl_1, Page A4140382-A4140382, November 12, 2024. Introduction:Although an estimated 54% of patients with heart failure (HF) and chronic pain report high symptom-associated distress, it is unclear whether pain predicts reduced physical function, cognitive function, independent activities of daily living (IADL) or health-related quality of life (HRQL) over time. The aims were to evaluate baseline pain presence as a predictor of physical function, cognitive function, IADL, and HRQL at baseline, 10 weeks, 4 months, and 8 months after baseline.Methods:In a retrospective longitudinal secondary analysis, data were analyzed from 237 participants with HF enrolled in the Cognitive Intervention to Improve Memory in Heart Failure Patients study. Pain presence was measured with the Health Utilities Index Mark-3 Questionnaire (HUI-3), physical function was measured by the Timed Up and Go (TUG), cognitive function was measured with the Montreal Cognitive Assessment (MoCA), IADL was measured by the Everyday Problems Test (EPT), and HRQL was measured by the Minnesota Living with Heart Failure Questionnaire (LHFQ). Descriptive statistics, independent t-tests, and linear mixed models were used to achieve the aims while controlling for gender.Results:The demographics were mean age 66.31 ± 12.02 years, gender 46% men, 54% women, race 13.5% Black, 85.7% White, 0.8% Other, NYHA class I: 9.7% II: 37.6% III: 52.7%, average LVEF: 48.9%. A total of 160 (67.51%) reported pain.In independent t-tests, patients with pain experienced significantly longer (i.e., worse) TUG scores at all timepoints except 10 weeks, and significantly higher (i.e., worse) LHFQ scores at all timepoints (see Table 1). However, in linear mixed models, pain at baseline did not predict TUG scores (F = 1.239, p = .298), MoCA scores (F = 0.148, p = .931), EPT scores, (F = 0.522, p = .668), or LHFQ scores (F = 0.364, p = .779) over time – see Table 1.Conclusions:Patients with HF and pain experienced significantly worse LHFQ and TUG scores at multiple timepoints. However, pain did not significantly predict cognitive function, physical function, IADL, or HRQL over time. Future prospective studies are needed to examine other outcomes associated with pain in this population and utilize more robust pain instruments.

Circulation, Volume 150, Issue Suppl_1, Page A4140089-A4140089, November 12, 2024. Background:Lipid-lowering therapy for patients with acute myocardial infarction (AMI) is highly recommended, however, a paradox may exist where lower low-density lipoprotein cholesterol (LDL-C) levels at myocardial infarction (MI) are associated with poorer prognoses.Aim:To evaluate the association between baseline LDL-C levels and cardiovascular events after MI.Methods:We studied 1,987 consecutive AMI patients who underwent primary percutaneous coronary intervention and who had available data on preprocedural LDL-C between 1999-2015 at Juntendo University Shizuoka Hospital. Patients were divided into quartiles based on their LDL-C levels. The incidence of major adverse cardiac events (MACE), including all-cause death and recurrent MI up to 5-year, were evaluated.Results:Patients in the lowest LDL-C group were older and had higher prevalence of hypertension, diabetes mellitus and chronic kidney disease. During follow-up, 455 (20.9%) MACE were identified. Cumulative incidence of MACE was significantly higher in the lowest LDL-C group than in other groups (p

Circulation, Volume 150, Issue Suppl_1, Page A4129733-A4129733, November 12, 2024. Background:The impact of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on lipid components is unclear. The objective of this study was to measure the lipid-lowering effect of GLP-1RAs.Methods:A thorough database search was performed to identify placebo-controlled randomized controlled trials (RCTs) on GLP-1RA therapy through January 2023. From these trials, data was extracted and a robust statistical analysis was performed using a random effects model to determine outcomes with weighted mean difference (MD) in milligrams per deciliter (mg/dL) and 95% confidence intervals (CIs). The primary outcome was the mean difference in low-density lipoprotein cholesterol (LDL-C). Secondary outcomes were mean differences in total cholesterol (TC), triglycerides, high-density lipoprotein-C (HLD-C), and very low-density lipoprotein-C (VLDL-C). To account for covariates, subgroup analyses and meta-regression were performed.Results:A total of 33 studies were included in the final meta-analysis carried out between 2008 and 2023, which were conducted in 26 countries. Of the 5,918 participants, the study population comprised 2,603 (44%) males and 3,315 (56%) females, aged between 33.7 and 65.9 years. GLP-1RAs significantly reduced LDL-C compared to placebo (MD -2.93, 95% CI (-5.01, -0.85), P=0.01). Treatment effect was consistent regardless of duration of treatment;12 weeks or less MD: -5.39, 95% CI (-10.36, -0.42), P=0.03 vs >12 weeks MD: -2.39, 95% CI (-4.70, -0.007), P=0.04, P interaction 0.28). In our analysis, GLP-1RA reduced TC by ~7 mg/dl. There was no significant reduction in triglycerides (MD = -7.19, 95% CI (- 15.01, 0.62], P=0.07) and VLDL-C ~4 mg/dl (MD = -3.99, 95%, CI (-8.73, 0.75), P=0.10). Furthermore, GLP-1RA did not increase HDL-C (MD = -0.12, 95% CI (-0.73, 0.49], P=0.69. Regression analysis determined that weight loss did not affect the treatment effect on LDL-C (tau2=28.38, I2=99.83, R2=0.0, p=0.67), and total cholesterol (tau2=93.6, I2=99.86, R2=0.0, p=0.92).Conclusion:Patients on GLP-1RA experienced modest LDL-C and TC lowering compared to placebo. GLP-1RA did not decrease triglycerides and VLDL-C. GLP-1RA did not increase HDL-C.

Circulation, Volume 150, Issue Suppl_1, Page A4139307-A4139307, November 12, 2024. Introduction:Heart failure (HF) is associated with unique comorbidities and sequelae, which can affect clinical presentation and patient outcomes. This is specifically challenging when patients are evaluated for suspected acute coronary syndrome (ACS). We sought to compare the most important predictors of poor outcomes in patients with and without HF seen in the emergency department (ED) for ACS.Methods:This was a secondary analysis of a prospective observational cohort study of consecutive patients seen for symptoms suggestive of ACS, such as chest pain (CP) and dyspnea, in the EDs of three UPMC-affiliated tertiary care hospitals (NCT04237688, clinicaltrials.gov). Primary outcome was 30-day major adverse cardiac events (MACE), adjudicated by two independent reviewers. Clinical data were collected form charts and we used KNN to impute missing data for features, most of which had less than 12.5% missingness. For features with greater than 12.5% missingness (i.e., BNP, Mg), binary indicators were added to flag missing values. Data were normalized using the Euclidean norm. Two random forest (RF) classifiers were trained using 10-fold cross validation with 71 manually selected features available early in the ED course (i.e., vital signs, labs, past medical history, ECG), and tested on patients with and without known HF. Model performance was evaluated using AUROC, and top features were identified with SHAP values.Results:The sample included 2400 patients (age 59 ± 16 years; 47% female, 41% Black, 15.9% ACS), of whom 438 had HF (age 66 ± 14 years; 45% female, 49% Black, 15.1% ACS). Individuals with HF were more likely to experience MACE (38% vs 23%,p

Circulation, Volume 150, Issue Suppl_1, Page A4139207-A4139207, November 12, 2024. Background:Occurring in 0.6% to 10% of percutaneous coronary interventions (PCI), no-reflow is a complication associated with poor outcomes like myocardial infarction extension and death. The mechanism behind no-reflow is complex and likely multifactorial, and several drugs have been described for its management including intracoronary epinephrine (ICE) at doses ranging from 50 to 400 µg.Hypothesis:We hypothesize that supraselective administration of ICE at very low doses could be effective in the successful management of no-reflow.Methods:This single-center case series from Bucaramanga, Colombia (August 2021-October 2023) reports on 9 patients with/without ST-segment elevation myocardial infarction who underwent PCI and developed no-reflow. As first-line therapy for no-reflow management, supraselective administration of 5 to 50 µg of ICE was performed through an ad hoc fenestrated angioplasty balloon with a two-way drug perfusion technique (proximal to distal, and distal to proximal) at an approximate rate of 2 µg/min. All patients received a 1000 µg intracoronary bolus of Tirofiban during the procedure, and an IV infusion of 0.15 µg/kg/min was continued up to 24 hours postangioplasty.Results:The mean age of patients was 72.7±10.6 years, and 8 out of 9 patients were male. The mean LVEF was 34±11.3% before PCI. Patients received varying doses of ICE (5, 10, 20, 40 and 50 µg), 7 received it as the first-line treatment, while 2 received it as a second-line option after 360 µg of intracoronary adenosine failed to improve blood flow. TIMI 2 flow (4 patients) and TIMI 3 flow (5 patients) were achieved with no consistent association between higher ICE doses and achieving TIMI 3 flow. All 9 patients were discharged alive from the Cath Lab. However, one patient with LVEF 20% died of pulmonary edema 7 hours postangioplasty. The mean heart rate before and after the procedure was 78±20.8 bpm and 84±18.3 bpm respectively. No severe cardiac arrhythmias were observed. Transient inotropic support with a norepinephrine infusion was needed by 2 patients.Conclusion:The supraselective administration of ICE at very low doses (5-50 µg) resolved no-reflow in 100% of patients with acute coronary syndrome. We propose the use of this drug at very low doses as a first-line therapy for the management of coronary no-reflow, as well as the development of future randomized control trials to evaluate its effectiveness, and compare it to current therapies, in a larger population.

Circulation, Volume 150, Issue Suppl_1, Page A4142085-A4142085, November 12, 2024. Background:Highly precise definition of high-risk features associated with HFpEF may guide targeted treatments and inform biological studies. The aim of this two-step study is to 1) define a high risk HFpEF cluster with unsupervised machine learning approach using cardiac magnetic resonance (CMR), 2) define novel pulmonary vascular mechanics at rest and with exercise in low- vs. high-risk phenotypes. Vascular mechanics defines vessel- and cardiac cycle-specific flow dynamics in pulmonary circulation.Methods:48 HFpEF participants underwent CMR and invasive cardiopulmonary exercise testing. With unsupervised K-means clustering analyses using CMR data, two specific clusters were identified with different survival outcomes at 12-months (mortality and heart failure hospitalizations): HR=5.4 (CI:1.7-17.4), log-rank p

Circulation, Volume 150, Issue Suppl_1, Page A4139384-A4139384, November 12, 2024. Background:Recent evidence suggests a therapeutic role for ketosis in patients with heart failure (HF). However, little is known regarding the safety and effectiveness of a low carbohydrate ketogenic diet (LCKD) in patients with overweight or obesity and HF.Purpose:To examine the safety and effectiveness of a LCKD in patients with overweight or obesity and HF.Methods:A retrospective review from 2006-2024 was conducted of all patients with overweight or obesity and HF who followed a LCKD with clinical oversight for at least one year in a university health system. Changes in metabolic outcomes, echocardiographic measures, and medication use were assessed. Heart failure hospitalization (HFH) rates and rate ratios (RR) and all-cause mortality rates were calculated and stratified by HF classification.Results:A total of 125 patients met inclusion criteria, including 59 patients with HF with reduced ejection fraction (HFrEF) and 66 patients with HF with preserved ejection fraction (HFpEF). Patients lost a median (interquartile range) of 11.2 kg (-19.5, 4.4;p

Circulation, Volume 150, Issue Suppl_1, Page A4139970-A4139970, November 12, 2024. Introduction:Anticoagulation (AC) is the mainstay of thromboprophylaxis for stroke prevention in atrial fibrillation (AF) and is recommended. Gastrointestinal bleeding (GIB) is a common complication with varied severity and often poses a challenge for cardiologists and gastroenterologists. The decision of whether to continue anticoagulation, when to resume and at what dose is often the challenge. Our study assesses the safety and efficacy of low-dose apixaban compared to a full-dose in patients with AF who had GIB over the course of 5 years.Methods:We queried the US Collaborative Network (which contains 63 healthcare organizations) of TriNetX deidentified research database. Patients with atrial fibrillation who have history of gastrointestinal bleed who received apixaban were identified and divided into two cohorts; patients on low dose of 2.5mg and those on full dose of 5mg. We excluded patients with serum creatinine ≥ 1.5 mg/dL and patients with body weight ≤ 132 lbs.Two well-matched cohorts were created using a 1:1 propensity-score matching (PSM) model using patients’ baseline characteristics and comorbidities. PSM components were age, gender, race, PPI use, anti-platelets, hypertension, coronary artery disease, heart failure, COPD, and CKD. We compared the risk of stroke, GIB, and mortality in 5 years.Results:A total of 19,427 patients with UGIB who have AFIB received oral apixaban were identified. Of those, 19% (n=3,701) were on low dose of 2.5mg and 81% (n=15,726) were on full dose of 5mg of apixaban. After PSM, each cohort included 3,701 patients. There was no statistically significant difference in the risk of stroke in 5 years between the patients on low dose compared to those on full dose (10.9% vs 11.9%, p=0.3). However, patients on low dose had a statistically significant lower risk of GIB compared to those on full dose (30.4% vs 35.3%, p