Risultati per: Follow-up ottimale dopo embolia polmonare acuta

Circulation, Volume 146, Issue Suppl_1, Page A12737-A12737, November 8, 2022. Introduction:Carotid sinus massage (CSM) has been used to evaluate carotid sinus hypersensitivity. Its role in evaluating a vasodepressor response has not been well studied. CSM can also result in a vasodepressor response in the absence of significant bradycardia. Its role in predicting the subsequent outcome of head-up tilt testing (HUT) is not well defined.Hypothesis:A vasodepressor response elicited with baseline carotid sinus massage (CSM) may predict the subsequent outcome of HUT.Methods:In this prospective study Consecutive patients with a history suggestive of a reflex neurocardiogenic etiology underwent HUT. Patients underwent HUT testing using a standard protocol, including baseline CSM in the supine posture followed by HUT testing at 60 degrees for 30 minutes. If negative, a repeat of CSM was performed in the upright posture. Then, isoproterenol was infused in incremental dose 1 to 3 mcg/minute.Results:25 patients (20 females and 5 males) with a mean age of 52.87±6.77 years underwent HUT. 5 out of 25 (20%) patients had a positive tilt result for a vasodepressor response. 4 of these 5 patients had a significant vasodepressor response (symptomatic hypotension BP drop less than 30 mmHg) without significant bradycardia (HR less than 50 BPM) during CSM in the supine posture. Of these patients, 3 patients became positive during HUT and 1 patient became positive during isoproterenol infusion. The positive predictive value was 0.8. Sensitivity was 67%. 20 out of 25 (80%) patients had a negative tilt result for a vasodepressor response despite protocol completion. 18 of these 20 patients had no drop in BP during CSM and no significant bradycardia. The negative predictive value was 0.9. The specificity was 94.74%. 2 of these patients had a negative response on CSM but a borderline response at HUT with borderline symptoms with the isoproterenol. These 2 had a transient drop in BP when CSM was repeated at the end of 30 minutes during the head-up position.Conclusions:In this population of patients, a negative CSM in the supine posture predicted a subsequent negative Tilt test. Baseline CSM can be performed at the bedside and may obviate the need for full tilt table testing even for patients with a clinical diagnosis of reflex syncope (vasodepressor).

Circulation, Volume 146, Issue Suppl_1, Page A15218-A15218, November 8, 2022. Background:Cardiac amyloidosis (CA) is most commonly caused by the infiltration of misfolded amyloid transthyretin (ATTR) or light chain (AL) molecules in the myocardium. The workup for CA requires serum assessment to exclude the rapidly progressive AL subtype before imaging to assess the more common and indolent ATTR form. The diagnostic algorithm has the potential to become complex as in this case about a woman with Sjogren’s syndrome which predisposes to plasma cell dyscrasias.Case:A 68-year-old female with congenital long QT syndrome requiring implantable cardioverter-defibrillator (ICD), bilateral carpal tunnel, and recent diagnosis of Sjogren’s syndrome was found to have new systolic heart failure during workup for interstitial lung disease. Labs revealed pancytopenia, abnormal kappa/lambda ratio (2.25), and polyclonal gammopathy on immunofixation. Echocardiogram showed moderately reduced systolic function with an ejection fraction of 35-40% and moderate concentric left ventricular hypertrophy.Decision-making:Cardiology obtained cardiac magnetic resonance imaging (CMR) that returned indeterminate due to ICD artifact. Hematology performed a bone marrow biopsy that was negative for plasma cell dyscrasia, though stained positive for amyloid on congo red with mass spectrometry revealing the valine 142 isoleucine (Val142Ile) amino acid substitution consistent with hereditary ATTR-CA. To definitively assess for endomyocardial ATTR involvement the patient was sent for cardiac scintigraphy using 99mTc-labeled pyrophosphate which returned negative with a cardiac to contralateral lung uptake ratio of 1.001 and visual grade of 0. With suspicion still high, an endomyocardial biopsy was pursued and stained positive for congo red with mass spectrometry confirming hereditary Val142Ile ATTR-CA, allowing for tafamidis initiation.Conclusion:We present a complex diagnostic case of ATTR amyloid in a patient who is at high risk for plasma cell dyscrasias with an abnormal kappa/lambda ratio, non-diagnostic CMR, and negative nuclear scan. Despite significant advances in imaging techniques allowing for less invasive diagnostics, this case highlights the role of endomyocardial biopsy in complicated cases.

Circulation, Volume 146, Issue Suppl_1, Page A12852-A12852, November 8, 2022. Introduction:Small aortic annulus (SAA) is a clinical challenge in managing aortic stenosis (AS). The SAA has been associated with poorer outcomes after surgical AVR with an increased risk of perioperative and overall mortality, suboptimal valvular hemodynamics, and adverse cardiovascular events.Hypothesis:TAVI could be a therapeutic alternative in these patients.Methods:We performed a retrospective analysis of all patients with AS treated with TAVI from 2015 to 2021 in our center, with SAA defined as the aortic annulus of ≤22mm perimeter-derived diameter (PDD), measured by CT.Results:Sixty-eight patients were included (85.3% women, 83.2± 6.5 years) with a mean PDD of 20.7 ± 1.1 mm. The 14.7% had LVEF 23mm in 17.7%. The perioperative implant success rate was 100% defined as single prosthesis implantation with a mean gradient

Circulation, Volume 146, Issue Suppl_1, Page A10049-A10049, November 8, 2022. Introduction:Telemedicine offers considerable opportunities to bring high-quality cardiovascular care. Its role in the ischemic-heart disease continuum in patients with acute coronary syndromes (ACS) has not been previously evaluated.Hypothesis:Virtual visits (VV) can be used as an alternative to in-person (IV) follow-up office visits in patients with ACS.Methods:418 patients undergoing angiography for ACS (104 STEMI/314 NSTEMI) were randomized to follow-up via VV (n=208) using a free patient commercial platform or IV (n=210) between February and December 2020. Primary endpoints included major adverse cardiovascular events (MACE) at 1,6 and12 months and 1-year all-cause mortality. Secondary endpoints included 1-year adherence to guideline based-medical therapy including LDL-c < 70 mg/dl, dual antiplatelet therapy, beta-blockers, ACE/ARB/ARNI, Aldosterone antagonists for patients with EF

Circulation, Volume 146, Issue Suppl_1, Page A9409-A9409, November 8, 2022. Introduction:Adults with congenital heart disease (CHD) benefit from cardiology follow-up. However, benefit for children is less clear as studies of follow-up patterns in children with CHD are limited.Hypothesis:There are identifiable risks for loss to cardiology follow-up in children with CHD, and loss to follow-up changes healthcare utilization and outcomes.Methods:Our cohort included children

Circulation, Volume 146, Issue Suppl_1, Page A13131-A13131, November 8, 2022. Introduction:Few studies have described the characteristics of the left atrial appendage (LAA) using three dimensional (3D) transesophageal echocardiography (TEE) in atrial fibrillation (AF).Hypothesis:We hypothesized that 3D characteristics of the LAA could further characterize patients in AF.Methods:We prospectively evaluated 156 patients hospitalized for AF with two-dimensional (2D) transthoracic and 3D TEE of the LAA within 24 hours of admission. 3D parameters were off-line analysed with Tomtec software (4D Cardio-View, Generic Volume, Philips) (Figure 1A). Patients were divided into two groups according to the cardiac rhythm at 2 years of follow up: restoration of sinus rhythm (SR group, 107 patients) or persistence of atrial fibrillation (AF group, 49 patients).Results:The mean age of the population was 66±11 years and 95 (61%) patients were male. At admission using 2D transthoracic echocardiography, AF group had in comparison with SR group higher left atrial end-systolic volume indexed (respectively 48.0 (38.7-57.0) versus 41.8 (35.0-51.5) ml/m2, p=0.0096), higher E velocity (respectively 0.90 (0.78-1.00) versus 0.76 (0.62-0.91) m/s, p= 0.0001) and higher pulmonary arterial pressure (respectively 31 (25-38) versus 28 (23-33) mmHg, p=0.0142). There were no significant differences in left ventricle ejection fraction and right atrial end-systolic volume indexed. At admission using 2D TEE, AF group had in comparison with SR group lower emptying flow velocity (29 (20-38) versus 38 (26-53) cm/s, p=0.002) and filling flow velocity (29 (20-39) versus 40 (29-56) cm/s, p=0.001) of the LAA. In 3D TEE, AF group had higher 3D end-systolic and end-diastolic LAA volumes (non-indexed and indexed) and no significant differences in LAA ostium in comparison with SR group (Figure 1B).Conclusions:3D evaluation of the LAA reflects a degree of cardiac cavities remodeling in AF and seems to be associated with the evolution of cardiac rhythm at two-years follow-up.

Circulation, Volume 146, Issue Suppl_1, Page A10067-A10067, November 8, 2022. Introduction:Preeclampsia is associated with cardiovascular disease (CVD), and follow-up in women for CVD prevention is essential. We examined racial differences in follow-up with primary or cardiology care and assessed if social factors modified that association.Methods:We conducted our analysis in an administrative database (Optum’s de-identified Clinformatics® Data Mart) and identified women with preeclampsia diagnosed from 9/2014-9/2019. Odds of a follow-up visit with a primary care provider or cardiologist within 6 months after delivery were compared among Black versus White women using multivariable logistic regression models adjusting for age, comorbidities (by Elixhauser score), income, education, insurance type, and number of adults per household. We examined the effect modification of education and income on follow-up by race. A Cox proportional hazard model was used to compare time to follow-up.Results:Of 22,887 women with a diagnosis of preeclampsia (age 31.7±5.6 years), 2,736 (12.0%) were identified as Black race and 3440 (15.0%) Hispanic. Education, income, and comorbidities differed by race and ethnicity. Black women had lower odds of follow-up with a primary care provider or cardiologist within 6 months after delivery: adjusted odds ratio (aOR) 0.85 [95% confidence interval (CI) 0.78-0.92] compared with White women and were 13% less likely to have follow-up in adjusted time to event models. Hispanic women also had lower odds of follow-up: aOR 0.84 [95% CI 0.78-0.91] and were 12% less likely to have follow-up compared with white women. There was an effect modification of education by race on follow-up (p for interaction=0.001), but not income (p for interaction=0.14).Conclusions:Black and Hispanic women have decreased odds of follow-up with a primary care provider or cardiologist than White women in the 6 months postpartum, a disparity that may be modified by socioeconomic factors. Improving follow-up care for Black women, particularly those with less than a college-level education, may enhance CVD prevention.

Circulation, Volume 146, Issue Suppl_1, Page A11762-A11762, November 8, 2022. Background:Considering a paucity of pooled data on the influence of Body Mass Index (BMI) on long-term cardiac outcomes in individuals with Hypertrophic Obstructive Cardiomyopathy(HOCM), we conducted this systematic review.Methods:PUBMED, Scopus, EMBASE and Google Scholar were used to screen studies reporting Mortality/Major Adverse Cardiac Events (MACE) and Sudden Cardiac Death(SCD) among obese vs nonobese HOCM patients. Pooled odds ratios(OR) and heterogeneity were assessed with random-effects models and I2statistics. Subgroup analysis was performed to assess the risk by study type, sample size, country and procedure. The leave-one-study-out method was used for sensitivity analysis.Results:Of the 178 titles screened, we included 13 studies published between 2016-2022 with a total of 2,409,397 HOCM patients followed for a median of 6 years (1.8-8.2 year range). The sample had a higher proportion of males (61.33%) with a mean age of 56.3 years (37-78 year range). The unadjusted [OR=1.55(1.09-2.21), I2=96%] and adjusted [OR=1.28 (1.06-1.54), I2=82.7%] pooled odds of all-cause mortality were significantly higher with increased BMI. On subgroup analyses, prospective studies showed higher odds [n=3, 1.79 (1.23-2.6), p=1000:OR=1.39(1.24-1.57)] but lower sample sizes from other countries [n

Circulation, Volume 146, Issue Suppl_1, Page A11732-A11732, November 8, 2022. Introduction:Recent data shows that when adults are discharged after hospitalization for acute heart failure (HF), a clinic follow up with either cardiology or general medicine within 7 days results in significantly lower chances of 30 day readmissions. We sought to analyze the trends of clinic follow up after acute HF hospitalization and the associated barriers and facilitators at our safety net hospital.Methods:Data was extracted from the electronic medical records using ICD 9,10 codes for acute HF admissions between Jan 2019 and Dec 2021. Quarterly trends of rates of clinic follow up were analyzed over the past 3 years; t-test was used to assess for statistical significance. Multivariable logistic regression models were constructed to test the association between patient level factors and clinic follow up after adjusting for sociodemographic factors. A p value < 0.05 was used to establish significance.Results:Of 1,037 patients admitted for acute HF between 2019-2021, 29.5% were 65 years or older, 64.7% were males, 48.7% were Black and 16.6% were uninsured. Only 8% and 23.1% had a 7 and 14 day clinic follow up respectively. Of those with scheduled follow up 65% and 56% showed up to their appointments at 7 and 14 days respectively. Overtime we noted an increase in the proportion of encounters with a 7 day follow up although the effective follow up (after accounting for no-shows) remained unchanged. Patients that had an inpatient cardiology consult had higher odds of getting a 7 day follow up (OR=1.42, p value = 0.001) after adjusting for age, gender, insurance status and race (black > white, OR = 1.34, p

Circulation, Volume 146, Issue Suppl_1, Page A14713-A14713, November 8, 2022. INTRODUCTION : Only limited data are available and long term follow up studies are insufficient about optimal treatment in patients with chronic total occlusion of a single coronary artery.METHODS : A total of 2,024 patients with CTO were retrospectively enrolled in Samsung Medical Center CTO registry between March 2003 and February 2012 and followed-up for 10 years. Patients underwent coronary artery bypass graft (n = 477) and Patients with multi-vessel CTO (n = 1,112) were excluded. Finally patients with chronic total occlusion of a single coronary artery (n = 435) were analyzed. Divided into two groups, optimal medical group (OMT, n = 147) and percutaneous coronary intervention group (PCI, n = 288) in accordance with initial treatment strategy. Cox regression analysis and propensity score matching was performed to adjust for confounding factors. Primary outcome was cardiac death.RESULT : During the follow up 10 years, we identified that there were no significant differences between OMT group and PCI group in rate of cardiac death (adjusted HR, 0.57 [95% CI, 0.26-1.24]; P=0.16) as well as rate of major adverse cardiac event (adjusted HR, 0.79 [95% CI, 0.52-1.19]; P=0.26) . After propensity score matching analyses, OMT group and PCI group still have no significant differences in rate of cardiac death (adjusted HR, 0.54 [95% CI, 0.24-1.19]; P=0.13) and rate of MACE (adjusted HR, 0.97 [95% CI, 0.62-1.52]; P=0.89).CONCLUSION : This retrospective observational study supported that as an initial treatment strategy in patients of single vessel CTO, PCI did not decrease the rate of cardiac death or MACE.KEYWORD : Chronic total occlusion, Optimal medical treatment, Percutaneous coronary intervention

Circulation, Volume 146, Issue Suppl_1, Page A234-A234, November 8, 2022. Introduction:Despite receiving conventional (C) CPR and other standard treatments, almost all out-of-hospital cardiac arrest (OHCA) patients with non-shockable presentations will still die. As non-shockable presentations comprise nearly 80% of all OHCA cases, alternative treatment strategies are clearly indicated.Hypothesis:Compared to C-CPR controls, treatment with AHUP CPR (defined as the combination of an automated head up positioning [AHUP] device, an impedance threshold device [ITD], and manual and/or automated suction cup-based CPR), increases the probability of survival (SURV) to hospital discharge as well as neurologically favorable survival (N-SURV) for OHCA patients with (first recorded) non-shockable presentations.Methods:Prospectively collected data were obtained from a national AHUP CPR registry from 5 early adopting first responder EMS agencies that routinely initiated immediate AHUP CPR and tracked OHCA outcomes. Comparisons were made to C-CPR controls using individual patient data from high-performing prehospital systems participating in the NIH-funded Resuscitation Outcomes Consortium ROC-PRIMED and ResQTrial studies. AHUP and C-CPR patients presenting with a non-shockable rhythm were matched for the same discrete time interval from the 9-1-1 call to EMS CPR start time and propensity score for the key baseline covariables associated with outcome (e.g., age, sex, bystander-witnessed, bystander CPR) with a 1:1 ratio. Neuro-intact survival was defined as a modified Rankin Scale

Circulation, Volume 146, Issue Suppl_1, Page A12498-A12498, November 8, 2022. Introduction:One of the most well-established risk markers for sudden cardiac death is non-sustained ventricular tachycardia (NSVT; 3 ventricular beats with a rate of ≥120 bpm, lasting for

Circulation, Volume 146, Issue Suppl_1, Page A14281-A14281, November 8, 2022. Background:The predictive value of termination of atrial fibrillation (AF) with direct-current (DC) cardioversion (CV) during catheter ablation (CA) during a long-term follow-up is not known.Methods:We studied the long-term success of CV during ablation in patients who underwent catheter ablation of AF and followed them for recurrence of AF/atrial flutter (AFL).Results:Of 187 patients (male: 75%, mean age: 60.3 ± 10.7 years), 96 (51.3%) patients required DC cardioversion during the initial CA. A mean number of 1.4 ± 0.6 ablations (p=NS) were performed during follow-up in both groups. There were no significant differences in baseline characteristics including age, gender, race, body mass index, left ventricular ejection fraction, and presence of hypertension, diabetes, and valvular disease. During a median (±1SE) follow-up of 5.23 ± 0.17 years, a significantly higher percentage of patients who needed CV during CA had recurrence of AF/AFL as compared to patients who did not need CV to terminate AF during CA (39.6 vs 16.5%, p < 0.001). Cox regression analysis confirmed DC cardioversion during ablation as a predictor of recurrence of AF/AFL at time of last follow-up (OR: 2.78, 95% CI 1.52 to 5.10, p < 0.001). Kaplan-Meier survival analysis shows significantly decreased time to recurrence in patients who had CV during initial ablation than those who did not require DC cardioversion (log-rank p

Circulation, Volume 146, Issue Suppl_1, Page A9265-A9265, November 8, 2022. Introduction:Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) has been shown to improve cardiovascular morbidity and mortality. To date, no studies have investigated disparities in utilization and delivery of RM. This study was performed to investigate if racial and socioeconomic disparities are present in CIED RM.Methods:Retrospective observational cohort study at a single tertiary care center in the United States. Patients who received a newly implanted CIED or device upgrade between 01/17 to 12/20 were included. Patients were classified as RM positive when they underwent at least ≥2 remote interrogations per year during follow-up.Results:Of all eligible patients, 2520 patients were included and 35% were female. The mean follow-up was 25 months. Mean age was 71±14 years. Pacemakers constituted 66% of implanted devices, while 26% were ICDs, and 8% CRT-Ds. Most patients (83%) were White non-Hispanic (WNH) patients. During follow-up, 66% of patients were classified as RM positive. In an adjusted regression model, these patients were younger (p=0.025) and more frequently had an ICD (HR=1.68; p

Circulation, Volume 146, Issue Suppl_1, Page A10849-A10849, November 8, 2022. Introduction:Long COVID syndrome is defined as physical, cognitive and psychological symptoms that persist for over 12 weeks following the acute illness and are not explained by other diagnosis.Aim:To assess medical and health-related quality of life (HR QOL) outcomes at medium-term follow-up in subjects previously infected with COVID-19.Methods:2646 patients who were diagnosed with COVID-19 infection were randomly selected. They were interviewed to assess for symptoms and HR QOL using a post-COVID questionnaire and Short Form Survey (SF-36) respectively. Blood investigations were taken.Results:The median age was 44 years (IQR 31-55), 49% were males. 5% were hospitalised and 1% intubated. Smokers comprised 17%, 10% were ex-smokers. 17% suffered from hypertension, 11% hyperlipidaemia, ischaemic heart disease was present in 2%, heart failure in 1%, obesity in 18%, chronic kidney disease in 0.2%, chronic respiratory disease in 7% and type 2 diabetes mellitus (DM) in 7%.Median time to follow up was 142 days (IQR 128-161). 22% of participants claimed they felt worse than before. Most common symptoms were anosmia (55%), abnormal taste (53%), fatigue (23%), dyspnoea (23%), headache (20%) and myalgia (15%). The SF-36 survey showed that hospitalized patients fared worse in all domains except for role-emotional.New onset DM was diagnosed in 50 patients, similar to the rate of undiagnosed DM in the population. Hospitalised patients had significantly higher liver transaminases, FPG, HbA1c, uric acid, RDW, MPV, triglyceride levels and troponin levels but lower eGFR and HDL-cholesterol at follow-up. The differences in RDW, MPV, triglyceride, GGT and FPG remained significant after adjusting for confounders (Table 1).Conclusions:A significant proportion of post-COVID patients were symptomatic at medium-term follow-up. Hospitalised patients had more biochemical and haematological abnormalities, suggesting ongoing inflammation in those more severely affected.

Circulation, Volume 146, Issue Suppl_1, Page A15674-A15674, November 8, 2022. Introduction:Cardiac amyloidosis (CA) is an underdiagnosed cause of heart failure. Echocardiography provides an excellent screening tool for cardiac amyloidosis. For patients with echocardiographic findings suggestive of cardiac amyloidosis, it is unknown how frequently follow-up imaging such as 99mTc PYP-scan or cardiac MRI is obtained. Diagnosis rates after a suggestive echocardiogram as well as disparities in rates of follow-up imaging and subsequent CA diagnosis are also unknown.Methods:We extracted all index cardiac echocardiograms at our institutions of adult patients that were suggestive of a possible diagnosis of CA, which was defined as: moderate or worse left ventricular concentric hypertrophy plus grade II or grade III diastolic dysfunction or diastology could not be determined due to arrhythmia in those with atrial fibrillation. Patients with known diagnosis of amyloidosis were excluded. We determined which patients underwent further testing with99mTc-PYP scan or cardiac MRI. We performed a population based case control study in which we compared clinical and demographic factors between those who underwent follow-up testing with either PYP scan or cardiac MRI (cases) vs those who did not (controls).Results:Of 1348 echoes that met inclusion criteria, only 110 (8.2%) underwent PYP scan or cardiac MRI. Of those, 10.0 (11%) patients ultimately were diagnosed with CA. Between cases and controls, there was no difference in age, gender, or race/ethnicity. There were no differences in rates of HFrEF or HFpEF between cases and controls. Cases had lower rates of CKD (27% vs. 40%, p=0.01) and ESRD (8.2% vs 15%, p=0.03) and had higher rates of carpal tunnel disease (12% vs. 6%), p