Risultati per: Low Back Pain: raccomandazioni

Circulation, Volume 150, Issue Suppl_1, Page A4134977-A4134977, November 12, 2024. Introduction:Coronary artery calcium (CAC) scoring is a powerful tool for atherosclerotic cardiovascular disease (ASCVD) risk assessment. Guidelines recommend consideration of CAC scoring in intermediate risk patients, but it’s utility in low and borderline risk patients is less clear.Methods:We used data from 2,894 participants from MESA with low (

Circulation, Volume 150, Issue Suppl_1, Page A4142236-A4142236, November 12, 2024. Background:Early aspirin is standard of care after acute ischemic stroke (AIS). There is increased incidence of venous thromboembolism (VTE) in patients with AIS and reduced mobility, but thromboprophylaxis with low molecular weight heparin (LMWH) must be weighed against the risk of bleeding. We compared safety and efficacy of early aspirin with or without LMWH in AIS and reduced mobility.Methods:Patients with AIS and Modified Rankin Scale of 4-5 were identified in the TriNetX Research Database. Patients were categorized as either aspirin alone or aspirin plus LMWH within 72 hours of AIS. We excluded patients receiving any other anticoagulant, thrombolytic agents, or with history of long-term anticoagulation or atrial fibrillation. Bivariable analysis was performed with chi-square and independentt-tests. Cohorts were then 1:1 propensity score-matched by 26 relevant covariables including demographics, comorbidities, and medications. Outcomes were all-cause mortality, VTE, intracranial hemorrhage, and extracranial hemorrhage at 30 and 90 days.Results:We included 2,572 patients in each cohort. Mean age and SD was 71±13, and 48% were male. There was no significant difference in all-cause mortality in patients treated with aspirin alone versus aspirin plus LMWH at 30 days (RR=1.1, 95% CI: 0.91-1.3) or 90 days (RR=1.2, 95% CI: 0.98-1.3). Similarly, the risks of VTE and intracranial or extracranial hemorrhage were not significantly different at either timepoint.Conclusions:In patients with AIS and reduced mobility, the early addition of LMWH to aspirin may have similar risks of bleeding, all-cause mortality, and VTE.

Circulation, Volume 150, Issue Suppl_1, Page A4140774-A4140774, November 12, 2024. Background:Recurrent pericarditis results from inflammasome activation and is associated with significant morbidity. Cannabidiol has been shown to block numerous inflammasome signaling pathways, including reducing transcription of pro-IL-1β and NLRP3, and inhibiting secretion of IL-1β and IL-6.Aim:To assess the impact of oral pharmaceutically manufactured (P-)cannabidiol in recurrent pericarditis patients (pts).Methods:Adult pts (≥18 years) with symptomatic, recurrent pericarditis (≥2 recurrences) were eligible for this open-label, multicenter study. Eligible pts had pericarditis chest pain with a numerical rating scale (NRS) pain score ≥4 within 7 days prior to enrollment, together with either elevated (≥1.0 mg/dL) C-reactive protein (CRP) within the prior 7 days or prior pericardial late gadolinium enhancement (LGE) on cardiac imaging. Pts had to be on chronic treatment with NSAIDs, colchicine or corticosteroids (any combination) with stable baseline (BL) doses. Oral P-cannabidiol was uptitrated to 10 mg/kg twice daily (BID), or maximum tolerated dose. The primary efficacy endpoint was improvement in NRS pain score at week 8 (WK8). A secondary efficacy endpoint among pts with elevated BL CRP was the percentage of pts with CRP normalization (≤0.5 mg/dL) at WK8.Results:27 pts, mean age of 53 years (range 24-77), 18 of female sex, with a median of 3 prior pericarditis episodes were enrolled. CRP was ≥1.0 mg/dL in 10 pts (37%) at BL. Prior evidence of LGE was present in 21 pts (78%). At BL, 41% of pts were receiving corticosteroid therapy. The highest tolerated study medication dose was BID 10 mg/kg in 20 pts (74.1%), 7.5 mg/kg in 4 pts (14.8%), and 5 mg/kg in 3 pts (11.1%). All 27 pts (100%) completed the WK8 visit. Mean NRS score decreased by 3.7, from 5.8 at BL to 2.1 at WK8. In those with CRP elevation at BL, CRP normalized in 8 pts (80%) by WK8, with mean CRP decreasing from 5.71 to 0.31 mg/dL. Study medication was discontinued due to AEs in 2 pts (7.4%). 24 pts (89%) tolerated P-cannabidiol with a treatment response and proceeded into the 18-week extension period (EP) where background therapy is weaned.Conclusions:Among pts with symptomatic pericarditis recurrence, oral administration of P-cannabidiol led to a clinically relevant reduction in pericarditis chest pain (measured by NRS score) and in CRP. P-cannabidiol was shown to be safe and generally well tolerated, with the majority of pts reaching the target dose and continuing into the study EP.

Circulation, Volume 150, Issue Suppl_1, Page A4137144-A4137144, November 12, 2024. Introduction:Subacute stent thrombosis (ST) is related to high rates of cardiac reinfarction. We present a case of reinfarction from ST. The patient’s chest pain (CP) was not alleviated with initial revascularization of his left circumflex (LCx) ST, requiring PCI to his right coronary artery (RCA) chronic total occlusion (CTO). This is a novel approach to CTO PCI which is traditionally a non-urgent procedure.Case:A 53-year-old male with a history of coronary artery disease and surgical turndown presented to the ED with CP. Two weeks prior he had impella guided LM bifurcation PCI with DES and ramus intermedius (RI) angioplasty (PTA) but was nonadherent to clopidogrel. He had a BP of 127/85, HR of 65, and was on room air. Exam was unremarkable. His EKG was in sinus rhythm with S-T depressions ~1mm in leads V1-V4 concerning for posterior infarction. HS-troponin (HST) was 60. Angiography (CA) showed thrombotic occlusion of his LCx DES (Fig 1a) and an RCA CTO (Fig 1c). Optical coherence tomography (OCT) revealed DES struts overlying the ostial LCx concerning for mechanical deformation from carinal shift. OCT guided PTA and laser thrombectomy (LT) of the LCx led to TIMI-3 Flow. LT and kissing balloon inflation (BI) was performed on the LAD and LCx to reshape the carina. HST peaked at 116,012. He had CCS Class IV CP despite medical therapy and returned for re-look CA with TIMI-3 flow in the left-sided circulation without thrombus (Fig 1b). He had PCI to his distal RCA CTO with two DES and TIMI-3 flow in the RCA (Fig 1d). He did not have recurrence of CP.Discussion:Bifurcation PCI leads to challenges from anatomic reconfiguration, metallic DES deformity, and changes in blood flow leading to increased risk of distal ST. This patient’s CA demonstrated LM DES material overlying the LCx from carinal shifting which likely led to interrupted flow dynamics. His LCx ST was partly due to this stasis and his clopidogrel nonadherence. Despite PCI of his LCx his CP remained with poor collateral flow from the left circulation. While CTO procedures are typically done non urgently, emergent intervention on our patient’s RCA CTO led to complete resolution of his CP and clear benefit for symptomatic management.

Circulation, Volume 150, Issue Suppl_1, Page A4143604-A4143604, November 12, 2024. Background:Rivaroxaban is a novel oral anticoagulant suggested as an alternative to low molecular weight heparin (LMWH). However, its efficacy and safety compared to LMWH for treating venous thromboembolism (VTE) in cancer patients remain unclear.Hypothesis:This study aims to compare the efficacy and safety of rivaroxaban against LMWH for treating VTE in cancer patients.Methods:We conducted a literature search for relevant articles on PubMed, Google Scholar, and Embase. Outcomes were pooled using the DerSimonian and Laird random-effects model as risk ratios (RR) with 95% confidence intervals (CI). A p-value of

Circulation, Volume 150, Issue Suppl_1, Page A4144297-A4144297, November 12, 2024. Introduction:Non-ST elevation myocardial infarction (NSTEMI) represents about 70% of ACS cases, and nearly one-third of these patients have an occluded coronary artery that may benefit from revascularization. The 13-item ACS Symptom Checklist is a validated tool designed for rapid assessment of Acute Coronary Syndrome (ACS) symptoms. We aimed to evaluate the effectiveness of the ACS Symptom Checklist in differentiating NSTEMI patients with and without an occluded artery.Methods:All NSTEMI patients treated at the University of Rochester Medical Center between 2015-2023 (n=3515) were included. The 13-items from the ACS Symptom Checklist were extracted using natural language processing (NLP) before coronary angiography or within 24 hours of presentation. An occluded coronary artery was one requiring revascularization with percutaneous coronary intervention. Chi-Square was used to assess the sensitivity and specificity of each symptom for an acutely occluded coronary artery. We used logistic regression models to assess the odds of an acutely occluded artery after controlling for age, obesity, and diabetes and stratified by sex.Results:Patients were predominantly male (58%, n=2048), older (69+13 years), and White (85%, n=2988), and 15% (n=524) underwent revascularization. Diabetes (18%, n=629) and obesity (40%, n=1387) were common comorbidities. Upper back pain (10.5% vs. 14.1%, p=0.03), palpitations (19.3% vs. 23.9%, p=0.02), arm pain (21.0% vs 16.7%, p=0.05), unusual fatigue (8.9% vs. 22.2%, p

Circulation, Volume 150, Issue Suppl_1, Page A4137942-A4137942, November 12, 2024. Introduction:Systemic anticoagulation in Extracorporeal Membrane Oxygenation (ECMO) aims to reduce the risk of patient and circuit thrombosis, but requires monitoring due to risk of bleeding. Activated partial thromboplastin time (aPTT) is one of many tests utilized for this purpose. However, it lacks validation in ECMO patients and its clinical utility necessitates further analysis.Aim:We aim to elucidate associations between low versus high aPTT-guided anticoagulation monitoring and total time, survival, bleeding, and thrombotic events during ECMO.Methods:A retrospective review was conducted on 93 patients requiring ECMO at our institution between January 2020 and March 2021. Study inclusion required more than 2 days on ECMO and maintenance on anticoagulation with aPTT targets predominantly greater ( >) or less than (60s and severe epistaxis (1/30 in the low and 9/44 in the high group; two-tailed p = .042). Though not significant, a greater incidence of oxygenator failure and circuit thrombosis was recorded in the high group.Conclusions:Our findings did not establish a relationship between aPTT target 60s and survival, bleeding, or thrombotic events. However, aPTT target >60s was associated with longer average ECMO time and severe epistaxis. Further investigation of aPTT-guided anticoagulation monitoring in ECMO patients is needed.

Circulation, Volume 150, Issue Suppl_1, Page A4146960-A4146960, November 12, 2024. Background:Hypertension (HTN) is a major risk factor for cardiovascular disease (CVD) and is the leading cause of morbidity and mortality globally, with a rise in prevalence in low and middle-income countries (LMIC). While HTN awareness, treatment, and control have increased in high-income countries (HIC), this increase is less marked in LMIC.Objective:To describe the characteristics of social determinants of health associated with HTN in LMIC rural areas.Methods:Data was obtained from a cluster-randomized trial in Guatemala, implemented in rural areas nationwide. Trained interviewers used standardized questionnaires and measurements to collect data. HTN stage was defined according to AHA’s 2018 guidelines. The chi-squared test compared sociodemographic characteristics between HTN stages I and II.Results:Data from 1580 hypertensive participants with blood pressure readings over 130/80 mmHg with or without anti-hypertensive treatment was analyzed. The median age was 63 years, with 72% women. Spanish (Guatemala’s official language) was spoken by 65%, and the illiteracy rate was 58%. Mayan ethnicity represented 43%. The proportion of people aware of their HTN diagnosis was 69%, but only 60% of them were on anti-hypertensives. Median systolic and diastolic blood pressure (BP) was 142.5 and 76.5 mmHg, respectively. Median BMI was 27.6 kg/m2. A statistically significant difference (p

Circulation, Volume 150, Issue Suppl_1, Page A4124585-A4124585, November 12, 2024. Introduction/Background:Low-value care is defined as care where harms or costs outweigh patient benefits. Prior studies have suggested that approximately 1 of every 10 carotid ultrasound tests are low-value because they were performed among patients without neurologic symptoms or a history of stroke. However, these studies have used administrative claims data that may not account for all patient symptoms or include all guideline-recommended indications. We assessed the validity of a claims-based measure of low-value carotid ultrasound testing compared to a reference standard of chart review.Hypothesis:Claims-based measures overestimate the proportion of carotid ultrasound tests classified as low-value care.Methods:We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries attributed to an accountable care organization with administrative claims data linked to electronic health record data. Using Current Procedural Technology codes, the first 150 patients that underwent carotid ultrasound in 2021 were identified. We applied a claims-based algorithm used by researchers and policymakers to identify if testing was low-value or appropriate. We used linked electronic health record data to assess appropriateness of testing using the 2012 American Heart Association clinical practice guidelines. We assessed agreement between claims and chart review using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Cohen’s Kappa.Results:Among 150 patients (mean age 76, 55% male, 86% white) who underwent carotid ultrasound, 76 tests (51%) were considered low value by the claims measure and 63 (42%) by chart review. Claims based measures were 67% sensitive, 61% specific, with a PPV of 55% and NPV of 62%. Cohen’s Kappa coefficient was 0.27 (CI 0.11 – 0.42), indicating only fair agreement between claims and chart review.Conclusion:We found that an often-used claims-based measure to identify low-value carotid ultrasound testing misclassifies a substantial proportion of tests as low-value. Using claims-based measures alone for assessing provider quality and making payment decisions could harm provider reputations and erode trust in the quality reporting system.

Circulation, Volume 150, Issue Suppl_1, Page A4140846-A4140846, November 12, 2024. Background:Young adult women with severe hyperlipidemia (sHLD), or low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL, are less likely to achieve guideline-recommended LDL-C reduction than their male or older counterparts. Lipoprotein(a) [Lp(a)] can serve as a risk modifier of cardiovascular disease and may have some utility in risk-stratification in young populations.Question:Do LDL-C control and Lp(a) testing differ by race among young adult women?Methods:We used clinical registry data from seven Mass General Brigham hospitals/affiliated practices to identify young women (18-45 years) between 2005-2022 with a qualifying LDL-C ≥190 mg/dL. We used linear mixed models to assess longitudinal differences in LDL-C levels by self-identified race. We compared Lp(a) testing and statin initiation rates of these groups and examined whether LDL-C control differed according to Lp(a) testing.Results:Our study included 4,633 women with sHLD, mean (SD) age 35.7 (7.0) years at qualifying LDL-C and median (IQR) follow up 5.8 (9.4) years. Compared to White women, Black women had persistently higher LDL-C levels during follow-up (coefficient=6.4, p

Circulation, Volume 150, Issue Suppl_1, Page A4146664-A4146664, November 12, 2024. Introduction:Short and long sleep durations have been associated with cardiovascular (CV) disease risk and mortality, but less is known about the relationship with heart failure (HF). Clinical guidelines recommend adults sleep at least 7 hours and less than 9 hours per night for optimal health. We prospectively investigated the association between sleep duration and incident HF in the Southern Community Cohort Study (SCCS), a large cohort of primarily low-income Black and White adults.Methods:The study included 26,669 Black and White SCCS participants without prevalent HF at enrollment (2002-2009) who were receiving Center for Medicare/Medicaid Services (CMS). Participants self-reported weekday and weekend sleep duration at enrollment; weighted average nightly sleep duration was calculated. Incident HF was ascertained using ICD-9/10 codes via CMS claims through December 31, 2016. Multivariable Cox models were conducted to test associations between sleep duration and incident HF.Results:Participants had a median age of 55 years, and were predominantly Black (69%), female (62%) and low-income (87% < $25,000/year). Approximately 27% of participants reported a habitual sleep duration of 8-9 hours per night, while 18%, 21%, 17% and 17% reported sleep durations 9 hours, respectively. Over median 10 years of follow-up, 7,375 participants (27.6%) developed HF. Compared to those who slept 8-9 hours a night, participants with a sleep duration

Circulation, Volume 150, Issue Suppl_1, Page A4145565-A4145565, November 12, 2024. Background:In patients with atrial fibrillation (AF), biphasic energy is superior to monophasic energy for cardioversion (CV). However, the optimal initial biphasic energy for CV is unknown. There are no studies in the US comparing the different biphasic energy levels.Objective:To compare the efficacy of initial high energy (IHE, 300-360J) versus initial low energy (ILE, ≤200J) biphasic shocks for CV of AF.Methods:Patients who received CVs at our institution for AF over a year were identified using the ICD-10 code. Patients who received internal CV, CV during other procedures, or CV for hemodynamic instability were excluded. Shocks were delivered using Lifepak® 20 through self-adhesive electrodes placed in an anteroposterior direction. Statistical analysis was performed using IBM® SPSS® Statistics software. The primary endpoint was conversion to sinus rhythm after the first shock (CSRF) and the secondary endpoint was conversion to sinus rhythm (SR) using multiple shocks.Results:A total of 594 patients were screened and 409 patients were included for final analysis. Results are shown in the table. Patients in the ILE group had lower BMI and lower rates of prior ablation. Patients in the IHE group had higher rates of CSRF (95.5% vs 87.6%, p=0.018). On subgroup analysis, higher rates of CSRF were observed with IHE even in patients with BMI >30 (97.4% vs 84.2%, p=0.019). More patients in the ILE group required multiple shocks. Even when multiple shocks were used, there was a higher rate of conversion to SR in IHE vs ILE (95.5% vs 92%, p=0.24). On multivariate analysis, the odds of CSRF were 6-fold higher with IHE after adjusting for sex, ejection fraction, prior ablation, obesity, and history of heart failure.Conclusion:Our study shows that IHE is better than ILE at converting AF into SR with the first shock. Even though the latest AF guidelines recommend 200J for initial cardioversion, select patients may benefit from >300J to avoid multiple shock attempts.

Circulation, Volume 150, Issue Suppl_1, Page A4142639-A4142639, November 12, 2024. Background:Low-density lipoprotein cholesterol (LDL-C) is the primary lipid factor for diagnosing and managing lipid disorders in children. Although multiple equations are available for estimating LDL-C, the best one for assessing long-term cardiovascular (CV) risk is unclear.Hypothesis:Childhood LDL-C levels estimated from different equations differently associates with adult CV events.Aim:To compare the prospective association of childhood LDL-C levels estimated by the Friedewald, Martin/Hopkins, Sampson, and DeLong equations with adult CV events.Methods:Data were from seven prospective cohorts in the US, Finland, and Australia within the International Childhood Cardiovascular Cohort Consortium. LDL-C levels were estimated using four equations: Friedewald, Martin/Hopkins, Sampson, and DeLong. Discordance was defined as differing LDL-C categorizations (acceptable

Circulation, Volume 150, Issue Suppl_1, Page A4147328-A4147328, November 12, 2024. Background:Heart failure (HF) is a leading cause of hospitalization and readmission. Understanding the burden and impact of social determinants of health (SDOH) among HF patients at safety-net hospitals is critical for improving outcomes.Methods:We conducted a prospective, cross-sectional study to identify the prevalence of adverse SDOH among patients hospitalized with acute HF at an urban, safety-net hospital. English or Spanish-speaking patients hospitalized for HF were enrolled between 11/2022-6/2023. We collected data across 5 SDOH domains based on the Healthy People 2030 SDOH Model from the U.S. Department of Health and Human Services. The overall burden of adverse SDOH parameters and their association with hospitalization or emergency room (ER) visits at 90 days was assessed. Multivariate logistic regression models adjusted for selected covariates from the total pool of demographic, clinical, and social covariates using stepwise regression.Results:174 individuals were included (mean age 55 y, 73.6% male, 61.5% Black, 20.7% Hispanic). A high adverse SDOH burden was noted, with 60% of patients unemployed, 65% living below 130% of the federal poverty limit, 53% with food insecurity, 49% with low social support, and 40% with housing instability (28% homeless). In multivariate logistic regression (area under the curve (AUC) = 0.80, F1 score = 0.71), increasing comorbidity burden (aOR 4.84, 95% CI 2.04-12.5, p

Circulation, Volume 150, Issue Suppl_1, Page A4137267-A4137267, November 12, 2024. Background:Traditional open- and closed-chest methods for inducing acute myocardial infarction (AMI) in pigs typically require extensive and expensive instrumentation, including ventilators and inhalation anesthesia. This study aims to evaluate a reproducible and low-cost model for AMI in pigs using lower hemisternotomy.Methods:Twenty Yorkshire swine (15-20 kg, 45-50 days of age) underwent permanent ligation of the roots of the first and second diagonal branches of the left anterior descending coronary artery. The procedure was performed under intramuscular anesthesia (1ml 0.5mg/kg Zoletil™ and 2ml 10mg/kg xylazine hydrochloride) with spontaneous respiration. Cardiac function was assessed via echocardiography and cardiac PET/MRI scans at 1 and 4 weeks post-MI. Heart tissue was collected for pathological analysis to evaluate the establishment of the AMI model.Results:All animals exhibited ECG changes, including premature ventricular complexes and ST-segment elevation immediately after ligation. No ventricular tachycardia and fibrillation was observed during the operation. No animals (0%) died during infarct creation. The “Skin-to-Skin” procedure time was 18±3.3 minutes. this procedure produced an infarction that occupies ~10% of the left ventricular mass accompanied with the decrease of LV heart function and LV anterior wall thickness 4 weeks post-MI.Conclusions:This novel low-cost technique provides reproducible acute coronary artery occlusion at a selected location with subsequent AMI. It avoids ventilation, inhalation anesthesia, major surgery and does not require expensive instrumentation for intracoronary intervention.

Circulation, Volume 150, Issue Suppl_1, Page A4140810-A4140810, November 12, 2024. Background:Inflammation is a significant residual risk factor for coronary artery disease. While intensive lipid-lowering therapy has reduced the prevalence of plaque rupture, plaque erosion in acute coronary syndrome (ACS) patients is increasing, with neutrophils playing a crucial role. It remains unclear whether varying low-density lipoprotein cholesterol (LDL-C) levels modify the relationship between neutrophil count and ischemic risk in ACS patients.Aim:To investigate the relationship between neutrophil counts and ischemic risk in ACS patients undergoing percutaneous coronary intervention (PCI) across different LDL-C levels.Methods:This large cohort study enrolled consecutive 10724 patients undergoing PCI at Fuwai Hospital (Peking Union Medical College) throughout the year of 2013. Patients were divided into subgroups according to baseline LDL-C levels, with cut-off points at 1.8mmol/L or 1.4mmol/L. The primary endpoint was major adverse cardiovascular event (MACE), and the secondary endpoint was revascularization.Results:Finally, 5717 ACS patients with PCI were included. The mean age was 58.43 ± 10.35 years, with 4399 (76.9%) being male. During the 5-year follow-up period, 1058 (18.5%) MACEs and 821 (14.4%) revascularizations were recorded. Restricted cubic spline analysis revealed a positive correlation between neutrophil and MACE and revascularizations only in patients with lower LDL-C levels (LDL-C