Risultati per: LBP (Low Back Pain): Cosa dicono le linee guida del mal di schiena

Circulation, Ahead of Print. Background: High-sensitivity cardiac troponin (hs-cTn) laboratory assays are used to rule out myocardial infarction (MI) on presentation, but prolonged result turn-around times can delay patient management. Our primary aim was to identify patients at low risk of index MI using a rapid, point of care (POC), whole blood hs-cTnI assay at presentation, with potential early patient discharge.Methods: Consecutive emergency department patients from two prospective, observational studies with suspected acute coronary syndrome were enrolled. A POC hs-cTnI assay (Atellica®VTLi) threshold using whole blood at presentation, that resulted in a negative predictive value (NPV) of ≥99.5% and sensitivity of ≥99% for index MI, was derived (Safe Emergency department dIscharGE rate [SEIGE]) and validated using plasma (Suspected acute myocardial infarction in Emergency [SAMIE]). Event adjudications were established using hs-cTnI assay results from routine clinical care. The primary outcome was MI at 30-days.Results: 1086 patients (8.1% MI) were enrolled in a US derivation cohort (SEIGE) and 1486 (5.5% MI) in an Australian validation cohort (SAMIE). A derivation whole blood POC hs-cTnI concentration of

Circulation, Volume 146, Issue Suppl_1, Page A9556-A9556, November 8, 2022. Introduction:Transvenous lead extraction (TLE) is associated with better outcomes in high-volume (HiV, >30 TLE/year) than low-volume centers. Little data exist regarding transitioning to a HiV TLE center. We examined the impact of strategic interventions at a tertiary care center transitioning to a HiV TLE center.Hypothesis:Systematic interventions to increase TLE volume and quality are expected to decrease the rate of major complications without adversely affecting procedural success rates.Methods:Consecutive patients undergoing TLE with leads >1 year post implantation from 2012-2021 were reviewed. The primary endpoints were TLE success and major complications including TLE-related mortality, vascular laceration, pericardial effusion, and emergent cardiothoracic surgery. Outcomes were compared between TLE completed in 2012-2018 prior to the intervention (n=125) and TLE after intervention 2019-2021 (n=127).Results:There were 252 consecutive TLE procedures included involving 398 leads. Strategic interventions were implemented in 2018 (Figure). Annual mean TLE volume increased from 19.5 TLE (29.7 leads) to 42.4 TLE (69.7 leads). Baseline characteristics including age (62.4±14.7 vs. 61.9±17.4), gender (52.4% vs. 47.7% male), and infectious indications (33.6% vs. 35.4%) were similar (P >0.05 for all). With the transition to a HiV center, there was no significant change in complete procedural success (84.0% vs. 85.8%, P=0.73) and clinical success (94.4% vs. 96.1%, P=0.57). Major complications significantly decreased from 10/125 (8.0%) to 3/127 (2.4%) after the interventions in 2018 (P=0.049).Conclusions:Multidisciplinary improvements in pre-procedural risk stratification, scheduling, and technique resulted in a successful transition to a HiV TLE center with a reduction in major complications and a high procedural success rate.

Circulation, Volume 146, Issue Suppl_1, Page A14524-A14524, November 8, 2022. Introduction:Low testosterone (LowT) has been suggested to be associated with increased ASCVD risk and mortality, but results are conflicting across studies. We evaluated the independent relationship between low testosterone levels in adult males and ASCVD using data from an EHR-based database. Methods Cross-sectional study using the Houston Methodist CVD Learning Health System Registry, which includes data from 1.1 million patients aged ≥18 years (June 2016-April 2022). Analyses were restricted to men, and those on testosterone replacement therapy were excluded. We evaluated the associations between total testosterone levels (categorized as quartiles [Q], lowest Q as exposure of interest and highest Q as reference) and ASCVD (CAD, PAD, stroke), using logistic regression. Conditions and risk factors were identified using ICD 10-CM codes.Results:We evaluated 30,150 men ≥18 years (mean age 55.3 years, 12% NHB, 15% Hispanics) with testosterone level data. Men in testosterone Q1 (lowest levels: ≤285 ng/dl) had higher prevalence of almost all risk factors and composite ASCVD compared to Q4 (highest levels: ≥515 ng/dl)(Panel A).In unadjusted analyses, men in testosterone Q1 vs Q4 had higher odds of ASCVD (OR 1.54, 95% CI 1.41-1.68). In multivariable adjusted logistic regression, the increased odds persisted adjusting for age, sex, and race OR 1.33 (CI 1.21 – 1.46), while it was fully attenuated (OR 1.04 CI 0.94 – 1.14) after adjusting for risk factors (DM, HTN, dyslipidemia, obesity)(Panel B).The attenuation in association with prevalent ASCVD was highest adjusting for DM (67%) and HTN (58%)(Panel C).Similar results were noted when cutoff of

Circulation, Volume 146, Issue Suppl_1, Page A10038-A10038, November 8, 2022. Introduction:Low endothelial shear stress (ESS) is a pro-atherogenic stimulus associated with coronary plaque development, while high plaque structural stress (PSS) and its heterogeneity is associated with plaque destabilization. Previous studies showed that combining ESS and PSS additively predicts plaque progression, but no studies have determined their ability to predict major adverse cardiovascular events (MACE). We examined whether combining ESS and PSS improves MACE prediction in patients with acute coronary syndrome.Methods:We examined baseline ESS, ESS gradient, PSS, and PSS heterogeneity index (HI) in 22 non-culprit lesions (NCL) leading to future MACE, and 64 randomly selected control NCLs without MACE from the PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) study. ESS was calculated by computational fluid dynamics and PSS by finite element analysis on co-registered lesions.Results:86 lesions (55 thin-cap and 31 thick-cap fibroatheromas) were analyzed from 67 patients. Lesions that caused future MACE showed baseline higher PSS HI (0.32 vs. 0.24, p

Circulation, Volume 146, Issue Suppl_1, Page A15009-A15009, November 8, 2022. Introduction:Patients with single ventricle physiology frequently demonstrate decreased exercise tolerance after the Fontan operation. The objective of this study was to investigate the contribution of ventricular stiffness to exercise function in these patients.Hypothesis:We hypothesized that ventricular stiffness, both extremes of high and low stiffness, would be associated with exercise tolerance in Fontan patients.Methods:We previously validated an echocardiographic measure of ventricular stiffness, lateral Doppler E: tissue Doppler e’/end-diastolic volume (lateral E:e’/EDV) in children. Core-lab echocardiograms and exercise test results were obtained from the publicly-available Pediatric Heart Network Fontan Cross-sectional Study database. Exercise function was quantified as % predicted VO2. Ejection fraction (EF) was considered abnormal if < 50%. Diastolic function was defined as high stiffness if the lateral E:e’/EDV was > 90th percentile or low stiffness if < 10th percentile. Patients were divided into four groups: 1 = normal EF and normal diastolic function, 2 = decreased EF with normal diastolic function, 3 = normal EF with high ventricular stiffness, and 4 = normal EF with low ventricular stiffness.Results:239 patients (61% left, 29% right, 10% mixed ventricular dominance) had EF, lateral E:e’/EDV, and VO2measured. Differences between groups are reported in the Table.Conclusion:Single ventricle patients with both high and low stiffness and preserved EF had worse exercise capacity than patients with both normal and abnormal EF. To our knowledge, this is the first study detecting a low stiffness heart failure phenotype in single ventricle physiology. Future studies should further investigate the pathophysiologic mechanisms that lead to these extremes of stiffness in Fontan patients.

Circulation, Volume 146, Issue Suppl_1, Page A11314-A11314, November 8, 2022. Introduction:Patients’ lack of access to affordable cardiovascular disease (CVD) medicines poses a crucial barrier to achieving desired cardiovascular outcomes. Many pharmacies have launched low-cost generic programs (LCGP) to expand medication accessibility. It is uncertain whether LCGPs include CVD drugs recommended by World Health Organization Essential Medicines List (WHO EML) and promote evidence-based prescribing. Our study aimed to estimate the availability of essential and guideline-recommended CVD medicines on LCGP in the United States (US).Methods:We selected 6 CVD conditions: atrial fibrillation (AF), heart failure (HF), hyperlipidemia (HLD), hypertension (HTN), stable angina (SA), and secondary prevention (SPX). LCGPs in the US with publicly available formularies were identified in February 2022. We used the 22ndWHO EML edition and Class 1A recommendations (1ARec) from current CVD guidelines as reference standards. Availability was estimated using the proportion of coverage for each LCGP overall, and by condition.Results:Nineteen LCGPs were included. There were 122 WHO EML and 155 1ARec CVD drugs. No LCGPs offered at least 50% of WHO EML and 1ARec. Both WHO EML and 1ARec analyses showed that 9 of 19 LCGPs covered at least 30% of listed medications. Out of the 19 LCGPs, the proportion of essential and evidence-based CVD medicine availability was highest at Kroger (46.3% and 47.9%) and lowest at Costco (5.0% and 6.1%), respectively. Higher availability was observed for HLD medications: only TOPS and the Mark Cuban Plan had at least 80% of WHO EML available, and only the Mark Cuban Plan had at least 80% of 1ARec medications covered. HTN drugs were least available for both.Conclusion:The accessibility of CVD medicines is low in LCGP formularies with variation in availability by pharmacy and condition. To optimize the accessibility of CVD medicines and health outcomes, pharmacies with LCGPs should offer more essential and evidence-based CVD medicines.

Circulation, Volume 146, Issue Suppl_1, Page A15024-A15024, November 8, 2022. Introduction:LDL transports dietary long chain fatty acids, constituents that may influence rates of lipid oxidation. Modified LDL promotes foam cell formation during atherosclerosis. The omega-3 fatty acid (n3-FA) eicosapentaenoic acid (EPA) administered as icosapent ethyl (IPE), reduced cardiovascular events in REDUCE-IT compared to mixed n3-FAs in similar high-risk patients (STRENGTH). Some have attributed these discordant outcomes, in part, to placebo choice (mineral versus corn oil) despite very limited oral absorption. We compared the effects of these oils and various FAs on rates of LDL oxidation at supra-pharmacologic doses.Methods:LDL was isolated from human plasma by isopycnic centrifugation, separated into test samples of 100 μg/mL before being incubated at 37°C for 30 min with pharmaceutical grade mineral or corn oil at high concentrations (100 μg/mL) that are comparable to treatment achieved n3-FAs (4 g/d) that have high oral absorption. We also tested FAs contained in these oils, including stearic acid (18:0), arachidic acid (20:0), and linoleic acid (18:2, n-6) as well as ascorbic acid (10 μM) and a water-soluble analog of vitamin E (Trolox, 10 μM) as controls. All samples then underwent copper-induced oxidation (20 μM) monitored by formation of malondialdehyde (MDA).Results:MDA formation increased from 0.28 ± 0.03 to 9.96 ± 0.58 μM (p

Circulation, Volume 146, Issue Suppl_1, Page A10438-A10438, November 8, 2022. Introduction:Increased levels of low-density lipoprotein cholesterol (LDL-C) and its constituent apolipoprotein B (ApoB) are associated with atherosclerotic coronary disease, a risk factor for heart failure (HF). However, among patients with established HF, increased LDL-C has been associated with a lower risk of death. The potential causality of this association is unclear.Hypothesis:This study investigated the relationship between ApoB/LDL-C and adverse outcomes in participants with HF.Methods:We measured ApoB levels using the SomaScan assay among participants in the Penn Heart Failure Study (PHFS, n=1268). We performed one-sample Mendelian Randomization (MR) for ApoB and two-sample MR for ApoB and LDL-C.Results:Measured ApoB levels were inversely associated with the risk of death (Fig 1A) or death and heart failure hospital admission (DHFA; Fig 1B). One-sample MR revealed no significant association between genetically determined ApoB and the risk of death (HR 0.497, [95% CI, 0.20-1.2], p=0.125) or DHFA (HR 0.653, [95% CI, 0.35-1.2], p=0.182). Two-sample MR analyses were also consistent with a non-significant association between ApoB (Fig 2) or LDL-C (Fig 3) and risk of death or DHFA.Conclusions:ApoB is associated with the risk of death or DHFA in established HF. However, MR does not support a causal link between ApoB/LDL-C and the risk of adverse outcomes in this population.

Circulation, Volume 146, Issue Suppl_1, Page A13323-A13323, November 8, 2022. Introduction:Acute heart failure is associated with higher post-discharge mortality, especially in low-middle income countries (LMIC). There are limited studies on adherence to the recommended post-discharge care guidelines in these settings. The study assessed adherence to the 2020 ACC/AHA inpatient heart failure performance and quality measure in Gaza Strip, Palestine.Methods:The study was a cross-sectional survey study. We chose a stratified random sample from the three different geographical areas across Gaza Strip with numbers proportional to the size of each region. Patients selected were adults ( >18 years) admitted to the various hospitals for acute decompensated heart failure between 4/2021 and 12/2021. We collected data through chart review. Measures were β blockers, ACEi/ARB and MRA prescription, and outpatient follow-up. Results reported as proportion with 95% CI.Results:The sample size was 155 patients. The mean age was 64 years. 59% were males. The mean length of stay was 2.8 days. β blockers were prescribed to 85.1% [79.5,90.8] of patients. For ACEi/ARB use, it was 42.7% [34.9,50.5]. For MRA, after excluding ineligible patients, it was prescribed in 48.5% [39.9, 57.2]. None of the patients were prescribed hydralazine/nitrate. Only 30.1% [ 23.6, 38.1] of patients had an outpatient appointment. The median time between discharge and appointment date was 22 days. Only 9.7% [5.0,14.3] of patients were discharged with all quality measures fulfilled.Conclusions:There are considerable gaps in the post-discharge care of heart failure patients in the Gaza Strip. There is a need to develop local care guidelines to improve care.

Circulation, Volume 146, Issue Suppl_1, Page A11734-A11734, November 8, 2022. Introduction:Chest pain is common in patients with Post-acute Sequelae of SARS-CoV-2 (PASC), also known as long COVID, but the mechanism is unknown.Hypothesis:We hypothesized that PASC patients with chest pain have impaired myocardial perfusion reserve (MPR) measured by stress perfusion cardiovascular magnetic resonance (CMR) imaging.Methods:We retrospectively identified the first 30 consecutive patients who underwent clinically ordered adenosine stress perfusion CMR for chest pain persisting >4 weeks after SARS-CoV-2 infection (PASC). Patients with a history of coronary artery disease (CAD) or left ventricular ejection fraction (LVEF) 2 SD below mean MPR for controls.Results:In 30 PASC (67% female, age 43±13) and 13 controls (54% female, age 50±12), with LVEF (61±6% vs 59±8%), native T1 (1001±49 vs 992±57 ms), T2 (49.5±3.7 vs 48.0±3.3 ms), and ECV (24.6±2.9 vs 24.6±2.6%) were similar (p >0.2 for all). Prior pericarditis (n=2) or prior myocarditis (n=3) were infrequent, with no acute disease by CMR. PASC patients had significantly lower global MPR than controls (1.54±0.25 vs. 2.20±0.36, p

Circulation, Volume 146, Issue Suppl_1, Page A12725-A12725, November 8, 2022. Introduction:Low serum albumin is a marker of protein malnutrition and is commonly associated with worse outcomes in various clinical settings. Furthermore, significant overlap exists between malnutrition and sarcopenia, which can be an independent predictor of worse outcomes.Hypothesis:We assessed the hypothesis that the presence of sarcopenia with low albumin (SLA) would lead to synergistically worse outcomes in patients with acute decompensated heart failure (ADHF).Methods:Patients hospitalized for ADHF from 2017 to 2019 with computed tomography of the abdomen/pelvis within 30 days and albumin level within 24 hours before discharge were studied (n=181). Given the high prevalence of hypoalbuminemia, low albumin was defined as the lower fiftieth percentile. Semi-automatic measurements of skeletal muscle area were made at L3 (Figure 1A) and adjusted using height squared to obtain skeletal muscle index (SMI). Sarcopenia was defined as the lowest sex-stratified SMI tertile.Results:The prevalence of sarcopenia alone was 11.6%, low albumin alone 28.7%, and SLA 20.4%. The groups had similar demographics but differed in BMI (lowest in sarcopenia alone, p

Circulation, Volume 146, Issue Suppl_1, Page A12772-A12772, November 8, 2022. Introduction:Aortic stenosis (AS) is the most common valvular disease, and severe disease can significantly impact morbidity. Less data exists examining the functional and quality of life (QOL) effects of transcatheter aortic valve replacement (TAVR) in patients with severe low-gradient AS in both low-flow and normal-flow states.Hypothesis:Patients with symptomatic, severe, low-gradient AS would have improvements in functional and QOL outcomes at 30-days and 1-year following TAVR procedures.Methods:A single center, retrospective study examined symptomatic, severe, low-gradient AS variants. These had an aortic valve area of ≤1.0 cm2, mean transvalvular gradient

Circulation, Volume 146, Issue Suppl_1, Page A12816-A12816, November 8, 2022. Introduction:High-sensitivity cardiac troponin (hs-cTn) laboratory assays are used to rule out myocardial infarction (MI) on presentation, but prolonged result turn-around times can delay patient management.Hypothesis:Our aim was to identify patients at low risk of index MI using a rapid, point of care (POC), whole blood hs-cTnI assay at presentation, with potential early patient discharge, with99% for index MI, was derived (SEIGE) and validated using plasma (SAMIE). Event adjudications were established using hs-cTnI assay results from usual clinical care. The primary outcome was MI at 30-days.Results:1086 patients (8.1% MI) were enrolled in a US derivation cohort (SEIGE) and 1486 (5.5% MI) in an Australian validation cohort (SAMIE). A derivation whole blood POC hs-cTnI concentration of

Circulation, Volume 146, Issue Suppl_1, Page A14613-A14613, November 8, 2022. Introduction:Carpal tunnel syndrome, spinal stenosis, and biceps tendon rupture may precede cardiac transthyretin amyloidosis (ATTR-CA).Hypothesis:We tested the hypothesis that amyloidosis-related orthopedic events herald amyloidosis and cardiac events consistent with ATTR-CA through transthyretin destabilization.Methods:In observational analysis in the Copenhagen General Population Study (CGPS; n=93,637), we first tested whether amyloidosis-related orthopedic events at baseline were associated with amyloidosis and incident cardiac events consistent with ATTR-CA (heart failure, atrial fibrillation, myocardial infarction, or death), and whether a low plasma transthyretin was associated with a higher risk. In genetic analysis, in CGPS and the Copenhagen City Heart Study(CCHS) combined (n=102,496), we tested whetherTTRgenotypes associated with stepwise lower plasma transthyretin, marking lower transthyretin tetramer stability and higher amyloidogenic potential, was associated with both orthopedic and incident cardiac events, implying a common mechanistic background through transthyretin destabilization.Results:In individuals with versus without orthopedic events at baseline, hazard ratios (HRs) were 10.7 (95% CI: 3.9-29.3) for amyloidosis, and 1.3(1.1-1.4) for cardiac events. Furthermore, in individuals with orthopedic events at baseline, HRs for cardiac events were 3.8(1.9-7.6) in those with transthyretin

Circulation, Volume 146, Issue Suppl_1, Page A12644-A12644, November 8, 2022. Introduction:Previously considered rare, spontaneous coronary artery dissection (SCAD) has emerged as an important cause of chest pain, acute coronary syndrome, and sudden cardiac death. Due to hormonal factors, SCAD often affects seemingly healthy women. SCAD in men remains little understood and under-recognized. We report a case of a 61-year-old gentleman who presented with NSTE-ACS and was found to have SCAD.Patient Presentation:A 61-year-old male with history of untreated hyperlipidemia presented with acute substernal chest pressure radiating to bilateral arms and back. On presentation, vitals and physical examination was normal.His labs showed troponin I at 0.015 ng/mL which later up trended to 21.7 ng/ml. ECG demonstrated sinus bradycardia with no ischemic changes. Decision was made to take him for cardiac catheterization.It demonstrated right coronary artery (RCA) was ecstatic. Distally, there was a a right conus branch fistula draining into pulmonary artery. There was evidence of microvascular dysfunction. An echocardiogram showed mid and basal inferolateral akinesis, normal EF.He was started on dual anti platelets (DAPT) and GDMT. At the time of discharge, he started having recurrence of his chest pain with exertion. Cardiac CT showed multiple spontaneous coronary artery dissections with healing dissections and remodeling throughout the ecstatic RCA and its distal branches with additional contour irregularities and non-obstructive dissection flaps in the diagonal branch of the left anterior dissecting artery. He was enrolled into cardiac rehabilitation.Conclusion:SCAD occurs by the formation of an intramural hematoma or intimal disruption causing a coronary obstruction. Coronary angiography remains the primary tool in the diagnosis. Alternative imaging modalities, such as intravascular ultrasound and optical coherence tomography, CT coronary angiography can be used to confirm the diagnosis. It is managed medically with DAPT and adequate control of blood pressure. Cardiac rehabilitation appears to be beneficial in preventing recurrence. We would also like to emphasize that SCAD can occur in any age group and gender, it’s crucial to recognize it early and is a condition that can be managed conservatively.

Circulation, Volume 146, Issue Suppl_1, Page A14607-A14607, November 8, 2022. Introduction:Heart failure (HF) is one of the most common causes of hospital readmission. Self-care is essential but challenging task in patients with HF, and self-care deficit is closely related to unplanned readmission and unnecessary health expenditure. Patient centered education using teach-back method (TBM) emerged as a key strategy to prevent patients’ adverse events by improving self-care. This study aims to evaluate the effects of TBM in patients with HF.Hypothesis:HEART program®, a TBM-based discharge education, will significantly improve self-care, symptom experience, caregiver dependency, and unplanned healthcare utilization.Methods:This was a randomized controlled trial in HF patients with left ventricular ejection fraction ≤50%. Before discharge, the experimental group (EG) received HEART program®by a trained nurse, while the control group (CG) received usual discharge education. Measures were self-care (self-care maintenance; symptom-perception; self-care management), symptom experience, caregiver dependency at 7-days after discharge, and healthcare utilization (readmission; emergency room visit; hospital contact, etc.) at 1-month after discharge. Outcomes were analyzed with ANCOVA and Chi-squared test using SPSS program 25.Results:A total of 86 patients (EG = 40, CG = 46) completed the study (mean age 61±12 years; mean left ventricular ejection fraction 30±9%; mean duration of illness 4 years; mean hospitalization day 8±7). Self-care (self-care maintenance,F=12.3; symptom perception,F=15.4; self-care management,F=6.0) in the EG significantly improved compared with the CG (allPs.05). For healthcare utilization, only hospital contact via telephone was significantly different between the EG and CG (N=1 vs. 8;P=.032).Conclusions:This result indicates that discharge education based on TBM is an effective strategy to improve self-care ability, which could lead to reducing unplanned health expenditure in patients with HF. We suggest that healthcare providers implement TBM education for patients with chronic HF.