In the patients on warfarin undergoing percutaneous coronary intervention included in the prospective, multicentre, observational WAR-STENT registry, age ≥75 years was associated with a significant ...increase in in-hospital major bleeding, length of hospitalization, and use of bare-metal stents, with no differences in the peri-procedural management and antithrombotic therapy.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Malnutrition represents a common and important feature in elderly people affected by cardiovascular diseases. Several studies have investigated its prevalence and prognostic role in most clinical ...settings, including cardiovascular disease. However, in daily practice it usually remains unrecognized and consequently untreated. The present review was ideated to answer the main questions about nutritional status assessment in patients with cardiovascular disease: why, when, where, how to evaluate it, and what to do to improve it. The three main cardiovascular diseases, namely aortic stenosis, ischaemic heart disease, and heart failure were considered. First, the main evidence supporting the prognostic role of malnutrition are summarized and analyzed. Second, the main tools for the assessment of malnutrition in the hospital and outpatient setting are reported for each condition. Finally, the possible strategies and interventions to address malnutrition are discussed.
In the last three decades also in our country it has been a huge growth of the use of non invasive testing for diagnosis of CAD. Therefore, appropriateness of prescription in diagnostic testing is ...crucial. Clinical evaluation is mandatory before a diagnostic test, including the evaluation of pre-test probability of the disease based on symptoms, age, sex and cardiovascular risk factors. The main benefit of testing is in patients with an intermediate pre-test probability. Testing for diagnosis of CAD is rarely appropriate in asymptomatic subjects, except for ECG exercise test in intermediate and high risk individuals, while stress or anatomic imaging is preferable in higher risk individuals. Coronary calcium score should not be used as screening test in asymptomatic subjects, except for excluding CAD in those with low pre-test probability. As far as diabetic patients is concerned, available evidence indicates an unfavorable risk-benefit ratio of extensive CAD screening, except in the presence of high clinical suspicion.
410 “SHARK-FIN“ ECG: NOT ALWAYS A STEMI Marrone, Andrea; Piscitelli, Laura; Zagnoni, Silvia ...
European heart journal supplements,
12/2022, Volume:
24, Issue:
Supplement_K
Journal Article
Peer reviewed
Open access
Abstract
Background
Coronary malperfusion due to type A aortic dissection is a life-threatening condition where timely recognition and treatment are mandatory. The International Registry of Acute ...Aortic Dissection (AAD) shows that only 5% of AAD patients present with ECG evidence of acute myocardial infarction, and prognosis is ominous due to the additional myocardial damage and missed or delayed diagnosis. The shark fin waveform is an uncommon but high-risk ECG pattern formed by fusion of QRS, ST-segment, and T waves. It is associated especially with the sub-occlusion of the left main coronary artery or proximal left anterior descending artery with a high risk of death due to cardiac arrest and cardiogenic shock.
Case presentation
A 61-year-old man was admitted to our cardiac cath-lab for typical chest pain and suspected acute ST segment elevation myocardial infarction (STEMI). A triangular pattern known as the ‘shark-fin’ sign in the precordial and inferior leads, and mirroring ST-segment depression in dI and aVL was detected. Unexpectedly coronary angiography revealed normal epicardial vessels, but a very-regular-shaped staining of the aortic sinus was observed. This finding was suspicious for acute aortic dissection. Bedside 2D-echocardiography within the cath-lab demonstrated an intimal flap in the aortic root and arch, with mild aortic regurgitation. Contrast-enhanced computerized tomography (CT) confirmed our diagnosis of Type A aortic dissection (AAD) highlighting the same dissection flap revealed by angiography arising from the left coronary cusp of the aortic root. The left main trunk was not directly involved, but the dissection extended from the ascending to the distal aorta involving both left and right external and internal iliac arteries with a thrombotic occlusion of the right femoral-iliac axis There was also a right inferior-pole renal infarction. Thus, the patient was immediately submitted to heart surgery.
Conclusions
Type A aortic dissection is a life-threatening disease in which early diagnosis and treatment are critical for survival. Occasionally it could mimic STEMI due to coronary involvement or dynamic obstruction of a coronary ostium. In our experience a bedside echocardiography performed before primary percutaneous coronary intervention (PCI) may confirm the clinical suspicious and avoid dangerous diagnostic delays.
Abstract
Takotsubo syndrome is a clinical condition characterized by transient impairment of left ventricular contractility, in association with symptoms, increase in indices of myocardial necrosis, ...as well as electrocardiographic changes, but without a coronary culprit lesion, and often after a significant psychological or physical stress. Albeit very similar to acute coronary syndrome (ACS) as far as presentation and clinical course, Takotsubo syndrome was considered, up until recently, a condition with very favourable long-term prognosis, in view of the frequent complete functional recovery. More recently, several retrospective observational studies as well as registers, unexpectedly called attention to a significant incidence of major adverse cardiovascular events, not limited to the recovery period but also during the long-term follow-up, in a way very similar to the outcome of patients after ACS. Several negative prognostic factors have been isolated, such as physical stress as trigger of the condition, the presence of severe left ventricular dysfunction, and the consequent cardiogenic shock during the acute phase. These factors are able to classify better the patient’s prognosis, both in the short- and long-term, and identify patients requiring a more stringent clinical follow-up, considering the higher likelihood of adverse cardiovascular events.
Left main trunk (LMT) occlusion is a rare angiographic finding. The primary purpose was to investigate the ECG pattern of patients with angiographic confirmation of LMT as culprit lesion.
Forty-eight ...patients (32 men; mean age 73 years) with angiographic total (21 patients; 44%) or subtotal (27 patients; 56%) occlusion of the LMT were analyzed. Twenty patients (42%) were found to have concomitant coronary lesions. Eighteen patients (38%) required intra-aortic balloon pump support.
A significant left axis deviation was observed in 26 cases (54%) and an intraventricular conduction delay in 32 patients (67%). The average QRS width and QTc interval were 122 and 433 ms, respectively. ST-segment elevation in lead aVR occurred in 32 patients (67%). ST-segment elevation in leads V2-5 and in leads I and aVL classic left anterior descending (LAD) type was frequently observed (18 cases; 35%). In six patients (13%), a partial LAD type was observed with ST-segment elevation in leads I and aVL, but not in peripheral leads. The remaining patients showed ST-segment elevation only in peripheral leads (12 cases), in inferior leads III + aVF (six cases), whereas six patients had no ST-segment elevation. Diffuse ST-segment depression only (>6 leads) was observed in 15 cases (31%). Eighteen patients (38%) died during hospitalization.
ST-segment elevation in lead aVR or a LAD-type pattern can be associated with LMT disease. Other relevant aspects are the presence of cardiogenic shock at admission, the left axis deviation and marked prolongation of QTc interval and QRS width.
The sodium-glucose co-transporter-2 (SGLT2) inhibitors are a new class of oral anti-diabetic drugs acting through the inhibition of renal reabsorbtion of glucose. Three important randomized clinical ...trial in diabetic patients receiving SGLT2 inhibitors (vs. placebo), demonstrated a significant reduction of major adverse cardiovascular events, but only in patients with known atherosclerotic disease, and a clear-cut and early reduction in hospital admissions for heart failure in patients in primary as well as secondary prevention settings. This latter information prompted the design of a recent study the DAPA-HF (Dapagliflozin And Prevention Of Adverse-outcomes In Heart Failure) trial, comparing dapagliflozin vs. placebo, and showing a significant reduction of clinical relevant episodes of heart failure in patients with reduced left ventricular ejection fraction, regardless the presence of diabetes mellitus. The mechanism by which the SGLT2 inhibitors exert their anti-heart failure action is not well understood but appears to be independent from its hypoglycaemic action. These results, along with the scarcity of adverse side effects of the drug, render dapagliflozin a new tool in the treatment of heart failure.
Background
Traditional cardiac rehabilitation (CR) is effective in improving physical performance and prognosis after myocardial infarction (MI). Anyway, it is not consistently recommended to older ...adults, and its attendance rate is low. Previous studies suggested that alternative, early and tailored exercise interventions are feasible and effective in improving physical performance in older MI patients. Anyway, the demonstration that they are associated also with a significant reduction of hard endpoints is lacking.
Aim
To describe rationale and design of the “Physical activity Intervention in Elderly patients with myocardial Infarction” (PIpELINe) trial.
Methods
The PIpELINe trial is a prospective, randomized, multicentre study with a blinded adjudicated evaluation of the outcomes. Patients aged ≥ 65 years, admitted to hospital for MI and with a low physical performance one month after discharge, as defined as short physical performance battery (SPPB) value between 4 and 9, will be randomized to a multi-domain lifestyle intervention (including dietary counselling, strict management of cardiovascular and metabolic risk factors, and exercise training) or health education. The primary endpoint is the one-year occurrence of the composite of cardiovascular death or re-hospitalization for cardiovascular causes.
Results
The recruitment started in March 2020. The estimated sample size is 456 patients. The conclusion of the enrolment is planned for mid-2023. The primary endpoint analysis will be available for the end of 2024.
Conclusions
The PIpELINe trial will show if a multi-domain lifestyle intervention is able to reduce adverse events in older patients with reduced physical performance after hospitalization for MI.
Trial registration
ClinicalTrials.gov NCT04183465.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia, and is associated with an increased risk of death, stroke, and other thromboembolic events. Valvular heart disease (VHD) ...frequently coexists with AF, mostly in elderly patients. After the introduction of novel oral anticoagulants (NOACs) approved for the prevention of stroke in non-valvular atrial fibrillation (NVAF) on the basis of recent trials, the importance of a universal definition of NVAF was raised in clinical practice. In the most recent guidelines, the term valvular AF is used to imply that AF is related to rheumatic valvular disease (predominantly mitral stenosis), or prosthetic heart valves. In all the trials comparing NOACs and warfarin, a significant percentage of patients presented any type of VHD, excluding rheumatic mitral stenosis and mechanical heart valve. The subgroups analysis performed, so far showed no significant differences in terms of efficacy in the VHD subgroup compared to the general AF population. A restrictive definition of valvular AF (i.e., rheumatic mitral stenosis and mechanical heart valve) seems to be the most appropriate to contraindicate treatment with NOACs for AF thromboprophylaxis. In the remaining AF patients with significant valvular disease who per se would not require oral anticoagulation, NOACs should be allowed.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
PDF
