The risk for symptomatic COVID-19 requiring hospitalization is higher in the older population. The course of the disease in hospitalised older patients may show significant variation, from mild to ...severe illness, ultimately leading to death in the most critical cases. The analysis of circulating biomolecules involved in mechanisms of inflammation, cell damage and innate immunity could lead to identify new biomarkers of COVID-19 severity, aimed to improve the clinical management of subjects at higher risk of severe outcomes. In a cohort of COVID-19 geriatric patients (n= 156) who required hospitalization we analysed, on-admission, a series of circulating biomarkers related to neutrophil activation (neutrophil elastase, LL-37), macrophage activation (sCD163) and cell damage (nuclear cfDNA, mithocondrial cfDNA and nuclear cfDNA integrity). The above reported biomarkers were tested for their association with in-hospital mortality and with clinical, inflammatory and routine hematological parameters. Aim of the study was to unravel prognostic parameters for risk stratification of COVID-19 patients.
Lower n-cfDNA integrity, higher neutrophil elastase and higher sCD163 levels were significantly associated with an increased risk of in-hospital decease. Median (IQR) values observed in discharged vs. deceased patients were: 0.50 (0.30-0.72) vs. 0.33 (0.22-0.62) for n-cfDNA integrity; 94.0 (47.7-154.0) ng/ml vs. 115.7 (84.2-212.7) ng/ml for neutrophil elastase; 614.0 (370.0-821.0) ng/ml vs. 787.0 (560.0-1304.0) ng/ml for sCD163. The analysis of survival curves in patients stratified for tertiles of each biomarker showed that patients with n-cfDNA integrity < 0.32 or sCD163 in the range 492-811 ng/ml had higher risk of in-hospital decease than, respectively, patients with higher n-cfDNA integrity or lower sCD163. These associations were further confirmed in multivariate models adjusted for age, sex and outcome-related clinical variables. In these models also high levels of neutrophil elastase (>150 ng/ml) appeared to be independent predictor of in-hospital death. An additional analysis of neutrophil elastase in patients stratified for n-cfDNA integrity levels was conducted to better describe the association of the studied parameters with the outcome.
On the whole, biomarkers of cell-free DNA integrity, neutrophil and macrophage activation might provide a valuable contribution to identify geriatric patients with high risk of COVID-19 in-hospital mortality.
•State of art of management and treatment of hypertension emergency/urgency in Italy.•Good knowledge of definition and treatment.•Fair quality of blood pressure measurement technique.•Lack of ...protocol or fast track for this problem.•Differences in terms of treatment and diagnosis across macro-areas.
Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Emergency Department (ED) and the approach may be different according to local clinical practice. Our aim was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of an on-line survey. The young investigator research group of the Italian Society of Hypertension developed a 23-item questionnaire spread by e-mail invitation to the members of Italian Scientific societies in the field of Hypertension. 665 questionnaires were collected from EDs, Emergency and Urgency Medicine, Cardiology or Coronary Units, Internal Medicines, Intensive care, Stroke units. Symptoms considered suspicious of acute organ damage were: chest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%) and epistaxis (34.4%). Exams more frequent prescribed were: electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). The use of intravenous or oral medications to treat HEs was 94.7% and 3.5%, while for HUs 24.4% and 70.8% respectively. Of note, a surprisingly high percentage of physicians (22 % overall, 24.5% in North Italy) used to prescribe sublingual nifedipine. After discharge, home blood pressure monitoring and general practitioner re-evaluation were more frequently suggested, while ambulatory blood pressure monitoring and hypertension specialist examination were less prescribed. The differences observed across the different macro-areas, regarded prescription of diagnostic test and drug administration. This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy.
OBJECTIVE:Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Italian Emergency Department (ED), however the diagnostic and therapeutic approach may differ ...across the Italian country. The aim of the study GEAR (Gestione delle Emergenze e urgenze in ARea critica) was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of on-line survey.
DESIGN AND METHOD:The young investigator research group of the Italian Society of Hypertension developed a 23-items questionnaire spread by e-mail invitation to the members of Italian Scientific societies involved in the field of Emergency Medicine and Hypertension.
RESULTS:665 questionnaires were collected59.7% from EDs, 22% from Emergency and Urgency Medicine wards, 8.7% from Cardiology or Coronary Units, 5.7% from Internal Medicines and 3.9% from Intensive care or Stroke units. The definition of HE and HU was correctly identified by 81.2% and 89.3% of the responders respectively. The symptoms considered suspicious of acute organ damage werechest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%), epistaxis (34.4%). Appropriate cuffs, for different arm sizes, were not widely available in all units94% had standard cuffs, 57% small and 75.6 % large cuffs, extra-large only 38.5%. The exams more frequent prescribed to evaluate target organ damage were electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). HEs were treated by 94.7% of the physicians by intravenous medications and by 3.5% by oral drugs, while HUs were treated by intravenous drugs in 24.4% of the cases and by oral drugs in 70.8%. When patients were discharged from ED, 87.5 % of the responders recommended home blood pressure monitoring, 87.5% general practitioner re-evaluation, while ambulatory blood pressure monitoring and hypertension specialist examination were less frequently recommended.
CONCLUSIONS:This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy. Strong unmet needs clearly emerged, especially for educational initiatives, standardized treatment protocols and interrelationship with the chronic care system.
OBJECTIVE:Sacubitril/Valsartan inhibits both the renin-angiotensin-aldosterone system (RAAS) and the degradation of natriuretic peptides. We evaluated the effects of this innovative drug on blood ...pressure (BP) and renal function in real-life patients with heart failure and reduced ejection fraction (HFrEF) followed for one year.
DESIGN AND METHOD:We performed a longitudinal, observational study on 54 consecutive ambulatory outpatients with chronic HFrEF and clinical indication for Sacubitril/Valsartan. Patients were evaluated at baseline (T0) and after six (T6) and twelve (T12) months after initiating Sacubitril/Valsartan. We excluded patients with a life expectancy of less than one year and patients hospitalized during the follow-up. We focused on office BP and renal function, that was assessed by serum creatinine and glomerular filtration rate (GFR-estimated by CKD-EPI formula). Chronic kidney disease (CKD) was defined by eGFR < 60 ml/min/1.73m2. All patients were treated according to the “good clinical practice”. Drugs were titrated, whenever possible, according to common clinical parameters (symptoms/signs, BP, elettrocardiography and laboratory parameters).
RESULTS:Mean age65.5 ± 11.7 years (range 44–95 years); male prevalence74.1%. Older patients (age >= 65 years)53.7%. Mean baseline eGFR59.4 ± 19.2 ml/min/1.73m2; patients with CKD53.7%. Drug therapy at baselineRAAS-blockers 100%, beta-blockers and loop diuretics 90.7%, mineralocorticoid-receptor antagonists (MRA) 74.1%. Sacubitril/Valsartan was less titrated in both older patients and CKD patients. There were no changes in both diuretics and MRA during follow-up. Both systolic and diastolic BP significantly decreased during follow-up (p = 0.014 and p = 0.002, respectively), while left ventricular ejection fraction slightly increased (p < 0.001). No symptomatic hypotension was reported during follow-up. Renal function improved after 12 months (p = 0.010) and a greater benefit was found in adults (p for interaction = 0.002) and patients with CKD (p for interaction = 0.009). A statistically (p = 0.009), but not clinically significant increase in serum potassium was also found, regardless age and CKD.
CONCLUSIONS:This is the first real-life study focused on the effects of Sacubitril/Valsartan on BP and renal function in HFrEF patients followed for 12 months. The improved eGFR, despite lower BP, even in older patients and those with CKD, represents an important confirmation outside the peculiar world of RCTs.
Laboratory studies on human adipose tissue and differentiated adipocytes indicate that natriuretic peptides (NPs) affect lipid metabolism and plasma cholesterol. Few previous clinical studies in ...non-elderly populations found associations between NPs in the physiological range and cholesterol. Aim: evaluate the association between NT-proBNP and lipid profile in very elderly hospitalized patients characterized by a wide range of NT-proBNP levels.
Cross-sectional study on 288 very elderly patients hospitalized for medical conditions, in which increased NT-proBNP levels are very common. NT-proBNP, total cholesterol (TC), HDL cholesterol (HDLc) and triglycerides were collected just few days before discharge. Patients taking lipid-lowering drugs and patients with an admission diagnosis of acute heart failure were excluded. Calculated LDL-cholesterol (LDLc) was used for the analyses. Mean age: 87.7 ± 6.2 years; female prevalence (57.3%). Median NT-proBNP: 2949 (1005–7335) pg/ml; mean TC: 145.1 ± 40.3 mg/dl; mean HDLc: 38.4 ± 18.6 mg/dl; median triglycerides: 100 (75–129) mg/dl; mean LDLc: 84.0 ± 29.5 mg/dl. We found negative correlations between NT-proBNP and both TC and LDLc (Rho = −0.157; p = 0.008 and Rho = −0.166; p = 0.005, respectively), while no correlations emerged between NT-proBNP and HDLc (Rho = −0.065; p = 0.275) or triglycerides (Rho = −0.009; p = 0.874). These associations were confirmed considering NT-proBNP tertiles. The inverse association between NT-proBNP and LDLc was maintained even after adjusting for confounding factors.
Our real-life clinical study supports the hypothesis that NPs play a role on cholesterol metabolism, given the association found between LDLc and NT-proBNP even in very elderly patients where NT-proBNP values are often in the pathological range.
•Natriuretic peptides correlate with lipid parameters.•Higher NT-proBNP independently correlates with lower LDL cholesterol in very elderly.•The inverse correlation between NT-proBNP and LDL cholesterol is continuous.•Natriuretic peptides might play a role in LDL cholesterol metabolism.
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