Background European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV in primary care was a cross-sectional survey carried out by the European Society of ...Cardiology, EURObservational Research Programme in 2014-2015 in 71 centres from 14 European countries. The main objective was to determine whether the 2012 Joint European Societies' guidelines on cardiovascular disease (CVD) prevention in people at high CVD risk have been followed in clinical practice. Methods Patients without a history of atherosclerotic disease started on either blood pressure and/or lipid and/or glucose-lowering treatments were identified and interviewed at least six months after the start of medication. Results Medical notes of 6700 patients were reviewed, and 4579 patients (58.7% women; mean age 58.8 (standard deviation (SD) 11.3) years) interviewed (interview rate 68.3%). Overall, 16.6% were smokers, 39.9% were overweight (body mass index (BMI)≥25 and <30 kg/m
), 43.5% obese (BMI ≥30 kg/m
) and 63.9% centrally obese (waist circumference of ≥88 cm for women, ≥102 cm for men). The medical risk factor control was very poor, with less than half (42.8%) of the patients on blood pressure lowering medication reaching the target of <140/90 mm Hg (<140/80 mm Hg in people with self-reported diabetes). Among treated dyslipidaemic patients only 32.7% attained the low-density lipoprotein (LDL)-cholesterol target of <2.5 mmol/l. Among people treated for type 2 diabetes mellitus, 58.5% achieved the glycated haemoglobin (HbA1c) target of <7.0%. Conclusion The EUROASPIRE IV survey shows that large proportions of patients at high CVD risk have unhealthy lifestyle habits and uncontrolled blood pressure, lipids and diabetes. The present data make it clear that more efforts must be taken to improve cardiovascular prevention in people at high CVD risk.
Background
Women with ST‐segment–elevation myocardial infarction (STEMI) have higher mortality rates than men. We investigated whether sex‐related differences in timely access to care among STEMI ...patients may be a factor associated with excess risk of early mortality in women.
Methods and Results
We identified 6022 STEMI patients who had information on time of symptom onset to time of hospital presentation at 41 hospitals participating in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776) from October 2010 through April 2016. Patients were stratified into time‐delay cohorts. We estimated the 30‐day risk of all‐cause mortality in each cohort. Despite similar delays in seeking care, the overall time from symptom onset to hospital presentation was longer for women than men (median: 270 minutes range: 130–776 versus 240 minutes range: 120–600). After adjustment for baseline variables, female sex was independently associated with greater risk of 30‐day mortality (odds ratio: 1.58; 95% confidence interval, 1.27–1.97). Sex differences in mortality following STEMI were no longer observed for patients having delays from symptom onset to hospital presentation of ≤1 hour (odds ratio: 0.77; 95% confidence interval, 0.29–2.02).
Conclusions
Sex difference in mortality following STEMI persists and appears to be driven by prehospital delays in hospital presentation. Women appear to be more vulnerable to prolonged untreated ischemia.
Clinical Trial Registration
URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01218776.
Abstract
Aims
The use of digitalis has been plagued by controversy since its initial use. We aimed to determine the relationship between digoxin use and outcomes in hospitalized patients with acute ...coronary syndromes (ACSs) complicated by heart failure (HF) accounting for sex difference and prior heart diseases.
Methods and results
Of the 25 187 patients presenting with acute HF (Killip class ≥2) in the International Survey of Acute Coronary Syndromes Archives (NCT04008173) registry, 4722 (18.7%) received digoxin on hospital admission. The main outcome measure was all-cause 30-day mortality. Estimates were evaluated by inverse probability of treatment weighting models. Women who received digoxin had a higher rate of death than women who did not receive it 33.8% vs. 29.2%; relative risk (RR) ratio: 1.24; 95% confidence interval (CI): 1.12–1.37. Similar odds for mortality with digoxin were observed in men (28.5% vs. 24.9%; RR ratio: 1.20; 95% CI: 1.10–1.32). Comparable results were obtained in patients with no prior coronary heart disease (RR ratio: 1.26; 95% CI: 1.10–1.45 in women and RR ratio: 1.21; 95% CI: 1.06–1.39 in men) and those in sinus rhythm at admission (RR ratio: 1.34; 95% CI: 1.15–1.54 in women and RR ratio: 1.26; 95% CI: 1.10–1.45 in men).
Conclusion
Digoxin therapy is associated with an increased risk of early death among women and men with ACS complicated by HF. This finding highlights the need for re-examination of digoxin use in the clinical setting of ACS.
Graphical Abstract
Graphical Abstract Figure.
Inverse probability of treatment weighting: relative risk for association between digoxin use and 30-day mortality by sex and acute coronary syndrome types in patients presenting with acute heart failure on hospital admission. Abbreviations: ACS, acute coronary syndrome; CHD, coronary heart disease; HF, heart failure; NSTE-ACS, non-ST segment elevation acute coronary syndromes; STEMI, ST segment elevation myocardial infarction.
Development of cardiac allograft vasculopathy represents the major determinant of long-term survival in patients after heart transplantation. Due to graft denervation, these patients seldom present ...with classic symptoms of angina pectoris, and the first clinical presentations are progressive heart failure or sudden cardiac death. Although coronary angiography remains the routine technique for coronary artery disease detection, it is not sensitive enough for screening purposes. This is especially the case in the first year after transplantation when diffuse and concentric vascular changes can be easily detected only by intravascular ultrasound. The treatment of the established vasculopathy is disappointing, so the primary effort should be directed toward early prevention and diagnosis. Due to diffuse vascular changes, revascularization procedures are restricted only to a relatively small proportion of patients with favorable coronary anatomy. Percutaneous coronary intervention is preferred over surgical revascularization since it leads to better acute results and patient survival. Although there is no proven long-term advantage of drug-eluting stents for the treatment of in-stent restenosis, they are preferred over bare-metal stents. Severe vasculopathy has a poor prognosis and the only definitive treatment is retransplantation. This article reviews the present knowledge on the pathogenesis, diagnosis, treatment, and prognosis of cardiac allograft vasculopathy.
Abstract Background Limited data are available on the outcome of primary percutaneous coronary intervention (PCI) in octogenarians patients, as elderly are under-represented in randomized trials. ...This study aims to provide insights on clinical characteristics, management and outcome of the elderly and very elderly presenting with STEMI. Methods 2225 STEMI patients ≥ 70 years old (mean age 76.8 ± 5.1 years and 53.8% men) were admitted into the network of the ISACS-TC registry. Of these patients, 72.8% were ≥ 70 to 79 years old (elderly) and 27.2% were ≥ 80 years old (very-elderly). The primary end-point was 30-day mortality. Results Thirty-day mortality rates were 13.4% in the elderly and 23.9% in very-elderly. Primary PCI decreased the unadjusted risk of death both in elderly (OR:0.32, 95% CI: 0.24-0.43) and very-elderly patients (OR: 0.45, 95% CI 0.30-0.68), without significant difference between groups. In the very-elderly hypertension and Killip class ≥ 2 were the only independent factors associated with mortality; whereas in the elderly female gender, prior stroke, chronic kidney disease and Killip class ≥ 2 were all factors independently associated with mortality. Factors associated with lack of use of reperfusion were female gender and atypical chest pain in the very-elderly and in the elderly; in the elderly, however, there were some more factors, namely: history of diabetes, current smoking, prior stroke, Killip class ≥ 2 and history chronic kidney disease. Conclusions Age is relevant in the prognosis of STEMI, but its importance should not be considered secondary to other major clinical factors. Primary PCI appears to have beneficial effects in the octogenarians STEMI patients.
Multivariate logistic regression models were adjusted to covariates significantly different between groups in univariate analysis.The primary endpoint was 30 day mortality Results Compared with a ...hospital admission greater than 2h, a time of 2h or less was associated with a lower incidence of death (6.5% vs 8.9%).
Abstract Background We explored benefits and risks of an early invasive compared with a conservative strategy in women versus men after non-ST elevation acute coronary syndromes (NSTE-ACS) using the ...ISACS-TC database. Methods From October 2010 to May 2014, 4145 patients were diagnosed as having a NSTE-ACS. We excluded 258 patients managed with coronary bypass surgery. Of the remaining 3887 patients, 1737 underwent PCI (26% women). The primary endpoint was the composite of 30-day mortality and severe left ventricular dysfunction defined as an ejection fraction < 40% at discharge. Results Women were older and more likely to exhibit more risk factors and Killip Class ≥ 2 at admission as compared with men. In patients who underwent PCI, peri-procedural myocardial injury was not different among sexes (3.1% vs. 3.2%). Women undergoing PCI experienced higher rates of the composite endpoint (8.9% vs. 4.9%, p = 0.002) and 30-day mortality (4.4% vs. 2.0%, p = 0.008) compared with men, whereas those who managed with only routine medical therapy (RMT) did not show any sex difference in outcomes. In multivariable analysis, female sex was associated with favorable outcomes (adjusted HR for the composite endpoint: 0.72, 95% CI: 0.58–0.91) in patients managed with RMT, but not in those undergoing PCI (adjusted HR: 0.96, 95% CI: 0.61–1.52). Conclusions We observed a more favorable outcome in women than men when patients were managed with RMT. Women and men undergoing PCI have similar outcomes. These data suggest caution in extrapolating the results from men to women in an overall population of patients in the context of different therapeutic strategies.
To assess the association between renal replacement therapy (RRT) and post-transplant infection incidence.
This single-center retrospective cohort study included 158 patients who underwent heart ...transplantation (HTx) in our center from 2008 to 2016, survived beyond the first post-procedural day, and had available microbial data. The patients were dichotomized according to the need for periprocedural RRT. Twenty-seven patients in RRT group had lower preoperative creatinine clearance, greater body mass index, and higher likelihood of having diabetes. Propensity score adjustment was used to account for multiple covariates. The primary outcome measure was the presence of bacteremia in patients with and without the need for RRT. The secondary outcome measures were the presence of microbial isolates from any culture and clinical outcome data.
Unadjusted analysis showed that the RRT group had higher incidence of any positive microbial isolate (93% vs 73%; odds ratio OR 4.77, 95% confidence interval CI 1.01-30.53; P=0.026) and an increased susceptibility to bacteremia (50% vs 22%; OR 3.50, 95% CI 1.28-9.67; P=0.012). Propensity score-adjusted analysis corroborated the between-group difference in positive blood cultures (OR 3.97, 95% CI 1.28-12.32; P=0.017). There was no difference in the incidence of total microbial isolates between the groups (OR 4.55, 95% CI 0.90-23.05; P=0.067).
Patients requiring RRT after HTx had an increased susceptibility to infections via various portals of entry, predominantly due to an increase in blood-borne infections. Understanding the underlying conditions leading to infection-related morbidity is important for infection control and prevention.
Cell-free DNA has been associated with outcome in several acute conditions including two reports concerning the outcomes after cardiac arrest that found association of circulating DNA quantities at ...admission with mortality. The origins of cell-free DNA are primarily necrosis and apoptosis, which in cardiac arrest occur during ischaemia (“no-flow” and “low-flow” period), during reperfusion injury and as a consequence of post-arrest inflammatory response. Respecting the facts that significant cellular damage may occur during the post-arrest period, and that damage might be reduced by mild therapeutic hypothermia, we investigated the prognostic value of cell free DNA at ICU admission and 24h after admission.
A prospective study was conducted in three university associated intensive care units and included patients resuscitated from non-traumatic out-of-hospital cardiac arrest. Patient data were collected in accordance with the Utstein protocol. Therapeutic hypothermia was performed according to ICU policies.
Blood for cell-free DNA quantification was sampled at admission and at 24±1h after admission. Outcome measures were hospital morality and cerebral performance expressed with CPC scale at discharge.
Inclusion criteria were met in 67 patients; 24-h mortality was 37.3% and hospital mortality was 71.6%. The following variables were associated with 24-h mortality in univariate analysis: asystole as the presenting rhythm, “no-flow” time, “low-flow” time and cell-free DNA at admission (median 0.081 in survivors vs. 0.160ng/μl in non-survivors; P=0.038). Multivariate analysis that included the above variables showed that no-flow time and low-flow time were independently associated with 24-h mortality.
Hospital mortality was associated with the following factors: “low flow” time, coronary intervention, cell-free DNA at ICU admission and at 24h after admission (0.042 vs. 0.188ng/μl; P=0.048). ROC curve for cell-free DNA 24h post-admission showed sensitivity of 81.0% and specificity of 78.3% for the cut-off value of 0.115ng/μl.
Multivariate analysis showed that “low-flow” time and cell-free DNA at 24h after ICU admission were independently associated with hospital mortality. Cell free DNA showed different dynamics in patients who were and who were not treated with mild therapeutic hypothermia: it decreased in treated patients and slightly increased in non-treated patients.
Cell-free DNA quantity at ICU admission and 24h after admission is associated with hospital mortality. Further studies will need to additionally investigate possible practical use of this new laboratory marker in patients resuscitated from cardiac arrest.
Abstract Cell-free DNA has been associated with outcome in several acute conditions including two reports concerning the outcomes after cardiac arrest that found association of circulating DNA ...quantities at admission with mortality. The origins of cell-free DNA are primarily necrosis and apoptosis, which in cardiac arrest occur during ischaemia (“no-flow” and “low-flow” period), during reperfusion injury and as a consequence of post-arrest inflammatory response. Respecting the facts that significant cellular damage may occur during the post-arrest period, and that damage might be reduced by mild therapeutic hypothermia, we investigated the prognostic value of cell free DNA at ICU admission and 24 h after admission. A prospective study was conducted in three university associated intensive care units and included patients resuscitated from non-traumatic out-of-hospital cardiac arrest. Patient data were collected in accordance with the Utstein protocol. Therapeutic hypothermia was performed according to ICU policies. Blood for cell-free DNA quantification was sampled at admission and at 24 ± 1 h after admission. Outcome measures were hospital morality and cerebral performance expressed with CPC scale at discharge. Inclusion criteria were met in 67 patients; 24-h mortality was 37.3% and hospital mortality was 71.6%. The following variables were associated with 24-h mortality in univariate analysis: asystole as the presenting rhythm, “no-flow” time, “low-flow” time and cell-free DNA at admission (median 0.081 in survivors vs. 0.160 ng/μl in non-survivors; P = 0.038). Multivariate analysis that included the above variables showed that no-flow time and low-flow time were independently associated with 24-h mortality. Hospital mortality was associated with the following factors: “low flow” time, coronary intervention, cell-free DNA at ICU admission and at 24 h after admission (0.042 vs. 0.188 ng/μl; P = 0.048). ROC curve for cell-free DNA 24 h post-admission showed sensitivity of 81.0% and specificity of 78.3% for the cut-off value of 0.115 ng/μl. Multivariate analysis showed that “low-flow” time and cell-free DNA at 24 h after ICU admission were independently associated with hospital mortality. Cell free DNA showed different dynamics in patients who were and who were not treated with mild therapeutic hypothermia: it decreased in treated patients and slightly increased in non-treated patients. Cell-free DNA quantity at ICU admission and 24 h after admission is associated with hospital mortality. Further studies will need to additionally investigate possible practical use of this new laboratory marker in patients resuscitated from cardiac arrest.
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