Abstract
Aims
Lipid management plays a key role in secondary prevention after acute coronary syndrome. Current European Society of Cardiology guidelines recommend a dual goal: to achieve LDL ...cholesterol (LDL-C) <55 mg/dL, and to reduce it ≥ 50% form baseline. Currently, data on the reduction of cardiovascular events in patients achieving both goals in a real-world population are missing. Accordingly, the objective of this study was to determine the prognosis in post myocardial infarction (PMI) patients and determine the risk of new events according to the achievement of the optimal goals indicated by the guidelines in terms of LDL-C reduction.
Methods and results
We conducted a retrospective analysis of a monocentric observational registry prospectively enrolling patients admitted to our hospital for ST segment elevation myocardial infarction (STEMI) and followed-up in our dedicated PMI ambulatory. The analysis considered the patients enrolled between 2013 and 2017. Demographical and clinical data were extracted from a dedicated digital database, and the clinical events occurred during follow-up were obtained by telephone interviews or clinical records. We considered a combined endpoint of major adverse cardiovascular events (MACE) of all-cause death, non-fatal MI, non-fatal stroke and unplanned revascularization. LDL-C was collected at baseline and at 1, 6 and 12 months after the event. The lower value collected at follow-up was used to define the achievement of the target goals. We conducted a Kaplan-Meier analysis and log-rank test comparing patients who achieved LDL-C < 55 mg/dL and ≤50% from baseline (group A) vs those with only LDL-C < 55 mg/dL (group B). Continue variable are presented as median (interquartile range). A total of 814 patients (23% female) were included in our analysis. Median age was 63 (55–72) years, 57% had hypertension, 19% diabetes, 36% were smoker and 17% obese. Baseline LDL-C was 124 (97–146) mg/dL, the median LDL-C at follow-up was 63 (52–78) mg/dL, significantly reduced from baseline (P < 0.0001). Between 6 and 12 months 83.3% of patients were treated with statin therapy alone (73% high intensity), 15.3% with the addition of ezetimibe, and 0.5% with ezetimibe alone. LDL-C < 55 mg/dl was achieved in 244 patients (30%), while 175 patients (21%) obtained also LDL-C ≤ 50% from baseline. Median follow-up was 52 (34–66) months. The net incidence of MACE was 12% in group A vs 27.5% in group B (HR 0.35; 95% CI 0.17–0.70; P log-rank = 0.0032; Number Needed to Treat = 6; see Figure).
Conclusion
Our data from a real-world cohort of PMI patients emphasize the importance of achieving both the guideline-recommended secondary prevention goals of LDL-C < 55 mg/dl and ≤50% from baseline in order to reduce MACE.
Abstract
Background
Cardiac Sympathetic Denervation (CSD) has been recently proposed for the treatment of refractory ventricular arrhythmias (VAs) in patients with cardiomyopathy (CMP). A ...multicentric American and Indian case series suggested a greater efficacy of bilateral denervation (BCSD), compared to the left-side only procedure (LCSD), albeit with the potential prize of an increased need for atrial pacing due to the right-side innervation of the sinus node. The impact of CSD on the risk of electrical storms (ES) in CMP has never been evaluated.
Aim
To describe our multicenter Italian experience with CSD in CMP patients with drug and/or catheter ablation refractory VAs, with a specific focus on ES incidence.
Methods
Thirty patients with CMP and refractory VAs underwent either LCSD or BCSD between April 2016 and June 2022. Among them, one patient received first LCSD and then right-side denervation due to ES recurrence after LCSD: to properly assess the risk of ES after LCSD and BCSD he was included in both groups with the corresponding follow-up, leading to 5 cases of LCSD and 26 cases of BCSD. All patients had a Video–Assisted Thoracoscopic Surgery (VATS), in 8 cases associated with the robotic technique. The main reason (3/5 cases, 60%) to perform LCSD instead of BCSD since the beginning was sinus bradycardia in single ICD lead recipients.
Results
87% of pts were male, the mean age was 56 ± 16 yrs and the mean LVEF 31± 12%; most (n=26, 85%) suffered non-ischemic cardiomyopathy and 37% were in NYHA functional class ≥3. Main indications for CSD were represented by refractory polymorphic/fast VAs (cycle length <250 msec) in 60% of pts and by refractory monomorphic VAs episodes in the rest. Except for 5 patients (17%) with previous thyrotoxicosis, the majority were either on amiodarone (n=19, 63%) or on sotalol (n=3, 10%) before CSD and 53% had previously undergone ≥1 catheter ablation for VAs. The median follow-up (FU) after denervation was 15 months (IQR 5-42 months).
No major complication directly related to the procedure occurred. Overall, 11 patients (37%) either died during FU (n=8, 27%), mostly due to end-stage heart failure, or underwent heart transplant (n=3, 10%). After denervation, the percentage of patients with ES decreased from 77% to 40% (p<0.01), while patients with appropriate shocks decreased from 100% to 60%. The antiarrhythmic benefit was even more pronounced among the 26 patients who received BCSD: ES incidence decreased from 85% to 39% (p<0.01), appropriate shock incidence from 100% to 54% (p<0.01), while no significant changes in ES and ICD shock incidence were observed after the few LCSD procedures (n=5). A NYHA class <3 was associated with a trend toward a better response after BCSD (37% vs 54% incidence of ICD shock, p=0.05).
Conclusions
Our case series of CSD in cardiomyopathies represents the largest reported in Europe and the first ever to specifically evaluate the impact of denervation on electrical storms. The occurrence of electrical storm was more than halved by bilateral CSD confirming the powerful protective effect of BCSD also on this ominous phenomenon. The greater antiarrhythmic benefit observed among patients with better functional class suggests the opportunity to perform this procedure earlier on in the trajectory of patients with progressive heart failure.
...we investigated whether they add to the predictive accuracy of major clinical variables associated with mortality in this setting, and which AKI definition performs better.
BACKGROUNDGlucocorticoid therapy has emerged as an effective therapeutic option in hospitalized patients with coronavirus disease 2019 (COVID-19). This study aimed to focus on the impact of relevant ...clinical and laboratory factors on the protective effect of glucocorticoids on mortality. METHODSA sub-analysis was performed of the multicenter Cardio-COVID-Italy registry, enrolling consecutive patients with COVID-19 admitted to 13 Italian cardiology units between 01 March 2020 and 09 April 2020. The primary endpoint was in-hospital mortality. RESULTSA total of 706 COVID-19 patients were included (349 treated with glucocorticoids, 357 not treated with glucocorticoids). After adjustment for relevant covariates, use of glucocorticoids was associated with a lower risk of in-hospital mortality (adjusted HR 0.44; 95% CI 0.26-0.72; p = 0.001). A significant interaction was observed between the protective effect of glucocorticoids on mortality and PaO2/FiO2 ratio on admission (p = 0.042), oxygen saturation on admission (p = 0.017), and peak CRP (0.023). Such protective effects of glucocorticoids were mainly observed in patients with lower PaO2/FiO2 ratio (<300), lower oxygen saturation (<90%), and higher CRP (>100 mg/L). CONCLUSIONSThe protective effects of glucocorticoids on mortality in COVID-19 were more evident among patients with worse respiratory parameters and higher systemic inflammation.
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