RESUMO
Troponin I and T as cardiac-specific biomarkers are highly useful tools not only in the diagnosis of acute coronary syndromes but also as independent predictors of several other clinical conditions. High-sensitivity cardiac troponin (hs-cTn) assays allow the detection of considerably low concentrations of cardiac troponin in apparently healthy and asymptomatic individuals, being a candidate tool for cardiovascular risk stratification in the general population. A group of Greek experts summarized the bulk of evidence regarding the use of hs-cTnI as a predictor of cardiovascular events and mortality in apparently healthy individuals and its additive value on top of existing risk stratification methods. This document could serve as a guide for the incorporation of hs-cTnI as an additional risk stratification tool in cardiovascular prevention strategies in apparently healthy individuals.
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Doenças Cardiovasculares , Troponina I , Humanos , Troponina T , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Biomarcadores , Fatores de RiscoAssuntos
Consenso , Diagnóstico por Imagem/normas , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/cirurgia , Guias de Prática Clínica como Assunto , Sociedades Médicas , Procedimentos Cirúrgicos Vasculares/normas , Idoso , Idoso de 80 Anos ou mais , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeAssuntos
Reabilitação Cardíaca/métodos , Doenças Cardiovasculares/prevenção & controle , Adulto , Fatores Etários , Idoso , Anti-Hipertensivos/uso terapêutico , Biomarcadores/metabolismo , Reabilitação Cardíaca/economia , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/etnologia , Análise Custo-Benefício , Angiopatias Diabéticas/prevenção & controle , Diagnóstico por Imagem/métodos , Dieta Saudável , Exercício Físico/fisiologia , Medicina Geral/métodos , Promoção da Saúde/métodos , Estilo de Vida Saudável , Humanos , Hiperlipidemias/prevenção & controle , Hipertensão , Pessoa de Meia-Idade , Múltiplas Afecções Crônicas , Linhagem , Padrões de Prática Médica/normas , Medição de Risco , Fatores Sexuais , Abandono do Hábito de Fumar , Fatores SocioeconômicosRESUMO
OBJECTIVE: to assess the effects of cilostazol on pain-free walking distance in PAD patients with IC at 3 and 6 months in a real world, prospective, observational study. We included 1015 PAD patients presenting with IC (71.3% men, 93.5% white, mean age 69.2 ± 8.7 years). Patients were followed up for 6 months by their physicians. RESULTS: Cilostazol significantly increased pain-free walking distance by a median of 285 and 387 m at 3 and 6 months, respectively (p < 0.01 for all comparisons). This effect was significant for patients 50-74 years (but not for those aged ≥ 75 years) and independent of smoking status, changes in physical activity, comorbidities and concomitant medication for PAD (i.e., acetylsalicylic acid and clopidogrel). Furthermore, significant reductions were observed in systolic (from 139 ± 16 to 133 ± 14 mmHg; p < 0.001) and diastolic blood pressure (from 84 ± 9 mmHg to 80 ± 10 mmHg; p < 0.001). Smoking cessation and increased physical activity were reported by the majority of participants. In conclusion, cilostazol was shown to safely decrease pain symptoms and improve pain-free walking in PAD patients with IC in a real world setting. Benefits also occurred in terms of BP and lifestyle changes.
Assuntos
Claudicação Intermitente , Doença Arterial Periférica , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Cilostazol/uso terapêutico , Claudicação Intermitente/induzido quimicamente , Claudicação Intermitente/tratamento farmacológico , Estudos Prospectivos , Tetrazóis/uso terapêutico , Doença Arterial Periférica/induzido quimicamente , Doença Arterial Periférica/tratamento farmacológico , Dor/tratamento farmacológico , CaminhadaRESUMO
Atrial fibrillation (AF) may often pre-exist in patients with newly diagnosed cancer or occur with increased frequency shortly after cancer diagnosis. Patients with active cancer and AF have a particularly high risk of thromboembolic complications, as both conditions carry a risk of thrombosis. Thromboembolic risk is determined by several factors, including advanced age, sex (females), cancer histology (adenocarcinomas), location (e.g., pancreas, stomach), advanced stage, anticancer regimens (e.g., platinum compounds, anti-angiogenic therapies, immune modulators), comorbidities (e.g., obesity, kidney disease) and concurrent therapies (e.g., surgery, central catheters). Physicians are often reluctant to prescribe anticoagulants to patients with active cancer and AF, mainly due to fear of bleeding complications, which is partly related to the paucity of evidence in the field. Decision making regarding anticoagulation for the prevention of ischemic stroke and systemic embolism in patients with active cancer and AF may be challenging and should not simply rely on the risk prediction scores used in the general AF population. By contrast, the administration and choice of anticoagulants should be based on the comprehensive, individualized and periodic evaluation of thromboembolic and bleeding risk, drug-drug interactions, patient preferences and access to therapies.
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Digital health technology is receiving increasing attention in cardiology. The rise of accessibility of digital health tools including wearable technologies and smart phone applications used in medical practice has created a new era in healthcare. The coronavirus pandemic has provided a new impetus for changes in delivering medical assistance across the world. This Consensus document discusses the potential implementation of digital health technology in older adults, suggesting a practical approach to general cardiologists working in an ambulatory outpatient clinic, highlighting the potential benefit and challenges of digital health in older patients with, or at risk of, cardiovascular disease. Advancing age may lead to a progressive loss of independence, to frailty, and to increasing degrees of disability. In geriatric cardiology, digital health technology may serve as an additional tool both in cardiovascular prevention and treatment that may help by (i) supporting self-caring patients with cardiovascular disease to maintain their independence and improve the management of their cardiovascular disease and (ii) improving the prevention, detection, and management of frailty and supporting collaboration with caregivers. Digital health technology has the potential to be useful for every field of cardiology, but notably in an office-based setting with frequent contact with ambulatory older adults who may be pre-frail or frail but who are still able to live at home. Cardiologists and other healthcare professionals should increase their digital health skills and learn how best to apply and integrate new technologies into daily practice and how to engage older people and their caregivers in a tailored programme of care.
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Cardiologia , Doenças Cardiovasculares , Fragilidade , Humanos , Idoso , Fragilidade/prevenção & controle , Doenças Cardiovasculares/prevenção & controle , Consenso , PandemiasRESUMO
The Council for Cardiology Practice of the European Society of Cardiology (ESC), in collaboration with the Digital Health Committee (DHC), undertook an electronic survey with 15 question multiple-choice questionnaire sent to 32â461 members of the ESC with the aim to assess the knowledge and usage of digital health (DH) technologies (DHTs) by office-based cardiologists. Of 559 respondents, 57% graded their knowledge about DH as 'fair' and three quarters identified the correct definition of DH. Clinical information systems, mHealth Apps, and telemedicine were the most frequently used DHTs, but 41% of respondents had concerns about their ethical and data transparency. Lack of legal clarity, low patient motivation, limited DH literacy, and poor access to DH were perceived as the main barriers to the adoption of DH. Seventy percent of the respondents were aware of the DH pages on the ESC website and 76% of the educational sessions in the DH area during the ESC Congress 2019. Only 16% had not read articles on DH. Eight-eight percent of responders declared that they would 'probably' or definitely attend future educational initiatives on DHT.
RESUMO
Cardiovascular (CV) engagement in coronavirus disease 2019 (COVID-19) is a huge determinant of prognosis during the acute phase of the disease. However, little is known about the potential chronic implications of the late phase of COVID-19 and about the appropriate approach to these patients. Heart failure, type 1 and type 2 myocardial infarction, arrhythmias, myocarditis, pulmonary fibrosis, and thrombosis have been shown to be related to severe acute respiratory syndrome coronavirus 2 infection, and a 'long COVID-19' illness has been recognized with fatigue, chest pain, and dyspnoea among the most frequent symptoms reported after discharge from hospital. This paper focuses on some open questions that cardiologists are going to face during the next months in a general cardiology outpatient clinic, in particular how to evaluate a 'post-COVID' patient during follow-up of CV complications of the acute phase and how to manage new CV symptoms that could be the consequence, at least in part, of heart/vessels and/or lung involvement of the previous virus infection. Present symptoms and signs, history of previous CV disease (both preceding COVID-19 and occurring during viral infection), and specific laboratory and imaging measurements during the acute phase may be of interest in focusing on how to approach the clinical evaluation of a post-COVID patient and how to integrate in our standard of care the new information on COVID-19, possibly in a multidisciplinary view. Dealing with the increased COVID-associated CV risk burden and becoming acquainted with potential new e-cardiology approaches aimed at integrating the cardiology practice are relevant new challenges brought by severe acute respiratory syndrome coronavirus 2 infection and its sequelae.
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COVID-19 , Cardiologia , COVID-19/complicações , Humanos , Pandemias , SARS-CoV-2 , Síndrome de COVID-19 Pós-AgudaRESUMO
BACKGROUND: Although plasma fibrinogen levels are related to cardiovascular risk, data regarding the role of fibrinogen genetic variation in myocardial infarction (MI) or coronary artery disease (CAD) etiology remain inconsistent. The purpose of the present study was to investigate the effect of fibrinogen A (FGA), fibrinogen B (FGB) and fibrinogen G (FGG) gene SNPs and haplotypes on susceptibility to CAD in a homogeneous Greek population. METHODS: We genotyped for rs2070022, rs2070016, rs2070006 in FGA gene, the rs7673587, rs1800789, rs1800790, rs1800788, rs1800787, rs4681 and rs4220 in FGB gene and for the rs1118823, rs1800792 and rs2066865 SNPs in FGG gene applying an arrayed primer extension-based genotyping method (APEX-2) in a sample of CAD patients (n = 305) and controls (n = 305). Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), before and after adjustment for potential confounders. RESULTS: None of the FGA and FGG SNPs and FGA, FGB, FGG and FGA-FGG haplotypes was associated with disease occurrence after adjustment. Nevertheless, rs1800787 and rs1800789 SNPs in FGB gene seem to decrease the risk of CAD, even after adjustment for potential confounders (OR = 0.42, 95%CI: 0.19-0.90, p = 0.026 and OR = 0.44, 95%CI:0.21-0.94, p = 0.039, respectively). CONCLUSIONS: FGA and FGG SNPs as well as FGA, FGB, FGG and FGA-FGG haplotypes do not seem to be important contributors to CAD occurrence in our sample. On the contrary, FGB rs1800787 and rs1800789 SNPs seem to confer protection to disease onset lowering the risk by about 50% in homozygotes for the minor alleles.
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Doença da Artéria Coronariana/genética , Doença da Artéria Coronariana/prevenção & controle , Fibrinogênio/genética , Variação Genética , Polimorfismo de Nucleotídeo Único , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/genética , Síndrome Coronariana Aguda/prevenção & controle , Idoso , Estudos de Casos e Controles , Doença da Artéria Coronariana/sangue , Feminino , Frequência do Gene , Genes Recessivos , Grécia , Haplótipos , Homozigoto , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Genéticos , Razão de Chances , Fatores de RiscoAssuntos
Ponte de Artéria Coronária/métodos , Doença das Coronárias/cirurgia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica/métodos , Intervenção Coronária Percutânea/métodos , Anticoagulantes/uso terapêutico , Arritmias Cardíacas/complicações , Arritmias Cardíacas/terapia , Transfusão de Sangue/métodos , Técnicas de Imagem Cardíaca/métodos , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/cirurgia , Doença Crônica , Meios de Contraste/efeitos adversos , Tomada de Decisões , Cardiomiopatias Diabéticas/complicações , Cardiomiopatias Diabéticas/cirurgia , Interações Medicamentosas , Fibrinolíticos/uso terapêutico , Rejeição de Enxerto/etiologia , Insuficiência Cardíaca/complicações , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/cirurgia , Coração Auxiliar , Humanos , Hipoglicemiantes/uso terapêutico , Consentimento Livre e Esclarecido , Infarto do Miocárdio/diagnóstico , Equipe de Assistência ao Paciente/organização & administração , Educação de Pacientes como Assunto , Doença Arterial Periférica/complicações , Doença Arterial Periférica/cirurgia , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Insuficiência Renal Crônica/complicações , Reoperação , Medição de Risco/métodos , Stents , Terapia Trombolítica/métodosRESUMO
BACKGROUND AND AIMS: We aimed to investigate potential eligibility for proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors in patients with coronary artery disease and dyslipidaemia according to patient characteristics and variable criteria. METHODS: We prospectively enrolled 2000 patients (acute coronary syndrome = 407, chronic coronary artery disease inpatients = 1087, outpatient Lipid's clinic = 506). To calculate PCSK-9 inhibitors real-world eligibility, a proprietary adjustable software was developed, which stores data and patient characteristics and can determine eligibility depending on different criteria. We tested four scenarios with different LDL thresholds according to ESC/EAS 2016 and 2019 Guidelines, 2017 American College of Cardiology Expert Consensus, and National criteria. RESULTS: The eligible percentage was 18.85%, 9.75%, 8.55% and 2.15%, in the total population for the four classifications, respectively, and it varied according to clinical status. The increase toward more recent guidelines was mostly attributed to the increasing number of coronary patients who become eligible as our criteria become stricter. CONCLUSIONS: For the first time, a realistic estimation of PCSK-9 eligibility is provided via an adjustable predictive model in a population of 2000 patients with acute coronary syndrome, chronic coronary artery disease and dyslipidaemia. This can be a valuable tool for the incorporation of PCSK-9 inhibitors in health care systems.
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Síndrome Coronariana Aguda , Doença da Artéria Coronariana , Dislipidemias , Inibidores de PCSK9 , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/tratamento farmacológico , LDL-Colesterol , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/tratamento farmacológico , Dislipidemias/diagnóstico , Dislipidemias/tratamento farmacológico , Humanos , Pacientes AmbulatoriaisRESUMO
Background Transcatheter aortic valve implantation (TAVI) continues to gain popularity in the management of patients with severe aortic stenosis (SAS). Distribution of resources to maximise appropriate use remains a priority. Design & methods To determine the current perceptions and behaviours regarding SAS patient management, an 18-point multiple-choice questionnaire was distributed to European Society of Cardiology (ESC) Council for Cardiology Practice (CCP) e-journal and/or electronic newsletter subscribers. Respondents to all questions were considered. Sub-analyses based on respondent age, practice setting and geographical location were performed. Results Of 1245 full respondents, 41.5% were aged ≥ 51 years, 22.7% were aged 41-50 years and 35.8% were aged ≤ 40 years. The majority were located in Europe (77.5%), followed by Asia/Oceania (11.6%), America (7.6%) and Africa (3.4%). In-hospital and out-of-hospital cardiologists accounted for 57.4% of and 28.5% of the sample, respectively, with the remainder being general practitioners/other. The majority of respondents (70.1%) claimed to diagnose between one and five cases of SAS per month. Free access to TAVI was reported by 41.2%, being less common for those aged ≤ 40 years (32.7%; p < 0.001), those located in Asia/Oceania, America and Africa (20.1%, 18.1% and 2.4%, respectively; p < 0.01 in each case) and in-hospital compared to out-of-hospital cardiologists (35.7% vs. 54.5%, respectively; p < 0.001). The most common reason for not referring a patient for an aortic valve intervention was assessment that the patient was high risk/non-operable (55.5%), followed by short life expectancy (30.5%). The most common reason for referring a patient for TAVI over surgical replacement was surgical risk score (56.9%). The most commonly perceived main complication of TAVI was stroke (28.9%), while the most frequently selected main benefit was improvement in quality of life (37.2%). A high proportion (82.5%) of respondents believed that TAVI is/may become a viable option for lower-risk SAS patients in future. Conclusion The population of potential TAVI is significant worldwide, with key barriers to referral being access limitations and poor physician education. Strategies to minimise these factors are paramount.
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Estenose da Valva Aórtica/cirurgia , Cardiologia , Inquéritos Epidemiológicos/métodos , Equipe de Assistência ao Paciente/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Sociedades Médicas , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Europa (Continente) , Qualidade de Vida , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Non-alcoholic fatty liver disease (NAFLD), the most common liver disease, is characterized by accumulation of fat (>5% of the liver tissue), in the absence of alcohol abuse or other chronic liver diseases. It is closely related to the epidemic of obesity, metabolic syndrome or type 2 diabetes mellitus (T2DM). NAFLD can cause liver inflammation and progress to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis or hepatocellular cancer (HCC). Nevertheless, cardiovascular disease (CVD) is the most common cause of death in NAFLD/NASH patients. Current guidelines suggest the use of pioglitazone both in patients with T2DM and in those without. The use of statins, though considered safe by the guidelines, have very limited use; only 10% in high CVD risk patients are on statins by tertiary centers in the US. There are data from several animal studies, 5 post hoc analyses of prospective long-term survival studies, and 5 rather small biopsy proven NASH studies, one at baseline and on at the end of the study. All these studies provide data for biochemical and histological improvement of NAFLD/NASH with statins and in the clinical studies large reductions in CVD events in comparison with those also on statins and normal liver. Ezetimibe was also reported to improve NAFLD. Drugs currently in clinical trials seem to have potential for slowing down the evolution of NAFLD and for reducing liver- and CVD-related morbidity and mortality, but it will take time before they are ready to be used in everyday clinical practice. The suggestion of this Expert Panel is that, pending forthcoming randomized clinical trials, physicians should consider using a PPARgamma agonist, such as pioglitazone, or, statin use in those with NAFLD/NASH at high CVD or HCC risk, alone and/or preferably in combination with each other or with ezetimibe, for the primary or secondary prevention of CVD, and the avoidance of cirrhosis, liver transplantation or HCC, bearing in mind that CVD is the main cause of death in NAFLD/NASH patients.
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Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/prevenção & controle , Fígado Gorduroso/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipoglicemiantes/uso terapêutico , Hepatopatia Gordurosa não Alcoólica/tratamento farmacológico , Tiazolidinedionas/uso terapêutico , Animais , Quimioterapia Combinada , Fígado Gorduroso/complicações , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Hipoglicemiantes/efeitos adversos , Hepatopatia Gordurosa não Alcoólica/complicações , Pioglitazona , Tiazolidinedionas/efeitos adversosRESUMO
OBJECTIVES: The aim of the current study was to estimate adverse event rates while awaiting myocardial revascularization and review criteria for prioritizing patients. METHODS: A PubMed search was performed on 19 January 2015, to identify English-language, original, observational studies reporting adverse events while awaiting coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Rates of death, non-fatal myocardial infarction (MI) and emergency revascularization were calculated as occurrence rates per 1000 patient-weeks and pooled using random-effects models. RESULTS: The search yielded 1323 articles, of which 22 were included with 66 410 patients and 607 675 patient-weeks on the wait list. When awaiting CABG, rates per 1000 patient-weeks were 1.1 [95% confidence interval 0.9-1.3] for death, 1.0 [0.6-1.6] for non-fatal MI and 1.8 [0.8-4.1] for emergency revascularization. Subgroup analyses demonstrated consistent outcomes, and sensitivity analyses demonstrated comparable event rates with low heterogeneity. Higher urgency of revascularization was based primarily on angiographic complexity, angina severity, left ventricular dysfunction and symptoms on stress testing, and such patients with a semi-urgent status had a higher risk of death than patients awaiting elective revascularization (risk ratio at least 2.8). Individual studies identified angina severity and left ventricular dysfunction as most important predictors of death when awaiting CABG. Adverse rates per 1000 patient-weeks for patients awaiting PCI were 0.1 [95% confidence interval 0.0-0.4] for death, 0.4 [0.1-1.2] for non-fatal MI and 0.7 [0.4-1.4] for emergency revascularization but were based on only a few old studies. CONCLUSIONS: Rates of death, non-fatal MI and emergency revascularization when awaiting myocardial revascularization are infrequent but higher in specific patients. Countries that not yet have treatment recommendations related to waiting times should consider introducing a maximum to limit adverse events, particularly when awaiting CABG.
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Revascularização Miocárdica/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Listas de Espera/mortalidade , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/estatística & dados numéricosRESUMO
Two proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, evolocumab and alirocumab, have recently been approved by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of hypercholesterolemia. These fully human monoclonal antibodies selectively block PCSK9, thus permitting the low-density lipoprotein (LDL) receptor to effectively recycle to the surface of liver cells. The administration of these antibodies leads to robust LDL cholesterol (LDL-C) lowering by 50-60% on top of maximum hypolipidemic treatment. At least 4 randomized, placebo-controlled studies are under way and will address the question of whether the administration of these PCSK9 inhibitors is associated with a significant reduction of cardiovascular events. Because of the high cost associated with the use of these medications it is very important to consider which patients may gain the most benefit, at least until the results of outcome studies are available. In this Consensus paper, 34 clinicians/scientists define 3 groups of patients that should be currently considered as candidates for the use of these novel drugs. These include: 1a. Adults with established cardiovascular disease and LDL-C≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 1b. Adults with diabetes and established cardiovascular disease or chronic kidney disease or target organ damage and LDL-C ≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 2. Adults with familial hypercholesterolemia (FH) without established cardiovascular disease and LDL-C ≥130 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe (evolocumab is also indicated in children above 12 years with homozygous FH), and 3. Adults at high or very high cardiovascular risk who are statin intolerant and have an LDL-C ≥100 and ≥130 mg/dL, respectively, while on any tolerated hypolipidemic treatment.