Predictors of In-Hospital Mortality in Type A Acute Aortic Syndrome: Data From the RENADA-RO Registry.

BACKGROUND: This study aimed to analyse the baseline characteristics of patients admitted with acute type A aortic syndrome (ATAAS) and to identify the potential predictors of in-hospital mortality in surgically managed patients. METHODS: Data regarding demographics, clinical presentation, laboratory work-up, and management of 501 patients with ATAAS enrolled in the National Registry of Aortic Dissections-Romania registry from January 2011 to December 2022 were evaluated. The primary endpoint was in-hospital all-cause mortality. Multivariate logistic regression was conducted to identify independent predictors of mortality in patients with acute Type A aortic dissection (ATAAD) who underwent surgery. RESULTS: The mean age was 60±11 years and 65% were male. Computed tomography was the first-line diagnostic tool (79%), followed by transoesophageal echocardiography (21%). Cardiac surgery was performed in 88% of the patients. The overall mortality in the entire cohort was 37.9%, while surgically managed ATAAD patients had an in-hospital mortality rate of 29%. In multivariate logistic regression, creatinine value (OR 6.76), ST depression on ECG (OR 6.3), preoperative malperfusion (OR 5.77), cardiogenic shock (OR 5.77), abdominal pain (OR 4.27), age ≥70 years (OR 3.76), and syncope (OR 3.43) were independently associated with in-hospital mortality in surgically managed ATAAD patients. CONCLUSIONS: Risk stratification based on the variables collected at admission may help to identify ATAAS patients with high risk of death following cardiac surgery.

Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature.

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.

Toll-like receptor 4 (TLR4) expression is correlated with T2* iron deposition in response to doxorubicin treatment: cardiotoxicity risk assessment.

Although doxorubicin (Dox) is an effective antitumor antibiotic in the anthracycline class, it often induces the undesirable side effect of cardiomyopathy leading to congestive heart failure, which limits its clinical use. The primary goal of this study is to evaluate a reliable translational method for Dox-induced cardiotoxicity (CTX) screening, aiming to identify a high-risk population and to discover new strategies to predict and investigate this phenomenon. Early identification of the presence of iron deposits and genetic and environmental triggers that predispose individuals to increased risk of Dox-induced CTX (e.g., overexpression of Toll-like receptor 4 (TLR4)) will enable the early implementation of countermeasure therapy, which will improve the patient's chance of survival. Our cohort consisted of 25 consecutive patients with pathologically confirmed cancer undergoing Dox chemotherapy and 12 control patients. The following parameters were measured: serum TLR4 (baseline), serum transferrin (baseline and 6-week follow-up) and iron deposition (baseline and 6-week follow-up). The average number of gene expression units was 0.121 for TLR4 (range 0.051-0.801). We subsequently correlated serum TLR4 levels in our cohort with myocardial iron overload using the cardiac magnetic resonance (CMR) T2* technique, the ventricular function (% ejection fraction, %EF) and serum transferrin levels. There is a strong negative linear relationship between serum TLR4 and CMR T2* values (r = - 0.9106, ****P < 0.0001). There is also a linear correlation (either positive or negative) with EF and transferrin; no established relationship related to the sex of the patients was found. Patients with elevated serum TLR4 at baseline also exhibited an increase in serum transferrin levels and Dox-induced left ventricular dysfunction with a decreased EF (< 50%); this phenomenon was observed in 7 of 25 patients (28%) at the 6-week follow-up. There were no significant differences or correlations based on sex. We concluded that there is a direct relationship between Dox-induced CTX (indicated by elevated serum TLR4) and the times (ms) for T2* (decreases in which correspond to immediate and rapid iron overload).

Revascularization in a 17-Year-Old Girl with Neurofibromatosis and Severe Hypertension Caused by Renal Artery Stenosis.

Renal artery stenosis caused by neurofibromatosis is a rare cause of renovascular hypertension. This hypertension can develop during childhood and is one of the leading causes of poor outcome. We report the case of a 17-year-old girl who was incidentally diagnosed with severe hypertension. During her examination for secondary hypertension, we reached a diagnosis of neurofibromatosis type 1 on the basis of a cluster of typical findings: optic nerve glioma, café au lait spots, nodular neurofibromas, and axillary freckling. Renal angiograms revealed a hemodynamically significant left renal artery stenosis (70%). Renal angioplasty with a self-expanding stent was performed one month later for rapidly progressive renal artery stenosis (90%) and uncontrolled blood pressure. Excellent blood pressure control resulted immediately and was maintained as of the 2-year follow-up evaluation. We think that percutaneous transluminal renal angioplasty can be effective in select patients who have neurofibromatosis type 1 and refractory hypertension caused by renal artery stenosis.

Predictive factors for obtaining a correct therapeutic range using antivitamin K anticoagulants: a tertiary center experience of patient adherence to anticoagulant therapy.

BACKGROUND: Patient adherence is an essential factor in obtaining efficient oral anticoagulation using vitamin K antagonists (VKAs), a situation with a narrow therapeutic window. Therefore, patient education and awareness are crucial for good management. Auditing the current situation would help to identify the magnitude of the problem and to build tailored education programs for these patients. METHODS: This study included 68 hospitalized chronically anticoagulated patients (mean age 62.6±13.1 years; males, 46%) who responded to a 26-item questionnaire to assess their knowledge on VKA therapy management. Laboratory and clinical data were used to determine the international normalized ratio (INR) at admission, as well as to calculate CHA2DS2-VASC and HAS-BLED scores for patients with atrial fibrillation. RESULTS: The majority of patients (62%) were receiving VKA for atrial fibrillation, the others for a mechanical prosthesis and previous thromboembolic disease or stroke. In the atrial fibrillation group, the mean CHA2DS2-VASC score was 3.1±1.5, while the average HAS-BLED score was 1.8±1.2. More than half of the patients (53%) had an INR outside of the therapeutic range at admission, with the majority (43%) having a low INR. A correct INR value was predicted by education level (higher education) and the diagnostic indication (patients with mechanical prosthesis being best managed). Patients presenting with a therapeutic INR had a trend toward longer treatment duration than those outside the therapeutic range (62±72 months versus 36±35 months, respectively, P=0.06). There was no correlation between INR at admission and the patient's living conditions, INR monitoring frequency, and bleeding history. CONCLUSION: In a tertiary cardiology center, more than half of patients receiving VKAs are admitted with an INR falling outside the therapeutic range, irrespective of the bleeding or embolic risk. Patients with a mechanical prosthesis and complex antithrombotic regimens appear to be the most careful with INR monitoring, especially if they have a higher level of education. Identifying patient groups with the lowest time interval spent in the therapeutic range could help attending physicians educate patients focusing on specific awareness issues.