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BACKGROUND: Among hypertensive patients, the association between treatment with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) and the clinical severity of COVID-19, remains uncertain. AIMS: To determine whether hypertensive patients hospitalised with COVID-19 are at risk of worse outcomes if on treatment with ACEI or ARB compared to other anti-hypertensive medications. METHODS: This is a retrospective study conducted at a single academic medical centre (Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy) from 1 to 31 March 2020. We compared patients on treatment with an ACEI/ARB (ACEI/ARB group) to patients receiving other anti-hypertensive medications (No-ACEI/ARB group). The end-points of the study were the all-cause in-hospital death and the combination of in-hospital death or need for intensive care unit (ICU) admission. RESULTS: The sample included 166 COVID-19 patients; median age was 74 years and 109 (66%) were men. Overall, 111 (67%) patients were taking an ACEI or ARB. Twenty-nine (17%) patients died during the hospital stay, and 51 (31%) met the combined end-point. After adjustment for comorbidities, age and degree of severity at the presentation, ACEI or ARB treatment was an independent predictor neither of in-hospital death nor of the combination of in-hospital death/need for ICU. No differences were documented between treatment with ACEI compared to ARB. CONCLUSIONS: Among hypertensive patients hospitalised for COVID-19, treatment with ACEI or ARB is not associated with an increased risk of in-hospital death.
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Antagonistas de Receptores de Angiotensina/administración & dosificación , Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , COVID-19/diagnóstico , Hospitalización/tendencias , Hipertensión/diagnóstico , Hipertensión/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Antagonistas de Receptores de Angiotensina/efectos adversos , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , COVID-19/epidemiología , Registros Electrónicos de Salud/tendencias , Femenino , Humanos , Hipertensión/epidemiología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios RetrospectivosAsunto(s)
Hipotermia , Recalentamiento , Adulto , Cánula , Humanos , Unidades de Cuidados Intensivos , Fenómenos Fisiológicos RespiratoriosRESUMEN
Patients with autonomic failure are characterized by orthostatic hypotension, supine hypertension, high blood pressure variability, blunted heart rate variability, and often have a "non-dipping" or "reverse dipping" pattern on 24-h ambulatory blood pressure monitoring. These alterations may lead to cardiovascular and cerebrovascular changes, similar to the target organ damage found in hypertension. Often patients with autonomic failure are on treatment with anti-hypotensive drugs, which may worsen supine hypertension. The aim of this review is to summarize the evidence for cardiac, vascular, renal, and cerebrovascular damage in patients with autonomic failure.
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Enfermedades Cardiovasculares/etiología , Insuficiencia Autonómica Pura/complicaciones , Fármacos del Sistema Nervioso Autónomo/efectos adversos , Fármacos del Sistema Nervioso Autónomo/uso terapéutico , Presión Sanguínea/fisiología , Enfermedades Cardiovasculares/patología , Humanos , Insuficiencia Autonómica Pura/patologíaRESUMEN
Several studies have suggested the potential role of Magnesium Sulfate (MgSO4) for the treatment of Atrial Fibrillation (AF) but, in clinical practice, the use of magnesium is not standardized although it is largely used for the treatment of supraventricular arrhythmias. Objectives. We evaluated the role of MgSO4 infusion in association with flecainide in cardioversion of patients presenting in ED with symptomatic AF started less than 48 h before. We retrospectively searched for all patients presented in ED from 1 January 2019 to 31 December 2019 requiring pharmacological cardioversion with flecainide 2 mg/kg. Ninety-seven patients met these criteria, 46 received the administration of intravenous MgSO4 2 gr (Group A), and 51 did not (Group B). Among the 97 patients, the overall cardioversion rate was 85.6%, 91.3% in Group A and 80.4% in Group B. In 27 patients out of 97, the Flecainide was not administered because of spontaneous restoration of sinus rhythm of 9 pts (Group B) and 18 pts (Group A). We also found a statistical significance in the HR at the time of cardioversion between Group A (77.8 ± 19.1 bpm) and Group B (87 ± 21.7 bpm). No complications emerged. The association between MgSO4 and Flecainide has not yielded statistically significant results. However, in consideration of its high safety profile, MgSO4 administration may play a role in ED cardioversion of acute onset AF, reducing the need for antiarrhythmic medications and electrical cardioversion procedures, relieving symptoms reducing heart rate, and reducing the length of stay in the ED.
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BACKGROUND: Ascending aorta dilatation is found in 13% of hypertensive patients. Little is known about elastic properties of ascending aorta in such patients. Echo-based transverse aortic strain analysis can describe mechanical properties of ascending aorta but has never been applied to patients with ascending aorta dilatation. AIM: To assess mechanical properties of ascending aorta by transverse aortic strain analysis (as ß2-stiffness index) in hypertensive patients with ascending aorta dilatation and association between mechanical properties of ascending aorta and cardiovascular damage. METHODS: A total of 100 hypertensive outpatients underwent transthoracic echocardiography and assessment of pulse wave velocity (PWV). Strain analysis of ascending aorta was performed with echocardiographic speckle-tracking software. Patients were divided in three groups based on ascending aorta diameter: less than 40, 40-45, and at least 45âmm. RESULTS: Beta-SI increased exponentially with ascending aorta dimensions (Pâ<â0.001). Patients with ascending aorta dilatation had Beta-SI significantly higher than those with normal ascending aorta diameter. A greater proportion of patient with impaired (i.e., elevated) Beta-SI was present in groups with larger ascending aorta (18.2 vs. 48.4 vs. 80%, respectively, Pâ<â0.05). On multivariate logistic regression only impaired Beta-SI predicted ascending aorta dilatation (Pâ<â0.001). Beta-SI was related to cardiovascular damage in terms of left ventricular (LV) mass (LV mass indexed to BSA, Pâ=â0.030) and PWV (Pâ=â0.028). Patients with high Beta-SI had greater LV mass indexed to BSA (117â±â47 vs. 94â±â24âg/m2; Pâ=â0.010) and PWV (10.20â±â2.99 vs. 8.63â±â1.88âm/s; Pâ=â0.013). CONCLUSION: Ascending aorta dilatation is associated with increased local aortic stiffness in hypertensive patients. Strain analysis adds functional information to the mere morphological evaluation of aortic diameter and could be a useful tool to better define cardiovascular risk in this population.
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Enfermedades de la Aorta , Rigidez Vascular , Aorta/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Dilatación , Dilatación Patológica/diagnóstico por imagen , Humanos , Análisis de la Onda del PulsoRESUMEN
BACKGROUND: Large artery stiffness, assessed by carotid--femoral pulse wave velocity (cfPWV), is a major risk factor for cardiovascular events, commonly used for risk stratification. Currently, the reference device for noninvasive cfPWV is SphygmoCor but its cost and technically challenging use limit its diffusion in clinical practice. AIM: To validate a new device for noninvasive assessment of cfPWV, ATHOS (Arterial sTiffness faitHful tOol aSsessment), designed in collaboration with the Politecnico di Torino, against the reference noninvasive method represented by SphygmoCor. METHODS: Ninety healthy volunteers were recruited. In each volunteer, we assessed cfPWV, using SphygmoCor (PWVSphygmoCor) and ATHOS (PWVATHOS) devices in an alternate fashion, following the ARTERY Society guidelines. The accuracy was assessed by Bland--Altman plot, and reproducibility was assessed by interoperator correlation coefficient (ICC). RESULTS: Mean PWVATHOS and mean PWVSphygmoCor were 7.88â±â1.96 and 7.72â±â1.95âm/s, respectively. Mean difference between devices was 0.15â±â0.56âm/s, with a high correlation between measurements (râ=â0.959, Pâ<â0.001). Considering only PWV values at least 8âm/s (nâ=â30), mean difference was 0.1â±â0.63âm/s. The ICC was 97.7% with ATHOS. CONCLUSION: ATHOS showed an excellent level of agreement with SphygmoCor, even at high PWV values, with a good reproducibility. Its simplicity of use could help increase clinical application of PWV assessment, improving patients' cardiovascular risk stratification.
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Análisis de la Onda del Pulso , Rigidez Vascular , Arterias Carótidas , Velocidad de la Onda del Pulso Carotídeo-Femoral , Humanos , Reproducibilidad de los Resultados , Factores de RiesgoRESUMEN
OBJECTIVES: Hypertension leads to aortic stiffening and dilatation but unexpected data from the Framingham Heart Study showed an inverse relationship between brachial pulse pressure and aortic diameter. Aortic dilatation would not only lead to lower pulse pressure but also to a worse prognosis (cardiac events, heart failure). Invasive pressure may be more informative but data are lacking. AIM: This study evaluated the relationship between invasively measured central blood pressure and proximal aortic diameter. METHODS: In 71 consecutive patients referred to invasive haemodynamic study, proximal aortic remodelling was evaluated in terms of Z-score, comparing diameters measured at the sinus of Valsalva to the diameter expected according to patients' age, sex and body height. Pressures were recorded directly in the proximal aorta by means of a catheter before coronary assessment. RESULTS: The mean invasive aortic SBPs and DBPs were 146â±â23 and 78â±â13âmmHg, respectively, giving a central pulse pressure (cPP inv) of 68â±â21âmmHg. Proximal aortic diameter was 34.9â±â19.4âmm, whereas Z-score was -0.3â±â1.7. Patients with higher cPPinv showed a significantly lower Z-score (-0.789 vs. 0.155, Pâ=â0.001). cPPinv was inversely related to Z-score (Râ=â-0.271, Pâ=â0.022) independently from age, mean blood pressure and heart rate (ßâ=â-0.241, Pâ=â0.011). CONCLUSION: Aortic root Z-score is inversely associated with invasively measured central pulse pressure in a cohort of patients undergoing invasive coronary assessment. Remodelling at the sinuses of Valsalva may be a compensatory mechanism to limit pulse pressure.
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Aorta , Hipertensión , Presión Arterial , Presión Sanguínea , Dilatación Patológica , HumanosRESUMEN
BACKGROUND: Ascending aorta (ASC) dilatation (AAD) is a common finding in arterial hypertension, affecting about 15% of hypertensive patients. AAD is associated with an increase in cardiac and vascular hypertension-related organ damage, but its prognostic role is unknown. The aim of the study was to evaluate the prognostic value of AAD as predictor of cardiovascular events in essential hypertensive patients. METHODS: Recruited patients underwent two-dimensional transthoracic echocardiography from 2007 to 2013 and followed-up for cardiovascular events until November 2018 by phone call and hospital information system check. ASC diameter and AAD were defined using both absolute and scaled definitions. Four hundred and twenty-three hypertensive patients were included in our study. RESULTS: During a median follow-up of 7.4 years (interquartile range 5.6-9.1 years), 52 events were observed. After adjusting for age, sex and BSA, both ASC diameter and AAD definition, according to ARGO-SIIA project, resulted associated with a greater risk of cardiovascular event (both Pâ<â0.010), even after adjusting for major confounders (both Pâ<â0.010). Moreover, we observed that the assessment of ASC improves risk stratification compared with pulse wave velocity alone, and that in absence of AAD, sinus of valsalva dilatation lost any prognostic value (Pâ=â0.262). CONCLUSIONS: ASC diameter and AAD are both associated with a greater risk of cardiovascular events. ASC should be assessed to optimize risk stratification in hypertensive patients and its dilatation may be considered as a surrogate for vascular organ damage.
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Hipertensión , Análisis de la Onda del Pulso , Aorta/diagnóstico por imagen , Dilatación , Dilatación Patológica/diagnóstico por imagen , Humanos , Hipertensión/complicaciones , PronósticoRESUMEN
We evaluated patients admitted through our ED for community-acquired pneumonia (CAP) to assess the relevance of an early procalcitonin (PCT) determination on patient's outcomes. METHODS: We reviewed all patients admitted for CAP in a 10 years period (2008-2017). Patients were stratified according to age groups: (18-65 years; 65-84 years; and ≥85 years), CURB-65 score, need for ventilation, Sepsis-3 criteria at admission, enrollment period, blood culture in ED. In-hospital mortality rate and length of hospital stay (LOS) were compared between patients that had an early PCT determination in ED vs. patients admitted without. RESULTS: Our study cohort consisted of 4056 CAP patients, age 76 [IQ range 64-84] years. We enrolled 1039 patients <65 years old, 2015 aged 65-84 years, and 1002 aged ≥85 years. Overall, the early PCT determination in ED was not associated to a reduced LOS (p=0.630), nor to a reduced mortality rate (p=0.134). However, in patients ≥ 85 years, the PCT determination in ED was associated with lower mortality in those with CURB-65 ≥ 2, and Charlson's score ≥ 2 (p=0.033 and p=0.002, respectively). CONCLUSIONS: Although an early PCT assessment in ED was not associated with better outcomes in term of LOS and mortality in patients with CAP, our findings suggest that it might be associated with reduced mortality in patients ≥ 85 years with severe CAP or high comorbidity.
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Infecciones Comunitarias Adquiridas , Neumonía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores , Servicio de Urgencia en Hospital , Humanos , Persona de Mediana Edad , Neumonía/diagnóstico , Polipéptido alfa Relacionado con Calcitonina , Pronóstico , Índice de Severidad de la Enfermedad , Adulto JovenRESUMEN
AIM: The aim of the present study was to describe the clinical presentation of patients aged ≥80 years with coronavirus disease 2019 (COVID-19), and provide insights regarding the prognostic factors and the risk stratification in this population. METHODS: This was a single-center, retrospective, observational study, carried out in a referral center for COVID-19 in central Italy. We reviewed the clinical records of patients consecutively admitted for confirmed COVID-19 over a 1-month period (1-31 March 2020). We excluded asymptomatic discharged patients. We identified risk factors for death, by a uni- and multivariate Cox regression analysis. To improve model fitting and hazard estimation, continuous parameters where dichotomized by using Youden's index. RESULTS: Overall, 69 patients, aged 80-98 years, met the inclusion criteria and were included in the study cohort. The median age was 84 years (82-89 years is interquartile range); 37 patients (53.6%) were men. Globally, 14 patients (20.3%) presented a mild, 30 (43.5%) a severe and 25 (36.2%) a critical COVID-19 disease. A total of 23 (33.3%) patients had died at 30 days' follow up. Multivariate Cox regression analysis showed that severe dementia, pO2 ≤90 at admission and lactate dehydrogenase >464 U/L were independent risk factors for death. CONCLUSIONS: The present data suggest that risk of death could be not age dependent in patients aged ≥80 years, whereas severe dementia emerged is a relevant risk factor in this population. Severe COVID-19, as expressed by elevated lactate dehydrogenase and low oxygen saturation at emergency department admission, is associated with a rapid progression to death in these patients. Geriatr Gerontol Int 2020; â¢â¢: â¢â¢-â¢â¢.
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Infecciones por Coronavirus , Demencia/epidemiología , Hipoxia/epidemiología , L-Lactato Deshidrogenasa/sangre , Pandemias , Neumonía Viral , Medición de Riesgo/métodos , Anciano de 80 o más Años , Betacoronavirus/aislamiento & purificación , COVID-19 , Infecciones por Coronavirus/sangre , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/mortalidad , Infecciones por Coronavirus/fisiopatología , Enfermedad Crítica/epidemiología , Femenino , Humanos , Italia/epidemiología , Masculino , Mortalidad , Neumonía Viral/sangre , Neumonía Viral/diagnóstico , Neumonía Viral/mortalidad , Neumonía Viral/fisiopatología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , SARS-CoV-2 , Índice de Severidad de la EnfermedadRESUMEN
AIMS: To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED). METHODS: In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48â¯h and 7 days were calculated. RESULTS: We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48â¯h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes. CONCLUSION: In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration.
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Betacoronavirus , Infecciones por Coronavirus/terapia , Unidades de Cuidados Intensivos/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Neumonía Viral/terapia , Medición de Riesgo/métodos , Anciano , COVID-19 , Infecciones por Coronavirus/epidemiología , Puntuación de Alerta Temprana , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/epidemiología , Curva ROC , Estudios Retrospectivos , SARS-CoV-2 , Tasa de Supervivencia/tendencias , TriajeRESUMEN
BACKGROUND: Aortic dilatation is common in hypertensive patients and is associated with higher risk of cardiovascular events. Parameters predicting further dilatation during lifetime are poorly understood. AIM: To predict the midterm aortic diameter evolution in a cohort of hypertensive patients with known aortic dilatation at Sinus of Valsalva (SOV) level. METHODS: We prospectively analyzed a cohort of essential hypertensive outpatients without any other known risk factor for aortic dilatation. They underwent serial echocardiographic evaluations from 2003 to 2016. RESULTS: Two hundred and forty-two hypertensive outpatients with a mild-to-moderate (37-53âmm) aortic dilatation were followed up for at least 5 years. Mean growth rate was 0.08â±â0.35âmm/year. No clinical or anthropometric parameters were significantly different in patients with and without aortic diameter increase. Aortic z score (number of standard deviations from the average value observed in the general population) at baseline was inversely associated with growth rate (R 0.04, Pâ<â0.05). Aortic diameter at first visit, demographic and echocardiographic variables were major determinants of aortic diameter at second visit, accounting for about 90% of its total variability. CONCLUSION: Mean growth rate of proximal aorta in hypertensive patients with known aortic dilatation was of about 0.1âmm/year. Dilatation over time is slower in patients with increased rather than normal aortic z score. Eventually, it could be possible to reliably predict aortic diameter at few months from first visit.
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Aorta/diagnóstico por imagen , Enfermedades de la Aorta/complicaciones , Presión Sanguínea/fisiología , Hipertensión/complicaciones , Seno Aórtico/diagnóstico por imagen , Adulto , Anciano , Enfermedades de la Aorta/diagnóstico por imagen , Dilatación Patológica/complicaciones , Dilatación Patológica/diagnóstico por imagen , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
We aimed to evaluate the performance of a mathematical model and currently available non-invasive techniques (generalized transfer function (GTF) method and brachial pressure) in the estimation of aortic pressure. We also aimed to investigate error dependence on brachial pressure errors, aorta-to-brachial pressure changes and demographic/clinical conditions. Sixty-two patients referred for invasive hemodynamic evaluation were consecutively recruited. Simultaneously, the registration of the aortic pressure using a fluid-filled catheter, brachial pressure and radial tonometric waveform was recorded. Accordingly, the GTF device and mathematical model were set. Radial invasive pressure was recorded soon after aortic measurement. The average invasive aortic pressure was 141.3 ± 20.2/76 ± 12.2 mm Hg. The simultaneous brachial pressure was 144 ± 17.8/81.5 ± 11.7 mm Hg. The GTF-based and model-based aortic pressure estimates were 133.1 ± 17.3/82.4 ± 12 and 137 ± 21.6/72.2 ± 16.7 mm Hg, respectively. The Bland-Altman plots showed a marked tendency to pressure overestimation for increasing absolute values, with the exclusion of mathematical model diastolic estimations. The systolic pressure was increased from the aortic to radial locations (7.5 ± 19 mm Hg), while the diastolic pressure was decreased (3.8 ± 9.8 mm Hg). The brachial pressure underestimated the systolic and overestimated diastolic intra-arterial radial pressure. GTF errors were independently correlated with the variability in pulse pressure amplification and with the brachial error. Errors of the mathematical model were related to only demographic and clinical conditions. Neither a multiscale mathematical model nor a generalized transfer function device substantially outperformed the oscillometric brachial pressure in the estimation of aortic pressure. Mathematical modeling should be improved by including further patient-specific conditions, while the variability in pulse pressure amplification may hamper the performance of the GTF method in patients at the risk of coronary artery disease.
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Presión Arterial , Modelos Cardiovasculares , Anciano , Cateterismo , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Arterial stiffness is a marker of cardiovascular damage and an independent predictor of major cardiovascular events, usually assessed via Carotid-Femoral Pulse Wave Velocity (cfPWV). The aim of this study was to test the feasibility and usefulness of aortic strain analysis using a simplified transthoracic echocardiography (TTE) speckle-tracking (ST) based method. 60 consecutive patients with normal blood pressure and aortic dimensions underwent TTE and cfPWV evaluation. Strain analysis was performed on the largest section of the ascending aorta (aA) with a dedicated software; three couples of speckles were identified within the anterior and posterior aortic wall and transverse segments connecting each couple traced. Peak ascending Aorta Strain (PaAS) was defined as the averaged peak percentage deformation of these segments during the cardiac cycle; aortic stiffness index ß2 was defined as 100 × Ln(SBP/DBP)/PaAS. 17 patients were excluded for suboptimal TTE images. In the 43 analyzed individuals (male 58%, age 63 years) PaAS was 5.5 [3.7-8.6] % with excellent inter and intra observer reproducibility (ICC 95% for both). PaAS showed significant correlation with age (r = - 0.64), aA diameter (r = - 0.45), cfPWV (r = - 0.41), stroke volume (r = - 0.41) and heart rate (r = - 0.49). Age remained the only independent determinant of PaAS in a multivariate analysis. ß2 (10.8 [5.9-15.0]) showed significant direct correlation with age, Pulse pressure, aA diameter and cfPWV. A simplified strain analysis of the ascending aorta is technically feasible with good reproducibility; PaAS and ß2 index correlate well with established parameters of arterial stiffness and might represent a new index in evaluating vascular biomechanics.