RESUMO
AIMS: In patients aged at least 80 years, atrial fibrillation is responsible for significant morbidity and mortality, with a high incidence of stroke. Four new direct oral anticoagulants (DOACs) have been introduced in Italy for the prevention of thromboembolism. Their safety and efficacy in the elderly have already been confirmed. Frailty is frequently associated with aging, but only a few studies have paid attention to interactions between frailty and anticoagulation therapy. METHODS: We retrospectively evaluated the effectiveness and safety of DOACs in a population aged at least 80 years. Frailty was appraised using an adaptation of the Reported Edmonton Frail Scale, considering a value at least 8 (on a scale from 0 to 18). RESULTS: The majority (644/731) of patients remained on DOACs for more than 1 year. A total of 19 patients experienced a thrombotic event while on anticoagulation (1.11 events per 100 person-years) and 26 patients a major bleeding episode (1.52 events per 100 person-years). The probability of interrupting therapy increased significantly with frailty [hazard ratio 2.91 with confidence interval (CI) 2.15-3.92 at univariate analysis, hazard ratio 2.80 with CI 2.03-3.86 at multivariate]; frailty showed a significant impact also on major bleeding (hazard ratio 3.28 with CI 1.45-7.37 at univariate analysis, hazard ratio 3.56 with CI 1.58-8.01 at multivariate). CONCLUSION: Our study highlights how DOACs are a safe and effective option for anticoagulation, even in frail elderly people; the introduction of these drugs is leading to an increased use of anticoagulation therapy in this population. Prospective trials will be needed to reinforce these results and to consider new variables in the thrombotic and hemorrhagic risk scores underlying the prescription of DOACs.
Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Fragilidade/complicações , Tromboembolia/prevenção & controle , Administração Oral , Fatores Etários , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Inibidores do Fator Xa/efeitos adversos , Feminino , Idoso Fragilizado , Fragilidade/diagnóstico , Hemorragia/induzido quimicamente , Humanos , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tromboembolia/diagnóstico , Tromboembolia/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Pulmonary hypertension due to left heart disease (PH-LHD) frequently complicates heart failure with reduced ejection fraction (HFrEF). Specific therapies for PH have not offered an advantage in patients with PH-LHD. The combined angiotensin receptor blocker-neprilysin inhibitor (ARNI), sacubitril/valsartan, is a novel therapy that can increase levels of natriuretic peptides (NPs). The resulting action on natriuresis and vasodilation may play an important role in the reduction of pulmonary pressures. Here, we report how the use of ARNI in two patients with HFrEF has resulted in an improvement in PH and, consequently, in clinical status and prognosis.
RESUMO
AIMS: Cardiac implantable electronic device (CIED) recipients who experienced an ischemic cerebral event may particularly benefit from continuous remote monitoring. We aimed to assess the effect of remote monitoring on the occurrence of 1-year serious adverse events in CIED recipients after ischemic stroke or transient ischemic attack (TIA). METHODS: Patients were eligible if they suffered a TIA/stroke. Study endpoints were all-cause mortality, all-cause hospitalization, and TIA/stroke recurrence. Patients were retrospectively divided according to the presence of remote monitoring for CIED follow-up. RESULTS: From January 2011 to December 2017, 71 CIED recipients were hospitalized in our institution for TIA/stroke: pacemaker (76%), cardiac resynchronization therapy device (17%), or implantable cardioverter defibrillator (7%). Among them, 26 (37%) were remotely monitored (RM-ON), whereas 45 (63%) were followed with conventional in-hospital visits (RM-OFF). No significant differences were found in baseline characteristics between groups. The all-cause mortality and hospitalization rates were significantly lower in the RM-ON group [2.2; 95% confidence interval (CI) 0.8-4.8, and 5.8; 95% CI 3.3-9.4 per 100 patient-months] as compared with the RM-OFF group (8.1; 95% CI 5.2-11.9, and 9.7; 95% CI 6.5-13.9 per 100 patient-months). Despite a similar incidence of new diagnosis of atrial fibrillation, the median time from the arrhythmic episode to the physician evaluation was dramatically lower in the RM-ON as compared with the RM-OFF group [2 (1-3) vs. 78 (64-92) days; Pâ=â0.002]. CONCLUSION: We found that remote monitoring as compared with conventional in-hospital visits may contribute to a better outcome in CIED recipients who had suffered from an ischemic cerebral event.
Assuntos
Estimulação Cardíaca Artificial , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Ataque Isquêmico Transitório/diagnóstico , Marca-Passo Artificial , Tecnologia de Sensoriamento Remoto/instrumentação , Acidente Vascular Cerebral/diagnóstico , Telemedicina/instrumentação , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Feminino , Hospitalização , Humanos , Ataque Isquêmico Transitório/mortalidade , Ataque Isquêmico Transitório/fisiopatologia , Ataque Isquêmico Transitório/terapia , Masculino , Valor Preditivo dos Testes , Recidiva , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/terapia , Fatores de TempoRESUMO
BACKGROUND: Obesity is a risk factor for acute myocardial infarction (AMI), due in part to obesity-related conditions. However, the relation between BMI (body mass index) and outcome in patients with AMI has not been completely clarified. The aim of our study was to assess the impact of BMI on short-term outcome after AMI. METHODS: We retrospectively studied 717 consecutive patients admitted to our Intensive Coronary Care Unit for AMI. The end-point of the study was all-cause mortality. RESULTS: The mean age was 64+/-12 years. Mean BMI was 26+/-3.5 kg/m2. During follow-up 15 patients died. Non-survivors were significantly older than survivors (p<0.0001); BMI (p = 0.0027) and weight (p = 0.0002) were significantly lower in non-survivors than survivors; left ventricular dimensions (end-diastolic diameter: p = 0.0023; end-systolic diameter: p = 0.0019), the number of akinetic segments (p<0.0001) and contractile efficiency (p<0.0001) were also significantly lower in non-survivors. At Cox proportional univariate analysis low BMI (p = 0.0019), female sex (p = 0.0041), age (p<0.0001), left ventricular dimensions (end-diastolic diameter = 0.0040, end-systolic diameter = 0.0053), number of akinetic segments (p = 0.0001) and degree of left ventricular dysfunction (p = 0.0002) were significant predictors of prognosis. The prognostic power of BMI remained after adjustment for age (p<0.05), left ventricular dimensions (end-diastolic diameter: p<0.0042; end-systolic diameter p = 0.04), contractile efficiency (p = 0.0045) or number of akinetic segments (p = 0.0070). CONCLUSION: Low BMI is an independent predictor of poor prognosis in the short-term outcome after AMI. The underlying mechanisms remain to be investigated.
Assuntos
Índice de Massa Corporal , Infarto do Miocárdio/mortalidade , Obesidade/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Análise de SobrevidaRESUMO
BACKGROUND: Primary angioplasty (pPCI) is the most effective reperfusion treatment of acute ST-elevation myocardial infarction (STEMI), but logistic- and organization-related problems could affect the outcome. The aim of this study was to investigate the in-hospital outcome according to reperfusion strategy in the Veneto Region cardiology network. METHODS: A treatment protocol, aimed to treat patients with high-risk STEMI by pPCI on-site or after transport, was developed and shared by the majority of cardiology departments in the Veneto Region. Data of all consecutive patients with STEMI were prospectively recorded during a 6-month period. RESULTS: 999 patients with symptom onset < 12 hours were admitted to the 28 participating hospitals: 860 were treated on-site and 139 were transferred from the admitting hospital to an interventional center for PCI. Overall, 82% of patients were treated with reperfusion therapy. Ten patients died immediately before any treatment could be initiated. In 170 patients who did not receive any reperfusion treatment, in 302 patients who received fibrinolysis (and eventually rescue PCI) and in 517 patients sent to pPCI, the following in-hospital outcome was observed respectively: mortality rate 10, 6.95 and 6.57%; reinfarction rate 0.6, 1 and 0.4%; incidence of stroke 1.7, 1.4 and 0.9%; the need for urgent revascularization procedure 6.5, 10 and 2.3%. After adjustment for confounding variables, the in-hospital occurrence of the combined events was significantly lower in patients treated with pP-CI (odds ratio 0.33, confidence interval 0.20-0.53, p < 0.01) as well as a trend for a reduced in-hospital mortality was observed (odds ratio 0.51, confidence interval 0.26-1.03, p = 0.06). CONCLUSIONS: In the VENERE registry, patients treated with pPCI had a better in-hospital outcome as compared to those treated with fibrinolytic strategy.
Assuntos
Sistema de Condução Cardíaco/fisiopatologia , Hospitais , Infarto do Miocárdio/terapia , Reperfusão Miocárdica , Idoso , Angioplastia Coronária com Balão/métodos , Unidades de Cuidados Coronarianos , Eletrocardiografia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Sistema de Registros , Resultado do TratamentoAssuntos
Assistência Ambulatorial/métodos , Ambulatório Hospitalar , Marca-Passo Artificial , Telemedicina/métodos , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/tendências , Feminino , Seguimentos , Humanos , Masculino , Ambulatório Hospitalar/tendências , Marca-Passo Artificial/tendências , Telemedicina/tendênciasAssuntos
Átrios do Coração/lesões , Traumatismos Cardíacos/etiologia , Esforço Físico , Complicações Pós-Operatórias/etiologia , Dispositivo para Oclusão Septal/efeitos adversos , Choque Cardiogênico/etiologia , Comunicação Interatrial/cirurgia , Humanos , Contração Isométrica , Masculino , Pessoa de Meia-Idade , Esforço Físico/fisiologia , Fatores de Tempo , Manobra de ValsalvaAssuntos
Esclerose Múltipla Recidivante-Remitente/complicações , Disfunção Ventricular Esquerda/etiologia , Função Ventricular Esquerda , Doença Aguda , Adulto , Cardiotônicos/uso terapêutico , Eletrocardiografia , Feminino , Humanos , Imunossupressores/uso terapêutico , Imageamento por Ressonância Magnética , Esclerose Múltipla Recidivante-Remitente/diagnóstico , Esclerose Múltipla Recidivante-Remitente/tratamento farmacológico , Índice de Gravidade de Doença , Choque Cardiogênico/etiologia , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/tratamento farmacológico , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda/efeitos dos fármacosRESUMO
BACKGROUND: No previous study has analyzed the possible responsibility of fellows-in-training in terms of the risk of complications during cardiac catheterization. Thus, we sought to identify possible risk factors for access site complications following cardiac catheterization procedures, with particular attention to the role of cardiology fellows. METHODS: A total of 1,288 left heart catheterization procedures (both diagnostic and interventional), performed over a 1-year period at a university hospital, were retrospectively evaluated to determine the incidence of local complications (pseudoaneurysm, arterio-venous fistula, major hematoma or bleeding, vascular dissection). Several clinical (age, gender, previous coronary artery bypass surgery, indication to the exam) and procedural (procedure performed by the fellow, access site, type of procedure, urgent setting, use of glycoprotein IIb/IIIa inhibitors, simultaneous right heart catheterization, use of closure devices) covariables were considered. Major adverse cardiovascular and cerebrovascular events (MACCE: death, myocardial infarction, cerebrovascular event) were also assessed. RESULTS: The overall access site complication rate was 2.6%. On multivariate regression analysis, the only two predictors of local complications were female gender (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.6-6.5) and femoral approach (OR 3.9, 95% CI 1.2-12.1). The rate of MACCE was 1.2%, mainly after percutaneous coronary interventions, with only 1 death overall (0.07%). Procedures performed by cardiology fellows were not associated with an increased incidence of either complication. CONCLUSIONS: Cardiology fellows can safely perform cardiac catheterization procedures without an increase in the rate of local and major cardiovascular complications. Of course, the presence and watchful supervision of an attending physician is still essential to ensure both patient safety and optimal training.
Assuntos
Cateterismo Cardíaco/normas , Cardiologia/educação , Cardiologia/normas , Bolsas de Estudo , Idoso , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/estatística & dados numéricos , Estudos de Coortes , Educação de Pós-Graduação em Medicina/normas , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , SegurançaRESUMO
BACKGROUND: The transradial approach to coronary interventions has been accepted as a safe and effective alternative to the femoral approach due to fewer access site complications and improved patient comfort. In the present study we aimed to investigate the safety and efficacy of transradial procedure in the elderly. METHODS: We analyzed 850 patients who underwent transradial coronary angiography and/or angioplasty. All patients were divided into two groups, according to age. The first group consisted of patients < 70 years (600; 70.5%) and the second group consisted of patients greater than or equal to 70 years (250; 29.5%). RESULTS: Baseline characteristics did not differ between the two groups, except for diabetes mellitus which affected more patients greater than or equal to 70 years of age. Procedure duration, X-ray time and number of catheters used were similar in the two groups. No deaths or acute myocardial infarctions occurred. There were some vascular complications in both groups, with no statistically significant difference between groups. In Group 2 (the older group) 2 TIAs and 1 stroke occurred, whereas in Group 1, there was 1 TIA (p = 0.08). CONCLUSIONS: From our experience, we conclude that the transradial catheterization is a safe and effective technique in the elderly, with a reduced risk of local vascular complications and a noteworthy increase in patient comfort, especially in view of the age-related diseases that frequently affect older patients.
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/métodos , Angiografia Coronária/efeitos adversos , Angiografia Coronária/métodos , Doença das Coronárias/terapia , Artéria Radial , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença das Coronárias/complicações , Complicações do Diabetes , Feminino , Humanos , Masculino , Estudos Retrospectivos , Segurança , Resultado do TratamentoRESUMO
AIMS: To compare, by meta-analytical techniques, the clinical impact of bare-metal stenting vs. balloon angioplasty for the treatment of lesions in small coronary arteries. METHODS AND RESULTS: We included trials with random allocation and prospective comparison of angioplasty vs. stenting, reference vessel diameter<3 mm, and follow-up>or=6 months. Random effect odds ratios (OR) for death, myocardial infarction (MI), repeat revascularization (RR), and major adverse cardiac events (MACEs) were computed. In a pre-specified subgroup analysis, we compared stenting with optimal (post-procedural stenosis<20%) and suboptimal (>20%) angioplasty. Thirteen studies (4383 patients) were selected. No differences were found in terms of death and MI, while MACEs, mainly driven by RR, were significantly less common after stenting (17.6%) than after angioplasty (22.7%), OR 0.71 (0.57-0.90). Heterogeneity among trials was present. When considering only optimal angioplasty, MACE rates were homogeneously similar, 17.9 vs. 21.1%, OR 0.86 (0.66-1.11). If angioplasty were suboptimal, MACEs were significantly more common after angioplasty (24%) than after stenting (17.3%), OR 0.62 (0.44-0.88). CONCLUSION: Stenting is superior to balloon angioplasty for the treatment of small vessels, in particular after suboptimal angioplasty. However, MACE and RR rates remain high after stenting, and the advantage of stent over angioplasty is moderate. An optimal balloon angioplasty strategy (with provisional stenting) may achieve results not inferior to routine stenting.