An estimation of the consequences of reinforcing the 2016 and 2019 European Society of Cardiology/European Atherosclerosis Society guidelines on current lipid-lowering treatment in patients with type 2 diabetes in tertiary care-a SwissDiab study

AIMS

In 2019, the European Society of Cardiology/European Atherosclerosis Society updated the 2016 guidelines for the management of dyslipidaemias recommending more stringent low-density lipoprotein cholesterol (LDL-C) targets in diabetes mellitus type 2 (DM2). Based on a real-world patient population, this study aimed to determine the feasibility and cost of attaining guideline-recommended LDL-C targets, and assess cardiovascular benefit.

METHODS AND RESULTS

The Swiss Diabetes Registry is a multicentre longitudinal observational study of outpatients in tertiary diabetes care. Patients with DM2 and a visit between 1 January 2018 and 31 August 2019 that failed the 2016 LDL-C target were identified. The theoretical intensification of current lipid-lowering medication needed to reach the 2016 and 2019 LDL-C target was determined and the cost thereof extrapolated. The expected number of major adverse cardiovascular events (MACE) prevented by treatment intensification was estimated. Two hundred and ninety-four patients (74.8%) failed the 2016 LDL-C target. The percentage of patients that theoretically achieved the 2016 and 2019 target with the indicated treatment modifications were high-intensity statin, 21.4% and 13.3%; ezetimibe, 46.6% and 27.9%; proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i), 30.6% and 53.7%; ezetimibe and PCSK9i, 1.0% and 3.1%; whereas one (0.3%) and five patients (1.7%) failed to reach target, respectively. Achieving the 2016 vs. 2019 target would reduce the estimated 4-year MACE from 24.9 to 18.6 vs. 17.4 events, at an additional annual cost of medication of 2140 Swiss francs (CHF) vs. 3681 CHF per patient, respectively.

CONCLUSIONS

For 68% of the patients, intensifying statin treatment and/or adding ezetimibe would be sufficient to reach the 2016 target, whereas 57% would require cost-intensive PCSK9i therapy to reach the 2019 target, with limited additional medium-term cardiovascular benefit.

Multiple endocrine neoplasia type 4: a new member of the MEN family

OBJECTIVE

Multiple endocrine neoplasia type 4 (MEN4) is caused by a CDKN1B germline mutation first described in 2006. Its estimated prevalence is less than one per million. The aim of this study was to define the disease characteristics.

METHODS

A systematic review was performed according to the PRISMA 2020 criteria. A literature search from January 2006 to August 2022 was done using MEDLINE® and Web of ScienceTM.

RESULTS

Forty-eight symptomatic patients fulfilled the pre-defined eligibility criteria. Twenty-eight different CDKN1B variants, mostly missense (21/48, 44%) and frameshift mutations (17/48, 35%), were reported. The majority of patients were women (36/48, 75%). Men became symptomatic at a median age of 32.5 years (range 10-68, mean 33.7 ± 23), whereas the same event was recorded for women at a median age of 49.5 years (range 5-76, mean 44.8 ± 19.9) (P = 0.25). The most frequently affected endocrine organ was the parathyroid gland (36/48, 75%; uniglandular disease 31/36, 86%), followed by the pituitary gland (21/48, 44%; hormone-secreting 16/21, 76%), the endocrine pancreas (7/48, 15%), and the thyroid gland (4/48, 8%). Tumors of the adrenal glands and thymus were found in three and two patients, respectively. The presenting first endocrine pathology concerned the parathyroid (27/48, 56%) and the pituitary gland (11/48, 23%). There were one (27/48, 56%), two (13/48, 27%), three (3/48, 6%), or four (5/48, 10%) syn- or metachronously affected endocrine organs in a single patient, respectively.

CONCLUSION

MEN4 is an extremely rare disease, which most frequently affects women around 50 years of age. Primary hyperparathyroidism as a uniglandular disease is the leading pathology.

Safety and efficacy of the 0 h/3 h protocol for rapid rule out of myocardial infarction

BACKGROUND

The early and accurate diagnosis of acute myocardial infarction (AMI) is an important medical and economic challenge. We aimed to prospectively evaluate the performance of the new European Society of Cardiology rapid 0-hour/3-hour (0 h/3 h) rule out protocol for AMI.

METHODS

We enrolled 2,727 consecutive patients presenting with suspected AMI without persistent ST-segment elevation to the emergency department in a prospective international multicenter study. The final diagnosis was adjudicated by 2 independent cardiologists. The performance of the 0 h/3 h rule out protocol was evaluated using 4 high-sensitivity (primary analysis) and 3 sensitive cardiac troponin (cTn) assays.

RESULTS

Acute myocardial infarction was the final diagnosis in 473 patients (17.3%). Using the 4 high-sensitivity cTn assays, the 0-hour rule out protocol correctly ruled out 99.8% (95% [confidence interval] CI, 98.7%-100%), 99.6% (95% CI, 98.5%-99.9%), 100% (95% CI, 97.9%-100%), and 100% (95% CI, 98.0%-100%) of late presenters (>6 h from chest pain onset). The 3-hour rule out protocol correctly ruled out 99.9% (95% CI, 99.1%-100%), 99.5% (95% CI, 98.3%-99.9%), 100% (95% CI, 98.1%-100%), and 100% (95% CI, 98.2%-100%) of early presenters (<6 h from chest pain onset). Using the 3 sensitive cTn assays, the 0-hour rule out protocol correctly ruled out 99.6% (95% CI, 98.6%-99.9%), 99.0% (95% CI, 96.9%-99.7%), and 99.1% (95% CI, 97.2%-99.8%) of late presenters; and the 3-hour rule out protocol correctly ruled out 99.4% (95% CI, 98.3%-99.8%), 99.2% (95% CI, 97.3%-99.8%), and 99.0% (95% CI, 97.2%-99.7%) of early presenters. Overall, the 0 h/3 h rule out protocol assigned 40% to 60% of patients to rule out. None of the patients assigned rule out died during 3-months follow-up.

CONCLUSIONS

The 0 h/3 h rule out protocol seems to allow the accurate rule out of AMI using both high-sensitivity and sensitive cTn measurements in conjunction with clinical assessment. Additional studies are warranted for external validation.

Perioperative myocardial infarction/injury after noncardiac surgery

Cardiovascular complications, particularly perioperative myocardial infarction/injury, seem to be major contributors to mortality after noncardiac surgery. With surgical procedures being very frequent (900 000/year in Switzerland), perioperative myocardial injury is common in everyday clinical practice. Over 80% of patients experiencing perioperative myocardial injury do not report symptoms. Therefore perioperative myocardial injury remains undiagnosed and untreated. Moreover, its silent presentation results in limited awareness among both clinicians and the public. Despite being largely asymptomatic, perioperative myocardial injury increases 30-day mortality nearly 10-fold. This review aims to increase the awareness of perioperative myocardial injury/infarction and give an overview of the emerging evidence, including pathophysiology, clinical presentation, prevention, and potential future treatments.

[Significantly shorter anesthesia time for surgery of the lumbar spine : process analytical comparison of spinal anesthesia and intubation narcosis]

INTRODUCTION

Most surgery of the lumbar spine is performed with the patient under general anesthesia (GA); however, qualitative benefits of spinal anesthesia (SA) have been reported. The goal of this study was to compare time efficiency between these two anesthesia methods in lumbar spine surgery. To test the hypothesis that the use of SA leads to significant time saving compared to GA for lumbar spine surgery, key points in the preoperative, intraoperative and postoperative anesthesiology care times were analyzed. The focus was on anesthesia time excluding surgery time.

MATERIALS AND METHODS

Electronically based data of 473 anesthesia procedures (368 SA, 105 GA) for lumbar spine interventions performed in the prone position (i. e. decompression, discectomy and transpedicular instrumentation) were analyzed retrospectively. Patient population data including gender, age, American Society of Anesthesiologists (ASA) classification and body mass index (BMI) were analyzed. The focus was on the documented perioperative key time points which are defined as follows: (1) induction, (2) positioning (turning into prone position), (3) scrubbing and covering, (4) surgery time (knife to skin closure), (5) closing (end of surgery until leaving operating room) and (6) handing over to recovery. Differences in the amount of time for each perioperative period were calculated for SA and GA.

RESULTS

In 7 out of the 368 SA patients SA failed and had to be converted to GA. There were no significant differences in BMI, ASA prevalence and gender between SA and GA patients but SA patients were significantly older (median 61.7 ± 15.4 years) than GA patients (median 56.1 ± 14.6 years). However, SA required significantly less time for induction (SA: 17.7 ± 7.0 min, GA: 21.6 ± 7.2 min), preoperative preparation (SA: 9.7 ± 3.6 min, GA: 13.3 ± 5.4 min) and closing period (SA: 4.9 ± 1.1 min, GA: 15.3 ± 5.7 min) compared to GA. Total anesthesia time with exclusion of the surgery time revealed a significant time reduction using SA of 19 min (95 % confidence interval: range 13.6-24.4 min, median in SA: 56.7 min, median in GA: 75.7 min, p < 0.0001).

CONCLUSIONS

This study showed that in lumbar spine surgery 19 min of anesthesia time can be saved using SA compared to GA which could have an impact on economic aspects. Gender, BMI and ASA had no statistically detectable influence on the choice between the two anesthesia methods. The fact that time-intensive complex instrumentation is mainly performed in younger patients may explain why GA patients were younger than SA patients.