Machine learning to identify a composite indicator to predict cardiac death in ischemic heart disease

BACKGROUND

Machine learning (ML) employs algorithms that learn from data, building models with the potential to predict events by aggregating a large number of variables and assessing their complex interactions. The aim of this study is to assess ML potential in identifying patients with ischemic heart disease (IHD) at high risk of cardiac death (CD).

METHODS

3987 (mean age 68 ± 11) hospitalized IHD patients were enrolled. We implemented and compared various ML models and their combination into ensembles. Model output constitutes a new ML indicator to be employed for stratification. Primary variable importance was assessed with ablation tests.

RESULTS

An ensemble classifier combining three ML models achieved the best performance to predict CD (AUROC of 0.830, F1-macro of 0.726). ML indicator use through Cox survival analysis outperformed the 18 variables individually, producing a better stratification compared to standard multivariate analysis (improvement of ∼20%). Patients in the low risk group defined through ML indicator had a significantly higher survival (88.8% versus 29.1%). The main variables identified were Dyslipidemia, LVEF, Previous CABG, Diabetes, Previous Myocardial Infarction, Smoke, Documented resting or exertional ischemia, with an AUROC of 0.791 and an F1-score of 0.674, lower than that of 18 variables. Both code and clinical data are freely available with this article.

CONCLUSION

ML may allow a faster, low-cost and reliable evaluation of IHD patient prognosis by inclusion of more predictors and identification of those more significant, improving outcome prediction towards the development of precision medicine in this clinical field.

High-resolution mapping and dispersion analyses of volcanic ballistics emitted during the 3rd July 2019 paroxysm at Stromboli

A detailed mapping of volcanic ballistic projectiles emplaced in a defined area, represents the starting point to derive preparatory data in hazard and risk studies of ballistics phenomena. Considering as case study the 3rd July 2019 paroxysmal eruption occurred at Stromboli volcano, we map and analyse at very high spatial resolution (8 cm) the distribution of the ballistic spatter clasts emplaced on the E flank of the volcano. The resulting map identifies and reproduces as geospatial polygon elements 152,228 spatter clasts with areal dimensions from 0.03 to 4.23 m2. Dispersed on 0.407 km2, the spatters cover an area of 29,000 m2 corresponding to an erupted products volume from 2.3 to 7.0 × 103 m3, calculated here for the first time. Spatial analyses indicate that the area mostly affected by the clasts emplacement is between N67.5 and N135 directions, identifying a preferential deposition between N112.50 and N123.75 directions. The clasts size distribution rapidly decreases with the size increase, highlighting a nearly constant ratio small/large clasts regardless the distance from the vent. Finally, additional investigations reveal that clasts dispersion parameters decrease progressively with the distance from the vent only along one direction (N67.5), highlighting how the morphology influences the deposition and remobilisation of mapped ballistics.

FIB-4 Index and Neutrophil-to-Lymphocyte-Ratio as Death Predictor in Coronary Artery Disease Patients

Nonalcoholic fatty liver disease (NAFLD)-associated liver fibrosis is likely related to coronary artery disease (CAD) by the mediation of systemic inflammation. This study aimed at evaluating the predictive value of neutrophil-to-lymphocyte-ratio (NLR) and fibrosis-4 index (FIB-4), indices of inflammation and fibrosis, respectively, on CAD mortality. Data from 1460 CAD patients (1151 males, age: 68 ± 10 years, mean ± SD) were retrospectively analyzed. Over a median follow-up of 26 months (interquartile range (IQR) 12−45), 94 deaths were recorded. Kaplan−Meier survival analysis revealed worse outcomes in patients with elevation of one or both biomarkers (FIB-4 > 3.25 or/and NLR > 2.04, log-rank p-value < 0.001). In multivariate Cox regression analysis, the elevation of one biomarker (NLR or FIB-4) still confers a significant independent risk for mortality (hazard ratio (HR) = 1.7, 95% confidence interval (95% CI): 1.1−2.7, p = 0.023), whereas an increase in both biomarkers confers a risk corresponding to HR = 3.5 (95% CI: 1.6−7.8, p = 0.002). Categorization of patients with elevated FIB-4/NLR could provide valuable information for risk stratification and reduction of residual risk in CAD patients.

Interaction of Uric Acid and Neutrophil-to-Lymphocyte Ratio for Cardiometabolic Risk Stratification and Prognosis in Coronary Artery Disease Patients

Oxidative stress and inflammation are key factors in cardiometabolic diseases. We set out to evaluate the relationship between serum uric acid (UA) and the neutrophil-to-lymphocyte ratio (NLR) with cardiometabolic risk factors in coronary artery disease (CAD) patients, and their additive and multiplicative interactive effects on outcomes (cardiac death/CD and hard events (HE)-death plus reinfarction). A total of 2712 patients (67 ± 11 years, 1960 males) who underwent coronary angiography was retrospectively analyzed and categorized into no-CAD patients (n =806), stable-CAD patients (n =1545), and patients with acute myocardial infarction (AMI) (n =361). UA and NLR were reciprocally correlated and associated with cardiometabolic risk factors. During a mean follow-up period of 27 ± 20 months, 99-3.6% deaths, and 213-7.8% HE were registered. The Kaplan-Meier survival estimates showed significantly worse outcomes in patients with elevated UA or NLR levels. Multivariate Cox regression analysis demonstrated that NLR independently predicted CD and HE. There was no multiplicative interaction between UA and NLR; however, the use of measures of additive interaction evidenced a positive additive interaction between UA and NLR for CD and HE. Although it is clear that correlation does not imply causation, the coexistence of NRL and UA appears to have a synergistic effect, providing further information for the risk stratification of CAD patients.

C45 LATE CARDIAC OUTCOMES IN PATIENTS AFTER COVID–19: A CARDIAC MAGNETIC RESONANCE STUDY

Background

Myocardial injury can occur in patients with coronavirus disease (COVID)–19. Cardiac magnetic resonance (CMR) provides information on functional and morphological cardiac parameters, as well myocardial tissue characterization. Actually, there are few data on late cardiac outcomes in patients after COVID–19.

Aim of the Study

To assess late functional, morphological and myocardial tissue parameters in patients positive to COVID–19 Methods 55 patients (age 50±16 yrs, Female n = 17) with a prior diagnosis of COVID 19, without a previous history of cardiac disease were enrolled in the study. Of these, 35 were hospitalized. The time interval between COVID–19 diagnosis and CMR was 418±28 days. Cardiac function and myocardial tissue characterization have been evaluated with the current CMR techniques. In particular, the presence of late gadolinium enhancement (LGE), as a sign of myocarditis outcome has been evaluated.

Results

LGE was present in 19 patients (34.5%). In all cases, LGE was localized at the level of lateral wall of left ventricle within the myocardium or at the subepicardial level (non–ischemic pattern). Left and right ventricular (LV, RV) ejection fraction were within normal values (mean±SD 65±5% and 65±7%, respectively), as well as volumes (LV endiastolic and endsystolic volumes 71±15 and 27±8 ml/m2; RV endiastolic and endsystolic volumes 72±15 and 25±9 ml/m2). In one case, LGE was associated to regional wall hypokinesia. Among the hospitalized patients, the following factors were associated to the presence of LGE: prone position during assisted ventilation, duration of hospitalization. LGE was present in 67% of patients put in prone position, against 33% of patients not pronated (p = 0.009 Fisher‘s exact test). Duration of hospitalization was 9±5 and 16±7 respectively in patients without and with LGE (p = 0.007)

Conclusion

LGE, as an outcome of myocarditis, is present in a significant number of patients with a history of COVID–19, but it is not associated with dilatation or global and regional dysfunction of left ventricle. LGE is mainly present in pts with more severe clinical presentation of COVID–19

Prognostic Value of Heart Rate Reserve during Dipyridamole Stress Echocardiography in Patients With Abnormal Chronotropic Response to Exercise

Heart rate reserve (HRR) during physical or pharmacological stress is a sign of cardiac autonomic function and sympathetic reserve, but it can be reduced during exercise for confounders such as poor motivation, drugs or physical fitness. In this study we sought to assess the prognostic meaning of HRR during dipyridamole stress echocardiography (DSE) in patients with abnormal chronotropic response to exercise. From 2004 to 2019, we prospectively acquired and retrospectively analyzed 379 patients (age 62 ± 11 years; ejection fraction 60 ± 5%) with suspected (n = 243) or known (n = 136) chronic coronary syndromes, referred to DSE for chronotropic incompetence during upright bicycle exercise-electrocardiography test defined as HRR used [(peak HR - rest HR) / (220 - age) - rest HR] ≤80% in patients off and ≤62% in patients on beta-blockers. All patients were in sinus rhythm and underwent DSE (0.84 mg/kg) within 3 months of exercise testing. During DSE, age-independent HRR (peak/rest HR) ≤1.22 was considered abnormal. All patients were followed-up. All-cause death was the only outcome measure. HRR during DSE was normal in 275 (73%) and abnormal in 104 patients (27%). During a follow-up of 9.0 ± 4.2 years, 67 patients (18%) died. The 15-year mortality rate was 23% in patients with normal and 61% in patients with abnormal HRR (p < 0.0001). At multivariable analysis a blunted HRR during DSE was an independent predictor of outcome (hazard ratio 2.01, 95% confidence intervals 1.23-3.29; p = 0.005) with age and diabetes, while neither inducible ischemia nor ongoing beta-blocker therapy were significant predictors. In conclusion, a blunted HRR during DSE predicts a worse survival in patients with chronotropic incompetence during exercise test. HRR during DSE is an appealingly simple biomarker of cardiac autonomic dysfunction independent of imaging, exercise and beta-blocker therapy.

Uncovering the eruptive patterns of the 2019 double paroxysm eruption crisis of Stromboli volcano

In 2019, Stromboli volcano experienced one of the most violent eruptive crises in the last hundred years. Two paroxysmal explosions interrupted the ‘normal’ mild explosive activity during the tourist season. Here we integrate visual and field observations, textural and chemical data of eruptive products, and numerical simulations to analyze the eruptive patterns leading to the paroxysmal explosions. Heralded by 24 days of intensified normal activity and 45 min of lava outpouring, on 3 July a paroxysm ejected ~6 × 10⁷ kg of bombs, lapilli and ash up to 6 km high, damaging the monitoring network and falling towards SW on the inhabited areas. Intensified activity continued until the less energetic, 28 August paroxysm, which dispersed tephra mainly towards NE. We argue that all paroxysms at Stromboli share a common pre-eruptive weeks-to months-long unrest phase, marking the perturbation of the magmatic system. Our analysis points to an urgent implementation of volcanic monitoring at Stromboli to detect such long-term precursors.

Integrated field and laboratory investigations, and numerical simulations of the 2019 paroxysmal explosions at Stromboli volcano revealed that they were anticipated by a week-to-month-long destabilization in the normal volcanic activity, a pattern common to all paroxysms.

Prognostic value of lung ultrasound in patients hospitalized for heart disease irrespective of symptoms and ejection fraction

Aims

Lung ultrasound B‐lines are the sonographic sign of pulmonary congestion and can be used in the differential diagnosis of dyspnoea to rule in or rule out acute heart failure (AHF). Our aim was to assess the prognostic value of B‐lines, integrated with echocardiography, in patients admitted to a cardiology department, independently of the initial clinical presentation, thus in patients with and without AHF, and in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF).

Methods and results

We enrolled consecutive patients admitted for various cardiac conditions. Patients were classified into three groups: (i) acute HFrEF; (ii) acute HFpEF; and (iii) non‐AHF. All patients underwent an echocardiogram coupled with lung ultrasound at admission, according to standardized protocols. We followed up 1021 consecutive inpatients (69 ± 12 years) for a median of 14.4 months (interquartile range 4.6–24.3) for death and rehospitalization for AHF. During the follow‐up, 126 events occurred. Admission B‐lines > 30, ejection fraction < 50%, tricuspid regurgitation velocity > 2.8 m/s, and tricuspid annular plane systolic excursion < 17 mm were independent predictors at multivariable analysis. B‐lines > 30 had a strong predictive value in HFpEF and non‐AHF, but not in HFrEF.

Conclusions

Ultrasound B‐lines can detect subclinical pulmonary interstitial oedema in patients thought to be free of congestion and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is more robust in patients with HFpEF compared with HFrEF.

Prognostic value of integrated cardiopulmonary ultrasound in inpatients with acute heart failure with preserved and reduced ejection fraction and without heart failure

Objective

To assess the prognostic value of B-lines integrated with echocardiography in patients admitted to a Cardiology Department, with and without acute heart failure (AHF).

Background

Lung-ultrasound (LUS) B-lines are sonographic signs of pulmonary congestion and can be used in the differential diagnosis of dyspnea to rule in or rule out AHF. Their prognostic value at admission is less established, as well as the different role in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF), or patients admitted for cardiac conditions but without overt signs and symptoms of AHF.

Methods

A total of 1021 consecutive in-patients (69±12 years) admitted for various cardiac conditions were enrolled. Patients were classified into three groups: 1) acute HFrEF; 2) acute HFpEF; 3) no AHF. All patients underwent on the admission an echocardiogram coupled with LUS, according to standardised protocols.

Results

Patients were followed-up for a median of 14.4 months (interquartile range: 4.6–24.3) for death and HF readmission (composite endpoint). During the follow-up, 126 events occurred. Kaplan-Meier survival analyses showed admission B-lines &gt;30 identified patients with worse outcome at follow-up in the overall population and each of the three groups (Figure). At multivariable analysis (Table), admission B-lines &gt;30, EF &lt;50%, tricuspid regurgitation velocity &gt;2.8 m/s and tricuspid annular plane systolic excursion (TAPSE) &lt;17 mm resulted in independent predictors of the composite endpoint. B-lines &gt;30 had a strong predictive value in HFpEF and non-AHF, but not in HFrEF.

Conclusions

Ultrasound B-lines can detect subclinical pulmonary interstitial edema in patients thought to be free of congestion, and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is stronger in patients with HFpEF compared to HFrEF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Major explosions and paroxysms at Stromboli (Italy): a new historical catalog and temporal models of occurrence with uncertainty quantification

Stromboli volcano (Italy), always active with low energy explosive activity, is a very attractive place for visitors, scientists, and inhabitants of the island. Nevertheless, occasional more intense eruptions can present a serious danger. This study focuses on the modeling and estimation of their inter-event time and temporal rate. With this aim we constructed a new historical catalog of major explosions and paroxysms through a detailed review of scientific literature of the last ca. 140 years. The catalog includes the calendar date and phenomena descriptions for 180 explosive events, of which 36 were paroxysms. We evaluated the impact of the main sources of uncertainty affecting the historical catalog. In particular, we categorized as uncertain 45 major explosions that reportedly occurred before 1985 and tested the effect of excluding these events from our analysis. Moreover, after analyzing the entire record in the period [1879, 2020], we separately considered, as sequences, events in [1879, 1960] and in [1985, 2020] because of possible under recording issues in the period [1960, 1985]. Our new models quantify the temporal rate of major explosions and paroxysms as a function of time passed since the last event occurred. Recurrence hazard levels are found to be significantly elevated in the weeks and months following a major explosion or paroxysm, and then gradually decrease over longer periods. Computed hazard functions are also used to illustrate a methodology for estimating order-of-magnitude individual risk of fatality under certain basis conditions. This study represents a first quantitatively formal advance in determining long-term hazard levels at Stromboli.

Prognostic Value of Heart Rate Reserve in Patients with Permanent Atrial Fibrillation during Dipyridamole Stress Echocardiography

In patients in sinus rhythm, a blunted heart rate reserve (HRR) during dipyridamole stress echocardiography (SE) is a prognostically unfavorable sign of cardiac autonomic dysfunction. In this study we sought to assess the prognostic meaning of HRR in patients with permanent atrial fibrillation (AF). The study population was made by 301 patients (176 men, age 73 ± 8 years) with suspected (n = 200) or known (n = 101) coronary artery disease and permanent AF who underwent high-dose dipyridamole SE. HRR was calculated on an average of 5 consecutive beats as the peak/rest ratio of HR from 12-lead EKG. During a median follow-up time of 77 months (first quartile 44, third quartile 115 months), 111 (37%) patients died. Receiver operating characteristics analysis identified HRR ≤1.17 as the best predictor of mortality. At multivariable analysis, HRR ≤1.17 (HR 1.75, 95% CI 1.17 to 2.62; p = 0.006) independently predicted mortality together with age (HR 1.09, 95% CI 1.06 to 1.13; p <0.0001), rest wall motion score index (HR 1.69, 95% CI 1.01 to 2.83; p = 0.04), and systemic hypertension (HR 1.76, 95% CI 1.06 to 3.00; p = 0.04). The annual mortality was 5.1% in the overall population, 7.0% in the 140 (46%) patients with abnormal HRR and 3.5% in the 161 (54%) patients with normal HRR. The 8-year mortality was 48% in patients with abnormal HRR and 18% in those with normal HRR (p <0.0001). In conclusion, patients with suspected or known coronary artery disease with permanent AF with a blunted HRR have an increased mortality. HRR outweighs inducible ischemia for prediction of survival. The assessment of HRR should become an integral part of dipyridamole SE reading also in AF.

P1479 Prognostic value of integrated cardiopulmonary ultrasound in heart failure patients with reduced and preserved ejection fraction

Background

Lung-ultrasound B-lines are the sonographic sign of pulmonary congestion and are present in patients with heart failure (HF). Their role as a diagnostic marker is quite established since they can be used for the differential diagnosis of dyspnea to both rule in or rule out HF, whereas their prognostic value at admission is less known.

Purpose

To assess the prognostic value of B-lines at admission in patients admitted to a Cardiology Department with a diagnosis of HF with reduced (HFrEF) and preserved (HFpEF) ejection fraction.

Methods

We enrolled a total of 310 consecutive in-patients (aged 69 ± 12 years, 751 males) who underwent on admission a two-dimensional and Doppler echocardiographic evaluation coupled with lung ultrasound assessment of B-lines, according to standardised protocols. The total number of B-line was obtained by summing the number of B-lines from 28 scanning sites on the anterior and lateral right and left hemithorax, as previously described.

Results

All patients were followed-up for a median period of 15 (interquartile range: 5-28) months for death and HF readmission. During the follow-up, 79 events occurred. Among standard echocardiographic parameters, ejection fraction (EF) &lt;50%, tricuspid annular plane systolic excursion (TAPSE) &lt; 17 mm, pulmonary artery systolic pressure (PASP) ³35 mmHg, inferior vena cava diameter &gt;21 mm and total B-lines ³30 were predictors of events at univariate analysis, whereas only B-lines ³30 (hazard ratio [HR] 2.06; 95% confidence interval [CI] 1.04-4.10) and TAPSE &lt;17 mm (HR 0.53; CI 0.29-0.97) were independent predictors at multivariate analysis. When analysing separately HFpEF patients (105 patients, 33.9%), B-lines ³30 was the only independent predictor of events (HR 6.11; CI 1.49-25.05) (Figure).

Conclusions

B-lines are a simple, user-friendly, bedside echographic sign of pulmonary congestion, that provides useful information not only for the diagnosis but also for the prognosis of HF patients. Their added value among standard echocardiographic parameters is stronger in patients with HFpEF compared to HFrEF. An integrated cardiopulmonary ultrasound assessment at HF admission provides excellent value for both diagnostic and prognostic stratification.

Abstract P1479 Figure

Usefulness of Blunted Heart Rate Reserve as an Imaging-Independent Prognostic Predictor During Dipyridamole Stress Echocardiography

A blunted heart rate (HR) response during dipyridamole myocardial perfusion imaging has been associated with a poor outcome. To assess the value of HR response in patients who underwent high-dose dipyridamole stress echocardiography (SE), we retrospectively selected a sample of 3,059 patients (none with pacemakers or atrial fibrillation; mean age 66 ± 11 years). All underwent high-dose (0.84 mg/kg) dipyridamole SE for evaluation of known or suspected coronary artery disease and/or heart failure in 2 laboratories of Pisa-IFC and Lucca. HR (with 12-lead ECG) was obtained each minute and recorded at rest and peak stress. HR reserve (HRR) was calculated as the peak/rest HR ratio. All patients were followed up. Patients were randomly divided into the modeling and validation group of equal size. During a median follow-up time of 1,004 days, 321 hard events occurred: 231 deaths and 90 nonfatal myocardial infarctions. HRR ≤ 1.22 identified by receiver operating characteristic analysis in the modeling group was an independent predictor of infarction-free survival in the modeling (hazard ratio 1.83, 95% confidence interval [CI] 1.30 to 2.60, p = 0.001), in the validation (hazard ratio 1.47, 95% CI 1.08 to 2.01, p = 0.02), and in the overall group (hazard ratio 1.60, 95% CI 1.27 to 2.02, p <0.0001), either off- or on-β blockers. Five-year event rate increased from 8% to 24 % from the highest (≥1.41) to the lowest (≤1.14) HRR quartile. In conclusion, blunted HRR is a useful nonimaging predictor of adverse events during high-dose dipyridamole SE, independent of inducible ischemia, and beta-blocker therapy.

Stress Echocardiography Positivity Predicts Cancer Death

Background

Stress echocardiography (SE) predicts cardiac death, but an increasing share of cardiac patients eventually die of cancer. The aim of the study was to assess whether SE positivity predicts cancer death.

Methods and Results

In a retrospective analysis of prospectively acquired single‐center, observational data, we evaluated 4673 consecutive patients who underwent SE from 1983 to 2009. All patients were cancer‐free at index SE and were followed up for a median of 131 months (interquartile range 134). We separately analyzed predetermined end points: cardiovascular, cancer, and noncardiovascular, noncancer death, with and without competing risk. SE was positive in 1757 and negative in 2916 patients; 869 cardiovascular, 418 cancer, and 625 noncardiovascular, noncancer deaths were registered. The 25‐year mortality was higher in SE‐positive than in SE‐negative patients, considering cardiovascular (40% versus 31%; P<0.001) and cancer mortality (26% versus 17%; P<0.01). SE positivity was a strong predictor of cancer (cause‐specific hazard ratio 1.19; 95% confidence interval, 1.16–1.73; P=0.05) and cardiovascular mortality (1.18; 95% confidence interval, 1.03–1.35; P=0.02). Fine–Gray analysis to account for competing risk gave similar results. Cancer risk diverged after 15 years, whereas differences were already significant at 5 years for cardiovascular risk.

Conclusions

SE results predict cardiovascular and cancer mortality. SE may act as a proxy of the shared risk factor milieu for cancer or cardiovascular death.

Gender differences for uric acid as predictor of hard events in patients referred for coronary angiography

Aim: To assess gender differences in uric acid (UA) as predictor for hard events (HE, mortality and nonfatal myocardial infarction) in a large cohort of patients referred for coronary angiography. Design & patients: 3020 inpatients (2177 males, age: 68 ± 9 years, mean ± SD) were retrospectively studied, collecting data from the Institute electronic databank which included demographic, clinical, instrumental and follow-up data. Results: Although the Kaplan–Meier survival estimates showed a significantly worst outcome in female patients, high UA did not remained a significant predictor for HE after adjustment. Moreover, UA correlated with antioxidant capacity in both sexes. Conclusion: Hyperuricemia was not an independent risk for HE, and being correlated with antioxidant capacity, its elevation appears more likely compensatory than causative for HE.

Low magnesium is not a significant predictor of hard events in acute myocardial infarction

Background

Although magnesium (Mg) has recognized cardioprotective properties and hypomagnesemia is common in patients with acute myocardial infarction (AMI), data regarding the role of Mg as prognostic factor for adverse events are scarce, as well as there are conflicting results on the use of Mg as adjuvant therapy in AMI.

Aim

To evaluate the role of Mg as predictor for hard events (HE, all cause death, and nonfatal myocardial infarction) in AMI patients.

Design and patients

We studied 406 AMI patients (306 males, age: 67 ± 12 years, mean ± SD). Patient data were collected from the Institute electronic databank which saves demographic, clinical, instrumental, therapeutical and follow-up data of all patients admitted to our Coronary Unit.

Results

During a mean follow-up period of 21 ± 18 months, the combined endpoint accounted for 63 HE, 44 (11%) deaths (35 cardiac deaths), 19 (5%) nonfatal MI.

The multiple regression model identified glycemia as the only independent determinant of Mg in AMI pts. (T value = − 2.8, standard coefficient = − 0.15, p < 0.01). The Kaplan–Meier survival estimates failed to show a significantly worst outcome in patients presenting low Mg (< 0.783 mmol/L, 25th percentile). Aging (> 67 years—50th percentile), and ejection fraction (< 40%) remained as prognostic factors for HE in the adjusted Cox multivariate proportional hazard model (HR = 2.8, 95% CI = 1.6–5, p < 0.001; HR = 3.2, 95% CI = 1.9–5.3 p < 0.001, respectively).

Conclusion

The present findings do not support a significant role of low Mg as predictor for HE in AMI.

•

It has been hypothesized that Mg may play a key role in ischemic heart disease.

•

Mg role as predictor for HE-death, nonfatal myocardial infarction-in AMI was studied.

•

Our results do not give support for a role of hypomagnesia as HE predictor in AMI.

Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study

Background

B-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF).

Methods

A prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 ± 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge.

Results

Mean B-lines at admission was 48 ± 48 with a statistically significant reduction before discharge (20 ± 23, p < .0001). During follow-up, 14 patients were rehospitalized for decompensated HF. The 6-month event-free survival was highest in patients with less B-lines (≤ 15) and lowest in patients with more B-lines (> 15) (log rank χ² 20.5, p < .0001). On multivariable analysis, B-lines > 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30–106.16) was an independent predictor of events at 6 months.

Conclusions

Persistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation.

Impact of mild to moderate reductions of glomerular filtration rate on coronary artery disease severity

BACKGROUND & AIMS

The bases of the link between reduced glomerular filtration rate (GFR) and coronary artery disease (CAD) are complex and to some extent still unclear. We performed this observational, single referral center, cohort study to evaluate whether mild to moderate GFR reduction is associated with more severe CAD and/or with a worse cardiac prognosis independently of proteinuria, diabetes and traditional risk factors.

METHODS AND RESULTS

In 1752 consecutive non-diabetic patients without proteinuria or moderate/severe kidney disease undergoing a clinically driven coronary angiography, coronary arteries lesions, myocardial function and hypertrophy and 10-yrs incidence of cardiac events and death were evaluated in relation to classes of estimated GFR defined according the lowest eGFR value (105+, 90+, 75+, 60+, 45+). A reduced eGFR was independently associated with hypertension, myocardial hypertrophy and stress induced ischemia, while the excess coronary lesions and the worse myocardial systolic function were both largely explained by age and cardiovascular risk factors. When compared to subjects 75+, both the risk of cardiac death (1.67[1.10-2.57] and 3.06[1.85-5.10]) and non-fatal myocardial infarction (2.58[1.12-6.49] and 2.73[1.31-6.41]) adjusted for age and comorbidities were higher in eGFR 60+ and 45+ patients.

CONCLUSIONS

A mild-moderate reduction of eGFR is closely associated to higher rates of stress-induced ischemia, myocardial hypertrophy and higher risk of fatal and non-fatal cardiac events. The associations of reduced eGFR with coronary atherosclerosis and myocardial systolic dysfunction are both largely explained by age and traditional risk factors.

Inappropriateness of cardiovascular radiological imaging testing; a tertiary care referral center study

AIMS

Radiological inappropriateness in medical imaging leads to loss of resources and accumulation of avoidable population cancer risk. Aim of the study was to audit the appropriateness rate of different cardiac radiological examinations.

METHODS AND PRINCIPAL FINDINGS

With a retrospective, observational study we reviewed clinical records of 818 consecutive patients (67 ± 12 years, 75% males) admitted from January 1-May 31, 2010 to the National Research Council - Tuscany Region Gabriele Monasterio Foundation cardiology division. A total of 940 procedures were audited: 250 chest x-rays (CXR); 240 coronary computed tomographies (CCT); 250 coronary angiographies (CA); 200 percutaneous coronary interventions (PCI). For each test, indications were rated on the basis of guidelines class of recommendation and level of evidence: definitely appropriate (A, including class I, appropriate, and class IIa, probably appropriate), uncertain (U, class IIb, probably inappropriate), or inappropriate (I, class III, definitely inappropriate). Appropriateness was suboptimal for all tests: CXR (A = 48%, U = 10%, I = 42%); CCT (A = 58%, U = 24%, I = 18%); CA (A = 45%, U = 25%, I = 30%); PCI (A = 63%, U = 15%, I = 22%). Top reasons for inappropriateness were: routine on hospital admission (70% of inappropriate CXR); first line application in asymptomatic low-risk patients (42% of CCT) or in patients with unchanged clinical status post-revascularization (20% of CA); PCI in patients either asymptomatic or with miscellaneous symptoms and without inducible ischemia on non-invasive testing (36% of inappropriate PCI).

CONCLUSION AND SIGNIFICANCE

Public healthcare system--with universal access paid for with public money--is haemorrhaging significant resources and accumulating avoidable long-term cancer risk with inappropriate cardiovascular imaging prevention.

Chapter 14 Stromboli volcano, Aeolian Islands (Italy): present eruptive activity and hazards

Stromboli, the northernmost island of the Aeolian archipelago, is known for its persistent volcanic activity over the last several centuries and for its cone which, on clear days, is surmounted by a gas plume rising from its summit. The island hosts two settled areas: the village of Stromboli (c. 500 inhabitants) to the NE and that of Ginostra (c. 40 inhabitants) to the SW, both situated along the coast. In summer the number of residents grows considerably, reaching c. 5000 people. This paper provides a description of the present activity and reassesses volcanic hazards on the basis of data from a new monitoring system and from studies on the 2002–2003 and 2007 crises. The normal activity, that of mild Strombolian explosions, is occasionally interrupted by violent eruptions of variable scale (paroxysmal events) and lava flows. Volcanic hazards directly generated by eruptive activity consist of ballistic and tephra fallout, pyroclastic flows, lava flows, wildfires and minor lahars, presenting serious problems to the settled areas only occasionally. In addition to hazards directly related to eruptive phenomena, the Sciara del Fuoco depression has been the site of landslides at various scales, sometimes accompanied by the formation of tsunamis.

Prognostic role of heart rate in patients referred for coronary angiography: age and sex differences

OBJECTIVE To evaluate the predictive value of resting heart rate (RHR) for cardiac and total mortality in a large population of patients referred for coronary angiography with an extended follow-up, stratified in four subpopulations according to gender and age (50th percentile corresponding to 67 years).

METHODS

We studied 3559 subjects (2603 males, age: 66 ± 11 years, mean ± SD), obtaining patient data from the Institute electronic databank which saves demographic, clinical, instrumental and follow-up data of patients admitted to our department.

RESULTS

During a mean follow-up period of 35 ± 25 months, 296 (8%) patients died; there were 173 (5%) cardiac deaths. In female patients irrespective of age, RHR (≥ 76 bpm, 75th percentile) did not appear predictive for cardiac death. In females, RHR was predictive for overall mortality after multivariate adjustment only in those aged ≥ 67 years (hazard ratio (HR) 1.7, 95% confidence interval (CI) 1-2.8, p ≤ 0.05). In male patients aged < 67 years, RHR remained as an independent predictive factor for overall mortality at the multivariate analysis (HR 2.5, 95% CI 1.5-4.2, p < 0.001), and as an independent predictor for both cardiac mortality (HR 1.8, 95% CI 1.2-2.7, p < 0.01) and total mortality (HR 1.6, 95% CI 1.2-2.3, p < 0.01) in male patients over 67 years.

CONCLUSION

The current study suggests that the prognostic importance of RHR may differ according to the patient's gender and age, suggesting significant differences in cardiovascular physiopathology between female and male patients.

A survey on virtual environment applications to fear of public speaking

BACKGROUND

Social Anxiety Disorder (SAD) is one of the most prevalent anxiety disorders in Europe and comprises the fear of public speaking as its typical sub-type. Cognitive-Behavioural Therapy (CBT) is the intervention of choice for SAD, and it includes exposure to anxiety-provoking stimuli to induce systematic desensitization and reduce anxiety. Similarly, exposure therapy per se has been used and found effective, although it is not as specific as CBT for the treatment of SAD. Interestingly, exposure to anxiety-provoking situations can be achieved in Virtual Environments (VEs) through the simulation of social situations allowing individuals with public speaking anxiety to live and develop real exposure-like reactions. The Virtual Reality Exposure Therapy (VRET) is the treatment of anxiety disorders based on such VEs.

AIM

This article aims to provide an overview of the scientific literature related to the applications of Virtual Reality to the treatment of fear of public speaking.

MATERIALS AND METHODS

We conducted the literature review on PubMed and Google Scholar for studies including the fear-of-public-speaking VEs.

RESULTS AND CONCLUSIONS

Reviewed studies addressed two main aspects: the design parameters of the VEs for adequate reactions to synthetic social stimuli, and the efficacy of VEs for fear of public speaking treatment. VEs resulted effective for triggering as-if-real reactions in relation to public speaking. VE-based exposures reduced public speaking anxiety measurements, decreased scores and maintained them at 3 month follow-up. Studies comparing VRET to pharmacological therapy are lacking, and there are few randomized controlled trials that compare VRET to CBT, especially on fear of public speaking treatment.

Prevalence of thyroid dysfunction and effect of contrast medium on thyroid metabolism in cardiac patients undergoing coronary angiography

BACKGROUND

Iodinated contrast media (CM) may influence thyroid function. Precautions are generally taken in patients with hyperthyroidism, even if subclinical, whereas the risks in patients with hypothyroidism or low triiodothyronine (T3) syndrome are not considered as appreciable.

PURPOSE

To assess the presence and type of thyroid dysfunction in patients admitted for coronary angiography (CA), to assess the concentration of free-iodide in five non-ionic CM, and to evaluate changes in thyroid function after CA in patients with low T3 syndrome.

MATERIAL AND METHODS

We measured free T3, free thyroxine (T4), and thyroid-stimulating hormone (TSH) in 1752 consecutive patients prior to CA and free-iodide in five non-ionic CM. Urinary free-iodide before and 24 h after CA, and thyroid hormone profile 48 h after CA were also made in 17 patients with low T3 syndrome. Patients were followed up for an average duration of 63.5 months.

RESULTS

The patients were divided into four groups: euthyroidism (60%), low T3 syndrome (28%), hypothyroidism (10%), and hyperthyroidism (2%). The free-iodide resulted far below the recommended limit of 50 µg/mL in all tested CM. In low T3 syndrome, 24-h free-iodide increased after CA from 99.9 ± 63 ug to 12276 ± 9285 ug (P < 0.0001). A reduction in TSH (4.97 ± 1.1 vs. 4.17 ± 1.1 mUI/mL, P < 0.01) and free T3 (1.44 ± 0.2 vs. 1.25 ± 0.3 pg/mL, P < 0.01), with an increase in free T4 (11.3 ± 2.9 vs. 12.5 ± 3.4 pg/dL, P < 0.001), was found. Patients with functional thyroid disease in the follow-up had a significant lower rate survival compared to euthyroid patients (90.7 vs. 82.2%, P < 0.00001).

CONCLUSION

Thyroid dysfunction is frequent in patients who perform a CA, and low T3 syndrome is the predominant feature. The administration of contrast medium may further compromise the thyroid function.

Trends of increasing medical radiation exposure in a population hospitalized for cardiovascular disease (1970-2009)

BACKGROUND

High radiation doses employed in cardiac imaging may increase cancer frequency in exposed patients after decades. The aim of this study was to evaluate the relative trends in medical radiation exposure in a population hospitalized for cardiovascular disease.

METHODS AND RESULTS

An observational single-center study was conducted to examine 16,431 consecutive patients with heart disease admitted to the Italian National Research Council Institute of Clinical Physiology between January 1970 and December 2009. In all patients, the cumulative estimated effective dose was obtained from data mining of electronic records of hospital admissions, adopting the effective dose typical values of the American Heart Association 2009 statement and Mettler's 2008 catalog of doses. Cumulative estimated effective dose per patient in the last 5 years was 22 (12-42) mSv (median, 25(th)-75(th) percentiles), with higher values in ischemic heart disease (IHD), 37 (20-59) vs non-IHD, 13 (8-22) mSv, p<0.001. Trends in radiation exposure showed a steady increase in IHD and a flat trend in non-IHD patients, with variation from 1970-74 to 2005-2009 of +155% for IHD (p<0.001) and -1% in non-IHD (NS). The relative contribution of different imaging techniques was remodeled over time, with nuclear cardiology dominating in 1970s (23% of individual exposure) and invasive fluoroscopy in the last decade (90% of individual exposure).

CONCLUSION

A progressive increase in cumulative estimated effective dose is observed in hospitalized IHD patients. The growing medical radiation exposure may encourage a more careful justification policy regarding ionizing imaging in cardiology patients applying the two main principles of radiation protection: appropriate justification for ordering and performing each procedure, and careful optimization of the radiation dose used during each procedure.

Routine laboratory tests to risk-stratify patients with chronic coronary artery disease

BACKGROUND

Several biohumoral variables, taken individually, are predictors of prognosis in patients with chronic coronary artery disease (CAD). We hypothesized that taken together, laboratory tests provide prognostic information that is additive to a complete diagnostic work-up.

METHODS

We prospectively examined 2370 consecutive patients with chronic CAD, as shown by a >50% coronary stenosis (in 95% of patients), previous coronary revascularization (in 31% of patients), and/or previous myocardial infarction (MI, in 54% of patients). We tested the ability of laboratory and clinical variables to predict future cardiac events (cardiac death and non-fatal MI).

RESULTS

During follow-up (median, 46 months), 147 patients (6.2%) died from cardiac causes and 81 (3.4%) experienced a non-fatal MI. Using multivariate analysis, after adjustment for clinical variables (including left ventricular ejection fraction and angiographic extent of coronary stenoses), a high-density lipoprotein cholesterol (HDLc) concentration<35 mg/dL (p<0.0001), a neutrophil-to-lymphocyte ratio >2.4 (p=0.0014), and an fT3 serum level<2.1 pg/mL with normal thyrotropin (low-T3 syndrome) (p=0.0260) showed an independent and incremental prognostic value, and were associated with an increase in the rate of cardiac events of 86%, 57% and 41%, respectively. When these variables were added to clinical and instrumental variables, the prognostic power of the model increased significantly (global chi-square improvement: from 157.01 to 185.07, p<0.0001).

CONCLUSION

Low HDLc, high neutrophil-to-lymphocyte ratio and low-T3 syndrome, both individually and taken together, provide prognostic information that is independent of and incremental to the main clinical and instrumental findings.

Elevated levels of oxidative stress as a prognostic predictor of major adverse cardiovascular events in patients with coronary artery disease

AIMS

To evaluate the prognostic significance of oxidative stress on the rate of major adverse cardiovascular events (MACEs: cardiac and all-cause death, nonfatal myocardial infarction, coronary revascularization-PTCA/CABG) in CAD.

METHODS

We studied 97 angiographically proven CAD patients (78 males, age: 67±11 years, mean± SD). Reactive oxygen metabolites and total antioxidant status, assessed by commercially assays (d-ROMs and OXY-Adsorbent Test; Diacron, Grosseto, GR, Italy), were used to calculate the oxidant/antioxidant balance. Patient data were collected from the Institute's electronic databank, which saves demographic, clinical, instrumental and follow-up data of all patients admitted to our department.

RESULTS

Kaplan-Meier survival estimates showed a significantly worst outcome in patients presenting with elevated oxidative stress levels (>75th percentile, p<0.01). Multivariate Cox models showed that a higher level of oxidative stress was an independent predictor of developing MACEs (hazard ratio=2.1, confidence intervals 1.2-3.6, p<0.01).

CONCLUSION

Oxidative stress may represent a useful additional tool in the prediction of MACE in CAD.

Psychiatric disorders and mitochondrial dysfunctions

BACKGROUND

Mitochondria play a key role in the production of the cell energy. The final product of this process is adenosine triphosphate (ATP), used as a source of chemical energy. Besides this major role, mithocondria have been shown to be involved in other functions, such as signaling, cellular differentiation, cell death, as well as the control of the cell cycle and cell growth. The aim of this paper is to highlight the relationships between psychiatric disorders, especially schizophrenia, bipolar disorder (BD), autism, attention deficit-hyperactivity disorder (ADHD) and Alzheimer's dementia.

RESULTS

The review of the available literature indicate that different mitochondrial dysfunctions may accompany and/or be part of the clinical picture of some neuropsychiatric disorders.

CONCLUSIONS

Different data would indicate that mitochondrial dysfunctions may be involved in the pathophysiology of different neuropsychiatric disorders, given their key role in the cell energy metabolism. Moreover, they would greatly contribute to the process of neural apoptosis that should be at the basis of neurodegenerative disorders, such as schizophrenia, Alzheimer's dementia and the most severe forms of BD. In addition, data are available that mithocondrial abnormalities are present also in developmental disorders, such as autism and ADHD, although the studies aiming at elucidating the role of mithocondria in the onset and pathophysiology of all these conditions should be considered preliminary. In any case, taken together, these scattered findings would suggest novel drugs targeting protecting mitochondria from oxidative stress.

Thyroid hormone, amiodarone therapy, and prognosis in left ventricular systolic dysfunction

BACKGROUND

Amiodarone protects patients with left ventricular systolic dysfunction (LVSD) against serious arrhythmias, but it also has numerous side effects on non-cardiac organs, such as the thyroid. Indeed, amiodarone may inhibit the peripheral conversion of T₄ into T₃. Pathologically reduced serum levels of T₃ - the so-called "low T₃ syndrome" (LOWT3) - increase mortality in patients with LVSD and not on amiodarone.

AIM

The aim of the study was to examine the relationship between thyroid hormone status, amiodarone therapy, and outcome in a population with LVSD. MATERIAL/ SUBJECTS AND METHODS: A total of 2344 patients with LVSD and free of overt hyper- and hypothyroidism were enrolled. The population was divided into 4 groups: group 1 (LOWT3 and amiodarone therapy, no.=126), group 2 (isolated amiodarone therapy, no.=74), group 3 (isolated LOWT3, no.=682), group 4 (controls, no.=1462).

RESULTS

Kaplan-Meier curves showed, after a mean follow-up of 31 months, increased total and cardiac mortality in groups 1 (30% and 20%, respectively), 2 (23%, 11%), and 3 (22%, 12%) compared to group 4 (total mortality log-rank 82.8, p<0.0001; cardiac mortality log-rank 63.1, p<0.0001). At Cox analysis, adjusted for several clinical variables, survival was reduced in groups 1 and 3 compared to group 4. Group 2 had a similar mortality to group 4, although the number of patients was too limited to accurately assess the effect of amiodarone on long-term prognosis.

CONCLUSIONS

LOWT3 exerts an adverse impact on prognosis in LVSD, which is not influenced by concomitant amiodarone therapy.

Through-the-scope large diameter self-expanding metal stent placement as a safe and effective technique for palliation of malignant colorectal obstruction: a single center experience with a long-term follow-up

OBJECTIVE

The aim of this study was to evaluate the outcomes of through-the-scope (TTS) large diameter self-expanding metal stent (SEMS) placement for palliation of malignant colorectal obstruction.

MATERIAL AND METHODS

Between January 2005 and December 2009, all patients who underwent endoscopic SEMS placement for palliation of malignant colorectal obstruction were prospectively enrolled.

RESULTS

Thirty-nine patients (17M and 22F; mean age 75.9 ± 10.6 years, range 50-91) were enrolled. The most frequent location was the sigmoid colon (13 cases). The causes of obstruction were colorectal malignancy in 32 patients and extracolonic malignancy in 7. Technical success was achieved in 36/39 patients (92.3%) and clinical success in 35/39 patients (89.7%). Technical failure was related to female sex (p = 0.04) and the extracolonic etiology of the stricture (p < 0.001). There were three early complications: two procedure-related perforations successfully managed conservatively and one hemorrhage treated with APC. Early complications were related to the location of strictures at the recto-sigmoid junction (p < 0.001). Late complications occurred in 10 patients: 8 of these patients experienced occlusive symptoms (attributable to tumor ingrowth in 5 cases and stool impaction in 3 cases); the remaining 2 were one case of tumor ingrowth with sub-occlusive symptoms and hemorrhage, and one case of distal migration. There was no procedure-related mortality and all complications were managed without surgical intervention. SEMS patency duration was 236 ± 128 days (range 31-497) and mean survival of the patients was 259 ± 121 days (range, 32-511).

CONCLUSIONS

In our experience, TTS large-diameter SEMS placement is a safe and effective treatment for palliation of malignant colorectal obstruction.

Long-term prognosis in stable angina; medical treatment or coronary revascularization in patients younger than 70 years?

BACKGROUND

Literature on the appropriateness of coronary revascularization in chronic angina is still scanty. The study aimed to compare long-term effects of revascularization with those of medical therapy in stable angina.

METHODS

In an observational single center study, we assessed 10 year follow-up of 1442 consecutive patients with chronic angina, at least one coronary vessel disease, no previous myocardial infarction, screened for inducible ischemia. Patients>70 years were excluded. The event-free probabilities were estimated by Kaplan-Meier curves; all cause death, cardiac death, non-fatal myocardial infarction were the considered end points.

RESULTS

Age was 56±8 yrs. Global left ventricular function was preserved in all. Myocardial ischemia was documented in 1190 patients. Coronary disease was more severe in patients with inducible ischemia as compared to those with negative stress test (p<0.001); 868 patients underwent one revascularization procedure, 511 coronary angioplasty. Median follow-up was 106 months; 13% all cause deaths, 8% cardiac deaths, 6% non-fatal myocardial infarction were registered. When provocative test was negative revascularization did not improve survival (1% per year mortality irrespective of type of treatment). Conversely survival was significantly improved by revascularization when ischemia was documented (0.7% vs 1.8% per year mortality for revascularization vs medical therapy, p<0.05). Incidence of non-fatal myocardial infarction was low and similar in both groups.

CONCLUSION

In low-risk chronic angina coronary revascularization does not improve long-term prognosis unless inducible myocardial ischemia is present. This suggests considering coronary revascularization as an effective tool in treating coronary artery disease only when myocardial ischemia has been documented.

Efficacy, safety and outcomes of 'inject and cut' endoscopic mucosal resection for large sessile and flat colorectal polyps

BACKGROUND AND STUDY AIMS

The study examines the outcomes of the 'inject and cut' endoscopic mucosal resection (EMR), for large sessile and flat colorectal polyps.

PATIENTS AND METHODS

Between January 2006 and December 2008 all patients referred to our institution for EMR of large polyps were prospectively evaluated. The accuracy of lifting sign and the rate of en bloc and piecemeal resection, complications and recurrence were analyzed.

RESULTS

A total of 157 patients with 182 lesions (median size 24.7 +/- 10.2 mm) were included in the study. The most frequent location was the sigmoid colon in 30.2%. Because of non-lifting sign, 5/182 lesions were referred to surgical resection and 177 (43 flat and 134 sessile) were resected, 79 (44.6%) en bloc and 98 (55.4%) piecemeal. There were 20 procedural (11.3%) and 2 late (1.1%) bleeding, 4 post-polypectomy syndrome (2.2%) and 2 perforations (1.1%). Bleeding was related to malignancy (p = 0.01). Intramucosal cancer was observed in 5 cases (2.8%) while invasive cancer was seen in 8 (4.5%). Malignancy was related to polyp size >or=30 mm (p = 0.002). Follow-up colonoscopy was performed in 147 patients with 172 EMR for a mean of 19.8 months. Recurrence was observed in 12/172 (6.9%) polyps.

CONCLUSION

Inject and cut EMR is practical and effective with a low risk of complication and local recurrence.

Endoclip-assisted resection of large pedunculated colorectal polyps: technical aspects and outcome

BACKGROUND

The most common complication of polypectomy is hemorrhage, and various techniques have been used to prevent this complication.

AIM

This study evaluates the outcomes of endoclip-assisted polypectomy in patients with large pedunculated colorectal polyps, in comparison with a historical control group of patients treated with endoloop-assisted polypectomy.

METHODS

Between January and December 2007, 32 patients with 32 large pedunculated polyps (>or=15 mm) were treated with endoclip-assisted polypectomy (group A). Between January and December 2006, 35 patients with 35 large pedunculated polyps were treated; 33 with endoloop-assisted polypectomy (control, group B) and two cases with endoclips and needle knife, which were included in group A for the analysis.

RESULTS

The mean (+/- standard deviation [SD]) size of polyp head was 26.8 +/- 8.1 mm (range 15-50) in group A and 22.3 +/- 4.1 mm (range 15-30) in group B (P = 0.004). In group A, six polyps had a mean (+/-SD) head size of 40.8 +/- 5.8 mm (range 35-50) and were resected with clips and needle knife. In group A, bleeding occurred in two cases (5.9%), which were associated with the presence of cancer at histology (P = 0.006) and were managed by applying new clips. No bleeding occurred in patients of group B and no perforation and post-polypectomy syndrome occurred in either group. There were three (8.8%) cancerized adenomas in group A and one (3%) in group B. Clip application was possible in all patients, while in two cases, loop placement was impossible.

CONCLUSIONS

In our experience, endoclip-assisted resection is a safe alternative to endoloop for the resection of large pedunculated colorectal polyps when endoloop placement is difficult or impossible.

ABO blood group alleles: A risk factor for coronary artery disease. An angiographic study

OBJECTIVES

To analyze the impact of ABO groups on coronary heart disease risk factors, coronary involvement and prognosis.

METHODS

An observational single center study was conducted to examine 4901 consecutive patients with heart disease receiving coronary angiography and ABO group determination at National Research Council Institute of Clinical Physiology between January 1993 and December 2003, with maximum 10 years follow-up. All-cause death and cardiac death, were the considered end points.

RESULTS

When compared to the official distribution of ABO groups in the Italian population (O 40%, A 36%, B 17%, AB 7%), a substantially different distribution was observed in the study population (O 43.3%, A 41.4%, B 11.2%, AB 4.1%). In addition, a significant association was found between group non-O and family history of ischemic heart disease, hypercholesterolemia and presence of coronary atherosclerosis. Higher prevalence of A and B alleles was found in patients with myocardial infarction (P<0.05). Group non-O was a powerful predictor of cardiac mortality in patients aged <65 years, particularly in women (HR 1.53, 95% CI 1.06-2.21 and HR 5.29, 95% CI 1.57-17.82, respectively).

CONCLUSIONS

Group non-O is associated with increased mortality in patients with ischemic heart disease. Group non-O increases the risk for cardiac death in non-elderly patients, particularly in younger females, and groups A and B prevail in myocardial infarction. ABO group determination might aid in genetic screening for ischemic heart disease and become relevant in the management of risk factor control.