[Countering antibiotic resistance: a new course of action is needed.]

Antibiotic resistance does not seem to be stopping despite international policies that have been aiming to combat this phenomenon for more than 10 years. The World health organization (Who) seeing the relentless growth of the issue has reiterated its recommendations that have been implemented at the national level. In fact, in Italy the new National plan against antibiotic-resistance 2022-2025 (Pncar 2022-2025) is in full operation. At Asl Napoli 3 Sud, which boasts a population of more than 1 million people, an analysis was carried out regarding antibiotic consumption in the first six months of 2022. The results showed consumption deviating from the regional and national average, thus suggesting that swift actions are needed to curb overprescription by physicians as much as possible. This work also aims to raise awareness among physicians and health care professionals of compliance with the requirements of regulatory agencies and scientific societies, so that a virtuous path toward a decisive change of pace can be taken.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

The number of risk factors not at target is associated with cardiovascular risk in a type 2 diabetic population with albuminuria in primary cardiovascular prevention. Post-hoc analysis of the NID-2 trial

Background

Nephropathy in Diabetes type 2 (NID-2) study is an open-label cluster randomized clinical trial that demonstrated that multifactorial intensive treatment reduces Major Adverse Cardiac Events (MACEs) and overall mortality versus standard of care in type 2 diabetic subjects with albuminuria and no history of cardiovascular disease. Aim of the present post-hoc analysis of NID- 2 study is to evaluate whether the number of risk factors on target associates with patient outcomes.

Methods

Intervention phase lasted four years and subsequent follow up for survival lasted 10 years. To the aim of this post-hoc analysis, the whole population has been divided into 3 risk groups: 0–1 risk factor (absent/low); 2–3 risk factors (intermediate); 4 risk factors (high). Primary endpoint was a composite of fatal and non-fatal MACEs, the secondary endpoint was all-cause death at the end of the follow-up phase.

Results

Absent/low risk group included 166 patients (52.4%), intermediate risk group 128 (40.4%) and high-risk group 23 (7.3%). Cox model showed a significant higher risk of MACE and death in the high-risk group after adjustment for confounding variables, including treatment arm (HR 1.91, 95% CI 1.04–3.52, P = 0.038 and 1.96, 95%CI 1.02–3.8, P = 0,045, respectively, vs absent/low risk group).

Conclusions

This post-hoc analysis of the NID-2 trial indicates that the increase in the number of risk factors at target correlates with better cardiovascular-free survival in patients with type 2 diabetes at high CV risk.

Clinical Trial Registration

ClinicalTrials.gov number, NCT00535925. https://clinicaltrials.gov/ct2/show/NCT00535925

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01674-7.

Incidence, clinical features and perinatal outcome in anomalous fetuses with late-onset growth restriction: cohort study

OBJECTIVE

To describe the incidence, clinical features and perinatal outcome of late-onset fetal growth restriction (FGR) associated with genetic syndrome or aneuploidy, structural malformation or congenital infection.

METHODS

This was a retrospective multicenter cohort study of patients who attended one of four tertiary maternity hospitals in Italy. We included consecutive singleton pregnancies between 32 + 0 and 36 + 6 weeks' gestation with either fetal abdominal circumference (AC) or estimated fetal weight < 10^th percentile for gestational age or a reduction in AC of > 50 percentiles from the measurement at an ultrasound scan performed between 18 and 32 weeks. The study group consisted of pregnancies with late-onset FGR and a genetic syndrome or aneuploidy, structural malformation or congenital infection (anomalous late-onset FGR). The presence of congenital anomalies was ascertained postnatally in neonates with abnormal findings on antenatal investigation or detected after birth. The control group consisted of pregnancies with structurally and genetically normal fetuses with late-onset FGR. Composite adverse perinatal outcome was defined as the presence of at least one of stillbirth, 5-min Apgar score < 7, admission to the neonatal intensive care unit (NICU), need for respiratory support at birth, neonatal jaundice and neonatal hypoglycemia. The primary aims of the study were to assess the incidence and clinical features of anomalous late-onset FGR, and to compare the perinatal outcome of such cases with that of fetuses with non-anomalous late-onset FGR.

RESULTS

Overall, 1246 pregnancies complicated by late-onset FGR were included in the study, of which 120 (9.6%) were allocated to the anomalous late-onset FGR group. Of these, 11 (9.2%) had a genetic syndrome or aneuploidy, 105 (87.5%) had an isolated structural malformation, and four (3.3%) had a congenital infection. The most frequent structural defects associated with late-onset anomalous FGR were genitourinary malformations (28/105 (26.7%)) and limb malformation (21/105 (20.0%)). Compared with the non-anomalous late-onset FGR group, fetuses with anomalous late-onset FGR had an increased incidence of composite adverse perinatal outcome (35.9% vs 58.3%; P < 0.01). Newborns with anomalous, compared to those with non-anomalous, late-onset FGR showed a higher frequency of need for respiratory support at birth (25.8% vs 9.0%; P < 0.01), intubation (10.0% vs 1.1%; P < 0.01), NICU admission (43.3% vs 22.6%; P < 0.01) and longer hospital stay (median, 24 days (range, 4-250 days) vs 11 days (range, 2-59 days); P < 0.01).

CONCLUSIONS

Most pregnancies complicated by anomalous late-onset FGR have structural malformations rather than genetic abnormality or infection. Fetuses with anomalous late-onset FGR have an increased incidence of complications at birth and NICU admission and a longer hospital stay compared with fetuses with isolated late-onset FGR. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

COVID-19 mRNA Vaccines: A Retrospective Observational Pharmacovigilance Study

Background and Objective

Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus has caused millions of deaths worldwide. The mRNA vaccines prevented the figure from being more severe. The objective of this retrospective study is to evaluate the safety of COVID-19 vaccines by analyzing the adverse events following immunization (AEFIs).

Methods

A retrospective observational pharmacovigilance study was conducted, based on the collection of reports of suspected AEFIs reported between 1 January 2021 and 31 December 2021 at the Naples 3 local health authority. AEFIs were stratified and described according to mRNA vaccine, demographics, clinical status, description of AEFI, and degree of severity. In 2021, local health authority Asl Naples 3 South received 1164 reports of suspected adverse events that occurred following the administration of mRNA vaccines.

Results

During the reporting period, 746 reports were related to the Comirnaty vaccine (64.1%), 281 to the Vaxzevria vaccine (24.1%), 107 to the Spikevax vaccine (9.2%), and 30 to the Jcovden vaccine (2.6%); 89.3% of the reports were classified as not serious (N = 1039 reports), the remaining 10.7% as serious (N = 125 reports).

Conclusions

This retrospective pharmacovigilance study demonstrates that COVID-19 mRNA vaccines are safe in all population groups.

Pharmacovigilance is an activity that ensures the safety of health care treatments. The COVID-19 pandemic has accelerated the administration of vaccines whose efficacy and safety is to be evaluated. In the year 2021, an analysis of all reported adverse events following immunization (AEFIs) to the vaccine was conducted on a sample of about 1 million people with the aim of understanding efficacy and safety. All adverse events were divided by age, sex, type of reaction, and severity. Serious reactions were divided into subcategories to report the most common critical issues. At the conclusion of the work, it can be seen that COVID-19 mRNA vaccines are safe but can give serious cardiovascular (12% of the total number of serious reports) and neurological (one serious case that led to the development of Guillain Barré syndrome) side effects that need to be monitored by medical personnel.

Comparison of the safety and efficacy of antithrombotic regimens following TAVR in patients without having an indication for chronic oral anticoagulation

Aims

To compare the safety and efficacy of antithrombotic regimens following transcatheter aortic valve replacement (TAVR) in patients without having an indication for chronic oral anticoagulation

Methods and results

We conducted a Prospero-registered systematic review and network meta-analysis of randomized controlled trials evaluating post-TAVR antithrombotic regimens up to March 2021. We estimated the relative risk and 95% confidence intervals using a fixed effect model in a frequentist pairwise and network metanalytic approach. We included 6 studies comprising of 3,777 patients with a mean weighted follow-up of 13.3 months. Single antiplatelet therapy (SAPT) was associated with a significant reduction of life-threatening, disabling, or major bleeding compared to dual antiplatelet therapy (DAPT) (Risk Ratio [RR] 0.44, 95% confidence interval [CI]: 0.28–0.69), apixaban (RR: 0.47, 95% CI 0.26–0.84) and low-dose rivaroxaban + 3-month SAPT (RR: 0.30, 95% CI: 0.16–0.57). Risk of all-cause death was significantly reduced with DAPT compared to low-dose rivaroxaban + 3-month SAPT (RR: 0.60, 95% CI: 0.41–0.88) and a consistent reduction was observed with SAPT and DAPT compared to apixaban (RR: 0.60, 95% CI: 0.31–1.16 and RR: 0.58, 95% CI: 0.32–1.04, respectively). There were no differences between the various regimens with respect to myocardial infarction and stroke. Apixaban significantly reduced the risk of pulmonary embolism, valve thrombosis and grade 3 or 4 reduced leaflet motion.

Conclusion

Following TAVR in patients without an indication for chronic oral anticoagulant, SAPT was associated with the lowest risk of bleeding compared to DAPT and direct oral anticoagulant-based regimens without significant ischemic offset.

Funding Acknowledgement

Type of funding sources: None.

Real use of a novel automatic motorized laser balloon for the ablation of atrial fibrillation

Background

Electric isolation of the pulmonary veins (PVs) can successfully treat patients with atrial fibrillation (AF). Isolation of pulmonary veins can be achieved by several methods: radiofrequency, cryoballoon or laser balloon ablation (LBA). The main procedural challenge with either method is to achieve a continuous circumferential lesion at the left atrium-PVs junction, with the persistence of functional gaps.

Purpose

A novel endoscopic ablation system equipped with a precise motor control system (MCS) has been evaluated. The balloon is used with an endoscope to directly visualize and ablate tissue at the left atrial-PVs junction with laser energy. This system enables uninterrupted, high-speed, circumferential lesion creation under direct control of the physician. The MCS is intended to reduce procedure time and to ensure continuity of ablation lesions. The feasibility of the motorized ablation in terms of extent of applicability along each PV-left atrium junction and time of use of the manual point-by-point mode has been investigated.

Methods

27 consecutive patients (male 70.3%, age 61.2±8.7 years) with paroxysmal or persistent AF who underwent LBA were enrolled in our institution. Exclusion criteria were any contraindication for the procedure including the presence of intracavitary thrombosis and contraindications to general anesthesia or deep sedation. After transseptal puncture, the balloon-based endoscopic ablation system was advanced to each PV ostium, and laser energy were projected onto the target.

Results

A total of 110 PVs were treated with LBA; in 9 patients there was a redundant right intermediate pulmonary vein; in 4 patients there was a right common ostium and in 2 a left common ostium. MCS was used for 82 PVs (74.5%): in particular, MCS was used continuously between 180° and 325° degrees (50 to 90% of PV circumference) for 35 PVs (31.8%) and between 326° and 359° degrees (91 to 99% of PV circumference) for 25 veins (22.7%). In 13 PVs (12%) MCS was used for the entire circumference. During 8508 (19.6%) seconds out of a total of 43.368 seconds, laser energy delivery occurred in the rapid mode by MCS.

No clinical complications, either local or systemic (stroke or TIA, pericardial effusion, pericardial tamponade, pulmonary vein stenosis, esophageal injury, temporary or permanent phrenic nerve palsy), were observed neither during the use of MSC nor during the use of manual point-by-point mode. Of note, a pinhole rupture of the balloon occurred in 3 cases of our series, during the use of MCS, without harm to the patient and requiring only replacement of the LBA.

Conclusions

In our case series, laser balloon ablation with the help of motor control system appears safe and feasible in most cases for large portions of pulmonary vein circumference, providing considerable time sparing (74.5% of total ablation extent in 19.6% of total ablation time).

Funding Acknowledgement

Type of funding sources: None.

Changes in Left atrial strain in patients with aortic stenosis after TAVI

Background

Evaluation of left atrial (LA) function is an emerging biomarker of cardiovascular disease (CVD). LA strain by 2D speckle tracking echocardiography (LA strain, LAS) is feasible and reliable, and has been recently associated with adverse long-term outcomes in CVD, including aortic stenosis (AS).

Purpose

To evaluate the changes in left atrial strain (LAS) after correction of severe AS with transcatheter aortic valve replacement (TAVR) and assess its prognostic impact.

Methods

One hundred consecutive patients with severe symptomatic AS who underwent TAVR at the Magna Graecia University of Catanzaro have been enrolled. Echocardiographic examination before and after TAVR was performed using Vivid E95 system and analysed using the EchoPAC 112.99 workstation (GE Healthcare). Patients underwent clinical follow up visits regularly. The primary study outcome was the difference in ΔLAS (postTAVR-preTAVR) between patients that met the main clinical endpoint (a composite of cardiovascular mortality and heart failure hospitalization) and those not meeting the endpoint. Statistical analyses were performed using JASP (version 0.14.1) and KMWin (version 1.52). Continuous variables were presented as mean and standard deviation and were compared through the unpaired Student's t test or the Mann-Whitney U test in case of a non-normal distribution. Differences between categorical variables were tested with the chi-square test. Multiple logistic regression analysis was performed to identify independent correlates of ΔLAS and to calculate Hazard Ratios (HR) with 95% CI. Kaplan-Meier was used to assess adverse event.

Results

During a median follow-up of 31 months, 35 patients (35%) met the composite clinical endpoint. The difference between LAS post-TAVR and LAS pre-TAVR (ΔLAS) was significantly larger in patients who met the combined endpoint (HR=0.76 [0.67–0.86]; p&lt;0.001). Multivariate logistic regression analysis including ΔLAS, EuroSCORE II and left ventricular ejection fraction (LVEF) showed that ΔLAS (HR=0.80, p&lt;0.001) was the only independent predictor of the combined clinical endpoint. Kaplan-Maier analysis showed that patients with a ΔLAS above its median value had a significantly better event-free survival compared to those below the median (p&lt;0.001).

Conclusions

A lower reduction in ΔLAS after TAVR was an independent predictor of the primary composite outcome of cardiovascular death and hospitalization for HF.

Funding Acknowledgement

Type of funding sources: None.

Third-generation laser balloon ablation: rapid mode applicability is associated with shorter time to pulmonary vein isolation

Background

The rapid mode feature implemented in the latest version of the laser balloon system (LB3, HeartLight, X3, Cardiofocus) offers an automated continuous 360° lesion for pulmonary vein isolation (PVI). However, data on its clinical applicability and the potential reduction of procedural times are not yet available.

Purpose

To explore the use of the rapid mode and its association with PV total and fluoroscopy times in our initial experience with LB3.

Methods

This analysis included consecutive patients who underwent PVI procedure with LB3. We attempted to perform a complete circular ablation line using the rapid mode at 13 W, but if needed to achieve successful isolation, rapid mode was interrupted and manual mode (5.5–8.5 W) applications were used. The percentage of rapid mode use on the 360° lesion was measured for each PV. Total and fluoroscopy times to complete PVI were also collected.

Results

A total of 110 PVs were identified in 27 LB3 procedures and successfully isolated with a mean procedural time of 85±31 min. Sixty (55%) PVs were treated by using rapid mode for more than 50% (180°) lesion and 13 (12%) of them had a pure rapid mode ablation (without necessity of manual mode applications). Right inferior PV had the highest use of rapid mode (median value 70%). The main reasons for manual applications were poor PV occlusion, imperfect ostium visualization and presence of blood. PVs with &gt;50% rapid mode use were treated in a significantly shorter time (21.2±13.7 vs 26.8±12.4, p=0.043). Fluoroscopy time did not differ significantly (4.7±4.2 vs 5.4±4.9, p=0.48). Three pinhole balloon ruptures were observed during rapid mode energy application in the second, third and twenty-fifth procedure. No other complications occurred.

Conclusions

Few PVs could be isolated using pure rapid mode; however, its applicability for more than 50% lesion was observed more frequently and significantly reduced the time to isolation.

Funding Acknowledgement

Type of funding sources: None. Time to isolation using Rapid Mode

Slow VT treatment in a contemporary population of primary prevention ICD recipients

Funding Acknowledgements

Type of funding sources: None.

Background

Implantable cardioverter defibrillator (ICD) is an effective therapy for sudden cardiac death (SCD). 2015 HRS/EHRA/APHRS/SOLAECE expert consensus document suggests long VT detection, above 185 bpm, as optimal ICD programming to reduce unnecessary therapies in primary prevention (PP).

Purpose

The aim of our study is to evaluate incidence, safety and efficacy of ICD treatment for VT arrhythmias below 185 bpm, in a contemporary population of PP ICD recipients with long detection intervals (LDI), morphological discrimination algorithm and antitachycardia pacing therapies (ATP) before shock.

Methods

We conducted a single centre retrospective study enrolling 236 patients implanted with a primary-prevention indication from January 2013 to June 2019. Patients were implanted with single or dual chamber single-lead transvenous ICD. All patients had standard device setting with long (at least 20 s in VT and 7 s in VF) VT/VF detection above 150 bpm and therapies starting from 171 with up to 5 ATP and multiple shocks. PainFREE-like bursts and Schaumann-like ramps ATP were always set in VT zone. Of each patient we collected a detailed report of up to five appropriate events and three inappropriate events. Arrhythmia diagnosis was confirmed from 3 independent expert physicians.  Date of the event, cycle length, type of morphology (polymorphic or monomorphic), therapies with their effect were collected.

Results

During a mean follow-up of 42 months, 47 (20 %) and 18 (8%) patients had at least one appropriate and inappropriate activation, respectively. The detailed-events analysis shows that 16 (7%) patients had 38 (30%) appropriate events with rate &lt;188 bpm. At these rate ATP were 97% effective. 14 (38%) of inappropriate activations were caused by arrythmias with ventricular rate below 188 bpm and half of these received a shock; 30% of inappropriate shocks were due to arrhythmia with rate &lt;188 bpm. 73% of treated events, with rate &lt;188 bpm, were appropriate. Only 5.6% (n = 10) of ATP attempts cause arrhythmia acceleration.

Conclusions

One third of detected arrhythmias had a rate below 188 bpm and 73% were true VT. In this slow VT zone, ATP had a high success rate with low percentage of acceleration.

Real use of a novel automatic motorized laser balloon for the ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Electric isolation of the pulmonary veins (PVs) can successfully treat patients with atrial fibrillation (AF). Isolation of pulmonary veins can be achieved by several methods: radiofrequency, cryoballoon or laser balloon ablation (LBA). The main procedural challenge with either method is to achieve a continuous circumferential lesion at the left atrium-PVs junction, with the persistence of functional gaps.

Purpose

A novel endoscopic ablation system equipped with a precise motor control system (MCS) has been evaluated. The balloon is used with an endoscope to directly visualize and ablate tissue at the left atrial-PVs junction with laser energy. This system enables uninterrupted, high-speed, circumferential lesion creation under direct control of the physician. The MCS is intended to reduce procedure time and to ensure continuity of ablation lesions. The feasibility of the motorized ablation in terms of extent of applicability along each PV-left atrium junction and time of use of the manual point-by-point mode has been investigated.

Methods

sixteen consecutive patients (male 68.7%, age 60.9 ± 7.8 years) with paroxysmal or persistent AF who underwent LBA were enrolled in our institution. Exclusion criteria were any contraindication for the procedure including the presence of intracavitary thrombosis and contraindications to general anesthesia or deep sedation. After transseptal puncture, the balloon-based endoscopic ablation system was advanced to each PV ostium, and laser energy were projected onto the target.

Results

A total of 62 PVs were treated with LBA; in 3 patients there was a redundant right intermediate pulmonary vein; in 4 patients there was a right common ostium and in one a left common ostium. MCS was used for 41 PVs (66.1%): in particular, MCS was used continuously between 180° and 325° degrees (50 to 90% of PV circumference) for 22 PVs (35.5%) and between 326° and 359° degrees (91 to 99% of PV circumference) for 16 veins (25.8%).  In 3 PVs (4.8%) MCS was used for the entire circumference.  During 5.659 (23.6%) seconds out of a total of 23.986 seconds, laser energy delivery occurred in the rapid mode by MCS.

No clinical complications, either local or systemic (stroke or TIA, pericardial effusion, pericardial  tamponade, pulmonary vein stenosis, esophageal injury, temporary or permanent phrenic nerve palsy), were observed neither during the use of MSC nor during the use of manual point-by-point mode. Of note, a pinhole rupture of the balloon occurred in the first 2 cases of our series, during the use of MCS, without harm to the patient and requiring only replacement of the LBA.

Conclusions

In our case series, laser balloon ablation with the help of motor control system appears safe and feasible in most cases for large portions of pulmonary vein circumference, providing considerable time sparing (66.1% of total ablation extent in 23.6% of total ablation time).

Reciprocal modulation of Linc-223 and its ligand miR-125a on the basis of platelet function level

Background

Cardiovacular diseases (CVD) are the leading cause of death worldwide. Platelet play a key role in the pathophysiology of multiple CVD. LincRNAs are long non-coding RNAs transcribed from intergenic DNA segments. Some members of this class were recently associated with human disease. Linc-223 is co-transcribed together with mir-223 and was recently shown to bind to miR-125. Both miR-223 and miR-125 are highly expressed in platelets.

Purpose

In light of the capability of Linc-223 to bind to miR-125, we aimed to investigate whether their reciprocal expression levels might reflect the degree of platelet activity.

Methods

RNA was extracted using miRVANA. MiRNAs and lncRNAs were measured by means of quantitative Real Time RT-PCR.

Results

We found a significant reduction of Linc-223 levels (p&lt;0.05) along with a significant increase in miR-125 levels (p&lt;0.05) after initiation of any antiplatelet treatment (n=30) compared to naïve patients (n=10). Moreover, the upgrade to a higher-intensity antiplatelet treatment with ASA+ticagrelor from ASA+clopidogrel (n=30) was associated to a further down-regulation of Linc-223 (p&lt;0.05) along with a further increase of miR-125. (p&lt;0.05). Finally, these results were validated in a larger cohort of 300 patients from the ATLANTIS study, demonstrating significant modulation of both miR-223 and miR-125 in patients with high on-treatment platelet aggregation levels compared to antiplatelet-responsive patients.

Conclusions

We identify a reciprocal modulation of Linc-223 and miR-125, its ligand upon different levels of platelet aggregations. These results are compatible with previous evidence from patients with Acute Myeloid Leukemia, that Linc-223 might bind to and sponge miR-125, inhibiting its effect. These results suggest that plasma levels of Linc-223, miR-125 and miR-223 might be used a biomarkers of platelet finction in a clinical context, for risk stratification of patients or to assess the responsiveness to antiplatelet treatments.

Funding Acknowledgement

Type of funding source: None

Sex-related trends of cardiovascular risk perception and prevention behaviors: results from the italian society of cardiovascular survey

Background

Recent reports evidenced gender differences in the knowledge, perception and awareness of cardiovascular risk factors and cardiovascular diseases.

Purposes

To evaluate trends in awareness of cardiovascular risk, as well as knowledge of symptoms and preventive behaviors related to cardiovascular disease (CVD).

Methods

As part of Vivi con il Cuore (campaign with the goal of raising awareness about women's heart disease) a nationwide survey was conducted. Standardized questions on awareness of CVD risk, as well as prevention behaviors and barriers, were provided through a computer-assisted web interviewing platform to a large sample of Italians citizens ranging from 40 to 70 years old. The sample was representative of the population by age, sex, and area of geographical residence.

Results

A total of 1,000 subjects were included in this survey, of which 511 (51%) female. About 60% of women indicated cancer as the leading cause of death among female sex, while only 22% indicated cardiovascular disease. Similarly, when the same question was asked to men, 44% indicated cancer and 21% cardiovascular disease, observations that were consistent across age categories. Although a well sizable part of the population (90% of the interviewees) have consulted the general practitioner in the last year, only 45% of women and 56% of men declared to receive information about CVD risk. Almost 84% among men and women, recognized the importance of knowing how to understand the symptoms of a heart attack due to the possibility of survival. An additional survey was conducted among young cardiologists under 40 years old, including a total of 200 young cardiologists, similarly distributed among men and women (47% and 53% respectively). About 24% of young cardiologists indicated breast cancer as the leading cause of death in women, while only 70% reported cardiovascular diseases. Furthermore, 35% of participants reported that they did not have adequate training on the risks of heart disease in women.

Conclusions

In this survey, only 22% of women were aware that cardiovascular disease is the number one killer of women. Likewise, a well sizable part of young cardiologists (30%) does not recognize cardiovascular disease as the leading cause of death in women. These data should inform public health campaigns to focus on evidence-based strategies to prevent CVD and to help target messages that resonate and motivate women to take action.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Abbott

Early aspirin discontinuation following acute coronary syndrome or percutaneous coronary intervention: a systematic review and meta-analysis of randomized controlled trials

Background

The respective ischemic and bleeding risks of early aspirin discontinuation following an acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remains uncertain.

Objectives

To evaluate the safety and efficacy of early aspirin discontinuation in ACS or PCI patients treated with P2Y12 inhibitors with or without anticoagulants.

Methods

We performed a review of randomized controlled trials (RCTs) comparing a P2Y12 inhibitor-based single antiplatelet strategy following early aspirin discontinuation to a strategy of sustained dual antiplatelet therapy (DAPT) in ACS or PCI patients requiring or not anticoagulation for another indication. The primary safety endpoint was major bleeding while non-major bleeding and all bleeding were secondary safety endpoints. The primary efficacy endpoint was all-cause mortality while secondary efficacy endpoints included major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), definite stent thrombosis (ST) or any stroke. We estimated risk ratios (RR) and 95% confidence intervals (CI) using random effect models. The study is registered in PROSPERO (CRD42019139576).

Results

We included 9 RCTs comprising 40,621 patients.Compared to prolonged DAPT, major bleeding (2.2% vs. 2.8%; RR 0.68; 95% CI: 0.54 to 0.87; p=0.002; I2: 63%), non-major bleeding (5.0% vs. 6.1%; RR: 0.66; 95% CI: 0.47 to 0.94; p=0.02; I2:87%) and all bleeding (7.4% vs. 9.9%; RR: 0.65; 95% CI: 0.53 to 0.79; p&lt;0.0001; I2: 88%) were significantly reduced with early aspirin discontinuation (Figure 1), without significant difference for all-cause death (p=0.60), MACCE (p=0.60), MI (p=0.77), definite ST (p=0.63), and any stroke (p=0.59). Results were consistent in patients with or without anticoagulation, without significant interaction for any outcomes but MI (p=0.04).

Conclusions

In patients on DAPT after an ACS or a PCI, early aspirin discontinuation prevents bleeding events with no effect on the ischemic risk or mortality.

Figure 1. Central illustration

Funding Acknowledgement

Type of funding source: None

157 Reduced non-invasive myocardial work predicts significant coronary artery disease

Funding Acknowledgements

ESC Training Grant 2019

Background

Non-invasive prediction of critical coronary artery stenosis (CCS) is challenging. CCS may cause persistent impaired longitudinal function at rest, which could be detected by two-dimensional speckle tracking echocardiography (2D-STE). However, strain parameters are load dependent, hence they might not reflect systolic function accurately. A novel non-invasive method to calculate MW recently showed a strong correlation with invasive work measurements.

Objectives

To investigate the ability of non-invasive Myocardial Work (MW) indices: 1) to identify the ischaemic risk area during acute coronary occlusion (ACO); 2) to predict the ischaemic risk area underlying a CCS before coronary angiography.

Methods

The study population comprises 80 individuals: fifty consecutive patients (pts) referred for coronary angiography in a single tertiary coronary care centre and thirty controls (CTRL). Echocardiography recordings (GE-Healthcare) with systolic and diastolic non-invasive pressures, were obtained immediately before coronary angiography, during ACO, and immediately after revascularization to measure longitudinal strain along with myocardial work indices: Myocardial Work Index (MWI), Myocardial Constructive Work (MCW), Myocardial Wasted work (MWW), Myocardial work efficiency (MWE).

Results

Compared to baseline, we found a significant reduction of global longitudinal strain (GLS) (p = 0.005), MWI, MCW and MWE (p &lt; 0.001) during ACO. After the procedure, we observed a significant improvement in GLS, MWI, MCW and MWE (p &lt; 0.001) compared to the findings obtained during CO.

Interestingly, baseline global MWI, MCW and MWE were significantly reduced in pts with CCS at angiography compared to controls (p &lt; 0.05). Moreover, regional MWE, but not longitudinal strain, measured within the myocardial segments underlying the CCS, was significantly reduced compared to non-target segments (p &lt; 0.001).

Conclusions

Our results demonstrate that non-invasive estimation of regional and global MW parameters are able to identify myocardial ischemia upon ACO. Moreover, myocardial work indices measured at rest were able to predict the presence of CCS before invasive angiography, whereas MWE was more sensitive than myocardial strain to document regional impairment of myocardial function.

Abstract 157 Figure.

P5367Indirect comparison of the safety and efficacy of alirocumab and evolocumab: from a comprehensive meta-analysis of 30 randomized controlled trials

Background

Alirocumab and evolocumab, two proprotein convertase subtilisin–kexin type 9 inhibitors, have both been associated with improved outcomes in patients with atherosclerotic cardiovascular disease in addition to standard lipid-lowering therapies. However, their comparative safety and efficacy profiles are unknown.

Purpose

To compare the safety and efficacy of alirocumab versus evolocumab.

Methods

We conducted a systematic review and network meta-analysis of placebo-controlled randomized trials available up to November 2018 evaluating the safety and efficacy of alirocumab and evolocumab. We estimated risk ratio and 95% confidence intervals using fixed effect model in a frequentist pairwise and network metanalytic approach. The primary safety endpoints were any adverse events leading to treatment-discontinuation, injection site reaction, systemic allergic reaction, neurocognitive events, ophthalmologic events and new-onset of diabetes mellitus (DM) or worsening of pre-existing DM. The primary efficacy endpoints were all-cause and cardiovascular (CV) death, myocardial infarction (MI) and stroke. This study was registered in PROSPERO (CRD42018090768).

Results

A total of 30 trials, enrolling 59,026 patients were included in this analysis, of whom 13,607 received alirocumab and 17,931 received evolocumab. Mean weighted follow-up time was 2.5 years, with an exposure time of 144,907 patients-years. Eligibility criteria varied significantly across trials evaluating alirocumab and evolocumab. There were no significant differences between alirocumab and evolocumab in terms of safety endpoints, except for injection site reaction with a 27% increased risk of injection site reaction with alirocumab compared to evolocumab (Figure). Compared with evolocumab, alirocumab was associated with a reduction of all-cause death but not CV death. There were no significant differences in MI or stroke between alirocumab and evolocumab.

Conclusion

Alirocumab and evolocumab share a similar safety profile. No significant differences were observed across the efficacy endpoints, except for all-cause death, which may be related to heterogeneity of the studied populations between the two drugs.

P1966Impact of coronary artery calcification on long-term outcomes after implantation of first and second-generation drug-eluting stents: a patient-level analysis of 18 randomized trials

Background

Available data on the long-term impact of coronary artery calcification (CAC) after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) are limited.

Purpose

We evaluated the long-term impact of CAC on outcomes after PCI and the respective performance of first- and second-generation DES.

Methods

We pooled patient-level data from 18 randomized trials evaluating DES categorized according to the presence of angiographic core lab-confirmed moderate or severe CAC in any target lesion. Outcome measures of interest were the patient-oriented composite endpoint (POCE; death, myocardial infarction [MI], or any revascularization), the device-oriented composite endpoint of target lesion failure (TLF; cardiac death, target vessel MI or ischemia-driven target lesion revascularization), and definite or probable stent thrombosis (ST). Multivariable Cox proportional regression with study as a random effect was used to assess 5-year outcomes.

Results

A total of 19,833 patients were included. Moderate or severe CAC was present in 6211 (31.3%) patients and associated with increased 5-year risk of the POCE (adjHR 1.12, 95% CI 1.05–1.20, p<0.001), TLF (adjHR 1.21, 95% CI 1.09–1.35, p<0.001), and a trend for greater ST (adjHR 1.24, 95% CI 0.99–1.54, p=0.06). In patients with CAC, second-generation DES were associated with a reduction in the 5-year risk of TLF and ST, and a trend for reduced POCE compared with first-generation DES (Table).

Conclusion

In this large-scale study, target lesion moderate or severe CAC was associated with adverse patient- and device-related outcomes at 5 years, risks that were reduced but not eliminated with second-generation DES.

Acknowledgement/Funding

This investigator-sponsored study was funded by Abbott Vascular.

P1629Crispr/Cas9 to elucidate cardiac specific effects of Gdf11

Background

Heart failure with preserved ejection fraction (HFpEF) is a prevalent clinical condition in the aging population. HFpEF lacks specific therapies with a significant impact on survival, different therapeutic approaches have indeed failed, indicating a specific need in understanding the pathophysiology of the disease. Cardiac hypertrophy is one of the main features of HFpEF that contributes to impair diastolic function. Reducing ventricular stiffness associated with cardiomyocyte hypertrophy may indeed result in improved diastolic filling. Growth differentiation factor 11 (Gdf11), a TGF-β family factor, has been identified as a circulating factor able to reduce cardiac hypertrophy.

Purpose

Similar to myostatin (Gdf8), Gdf11 promotes the activation of atrophy pathways that induce ubiquitination of sarcomeric proteins. Gdf11 and Gdf8 activate both type I and II Tgf-β receptors, specifically by interacting with Acvr2a and Acvr2b (type II) and Alk 4/5/7 (type I), they activate Smad 3/4 pathway. Our data indicate a specific and more potent effect of Gdf11 in reducing cardiomyocytes size that is not recapitulated by Gdf8. Understanding the specific effect of Gdf11 on cardiomyocytes is crucial to develop therapeutic strategies to target the hypertrophic phenotype.

Methods

To investigate the effects of specific type I receptor KO on Smad signaling cascade we performed our preliminary experiment on HL-1 cells, a cardiac muscle cell line carrying a doxycycline inducible Cas9 transgene. Cell sensitivity of HL-1 to Gdf11 and Gdf8 was tested by performing a dose-response curve using a luciferase reporter for Smad 3/4 pathway activation (CAGA12). Selective Tgf-β type I receptor KO was induced using, for each receptor, two sgRNAs that have been designed to cleave the receptor coding sequence creating INDEL mutations and disrupt proper translation of the protein and confirmed by western blotting. Smad 3/4 activity was measured using a CAGA12-luciferase assay on HL-1-Cas9 transduced cells.

Results

Our data in HL-1 cells confirm a more potent effect of Gdf11 in activating Smad 3/4 pathway when compared to Gdf8 (Fig. 1A). Selective Alk4 and Alk5 KO induced a similar reduction in Smad 3/4 activation for both Gdf11 and Gdf8. Interestingly, Alk7 KO significantly reduced Gdf11 signaling that was not recapitulated when using Gdf8, suggesting that Alk7 receptor is crucial for Gdf11-dependent Smad 3/4 activation in HL-1 cells (Fig. 1B).

Figure 1

Conclusions

Our preliminary results indicate that part of Gdf11 cardiac specificity when compared to Gdf8 may reside in the usage of Alk7 for signaling. Alk7 has proposed as a protective factor for pathological cardiac hypertrophy by negatively regulating Mek-Erk1/2 signalling. Our results are now under investigation in vitro using mouse neonatal cardiomyocytes expressing Cas-9 and in vivo using cardiac-specific-Cas9-expressing C57 transgenic mice, in resting condition and after induction of pathological hypertrophy.

miR-125a-5p Modulates Phenotypic Switch of Vascular Smooth Muscle Cells by Targeting ETS-1

MicroRNAs are key regulators of vascular smooth muscle cells (VSMCs) phenotypic switch, one of the main events responsible for bare metal in-stent restenosis after percutaneous coronary intervention. miR-125a-5p is an important modulator of differentiation, proliferation, and migration in different cell types; however, its role in VSMCs is still unknown. The aim of this study was to evaluate the role of miR-125a-5p in VSMCs phenotypic switch. Our results suggest that miR-125a-5p is highly expressed in VSMCs, but it is down-regulated after vascular injury in vivo. Its overexpression is sufficient to reduce VSMCs proliferation and migration, and it is able to promote the expression of selective VSMCs markers such as alpha smooth muscle actin, myosin heavy chain 11, and smooth muscle 22 alpha. Interestingly, miR-125a-5p directly targets ETS-1, a transcription factor implicated in cell proliferation and migration and is crucial in PDGF-BB pathway in VSMCs. Thus, miR-125a-5p in this context inhibits PDGF-BB pathway and is therefore a potential regulator of VSMCs phenotypic switch.

Congenital neuroblastoma with symptoms of epidural compression at birth

The occurrence of congenital neuroblastoma presenting at birth with symptoms of epidural compression secondary to spinal canal invasion is rare. Almost all cases reported in the literature have survived from the tumor but suffer severe sequelae, with the exception of the 2 most recently described whose birth was anticipated. The 3 cases of this article have been followed for a minimum of 5 years with the aim to describe their definitive late complications. In none of these cases had the routine ultrasound scan performed in third trimester of pregnancy discovered a tumor mass, nor had it shown abnormal fetal movements. All had leg hypotonia detected on the first day of life. In all, both primary and intraspinal tumors responded well to chemotherapy. All survive with motor deficit and severe bladder dysfunction despite early physiotherapy. Scoliosis has developed in the case with the longest follow-up. The description of these patients enforces the importance of early diagnosis of tumor masses in late pregnancy. Neonatologists should be aware of this rare clinical entity and take it into account in the differential diagnosis with other conditions of early-onset hypotonia. On the other hand, obstetric sonologists should be aware of the possibility to detect such rare tumors in late pregnancy, as anticipation of delivery may reduce the risk of late sequelae.

Expression of IL-23, VEGF and TLR2/TLR4 on mononuclear cells after exposure to Pseudomonas aeruginosa

Pseudomonas aeruginosa is a Gram-negative, aerobic bacillus causing infections of the respiratory and other organ systems in susceptible hosts. Although it does not cause pulmonary infections in immunocompetent individuals, P. aeruginosa causes chronic lung infection in individuals with cystic fibrosis and nosocomial pneumonia resulting in significant morbidity and mortality. Exogenous administration of an important P. aeruginosa virulence factor, lipase, present in P. aeruginosa culture supernatant, induces potent mononuclear cell activation leading to the production of numerous proinflammatory cytokines. In particular, P. aeruginosa culture supernatant stimulated increased proliferation of THP-1 cells and monocytes (MN). The addition of culture supernatant to THP-1 cells and MN also induced Interleukin (IL)-23 and vascular endothelial growth factor (VEGF) release in a time-dependent manner. To investigate whether any compounds present in the supernatant lipase contributed to releasing IL-23 and VEGF, the culture supernatant from P. aeruginosa containing lipase was treated with hexadecylsulfonylfluoride (AMSF). The AMSF-treated culture supernatant (CS) did not show any induction on the IL-23 and VEGF release compared to the cells treated with CS without AMSF. We also showed that Toll-like receptors (TLR)2/TLR4 are expressed in THP-1 cells and MN treated with P. aeruginosa CS in a time-dependent fashion. Flow cytometry analysis revealed a higher TLR4 and a lower TLR2 expression at 48 and 72 h of treatment. The treatment of cells with TLR4 neutralizing antibody, and to a lesser extent with TLR2 neutralizing antibody, resulted in a decrease in P. aeruginosa CS-induced IL-23 and VEGF production.

Bone marrow infiltration in infants with disseminated neuroblastoma

10056

Background: The INSS definition of stage 4S neuroblastoma allows a bone marrow infiltration (BMI) no greater than 10%. More extensive involvement is to be consider stage 4. However, the degree of BMI may be difficult to establish, since tumor cells in the marrow commonly aggregate in clumps. So far, no studies have specifically investigated this issue. In this study we have reviewed the bone marrow slides of infants with disseminated neuroblastoma enrolled between January 1998 and July 2008 in the Italian Neuroblastoma Registry. Methods: BMI was arbitrarily considered <10% when it consisted of a maximum of 5 tumor cell aggregates/slide in association to normal cellularity. Marrow was aspirated from iliac crests and slides were stained with Wright-Giemsa method. A minimum of 2 slides for aspirate were examined at low magnification. The same 2 hematologists (CR, MP) examined the slides independently along the study period, blind for clinical data. A third hematologist (FS) joined to perform the reviewing process. Results: Of 142 infants enrolled, we retrieved and reviewed bone marrow slides of 73. Before results of bone marrow study, 31 patients were defined as stage 4, and 42 as stage 4S. Following bone marrow study, 2 patients previously defined as stage 4S who had ≥10% BMI were moved to stage 4. The results of the revision are summarized ( Table ). Conclusions: In this study, only 2/42 infants with stage 4S clinical features had BMI ≥ 10% and were eventually labeled as stage 4. Whether chemotherapy for stage 4 is of advantage for these patients remains to be seen. [Table: see text]

No significant financial relationships to disclose.

Prognostic role of sub-clinical hypothyroidism in chronic heart failure outpatients

BACKGROUND

It has been suggested that low thyroid hormones levels may be associated with increased mortality in patients with cardiovascular disease.

AIM

To evaluate the prognostic role of thyroid function deficiency in patients with chronic heart failure (CHF).

METHODS

We evaluated 338 consecutive outpatients with stable CHF receiving conventional therapy, all of whom underwent a physical examination, electrocardiography and echocardiography. Blood samples were drawn to assess renal function, and Na+, hemoglobin, NT-proBNPs, fT3, fT4 and TSH levels. Patients with hyperthyroidism were excluded.

RESULTS

During the follow-up (15+/-8 months), heart failure progression was observed in 79 patients (including 18 who died of heart failure after hospitalisation and six who underwent transplantation). Univariate regression analysis showed that TSH (p<0.0001), fT3 (p<0.0001), fT4 (p=0.016) and fT3/fT4 (p<0.0001) were associated with heart failure progression but multivariate analysis showed that only TSH considered as a continuous variable (p = 0.001) as well as subclinical hypothyroidism (TSH &gt 5.5 mUI/l; p=0.014) remained significantly associated with the events.

CONCLUSIONS

In CHF patients TSH levels even slightly above normal range are independently associated with a greater likelihood of heart failure progression. This supports the need for prospective studies aimed at clarifying the most appropriate therapeutic approach to sub-clinical hypothyroidism in such patients.

Carcinoma of eyelid sebaceous glands: a case report

The authors present a case of a rare tumour of the eyelid sebaceous glands with an unfavourable prognosis, and emphasize the importance of carrying out histological examination of all eyelid neoformations to better identify the lesion and obtain an accurate diagnosis. The Authors discuss the histopathologic aspects of this case, and the findings in the literature.

Ecology of Increasing Diseases: Population Growth and Environmental Degradation

The World Health Organization (WHO) and other organizations report that the prevalence of human diseases during the past decade is rapidly increasing. Population growth and the pollution of water, air, and soil are contributing to the increasing number of human diseases worldwide. Currently an estimated 40% of world deaths are due to environmental degradation. The ecology of increasing diseases has complex factors of environmental degradation, population growth, and the current malnutrition of about 3.7 billion people in the world.

[Conservative treatment of breast carcinoma in small breasts: new minimally invasive surgical technique]

To achieve satisfactory cosmetic results after breast conserving treatment (BCT) of cancer in patients (with small breasts, the association of BCT and bilateral video-assisted augmentation mammoplasty with differentiated prosthesis volume was performed. From January 2001 21 small breast pts with breast cancer (stage T1N0M0) were treated with BCT and immediate trans-axillary video-assisted breast reconstruction with differentiated volumes. In 15 patients sentinel node biopsy was performed and 6 patients required total axillary dissection. Tumor-free margins were confirmed by histological examination. All patients underwent postoperative radiotherapy. Cosmetic results were evaluated through 6 parameters: breast shape with and without underwear, symmetry, mobility, inframammary fold, tenderness. We observed 4 minor complications: seroma3, paresthesia and slight arm weakness. Mini-invasive surgical revision was required in 3 cases due to scar retraction of the prosthesis pocket. Prosthesis volume resulted 30% (range, 0-47%) higher in the affected side. Cosmetic result was positive in 85% of cases (excellent 15%, good 45%, fair 25%). Trans-axillary video-assisted breast mammoplasty with differentiated prosthesis volumes allows to obtain good aesthetic results in small breast patients and to extend BCT indications with a low morbidity rate.