bluuebunny/crossref_metadata_2025 huggingface dataset:
P198 ACUTE CORONARY SYNDROME COMPLICATED BY LEFT VENTRICULAR THROMBOSIS AND ISCHEMIC STROKE IN YOUNG WOMAN WITH ACUTE LYMPHOBLASTIC LEUKEMIA IN CHEMOTHERAPY TREATMENT
Authors: Magnano R , D‘Alleva A , Forlani D , Di Marco M , Pezzi L , Vitulli P , Fulgenzi F , Verrengia E , Paloscia L
Published: May 2022

Acute lymphoblastic leukemia (ALL) is the most common cancer in children and accounts for 75% of all leukemias. In ALL, very immature leukemia cells build up in the bone marrow, destroying and replacing normal cells. Thrombotic events are a complication of acute leukemia induction therapy, particularly acute lymphoblastic leukemia (ALL) treated with L – asparaginase. We present the case of a 23–year–old girl suffering from acute lymphoblastic leukemia from pediatric age, undergoing chemotherapy treatment. In August 2021 she was admitted to ICU for acute myocarditis in shock which resolved after specific therapy. In September 2021 he came to our observation again for chest pain, fever, pulmonary thickening, but with normal echocardiography and echocardiography. The next day, the patient presented a worsening of symptoms, with the appearance of an elevated ST in the anterior to the ecg trace and apical, SIV and anterior wall akinesia with severely reduced FE on the echocardiogram. After collegial discussion also with fellow haematologists for the presence of thrombocytopenia, antithrombotic therapy was administered and an urgent coronary examination was carried out. The examination showed acute thrombotic occlusion of the middle–distal VAT. In the same session we proceeded to thrombus aspiration and implantation of medicated stents, procedure concluded in the absence of complications. The following morning the patient complained of paresthesia and weakness in the right side. On the echocardiogram, the presence of a thrombus in the apical area of about 2 cm. Skull CT was performed in urgency which showed cortical–subcortical hypodensity area in the left frontal–parietal site, referring to a recent ischemic lesion. In agreement with colleagues from Stroke Unite and hematology, heparin was infused intravenously in an attempt to dissolve the thrombus, but three episodes of VF were treated with effective DC shock during the hospital stay. On the same day, the girl was transferred intubated to resuscitation for respiratory arrest; in the following hours we witnessed the exitus. Our patient presented acute thrombosis both in the heart and in the brain, although she was being treated with antiplatelet and antithrombotic drugs and in the presence of thrombocytopenia. This case highlights the strong procoagulative role of haematological disease and of the chemotherapy indicated for it.
P207 KOUNIS SYNDROME TYPE 2: A COLD CASE
Authors: Zerillo L , Oppo I , Aveta P , Rotunno R
Published: May 2022

Case Report

A 61–year–old man, smoker and family history of cardiovascular diseases, started oral antibiotic therapy with amoxicillin / clavulanic acid following the appearance of a dental abscess. About 30 minutes after taking the antibiotic, he complained of widespread erythema in the limbs, followed by intense itching and dyspnea. Upon arrival of the medical staff, IV cortisone and antihistamine therapy was performed with gradual and progressive resolution of the symptoms. Despite the doctors’ invitation, the patient refused access to the emergency room for fear of a possible hospital infection with SARS–CoV–2. Almost two months later, due to the onset of exertional dyspnea, he is persuaded to go to the hospital for further tests. The ECG showed signs of diffuse anterolateral necrosis (Figure 1). Echocardiography showed severe left ventricular dysfunction (FE 35%) with extensive akinesia of the mid–distal SIV, apex, and anterior mid–distal wall. Myocardiocytolysis indices were negative and allergy tests positive for beta–lactam antibiotics. Subsequently he underwent coronary angiography which showed proximal occlusion of an intermediate branch (Figure 2) treated with angioplasty and drug stent release. Cardiac MRI was then performed with evidence of a large area of ischemic necrosis (subendocardial / transmural) of the antero–septal, anterior and anterolateral wall with FE 35% (Figure 3).

Comment

Kounis syndrome is a clinical emergency characterized by the appearance of an acute coronary syndrome during an anaphylactic–type reaction. A correct diagnosis is of fundamental importance to limit the extent of myocardial damage as much as possible. In Kounis type 2, the mediators of the allergic reaction can cause not only vasospasm but also the activation of metalloproteases that induce the degradation of collagen with consequent rupture of pre–existing atheromatous plaques, as in our patient. Failure to perform an ECG during first aid leaves doubts about the possible allergic genesis of the episode, which however cannot be excluded with certainty. We have decided to report this clinical case to emphasize the importance of always taking into consideration the possibility of being compared with a case of Kounis when assisting a patient with an anaphylactic type reaction.
P211 LONG–TERM OUTCOME OF PATIENTS WITH STEMI AND CARDIOGENIC SHOCK TREATED BY PPCI
Authors: Frattini S , Maccagni G , Danzi G
Published: May 2022

Background

There is little data on the long–term outcome of patients with cardiogenic shock (CS) treated with primary angioplasty (PPCI) in the setting of acute ST–segment elevation myocardial infarction (STEMI). The aim of this study was to assess long–term mortality among hospital STEMI survivors who received a PPCI procedure, based on the presence of acute–phase CS.

Methods

We analyzed long–term follow–up data in a series of consecutive patients admitted to our institution for STEMI from 2009 to 2019 who were treated with PPCI.

Results

Of the 1288 patients who presented with STEMI, 1137 received a PPCI procedure. CS occurred in 111 (9.8%) of these patients. The in–hospital mortality rate was 5.6%; 2.9% in patients without and 30.6% in those with shock (P < 0.001)). The 1073 patients who survived the acute phase were followed up for 9 + 5 years. Survivors with CS had a more severe clinical profile and more frequent concomitant hospital complications. Long–term survival was 75.6% in patients with shock versus 84.0% in those without shock (P < 0.05). Patients with complete revascularization at the index procedure had similar survival compared to other patients with CS (survival rate 75% vs 75.4%; P = ns).

Conclusions

CS carries an increased risk of death during the hospital phase and at long–term follow–up: complete revascularization at the index procedure does not appear to offer any additional benefit on outcome
P214 PROGNOSTIC IMPACT OF RESIDUAL INFLAMMATORY RISK AFTER ACUTE CORONARY SYNDROME
Authors: Toso A , Leoncini M , Villani S , Tropeano F , Maioli M , Bellandi F
Published: May 2022

Background

Recent randomized clinical trials have shown that an anti–inflammatory treatment may reduce the recurrence of cardiovascular events in association with traditional secondary prevention measures. Aim: The aim of this observational retrospective study based on patients with acute coronary syndrome (ACS), treated with high intensity statins and undergoing an early invasive strategy, was to evaluate the incidence of residual inflammatory risk after 1 month, its possible determinants and its association with the medium–long term prognosis.

Methods

We selected patients with ACS without ST segment elevation (ACS–NSTEMI) admitted to our hospital from June 2015 to June 2018 who had a complete biochemical examination at 1 month after the acute event. All these patients were included in the PRATO–ACS Registry (ClinicalTrials.gov ID: NCT04087200). All–cause mortality was analyzed within 3 years. Residual inflammatory risk (RIR) was defined as 1–month high sensitivity C reactive protein (hs–CRP) value > 2 mg/l. The association between 1–month hs–CRP and 3–year all–cause mortality was expressed by hazard ratio (HR) and 95% confidence interval (CI).

Results

The study group consisted of 739 patients (mean age 68 ± 12 years, male 68.3%, mean hospital stay 5 ± 2 days) all treated with high intensity statins (rosuvastatin 20–40 mg or atorvastatin 40–80 mg) immediately upon admission and scheduled for early invasive strategy (74.5% underwent PCI). At baseline 525 patients (71%) had hs–CRP values ≥ 2 mg/l and 568 (77%) LDL cholesterol levels > 100 mg/dl. The incidence of RIR was 58.7%, with no significant differences between patients with LDL  70 mg/dl. Lipid profile (LDL > 100 mg/dl, HDL < 40mg/dl in man and < 50mg/dl in woman), hs–CRP > 2 mg/l, the left ventricular ejection fraction < 40% and glomerular filtration rate <60 ml/min/m2 were independently associated with RIR. Multivariate analysis showed that RIR was an independent predictor of 3–year all–cause mortality (HR = 2.15 (95% CI 1.06–4.33; p = 0.03)) while LDL cholesterol > 70 mg/dl did not (HR = 0.98 95% (CI 0.50–1.91; p = 0.9)).

Conclusions

In a population of ACS patients treated with high intensity statins and an early invasive therapeutic strategy, the incidence of RIR (hs–CRP ≥ 2 mg/l) at 1 month after ACS is high (58.7%). The RIR is associated with a higher baseline clinical risk profile and was an independent predictor of 3 year all–cause mortality regardless of achieved LDL values.
P215 PROGNOSTIC IMPACT OF EARLY VERSUS DEFERRED CORONARY ANGIOGRAPHY IN MINOCA PATIENTS
Authors: Armillotta M , Sansonetti A , Amicone S , Stefanizzi A , Fabrizio M , Angeli F , Bergamaschi L , Paolisso P , Impellizzeri A , Foà A , Rinaldi A , Casella G , Galiè N , Pizzi C
Published: May 2022

Background

Although an early invasive strategy (coronary angiography performed < 24 hours) is associated with a lower risk of recurrent/refractory ischaemia among patients with acute myocardial infarction (AMI) and obstructive coronary arteries, the optimal timing of invasive examination in patients with non–obstructive coronary arteries and non–ST–segment elevation presentation (NSTE–MINOCA) has not been explored.

Purpose

This study tested the hypothesis that, compared to early (< 24 h) invasive strategy, deferred (≥ 24 h) coronary angiography has an equivalent prognostic impact in patients with NSTE–MINOCA.

Methods

From 2016 to 2020, all consecutive MINOCA patients diagnosed according to the current ESC diagnostic criteria (angiographic conventional cut–off of < 50% coronary stenosis without a clinically apparent alternative diagnosis) and admitted to our Centre with non–ST–segment elevation myocardial infarction (NSTEMI) presentation were enrolled. Very high–risk NSTEMI patients had been excluded from the study. The prognostic value of an early (< 24 h) vs. deferred (≥ 24 h) coronary angiography was assessed. All–cause mortality and a composite endpoint (MACE) of all–cause mortality, stroke, re–hospitalization for heart failure and myocardial re–infarction were evaluated.

Results

198 NSTE–MINOCA patients were enrolled, of which 79 underwent coronary angiography < 24 hours and 119 ≥ 24 hours. MINOCA patients were more frequently females (64%) and the mean age was 66.8±13.2 years. After a median follow–up of 26 [14–40] months, the overall all–cause mortality was 13,6% and the composite endpoint (MACE) was achieved in 27.3% of the entire population. Kaplan–Meier curves showed that there was no statistically significant difference (p = 0.88) between the two study groups depending on the time of invasive strategy adopted. Specifically, rates of death (11.4% vs. 15.1%) and MACE (25.3% vs. 28.6%) were similar in MINOCA patients undergoing early versus deferred coronary angiography.

Conclusions

We demonstrated for the first time that in the MINOCA population the prognosis is not influenced by an early versus deferred coronary angiography, as opposed to AMI patients with obstructive coronary arteries. These results add another piece to the puzzle and pave the way for the initial use of a non–invasive imaging strategy (eg. Coronary–CT), mostly in patients with NSTEMI and high clinical suspicion of non–obstructive coronary arteries.
P218 POTENTIAL ROLE OF NITROGLYCERIN FOR DIURETIC RESISTANCE IN ACUTE DECOMPENSATED HEART FAILURE: A PROOF OF CONCEPT STUDY
Authors: Scollo A , Frea S , Bocchino P , Angelini F , De Ferrari G
Published: May 2022

Background

Congestion is a major determinant of end–organ dysfunction and diuretic resistance in acute decompensated heart failure (ADHF). Vasodilator therapy with nitroglycerin may help treat misdistribution of blood volume, reduce intra–abdominal pressure and improve end–organ function by recruiting capacitance veins. We assessed the role of intravenous nitroglycerin on top of maximal medical therapy to overcome diuretic resistance in ADHF patients.

Methods

This is a monocentric prospective study including patients with ADHF, systolic dysfunction (left ventricular ejection fraction [LVEF]<35%), persistent moderate–to–severe congestion and oliguria (<0.5 ml/Kg/h) despite high dose intravenous furosemide (>250 mg/die) plus a second diuretic (metolazone and/or acetazolamide). Exclusion criteria were systolic blood pressure < 90mmHg and eGFR < 20 ml/min/1.73m2. Intravenous nitroglycerin was added and uptitrated to the maximum tolerated dose while keeping the other treatments unchanged for at least 24 hours. The primary endpoint was change in urine output at 24 hours (T1) and 72 hours (T3) after nitroglycerin initiation compared to baseline (T0). Secondary endpoints were changes in central venous pressure (CVP), creatinine and total bilirubin.

Results

We enrolled 17 consecutive patients between March 2020 and October 2021. Mean age was 63±14 years, mean LVEF 31±15%, mean tricuspid annular plane systolic excursion 14.5±4 mm and mean eGFR 41.7±27.3 ml/min/1.73m2. 13 (76%) patients showed a cold profile; among them, 9 (69%) were on dobutamine, 5 (38%) on adrenaline and 3 (23%) on dopamine. At study enrolment all patients were receiving high dose intravenous furosemide (535±395mg/die), 8 (47%) sodium nitroprusside (0.3±0.5y/Kg/min), 9 (53%) metolazone (5mg/die) and 8 (47%) acetazolamide (250 mg/die). Urine output was significantly higher both at T1 and T3 compared to T0 (192±140ml/h vs 50±34ml/h, p < 0.001, and 153±87ml/h vs 50±34ml/h, p < 0.001, respectively; p for overall comparison<0.001). Also, a significant reduction of CVP was found at T1 and T3 compared to T0 (14±6mmHg vs 19±3mmHg, p = 0.025, and 12±5mmHg vs 19±3mmHg, p = 0.022, respectively; p for overall comparison=0.039). No significant changes of creatinine and total bilirubin were reported.

Conclusions

In this cohort of ADHF patients with diuretic resistance, adding nitroglycerin on top of maximal treatment yielded a potential benefit by significantly increasing hourly urine output whilst reducing CVP.
P236 LONG TERM FOLLOW UP WITH A DRASTIC REDUCTION OF HOSPITALIZATION IN HEART FAILURE PATIENT WITH MULTIPLE AETIOLOGIES TREATED WITH CARDIAC CONTRACTILITY MODULATION THERAPY: A CASE REPORT
Authors: Mattera A , Brignoli M , Coscia V , Fusco A , Diana V , Chianese R , De Michele A , Concilio C , Pariggiano I , Viscusi M , Calabrò P
Published: May 2022

Aims

Cardiac contractility modulation (CCM) shows to be a concrete therapeutic option in patients with symptomatic HF despite optimal medical therapy (OMT), with Left Ventricular Ejection Fraction (LVEF) between 25% and 45%, with narrow QRS complex (<130ms) for reduction of hospitalization and improvement Quality of life (QoL). This case aims to explore the effectiveness of CCM therapy in a patient affected by concomitant ischemic cardiomyopathy and cardiac amyloidosis (CA)

Methods

A 42–year–old man with Chronic HF secondary to both post–ischemic due to spontaneous coronary artery dissection (SCAD) and post alcoholic dilated cardiomyopathy was hospitalized at our department in February 2020 due to worsening HF (3rd HF hospitalization in the same year). The patient was a NYHA class III, with chronic kidney failure, a narrow QRS complex (100 ms) and a LVEF of 27% with familiar history of sudden death, already implanted with ICD. The patient resulted untreatable with Sacubitril/Valsartan, as it elicited strong hypotension. During current hospitalization the BNP value was 942,60 pg/ml, and the Quality of Life (QoL) evaluated from Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was 72 points. Moreover, the patient underwent umbilical biopsy that confirmed the presence of amyloidosis. Thus, the CCM therapy device (Optimizer® Smart, Impulse Dynamics) was implanted to try to reduce HF symptoms and hospitalizations (Fig 1 A/B).

Results

The patient significantly improved as early as the first period after implantation. The 10–month in–office FU performed on December 2020 revealed in addition to the absence of new HF hospitalizations, a significant improvement in QoL and HF–symptoms, with a MLWHFQ score of 42, an enhancement to NHYA class II and even a slight decrease of BNP of 767 pg/ml. The echo exam revealed no significant changes in the EF, with an improvement of global longitudinal strain and no worsening of other hemodynamic parameters. A further FU performed in June 2021 showed continuous improvement of QoL (MLWHFQ = 25) e no HF hospitalizations.

Conclusions

In this patient affected by multiple cardiomyopathies, including CA, CCM therapy proved to improve its QoL with no HF hospital admissions since the implantation. The absence of significant echocardiographic worsening is a positive aspect, considering the patient’s status, the concomitant aetiologies, and the presence of amyloidosis, given its progressive and infiltrative nature.
P242 ADVANCED HEART FAILURE: ENHANCEMENT OF INTEGRATED MANAGEMENT IN THE METROPOLITAN AREA OF FORLÌ
Authors: Delvecchio A , Galvani M , Monti E , Nanni D , Lombardi E , Brighi C , Guidi I , Greppi R , Gardini E
Published: May 2022

The aim of this study is to assess the effectiveness of a multi–professional home care (HC) model – cardiologist, general practitioner, cardiology nurse – which has been active in the metropolitan area of Forlì since 1999. In May 2021, 14 patients were enrolled (mean age=75.43). Inclusion criteria: heart failure (HF) in NYHA class III–IV, recurrent hospitalizations for HF and difficulties to reach the clinic. 4 out of 14 patients had been followed by the cardiologic HC program since 2016, 3 patients since 2018, 1 patient since 2019, 1 patient since 2020, 5 patients since 2021.

Outcome Measures

Rate of hospital admissions for HF 6 and 12 months before and after admission in HC pathway, quality of life (Minnesota Test), functional residual capacity (Palliative Performance Scale, PPS), compliance to the therapeutic program (Morisky Test). Questionnaires were administered when patients were included in HC and repeated at the time of enrollment and after 6 months. 3 patients were excluded from the analysis after enrollment because they died (n = 2) or were admitted in nursing homes (n = 1). It was observed that hospitalizations due to HF decreased from 1.64 during the 6 months preceding the admission in HC to 0.36 in the following 6 months (–78.05%, p = .002); furthermore, patients included in HC for more than 12 months (n = 9) decreased their hospitalizations from 1.78 in the year before their inclusion in the HC pathway to 0.33 in the year after (81.46%, p = .012). Since the cost of an average hospitalization for HF has been evaluated to be € 3,265.90 (DRG 127 Emilia–Romagna Region 2020), it was estimated a reduction in costs per patient of € 4,180.36 in 6 months and € 4,735.55 in 12 months. During the follow–up period, patients experienced a clinically significant improvement in psychophysical and social well–being and in the performance of daily activities. The mean Minnesota Test score improved (p = .001) from 62.86 (at the admission in HC) to 44.21 (at the enrollment) and 40.09 (at 6 months); the PPS score increased (p = .0021) from 56.43% (at the admission in HC) to 61.43% (at the enrollment) and 67.27% (at 6 months). Good therapeutic adherence was maintained, with a Morisky Test score ≥ 10.

In conclusion, these preliminary results are consistent with recent ESC guidelines for the multi–professional care of patients with chronic HF and show the efficacy of this approach in order to prevent hospital admissions and to improve quality of life.
P246 URINARY SODIUM–GUIDED I.V. DIURETIC THERAPY IN ACUTE HEART FAILURE: APPLICATION OF THE YALE DIURETIC PROTOCOL IN A REAL–WORLD ITALIAN SETTING
Authors: Pellegrino M , Gasparini G , Ghianda D , Villaschi A , Oliva A , Loiacono F , Pagliaro B , Natali Testona N , Atuncar M , Pini D
Published: May 2022

Background

Loop diuretics are the cornerstone of acutely decompensated heart failure (ADHF) treatment, but evidences on doses and administration modalities are still lacking. Veena S. et al have recently validated the Natriuretic Response Prediction Equation and applied it with the Yale Diuretic Protocol (YDP) in a clinical implementation cohort demonstrating its safety.

Objectives

Our purpose is to test the applicability and safety of YDP for titration of diuretic therapy in a real–world in–hospital setting, as compared to standard diuretic therapy. METHODS From 15th September 2021 patients hospitalized with ADHF, almost one sign of congestion and need of i.v. diuretics were enrolled. Patients with active bleeding, hematocrit < 21%, or on dialysis were excluded. Patients were treated with i.v. diuretic therapy guided by urinary sodium (YDP–group) or by weight changes and urinary output (control group) based on logistic in–hospital reasons.

Results

Thirty patients were included. Median age was 76.4 [IQR 68.3; 82.7] years old; median EF and glomerular filtration rate were 40% [IQR 30; 55] and 57.2 ml/min/m2 [IQR 44.9; 79.9], respectively. Nineteen (63.3%) patients were on chronic loop diuretic treatment. Ten (33.3%) patients were treated according to YDP. Main results are shown in the Table attached. YDP patients were younger (p = 0.02) and received shorter treatment with i.v. diuretics (YDP 36 [IQR 27; 48] hours, controls 48 [IQRS 38; 88] hours; p = 0.03). No differences in terms of total diuresis, weight loss at the end of i.v. diuretic therapy and length of hospitalization were shown. YDP patients experienced significant lower increase in creatinine during i.v. diuretic therapy (p = 0.02). The incidence of adverse events was comparable between groups, with equal hypotension rate (10%), and similar plasma levels of electrolytes at the end of i.v. diuretic therapy; YDP patients required less potassium supplementation. Reasons for i.v. diuretic therapy suspension were comparable between groups; 7 (70%) YDP patients concluded i.v. diuretic therapy for satisfactory decongestion, while only one patient because of hypotension and none because of worsening of renal function.

Conclusion

In our reality the YDP appeared to be applicable, safe and comparable to the standard i.v. diuretic therapy in terms of in–hospital outcomes. These preliminary results need to be confirmed in a larger cohort and longer term outcomes still need to be explored.
P267 EFFECTIVENESS OF SHOCK INDICES AND ALTERATION OF VITAL PARAMETERS IN THE DIAGNOSTIC SUSPICION OF ORGAN DAMAGE FROM PULMONARY EMBOLISM IN ELDERLY: THE EMERGENCY ROOM AS A WINDOW ON REAL LIFE
Authors: Savioli G , Ceresa I , Mugellini A , Martignoni A , Maggioni P , Fumoso F , Lapia F , Muzzi A , Novelli V , Preda L , Lava M , Manzoni F , Brattoli M , Bressan M
Published: May 2022

Aim

Assess which vital parameters and shock indices correlate with the presence of organ damage from pulmonary embolism to see which ones can help to suspect this condition early.

Methods

Single–center retrospective observational study, on all geriatric patients (> 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We went to see the correlation of vital parameters and shock indexes from these derivatives with the presence of organ damage from pulmonary embolism. We considered right ventricular dilation, pulmonary artery dilation and the presence of pulmonary infarction organ damage. We have considered as shock indices: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results

We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these 79 (32%) have organ damage from pulmonary embolism. There is no correlation between the values of blood pressure, systolic and diastolic, respiratory rate with the presence of organ damage (p > 0.05). However, there is a strong statistical correlation between heart rate values and the presence of organ damage from pulmonary embolism (p < 0.001) The shock index correlates with the presence of organ damage with good statistical strength (p < 0.001 ); also the modified shock index, albeit with a slightly lower statistical strength (P < 0.005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p < 0.001).

Conclusions

The alteration of the shock indices, in particular the AGE–shock index, correlate with the condition of organ damage. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, which can be easily performed in the various Italian situations, can help to raise the suspicion of organ damage from pulmonary embolism early and address more quickly the patient towards the therapeutic diagnostic process.
P270 TELL ME HOW LONG WILL YOU STAY … TELL ME HOW LONG HOW LONG … ANALYSIS OF THE DURATION OF HOSPITAL STAY (HOSPITAL LENGTH OF STAY) OF ELDERLY PATIENTS WITH EMBOLISM: EXPERIENCE OF 4 YEARS IN FIRST AID
Authors: Savioli G , Ceresa I , Amedeo M , Martignoni A , Lava M , Muzzi A , Fumoso F , Lapia F , Brattoli M , Bressan M
Published: May 2022

Premise

Pulmonary embolism is a disease still characterized by high mortality. It requires emergency department resources to be diagnosed promptly and can require lengthy hospital care.

Purpose

to assess which parameters, in the real life of an Emergency Department, correlate with the duration of a hospitalization for pulmonary embolism (hospital LOS).

Methods

Single–center retrospective observational study, on all geriatric patients (> 75) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed all the blood chemistry and blood gas analyzes performed upon access to the emergency room. We then had all chest CTs retested by an experienced radiologist. We also analyzed vital parameters and the various shock indexes from these derivatives. We then analyzed whether patients had massive pulmonary embolism or the presence of organ damage (right ventricular dilation, pulmonary artery dilation and presence of pulmonary infarction).

Results

We enrolled 247 patients, all in need of hospitalization for acute pulmonary embolism. The average age is 83 with female precalence (F = 63%). Regarding the length of hospital stay, the presence of massive embolism shows a good statistical correlation (p < 0.01), while the presence of organ damage seems irrelevant (p > 0.05). The need for resuscitation care and the high sPESI index also show no correlation (p > 0.05). Age and vital signs (blood pressure, respiratory rate, heart rate) as well as derived shock indices are unrelated (rho∼0; p > 0.05). A weak correlation is instead present with high D–Dimer values (rho∼0.20; p < 0.005) while the other blood samples do not show correlation (rho∼0; p > 0.05). No correlation for the blood gas analysis parameters taken into consideration (pH; pO2; pCO2; lactates).

Conclusions

The study suggests that the presence of massive pulmonary embolism and to a lesser extent high D–Dimer values correlates with a long hospital stay.
P273 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN GERIATRIC PATIENTS IN THE EMERGENCY ROOM: DOES ADHERENCE TO INTERNATIONAL GUIDELINES REDUCE IN ATYPICAL SYMPTOMS?
Authors: Savioli G , Lapia F , Fumoso F , Brattoli M , Mugellini A , Martignoni A , Maggioni P , Muzzi A , Novelli V , Preda L , Lava M , Manzoni F , Ceresa I , Bressan M
Published: May 2022

Purpose of the Study

Evaluate if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the presence of atypical symptoms. We understood dyspnoea, chest pain, signs and symptoms of deep vein thrombosis and syncope as typical symptoms. As atypical symptoms all the others (low–grade fever, vertigo …)

Methods

Single–center retrospective observational study on all geriatric patients (>75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We then analyzed adherence to the guidelines in three decision turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with evidence of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 63%). Of these, only 17 with atypical symptoms and 231 with typical symptoms. The vital signs were comparable in the two groups with no statistically significant difference (p > 0.05). Long–term outcomes such as mortality, need for hospitalization, hospitalization in intensive care and length of stay in hospital are also comparable results with no statistically significant difference (p > 0.05). However, adherence to international guidelines was statistically significantly lower in patients with atypical symptoms (33%) than in patients with typical symptoms (59%) (p < 0.05).

Conclusions

The study suggests that patients with atypical symptoms are more likely to have reduced adherence to international guidelines, most likely due to diagnostic delay.
P280 USE OF SYSTEMIC THROMBOLYSIS IN HEMODYNAMICALLY UNSTABLE PULMONARY EMBOLISM PATIENTS WITH AND WITHOUT CARDIAC ARREST: DATA FROM THE IPER REGISTRY
Authors: Zuin M , Bilato C , Bongarzoni A , Zonzin P , Casazza F , Roncon L
Published: May 2022

Background

Systemic thrombolysis (ST) remains the treatment of choice in haemodynamically unstable patients with acute pulmonary embolism (PE). However, it remains frequently underused in clinical practice. The purpose of the study is to evaluate the use of ST in hemodynamically unstable PE patients with aand without acute cardiac arrest using the IPER registry.

Materials and Methods

IPER is a multicentre, national, prospective, web–based registry based on 47 Italian hospitals. In this study, the population was divided into two groups: patients with (ACC) and without (No ACC) cardio–circulatory arrest at admission.

Results

Of 1716 patients enrolled between September 2006 and August 2010, 201 (11.7%) [mean age 74 ± 14 years 127 females] were defined as high risk (i.e. haemodynamically unstable). Of these 59 (29.4%, mean age 76.4 ± 13.3 years, 40 females) were admitted with ACC while the remaining 142 (70.6, mean age 73.5 ± 13.7 years, 87 females) without. No differences were observed for venous thromboembolism risk factors, such as immobilization for more than three days, trauma, surgery within the previous 4 weeks, previous venous thromboembolism, history of heart failure, cancer and ischemic heart disease, among the two gropus. Mortality from all causes (62.7% vs 19.0, p < 0.001) and for acute PE (55.9% vs 9.9%, p < 0.001) was higher in ACC patients. Thrombolysis was administered in 82 (40.7%) of haemodynamically unstable patients and more frequently in ACC subjects (55.9% VSA 34.5%, p = 0.005) (Figure 1, panel A). The administration of systemic thrombolysis increased with aging in the No ACC group but showed a significant reduction in over–octogenarian patients (Figure 1, panel B). Major bleeding complications following reperfusive treatment were observed in 8 patients (3.9%); among these, intracranial hemorrhage was registered in 2.4% of cases.

Conclusions

Although systemic thrombolysis remains the first–line treatment in patients with hemodynamically unstable acute PE and is capable of improving both the mortality and morbidity, it continues to be underused in daily clinical practice, often for fear of major bleeding complications.
P286 ECHOCARDIOGRAPHIC FINDINGS IN SUBJECTS WITH AN AMYLOIDOGENIC APOLIPOPROTEIN A1 MUTATION
Authors: Aimo A , Tomasoni D , Lombardi C , Panichella G , De Angelis M , Fabiani I , Regazzoni V , Vergaro G , Nardi M , Passino C , Scolari F , Emdin M , Metra M
Published: May 2022

Background

The APOA1 gene encodes the precursor of apolipoprotein AI (ApoAI), whose mature form is the major component of high–density lipoproteins. APOA1 mutations may cause a form of hereditary amyloidosis (AApoAI). Only very small case series of patients with AApoAI are available.

Methods

We examined 189 consecutive subjects with the heterozygous APOA1 Leu75Pro mutation referred for cardiac screening over a 10–year timespan at the Spedali Civili of Brescia (Italy).

Results

Subjects (men 54%, median age 55 years, renal disease 39%, liver disease 31%) had a median left ventricular ejection fraction (LVEF) of 60% (55–66), did not display a prominent diastolic dysfunction (E/e’ ratio 7 [6–10]) nor LV hypertrophy (LV mass index [LVMI] 92 g/m2 [74–111]). LV global longitudinal strain (GLS) (–19% [–21 to –17]), and mass to strain ratio (MSR) (10.0 [6.8–12.1]) were within normal limits. Age correlated with several echocardiographic parameters, including interventricular septal (IVS) thickness (r = 0.484), LVMI (r = 0.459), E/e’ (r = 0.501), and right ventricular free wall thickness (r = 0.459) (all p < 0.001). Some individuals displayed echocardiographic red flags of cardiac amyloidosis (CA; “granular sparkling” of the IVS, 19%; pericardial effusion, 11%; apical sparing, 10%; thickened atrioventricular valves, 8%). Thirteen out of 96 (14%) fulfilled non–invasive criteria for CA. Twenty–nine subjects died over 5.8 years (4.1–8.0), with 10 deaths for cardiovascular causes; 14 out of 182 (8%) were hospitalized because of HF, and 17 (9%) died for cardiovascular causes or were hospitalized for HF. Individuals with suspected CA had a much higher risk of all–cause death (p = 0.009), cardiovascular death (p < 0.001), cardiovascular death or HF hospitalization (p < 0.001), and HF hospitalization alone (p < 0.001). Furthermore, subjects with either renal or liver involvement had a higher risk of events and a worse outcome.

Conclusions

In subjects with an amyloidogenic APOA1 mutation, transthoracic echocardiography showed only minor signs of cardiac disease. The correlations between age and echocardiographic findings suggested a progressive increase in wall thickness, a decline in systolic and diastolic function, and a greater uncoupling between LV mass and contractility over time. Subjects with both renal and liver disease displayed the most evident signs of biventricular involvement and had a worse outcome.
P288 PREVALENCE OF AMYLOID TRANSTHYRETIN CARDIOMYOPATHY IN ELDERLY SUBJECTS FROM THE GENERAL POPULATION: FIRST RESULTS FROM THE CATCH STUDY
Authors: Aimo A , Vergaro G , Fabiani I , Barison A , Moscardini S , Poggianti E , Spini V , Arzilli C , Castiglione V , Gentile F , Passino C , Emdin M
Published: May 2022

Background

Amyloid transthyretin cardiomyopathy (ATTR–CM) has become treatable. Wild–type ATTR–CM is an age–related disorder. Establishing the exact prevalence of ATTR–CM in elderly subjects from the general population may be useful for healthcare providers and policy makers.

Methods

The Characterizing the burden of Amyloid Transthyretin CardiomyopatHy in the elderly (CATCH) study is a population screening on all subjects aged ≥65 years followed by general practitioners in a part of Tuscany (Italy) where there is no cluster of variant ATTR. The study started on March 12, 2021 and is ongoing. Patients with 1) any clinical red flag of amyloidosis, 2) interventricular septal thickness ≥12 mm or other echocardiographic red flags, and/or 3) hs–troponin T > 14 ng/L are referred to diphosphonate scintigraphy and search for a monoclonal protein.

Results

As of October 13, 2021, 514 subjects ≥65 years have been evaluated for possible participation. Among them, 135 (26%) could not be contacted, were reluctant to enter the study, died before being contacted, or were bedridden. Out of the other 379 subjects, 329 (87%) have already undergone the first step. Forty percent of individuals (n = 132) have been referred to the second step. Thirteen subjects have declined (10%); 69 patients have undergone diphosphonate scintigraphy and the search for a monoclonal protein (while the other 50 are awaiting these exams). Two subjects showed an intense myocardial uptake of the diphosphonate tracer (Perugini score 2–3) and no monoclonal protein, and were then diagnosed with ATTR–CM. They were both women, aged 83 and 78 years, both mildly symptomatic for dyspnea (New York Heart Association II) and with unexplained hypertrophy. The search for TTR gene mutation was negative in the first case and is still ongoing in the second. Based on these preliminary data, the prevalence of ATTR–CM in the elderly population can be calculated as 2/266=0.8%.

Conclusions

The CATCH study is expected to enroll at least 1,000 subjects and will provide the first data on the epidemiology of ATTR–CM in elderly subjects. Based on an interim analysis, almost 1 in 100 individuals ≥65 years has ATTR–CM.
P290 CARDIAC AMYLOIDOSIS, A CHALLENGING DIAGNOSTIC WORK – UP
Authors: Roccabruna A , Benini A , Piccoli A , Ribichini F
Published: May 2022

A 79 years–old male presented to our outpatient clinic with symptoms of an initial heart failure. He had an history of atrial fibrillation (AF), anaemia and thrombocytopaenia, which have never been deeply investigated, bilateral carpal tunnel syndrome. Electrocardiogram (EKG) showed AF with normal ventricular rate and low peripherical QRS voltages. Laboratory testing was significant for NT proBNPelevation, pancytopenia and iron overload. An echocardiogram (ECHO) was done showing a hypokinetic and dilated biventricular cardiopathy. The therapy was therefore optimized with clinical benefit. At coronary angiography a severe stenosis of left coronary artery was observed with normal myocardial perfusion imaging. Cardiovascular magnetic resonance (CMR) excluded an iron intramyocardial overload (in contrast to the hepatic and splenic parenchyma) and detected a subendocardial pattern of LGE at lateral and mid–basal septal area. Emochromatosis and Gaucher disease were excluded. As suggested by hematologists, he underwent osteomedullary biopsy (OMB) and a myelodysplastic syndrome (MDS) was diagnosed. He was still symptomatic for dyspnea on mild exertion. The following ECHO revealed normal left ventricular (LV) size with moderate concentric remodeling, mildly impaired LV systolic function and LV filling pattern suggestive of restrictive cardiomyopathy. All these data prompted suspicion for an infiltrative cardiopathy. Nuclear scintigraphy with the use of bone seeking agent was done and showed Perugini grade 2 cardiac uptake. Moreover, amyloid deposits were identified after Congo red–staining from OMB. immunoglobulin light chain (LA) amyloidosis was excluded.

Conclusion

based on the above findings, Cardiac Amyloidosis TTR–related wild type was diagnosed. The diagnosis of MDS and the identification of iron overload were incidental findings. The patient, currently in follow up at our center, is a candidate to Tafamidis.
P292 REDEFINING THE EPIDEMIOLOGY OF CARDIAC AMYLOIDOSIS. A SYSTEMATIC REVIEW OF SCREENING STUDIES
Authors: Aimo A , Merlo M , Porcari A , Pagura L , Sinagra G , Vergaro G , Emdin M , Rapezzi C
Published: May 2022

Background

Over the last years, an algorithm for non–invasive diagnosis of amyloid transthyretin cardiac amyloidosis (ATTR–CA) and novel disease–modifying therapies have prompted an active search of CA in different clinical settings.

Methods

We performed a systematic search of screening studies investigating CA.

Results

The average prevalence of CA in different settings were as follows: total body scintigraphy with “bone tracers” for non–cardiac reasons (n = 5 studies), 1%; heart failure (HF) with preserved ejection fraction (n = 6), 12%; HF with reduced or mildly reduced ejection fraction (n = 2), 10%, conduction disorders warranting pacemaker implantation (n = 1), 2%; surgery for carpal tunnel syndrome (CTS; n = 3), 7%; hypertrophic cardiomyopathy phenotype (n = 2), 9%; aortic stenosis (AS) undergoing surgical or transaortic valve replacement (n = 7), 10%; autopsy series of “unselected” elderly individuals (n = 4), 15%. Many of these patients had ATTR–CA, but the percentage of cases with amyloid light–chain CA was far from negligible.

Conclusions

Screening for CA in specific settings allows to identify a relatively high number of cases, in agreement with the notion that CA is not a rare disease. Many patients have ATTR–CA. Most studies focused on elderly subjects, given the clear relationship between age and the likelihood of CA. Men accounted for a high proportion of patients with CA, but women were quite represented.
P323 MYOCARDIAL INVOLVEMENT IN ANTI–PHOSPHOLIPID SYNDROME: A CASE OF A YOUNG BREASTFEEDING WOMAN
Authors: Varotto L , Leonardi D , Hoxha A , De Luca C , Siviero V , Bragantini G , Cerrito L , Caprioglio F
Published: May 2022

Introduction

In Antiphospholipid Syndrome (APS) myocardial tissue can be involved through immune–mediated or thrombotic mechanisms, giving chest pain and increase of myocardial cytolysis markers. This may occur without any signs of myocardial injury at the moment of echocardiography, coronarography and cardiac magnetic resonance (CMR). The aim is to increase the awareness about this life–threating condition.Case summary. We present the case of 26–year–old woman few days after childbirth, affected by APS in anticoagulant therapy with previous deep vein thrombosis and without any other cardiovascular risk factors. She was symptomatic for intermittent chest–epigastric pain, fever and skin livedo reticularis. Lab Tests: TnI 750 ng/L, C–reactive protein 9.6 mg/dL, D–dimer 1693 µg/L; anemia; Antithyroid Antibodies and ANA 1:160 (SSB/LA). Blood cultures and COVID test were negative.Results. Echocardiography showed normal left/right ventricular function, but minimal pericardial effusion was present. Pulmonary Angio–CT revealed small thromboembolic event, ground–glass lungs compatible with hemorrhagic alveolitis.After a few days, the patient presented increased epigastric pain, headache, vomiting up to presenting a comatose state. Thrombotic or hemorrhagic events with cerebral CT and MR were excluded. Total–body CT was negative, except for peri–splenic and recto–uterine pouches.For the increase of TnI up to 4741 ng/L, the patient underwent coronary angiography which demonstrated non–obstructive coronary arteries. The assembled Neuro–Cardio–Rheumatology team suspected a rapidly developing Catastrophic APS which was developing quickly with multi–organ and life–threatening involvement.The patient underwent 4 cycles of plasmapheresis, intravenous human IgG and corticosteroids, with rapid clinical improvement. CMR subsequently demonstrated a small transmural late enhancement area on lateral left ventricle wall.The patient was discharged from the hospital on Day 6 post–therapies.Conclusions. APS may involve more organs, including myocardial tissue with different mechanisms of damage and high mortality rate. The presented case poses a multidisciplinary challenge, because thrombotic multiorgan microangiopathy may be not always diagnosed. Imaging methods such as CMR could be optimized with adenosine stress–CMR. Clinical attention is required among women with APS, to reach early diagnosis of myocardial thrombotic microangiopathy and to establish the best effective treatment.
P326 SURGICAL VERSUS TRANSCATHETER AORTIC VALVE REPLACEMENT WITH NEWER GENERATION DEVICES IN REAL–WORLD PRACTICE: ONE–YEAR OUTCOMES FROM THE ITALIAN OBSERVANT STUDIES
Authors: Rosato S , Biancari F , D‘errigo P , Tarantini G , Costa G , Baglio G , Seccareccia F , Tamburino C
Published: May 2022

Objective

To compare the early and 1–year outcomes after transcatheter aortic valve replacement (TAVR) with new–generation devices over surgical replacement (SAVR) among patients with severe aortic stenosis (AS).

Background

TAVR is gaining acceptance for the treatment of lower risk patients with AS after several randomized and observational studies confirmed comparable early results to SAVR. On the other hand, clinical studies have shown that SAVR is still widely used in intermediate and high risk patients. There is need of data from large clinical registries to demonstrate the efficacy and safety of TAVR in the real–world setting, particularly after the introduction of new TAVR technology.

Methods

A total of 5706 AS patients who underwent SAVR and 2989 AS patients who underwent TAVR enrolled in the national, prospective OBSERVANT and OBSERVANT II studies, respectively in 2010–2012 and 2016–2018, were analyzed. Outcomes were adjusted using the propensity score matching. The primary outcomes of interest were all–cause mortality, major adverse cardiac and cerebrovascular events (MACCEs) and hospital readmission due to heart failure at 1–year. Secondary outcomes were major adverse events occurring during the index hospitalization.

Results

Among 1008 propensity score matched pairs, TAVR was associated with significantly lower 30–day mortality (1.8 vs. 3.5%, p = 0.020), stroke (0.8 vs. 2.3%, p = 0.005), acute kidney injury (0.6 vs. 8.2%, p < 0.001), infectious complications (3.8 vs. 6.5%, p = 0.006) and cardiogenic shock (1.4 vs. 5.1%, p < 0.001) compared to SAVR. Moderate–to–severe paravalvular regurgitation (5.9 vs. 2.0%, p < 0.001), major vascular complications requiring invasive treatment (2.2 vs. 0.1%, p < 0.001) and permanent pacemaker implantation (during the index hospitalization, 13.8 vs. 3.3%, p < 0.001) were more frequent after TAVR. At 1–year, TAVR was associated with lower risk of all–cause death (7.9 vs. 11.5%, p = 0.006), MACCE (12.0 vs. 15.8%, p = 0.011), readmission due to heart failure (10.8 vs. 15.9%, p < 0.001) and stroke (3.2 vs. 5.1%, p = 0.033) compared to SAVR.

Conclusions

In a real–world setting, patients with intermediate operative risk treated with newer generation TAVR devices had a low risk of major adverse events during the index–hospitalization and at 1–year follow–up. TAVR could become the treatment of choice for AS in the elderly provided that its durability is proved by long–term follow–up studies.