Awareness and appropriateness of the management of preclinical heart failure in outpatient clinics in Italy: Insights from the VASTISSIMO study - EValuation of the AppropriateneSs of The preclInical phase (Stage A and Stage B) of Heart FaIlure Management in Outpatient Clinics in Italy

A key factor in cardiovascular prevention is the detection and appropriate management of preclinical heart failure (HF), but information on the subject is scarce. We designed VASTISSIMO as a prospective, observational study to investigate Outpatient Clinic Cardiologists’ skills in detecting and managing preclinical HF in Italy. Quality scores were used to assess the appropriateness of clinical management according to guideline recommendations. The feasibility of making a diagnosis of preclinical HF in a cardiology outpatient clinical setting, cardiologists’ awareness of preclinical HF and consistency between physician’s perceived risk of HF and the patient’s classification into the preclinical HF Stages A [(SAHF) or B (SBHF)] have been investigated. Consistency was defined acceptable if the concordance between perceived risk and actual risk was >70%. Out of 3322 patients included in the study data necessary for identifying SBHF were collected in 2106 (63.4%). Many SBHF patients had their risk underestimated: 16.2% of those with previous acute myocardial infarction (AMI), 23.1% with left ventricular hypertrophy (LVH) at ECG/echocardiography, 30% with systolic/diastolic dysfunction, and 14.3% with valve disease. Cardiologists’ awareness of preclinical HF in the outpatient setting should be improved. This is a critical area of cardiovascular prevention that requires attention to improve good clinical practice and adherence to guidelines

A Prognostic Model for Estimating the Time to Virologic Failure in HIV-1 Infected Patients Undergoing a New Combination Antiretroviral Therapy Regimen

<p>Abstract</p> <p>Background</p> <p>HIV-1 genotypic susceptibility scores (GSSs) were proven to be significant prognostic factors of fixed time-point virologic outcomes after combination antiretroviral therapy (cART) switch/initiation. However, their relative-hazard for the time to virologic failure has not been thoroughly investigated, and an expert system that is able to predict how long a new cART regimen will remain effective has never been designed.</p> <p>Methods</p> <p>We analyzed patients of the Italian ARCA cohort starting a new cART from 1999 onwards either after virologic failure or as treatment-naïve. The time to virologic failure was the endpoint, from the 90^thday after treatment start, defined as the first HIV-1 RNA > 400 copies/ml, censoring at last available HIV-1 RNA before treatment discontinuation. We assessed the relative hazard/importance of GSSs according to distinct interpretation systems (Rega, ANRS and HIVdb) and other covariates by means of Cox regression and random survival forests (RSF). Prediction models were validated via the bootstrap and c-index measure.</p> <p>Results</p> <p>The dataset included 2337 regimens from 2182 patients, of which 733 were previously treatment-naïve. We observed 1067 virologic failures over 2820 persons-years. Multivariable analysis revealed that low GSSs of cART were independently associated with the hazard of a virologic failure, along with several other covariates. Evaluation of predictive performance yielded a modest ability of the Cox regression to predict the virologic endpoint (c-index≈0.70), while RSF showed a better performance (c-index≈0.73, p < 0.0001 vs. Cox regression). Variable importance according to RSF was concordant with the Cox hazards.</p> <p>Conclusions</p> <p>GSSs of cART and several other covariates were investigated using linear and non-linear survival analysis. RSF models are a promising approach for the development of a reliable system that predicts time to virologic failure better than Cox regression. Such models might represent a significant improvement over the current methods for monitoring and optimization of cART.</p

CARDIOVASCULAR EVENTS AND INCEPTION OF DIALYSIS IN DIABETIC AND NON-DIABETIC CKD PATIENTS WITH CORONARY ARTERY CALCIFICATION. FOLLOW-UP STUDY

Coronary artery calcification (CC) is frequent in patients with CKD and even more in those with concomitant type 2 diabetes. Presence and progression of CC are both strong predictive factors of cardiovascular events (CVE) in on-dialysis patients. In contrast, the effects of CC on the rate of CVE has been seldom evaluated as predictors in pre-dialysis (NDD-CKD) diabetic patients. Main aim of the present study is the evaluation of the rate of CVE and inception to dialysis in NDD-CKD patients with CC. METHODS: Outpatients with stage 2 to 4 CKD were screened for presence of CC with CT scan. Inclusion criteria were: age > 18 years, CKD stage 2-4. Exclusion criteria were: symptoms of heart failure and/or coronary artery disease, previous history of myocardial infarction, coronary bypass surgery, angioplasty, stroke, arrhythmia. Routine blood chemistry was assessed at enrollment and every six months. Recorded events were: sudden death, fatal and not fatal myocardial infarction, other-cause mortality, and inception of dialysis. The scheduled followup for evaluation of events was 48-month long. Coronary Calcium Score (CAC-Score) was assessed by computed tomography at study entry, and on 48th month. RESULTS: Recruited patients (n.275) were divided in 4 groups according to presence of CC and diabetes. Patients without CC and without diabetes were n.126; those with CC but without diabetes were n.88; those with CC and diabetes were n.48; those without CC but with diabetes were n.13. Presence of CC was significantly (p<0.001) higher in diabetics (79% Vs 41%) as well as baseline CAC-score (489±571 Vs 335±666 SD; median: 250 Vs 132; Agatston Unit). At the end of follow-up progression was 76% higher in diabetics compared to non-diabetics. Descending artery was more frequently involved both in diabetics and not diabetics (80-91%); circumflex coronary artery was mostly involved (71% Vs 31%) in diabetics. Composite endpoint (CVE and inception of dialysis) was encountered in 42%, and in 69% of calcified NDDCKD patients without and with diabetes, respectively. In the whole population, patients with CC more frequently experienced CV events. Inception to dialysis was more frequent in non calcified patients because fatal CVE were less frequent than those occurring in calcified patients. CONCLUSIONS: Calcified NDD-CKD diabetic patients are more prone to composite end-point of CVE and inception to dialysis. Initiation of dialysis is more frequent in non calcified NDD-CKD patients. Because of the higher risk for cardiovascular events, NDD-CKD diabetic patients might benefit from risk stratification with CAC-score screening. This non invasive procedure may help physicians in choosing the better medical therapy for diabetics Saturday, Ma

Management of chronic heart failure: Role of home echocardiography in monitoring care programs

AIM: To identify a possible role of home echocardiography for monitoring chronic heart failure (CHF) patients

Exploring Contemporary Data on Lipid-Lowering Therapy Prescribing in Patients Following Discharge for Atherosclerotic Cardiovascular Disease in the South of Italy

Current international guidelines strongly recommend the use of high-intensity lipid-lowering therapy (LLT) after hospitalization for atherosclerotic cardiovascular disease (ASCVD) events. With this study, our aim was to evaluate LLT prescribing in a large Italian cohort of patients after discharge for an ASCVD event, exploring factors associated with a lower likelihood of receiving any LLT and high-intensity LLT. Individuals aged 18 years and older discharged for an ASCVD event in 2019&ndash;2020 were identified using hospital discharge abstracts from two local health units of the Campania region. LLT treatment patterns were analyzed in the 6 months after the index event. Logistic regression models were developed for estimating patient predictors of any LLT prescription and to compare high-intensity and low-to-moderate-intensity LLT. Results: A total of 8705 subjects were identified. In the 6 months post-discharge, 56.7% of patients were prescribed LLT and, of those, 48.7% were high-intensity LLT. Female sex, older age, and stroke/TIA or PAD conditions were associated with a higher likelihood of not receiving high-intensity LLT. Similar predictors were found for LLT prescriptions. LLT utilization and the specific use of high-intensity LLT remain low in patients with ASCVD, suggesting a substantial unmet need among these patients in the contemporary real-world setting

Prevalence of acquired resistance mutations in a large cohort of perinatally infected HIV-1 patients

Data of drug resistance mutations (DRMs) within the Italian vertically infected population are scarce. The aim of the present work was to assess the prevalence of DRMs in this setting. We retrospectively analysed HIV-1 pol sequences of vertically infected patients obtained from the Italian Antiviral Response Cohort Analysis (ARCA) database (https://www.dbarca.net/). Our queries were restricted to adults. DRMs were interpreted using the Stanford HIVDB resistance interpretation algorithm (https://hivdb.stanford.edu/hivdb/by-mutations/). Any modification of antiretroviral therapy after initiation was considered a change in the therapeutic regimen. Data from a total of 94 patients were analysed (Fig. 1). Patient clinical characteristics are summarized in Table 1. The population was exposed to a median of five different antiretroviral regimens (range, 1–35 regimens). Data about the ongoing antiretroviral regimen were recovered for 73 patients (78%). Fourteen (15%) had no DRMs. At least one major DRM to nucleos(t)ide reverse transcriptase inhibitors (N(t)RTIs) was found in 74 cases (79%), to nonnucleoside reverse transcriptase inhibitors (NNRTIs) in 61 (65%) cases, to protease inhibitors (PIs) in 33 cases (35%) and to integrase strand transfer inhibitor (INSTIs) in 7 (7%)

Genotypic resistance profiles associated with virological failure to darunavir-containing regimens: a cross-sectional analysis

INTRODUCTION: This study aimed at defining protease (PR) resistance mutations associated with darunavir (DRV) failure and PR resistance evolution at DRV failure in a large database of treatment-experienced human immunodeficiency virus (HIV) patients. RESULTS: Overall, 1,104 patients were included: 118 (10.7%) failed at a median observation time of 16\ua0months. The mean number of PR mutations at baseline was 2.7, but it was higher in patients who subsequently failed DRV. In addition, the number of PR mutations increased at failure. The increase in the mean number of mutations was completely related to mutations considered to be associated with DRV resistance following the indications of the main DRV clinical trials. DISCUSSION: The higher statistical difference at baseline between failing versus non-failing patients was observed for the V32I and I84V mutations. At DRV failure, the major increase was still observed for V32I; I54L, V11I, T74P and I50V also increased. Despite the increment in the mean number of mutations per patient between baseline and failure, in 21 patients (17.8%) at baseline and 36 (30.5%) at failure, no PR mutation was detected. CONCLUSION: The HIV-DB interpretation algorithm identified few patients with full DRV resistance at baseline and few patients developed full resistance at DRV failure, indicating that complete resistance to DRV is uncommon

Genotypic resistance profiles associated with virological failure to darunavir-containing regimens: a cross-sectional analysis.

INTRODUCTION: This study aimed at defining protease (PR) resistance mutations associated with darunavir (DRV) failure and PR resistance evolution at DRV failure in a large database of treatment-experienced human immunodeficiency virus (HIV) patients. RESULTS: Overall, 1,104 patients were included: 118 (10.7%) failed at a median observation time of 16 months. The mean number of PR mutations at baseline was 2.7, but it was higher in patients who subsequently failed DRV. In addition, the number of PR mutations increased at failure. The increase in the mean number of mutations was completely related to mutations considered to be associated with DRV resistance following the indications of the main DRV clinical trials. DISCUSSION: The higher statistical difference at baseline between failing versus non-failing patients was observed for the V32I and I84V mutations. At DRV failure, the major increase was still observed for V32I; I54L, V11I, T74P and I50V also increased. Despite the increment in the mean number of mutations per patient between baseline and failure, in 21 patients (17.8%) at baseline and 36 (30.5%) at failure, no PR mutation was detected. CONCLUSION: The HIV-DB interpretation algorithm identified few patients with full DRV resistance at baseline and few patients developed full resistance at DRV failure, indicating that complete resistance to DRV is uncommon

The role of baseline HIV-1 RNA, drug resistance, and regimen type as determinants of response to first-line antiretroviral therapy

The factors influencing virological response to first-line combined antiretroviral therapy (cART) in an Italian cohort of HIV-1-infected patients were examined. Eligible patients were those enrolled in a national prospective observational cohort (Antiretroviral Resistance Cohort Analysis), starting first-line cART between 2001 and 2011 and who had at least one follow-up of HIV-1 RNA. The primary endpoint was virological success, defined as the first viral load 100,000 copies/ml, virologic success was only associated with the use of integrase inhibitors in the first cART regimen. Independent predictors of immunological success were baseline CD4+ cell count and wGSS <3. High baseline HIV-1 RNA, predicted activity of the first-line regimen based on genotypic resistance testing, gender, and use of new agents were found to predict time to achieve virological success. The type of initial nucleoside analog backbone was not found to predict virological response