High Thrombotic Risk Increases Adverse Clinical Events Up to 5 Years After Acute Myocardial Infarction. A Nationwide Retrospective Cohort Study

The risk of recurrent events among survivors of acute myocardial infarction (AMI) is understudied. The aim of this analysis was to investigate the role of residual high thrombotic risk (HTR) as a predictor of recurrent in-hospital events after AMI. This retrospective cohort study included 186,646 patients admitted with AMI from 2009 to 2010 in all Italian hospitals who were alive 30 days after the index event. HTR was defined as at least one of the following in the 5 years preceding AMI: previous myocardial infarction, ischemic stroke/other vascular disease, type 2 diabetes mellitus, renal failure. Risk adjustment was performed in all multivariate survival analyses. Rates of major cardiac and cerebrovascular events (MACCE) within the following 5 years were calculated in both patients without fatal readmissions at 30 days and in those free from in-hospital MACCE at 1 year from the index hospitalization. The overall 5-year risk of MACCE was higher in patients with HTR than in those without HTR, in both survivors at 30 days [hazard ratio (HR), 1.49; 95% confidence interval (CI), 1.45-1.52; p<0.0001] and in those free from MACCE at 1 year (HR, 1.46; 95% CI, 1.41-1.51; p<0.0001). The risk of recurrent MACCE increased in the first 18 months after AMI (HR, 1.49) and then remained stable over 5 years. The risk of MACCE after an AMI endures over 5 years in patients with HTR. This is also true for patients who did not have any new cardiovascular event in the first year after an AMI. All patients with HTR should be identified and addressed to intensive preventive care strategies

Selection criteria for referral to cardiac rehabilitation centers

Current guidelines state that cardiac rehabilitation is indicated after the acute phase of major cardiovascular diseases and interventions; on the other hand implementation of these indications is difficult because of several barriers, i.e. the number of patients per year with an indication exceeds by far the accommodation offer of cardiac rehabilitation centers; the demand for access to cardiac rehabilitation from acute cardiac care hospitals is low because the attention is focused on the acute phase of cardiac diseases. The present Consensus Document describes the changes in clinical epidemiology of the main cardiovascular diseases, showing that complications are increasingly more frequent in the postacute phase, especially in the setting of myocardial infarction. The Joint ANMCO/IACPR-GICR Committee defines priority criteria based on clinical risk for admission to cardiac rehabilitation centers as inpatients. This Consensus Document represents, therefore, an important step forward in the search for continuity of care in high-risk patients during the post-acute phase

Early and mid-term outcome of patients with low-flow-low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

Patients with non-paradoxical low-flow-low-gradient (LFLG) aortic stenosis (AS) are at increased surgical risk, and thus, they may particularly benefit from transcatheter aortic valve replacement (TAVR). However, data on this issue are still limited and based on the results with older-generation transcatheter heart valves (THVs). The aim of this study was to investigate early and mid-term outcome of TAVR with newer-generation THVs in the setting of LFLG AS. Data for the present analysis were gathered from the OBSERVANT II dataset, a national Italian observational, prospective, multicenter cohort study that enrolled 2,989 consecutive AS patients who underwent TAVR at 30 Italian centers between December 2016 and September 2018, using newer-generation THVs. Overall, 420 patients with LVEF &lt;= 50% and mean aortic gradient &lt;40 mmHg were included in this analysis. The primary outcomes were 1-year all-cause mortality and a combined endpoint including all-cause mortality and hospital readmission due to congestive heart failure (CHF) at 1 year. A risk-adjusted analysis was performed to compare the outcome of LFLG AS patients treated with TAVR (n = 389) with those who underwent surgical aortic valve replacement (SAVR, n = 401) from the OBSERVANT I study. Patients with LFLG AS undergoing TAVR were old (mean age, 80.8 +/- 6.7 years) and with increased operative risk (mean EuroSCORE II, 11.5 +/- 10.2%). VARC-3 device success was 83.3% with 7.6% of moderate/severe paravalvular leak. Thirty-day mortality was 3.1%. One-year all-cause mortality was 17.4%, and the composite endpoint was 34.8%. Chronic obstructive pulmonary disease (HR 1.78) and EuroSCORE II (HR 1.02) were independent predictors of 1-year mortality, while diabetes (HR 1.53) and class NYHA IV (HR 2.38) were independent predictors of 1-year mortality or CHF. Compared with LFLG AS treated with SAVR, TAVR patients had a higher rate of major vascular complications and permanent pacemaker, while SAVR patients underwent more frequently to blood transfusion, cardiogenic shock, AKI, and MI. However, 30-day and 1-year outcomes were similar between groups. Patients with non-paradoxical LFLG AS treated by TAVR were older and with higher surgical risk compared with SAVR patients. Notwithstanding, TAVR was safe and effective with a similar outcome to SAVR at both early and mid-term

Use of hierarchical models to evaluate performance of cardiac surgery centres in the Italian CABG outcome study

<p>Abstract</p> <p>Background</p> <p>Hierarchical modelling represents a statistical method used to analyze nested data, as those concerning patients afferent to different hospitals. Aim of this paper is to build a hierarchical regression model using data from the "Italian CABG outcome study" in order to evaluate the amount of differences in adjusted mortality rates attributable to differences between centres.</p> <p>Methods</p> <p>The study population consists of all adult patients undergoing an isolated CABG between 2002–2004 in the 64 participating cardiac surgery centres.</p> <p>A risk adjustment model was developed using a classical single-level regression. In the multilevel approach, the variable "clinical-centre" was employed as a group-level identifier. The intraclass correlation coefficient was used to estimate the proportion of variability in mortality between groups. Group-level residuals were adopted to evaluate the effect of clinical centre on mortality and to compare hospitals performance. Spearman correlation coefficient of ranks (<it>ρ</it>) was used to compare results from classical and hierarchical model.</p> <p>Results</p> <p>The study population was made of 34,310 subjects (mortality rate = 2.61%; range 0.33–7.63). The multilevel model estimated that 10.1% of total variability in mortality was explained by differences between centres. The analysis of group-level residuals highlighted 3 centres (VS 8 in the classical methodology) with estimated mortality rates lower than the mean and 11 centres (VS 7) with rates significantly higher. Results from the two methodologies were comparable (<it>ρ </it>= 0.99).</p> <p>Conclusion</p> <p>Despite known individual risk-factors were accounted for in the single-level model, the high variability explained by the variable "clinical-centre" states its importance in predicting 30-day mortality after CABG.</p

One-Year Outcomes after Surgical versus Transcatheter Aortic Valve Replacement with Newer Generation Devices

The superiority of transcatheter (TAVR) over surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS) has not been fully demonstrated in a real-world setting. This prospective study included 5706 AS patients who underwent SAVR from 2010 to 2012 and 2989 AS patients who underwent TAVR from 2017 to 2018 from the prospective multicenter observational studies OBSERVANT I and II. Early adverse events as well as all-cause mortality, major adverse cardiac and cerebrovascular events (MACCEs), and hospital readmission due to heart failure at 1-year were investigated. 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), and acute kidney injury (0.6 vs. 8.2%, p &lt; 0.001) compared to SAVR. Moderate-to-severe paravalvular regurgitation (5.9 vs. 2.0%, p &lt; 0.001) and permanent pacemaker implantation (13.8 vs. 3.3%, p &lt; 0.001) were more frequent after TAVR. At 1-year, TAVR was associated with lower risk of all-cause mortality (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 &lt; 0.001), and stroke (3.2 vs. 5.1%, p = 0.033) compared to SAVR. TAVR reduced 1-year mortality in the subgroups of patients aged 80 years or older (HR 0.49, 95% CI 0.33-0.71), in females (HR 0.57, 0.38-0.85), and among patients with EuroSCORE II &gt;= 4.0% (HR 0.48, 95% CI 0.32-0.71). In a real-world setting, TAVR using new-generation devices was associated with lower rates of adverse events up to 1-year follow-up compared to SAVR

Indicatori PNE. Ieri, oggi e domani

L’edizione 2019 di PNE analizza 176 indicatori (72 di esito/processo, 74 di volumi di attività e 30 di ospedalizzazione), coprendo 11 aree cliniche. In questo articolo, riportiamo a titolo esemplificativo una selezione di indicatori riguardanti 4 aree cliniche con il duplice intento di rappresentare alcuni dei contenuti del PNE e di illustrare i cambiamenti temporali che è possibile apprezzare attraverso questo strumento di valutazione

Is patent foramen ovale closure an OPTION in patients with cryptogenic stroke? An Italian multicentre registry proposal

[No abstract available

The prediction of coronary heart disease mortality as a function of major risk factors in over 30000 men in the Italian RIFLE Pooling Project. A comparison with the MRFIT primary screenees

Background: Few risk functions for the prediction of coronary heart disease mortality have been produced in Italy. This study used a large population sample to evaluate the effect of major risk factors on coronary mortality. Methods: Coronary deaths in 45 cohorts of men (n = 31 31 7, aged 30-69 years) were studied and related to selected cardiovascular risk factors. Results: After 6 years, 1089 men had died, of whom 239 were coronary fatalities. Univariate and multivariate (Cox model) analyses conducted on each age group (30-39, 40-49, 50-59 and 60-69 years) showed a positive association between coronary deaths and systolic blood pressure, serum cholesterol level and cigarette smoking, with few exceptions. A multiple logistic model was produced for men aged 35-57 years, assessing the role of age, serum cholesterol, cigarettes smoked per day and diastolic instead of systolic blood pressure, using the same endpoint as that employed in a similar model published from the analysis of MRFIT primary screenees in the USA to facilitate valid comparison. The coefficients in the present study were similar to those in the US cohort: no statistically significant differences could be detected when comparing the pairs of coefficients. Conclusion: Coefficients relating cholesterol, blood pressure and cigarette smoking to coronary mortality in Italian men are similar to those in American men from the same age groups