Parity as predictor of early hypertension during menopausal transition

Studies regarding the effects of parity on blood pressure in later life produced conflicting results. The aim of our study is to analyse whether parity influences the prevalence of hypertension in perimenopausal and postmenopausal women. METHODS: One thousand perimenopausal and postmenopausal women (mean age 55.2\u200a\ub1\u200a5.4 years) were enrolled with a median follow-up of 63.0 months. The study sample consisted of patients who self-referred, in 1998-2009, to the BenEssere Donna Clinic, dedicated to menopause-related disorders. RESULTS: One hundred and twenty-two (12.2%) women were nulliparous and 878 (87.8%) had at least one child. Thirty-four (27.9%) women among nulliparous and 326 (37.1%) among parous were hypertensive at baseline (P\u200a=\u200a0.046) and 812 women (81.2%) were in their postmenopausal period. Univariate analysis showed that women with one or more children were at higher risk of being hypertensive [odds ratio (OR): 1.529; 95% confidence interval (CI): 1.006-2.324; P\u200a=\u200a0.047]. Likewise, multivariate analysis revealed that parity (OR: 2.907; 95% CI: 1.290-6.547; P\u200a=\u200a0.010), BMI (OR: 1.097; 95% CI: 1.048-1.149; P\u200a<\u200a0.001) and family history of hypertension (OR: 3.623; 95% CI: 2.231-5.883; P\u200a<\u200a0.001) were independently related to hypertension at baseline. In a subanalysis of 640 initially normotensive women, 109 (17.0%) patients developed hypertension after follow-up, without a statistically significant association with parity (13.6% in nulliparous versus 17.6% in parous; P\u200a=\u200a0.362). Consistently, parity showed no relationship with the incidence of hypertension during follow-up (OR: 1.350; 95% CI: 0.707-2.579; P\u200a=\u200a0.363). CONCLUSION: For the first time in a population of White perimenopausal and postmenopausal women, parity was demonstrated to be independently associated with early hypertension during menopausal transition. Conversely, postmenopausal hypertension was not related with parity

Transdermal 17-&#946;-estradiol and risk of developing type 2 diabetes in a population of healthy, nonobese postmenopausal women

WSTĘP. W wielu obserwacyjnych i randomizowanych badaniach wykazano zmniejszenie częstości cukrzycy typu 2 u kobiet w okresie pomenopauzalnym, przyjmujących doustne estrogeny. Nie było jednak prac, w których oceniano częstość występowania cukrzycy u kobiet stosujących przezskórne preparaty 17-&#946;-estradiolu. Celem niniejszego badania była ocena wpływu przezskórnego preparatu 17-&#946;-estradiolu na częstość cukrzycy typu 2 w populacji zdrowych, nieotyłych kobiet w okresie pomenopauzalnym. MATERIAŁ I METODY. W okresie od stycznia 1998 roku do grudnia 2002 roku do badania włączono 673 zdrowe kobiety w okresie pomenopauzalnym, u których nie stwierdzano nadwagi (średni wiek 54 &plusmn; 5 lat): 144 z nich (21,4%) otrzymywało 17-&#946;-estradiol w postaci preparatów przezskórnych, a 529 (78,6%) nie przyjmowało hormonów po menopauzie. Końcową analizę danych przeprowadzono w lipcu 2003 roku. Średni okres obserwacji wynosił 3,7 &plusmn; 0,7 roku (0,5&#8211;5 lat). WYNIKI. Podczas obserwacji stwierdzono, że cukrzyca typu 2 rozwinęła się u 60 pacjentek, co odpowiada 22 przypadkom na 1000 kobietolat. W grupie nieprzyjmującej estrogenów cukrzycę stwierdzono u 54 z 529 kobiet, czyli w 10% przypadków, co odpowiada 26,5 przypadkom na 1000 kobietolat, natomiast w grupie leczonej hormonalnie cukrzyca rozwinęła się u 4,16% kobiet, czyli 6 ze 144 kobiet, co odpowiada 12,1 przypadkom na 1000 kobietolat. Wykazano, że leczenie preparatem przezskórnym 17-&#946;-estradiolu istotnie zmniejszyło ryzyko rozwoju cukrzycy (RR 2,19; 95% CI 1,79&#8211;3,56; p = 0,006). WNIOSKI. Wyniki pracy wskazują, że u zdrowych kobiet bez nadwagi stosowanie przeskórnych preparatów17-&#946;-estradiolu w okresie pomenopauzalnym istotnie zmniejsza ryzyko rozwoju cukrzycy typu 2. Może to sugerować, że u niektórych kobiet niedobór estrogenów po menopauzie stanowi istotny element w procesie rozwoju cukrzycy.INTRODUCTION. Various observational and randomized studies have demonstrated a reduction in the incidence of type 2 diabetes in postmenopausal women who received estrogen orally. No studies have been performed on the incidence of type 2 diabetes in postmenopausal women treated with transdermal 17-&#946;-estradiol. The purpose of our study was to assess the influence of transdermal 17-&#946;-estradiol on the incidence of type 2 diabetes in a population of healthy, nonobese postmenopausal women. MATERIAL AND METHODS. Between January 1998 and December 2002, 673 healthy, nonobese postmenopausal women (mean age 54 &#177; 5 years) were enrolled: 144 (21.4%) of these took transdermal 17-&#946;-estradiol and 529 (78.6%) had never taken hormones during their postmenopausal period. Final elaboration of the data took place in July 2003, with a mean follow-up of 3.7 &#177; 0.7 years (ranging from 0.5 to 5 years). RESULTS. Type 2 diabetes developed in 60 patients during the follow-up period, which is the equivalent of 22 cases per 1,000 women-years. In the &#8222;hormones nonusers&#8221; group, diabetes developed in 10% (54 of 529 women; equivalent of 26.5 cases/1,000 women-years), whereas in the &#8222;hormones users&#8221; group, diabetes developed in 4.16% (6 of 144 women; equivalent of 12.1 cases/1,000 women-years). Transdermal 17-&#946;-estradiol emerged as a treatment that significantly reduced the risk of developing diabetes (RR 2.19; 95% CI 1.79&#8211;3.56; P = 0.006). CONCLUSIONS. Our results suggest a significant reduction in the incidence of type 2 diabetes in our population of nonobese, healthy postmenopausal women who used transdermal 17-&#946;-estradiol. This could suggest that, in some women, the estrogen deficiency that occurs after menopause could represent a fundamental step in the process of diabetogenesis

Acute myocardial infarction with occlusion of all three main epicardial coronary arteries: When Mother Nature takes care more than physicians

Double-arterial coronary stent thrombosis in acute myocardial infarction (AMI) is an infrequent but severe complication, especially when the third main coronary artery is chronically occluded. The conus artery (CA) can serve as a major source of collateral when the left anterior descendent coronary artery (LAD) becomes obstructed. We report a case of a 48-year-old man presenting with AMI due to a very late double-arterial stent thrombosis (ST) following drug-eluting stent implantation and a chronic occlusion of LAD collateralized by a large anomalous CA, which provided for the entire vascularization of the coronary tree. © 2010 Springer

Right versus left radial artery access for coronary procedures: an international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients

BACKGROUND: Radial artery access is a mainstay in the diagnosis and treatment of coronary artery disease. However, there is uncertainty on the comparison of right versus left radial access for coronary procedures. We thus undertook a systematic review and meta-analysis comparing right versus left radial access for coronary diagnostic and interventional procedures. METHODS: Pertinent studies were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus, together with international conference proceedings. Randomized trials comparing right versus left radial (or ulnar) access for coronary diagnostic or interventional procedures were included. Risk ratios (RR) and weighted mean differences (WMD) were computed to generate point estimates (95% confidence intervals). RESULTS: A total of 5 trials (3210 patients) were included. No overall significant differences were found comparing right versus left radial access in terms of procedural time (WMD=0.99 [-0.53; 2.51]min, p=0.20), contrast use (WMD=1.71 [-1.32; 4.74]mL, p=0.27), fluoroscopy time (WMD=-35.79 [-3.54; 75.12]s, p=0.07) or any major complication (RR=2.00 [0.75; 5.31], p=0.49). However, right radial access was fraught with a significantly higher risk of failure leading to cross-over to femoral access (RR=1.65 [1.18; 2.30], p=0.003) in comparison to left radial access. CONCLUSIONS: Right and left radial accesses appear largely similar in their overall procedural and clinical performance during transradial diagnostic or interventional procedures. Nonetheless, left radial access can be recommended especially during the learning curve phase to reduce femoral cross-overs

Remote ischaemic preconditioning in coronary artery bypass surgery: a meta-analysis

Aim Randomised trials exploring remote ischaemic preconditioning (RIPC) in patients undergoing coronary artery bypass graft (CABG) surgery have yielded conflicting data regarding potential cardiovascular and renal protection, and are individually flawed by small sample size. Methods Three investigators independently searched the MEDLINE, EMBASE and Cochrane databases to identify randomised trials testing RIPC in patients undergoing CABG. Results Nine studies with 704 patients were included. Standardised mean difference of troponin I and T release showed a significant decrease ( 120.36 (95% CI 120.62 to 120.09)). This difference held true after excluding the trials with cross-clamp fibrillation, the study with off-pump CABG and studies using a flurane as anaesthetic agent ( 120.41 (95% CI 120.69 to 120.12), 120.38 (95% CI 120.70 to 120.07) and 120.37 (95% CI 120.63 to 120.12), respectively). A similar trend was also obtained for patients with multivessel disease ( 120.41 (95% CI 120.73 to 120.08)). The trials evaluating postoperative creatinine reported a non-significant reduction (0.02 (95% CI 120.09 to 0.13)). Moreover, the length of in-hospital stay was not influenced by the kind of treatment (weighted mean difference 0.27 (95% CI 120.24 to 0.79)). Conclusion RIPC reduced the release of troponin in patients undergoing CABG. Larger randomised trials are needed to clarify the presence of a causal relationship between RIPC-induced troponin release and clinical adverse events

Epidemiology and social impact of early onset dementia in the province of Modena, Northern Italy

Aims of the study. Early onset dementia (EOD), defined as onset of dementia &lt;65 years, has a much higher social impact compared to the more common late onset dementia. EOD epidemiologic data in Italy are extremely scarce, and international estimates of prevalence are considerably variable, ranging between 15.1 and 153/100.000 in the age 45-65. We present data from an ongoing study aimed at establishing EOD epidemiology in a Northern Italy community (Modena province, around 700.000 inhabitants). Materials. We retrospectively recruited all patients residing in Modena province referred to the Modena Baggiovara Hospital Neurologic Clinic CDCD (Centro disturbi cognitivi e demenze), by family practitioners and geriatricians of the province. Eligible patients were those affected by EOD from 2012 to January 2019. EOD was diagnosed in patients &lt;65 years presenting with cognitive/behavioral symptoms, following a comprehensive neurological examination by a cognitive neurologist, as well as brain MRI, FDG PET scanning and CSF analyses when appropriate. Methods. We collected clinical data such as age at onset, disease severity at time of diagnosis, time delay from onset to diagnosis, and epidemiologic data including residence and occupational status. Results. We identified 223 patients with an EOD diagnosis from 2012 to January 2019. Of these, 103 are males (46,2%). 97 patients have AD (21 lvPPA, 13 PCA, 2 frontal variant), 47 have FTD (33 bvFTD, 14 svPPA), 6 have leucoencephalopathy. Mean onset age was 58,6 years (SD 5,1). Median time from symptoms onset to diagnosis was 3.1 years (SD 29,83). Mean MMSE score at diagnosis was 22,63/30 (SD 5,2). 24 patients were working at time of diagnosis (10,76%) and had to quit working due to the cognitive impairment. Two patients (0,89%) had young children (&lt;18) at time of diagnosis. Discussion. We provide the first epidemiological data on EOD in Italy. These are consistent with the estimates calculated by transposing European data to the population of Modena province (estimated prevalence=200 patients, detected prevalence=223 patients)1. Our data show a higher percentage of atypical AD phenotypes and FTD in the EOD group compared to late onset disease2. Also, CAA and leucoencephalopaties were over-represented compared to LOD. From a social perspective, EOD has significant impacts on patients and their families: patients are generally forced to leave work, and their children are expected to need psychological support, currently not routinely available. Conclusions. Our population study provides the first data regarding EOD epidemiology and social impact in Italy

Use and misuse of multivariable approaches in interventional cardiology studies on drug-eluting stents: a systematic review.

Aims: Randomized clinical trials (RCTs) are the most reliable evidence, even if they require important resource and logistic efforts. Large, cost-free and real-world datasets may be easily accessed yielding to observational studies, but such analyses often lead to problematic results in the absence of careful methods, especially from a statistic point of view. We aimed to appraise the performance of current multivariable approaches in the estimation of causal treatment and effects in studies focusing on drug-eluting stents (DES). Methods and Results: Pertinent studies published in the literature were searched, selected, abstracted, and appraised for quality and validity features. Six studies with a logistic regression were included, all of them reporting more than 10 events for covariates and different length of follow-up, with an overall low risk of bias. Most of the 15 studies with a Cox proportional hazard analysis had a different follow-up, with less than 10 events for covariates, yielding an overall low or moderate risk of bias. Sixteen studies with propensity score were included: the most frequent method for variable selection was logistic regression, with underlying differences in follow-up and less than 10 events for covariate in most of them. Most frequently, calibration appraisal was not reported in the studies, on the contrary of discrimination appraisal, which was more frequently performed. In seventeen studies with propensity and matching, the latter was most commonly performed with a nearest neighbor-matching algorithm yet without appraisal in most of the studies of calibration or discrimination. Balance was evaluated in 46% of the studies, being obtained for all variables in 48% of them. Conclusions: Better exploitation and methodological appraisal of multivariable analysis is needed to improve the clinical and research impact and reliability of nonrandomized studies. (J Interven Cardiol 2012;**:1-1

Incidence, etiology and predictors of adverse outcomes in 43,315 patients presenting to the Emergency Department with syncope: An international meta-analysis.

BACKGROUND: Syncope remains challenging for Emergency Department (ED) physicians due to difficulties in assessing the risk of future adverse outcomes. The aim of this meta-analysis is to establish the incidence and etiology of adverse outcomes as well as the predictors, in patients presenting with syncope to the ED. METHODS: A systematic electronic literature review was performed looking for eligible studies published between 1990 and 2010. Studies reporting multivariate predictors of adverse outcomes in patients presenting with syncope to the ED were included and pooled, when appropriate, using a random-effect method. Adverse events were defined as 'incidence of death, or of hospitalization and interventional procedures because of arrhythmias, ischemic heart disease or valvular heart disease'. RESULTS: 11 studies were included. Pooled analysis showed 42% (CI 95%; 32-52) of patients were admitted to hospital. Risk of death was 4.4% (CI 95%; 3.1-5.1) and 1.1% (CI 95%; 0.7-1.5) had a cardiovascular etiology. One third of patients were discharged without a diagnosis, while the most frequent diagnosis was 'situational, orthostatic or vasavagal syncope' in 29% (CI 95%; 12-47). 10.4% (CI 95%; 7.8-16) was diagnosed with heart disease, the most frequent type being bradyarrhythmia, 4.8% (CI 95%; 2.2-6.4) and tachyarrhythmia 2.6% (CI 95%; 1.1-3.1). Palpitations preceding syncope, exertional syncope, a history consistent of heart failure or ischemic heart disease, and evidence of bleeding were the most powerful predictors of an adverse outcome. CONCLUSION: Syncope carries a high risk of death, mainly related to cardiovascular disease. This large study which has established the most powerful predictors of adverse outcomes, may enable care and resources to be better focused at high risk patients. Copyright \ua9 2011 Elsevier Ireland Ltd. All rights reserved

Outcomes in Mitral Regurgitation Due to Flail Leaflets. A Multicenter European Study

Objectives: The purpose of this study was to assess incidence and predictors of events associated with nonsurgical and surgical management of severe mitral regurgitation (MR) in European institutions. Background: The management of patients with MR remains disputed, warranting multicenter studies to define clinical outcome in routine clinical practice. Methods: The MIDA (Mitral Regurgitation International DAtabase) is a registry created for multicenter study of MR with echocardiographically diagnosed flail leaflet as a model of pure, organic MR. Our cases were collected from 4 European centers. We enrolled 394 patients (age 64 ± 11 years; 67% men; 64% in New York Heart Association functional class I to II; left ventricular ejection fraction 67 ± 10%). Results: During a median follow-up of 3.9 years, linearized event rates/year under nonsurgical management were 5.4% for atrial fibrillation (AF), 8.0% for heart failure (HF), and 2.6% for death. Mitral valve (MV) surgery was performed in 315 (80%) patients (repair in 250 of 315, 80%). Perioperative mortality, defined as death within 30 days from the operation, was 0.7% (n = 2). Surgery during follow-up was independently associated with reduced risk of death (adjusted hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.21 to 0.84; p = 0.014). Benefit was largely driven by MV repair (adjusted HR vs. replacement 0.37, 95% CI 0.18 to 0.76; p = 0.007). In 102 patients strictly asymptomatic and with normal ventricular function, 5-year combined incidence of AF, HF, or cardiovascular death (CVD) was 42 ± 8%. In these patients, surgery also reduced rates of CVD/HF (HR 0.26, 95% CI 0.08 to 0.89; p = 0.032). Conclusions: In this multicenter study, nonsurgical management of severe MR was associated with notable rates of adverse events. Surgery especially MV repair performed during follow-up was beneficial in reducing rates of cardiac events. These findings support surgical consideration in patients with MR due to flail leaflets for whom MV repair is feasible. © 2008 American College of Cardiology Foundation

TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: A meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients.

BACKGROUND: Acute coronary syndromes (ACS) represent a difficult challenge for physicians. Risk scores have become the cornerstone in clinical and interventional decision making. METHODS AND RESULTS: PubMed was systematically searched for ACS risk score studies. They were divided into ACS studies (evaluating Unstable Angina; UA, Non ST Segment Elevation Myocardial Infarction; NSTEMI, and ST Segment Elevation Myocardial Infarction; STEMI), UA/NSTEMI studies or STEMI studies. The c-statistics of validation studies were pooled when appropriate with random-effect methods. 7 derivation studies with 25,525 ACS patients and 15 validation studies including 257,654 people were formally appraised. Pooled analysis of GRACE scores, both at short (0.82; 0.80-0.89 I.C 95%) and long term follow up (0.84; 0.82-0.87; I.C 95%) showed the best performance, with similar results to Simple Risk Index (SRI) derivation cohorts at short term. For NSTEMI/UA, 18 derivation studies with 56,560 patients and 18 validation cohorts with 56,673 patients were included. Pooled analysis of validations studies showed c-statistics of 0.54 (95% CI = 0.52-0.57) and 0.67 (95% CI = 0.62-0.71) for short and long term TIMI validation studies, and 0.83 (95% CI = 0.79-9.87) and 0.80 (95% CI = 0.74-0.89) for short and long term GRACE studies. For STEMI, 15 studies with 134,557 patients with derivation scores, and 17 validation studies with 187,619 patients showed a pooled c-statistic of 0.77 (95% CI = 0.71-0.83) and 0.77 (95% CI = 0.72-0.85) for TIMI at short and long term, and a pooled c-statistic of 0.82 (95% CI = 0.81-0.83) and 0.81 (95% CI = 0.80-0.82) for GRACE at short and long terms respectively. CONCLUSIONS: TIMI and GRACE are the risk scores that up until now have been most extensively investigated, with GRACE performing better. There are other potentially useful ACS risk scores available however these have not undergone rigorous validation. This study suggests that these other scores may be potentially useful and should be further researched