Prognostic value of low heart rates in patients admitted with acute myocardial infarction

INTRODUCTION AND OBJECTIVES: The risk prediction scores adopted in acute coronary syndromes (ACS) use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, previous studies reported a nonlinear relationship between HR and events, suggesting that low HR may have an unrecognized prognostic role. We aimed to assess the prognostic impact of low HR in ACS, defined as admission HR <50 bpm. METHODS: This study analyzed data from the AMIS Plus registry, a cohort of hospitalized patients with ACS between 1999 and 2021. The primary endpoint was in-hospital all-cause mortality, while a composite of all-cause mortality, major cardiac/cerebrovascular events was set as the secondary endpoint. A multilevel statistical method was used to assess the prognostic role of low HR in ACS. RESULTS: The study included 51 001 patients. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. A nonlinear relationship between HR and in-hospital mortality was observed on restricted cubic spline analysis. An HR of 50 to 75 bpm showed lower mortality than HR <50 bpm (OR, 0.67; 95%CI, 0.47-0.99) only after primary multivariable analysis, which was not confirmed after multiple sensitivity analyses. After propensity score matching, progressive fading of the prognostic role of HR <50 bpm was evident. CONCLUSIONS: Low admission HR in ACS is associated with a higher crude rate of adverse events. Nonetheless, after correction for baseline differences, the prognostic role of low HR was not confirmed. Therefore, low HR probably represents a marker of underlying morbidity. These results may be clinically relevant in improving the accuracy of risk scores in ACS

Technical and Clinical Outcomes After Transcatheter Edge-to-Edge Repair of Mitral Regurgitation in Male and Female Patients: Is Equality Achieved?

Currently, no clear impact of sex on short- and long-term survival following transcatheter edge-to-edge mitral valve repair (TEER) is evident, although no data are available on postprocedural life expectancy. Our aim was to assess sex-specific differences in outcomes of patients with mitral regurgitation (MR) treated by TEER. Short-term and 5-year outcomes in men and women undergoing TEER between 2011 and 2018 who were included in the large, multicenter, real-world MitraSwiss registry were analyzed. Outcomes were compared stratified by sex and according to MR cause (primary versus secondary). The impact of TEER on postprocedural life expectancy was estimated by relative survival analysis. Among 1142 patients aged 60 to 89 years, 39.8% were women. They were older, with fewer cardiovascular risk factors and lower functional capacity compared with men. Thirty-day mortality was higher in men than in women (3.3% versus 1.1%; odds ratio, 3.16 [95% CI, 1.16-10.7]; P=0.020). Five-year survival was comparable in both sexes (adjusted hazard ratio for 5-year mortality in men, 1.14 [95% CI, 0.90-1.44], P=0.275). Both men and women with either primary or secondary MR showed similar clinical efficacy over time. TEER provided high relative survival estimates among all groups, and fully restored predicted life expectancy in women with primary MR (5-year relative survival estimate, 97.4% [95% CI, 85.5-107.0]). TEER is not associated with increased short-term mortality in women, whereas 5-year outcomes are comparable between sexes. Moreover, TEER completely restored normal life expectancy in women with primary MR. A residual excess mortality persists in secondary MR, independently of sex

Metal free percutaneous coronary interventions in all-comers: First experience with a novel sirolimus-coated balloon

Background: Limus-eluting stents have become the mainstay for percutaneous coronary intervention (PCI). However, even with the latest generation drug-eluting stent, in-stent restenosis and very late stent thrombosis remain a concern. The Selution SLR™ drug-coated balloon (DCB) is a novel sirolimus-coated balloon that provides a controlled release of the antiproliferative drug. Herein is evaluated its performance in a real-world patient cohort with complex coronary artery lesions. Methods: Patients undergoing PCI using the Selution SLR™ DCB were analyzed from the prospective SIROOP registry. We evaluated procedural success and clinical outcomes, including major adverse cardiovascular event (MACE), cardiac death, target vessel myocardial infarction and target lesion revascularization. Results: From September 2020 to April 2021, we enrolled 78 patients (87 lesions) treated using a “DCB only” strategy. The mean age was 66.7 ± 10.4 years and 28 (36%) presented with an acute coronary syndrome. Almost all lesions were type B2/C 86 (99%) and 49 (63%) had moderate to severe calcifications. Procedural success was 100%. After a median follow-up of 11.2 months (interquartile range: 10.0–12.6), MACE occurred in 5 (6.8%) patients. No acute vessel closure was observed. Conclusions: In complex coronary lesions, a “DCB only” strategy using the Selution SLR™ DCB is not just safe and feasible, but also seems to be associated with a low rate of MACE at 1-year follow-up. Our promising results warrant further evaluation in a dedicated comparative trial

Acute coronary syndrome, antiplatelet therapy, and bleeding: a clinical perspective

Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described

ANALISI DELL&#8217;IMPATTO DELLE POLITICHE TARIFFARIE SUI PROFILI DI ACCESSO ALLA PRESTAZIONI SANITARIE IN REGIONE LOMBARDIA: IL CASO DELL&#8217;ASL DI COMO

OBIETTIVI: Dal primo agosto 2011 in Regione Lombardia \ue8 entrato in vigore un provvedimento (DGR 2027 del 20.07.2011)di rimodulazione del ticket previsto dalla manovra economica del Governo sulle prestazioni di specialistica ambulatoriale; a differenza, per\uf2, di quanto indicato nel provvedimento nazionale in Regione Lombardia si \ue8 optato per un\u2019applicazione, che assieme agli obiettivi economici di interesse nazionale tenesse conto delle necessit\ue0 economiche dei cittadini: l\u2019importo \ue8 divenuto variabile in proporzione al valore della prestazione in un range compreso tra 0 e 30\u20ac. Con il presente lavoro si vuole verificare se questa impostazione ha inciso sul ricorso alla prestazioni sanitarie da parte degli utenti. METODI: Sono stati analizzati i dati relativi alle prestazioni ambulatoriali erogate dalle strutture accreditate presenti nella provincia di Como nel secondo semestre 2010 confrontandoli con gli analoghi riferiti allo stesso periodo del 2011 utilizzando i flussi regionali validati (flusso 28/San). RISULTATI: Dall\u2019elaborazione dei dati si \ue8 evidenziata una diminuzione degli accessi per eseguire prestazioni ambulatoriali di utenti non esenti pari a circa il 2% sul territorio della ASL, invece per gli utenti esenti si assiste ad un lieve aumento pari al 1%. La diminuzione maggiore si registra per le analisi di laboratorio. Infine, si rileva una diminuzione del ricorso a prestazioni in regime di solvenza (-8%). CONCLUSIONI: Dal confronto dei periodi presi in considerazione si evince una diminuzione del ricorso alle prestazioni ambulatoriali da parte dei cittadini che non hanno un esenzione per reddito o patologia; tale fenomeno potrebbe ricondursi in parte all\u2019introduzione della nuova modulazione del ticket e in parte alla situazione economica del nostro Paese; si ritiene comunque necessario effettuare una analisi sui primi mesi 2012 al fine di verificare se questo andamento risulter\ue0 confermato