Time course of ischemic and bleeding burden in consecutive patients undergoing transcatheter aortic valve replacement (FOCUS-ONE registry)

BACKGROUND AND AIMS

Ischemic or bleeding events might occur after transcatheter aortic valve replacement (TAVR), with the potential to hamper clinical outcomes. This study aimed to characterize the average daily ischemic risks (ADIRs) and the average daily bleeding risks (ADBRs) over 1-year in all consecutive patients undergoing TAVR.

METHODS

ADBR included all bleeding events according to VARC-2 definition, and ADIR included cardiovascular deaths, myocardial infarction and ischemic stroke. ADIRs and ADBRs were assessed within different timeframes post TAVR: acute (0-30 days), late (31-180 days), and very late (>181 days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparison of ADIRs and ADBRs. Our analysis was performed in the overall cohort and according to antithrombotic strategy (LT-OAC vs No LT-OAC).

RESULTS

Ischemic burden was higher than bleeding burden, independently from the indication to LT-OAC, and in all timeframes examined. In the overall population, ADIRs were three-fold ADBRs (0.0467 [95% CI, 0.0431-0.0506] vs 0.0179 [95% CI, 0.0174-0.0185]; p < 0.001*). While ADIR was significantly higher in the acute phase, ADBR was relatively stable in all timeframes analysed. Of note, in LT-OAC population, OAC + SAPT group showed lower ischemic risk and higher bleeding events compared with OAC alone (ADIR: 0.0447 [95% CI: 0.0417-0.0477] vs 0.0642 [95% CI: 0.0557-0.0728]; p < 0.001*, ADBR 0.0395 [95% CI: 0.0381-0.0409] vs 0.0147 [95% CI: 0.0138-0.0156]; p < 0.001*).

CONCLUSIONS

In patients undergoing TAVR Average daily risk fluctuates over time. However, ADIRs overcome ADBRs in all timeframes, especially in the acute phase and regardless of antithrombotic strategy adopted.

Convalescent Plasma for Hospitalized COVID-19 Patients: A Single-Center Experience

In Winter 2020, Italy, and in particular the Lombardy region, was the first country in the Western hemisphere to be hit by the COVID-19 pandemic. Plasma from individuals recovered from COVID-19 (COVID-19 convalescent plasma, CCP) was the first therapeutic tool adopted to counteract the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In this retrospective cohort study, we report the experience of the city hospital of Mantua, Lombardy region, on the compassionate use of CCP in patients hospitalized for severe COVID-19. Between April 2020 and April 2021, 405 consecutive COVID-19 patients received 657 CCP units with a median anti-SARS-CoV-2 neutralizing antibody (nAb) titer of 160 (interquartile range (IQR), 80−320). Their median age was 68 years (IQR, 56−78 years), and 62% were males. At enrollment, 55% of patients had an increased body mass index (BMI), and 25.6% had at least three comorbidities. The 28-day crude mortality rate was 12.6% (51/405). Young age (<68 years), mild disease (admission to low-intensity departments) and early treatment (<7 days from symptoms onset) with high nAb titer (≥320) CCP were found as independently associated with a favorable response to CCP treatment. No safety concerns were recorded, with a rate of CCP-related adverse reactions (all of mild intensity) of 1.3%. In our real-life experience, the first in the western world, early administration of high-titer CCP was a safe and effective treatment for hospitalized COVID-19 patients.

Impact of the COVID-19 pandemic on hospitalizations for acute coronary syndromes: a multinational study

BACKGROUND

COVID-19 has challenged the health system organization requiring a fast reorganization of diagnostic/therapeutic pathways for patients affected by time-dependent diseases such as acute coronary syndromes (ACS).

AIM

To describe ACS hospitalizations, management, and complication rate before and after the COVID-19 pandemic was declared.

DESIGN

Ecological retrospective study. Methods: We analyzed aggregated epidemiological data of all patients > 18 years old admitted for ACS in twenty-nine hub cardiac centers from 17 Countries across 4 continents, from December 1st, 2019 to April 15th, 2020. Data from December 2018 to April 2019 were used as historical period.

RESULTS

A significant overall trend for reduction in the weekly number of ACS hospitalizations was observed (20.2%; 95% confidence interval CI [1.6, 35.4] P = 0.04). The incidence rate reached a 54% reduction during the second week of April (incidence rate ratio: 0.46, 95% CI [0.36, 0.58]) and was also significant when compared to the same months in 2019 (March and April, respectively IRR: 0.56, 95%CI [0.48, 0.67]; IRR: 0.43, 95%CI [0.32, 0.58] p < 0.001). A significant increase in door-to-balloon, door-to-needle, and total ischemic time (p <0.04 for all) in STEMI patents were reported during pandemic period. Finally, the proportion of patients with mechanical complications was higher (1.98% vs. 0.98%; P = 0.006) whereas GRACE risk score was not different.

CONCLUSIONS

Our results confirm that COVID-19 pandemic was associated with a significant decrease in ACS hospitalizations rate, an increase in total ischemic time and a higher rate of mechanical complications on a international scale.

Clinical utility of the academic research consortium new proposed criteria for high bleeding risk definition in patients with acute coronary syndromes

Background

The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria have been proposed to stratify the bleeding risk of patients undergoing percutaneous coronary intervention (PCI). While most criteria were established, 4 criteria have been proposed on a de novo basis.

Purpose

We assessed the prevalence and prognosis of new ARC-HBR criteria in a contemporary, prospective, multicenter, quality-improvement registry of all-comers patients with acute coronary syndromes.

Methods

Between 2016 and 2020, consecutive subjects were enrolled; baseline characteristics and medications were prospectively collected, and patients were followed-up at 1 year. All clinical events (including bleeding) were adjudicated by an independent committee. All 17 ARC-HBR criteria were individually evaluated by reviewing patients' charts.

Results

Of the 2804 patients enrolled, 782 (28.0%) met the ARC-HBR definition and 47 (6%) of them experienced a major BARC 3 or 5) bleeding at 1-year. HBR patients had a significantly higher risk of BARC 3–5 bleedings (HR for: 3.07; 95% CI: 2.02–4.67; p&lt;0.0001; Fig. 1A), BARC 2–5 (HR: 1.845; 95% CI: 1.4–2.42; p&lt;0.0001). Fig. 1B indicates the proportion of patients meeting each criterion. Age, (moderate or severe) chronic kidney disease, (moderate or severe) anemia and oral anticoagulant therapy included 88% of HBR patients.

The 4 new ARC-HBR criteria, all together, were present in only 1.7% of our population: 1.0% was planned for major surgery while on dual antiplatelet therapy, 0.5% had a recent intracranial hemorrhage/ictus or brain arteriovenous malformations, 0.1% had hepatic cirrhosis with portal hypertension and 0.1% had a recent surgery or trauma. In a multivariable Cox regression analysis including individual ARC-HBR criteria, only CKD (major and minor criteria), anemia (major and minor criteria) and cancer were the independent predictors of BARC 3–5 events with a concordance-index for this model of 0.698 (p&lt;0.001). In a second model including only CKD (major criterion), anemia (major criterion), age and oral anticoagulation therapy, all these criteria were independent predictors of BARC 3–5 events with a concordance index of 0.674 (pmodel&lt;0.001 for the model) (Fig. 2).

Conclusion

Almost one third of contemporary ACS patients was at HBR according to the ARC-HBR definition and these patients presented a significantly higher risk of bleedings at 1-year. The most common 4 criteria (age, CKD, anemia, and oral anticoagulant therapy) allowed the identification of 88% of HBR patients. The newly proposed HBR criteria were extremely rare and therefore challenging to validate and of uncertain clinical utility. These data may inform and simplify clinical decision making and provide priority for future directions of HBR definitions.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prognosis and prescriptions of glifozines in candidates patients in a prospective, multicenter, quality-improvement study of patients with acute coronary syndrome

Background

Sodium-glucose transporter 2 inhibitors (SGLT2-i) have demonstrated substantial improvement in clinical outcomes for patients with heart failure (HF) and chronic kidney disease (CKD) with or without diabetes mellitus (DM). Prescription patterns and outcome of SGLT2-i candidates in patients hospitalized for an acute coronary syndrome (ACS) are less well established.

Purpose

We aimed to assess the proportion of candidates to SGLT2-i and to characterize their clinical outcome in a contemporary, prospective, multicenter, quality-improvement study of all-comers patients with ACS. We also aimed to ascertain prescriptions of SGLT2-i at discharge.

Methods

Between 2018 and 2020, subjects were enrolled in the study; baseline characteristics and medications were prospectively collected, and patients were followed-up at 1 year. Subjects were considered candidates to SGLT2-i if any of the following were: (i) known (medically treated) or new (HbA1c &gt;6.5%) diagnosis of type 2 DM; (ii) left ventricular systolic dysfunction (LVSD; new or known left ventricular ejection fraction &lt;40%) or clinical HF; (iii) CKD (estimated glomerular filtration rate 25–74 mL/min/m2, according to DAPA-CKD trial eligibility).

Results

Of the 2804 consecutive ACS patients enrolled, 798 (28.5%) had new or known DM and only 10 were already on SGLT2-I at baseline. Additionally, 1,098 (39.2%) patients qualified for SGLT2-i prescription as having known or new LVSD or HF, and 803 (28.6%) as having CKD. (Fig. 1A) Overall, these 1,767 (63.1%) SGLT2-i candidates had substantially higher hazard of death as compared to no candidate (Hazard Ratio [HR] at 1-year: 6.82; 95% Confidence Interval: 4.32–10.8; p&lt;0.001; Fig. 1B) and each indication to SGLT2-i independently predicted death at 1 year (HR: 2.30/2.11/3.06; 95% CI: 1.78–2.97/1.62–2.74/2.35–3.97; all p&lt;0.0001; for DM, HF, CKD, respectively; Fig. 2). At discharge, only 18 (1.0% of the candidates) were prescribed with SGLT2-i and, of those with DM, having a diabetological consultation before discharged modestly but significantly increased the likelihood of being discharged with SGLT2-i (4.3% vs. 6.6%; p=0.0015).

Conclusion

Most (two out of three) contemporary ACS patients are candidates to SGLT2-i therapy, and they have a significant and substantial higher risk of mortality at 1-year as compared to no candidates. Current prescription rates are still extremely low (1%) and highlight opportunity for quality improvement and multidisciplinary decision-making.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Myocardial injury in patients hospitalized for SARS-CoV19: a maker or a marker of prognosis?

Background

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, literature data are progressively accumulating, attesting to the possible prognostic role of cardiac troponins in patients who need hospitalization because of COVID-19 infection.

Purpose

To assess whether myocardial injury (measured by high sensitivity troponins) is an independent cause of disease severity and prognosis.

Methods

We performed a patient-level metanalysis (PROSPERO ID: CRD42020213209) in unselected patients hospitalized because of COVID-19 infection in whom the severity of respiratory failure was also evaluated at admission. To allow for comparison, troponin values were normalized to their threshold levels to obtain a normalized troponin (nTn) value which was used as a continuous variable in all analysis.

Results

A total of 722 patients were included in the analysis. Of note, patients who had elevated troponins at hospital admission had a significantly lower oxygenation status than those with normal nTn (PaO2/FiO2 232±215 vs. 276±124 mmHg/%; p&lt;0.001). On the contrary, those with cardiovascular comorbidities had similar PaO2/FiO2 but higher nTn than those without (5.6817 vs. 2.1110 ng/mL; p=0.002).

After a median follow-up of 14 days, 180 deaths were observed. At multivariable regression analysis, age, male sex, moderate-severe renal dysfunction (eGFR &lt;30 mL/min/m2) and lower PaO2/FiO2, were independent predictor of death (igure 1). The restricted cubic spline curves in Figure 2A and 2B show the hazard ratios (HRs) and 95% confidence interval for death according to nTn and PaO2/FiO2 levels as continuous variables. A linear increase in the HR is observed with lower PaO2/FiO2 values below the normal value of 300. On the contrary, the nTn spline curve is near-flat with large confidence interval for values above the normality thresholds.

Conclusion

In patients hospitalized for COVID-19, mortality is mainly driven by gender, age and respiratory failure while myocardial damage is not an independent predictor of worse survival when respiratory function is accounted for.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Bleeding risk prediction in elderly patients managed invasively for Acute Coronary Syndromes: external validation of the PRECISE-DAPT and PARIS risk scores

Background

Tailoring Dual Antiplatelet Therapy (DAPT) to each patient bleeding and ischemic risk profile is a majopr challenge in everyday clinical practice. As the elderlies were underrepresented in validation cohorts of bleeding risk scores, their generalizability in this context is uncertain.

Purpose

We sought to assess the clinical utility of the PRECISE-DAPT and PARIS bleeding risk scores to elderly patients suffering from ACS and undergoing invasive management.

Methods

Our external validation cohort included 1,883 patients older &gt;74 years admitted for ACS and treated with PCI from 3 multicenter, randomized trials. Bleeding risk scores were calculated on a patient-level and subjects were stratified into risk categories according to each risk score definition.

Results

After a median follow-up of 365 days, patients in the high-risk categories according to the PRECISE-DAPT score experienced a higher rate of BARC 3–5 bleedings (log rank p=0.002) while this was not observed for those in the high-risk category according to the PARIS risk score (log rank p=0.3). Both scores had a moderate discriminative power (c-statistics 0.70 and 0.64, respectively) and calibration was accurate for both risk scores (all χ2&gt;0.05), but PARIS risk score was associated to a greater overestimation of the risk (mean D observed-predicted probability = −0.65 for PRECISE DAPT and −4.62 for PARIS, p=0.02; Figure 1). Decision curve analysis was in favor of the PRECISE-DAPT score up to a risk threshold of 2%. A sensitivity showed that calibration and discrimination power was moderate for both risk scores also after including BARC 2 events.

Conclusion

In the setting of older adults managed invasively for ACS both the PARIS and the PRECISE-DAPT scores were moderately accurate in predicting bleeding risk. However, the use of the PRECISE-DAPT is associated with better performance and a higher net benefit.

Figure 1

Funding Acknowledgement

Type of funding source: None

258Use of low-dose prasugrel vs. clopidogrel in elderly patients undergoing complex or non-complex PCI for acute coronary syndromes: insights from the Elderly ACS 2 study

Background

Prasugrel was superior to clopidogrel in the setting of acute coronary syndromes (ACS) and recent data highlighted its possible role in the setting of complex percutaneous coronary intervention (PCI). Nonetheless, evidence supporting its use in high bleeding risk population are lacking.

Purpose

The aim of this post-hoc subgroup analysis was to evaluate the impact of prasugrel administration in elderly patients undergoing complex PCI for ACS. A primary composite endpoint of composite of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year and secondary endpoints of all-cause mortality and any bleeding at 1 year were analyzed.

Methods

In the multicenter Elderly ACS 2 Study 1,443 patients aged >74 y were randomly assigned to receive low-dose prasugrel (5 mg) or clopidogrel (75 mg) and were prospectively followed for 1 year (Table 1). Complex PCI was defined if ≥3 lesions were treated, if ≥3 stents were deployed, or if any bifurcation, trifurcation, chronic total obstruction or moderate-to-severe calcified lesions were treated.

Results

Patients undergoing complex PCI (n=607) did not experience worse outcome, as compared to those with simpler PCI, in terms of primary endpoint (p=0.21, Figure 1A). Furthermore, in this subgroup, no significant difference was observed with prasugrel vs clopidogrel with regard to the primary endpoint (HR 1.17; CI 0.819–1.67; p=0.39, Figure 1A), all-cause death and bleeding (Figure 1C and 1D). No significant interaction was observed between treatment and PCI complexity (interaction p=0.34).

Table 1 Overall Non-complex PCI Complex PCI p value Age (y) 80.60±4.46 80.00 [77.00, 84.00] 80.00 [77.00, 83.00] 0.215 STE-ACS 595 (41.2) 272 (32.5) 323 (53.4) <0.001 Diabetes mellitus 253 (17.5) 159 (19.0) 94 (15.5) 0.104 LVEF 48.27±9.59 49.08±9.55 47.26±9.54 0.002 Total number of diseased vessels 2.29±1.06 2.22±1.06 2.38±1.05 0.005 Previous Myocardial Infarction 274 (19.0) 171 (20.4) 103 (17.0) 0.122 Randomized to prasugrel 713 (49.4) 404 (48.2) 404 (48.2) 0.307 Data are expressed as mean ± SD or [IQR] and count/valid %).

Figure 1

Conclusions

In elderly patients presenting with ACS low-dose prasugrel was comparable to clopidogrel in terms of all-cause mortality and any bleeding at 1 year.

Acknowledgement/Funding

None

P1781Burden of significant valvular heart disease in elderly patients presenting with acute coronary syndromes

Background

Elderly patients with acute coronary syndromes (ACS) represent a group seldom included in clinical trials and in whom robust data regarding mid-term impact of significant concomitant valvular heart disease are lacking.

Purpose

Our aim was to evaluate the impact of moderate-to-severe mitral regurgitation (MR), moderate-to-severe aortic stenosis (AS), or both conditions combined on a primary composite endpoint of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year in a population of ACS patients included in the Elderly ACS 2 trial.

Methods

In the multicenter Elderly II ACS Study, 1,443 patients aged >74 y undergoing percutaneous coronary intervention (PCI) for ACS, were randomly assigned to receive prasugrel (5 mg) or clopidogrel (75 mg) and were prospectively followed for 1 year. Amongst these, 1,102 patients received full echocardiographic assessment and were included in the post-hoc analysis (Table 1).

Results

Survival analysis showed that patients presenting with moderate-to-severe MR, AS or both (Figure 1A), had worse outcome in terms of primary endpoint (p<0.001) as compared to no valve disease. A multivariable Cox regression model revealed that the presence of moderate-to-severe MR, AS or both were independent predictors of primary endpoint (HR 1.84; HR 2.8; HR 2.9 and p<0.001; p=0.004; p=0.01, respectively), regardless of age, gender, left ventricular ejection fraction, diabetes mellitus, history of cancer and total number of diseased vessels (Figure 1B).

Table 1 Overall No residual valvular heart disease Moderate-to-severe MR Moderate-to-severe AS Both Age (y) 80.68±4.50 80.40±4.42 81.47±4.45 82.92±5.42 83.23±5.42 Male gender 652 (59.2) 538 (61.6) 92 (48.4) 19 (73.1) 3 (23.1) STE-ACS 420 (38.1) 319 (36.5) 91 (47.9) 6 (23.1) 4 (30.8) Diabetes mellitus 203 (18.4) 158 (18.1) 35 (18.4) 5 (19.2) 5 (38.5) LVEF (%) 48.30±9.58 49.26±9.27 44.61±9.45 48.50±11.22 38.31±10.87 History of cancer 32 (2.9) 26 (3.0) 3 (1.6) 2 (7.7) 1 (7.7) Tot number of diseased vessel 2.31±1.05 2.28±1.04 2.49±1.05 2.04±0.87 2.54±1.13 Data are expressed as mean ± SD or count (valid %).

Figure 1

Conclusions

Moderate-to-severe MR and AS represent significant predictors of 1-year outcome in elderly patients hospitalized for ACS, even when other well-established prognostic factors are taken into account and after revascularization with PCI. Therefore, these patients should be carefully screened for the presence of valvular heart disease at the time of presentation and the need for surgical or percutaneous correction should be assessed accordingly.

Acknowledgement/Funding

None

P970DK-crush is the best treatment strategy to reduce stent oriented clinical outcome, results from a network meta-analysis of twenty-six randomized clinical trials comparing different stent techniques

Background

Coronary bifurcation disease (CBD) accounts for approximately 20% of all and is associated with worse short- and long- term clinical outcomes. Provisional stenting (PS) is the preferred choice, however, this approach may not be suitable in all CBD anatomies, therefore several elective two-stents techniques have been described, however there is lack of randomized evidence to guide interventionalist across different stent techniques. Objectives. To identify the best percutaneous coronary interventions (PCI) technique for CBD.

Methods

We systematically review randomized clinical (RCTs) of patients receiving CBD PCI with either PS or six type of elective two-stent techniques (DK-crush, TAP, culotte, dedicated bifurcation stents, crushing, T-stenting) and compare device oriented clinical events (DOCE) in a network meta-analysis. DOCE was defined as composite of cardiac death, target-vessel myocardial infarction, stent thrombosis, target lesion revascularization OR target vessel revascularisation.

Results

We included 26 RCTs leading to a pooled population of 10339 patients-years with 1229 DOCE. Compared to PS, the DK-crush technique had a lower DOCE with RR=0.62, [0.42–0.92]. Figure. DK-crush had the highest likelihood (model likelihood=90.2%, SUCRA=98.0%) of being the best treatment to reduce DOCE.

Figure 1

Conclusions

In the management CBD, when a two-stent technique is required as upfront strategy, the DK- Crush technique should be privileged as it showed to reduce stent-related clinical outcomes (DOCE) when compared to other bifurcation techniques.

P1856Percutaneous mitral edge-to-edge valvuloplasty in end-stage heart failure as a bridge to heart transplant: a case series from a single tertiary referral center

Background

Improved outcomes after percutaneous edge-to-edge mitral valvuloplasthy with MitraClip implantation were recently observed in patients with heart failure (HF) and functional severe mitral regurgitation (MR). Nonetheless, its efficacy in end-stage heart failure (HF) are lacking.

Purpose

Our aim was to investigate feasibility, preliminary efficacy on hemodynamics and follow-up of MitraClip implantation in a cohort of patients with very advanced HF.

Methods

Patients were retrospectively included in the present analysis if already in HT list, unsuitable for HT despite optimal medical and device therapy, or if implantation was a “bridge-to-candidacy”.

Results

Baseline and procedural characteristics are listed in Table 1; MR etiology was predominantly functional (n=7). No major complications were observed in the peri-operative period. At 6-month follow-up, invasive hemodynamics was available for 8 patients. A significant increase in cardiac index was observed (Least Square Mean Difference, LSMD = +0.47 L/min/m2; p=0.03; Figure 1), in conjunction with a numerical reduction in pulmonary vascular resistance (LSMD = −1.02 WU; p=0.3), a trend towards lower mean pulmonary arterial pressure (LSMD = −6.5 mmHg; p=0.053) and lower ejection fraction (LSMD = −6.5%; p=0.053). At a median follow-up of 772 days (IQR 156–1,578), all three patients unsuitable for HT at baseline could be eligible to HT list and one of them received LVAD. Moreover, two patients were transplanted, four experienced unplanned rehospitalization for HF, and one died of non-cardiac cause.

Table 1. Baseline clinical evaluation (n=10) Age (y) 53.67±8.43 HF Etiology – post ischemic 4 (40) Male sex 6 (60) HF Etiology – no CAD 4 (40) Body Surface Area (m2) 1.76±0.22 HF Etiology – other 2 (20) Chronic Resynchronization Therapy 5 (50) Euroscore II 6.00±2.74 Baseline MR grade (+) 4 (40) STS mortality 1.71±2.65 Residual MR grade (+) 1.71±0.49 Clips implanted (number) 1.78±0.67 Data are expressed as mean ± SD or count (valid %). MR scored on a scale from 0+ to 4+. STS, Society of Thoracic Surgeons.

Figure 1

Conclusions

Percutaneous edge-to-edge mitral valvuloplasty with MitraClip appears safe and effective in end-stage patients, impacts on clinical decision-making and therefore might be considered as a “bridge” towards a more definite strategy.

Acknowledgement/Funding

None

Fluorescence-determined kinetics of plasma high oxidability in diabetic patients

The peroxidative potential of whole plasma was studied in thirteen control subjects and twenty-three diabetic patients divided into two groups on the basis of their metabolic control, defined as good (n = 12) or poor (n = 11) according to the fasting blood glucose, glycated hemoglobin and fructosamine levels. The amounts of thiobarbituric reactive substances (TBARS) were determined before and after an exhaustive peroxidation induced by incubation with cupric sulfate; the kinetics of Cu-dependent plasma peroxidation, determined by the time course of endogenous fluorescence emission at 430 nm, were also evaluated. Our data indicate that in diabetic patients, and particularly in those with a long-lasting poor metabolic control, a significant increase in plasma susceptibility to peroxidative stress is evident only when we consider the lag-time of fluorescence emission in the course of Cu-induced plasma peroxidation. A good inverse correlation was observed between the lag-time and the blood glucose concentration, the glycated hemoglobin and the fructosamine blood levels. Furthermore a multivariate analysis, performed by Principal Component Analysis, strongly supports the relation between the extent and duration of the diabetic pathology, and the decrease in the lag-time of oxidation.

A clinical assessment of the potential for pharmacological interaction between nimesulide and digoxin in patients with heart failure

The potential interaction between nimesulide, a nonsteroidal anti-inflammatory drug, and digoxin was studied in 9 patients [6 males, 3 females; mean age 67 (range 57 to 70) years] with mild heart failure. All patients were receiving maintenance therapy with digoxin (0.25 mg/day, orally) and were treated with oral nimesulide 100mg twice daily for 7 days. Blood samples were collected at 8am and 6pm for 4 days before and throughout the nimesulide treatment period for determination of serum digoxin concentrations. Physical health, electrocardiographic recordings and blood and urine samples were also monitored. Mean serum digoxin concentrations remained within the normal therapeutic range throughout the study despite large interindividual variation. Furthermore, there were no significant differences between the morning and afternoon serum digoxin concentrations and there was no major change in the clinical condition of any patient. These results indicate that short term administration (7 days) of conventional therapeutic doses of nimesulide (100mg twice daily) does not modify the serum digoxin profile in patients with low class heart failure treated with a maintenance dose (0.25 mg/day) of this cardiac glycoside.

Effects of slow release bezafibrate on the lipid pattern and on blood glucose of type 2 diabetic patients with hyperlipidaemia

Ninety-eight type 2 diabetic patients with hyperlipidaemia in stable metabolic control with diet alone (41) or diet plus hypoglycaemic agents (57) were divided into two groups: group 1 was put on treatment with slow release bezafibrate 400 mg a day, while group 2 was considered as control. In group 1, after 1 month of bezafibrate, serum triglycerides fell by 47% and cholesterol by 13%. HDL cholesterol showed a non-significant trend toward an increase. Fasting blood glucose significantly decreased by 6%, fructosamine and glycated haemoglobin by 5%. During OGTT, the area under the curve of both serum C-peptide and blood glucose showed a trend toward a decrease after bezafibrate. However, the difference did not reach statistical significance. Thirty-six patients continued the treatment with the drug for 4 months and 23 for 8 months, without further changes of the lipid pattern and glycaemic control. In the control group no significant variation of the lipid levels occurred and diabetic control slightly worsened during the study. Bezafibrate has been proved to be effective in the treatment of hyperlipidaemia in type 2 diabetic patients. The drug seems moreover to improve glycaemic control. The mechanism by which bezafibrate produces this latter effect remains to be elucidated, though an increase of peripheral insulin sensitivity might be suggested.

[Grade II and III acute pancreatitis. Diagnostic classification and surgical treatment]

Thirteen cases of acute IIIrd degree pancreatitis and 5 homogeneous cases of IInd degree, treated surgically during the first 48 hours from onset of the symptomatology, are described. The importance of careful cardiorespiratory, haemodynamic and metabolic monitoring to establish the most appropriate moment for intervention after a period of intensive therapy designed to restore the basic parameters is stressed. In the present series, total mortality was 44%. Forms with biliary aetiology have the best prognosis and justify the earliest possible surgical intervention.