Differences between cardiogenic shock related to acute decompensated heart failure and acute myocardial infarction

AIMS

The present analysis from the multicentre prospective Altshock-2 registry aims to better define clinical features, in-hospital course, and management of cardiogenic shock complicating acutely decompensated heart failure (ADHF-CS) as compared with that complicating acute myocardial infarction (AMI-CS).

METHODS AND RESULTS

All patients with AMI-CS or ADHF-CS enrolled in the Altshock-2 registry between March 2020 and February 2022 were selected. The primary objective was the characterization of ADHF-CS patients as compared with AMI-CS. In-hospital length of stay and mortality were secondary endpoints. One-hundred-ninety of the 238 CS patients enrolled in the aforementioned period were considered for the present analysis: 101 AMI-CS (80% ST-elevated myocardial infarction and 20% non-ST-elevated myocardial infarction) and 89 ADHF-CS. As compared with AMI-CS, ADHF-CS patients were younger [63 (IQR 59-76) vs. 67 (IQR 54-73) years, P = 0.01], but presented with higher creatinine [1.6 (IQR 1.0-2.6) vs. 1.2 (IQR 1.0-1.4) mg/dL, P < 0.001], bilirubin [1.3 (IQR 0.9-2.3) vs. 0.6 (IQR 0.4-1.1) mg/dL, P = 0.01], and central venous pressure values [14 mmHg (IQR 8-12) vs. 10 mmHg (IQR 7-14),P = 0.01]. Norepinephrine was the most common catecholamine used in AMI-CS (79.3%), whereas epinephrine was used more commonly in ADHF-CS (65.5%); 75.8% vs. 46.6% received a temporary mechanical support in AMI-CS and ADHF-CS, respectively (P < 0.001). Length of hospital stay was longer in the latter [28 (IQR 13-48) vs. 17 (IQR 9-29) days, P = 0.001]. Heart replacement therapies were more frequently used in the ADHF-CS group (heart transplantation 13.5% vs. 0% and left ventricular assist device 11% vs. 2%, P < 0.01 and 0.01, respectively). In-hospital mortality was 41.1% (38.6% AMI-CS vs. 43.8% ADHF-CS, P = 0.5).

CONCLUSIONS

ADHF-CS is characterized by a higher prevalence of end-organ and biventricular dysfunction at presentation, a longer hospital length of stay, and higher need of heart replacement therapies when compared with AMI-CS. In-hospital mortality was similar between the two aetiologies. Our data warrant development of new management protocols focused on CS aetiology.

Updates in Small Interfering RNA for the Treatment of Dyslipidemias

PURPOSE OF REVIEW

Atherosclerotic cardiovascular disease (ASCVD) is still the leading cause of death worldwide. Despite excellent pharmacological approaches, clinical registries consistently show that many people with dyslipidemia do not achieve optimal management, and many of them are treated with low-intensity lipid-lowering therapies. Beyond the well-known association between low-density lipoprotein cholesterol (LDL-C) and cardiovascular prevention, the atherogenicity of lipoprotein(a) and the impact of triglyceride (TG)-rich lipoproteins cannot be overlooked. Within this landscape, the use of RNA-based therapies can help the treatment of difficult to target lipid disorders.

RECENT FINDINGS

The safety and efficacy of LDL-C lowering with the siRNA inclisiran has been documented in the open-label ORION-3 trial, with a follow-up of 4 years. While the outcome trial is pending, a pooled analysis of ORION-9, ORION-10, and ORION-11 has shown the potential of inclisiran to reduce composite major adverse cardiovascular events. Concerning lipoprotein(a), data of OCEAN(a)-DOSE trial with olpasiran show a dose-dependent drop in lipoprotein(a) levels with an optimal pharmacodynamic profile when administered every 12 weeks. Concerning TG lowering, although ARO-APOC3 and ARO-ANG3 are effective to lower apolipoprotein(apo)C-III and angiopoietin-like 3 (ANGPTL3) levels, these drugs are still in their infancy. In the era moving toward a personalized risk management, the use of siRNA represents a blossoming armamentarium to tackle dyslipidaemias for ASCVD risk reduction.

1128 CLINICAL CHARACTERISTICS AND MANAGEMENT OF CARDIOGENIC SHOCK IN PATIENTS ELIGIBLE FOR CARDIAC TRANSPLANTATION AND LEFT VENTRICULAR ASSIST DEVICE

Aims

to describe epidemiology, clinical characteristics and treatment modalities adopted in a cohort of patients eligible for cardiac transplantation or left ventricular assist device implantation admitted for cardiogenic shock atour center. Secondly, to identify clinical risk factors for in-hospital mortality to evaluate the role of surgical treatment options (cardiac transplantation and L-VAD implant) as modifiers of prognosis in this patient population.

Methods

We retrospectively identified discharge charts containing ICD-9 codes of cardiogenic shock (785.51) and IABP implantation (37.61) at our center in the period 2016-2021. Patients were considered eligible in the age rage 18-70 years old, according to the upper age limit of cardiac transplant and LVAD program. Patients presenting with cardiogenic shock after cardiac surgery, cardiogenic shock secondary to acute pulmonary embolism and acute aortic syndrome or patients needing IABP placement as preventive support for high-risk percutaneous or surgical myocardial revascularization procedures were excluded.

Results

163 patients were included in the study (mean age 56 years, 80% male). In this cohort of patients, the most common etiologies were represented by coronary artery disease (64% of patients) and cardiomyopathy (26% of patients), mostly idiopathic dilated forms followed by hypertrophic cardiomyopathy and cardiac amyloidosis. The remaining 10% of patients were affected by other forms of cardiac disease (which included acute myocarditis and cancer therapy-related CV toxicity). Diabetes mellitus and hypertension were the most common CV risks factors. Acute coronary syndrome was the underlying cause in 45% patients presenting with cardiogenic shock, while 56% of CS cases were due to acute decompensated heart failure not in the setting of ACS. Most patients (80%) were supported with IABP alone, while 10% needed cardiocirculatory support with ECMO. Regarding outcome, in-hospital mortality for CS was 30% (48 patients), while 36 patients (22%) underwent surgical treatment of heart failure with cardiac transplantation (21 patients) or L-VAD implantation (15 patients). Predictors of in-hospital mortality at univariate analysis were older age, lower eGFR at the time of shock (p=0,0001), persistence of elevated blood lactates &gt; 2 at CS presentation and at 24 hours (p=0,0001), and a failure to improve in renal impairment at 24 hours. Multivariate analysis identified lower eGFR and high lactates at 24 hours as independent risk factors for in-hospital mortality.

Conclusions

cardiogenic shock still remains a high-mortality condition. Mechanical circulatory support could provide stabilization and bridge to urgent cardiac transplantation and L-VAD implantation in order to improve prognosis. There is still need for diagnostic and therapeutic protocols standardized to improve the prognostic stratification and survival of patients with cardiogenic shock.

1119 INTRA-AORTIC BALLOON PUMP AS BRIDGE TO HEART REPLACEMENT THERAPY IN CARDIOGENIC SHOCK COMPLICATING CHRONIC HEART FAILURE

Background

Temporary mechanical circulatory support (MCS) could provide stabilization and improve prognosis in selected patients with cardiogenic shock (CS). Intra-aortic balloon pump (IABP) is a common percutaneous MCS device, characterized by wide availability, easy deployment and low complication rate. Despite its use in CS caused by acute myocardial infarction has been discouraged based on available evidence, recent data have renewed the interest in IABP as bridge to heart replacement therapy (HRT; heart transplantation or durable LVAD implant) in patients with cardiogenic shock complicating acutely decompensated chronic heart failure. We sought to review our experience with IABP support in this population eligible for HRT at a large-volume transplant center.

Methods

We retrospectively reviewed all adult patients (&gt; 18 years old) who received IABP at our center between 2016 and 2021. We included patients with chronic heart failure with reduced ejection fraction (LVEF &lt; 40% for at least 3 months) eligible for heart replacement therapy (i.e. &lt; 70 years old). Primary endpoint was IABP success defined as weaning to discharge or successful bridge to HRT without need for MCS escalation. In addition, in-hospital mortality without HRT and MCS complications were assessed.

Results

Study population consisted of 49 patients with mean age of 54±9 years, 84% of whom were male. Etiology was non-ischemic dilated cardiomyopathy in 72% of patients and mean LVEF was 19±5%. 12 patients (24%) were already listed for heart transplantation. 26 patients (53%) developed cardiogenic shock during hospitalization for acutely decompensated heart failure, while the others presented CS upon admission. IABP success was achieved in 32 (65%) of patients, of whom 13 (39%) were bridged to heart transplantation, 6 (18%) to durable LVAD, while 13 (43%) were weaned from support and discharged. 11 patients (22%) died without MCS upgrade or HRT, including one death occurring 18 days after IABP weaning. 6 patients (12%) required escalation of mechanical circulatory support: 5 with extracorporeal membrane oxygenator (ECMO), 2 of whom were transplanted, and 1 with axillary-implanted Impella 5.0 as effective bridge to durable LVAD. In-hospital mortality without HRT was 28%. Median duration of IABP support was 8 days (0-107). 66% of patients were treated with at least one and 12% with two or more inotropes. Complications occurred in 4 (9%) patients in IABP group, including 3 cases of limb ischemia without sequelae and one fatal bleeding not related to insertion site. Ischemic and bleeding complications were found in 4 out of 5 ECMO-supported patients. Among demographic and laboratory characteristics assessed at baseline and after 24 hours from shock, persistence of increased lactates (&gt;2 mmol/l) at 24 hours and number of inotropic drugs were independently associated with both IABP failure and mortality.

Conclusions

In patients with cardiogenic shock complicating chronic heart failure, IABP appears a safe and effective bridge strategy to heart replacement therapy with favorable outcomes and acceptable complication rates. Persistence of markers of hypoperfusion and increased need for cardioactive drugs are associated with worse outcomes and should trigger evaluation for MCS escalation. More studies are needed to fully characterize the role and timing of IABP support in this clinical scenario.

665 THE UNFORSEEN MECHANISM: A CASE OF DISTRIBUTIVE SHOCK SECONDARY TO REACTIVE HAEMOPHAGOCYTIC SYNDROME LEADING TO SEVERE REVERSIBLE BIVENTRICULAR DYSFUNCTION

Distributive shock comprises a variety of processes causing dysregulated vasodilation with consequent life-threatening end-organ dysfunction. While sepsis constitutes by far its most common aetiology, other pathological mechanisms with different therapeutic targets may lead to a similar haemodynamic picture.

We hereby present the case of a 35-year-old male with no past cardiological history and a recent diagnosis of stage IVsB Hodgkin's lymphoma relapse 10 years after effective disease eradication with first-line chemotherapy. Shortly after a single cycle of second-line chemotherapy, the patient presented with high fever, acute chest pain and dyspnea associated with marked hypotension and sinus tachycardia. Laboratory tests revealed pancytopenia and raised inflammatory markers as well as evidence of acute kidney injury and hepatocellular damage. Urgent thoracic CT revealed no signs of pneumonia while echocardiography demonstrated severe biventricular dysfunction with 25% left ventricular ejection fraction and severe functional mitral regurgitation. Due to worsening tachypnea and desaturation the patient was intubated and transferred to our Intensive Cardiac Care Unit where urgent instatement of circulatory support with iv fluids, blood transfusions, adrenaline and intra-aortic balloon pump were performed and empirical broad-spectrum antibiotic therapy was started after performing blood cultures from peripheral and central veins. Concurrent right ventricular catheterisation demonstrated high-output cardiac failure (Qs Fick 7.89 Qp/m2, Qs thermodilution 8.0 Qp/m2) with mild increase in biventricular filling pressures and post-capillary pulmonary hypertension. Endomyocardial biopsy in turn revealed only mild subendocardial fibrosis and oedema thus excluding myocarditis as a potential cause for the severe biventricular dysfunction. Due to worsening of renal function with persistent anuria despite circulatory support the patient required continuous veno-venous haemofiltration. Notably, over the coming days no pathogen was isolated from any of the cultures with haemodynamic and respiratory parameters gradually improving, allowing for weaning from circulatory and respiratory support. On further examination of blood tests on admission, hypertriglyceridemia, raised ferritin levels and thrombin consumption were noted. These biochemical features, together with the history of Hodgkin's lymphoma relapse, recent chemotherapy, pancytopenia and splenomegaly, suggestive of natural killer cell dysfunction-related haemophagocytosis, pointed to reactive haemophagocytic syndrome as a potential aetiology of the severe distributive shock (&gt; 99% probability on recently published “HS Score” for Reactive Haemophagocytic Syndrome). This hypothesis was further corroborated by the gradual albeit not complete regression of the severe biventricular dysfunction after haemodynamic support suggesting that this may have represented a byproduct of the patient's high-output state. Unfortunately, due to lymphoma progression with severe multiorgan involvement the patient was admitted shortly after discharge and deceased thereafter.

This case provides an example of the diversity of potential disease mechanisms underlying distributive shock where biventricular dysfunction may represent a reversible albeit severe bystander rather than the true driving factor of its life-threatening haemodynamic compromise.

Prognostic value of high-sensitivity cardiac troponin I early after coronary artery bypass graft surgery

BACKGROUND

The diagnosis of periprocedural myocardial infarction (PMI) after coronary artery bypass graft (CABG) is based on biochemical markers along with clinical and instrumental findings. However, there is not a clear cutoff value of high-sensitivity cardiac troponin (hs-cTn) to identify PMI. We hypothesized that isolated hs-cTn concentrations in the first 24 h following CABG could predict cardiac adverse events (in-hospital death and PMI) and/or left ventricular ejection fraction (LVEF) decrease.

METHODS

We retrospectively enrolled all consecutive adult patients undergoing CABG, alone or in association with other cardiac surgery procedures, over 1 year. Hs-cTn I concentrations (Access, Beckman Coulter) were serially measured in the post-operative period and analyzed according to post-operative outcomes.

RESULTS

300 patients were enrolled; 71.3% underwent CABG alone, 33.7% for acute coronary syndrome. Most patients showed hs-cTn I values superior to the limit required by the latest guidelines for the diagnosis of PMI. Five patients (1.7%) died, 8% developed a PMI, 10.6% showed a LVEF decrease ≥ 10%. Hs-cTn I concentrations did not significantly differ with respect to death and/or PMI whereas they were associated with LVEF decrease ≥ 10% (p value < 0.005 at any time interval), in particular hs-cTn I values at 9-12 h post-operatively. A hs-cTn I cutoff of 5556 ng/L, a value 281 (for males) and 479 (for females) times higher than the URL, at 9-12 h post-operatively was identified, representing the best balance between sensitivity (55%) and specificity (79%) in predicting LVEF decrease ≥ 10%.

CONCLUSIONS

Hs-cTn I at 9-12 h post-CABG may be useful to early identify patients at risk for LVEF decrease and to guide early investigation and management of possible post-operative complications.

Author Correction: Antihypertensive treatment with calcium channel blockers and renal protection: focus on lercanidipine and lercanidipine/enalapril

Correction to: European Review for Medical and Pharmacological Sciences 2022; 26 (20): 7482-7492. DOI: 10.26355/eurrev_202210_30018-PMID: 36314318, published online on October 28, 2022. After publication, the authors applied some corrections to the text: - The section "Clinical Oharmacology of Lercanidipine" has been corrected into "Clinical Pharmacology of Lercanidipine" - The Legend of Figure 2 has been corrected as follows: Ca T-type channels vs. Ca L-type channels selectivity ratio. LAC, lacidipine, AML, amlodipine; MIB, mibefradil; LER, lercanidipine; *p<0.05, ** p<0.01 vs. LAC (low concentrations); †p<0.01 LAC vs. all other CCBs (high concentrations). Source: Modified from 25. - The reference 25 has been changed into: Hart P, Bakris GL. Calcium antagonists: Do they equally protect against kidney injury? Kidney Int 2008; 73: 795-796. There are amendments to this paper. The Publisher apologizes for any inconvenience this may cause. https://www.europeanreview.org/article/30018.

Clinical profile and in-hospital outcome of patients supported by intra-aortic balloon pump in the clinical setting of cardiogenic shock according to aetiology

Background

Despite controversial evidence, intra-aortic balloon pump (IABP) is still the most used temporary mechanical support in cardiogenic shock (CS), as a bridge to recovery or to more advanced mechanical support and/or heart transplantation [1]. Indeed, the available evidence, which is mainly restricted to the context of acute coronary syndromes (ACS) and is limited by the variability of CS definitions, shows no benefit in terms of mortality [2]. Randomized controlled trials on IABP in the setting of non-ACS CS are still missing. As a result, European guidelines do not recommend the routine use of IABP, which may be considered in refractory CS [3].

Purpose

The aim of our study was to analyse the use of IABP in the context of CS, providing insights into its indications, outcomes, and complications in relation to the aetiology (ACS vs non-ACS) of CS.

Methods

We retrospectively enrolled all consecutive adult patients receiving IABP for refractory CS at our tertiary referral Hospital between 2009 and 2018, and analysed data focusing on in-hospital outcomes, including death, recovery, heart transplantation, and escalation to more advanced mechanical support such as venoarterial extracorporeal membrane oxygenation (VA-ECMO) or left ventricular assist device (LVAD), and on IABP-related complications.

Results

403 patients received IABP, 75.2% (n=303) for ACS CS and 24.8% (n=100) for non-ACS CS. With respect to ACS patients, non-ACS patients were younger (age 59±18.3 vs 73.1±12.6 years old, p&lt;0.001), had a lower left ventricular ejection fraction (LVEF) [25% (IR 18–35%) vs 38% (IR 25–45%), p&lt;0.001], were supported by IABP for longer time [6 (IR 2–18) vs 2 (IR 1–4) days, p&lt;0.001], required more use of inotropes/vasoconstrictors [80.0% (n=80) vs 33.8% (n=102), p&lt;0.001], and needed more often escalation to VA-ECMO [23.0% (n=23) vs 1.3% (n=4), p&lt;0.001]. Non-ACS patients showed higher in-hospital mortality than ACS patients [46.0% (n=46) vs 33.9% (n=103), p=0.042]. Non-ACS patients were more frequently bridged to heart transplantation [20.0% (n=20) vs 0.3% (n=1), p&lt;0.001] or LVAD [4.0% (n=4) vs 0.6% (n=2), p=0.055] than ACS patients; mortality after transplantation/LVAD did not significantly differ between the two groups [12.5% (n=3/24) vs 66.7% (n=2/3), p&gt;0.05]. The incidence of IABP-related overall and major complications (including ischemic stroke, major bleeding, and peripheral or visceral ischemia) was not different with respect to the non-ACS vs ACS aetiology [major complications: 8.0% (n=8) vs 5.0% (n=15), p&gt;0.05].

Conclusions

In our experience, in the clinical setting of CS treated with IABP, non-ACS patients show a worse clinical profile and prognosis than ACS patients, and more often require escalation to more advanced mechanical support and/or heart transplantation, while the incidence of IABP-related complications appears similar independently of the aetiology.

Funding Acknowledgement

Type of funding sources: None.

Antihypertensive treatment with calcium channel blockers and renal protection: focus on lercanidipine and lercanidipine/enalapril

OBJECTIVE

The aim of the study was to review the literature on clinical pharmacology of lercanidipine and experimental and clinical evidence and evaluate its ability to reduce proteinuria and preserve renal function when used as monotherapy or in combination with the angiotensin-converting enzyme (ACE) inhibitor enalapril.

MATERIALS AND METHODS

MEDLINE/PubMed was searched for appropriate keywords.

RESULTS

Lercanidipine, a third-generation calcium channel blocker, has been shown to have a unique pharmacological and clinical profile, which translates into favorable renal hemodynamic changes. The fixed-dose combination lercanidipine/enalapril has been proposed to overcome unmet therapeutic needs, often as the initial treatment in the high-risk patient.

CONCLUSIONS

Lercanidipine may be regarded as an ideal antihypertensive drug for patients at renal risk and possibly the preferred choice among calcium channel blocker drugs.

Clinical profile and in-hospital outcome of patients supported by intra-aortic balloon pump in the clinical setting of cardiogenic shock

Background

Despite controversial evidences, intra-aortic balloon pump (IABP) is still the most widely used temporary mechanical support device in cardiogenic shock (CS), as a bridge to recovery or to more invasive mechanical supports/heart transplantation.

Methods

We analyzed retrospectively data of all patients receiving IABP for CS from 2009 to 2018 in a referral centre for advanced heart failure and heart transplantation; we included CS following acute coronary syndrome (ACS) and other CS etiologies different from ACS. We excluded patients in which IABP was implanted as a support following cardiac surgery, non-cardiac surgery in patients with severe chronic heart failure, or in elective high risk or complicated Cath Lab procedures.We focused on in-hospital outcomes (including death, recovery, heart transplantation, LVAD) and IABP complications.

Results

403 patients received IABP, 303 (75.2%) following ACS and 100 (24.8%) in non-ACS CS. Non-ACS patients were younger (59 ± 18.3 vs 73.1 ± 12.6 years, p < 0.001), had lower median left ventricular ejection fraction (LVEF) (25% [18-35] vs 38% [25-45], p < 0.001). In patients with non-ACS etiologies IABP was more frequently a bridge to heart transplantation [20% (n = 20) vs 0.3% (n = 1), P < 0.001] or LVAD [4% (n = 4) vs 0.6% (n = 2), P = 0.055], while ACS patients were more frequently discharged without transplantation/LVAD [65.7% (n = 199) vs 33% (n = 33), P < 0.001]. Non-ACS patients showed higher in-hospital mortality [46% (n = 46) vs 33.9% (n = 103), P = 0.042]. Post-transplant/LVAD outcome in non-ACS subgroup was favorable (21 out of 24 patients were discharged). Serious IABP-related adverse events occurred in 21 patients (5.2%). Ischemic/hemorrhagic complications, infections and thrombocytopenia were more frequent with longer IABP stay.

Conclusions

Despite therapy including percutaneous circulatory support, mortality in CS is still high. In our experience, in the clinical setting of refractory CS an IABP support represents a relatively safe circulatory support, associated with a low rate of serious complications in complex clinical scenarios.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

222 Prognostic value of high-sensitivity cardiac troponin I early after coronary artery bypass graft surgery

Aims

The diagnosis of periprocedural myocardial infarction (PMI) after coronary artery bypass graft (CABG) is based on biochemical markers along with clinical and/or instrumental findings. However, there is not a clear cut-off value of high-sensitivity cardiac troponin (hs-cTn) to identify PMI. We hypothesized that isolated hs-cTn concentrations in the first 24 h following CABG could predict cardiac adverse events (in-hospital death and PMI) and/or left ventricular ejection fraction (LVEF) decrease.

Methods and results

We retrospectively enrolled all consecutive adult patients undergoing CABG at our Institution over 1 year. Hs-cTnI concentrations (Access assay, Beckman-Coulter) were serially measured in the post-operative period and correlated with post-operative outcomes. 300 patients were enrolled; 71.3% of them underwent CABG alone, mainly on-pump (96.7%), 33.7% in the setting of an acute coronary syndrome. Most patients showed hs-cTnI values superior to the limit required by the latest guidelines for the diagnosis of PMI. Five patients (1.7%) died, 8% developed a PMI, and 10.6% showed a LVEF decrease ≥10%. Hs-cTnI concentrations did not correlate with death or PMI whereas they did correlate with LVEF decrease ≥ 10% (P-value &lt; 0.05 at any time interval). Indeed, higher hs-cTnI values at 9–12 h post-operatively, along with previous cardiac surgery, number of surgical procedures, longer cardiopulmonary bypass time, and PMI diagnosis were predictors of LVEF decrease.

Conclusions

After CABG surgery, hs-cTnI at 9–12 h post-operatively may be a useful method to early identify patients at risk for LVEF decrease and to guide early investigation and management of possible post-operative complications.

Maternal exposure to air pollutants, PCSK9 levels, fetal growth and gestational age - An Italian cohort

OBJECTIVE

Exposure to airborne pollutants during pregnancy appears to be associated with uterine growth restriction and adverse neonatal outcome. Proprotein convertase subtilisin/kexin type (PCSK9), the key modulator of low-density lipoprotein (LDL) metabolism, increases following particulate matter (PM₁₀) exposure. Because maternal cholesterol is required for fetal growth, PCSK9 levels could be used to evaluate the potential impact of airborne pollutants on fetal growth.

DESIGN

A cohort of 134 healthy women during early pregnancy (11-12 weeks of gestational age) was studied.

RESULTS

A significant association between circulating PCSK9 levels and three tested air pollutants (PM₁₀, PM_2.5, nitric oxide (NO₂)) was found. Of importance, gestational age at birth was reduced by approximately 1 week for each 100 ng/mL rise in circulating PCSK9 levels, an effect that became more significant at the highest quartile of PM_2.5 (with a 1.8 week advance in delivery date for every 100 ng/mL rise in circulating PCSK9; p for interaction = 0.026). This finding was supported by an elevation of the odds ratio for urgent cesarean delivery for each 100 ng/mL rise in PCSK9 (2.99, 95% CI, 1.22-6.57), similar trends being obtained for PM₁₀ and NO₂.

CONCLUSIONS

The association between exposure to air pollutants during pregnancy and elevation in PCSK9 advances our understanding of the unforeseen influences of environmental exposure in terms of pregnancy associated disorders.

Recombinant human thyrotropin stimulation test in 114 dogs with suspected hypothyroidism: a cross-sectional study

OBJECTIVE

To evaluate the performance and define cut-offs for the interpretation of a thyroid-stimulating hormone (TSH) stimulation test with a recombinant human TSH dose of 75 μg/dog administered intravenously in dogs with suspected hypothyroidism.

MATERIALS AND METHODS

Cross-sectional study. Medical records of dogs presented for suspected hypothyroidism were retrospectively reviewed. Animals were included if a TSH stimulation test with a recombinant human TSH dose of 75 μg/dog was performed and follow-up was available. Dogs with a post-TSH serum total thyroxine (T4) level of ≥2.2 μg/dL were considered euthyroid. Dogs with a post-TSH T4 level of <2.2 μg/dL were classified as hypothyroid or euthyroid based on follow-up, including response to levothyroxine supplementation. A receiver operating characteristic curve analysis was used to define the performance of the test.

RESULTS

One hundred and fourteen dogs were included. Forty were classified as hypothyroid and 74 as euthyroid. Post-TSH T4 cut-offs of 1.3 and 1.7 μg/dL showed sensitivities of 92.5 and 100% and specificities of 97.3 and 93.2%, respectively. Post-TSH T4 levels of >1.7 μg/dL had a negative predictive value of 100%. Post-TSH T4 levels of <1.3 μg/dL showed a positive predictive value of 94.9%. Area under the ROC curve for post-TSH T4 was 0.99.

CLINICAL SIGNIFICANCE

A TSH stimulation test performed with a recombinant human TSH dose of 75 μg/dog is highly reliable to discriminate between hypothyroid and euthyroid dogs, even in cases of concurrent non-thyroidal illness or administration of medications. A post-stimulation T4 concentration of >1.7 μg/dL is suggestive of normal thyroid function.

Depression and cardiovascular risk-association among Beck Depression Inventory, PCSK9 levels and insulin resistance

BACKGROUND

Depression and cardiovascular disease (CVD) are among the most common causes of disability in high-income countries, depression being associated with a 30% increased risk of future CV events. Depression is twice as common in people with diabetes and is associated with a 60% rise in the incidence of type 2 diabetes, an independent CVD risk factor. Proprotein convertase subtilisin/kexin type 9 (PCSK9), a key regulator of low-density lipoprotein cholesterol, has been related to a large number of CV risk factors, including insulin resistance. Aim of this study was to investigate whether the presence of depression could affect PCSK9 levels in a population of obese subjects susceptible to depressive symptoms and how these changes may mediate a pre-diabetic risk.

RESULTS

In 389 obese individuals, the Beck Depression Inventory (BDI-II) was significantly associated with PCSK9 levels. For every one-unit increment in BDI-II score, PCSK9 rose by 1.85 ng/mL. Depression was associated also with the HOMA-IR (homeostatic model assessment index of insulin resistance), 11% of this effect operating indirectly via PCSK9.

CONCLUSIONS

This study indicates a possible mechanism linking depression and insulin resistance, a well-known CV risk factor, providing evidence for a significant role of PCSK9.

Derivation and validation of a scoring system to predict after discharge risk of cardiac events in patients with acute myocardial infarction undergoing percutaneous coronary revascularization

Background

In the acute coronary syndromes (ACS) setting, despite the extensive use of coronary revascularization and P2Y12 inhibitors such as prasugrel and ticagrelor, with a more pronounced inhibitory effect on platelets than clopidogrel, the rate of death and recurrent myocardial infarction (MI) at 1 year is still high. In this clinical setting the development of a risk score which takes into account patient's and procedural characteristics could represent a useful tool to identify patients at high risk for ischaemic events at 1 year who could take advantage from more aggressive secondary prevention strategies.

Purpose

The aim of our study was to develop a risk score to predict 1-year probability of after discharge cardiac events (recurrent MI and cardiac death) in patients with acute MI treated with percutaneous coronary intervention (PCI).

Methods

We prospectively enrolled all consecutive patients hospitalized for acute MI between 2003 and 2017 treated with PCI with/without stent placement at our center. We excluded patients who died in-hospital or who experienced in-hospital recurrent MI and patients undergoing surgical revascularization by coronary artery bypass graft (CABG). The patients of the final study cohort were therefore randomly assigned to either a derivation sample (60%) or a validation sample (40%). Based on the multivariate analysis we developed a point system according to the “Framingham Risk Score” method.

Results

The final study cohort, represented by 4922 patients, was split in a derivation sample of 2972 patients and in a validation sample of 1950 patients: in both groups the median age was around 70 years; the male prevalence was 73%; 65% of patients were dagnosed with ST-segment elevation MI.

The clinical prediction score underlined as risk factors for recurrent cardiac events older age, diabetes mellitus, peripheral arterial disease, prior MI, Killip class &gt;2 at presentation, higher platelet count and creatinine values, lower left ventricular ejection fraction; radial access and the use of second generation drug eluting stents resulted to be protective. This model showed a good discrimination power in both the derivation and the validation samples with an area under the curve (AUC) of 0.75 and 0.71, respectively. The calibration showed a good concordance between predicted and observed events in both the derivation and the validation samples. Same results were observed in patients with/without ST-segment elevation MI and in gender subgroups.

Conclusions

The present study, conducted retrospectively on a large population of patients with acute MI treated with PCI enrolled prospectively, enabled us to derivate and validate a risk score of cardiac death and recurrent MI at 1 year which took into account both clinical and procedural characteristics and which demonstrated a good predictive performance.

After-discharge events by risk subgroups

Funding Acknowledgement

Type of funding source: None

Symmetric dimethylarginine concentrations in dogs with hypothyroidism before and after treatement with levothyroxine

OBJECTIVES

To evaluate the serum symmetric dimethylarginine (SDMA) and serum creatinine concentrations in a population of hypothyroid dogs at the time of diagnosis and after treatment.

MATERIALS AND METHODS

Serum SDMA and serum creatinine were measured in serum samples of 24 healthy dogs and 24 hypothyroid dogs, at the time of diagnosis (T0) and after supplementation with levothyroxine (T1).

RESULTS

The mean SDMA concentrations (reference intervals [RI] <18 μg/dL and <14 μg/dL depending on the source) were 11.7 ± 3.5 μg/dL, 13.8 ± 3.1 μg/dL and 11.83 ± 2.87 μg/dL in healthy dogs, and in the hypothyroid dogs at T0 and T1, respectively. The SDMA concentrations were higher in the hypothyroid dogs at T0 in comparison with the healthy dogs. Of the hypothyroid dogs, 1 out of 24 had an SDMA concentration above 18 μg/dL and 12 out of 24 above 14 μg/dL at T0. At T1, none of the hypothyroid dogs had SDMA concentrations above 18 μg/dL and two of them had SDMA concentrations above 14 μg/dL. The serum creatinine concentration was higher in the hypothyroid dogs at T0 as compared to the healthy dogs. At T0, 8 out of 24 hypothyroid dogs had serum creatinine concentrations above the RI (>1.4 mg/dL). In all but one dog, serum creatinine normalised after treatment.

CLINICAL SIGNIFICANCE

The SDMA and serum creatinine concentrations were higher in hypothyroid dogs at diagnosis as compared to healthy dogs. Serum creatinine concentrations were increased in one-third of the hypothyroid dogs and in the majority of cases normalised after levothyroxine supplementation. SDMA concentrations were rarely above the upper limit of the RI when the higest (<18 μg/dL) cut-off was employed. The diagnostic accuracy of SDMA in dogs with thyroid dysfunction requires additional evaluation.

2288Oxidized LDL/CD36/PPARg circuitry is a trigger of adipogenesis in arrhythmogenic cardiomyopathy

Background

Arrhythmogenic Cardiomyopathy (ACM) is a genetic condition hallmarked by ventricular fibro-fatty replacement and arrhythmias. Cardiac mesenchymal stromal cells (C-MSC) differentiate into adipocytes in ACM hearts, through the activation of PPARγ, caused by ACM mutations (e.g. PKP2). The clinical phenotype of ACM is variable for poorly understood reasons. The only recognized cofactor is physical exercise, which is known to increases oxidative stress. An accepted marker of exercise-induced oxidative stress is 13HODE, a component of oxLDL and direct activator of PPARγ. In macrophages, during foam cell formation, 13HODE creates a feed-forward loop increasing both PPARγ and the oxLDL receptor CD36, resulting in fat accumulation.

Purpose

To investigate oxLDL effects on ACM adipogenesis and to dissect the involved pathways.

Methods

We analyzed plasmas (n=42) and ventricular tissues (n=4) of ACM patients and matched healthy controls (HC). For in vitro experiments, ACM and HC C-MSC (n=10) have been used, while in vivo experiments have been conducted in heterozygous Pkp2 knock-out mice (Pkp2+/−; n=10).

Results

We observed higher plasma oxLDL in ACM patients compared to HC (ACM 246.70±55.89 vs HC 102.5±17.95ng/ml; p=0.019). oxLDL levels also discriminate between ACM patients with overt phenotype and their unaffected relatives carriers of the same causative mutations (p=0.03). We observed higher oxidative stress (MDA intensity 40.87±11.76 fold; p=0.015) and CD36 levels (14.72±2.10 fold; p=0.0007) in ACM ventricular tissue, compared to HC.

In basal conditions, ACM C-MSC showed greater oxidative stress (MDA intensity 8.83±2.78 fold p=0.017) and higher expression of PPARγ (1.47±0.14 fold; p=0.009) compared to HC C-MSC. The adipogenic stimulation led to a parallel increase of CD36 and lipid accumulation, mainly in ACM C-MSC (slopes statistically different p=0.016). OxLDL and 13HODE administration increased lipid accumulation in ACM C-MSC (ORO staining ACM vs ACM+oxLDL p=0.01; ACM vs ACM+13HODE p=0.014). On the contrary, the antioxidant N-Acetylcysteine (NAC) prevented lipid accumulation in ACM C-MSC (ORO staining ACM+13HODE vs ACM+13HODE+NAC p=0.0009). Through CD36 silencing of ACM C-MSC, we obtained a significantly lower lipid accumulation than non-silenced cells (ORO staining 0.35±0.10 fold; p=0.003).

Pkp2+/− mice do not spontaneously accumulate adipocytes in the heart, however Pkp2+/− C-MSC are more prone to lipid accumulation in vitro than WT cells (p=0.007). Accordingly, mice have low plasma oxLDL and cardiac oxidative stress. By increasing plasma cholesterol and oxidative stress through high fat diet, we observed fibro-fatty substitution in Pkp2+/− hearts (p=0.046).

Figure 1

Conclusions

These findings reveal a modulatory role of oxidized lipids in ACM adipogenesis at a cellular, tissue and clinical level, enlightening novel targets for pharmacological strategies to prevent adipogenic substitution and consequent ACM clinical phenotypes.

Acknowledgement/Funding

Telethon Foundation; Italian Ministry of Health

P6455Differences in cardiac phenotype and natural history of laminopathies with and without neuromuscular presentation

Aim

To look for differences in cardiac phenotype and natural history of patients affected by laminopathy, according to the presence or less of neuromuscular involvement at clinical presentation.

Methods

We prospectively analyzed 47 consecutive pts with a genetic diagnosis of laminopathy followed at a single centre between 1994 and 2017. Additionally, reports of clinical and instrumental evaluations before referral at our centre were retrospectively evaluated.

Results

Neuromuscular presentation, mainly as Emery-Dreifuss muscular dystrophy (EDMD), was present in 21 (46%) cases (14 LMNA and 7 EMD gene mutations). These pts had symptoms earlier (9 vs 39 years, p<0.001) in life compared to pts without neuromuscular onset (26 LMNA gene mutations), and clinical manifestations anticipated the first evidence of cardiac disease by a mean time of 15±8 years (maximum time gap of 38 years). Despite a similar prevalence of atrial fibrillation/flutter (AF) (71% vs 65%, p=0.758) and atrio-ventricular blocks (48% vs 65%, p=0.250), pts with neuromuscular onset experienced AF and pace-maker implantation at a significantly younger age (27 vs 41 yrs, p=0.015 and 23 vs 44 yrs, p=0.027 respectively). Differently a higher prevalence of sinus node dysfunction (33% vs 4%; p=0.015) and atrial paralysis (14% vs 4%; p=0.311) was reported in pts with neuromuscular onset. Prevalence of cardiomyopathy (CMP) (73% vs 33%, p=0.008) and sustained ventricular tachyarrhythmias were higher among pts with cardiac onset (23% vs 4%, p=0.111) whereas the prevalence of heart transplantations and median age of recipients were similar in the two groups (24% vs 20%, p=1.000 and 46 vs 43, p=0.592 years respectively). All pts with neuromuscular onset who received a diagnosis of CMP had a previous history of rhythm disturbance except 2 cases, where a concomitant diagnosis of the 2 disorders was formulated. On the contrary a strict temporal progression from rhythm disturbances to CMP (or viceversa) was not appreciable in the other group: AF and AVBs could precede the diagnosis of CMP be diagnosed at the same time or later.

Conclusions

In pts affected by laminopathy neuromuscular involvement, when present, was most often the first clinical manifestation and preceded cardiological involvement, with a long time frame in some cases. Except for sinus node dysfunction, much more frequent in patients with EDMD, a similar prevalence of rhythm disturbances was reported, although pts with neuromuscular clinical onset were younger at diagnosis of AF and at PM implantation. Pts without neuromuscular presentation had a higher prevalence of CMP and ventricular arrhythmias, albeit a similar rate of heart transplantation. In pts with neuromuscular onset, cardiac involvement was characterized by a stepwise progression from rhythm disturbances to CMP, where a strict temporal progression from rhythm disturbances to CMP was not observed in the group of pts without neuromuscular clinical onset.

The complex interplay among atherosclerosis, inflammation, and degeneration in ascending thoracic aortic aneurysms

OBJECTIVE

To assess the histopathological findings of a large series of ascending thoracic aortic aneurysm (TAA) surgical specimens applying the updated classification on noninflammatory degenerative and inflammatory aortic diseases proposed by the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology clinicopathological correlations.

METHODS

A total of 255 patients surgically treated for ascending TAA were enrolled. Surgical ascending aorta specimens were examined.

RESULTS

The histopathological substrate of ascending TAAs was mainly degenerative (67.5%), but with a remarkable prevalence of atherosclerotic lesions (18.8%) and aortitis (13.7%). Degenerative patients more frequently had bicuspid aortic valve (37.2%; P = .002). Patients in the atherosclerotic group were older (median age, 69 years; P < .001), more often with a history of hypertension (87.5%; P = .059), hypercholesterolemia (75%; P = .019), diabetes (16.6%; P = .054), current smoking (22.9%; P = .066), and a history of coronary artery disease (18.7%; P = .063). Patients with aortitis represented the older group (median age, 75 years, P < .001), were mostly females (68.6%; P < .001), and had a larger ascending aorta diameter (median, 56 mm; P < .001). Both patients with atherosclerosis and aortitis presented a higher incidence of concomitant abdominal aortic aneurysm (20.8% and 22.8%, respectively; P < .001).

CONCLUSIONS

Although degenerative histopathology is the most frequent substrate in ascending TAA, atherosclerosis and inflammation significantly contribute to the development of chronic aortic thoracic disease.

Surgical Risk Scores Applied to Transcatheter Aortic Valve Implantation: Friends or Foes? Short-Term and Long-Term Outcomes From a Single-Center Registry

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgical aortic valve replacement for the treatment of symptomatic aortic stenosis. The EuroScore (ES) II, logistic EuroScore (log ES), and the Society of Thoracic Surgeons (STS) score are the most applied scores for surgical risk stratification. However, their predictive value for patients undergoing TAVI is still unclear.

AIM

To evaluate the performance of STS, log ES and ES II as predictors of short-term and long-term mortality in patients undergoing TAVI.

METHODS

Between February 2008 and October 2017, a total of 384 patients underwent transfemoral TAVI at our institution and constituted the study population. Patients were divided into three groups based on the class of risk (low, intermediate, and high) calculated by each score. In-hospital complications, 30-day outcomes, and 5-year outcomes were assessed.

RESULTS

In-hospital mortality rate was 2.6% (n = 10). All scores over-estimated the risk of 30-day mortality, especially for the highest risk classes. At the end of follow-up (5 years), STS risk stratification was able to stratify all-cause and cardiovascular (CV) mortality (P<.01 and P=.02, respectively). Patients with intermediate ES II risk showed a lower survival rate (P=.04) while CV deaths did not differ between classes of risk. All-cause mortality and CV mortality curves did not diverge according to the patients' risk profiles derived from log ES.

CONCLUSION

Conventional surgical risk scores are not appropriate to predict 30-day mortality in patients undergoing transfemoral TAVI. STS assessment was the only risk score able to stratify long-term all-cause and CV mortality.

A new dawn for managing dyslipidemias: The era of rna-based therapies

The high occurrence of atherosclerotic cardiovascular disease (ASCVD) events is still a major public health issue. Although a major determinant of ASCVD event reduction is the absolute change of low-density lipoprotein-cholesterol (LDL-C), considerable residual risk remains and new therapeutic options are required, in particular, to address triglyceride-rich lipoproteins and lipoprotein(a) [Lp(a)]. In the era of Genome Wide Association Studies and Mendelian Randomization analyses aimed at increasing the understanding of the pathophysiology of ASCVD, RNA-based therapies may offer more effective treatment options. The advantage of oligonucleotide-based treatments is that drug candidates are targeted at highly specific regions of RNA that code for proteins that in turn regulate lipid and lipoprotein metabolism. For LDL-C lowering, the use of inclisiran - a silencing RNA that inhibits proprotein convertase subtilisin/kexin type 9 (PCSK9) synthesis - has the advantage that a single s.c. injection lowers LDL-C for up to 6 months. In familial hypercholesterolemia, the use of the antisense oligonucleotide (ASO) mipomersen, targeting apolipoprotein (apoB) to reduce LDL-C, has been a valuable therapeutic approach, despite unquestionable safety concerns. The availability of specific ASOs lowering Lp(a) levels will allow rigorous testing of the Lp(a) hypothesis; by dramatically reducing plasma triglyceride levels, Volanesorsen (APOC3) and angiopoietin-like 3 (ANGPTL3)-LRx will further clarify the causality of triglyceride-rich lipoproteins in ASCVD. The rapid progress to date heralds a new dawn in therapeutic lipidology, but outcome, safety and cost-effectiveness studies are required to establish the role of these new agents in clinical practice.

ETC-1002 (Bempedoic acid) for the management of hyperlipidemia: from preclinical studies to phase 3 trials

INTRODUCTION

Tolerability problems in treating hypercholesterolemic patients undergoing statin treatment are of growing concern to physicians and patients, thus underlining the need for an agent with a similar mechanism but minimal side effects. A drug with a somewhat similar mechanism to statins but free of muscular side effects is ETC-1002 (bempedoic acid). It inhibits cholesterol biosynthesis at a step preceding HMG-CoA reductase, i.e. ATP citrate lyase (ACLY). A prodrug, ETC-1002 is converted to the active agent only in liver, not in skeletal muscle, and this may prevent any myotoxic activity. Area covered: The mechanism of ETC-1002 activity is described in detail, considering that ACLY inhibition markedly attenuated atherosclerosis in animal models. Clinical studies are also reported. Expert opinion: Present day LDL-C lowering treatments lead to significant reductions of cardiovascular (CV) events but, at times, the need to interrupt statin treatment appears to be dangerous due to a rapid rise in CV risk. The excellent tolerability of ETC-1002 makes it a useful alternative, either alone or as an adjunct to ezetimibe, for patients with statin intolerance needing to achieve significant CV risk reduction. ETC-1002 is also associated with a marked fall in high-sensitivity C-reactive protein.

Changes in circulating pro-protein convertase subtilisin/kexin type 9 levels - experimental and clinical approaches with lipid-lowering agents

Regulation of pro-protein convertase subtilisin/kexin type 9 (PCSK9) by drugs has led to the development of a still small number of agents with powerful activity on low-density lipoprotein cholesterol levels, associated with a significant reduction of cardiovascular events in patients in secondary prevention. The Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) studies, with the two available PCSK9 antagonists, i.e. evolocumab and alirocumab, both reported a 15% reduction in major adverse cardiovascular events. Regulation of PCSK9 expression is dependent upon a number of factors, partly genetic and partly associated to a complex transcriptional system, mainly controlled by sterol regulatory element binding proteins. PCSK9 is further regulated by concomitant drug treatments, particularly by statins, enhancing PCSK9 secretion but decreasing its stimulatory phosphorylated form (S688). These complex transcriptional mechanisms lead to variable circulating levels making clinical measurements of plasma PCSK9 for cardiovascular risk assessment a debated matter. Determination of total PCSK9 levels may provide a diagnostic tool for explaining an apparent resistance to PCSK9 inhibitors, thus indicating the need for other approaches. Newer agents targeting PCSK9 are in clinical development with a major interest in those with a longer duration of action, e.g. RNA silencing, allowing optimal patient compliance. Interest has been expanded to areas not only limited to low-density lipoprotein cholesterol reduction but also investigating other non-lipid pathways raising cardiovascular risk, in particular inflammation associated to raised high-sensitivity C-reactive protein levels, not significantly affected by the present PCSK9 antagonists.

Basin-scale analysis of the geomorphic effectiveness of flash floods: A study in the northern Apennines (Italy)

Large floods may produce remarkable channel changes, which determine damages and casualties in inhabited areas. However, our knowledge of such processes remains poor, as is our capability to predict them. This study analyses the geomorphic response of the Nure River (northern Italy) and nine tributaries to a high-magnitude flood that occurred in September 2015. The adopted multi-disciplinary approach encompassed: (i) hydrological and hydraulic analysis; (ii) analysis of sediment delivery to the stream network by means of landslides mapping; (iii) assessment of morphological modifications of the channels, including both channel width and bed elevation changes. The spatial distribution of rainfall showed that the largest rainfall amounts occur in the upper portions of the catchment, with cumulative rainfall reaching 300 mm in 12 h, and recurrence intervals exceeding 100-150 years. The unit peak discharge ranged between 5.2 and 25 m³ s^-1 km^-2. Channel widening was the most evident effect. In the tributaries, the ratio between post-flood and pre-flood channel width averaged 3.3, with a maximum approaching 20. Widening was associated with channel aggradation up to 1.5 m and removal of riparian vegetation. New islands formed due to the fragmentation of the former floodplain. In the Nure River, the average width ratio was 1.7, and here widening occurred mainly at the expenses of islands. Bed level dynamics in the Nure were varied, including aggradation, incision, and overall stability. The flood geomorphic effectiveness was more pronounced in the middle-higher portions of the basin. Planimetric and elevation changes were well correlated. Regression analysis of the relationship between widening and morphological/ hydraulic controlling factors indicated that unit stream power and confinement index were the most relevant variables. The study provides useful insights for river management, especially with regard to the proportion of the valley floor subject to erosion and/or deposition during large events.

Prodromal angina and risk of 2-year cardiac mortality in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous intervention

We sought to investigate the prognostic significance of prodromal angina (PA) in unselected patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) and its additive predictive value to the GRACE score.We prospectively enrolled 3015 consecutive STEMI patients undergoing PPCI. Patients were divided in 2 groups according to the presence or absence of PA. Multivariable Cox regression was used to establish the relation to 2-year cardiac mortality of PA.The mean age of the study population was 68 (±14) years; 2178 patients (72%) were male. During follow-up, 395 (13%) patients died with 278 of these (9.2%) suffering from cardiac mortality. Kaplan-Meier estimates showed a survival rate of 95% and 87% for patients with PA and no PA, respectively (log rank test < 0.001). After multivariable analysis, patients with PA had still a lower risk of 2 years' cardiac mortality compared with patients without PA (adjusted hazard ratio = 0.50; 95% confidence interval [CI] 1.06-1.81, P = .001). Evaluation of net reclassification improvement showed that reclassification improved by 0.16% in case patients, whereas classification worsened in control patients by 1.08% leading to a net reclassification improvement of -0.93% (95% CI: -0.98, -0.88).In patients with STEMI undergoing PPCI the presence of PA is independently associated with a lower risk of 2-year cardiac mortality. However, the incorporation of this variable to the GRACE score slightly worsened the classification of risk. Accordingly, it seems unlikely that the evaluation of PA may be useful in clinical practice.

Lipid lowering drugs and inflammatory changes: an impact on cardiovascular outcomes?

Inflammatory changes are responsible for maintenance of the atherosclerotic process and may underlie some of the most feared vascular complications. Among the multiple mechanisms of inflammation, the arterial deposition of lipids and particularly of cholesterol crystals is the one responsible for the activation of inflammasome NLRP3, followed by the rise of circulating markers, mainly C-reactive protein (CRP). Elevation of lipoproteins, LDL but also VLDL and remnants, associates with increased inflammatory changes and coronary risk. Lipid lowering medications can reduce cholesterolemia and CRP: patients with elevations of both are at greatest cardiovascular (CV) risk and receive maximum benefit from therapy. Evaluation of the major drug series indicates that statins exert the largest LDL and CRP reduction, accompanied by reduced CV events. Other drugs, mainly active on the triglyceride/HDL axis, for example, PPAR agonists, may improve CRP and the lipid pattern, especially in patients with metabolic syndrome. PCSK9 antagonists, the newest most potent medications, do not induce significant changes in inflammatory markers, but patients with the highest baseline CRP levels show the best CV risk reduction. Parallel evaluation of lipids and inflammatory changes clearly indicates a significant link, both guiding to patients at highest risk, and to the best pharmacological approach. Key messages Lipid lowering agents with "pleiotropic" effects provide a more effective approach to CV prevention In CANTOS study, patients achieving on-treatment hsCRP concentrations ≤2 mg/L had a higher benefit in terms of reduction in major CV events The anti-inflammatory activity of PCSK9 antagonists appears to be of a minimal extent.

Efficacy and safety of thrombus aspiration in ST-segment elevation myocardial infarction: an updated systematic review and meta-analysis of randomised clinical trials

BACKGROUND:

The role of thrombus aspiration plus primary percutaneous coronary intervention in ST-segment elevation myocardial infarction remains controversial.

METHODS:

We performed a meta-analysis of 25 randomised controlled trials in which 21,740 ST-segment elevation myocardial infarction patients were randomly assigned to thrombus aspiration plus primary percutaneous coronary intervention or primary percutaneous coronary intervention. Study endpoints were: death, myocardial infarction, stent thrombosis and stroke.

RESULTS:

On pooled analysis, the risk of death (4.3% vs. 4.8%, odds ratio (OR) 0.90, 95% confidence interval (CI) 0.79-1.03; P=0.123), myocardial infarction (2.4% vs. 2.5%, OR 0.95, 95% CI 0.80-1.13; P=0.57) and stent thrombosis (1.3% vs. 1.6%, OR 0.80, 95% CI 0.63-1.01; P=0.066) was similar between thrombus aspiration plus primary percutaneous coronary intervention and primary percutaneous coronary intervention. The risk of stroke was higher in the thrombus aspiration plus primary percutaneous coronary intervention than the primary percutaneous coronary intervention group (0.84% vs. 0.59%, OR 1.401, 95% CI 1.004-1.954; P=0.047). However, on sensitivity analysis after removing the TOTAL trial, thrombus aspiration plus primary percutaneous coronary intervention was not associated with an increased risk of stroke (OR 1.01, 95% CI 0.58-1.78). The weak association between thrombus aspiration and stroke was also confirmed by the fact that the lower bound of the 95% CI was slightly below unity after removing either the study by Kaltoft or the ITTI trial. There was no interaction between the main study results and follow-up, evidence of coronary thrombus, or study sample size.

CONCLUSIONS:

In patients with ST-segment elevation myocardial infarction, thrombus aspiration plus primary percutaneous coronary intervention does not reduce the risk of death, myocardial infarction or stent thrombosis. Thrombus aspiration plus primary percutaneous coronary intervention is associated with an increased risk of stroke; however, this latter finding appears weak.

Appropriateness of statin prescription in the elderly

Statins, the most widely used drugs in the Western world, have become a pivotal component in the primary and secondary prevention of vascular diseases. Although benefits have been well documented in younger-than-75-year-old individuals, the value of statins in people aged >75years and over is controversial. The CTT meta-analysis calculated an absolute risk reduction of 0.6%/year per 38.7mg/dl reduction in LDL-C levels in patients aged >75years, that would translate into a number needed to treat of 167. However, the absolute effect of a 38.7mg/dl cholesterol lowering on the rate of annual ischemic heart disease mortality is 10-fold larger in older vs younger patients. In order to advise physician prescription, three major Guidelines have been published over the last few years, i.e. the AHA/ACC and the NLA in the US, and the ESC/EAS in Europe. Moreover, statin prescription in the elderly should also consider the cardiovascular outcomes of elderly patients reported in classical statin preventive trials which give important clues on adherence and persistence of use, as well as on drug safety. The present review discusses benefits of intensive vs moderate statin therapy, justifications for the use of aggressive lipid management in the very old and the use of statins in frail elderlies. The final decision on the therapeutic strategy with statins in elderlies at higher risk to develop cardiovascular events should be always based on a careful analysis of the patient's general health and on the presence of metabolic abnormalities or drug interactions potentially leading to risk.

Phylogenetic Structure and Metabolic Properties of Microbial Communities in Arsenic-Rich Waters of Geothermal Origin

Arsenic (As) is a toxic element released in aquatic environments by geogenic processes or anthropic activities. To counteract its toxicity, several microorganisms have developed mechanisms to tolerate and utilize it for respiratory metabolism. However, still little is known about identity and physiological properties of microorganisms exposed to natural high levels of As and the role they play in As transformation and mobilization processes. This work aims to explore the phylogenetic composition and functional properties of aquatic microbial communities in As-rich freshwater environments of geothermal origin and to elucidate the key microbial functional groups that directly or indirectly may influence As-transformations across a natural range of geogenic arsenic contamination. Distinct bacterial communities in terms of composition and metabolisms were found. Members of Proteobacteria, affiliated to Alpha- and Betaproteobacteria were mainly retrieved in groundwaters and surface waters, whereas Gammaproteobacteria were the main component in thermal waters. Most of the OTUs from thermal waters were only distantly related to 16S rRNA gene sequences of known taxa, indicating the occurrence of bacterial biodiversity so far unexplored. Nitrate and sulfate reduction and heterotrophic As(III)-oxidization were found as main metabolic traits of the microbial cultivable fraction in such environments. No growth of autotrophic As(III)-oxidizers, autotrophic and heterotrophic As(V)-reducers, Fe-reducers and oxidizers, Mn-reducers and sulfide oxidizers was observed. The ars genes, involved in As(V) detoxifying reduction, were found in all samples whereas aioA [As(III) oxidase] and arrA genes [As(V) respiratory reductase] were not found. Overall, we found that As detoxification processes prevailed over As metabolic processes, concomitantly with the intriguing occurrence of novel thermophiles able to tolerate high levels of As.

Transcatheter Mitral Valve Implantation in Open Heart Surgery: An Off-Label Technique

Extensive mitral annulus calcifications are considered a contraindication for valve surgery. We describe the case of a 76-year-old female with severe mitral and aortic stenosis associated with extensive calcifications of the heart. The patient underwent an open mitroaortic valve replacement using transcatheter aortic valve implantation with an Edwards SAPIEN XT valve (Edwards Lifesciences Corp., Irvine, CA, USA) in the mitral position. The aortic valve was replaced using a stentless valve prosthesis (LivaNova SOLO; LivaNova PLC, London, UK). Postoperative echocardiography showed that the prosthetic valve was in the correct position and there were no paravalvular leaks. A bailout open transcatheter valve implantation can be considered a safe and effective option in selected cases with an extensively calcified mitral valve.