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Background Current guidelines recommend extending the use of dual antiplatelet therapy (DAPT) beyond 1 year in patients with an acute coronary syndrome (ACS) and a high risk of ischaemia and low risk of bleeding. No data exist about the implementation of this strategy in older adults from routine clinical practice. Methods We conducted a Spanish multicentre, retrospective, observational registry-based study that included patients with ACS but no thrombotic or bleeding events during the first year of DAPT after discharge and no indication for oral anticoagulants. High bleeding risk was defined according to the Academic Research Consortium definition. We assessed the proportion of cases of extended DAPT among patients 65 ≥ years that went beyond 1 year after hospitalisation for ACS and the variables associated with the strategy. Results We found that 48.1% (928/1,928) of patients were aged ≥ 65 years. DAPT was continued beyond 1 year in 32.1% (298/928) of patients ≥ 65; which was a similar proportion as with their younger counterparts. There was no significant correlation between a high bleeding risk and DAPT duration. Contrastingly, there was a strong correlation between the extent of coronary disease and DAPT duration (p Conclusion There was no correlation between age and extended use of DAPT beyond 1 year in older patients with ACS. DAPT was extended in about one-third of patients ≥ 65 years. The severity of the coronary disease, prior heart failure, left ventricle ejection fraction and prior stent thrombosis all correlated with extended DAPT.

Introduction and objectives: The optimal time to perform a diagnostic coronary angiography in patients admitted due to non- ST-segment elevation acute coronary syndrome (NSTEACS) and start pretreatment with dual antiplatelet therapy is controversial. Our study aims to identify the current diagnostic and therapeutic approach, and clinical progression of patients with NSTEACS in our country. Methods: The IMPACT-TIMING-GO trial (Impact of time of intervention in patients with myocardial infarction with non-ST segment elevation. Management and outcomes) is a national, observational, prospective, and multicenter registry that will include consecutive patients from 24 Spanish centers with a clinical diagnosis of NSTEACS treated with diagnostic coronary angiography and with present unstable or causal atherosclerotic coronary artery disease. The study primary endpoint is to assess the level of compliance to clinical practice guidelines in patients admitted due to NSTEACS undergoing coronary angiography in Spain, describe the use of antithrombotic treatment prior to cardiac catheterization, and register the time elapsed until it is performed. Major adverse cardiovascular events will also be described like all-cause mortality, non-fatal myocardial infarction and non-fatal stroke, and the rate of major bleeding according to the BARC (Bleeding Academic Research Consortium) scale at 1- and 3-year follow-up. Results: This study will provide more information on the impact of different early management strategies in patients admitted with NSTEACS in Spain, and the degree of implementation of current recommendations into the routine clinical practice. It will also provide information on these patients' baseline and clinical characteristics. Conclusions: This is the first prospective study conducted in Spain that will be reporting on the early therapeutic strategies-both pharmacological and interventional-implemented in our country in patients with NSTEACS after the publication of the 2020 European guidelines, and on the clinical short- and long-term outcomes of these patients.

Background: End-stage renal disease is associated with a high risk of cardiovascular events. It is unknown, however, whether mild-to-moderate kidney dysfunction is causally related to coronary heart disease (CHD) and stroke. Methods: Observational analyses were conducted using individual-level data from 4 population data sources (Emerging Risk Factors Collaboration, EPIC-CVD [European Prospective Investigation into Cancer and Nutrition–Cardiovascular Disease Study], Million Veteran Program, and UK Biobank), comprising 648 135 participants with no history of cardiovascular disease or diabetes at baseline, yielding 42 858 and 15 693 incident CHD and stroke events, respectively, during 6.8 million person-years of follow-up. Using a genetic risk score of 218 variants for estimated glomerular filtration rate (eGFR), we conducted Mendelian randomization analyses involving 413 718 participants (25 917 CHD and 8622 strokes) in EPIC-CVD, Million Veteran Program, and UK Biobank. Results: There were U-shaped observational associations of creatinine-based eGFR with CHD and stroke, with higher risk in participants with eGFR values 105 mL·min –1 ·1.73 m –2 , compared with those with eGFR between 60 and 105 mL·min –1 ·1.73 m –2 . Mendelian randomization analyses for CHD showed an association among participants with eGFR –1 ·1.73 m –2 , with a 14% (95% CI, 3%–27%) higher CHD risk per 5 mL·min –1 ·1.73 m –2 lower genetically predicted eGFR, but not for those with eGFR >105 mL·min –1 ·1.73 m –2 . Results were not materially different after adjustment for factors associated with the eGFR genetic risk score, such as lipoprotein(a), triglycerides, hemoglobin A1c, and blood pressure. Mendelian randomization results for stroke were nonsignificant but broadly similar to those for CHD. Conclusions: In people without manifest cardiovascular disease or diabetes, mild-to-moderate kidney dysfunction is causally related to risk of CHD, highlighting the potential value of preventive approaches that preserve and modulate kidney function.

Vascular access is an essential part of all interventional procedures whether coronary or structural. Over the last 15 to 20 years, in coronary interventions, traditional femoral access has been mostly replaced by the radial approach. Nonetheless, the femoral approach through both artery and vein is still the main approach for structural heart procedures. Over the last few years, femoral access has evolved from a puncture guided by anatomical references to more accurate ultrasound-guided approaches. The relatively recent introduction of interventions such as transcatheter aortic valve replacement has conditioned the use of large introducers and ultimately the need for specific hemostatic systems, above all, percutaneous closure devices. This manuscript reviews different anatomical concepts, puncture techniques, diagnostic assessments, and closure strategies of the main arterial and venous approaches for the diagnosis and treatment of different structural heart procedures.

Current guidelines for patients with acute coronary syndrome (ACS) recommend dual antiplatelet therapy (DAPT) for 12 months. Since bleeding is the main Achilles' heel of DAPT, in recent years several randomized controlled trials have evaluated the safety and efficacy of de-escalation of DAPT with respect to ischaemic and bleeding endpoints. These trials can be broadly divided into studies evaluating a shorter duration of DAPT, and those studies in which DAPT that includes a potent P2Y12 inhibitor, such as prasugrel or ticagrelor, is compared to less intense DAPT, mainly clopidogrel or reduced-dose prasugrel. We sought to evaluate the studies assessing de-escalation of DAPT in patients with ACS undergoing PCI. We review the studies evaluating the strategies of de-escalation of DAPT intensity and those evaluating a strategy of de-escalation of DAPT duration in ACS patients undergoing PCI. We summarize the limitations of studies to date, gaps in evidence and make recommendations for future studies.

IntroductionPatients with diabetes mellitus (DM) have augmented platelet reactivity and diminished responsiveness to clopidogrel. Ticagrelor, a more potent P2Y12 inhibitor, is clinically superior to clopidogrel in acute coronary syndromes, although its role in chronic coronary syndromes (CCS) is still the subject of debate. The aim of this investigation was to compare the pharmacodynamic effectiveness of ticagrelor and clopidogrel in Mediterranean DM patients with CCS.Materials and methodsIn this prospective, randomized, crossover study, patients (n = 20) were randomized (1:1) to receive, on top of aspirin therapy, either ticagrelor 180 mg loading dose (LD)/90 mg maintenance dose (MD) b.i.d. or clopidogrel 600 mg LD/75 mg MD o.d. for 1 week in a crossover fashion with a 2–4 week washout period between regimens. Platelet function measurements were performed at 4 timepoints in each period (baseline, 2 h and 24 h after LD, and 1 week), including light transmission aggregometry (LTA, primary endpoint), VASP assay, Multiplate and VerifyNow P2Y12.ResultsThe ticagrelor LD achieved greater platelet inhibitory effect than clopidogrel LD, assessed with LTA (20 μM ADP as agonist), at 2 h (34.9 ± 3.9% vs. 63.6 ± 3.9%; p < 0.001) and 24 h (39.4 ± 3.5% vs. 52.3 ± 3.8%; p = 0.014). After 1 week of therapy, platelet reactivity was again significantly inferior with ticagrelor compared to clopidogrel (30.7 ± 3.0% vs. 54.3 ± 3.0%; p < 0.001). The results were consistent with the other platelet function assays employed.ConclusionIn Mediterranean patients with DM and CCS, ticagrelor provides a more potent antiplatelet effect than clopidogrel after the LD and during the maintenance phase of therapy.Clinical trial registration[ClinicalTrials.gov], identifier [NCT02457130].

Moderate exercise has well-founded benefits in cardiovascular health. However, increasing, yet controversial, evidence suggests that extremely trained athletes may not be protected from cardiovascular events as much as moderately trained individuals. In our rodent model, intensive but not moderate training promoted aorta and carotid stiffening and elastic lamina ruptures, tunica media thickening of intramyocardial arteries, and an imbalance between vasoconstrictor and relaxation agents. An up-regulation of angiotensin-converter enzyme, miR-212, miR-132, and miR-146b might account for this deleterious remodeling. Most changes remained after a 4-week detraining. In conclusion, our results suggest that intensive training blunts the benefits of moderate exercise.

Vascular tortuosity of supra-aortic vessels is widely considered one of the main reasons for failure and delays in endovascular treatment of large vessel occlusion in patients with acute ischemic stroke. Characterization of tortuosity is a challenging task due to the lack of objective, robust and effective analysis tools. We present a fully automatic method for arterial segmentation, vessel labelling and tortuosity feature extraction applied to the supra-aortic region. A sample of 566 computed tomography angiography scans from acute ischemic stroke patients (aged 74.8 ± 12.9, 51.0% females) were used for training, validation and testing of a segmentation module based on a U-Net architecture (162 cases) and a vessel labelling module powered by a graph U-Net (566 cases). Successively, 30 cases were processed for testing of a tortuosity feature extraction module. Measurements obtained through automatic processing were compared to manual annotations from two observers for a thorough validation of the method. The proposed feature extraction method presented similar performance to the inter-rater variability observed in the measurement of 33 geometrical and morphological features of the arterial anatomy in the supra-aortic region. This system will contribute to the development of more complex models to advance the treatment of stroke by adding immediate automation, objectivity, repeatability and robustness to the vascular tortuosity characterization of patients.

Introduction: Coronary heart disease (CHD) is a dynamic process in which there are interactions between endothelial dysfunction, oxidative stress, and inflammatory responses. The aim of the present study was to investigate the function and mechanism of HSCARG in the treatment of CHD. Methods: Male apolipoprotein E/low-density lipoprotein receptor-deficient mice were given a high-fat diet with 21% fat and 0.15% cholesterol for the in vivo model. Human umbilical vein endothelial cells were incubated with angiotensin II for the in vitro model. HSCARG expression was inhibited in patients or mice with CHD. Results: HSCARG reduced oxidative stress in mice with CHD. HSCARG also reduced reactive oxygen species (ROS)-oxidative stress in the in vitro model. HSCARG induced p47phox expression in the in vitro model by NF-κB activity. The regulation of nuclear factor kappa B (NF-κB) activity or p47phox expression participates in the effects of HSCARG in CHD. Conclusion: Altogether, our data indicate that HSCARG reduced ROS-oxidative stress in in vivo and in vitro models of CHD via p47phox by NF-κB activity and may be a clinical target for CHD.

Objective: To determine whether miR-125b regulates cholesterol efflux in vivo and in vitro through the regulation of scavenger receptor type B1 (SR-B1). Approach and results: We demonstrated that miR-125b is up-regulated in the human aortas of patients with CAD and is located in macrophages and vascular smooth muscle cells (VSMCs). We identified SCARB1 as a direct target of miR-125b by repressing the activity of the SCARB1 3'-untranslated region reporter construct. Moreover, the overexpression of miR-125b in both human and mouse macrophages as well as VSMCs was found to downregulated the expression of the SCARB1 and the SR-B1 protein levels, thereby impairing alpha-HDL-mediated macrophage cholesterol efflux in vitro. The in vivo reverse cholesterol transport (RCT) rate from non-cholesterol-loaded macrophages transfected with miR-125b to feces was also found to be decreased when compared with that of control mimic-transfected macrophages. Conclusions: Together, these results provide evidence that miR-125b downregulates SCARB1 and SR-B1 in both human and mouse macrophages as well as VSMCs, thereby impairing macrophage cholesterol efflux in vitro and the whole macrophage-specific RCT pathway in vivo.

Objectives. The aim of this study is to assess the utility of optical coherence tomography (OCT) in patients with exercise-related acute coronary syndrome (ACS) presenting with inconclusive angiographic findings. Background. Regular physical activity reduces the incidence of cardiovascular events. Nevertheless, the risk of ACS or sudden cardiac death (SCD) increases during sport. In adults older than 35 years, exercise-related ACS or SCD is associated with plaque rupture, but not infrequently patients present ambiguous angiographic findings. Methods. Between September 2015 and January 2020, patients admitted for ACS or SCD triggered by physical exertion and with coronary stenosis ≤50% were included in this prospective observational study. OCT was performed on the artery deemed to be responsible of the event. Results. Ten patients were enrolled, predominantly men (80%) of middle age (51 years old, IQR 41–63) with low cardiovascular risk burden. Cycling was the most frequent (50%) exercise-related trigger, 8 patients were regular sport practitioners, and 7 had the clinical event during strenuous exertion. Five patients presented with non-ST-elevation ACS, two with ST-elevation ACS, and three with SCD. Angiographic analysis showed nonsignificant stenosis in all patients (42% stenosis, IQR 36–46). OCT identified the etiology of the event in 9 patients (4 plaque erosion, 3 plaque rupture, 1 eruptive calcific nodule, and 1 coronary dissection). Treatment was adjusted according to OCT findings. Conclusions. OCT is a valuable technique to identify the etiology of exercise-related ACS or SCD in patients with nonobstructive coronary arteries and, as a result, may lead to a more specific treatment.

Treballs Finals de Grau d'Enginyeria Informàtica, Facultat de Matemàtiques, Universitat de Barcelona, Any: 2022, Director: Simone Balocco, [en] Ischemic Heart Disease (IHD) is one of the leading causes of mortality in Spain; early diagnosis is key. Intravenous ultrasound imaging (IVUS) can help identify symptoms of IHD, at the cost of segmenting a large volume of frames by medical professionals. While promising, automated image segmentation using Convolutional Neural Networks (CNN) suffer from sample scarcity: a large amount of parameters is often used, and medical imaging datasets are typically small and costly to acquire and label. In this report we study and compare state of the art methods used to deal with sample scarcity. In particular we introduce data augmentation methodologies, specialized training losses and transfer learning methods, and compare their performance on IVUS segmentation of the media and lumen or the artery. Additionally we introduce a promising paradigm, few-shot segmentation, and provide an initial implementation using PFENet. This implementation can avoid significant overfitting, even when trained with a single example, outperforming traditional CNNs on the same segmentation problem.

Treballs Finals de Grau d'Enginyeria Biomèdica. Facultat de Medicina i Ciències de la Salut. Universitat de Barcelona. Curs: 2021-2022. Tutora/Directora: Paz Garré Anguera de Sojo and Sara Vázquez, In patients with ventricular tachycardia of ischemic origin, arrhythmogenic channels are the pathway of abnormal tissue activation and their determination in the substrate is a essential factor when treating these cases by radiofrequency ablation. Extracting this information from images obtained by magnetic resonance imaging has great advantages over other more invasive imaging techniques. The most commonly used reconstruction technique in MRI-2D is the Magnitude sequence. Recently, another sequence called Phase Sensitive Inversion Recovery (PSIR) is beginning to be established, which takes into account the polarity of the protons, apart from their magnitude, when generating the image. In this project the level of validity of the PSIR reconstruction sequence to determine the arrhythmogenic channels has been demonstrated, comparing data obtained using this sequence with data obtained using the strongly validated and referenced Magnitude sequence. Data from 21 patients with specific conditions have been used for this study. The images have been segmented and processed in order to extract the parameters that have allowed to solve the question raised by means of a statistical analysis of the information obtained. We have worked with ADAS-3D rendering software to study the cases and have determined the configuration that allows the highest quality in the visualization of PSIR images, specifically the setting of contrast thresholds. From the information provided by the ADAS-3D we selected the information considered relevant for the statistical analysis, descriptive information about the channels and characteristics of the tissue. These data, together with the contrast thresholds set in the study, have been statistically analysed with the RStudio programme. Valuable information has been obtained from the results. The ideal thresholds for studying PSIR images have been found and it has been concluded that there is a considerable similarity between both sequences when interpreting MRI images clinically, although not enough to validate it completely. Regarding the characterisation of channels, a high accuracy in the calculation of their mass has been determined, but a great inaccuracy in their counting. In terms of quantification, identification and classification of ventricular tissue, considerable correlation and acceptable measurement accuracy have been demonstrated.

Acute coronary syndrome (ACS) is one of the main causes of mortality and morbidity in the elderly. The prevalence of ACS increases with age and patients with advanced age have some co-morbidities that require an individualized approach, which includes a comprehensive geriatric assessment. Ageism is a matter of great concern. In this scenario, some ethical conflicts may arise which should be anticipated, considered, and solved. Clinicians will need to prioritize and allocate resources, to avoid futility/proportionality, which is not always easy to assess in these patients. This review aims to summarize the evidence regarding ethical conflicts that may arise in the management of patients with ACS and advanced age. We will discuss how to choose the best option (which frequently is not the only one) with the lowest risk for harm, considering and respecting the patients' decision. The four basic principles of bioethics (beneficence, non-maleficence, autonomy, and justice) are thoroughly reviewed, and discussed, regarding their role in the decision making process. Sin financiación 4.430 JCR (2021) Q2, 57/143 Cardiac & Cardiovascular Systems 0.590 SJR (2021) Q2, 158/356 Cardiology and Cardiovascular Medicine No data IDR 2020 UEM

Acute coronary syndrome; Dual antiplatelet therapy; Ischemic risk Síndrome coronario agudo; Terapia antiplaquetaria dual; Riesgo isquémico Síndrome coronària aguda; Teràpia antiplaquetària dual; Risc isquèmic Clinical practice guidelines recommend extending dual antiplatelet therapy (DAPT) beyond 1 year after acute coronary syndrome (ACS) in patients with high ischemic risk and without high bleeding risk. The aim of this study was to identify variables associated with DAPT prolongation in a cohort of 1967 consecutive patients discharged after ACS without thrombotic or hemorrhagic events during the following year. The sample was stratified according to whether DAPT was extended beyond 1 year, and the factors associated with this strategy were analyzed. In 32.2% of the patients, DAPT was extended beyond 1 year. Overall, 770 patients (39.1%) were considered candidates for extended treatment based on PEGASUS criteria and absence of high bleeding risk, and DAPT was extended in 34.4% of them. The presence of a PEGASUS criterion was associated with extended DAPT in the univariate analysis, but not history of bleeding or a high bleeding risk. In the multivariate analysis, a history of percutaneous coronary intervention (odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.4–2.4), stent thrombosis (OR = 3.8, 95% CI 1.7–8.9), coronary artery disease complexity (OR = 1.3, 95% CI 1.1–1.5), reinfarction (OR = 4.1, 95% CI 1.6–10.4), and clopidogrel use (OR = 1.3, 95% CI 1.1–1.6) were significantly associated with extended use. DAPT was extended in 32.2% of patients who survived ACS without thrombotic or hemorrhagic events. This percentage was 34.4% when the candidates were analyzed according to clinical guidelines. Neither the PEGASUS criteria nor the bleeding risk was independently associated with this strategy. This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” [grant numbers JR/21/00041, PI20/00637 and CIBERCV16/11/00486] and by Conselleria de Educación – Generalitat Valenciana (PROMETEO/2021/008).

Aim Patients with diabetes mellitus are at high risk of adverse events after percutaneous revascularization, with no differences in outcomes between most contemporary drug-eluting stents. The Cre8 EVO stent releases a formulation of sirolimus with an amphiphilic carrier from laser-dug wells, and has shown clinical benefits in diabetes. We aimed to compare Cre8 EVO stents to Resolute Onyx stents (a contemporary polymer-based zotarolimus-eluting stent) in patients with diabetes. Methods and results We did an investigator-initiated, randomized, controlled, assessor-blinded trial at 23 sites in Spain. Eligible patients had diabetes and required percutaneous coronary intervention. A total of 1175 patients were randomly assigned (1:1) to receive Cre8 EVO or Resolute Onyx stents. The primary endpoint was target-lesion failure, defined as a composite of cardiac death, target-vessel myocardial infarction, and clinically indicated target-lesion revascularization at 1-year follow-up. The trial had a non-inferiority design with a 4% margin for the primary endpoint. A superiority analysis was planned if non-inferiority was confirmed. There were 106 primary events, 42 (7.2%) in the Cre8 EVO group and 64 (10.9%) in the Resolute Onyx group [hazard ratio (HR): 0.65, 95% confidence interval (CI): 0.44–0.96; P non-inferiority < 0.001; P superiority = 0.030]. Among the secondary endpoints, Cre8 EVO stents had significantly lower rate than Resolute Onyx stents of target-vessel failure (7.5% vs. 11.1%, HR: 0.67, 95% CI: 0.46–0.99; P = 0.042). Probable or definite stent thrombosis and all-cause death were not significantly different between groups. Conclusion In patients with diabetes, Cre8 EVO stents were non-inferior to Resolute Onyx stents with regard to target-lesion failure composite outcome. An exploratory analysis for superiority at 1 year suggests that the Cre8 EVO stents might be superior to Resolute Onyx stents with regard to the same outcome. Clinical trial registration ClinicalTrials.gov: NCT03321032.

Introduction and objectives: Coronary lesions with stent overlapping are associated with higher neointimal proliferation that leads to more restenosis. Furthermore, the tapering of coronary arteries is a major challenge when treating long coronary lesions. This study attempted to assess the safety and clinical level of performance of long nontapered sirolimus-eluting coronary stent systems (> 36 mm) to treat long and diffused de novo coronary lesions in real-world scenarios. Methods: This was a prospective, non-randomized, multicentre study that included 696 consecutive patients treated with the long nontapered BioMime sirolimus-eluting coronary stent system in long and diffused de novo coronary lesions. The safety endpoint was major adverse cardiovascular events defined as a composite of cardiac death, myocardial infarction, clinically driven target lesion revascularization, stent thrombosis, and major bleeding at the 12-month follow-up. Results: Of a total of 696 patients, 38.79% were diabetic. The mean age of all the patients was 64.6 ± 14 years, and 80% were males. The indication for revascularization was acute coronary syndrome in 63.1%. A total of 899 lesions were identified out of which 742 were successfully treated with long BioMime stents (37 mm, 40 mm, 44 mm, and 48 mm). The cumulative incidence of major adverse cardiovascular events was 8.1% at the 12-month follow-up including cardiac death (2.09%), myocardial infarction (1.34%), and total stent thrombosis (0.5%). Conclusions: This study confirms the safety and good performance of long nontapered BioMime coronary stents to treat de novo coronary stenosis. Therefore, it can be considered a safe and effective treatment for long and diffused de novo coronary lesions in the routine clinical practice.

Background: ST-segment elevation acute myocardial infarction (STEMI) is a pathological process that involves cardiac muscle tissue death. Intravenous thrombolysis with fibrinolytics or primary percutaneous coronary intervention (PCI), an invasive technique, can be performed for tissue revascularization. PCI has been preferred as compared to non-invasive methods, although few studies have described its use in Brazil. Objectives: The aim of the present study was to analyze data on the use of primary PCI and investigate the relevance of hospitalizations for the treatment of STEMI in the country. Methods: A descriptive, cross-sectional analysis of data from the Brazilian Unified Health system (SUS) Department of Informatics (DATASUS) from 2010 to 2019 was conducted. Results: Hospitalizations for STEMI represented 0.6% of all hospital admissions in Brazil in the analyzed period, 0.9% of hospital costs, and 2.1% of deaths. The number of hospitalizations due to STEMI was 659,811, and 82,793 for PCIs. Length of hospital stay was 36.0% shorter and mortality rate was 53.3% lower in PCI. The mean cost of PCI was 3.5-fold higher than for treatment of STEMI. Conclusions: Data on hospitalizations for STEMI treatment in Brazil revealed high hospitalization and mortality rates, elevated costs, and long hospital stay. Although primary PCI is a more expensive and less used technique than other methods, it can reduce the length of hospital stay and mortality in the treatment of STEMI.

Few studies have addressed to date the interaction between sex and diabetes mellitus (DM) in the prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Our aim was to address the role of DM in the prognosis of non-selected elderly patients with NSTEACS according to sex. A retrospective analysis from 11 Spanish NSTEACS registries was conducted, including patients aged ≥70 years. The primary end point was one-year all-cause mortality. A total of 7211 patients were included, 2,770 (38.4%) were women, and 39.9% had DM. Compared with the men, the women were older (79.95 ± 5.75 vs. 78.45 ± 5.43 years, p &lt, 0.001) and more often had a history of hypertension (77% vs. 83.1%, p &lt, 0.01). Anemia and chronic kidney disease were both more common in women. On the other hand, they less frequently had a prior history of arteriosclerotic cardiovascular disease or comorbidities such as peripheral artery disease and chronic pulmonary disease. Women showed a worse clinical profile on admission, though an invasive approach and in-hospital revascularization were both more often performed in men (p &lt, 0.001). At a one-year follow-up, 1090 patients (15%) had died, without a difference between sexes. Male sex was an independent predictor of mortality (HR = 1.15, 95% CI 1.01 to 1.32, p = 0.035), and there was a significant interaction between sex and DM (p = 0.002). DM was strongly associated with mortality in women (HR: 1.45, 95% CI = 1.18–1.78, p &lt, 0.001), but not in men (HR: 0.98, 95% CI = 0.84–1.14, p = 0.787). In conclusion, DM is associated with mortality in older women with NSTEACS, but not in men.

Irene Lizano-Díez,1 Silvia Paz Ruiz2 1Ferrer, Barcelona, Spain; 2SmartWorking4U SLU, Benicàssim, SpainCorrespondence: Irene Lizano-DíezFerrer, Av Diagonal 549, Barcelona 08029, SpainTel +34 93 600 37 00Email ilizano@ferrer.comPurpose: Cangrelor is an intravenous, direct-acting, reversible P2Y12 inhibitor indicated for the reduction of thrombotic cardiovascular events in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) in whom oral P2Y12 inhibitors are not feasible or desirable. The objective was to assess the financial impact of introducing cangrelor into the hospital formulary in Spain.Patients and Methods: A budget impact model was developed to calculate the cost difference between two scenarios (without and with cangrelor) to treat CAD patients undergoing PCI in whom oral P2Y12 inhibitors are not feasible or desirable, over 3 years. Intravenous P2Y12 inhibitor (cangrelor), oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor), and glycoprotein IIb-IIIa inhibitors (GPIs) for bail-out use were considered. Epidemiological, efficacy (thrombotic events including cardiac death), safety (bleeding events), and costs (€, 2019) data were based on Spanish registries, clinical trials, and meta-analyses. One-way sensitivity analysis established the effect of uncertainty on results.Results: For years 1, 2, and 3, the target population to receive cangrelor was 607, 1,822, and 3,340 patients, and cangrelor uptake was 23.70%, 58.30%, and 51.30%, respectively. The 3-year budget impact was 1,021,717€ varying from 50,245€ in year 1 to 599,272€ in year 3. The results were sensitive to the number of patients treated with GPIs in Spanish hospitals.Conclusion: Based on our results, the financial effort needed to introduce the use of cangrelor in patients undergoing PCI in whom antiplatelet therapy with oral P2Y12 inhibitors is not feasible or desirable barely exceeds one million € over three years, in Spain.Keywords: P2Y12 inhibitors, cangrelor, percutaneous coronary intervention, budget impact

Danışman: DR. ÖĞR. ÜYESİ SELVA ZEREN Yer Bilgisi: İstanbul Gelişim Üniversitesi / Lisansüstü Eğitim Enstitüsü / Odyoloji Ana Bilim Dalı / Odyoloji Bilim Dalı Konu: Göğüs Kalp ve Damar Cerrahisi = Thoracic and Cardiovascular Surgery ; Kulak Burun ve Boğaz = Otorhinolaryngology (Ear-Nose-Throat) Dizin: Kalp hastalıkları = Heart diseases ; Kardiyopulmoner bypass = Cardiopulmonary bypass ; Koklea = Cochlea ; Koroner hastalık = Coronary disease ; Otoakustik emisyonlar = Otoacoustic emissions, Koroner hastalıklarda revaskülarizasyon ihtiyacına gereksinim duyulan hastalarda kardiyopulmoner bypass cerrahisi uygulanmaktadır. Bu çalışmanın amacı kardiyopulmoner bypass cerrahisi uygulanan hastaların medial-olivokoklear refleks (MOC) cevaplarının cerrahi öncesi ve sonrası karşılaştırılarak etkilenme düzeylerinin belirlenmesidir. Bu çalışmaya 40'ı koroner arter bypass (KAB) ameliyatı olan, 40'ı herhangi bir kalp damar hastalığı olmayan birey katılmıştır. KAB ameliyatı olan hastalara ameliyat öncesinde ve sonrasında timpanometri, safses odyometrisi, transient otoakustik emisyon (TEOAE), ve supresyonda emisyon testleri yapılmıştır. Cerrahi öncesi ve sonrası sonuçlar istatistiksel olarak analiz edilmiştir. Koroner bypass grubu olguların cerrahi öncesi TEOAE değerleri, kontrol grubu olgulara göre istatistiksel olarak anlamlı düzeyde düşük saptanmıştır (p=0,001; p, Cardiopulmonary bypass surgery is performed in patients who need revascularization in coronary diseases. The aim of this study is to compare the medial-olivocochlear reflex (MOC) responses of patients who underwent cardiopulmonary bypass surgery before and after surgery and to determine their level of influence. In this study, 40 individuals who had coronary artery bypass (CAB) surgery and 40 did not have any cardiovascular disease participated in this study. Preoperative and postoperative tympanometry, pure tone audiometry, transient otoacoustic emission (TEOAE), and emission tests in suppression were performed on patients who had CAB surgery. The results before and after surgery were statistically analyzed. Preoperative TEOAE values of the patients in the coronary bypass group were found to be statistically significantly lower than those in the control group (p=0.001; p

[spa] INTRODUCCIÓN: El envejecimiento de la población está provocando un aumento del número de pacientes ancianos con Infarto Agudo de Miocardio (IAM). Estos pacientes tienen mayor carga de comorbilidades, fragilidad, mayor riesgo de complicaciones y una mala adherencia a la medicación, lo que a su vez se asocia con un mayor gasto en recursos sanitarios. Los programas de enfermería pueden ayudar a mejorar la adherencia en estos pacientes complejos. OBJETIVO PRINCIPAL: Comparar el grado de adherencia al tratamiento al año en pacientes mayores de 75 años tras un IAM que han participado en un programa de educación sanitaria enfermero, respecto a otro grupo control. OBJETIVOS ESPECÍFICOS: (1) Conocer la prevalencia de fragilidad, deterioro cognitivo y funcional y su impacto en la evolución de los pacientes mayores de 75 años con IAM; (2) Analizar si hay variación en la calidad de vida del paciente antes y 12 meses después del IAM; (3) Analizar la posible asociación entre los diferentes componentes de la valoración geriátrica y la adherencia terapéutica en estos pacientes. METODOLOGÍA: Este proyecto de tesis está compuesto por 2 bloques. En el primero se analizan las características de los pacientes en cuanto a fragilidad, deterioro cognitivo y funcional y otras variables vinculadas al envejecimiento y su posible impacto en la evolución del paciente anciano tras un IAM. Para ello se realizó un estudio observacional prospectivo. Se incluyó de forma consecutiva pacientes mayores de 75 años ingresados en la Unidad Coronaria del Hospital Universitario de Bellvitge con el diagnóstico de SCA con elevación de segmento ST (SCAEST), sometido a angioplastia percutánea coronaria entre enero de 2013 y noviembre de 2016. Se registraron datos clínicos, así como una valoración geriátrica durante el ingreso, incluyendo fragilidad (FRAIL), deterioro cognitivo (test de Pfeiffer), dependencia para las actividades básicas (Barthel) e instrumentales (test de Lawton Broody) de la vida diaria, riesgo nutricional (MNA Short Form), comorbilidad (índice de Charlson) y calidad de vida (Seattle Angina Questionnaire). Esta valoración geriátrica se refirió a la situación previa al ingreso. El segundo gran bloque de este proyecto va destinado a analizar el posible impacto de una intervención de enfermería en la adherencia terapéutico al año en ancianos tras un SCAEST. Para ello se realizó un estudio experimental, no probabilístico con asignación aleatoria de los grupos de estudio. El periodo de inclusión y seguimiento de pacientes fue de abril de 2016 a diciembre de 2019. Se realizó valoración geriátrica durante el ingreso. En los pacientes incluidos en el grupo experimental se realizó a los 3 meses un “Programa de educación sanitaria enfermero” (PESE), haciendo hincapié en la valoración y aplicación de intervenciones para mejorar la adherencia terapéutica. Al año, se evaluó la adherencia terapéutica mediante la combinación de 4 métodos: cuestionario de Morisky-Green (4- items), test de Haynes-Sackett, registro de dispensación de farmacia y asistencia a citas programadas, considerándose “adherente” aquel paciente adherente en los 4 métodos. Esta valoración se realizó por personal que no conocía el grupo de asignación de los pacientes. También a los 12 meses se repitió la valoración geriátrica, en ambos grupos. El análisis de datos se realizó con el paquete estadístico SPSS. RESULTADOS: En el primer estudio se analizó una muestra de 259 pacientes con una edad media de 82.6 ± 6 años, 57,9% de los cuales eran hombres. Un 19,7% de los pacientes eran frágiles, un 10% presentaba discapacidad moderada o grave y un 31,7% tenía riesgo de desnutrición. La fragilidad se asoció con una mayor prevalencia de diabetes, hipertensión y accidente cerebrovascular previo, y una mayor mortalidad (21,6% frente a 3,4%; P, [eng] INTRODUCTION: The aging of the population is causing an increase in the number of elderly patients with Acute Myocardial Infarction (AMI). These patients have a higher burden of comorbidities, frailty, higher risk of complications, and poor adherence to medication, which in turn is associated with higher spending on healthcare resources. Nursing programs can help improve adherence in these complex patients. MAIN OBJECTIVE: To compare the degree of adherence to treatment in one year in patients older than 75 years after an AMI who have participated in a nursing health education program, compared to another control group. SPECIFIC OBJECTIVES: (1) To know the prevalence of frailty, cognitive and functional impairment, and its impact on the evolution of patients older than 75 years with AMI; (2) To analyze whether there is variation in the patient's quality of life before and 12 months after AMI; (3) To analyze the possible association between the different components of geriatric assessment and therapeutic adherence in these patients. METHODOLOGY: This thesis project is divided in 2 blocks. The first analyzes the characteristics of the patients in terms of frailty, cognitive and functional impairment and other variables related to aging and their possible impact on the evolution of the elderly patient after an AMI. For this, a prospective observational study was carried out. Patients older than 75 years admitted to the Coronary Unit of the Bellvitge University Hospital with the diagnosis of acute coronary syndrome with ST segment elevation, who underwent percutaneous coronary angioplasty between January 2013 and November 2016, were consecutively included. Clinical data were recorded, as well as a geriatric assessment during admission, including frailty (FRAIL), cognitive impairment (Pfeiffer test), dependence for basic (Barthel) and instrumental activities (Lawton Broody test) of daily life, nutritional risk (MNA Short Form), comorbidity (Charlson index) and quality of life (Seattle Angina Questionnaire). This geriatric assessment referred to the situation prior to admission. The second large block of this project is intended to analyze the possible impact of a nursing intervention on therapeutic adherence at one year in elderly patients after Acute Coronary Syndrome with ST segment elevation. For this, an experimental, non-probabilistic study was carried out with random assignment of the study groups. The period of inclusion and follow-up of patients was from April 2016 to December 2019. A geriatric assessment was performed during admission. In the patients included in the experimental group, a “Nursing Health Education Program” (PESE) was carried out at 3 months, emphasizing the assessment and application of interventions to improve therapeutic adherence. At one-year, therapeutic adherence was evaluated by a combination of 4 methods: Morisky-Green questionnaire (4-items), Haynes-Sackett test, pharmacy dispensing record and attendance at scheduled appointments, with the adherent patient being considered "adherent" in all 4 methods. This assessment was carried out by nurses who were unaware of the patient assignment group. Moreover, at 12 months the geriatric assessment was repeated in both groups. Data analysis was performed with the SPSS statistical package. RESULTS: In the first study, a sample of 259 patients with a mean age of 82.6 ± 6 years was analyzed, 57.9% of whom were men. 19.7% of the patients were frail, 10% had moderate or severe disability, and 31.7% were at risk of malnutrition. Frailty was associated with a higher prevalence of diabetes, hypertension, and prior stroke, and higher mortality (21.6% vs 3.4%; P

Framework: Although gestation marks some of the most important moments in a woman’s life, it becomes complex when associated with the problems, limitations, and risks inherent in heart disease. Objective: to comprehend the meanings women with heart disease attribute to their high-risk pregnancy and to identify their perception of the risks to the mother-child binomial. Methodology: A quantiqualitative study involving 39 pregnant women with heart disease from a public university of an inland city of São Paulo, Brazil, was conducted. Data were collected through interviews with patients and analyzed using the Discourse of the Collective Subject. Results: This study showed high-risk gestation is a process linked to personal satisfaction and fulfillment of a dream, often associated with a lack of planning, uncertainties and fears. Some participants anchored in religion/spirituality to overcome difficulties, while others used self-reliance as a support. The risks are poorly understood and often underestimated. Conclusion: High-risk gestation is a process associated with personal satisfaction, fulfillment of a dream and even a common experience, often permeated by negative feelings about the inevitable risks to the mother-child binomial. Resumen: Marco contextual: Aunque la gestación marca algunos de los momentos más importantes en la vida de una mujer, se vuelve compleja cuando se asocia con los problemas, las limitaciones y los riesgos inherentes a la enfermedad cardíaca. Objetivo: entender los significados que las mujeres con enfermedad cardíaca atribuyen a embarazos de alto riesgo e identificar su percepción de los riesgos para el binomio madre-hijo. Metodología: Fue desarrollado un estudio cuanti-cualitativo con 39 embarazadas cardíacas en una universidad pública en el interior de São Paulo, Brazil. Los datos fueron recolectados mediante entrevistas con pacientes y analizados mediante el Discurso del Sujeto Colectivo. Resultados: Este estudio reveló que el embarazo de alto riesgo es un proceso vinculado a satisfacción personal y cumplimiento de un sueño, muchas veces asociado con una falta de planificación, incertidumbres y miedos. Algunas participantes se apoyaron en la religión/espiritualidad para superar dificultades, mientras otras utilizaron la autoconfianza como apoyo. Hay poca comprensión y muchas veces subestimación de los riesgos. Conclusión: El embarazo de alto riesgo es un proceso asociado con satisfacción personal, cumplimiento de un sueño e incluso con una experiencia común, muchas veces permeada por sentimientos negativos sobre los riesgos inevitables para el binomio madre-hijo. Resumo: Marco contextual: Embora a gestação marque alguns dos momentos mais importantes na vida de uma mulher, ela se torna complexa quando associada aos problemas, limitações e riscos inerentes às doenças cardíacas. Objetivo: compreender os significados que mulheres cardiopatas atribuem à gravidez de alto risco e identificar sua percepção sobre os riscos para o binômio mãe-filho. Metodologia: Foi realizado um estudo quantitativo com 39 gestantes cardiopatas de uma universidade pública de uma cidade do interior de São Paulo, Brasil. Os dados foram coletados por meio de entrevista com os pacientes e analisados por meio do Discurso do Sujeito Coletivo. Resultados: Este estudo mostrou que a gestação de alto risco é um processo atrelado à satisfação pessoal e realização de um sonho, muitas vezes associado à falta de planejamento, incertezas e medos. Alguns participantes se ancoraram na religião / espiritualidade para superar as dificuldades, enquanto outros usaram a autossuficiência como suporte. Os riscos são mal compreendidos e frequentemente subestimados. Conclusão: A gestação de alto risco é um processo associado à satisfação pessoal, realização de um sonho e até mesmo uma experiência comum, muitas vezes permeada por sentimentos negativos sobre os riscos inevitáveis para o binômio mãe-filho.

Background Coronary disease and Hypertension are highly prevalent health problems worldwide, with the latter being one of the most common diseases in patients visiting dental clinics. Local anesthetics (LAs) with vasoconstrictor agents (VC) are known to be commonly used in dental practice. For the above-mentioned reasons, dentists should know how to adapt and treat patients with these hazardous conditions. Objective The aim of this study was to find out if the use of local anesthetics (LAs) in combination with vasoconstrictor (VC) agents in dental treatment presents a risk in patient with a known history of Hypertension and/or Coronary disease. Materials and methods This systematic review was conducted in accordance with The PRISMA guidelines and registered on the PROSPERO database (CRD42020187369). The search strategy was based on Mesh terms, Boolean operator AND, and the PICO model. It was designed to identify all the randomized clinical trials (RCTs) published in the last 30 years, which assessed whether the use of LA with VC agents in dental treatment produces a significant increase/decrease in hemodynamics in patients with known history of Hypertension and/or Coronary disease. The Cochrane Collaboration's tool was used to assess risk of bias of the included RCTs. Results An initial electronic search resulted in 87 papers; however only 9 RCTs met the inclusion criteria. There was a total of 482 subjects (N = 482), of which 412 had a known history of Hypertension or Coronary disease. Conclusions According to the literature reviewed, the use of 1 to 2 cartridges of local anesthetics with 1:80,000, 1:100,000 or 1:200,000 epinephrine in patients with controlled Hypertension and/ or Coronary disease is safe. Randomized clinical trials are essential in determining the safety or risks associated with the use of LAs with VC agents in patients with poorly controlled Hypertension and Coronary disease.

Cardiovascular mortality increases with decreasing renal function although the cause is yet unknown. Here, we have investigated whether low chronic inflammation in chronic kidney diseases (CKD) could contribute to increased risk for coronary artery diseases (CAD). Thus, a prospective case&ndash, control study was conducted in patients with CAD and CKD undergoing coronary artery bypass graft surgery with the aim of detecting differences in cardiovascular outcomes, epicardial adipose tissue volume, and inflammatory marker activity associated with renal dysfunction. Expression of membrane CD14 and CD16, inflammatory cytokines and chemokines, mitogen-activated protein (MAP) kinases and hsa-miR-30a-5p were analyzed in peripheral blood mononuclear cells (PBMCs). Epicardial fat volume and tissue inflammation in perivascular adipose tissue and in the aorta were also studied. In the present study, 151 patients were included, 110 with CAD (51 with CKD) and 41 nonCAD controls (15 with CKD). CKD increased the risk of cardiac surgery&ndash, associated acute kidney injury (CSA-AKI) as well as the 30-day mortality after cardiac surgery. Higher counts of CD14++CD16+ monocytes were associated with vascular inflammation, with an increased expression of IL1&beta, and with CKD in CAD patients. Expression of hsa-miR-30a-5p was correlated with hypertension. We conclude that CKD patients show an increased risk of CSA-AKI and mortality after cardiovascular surgery, associated with the expansion of the CD14++CD16+ subset of proinflammatory monocytes and with IL1&beta, expression. We propose that inflammation associated with CKD may contribute to atherosclerosis (ATH) pathogenesis.

Direct oral anticoagulants (DOACs) have been demonstrated to be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). This meta-analysis aims to assess the effect of DOACS vs. VKA in patients ≥ 80 and AF. Primary endpoints were stroke or systemic embolism and all-cause death. Secondary endpoints included major bleeding, intracranial bleeding, and gastrointestinal bleeding. A random-effects model was selected due to significant heterogeneity. A total of 147,067 patients from 16 studies were included, 71,913 (48.90%) treated with DOACs and 75,154 with VKA (51.10%). The stroke rate was significantly lower in DOACs group compared with warfarin group (Relative risk (RR): 0.72; 95% confidence interval (CI): 0.63–0.82; p < 0.001). All-cause mortality was significantly lower in DOACs group compared with warfarin group (RR: 0.82; 95% CI: 0.70–0.96; p = 0.012). Compared to warfarin, DOACs were not associated with reductions in major bleeding (RR: 0.85, 95% CI 0.69–1.04; p = 0.108) or gastrointestinal bleeding risk (RR: 1.08, 95% CI 0.76–1.53; p = 0.678) but a 43% reduction of intracranial bleeding (RR: 0.47, IC 95% 0.36–0.60; p < 0.001) was observed. Our meta-analysis demonstrates that DOACs are effective and safe with statistical superiority when compared with warfarin in octogenarians with AF.