How do cardiologists select patients for dual antiplatelet therapy continuation beyond 1 year after a myocardial infarction? Insights from the EYESHOT Post-MI Study

Background: Current guidelines suggest to consider dual antiplatelet therapy (DAPT) continuation for longer than 12 months in selected patients with myocardial infarction (MI). Hypothesis: We sought to assess the criteria used by cardiologists in daily practice to select patients with a history of MI eligible for DAPT continuation beyond 1 year. Methods: We analyzed data from the EYESHOT Post-MI, a prospective, observational, nationwide study aimed to evaluate the management of patients presenting to cardiologists 1 to 3 years from the last MI event. Results: Out of the 1633 post-MI patients enrolled in the study between March and December 2017, 557 (34.1%) were on DAPT at the time of enrolment, and 450 (27.6%) were prescribed DAPT after cardiologist assessment. At multivariate analyses, a percutaneous coronary intervention (PCI) with multiple stents and the presence of peripheral artery disease (PAD) resulted as independent predictors of DAPT continuation, while atrial fibrillation was the only independent predictor of DAPT interruption for patients both at the second and the third year from MI at enrolment and the time of discharge/end of the visit. Conclusions: Risk scores recommended by current guidelines for guiding decisions on DAPT duration are underused and misused in clinical practice. A PCI with multiple stents and a history of PAD resulted as the clinical variables more frequently associated with DAPT continuation beyond 1 year from the index MI

Echocardiographic Grading of Right Ventricular Afterload in Left Heart Disease: Relation to Right Ventricular Function, Pulsatile and Resistant Load, and Outcome

ABSTRACT The hemodynamic definitions of pulmonary hypertension consider resistive loading (pulmonary vascular resistance [PVR]), but there are increasing evidence that pulsatile loading (pulmonary artery compliance [PAC]) has functional and prognostic importance. The aims of the present study on patients with left heart disease, were to evaluate a novel echocardiographic right ventricular (RV) afterload score and to investigate its relation to risk of mortality or implantation of a left ventricular assist device. Patients (n = 220) with left ventricular ejection fraction  3 Wood units (WU). One point was allocated for sPAPDoppler 36–59 mmHg and for pressure reflection variables above the upper normal limit. Low afterload was defined as 0‐to‐1 points, intermediate as 2‐to‐4 points, and high as 5‐to‐8 points. There were in‐between the groups significant differences in PAC and PVR. A 5‐point RV dysfunction score showed with stepwise increased RV afterload more severe dysfunction. Unadjusted hazard ratio for endpoint was 3.34 (1.69–6.79) for intermediate score, and 5.11 (2.52–10.40) for patients with high score. In conclusion, in patients with severe heart failure, a novel echocardiographic RV afterload score is related to increased pulsatile and resistant load, more severe RV dysfunction, and increased risk of adverse outcome

Blood pressure variations and low blood pressure values at home after hospital discharge in older hypertensives

Background: Blood pressure (BP) variations occurring after hospital discharge in a population of older hypertensives have not been previously investigated. Design: elderly (≥65 years) hypertensives admitted to the geriatric acute ward of a university-teaching hospital were enrolled in this prospective observational study. Methods: Exclusion criteria were terminal illness, discharge to institution, and changes in antihypertensive regimen. BP was recorded in the emergency room, at ward admission, daily during hospital stay, and at discharge. Home self blood pressure measurement was performed after discharge. Results: The study population included 106 patients. There was a significant decrease in systolic BP (SBP) and diastolic BP (DBP) throughout the study time points. SBP and DBP decreased after discharge (from 135.1 ± 15.0 to 131.5 ± 16.1 mmHg and from 77.2 ± 8.4 to 71.6 ± 8.7 mmHg, respectively), the difference being significant only for DBP ( p = 0.000). We further observed higher prevalence of critically low BP values (SBP &lt;120 mmHg and DBP &lt;70 mmHg) at home (23.6% and 48.1%, respectively) compared to discharge (8.5% and 9.4%, p = 0.006 and p = 0.000, respectively). Conclusions: We observed a decrease in BP values, and particularly DBP values, after hospital discharge, in a sample of older hypertensives. Critically low BP values were observed at home in a high proportion of subjects, suggesting wise use of antihypertensive therapy at discharge and early monitoring of BP values at home. </jats:p

Hospital at Home Treatment of Haematological Patients

Abstract In the Western World, health care systems are facing the challenge of providing high quality services in a cost effective fashion (Madgwick KV and Yardumian A 1999, Szterling LN 2005). At the same time, the number of old and frail patients is increasing. For these reasons, medical home services have been recently developed that can guarantee hospital-like assistance, with lower costs (Cartoni C et al 2007) and greater respect of patients’frailty. Despite the increasing number of haematological home services world-wide, the volume of out-of-hospital transfusions, in the United States, is estimated to be &amp;lt;1% of the total blood transfusions (Benson K 2006). Here, we present our Hospital at Home Service (HHS), together with a one-year serie (January 2007 to December 2007) of patients admitted for an acute illness and with a main or secondary diagnosis of haematological illness or requiring emocomponent transfusion. HHS is a service of the University Hospital of Torino, aiming to provide selected, acutely ill patients with a hospital-like assistance at their home. In this alternative setting of care, physicians and nurses work as a real mobile team, while the care-givers are educated to actively take part in the nursing of the patients. Blood tests, instrumental investigations (EKG, pulse oximetry, spirometry, abdominal, vascular and cardiac ultrasonography, radiograms), intravenous therapies, emocomponent transfusions, oxygen therapy and surgical treatment of pressure ulcers are performed at the patients’ home. As to transfusion of emocomponents at home, pre-transfusion blood samples are collected by a nurse the day before and the entire process is started by a physician and then monitored by a specialist nurse. Randomized controlled trials of patients affected by minor stroke, exacerbated heart failure and exacerbated COPD have been conducted (Aimonino Ricauda N et al 2004 and 2008), showing the non-inferiority and the higher cost-effectiveness of HHS as compared to admission to traditional hospital wards. In the present retrospective study general data, functional status (Activities of Daily Living – ADL, Instrumental Activities of Daily Living – IADL, Karnofsky performance status), comorbidity level (Cumulative Illness Rating Scale – CIRS) and severity of diseases (Acute Physiology and Chronic Health Evaluation – APACHE II) at admission, blood parameters and length of stay were collected. Over a total of 481 patients treated in 2007, 54 (11.2%) patients were enrolled on the basis of their diagnosis code at discharge: 4 (7.4%) with lymphatic cell neoplasia, 42 (77.7%) with anemia and 8 (14.8%) with anemia and lymphatic cell neoplasia. Mean age was 80.9 ± 9.6 years. Patients showed severe functional impairment and comorbidity. Mean length of stay was 26.04 ± 21.26 days. Thirty-five patients 41 (76%) were discharged at home, 3 (5.5%) were transferred to another hospital unit and 10 (18.5%) died. Thirty one (64.8%) needed an emocomponent transfusion, for a total of 112 blood units and 49 platelet pools. No adverse reactions were observed. The data presented show that a consistent proportion of the patients admitted to the HHS have a haematological illness. Even though we have no comparative data, our experience shows the feasibility of the treatment of selected haematological patients in a hospital-at-home setting of care.</jats:p