European Journal of Internal Medicine最新文献

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant vascular disease with a high risk of iron deficiency anemia secondary to epistaxis and gastrointestinal bleeding. Atrial fibrillation (AF) is associated with a high risk of ischemic stroke and oral anticoagulation therapy is indicated for its prevention. Percutaneous left atrial appendage closure (LAAC) is recommended to prevent stroke in patients with AF and high risk of bleeding such as HHT patients. However, double antiplatelet therapy at first, followed by long-term single antiplatelet therapy, is also recommended after the procedure to prevent device-related thrombus (DRT), which most HHT patients cannot tolerate. This prospective observational study describes 36 HHT patients with AF, 23 of whom underwent LAAC. To prevent DRT, simple antiplatelet therapy was indicated for 3 months if tolerated. In addition, a systematic review on LAAC in HHT patients was performed to compare our results with what has been previously reported. A total of 57 HHT patients with AF and LAAC were analysed. Although only 12.3% tolerated long-term simple antiplatelet therapy, none presented DRT during follow-up. Three ischemic events were reported but only one of them appears to be partially related to AF in a patient with significant leakage peri-device. In conclusion, percutaneous LAAC is a safe and potentially effective strategy for preventing ischemic stroke in HHT patients with AF. A simplified and personalized antiplatelet regimen was not associated with DRT or ischemic events.

Background: Growth differentiation factor 15 (GDF-15) is a stress-induced circulating cytokine known to predict mortality in patients with established myocardial infarction (MI) and has been implicated in the development of cachexia.

Methods: This international multicenter study aimed to investigate the diagnostic and prognostic performance of GDF-15 among unselected patients presenting with acute chest pain to the emergency department (ED). GDF-15, high-sensitivity cardiac troponin T (hs-cTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations were measured at ED presentation. The primary diagnostic endpoint was Non-ST-elevation MI at presentation, and the primary prognostic endpoints were all-cause death at 90 days and 5-year follow-up.

Results: Among 4779 patients, median age 61 years, 33.2% female, 856 (17.9 %) were adjudicated to have MI, 994 (20.8%) to have other cardiac conditions, and 2929 (61.3%) to have non-cardiac disorders. GDF-15 exhibited only modest diagnostic accuracy for MI (AUC 0.69). During 5 years of follow-up, 557 (12.1%) deaths occurred. GDF-15 demonstrated a very high discriminative ability for all-cause death, both at 90 days (C-index 0.86, 95% CI 0.82-0.90) and at 5 years (C-index 0.84, 95% CI 0.82-0.85). This was comparable to hs-cTnT and NT-proBNP at 90 days, and higher at 5 years. When added to a rich-for-prior-information base model incorporating age, sex, cardiovascular risk factors, creatinine, hs-cTnT and NT-proBNP, GDF-15 provided meaningful incremental prognostic discrimination for 90 days and 5-year all-cause mortality.

Conclusions: In chest pain patients presenting to the ED, GDF-15 had very high prognostic accuracy for all-cause mortality over 5 years, outperforming both hs-cTnT and NT-proBNP.