ΕΠΙΣΤΗΜΟΝΙΚΑ ΚΙ … ΑΛΛΑ”από τον Ομ. Καθηγητή, Ιωάννη Γουδέβενο, 1.10.2024 – Αναστολείς αλδοστερόνης

Κύριος επισκέφτηκε κατάστημα πτηνών(pet shop) για να αγοράσει έναν παπαγάλο και ιδού ο ακόλουθος διάλογος με το πωλητή:

Πωλητής. Αυτός ο παπαγάλος εκεί στοιχίζει 1 000 € γιατί ξέρει την Aγία Γραφή απ έξω  και ο άλλος δίπλα  2 000 € γιατί ξέρει και το Κοράνιο!

Αγοραστής:  Εκείνος εκεί στη γωνία που δείχνει σκεπτικός και δεν μιλάει πόσο κοστίζει;

Πωλητής: Αυτός κοστίζει 50 000 €

Αγοραστής: έκπληκτος Τι ξέρει και κοστίζει τόσο πολύ;

Πωλητής:   Δεν ξέρω τι ξέρει αλλά οι άλλοι δύο τον φωνάζουν  ΚΥΡΙΕ ΚΑΘΗΓΗΤΑ!

Τώρα καταλαβαίνεται για τη πρεμούρα του Αδωνη  να δώσει θέσεις ΕΣΥ στο πανεπιστήμιο, να ιδρύσει πανεπιστημιακά κέντα υγείας και να επαναφέρει τους ευδοκίμως αφυπηρετήσαντες (συνταξιούχους) καθηγητές στη ενεργό δράση!

Συνάδελφοι Συναδέλφισσες

J club Fastrack!

Μετα ανάλυση έδειξε ότι η προφυλαχτική σύγκλειση του ωτίου του αριστ κόλπου στη διάρκεια καρδιακού χειρουργείου  σ ασθενείς χωρίς ιστορικό ΚΜ δεν πολύ βοήθησε. https://doi.org/10.1161/CIRCINTERVENTIONS.124.014296 Για το θέμα τρέχουν μεγάλες μελέτες

Το κλινικό ερώτημα αν  η CTA προηγηθεί της Στεφανιογραφίας(ΣΦ)  σ ασθενείς  με CABG   ωφελεί ήταν ο στόχος  μελέτης από την Πάτρα(Gr Tsingas et al . https://doi.org/10.1161/CIRCINTERVENTIONS.124.014045

H ως άνω στρατηγική  έδειξε επιτάχυνση  του χρόνου διενέργειας της εξέτασης και  λιγότερη έκθεση σε ακτινοσκόπηση

ΑCC/AHA GUIDELINES: ΠΕΡΙΕΧΓΕΙΡΗΤΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΣΕ ΜΗ ΚΑΡΔΙΑΚΑ ΧΕΙΡΟΥΡΓΕΙΑ(NCS) ΣΕ ΚΑΡΔΙΑΓΓΕΙΑΚΟΥΣ ΑΣΘΕΝΕΙΣ . JACC & Circulation 2024

Oι τελευταίες οδηγίες των ACC/AHA είναι από το 2014  ενώ οι Ευρωπαϊκές  το 2022

key points 

1. A stepwise approach to perioperative cardiac assessment assists clinicians in determining when surgery should proceed or when a pause for further evaluation is warranted. For patients who have known CVD or risk factors, or symptoms concerning for CVD, use of validated risk-prediction tools can inform clinical decision-making(Class IIa). Several CV conditions   can increase the risk of complications, the writing committee includes risk modifiers as part of the evaluation. Modifiers of CV risk include the presence of severe valvular heart disease, severe pulmonary hypertension, congenital heart disease, prior coronary stent/CABG surgery, recent stroke, pacemaker/ ICD, and frailty. These conditions, confer additional risk that isn’t represented by the risk calculators. In addition to risk modifiers, the risk-assessment algorithm newly incorporates preoperative biomarker assessment (NT-proBNP and  troponin) in select patients.
2.  CV screening and treatment of patients undergoing NCS should adhere to the same indications as nonsurgical patients, carefully timed to avoid delays in surgery and chosen in ways to avoid over screening and overtreatment.  The recommendations are primarily focused on elevated-risk noncardiac operations(neurosurgery, thoracic, and vascular) , and moderate-risk procedures(orthopedic, breast,  urologic) . There is little to be gained by extensive preoperative testing in patients scheduled for low-risk procedures, such as cataract , dental procedures, or skin biopsies A high-risk patient can still be at risk for CV  complications while undergoing a low-risk procedure. An example of this would be a sedated  GI procedure, perhaps even in an outpatient setting, that’s considered a fairly low-risk procedure, It’s important that all clinicians—not just the anesthesiologist or the cardiologist, but also the proceduralist—know that there are patients going for what might be, in other patients, a fairly routine low-risk procedure but can be an elevated-risk procedure for a patient with preexisting CVD.
3.  Preoperative stress testing should be performed only in highly selected patients, including those with poor or unknown functional capacity and at elevated risk for perioperative events based on a validated risk tool (Class 2b). Patients who are at low risk for perioperative events, have good functional capacity, or who are undergoing low-risk procedures should not undergo routine stress testing (Class 3).

The guidelines now include cardiac CT angiography as a screening tool, specifically for those with poor or unknown functional capacity and elevated risk for perioperative events (class 2b). In patients undergoing NCS, routine preoperative invasive coronary angiography (ICA) is not recommended to improve perioperative outcomes. In patients with non–left main CAD who are planned for NCS, routine preoperative coronary revascularization is not recommended to reduce perioperative cardiovascular events.

4. The guideline emphasizes a team-based, patient-centered approach to perioperative care, particularly for patients with complex or unstable CVD.
5. SGLT2 inhibitors, prescribed for heart failure and/or diabetes, should be stopped 3-4 days prior to planned surgery to reduce the risk of perioperative metabolic acidosis (Class 1).
6.  For most patients on therapeutic anticoagulation, withholding DOACs or warfarin prior to surgery is appropriate, and bridging with parenteral heparin may cause harm due to increased bleeding risk (Class 3  for bridging). In patients at high thrombotic risk(mechanical mitral valves, left ventricular thrombus) within the past 3 months, and AF with recent stroke, bridging with heparin or LMWH can reduce thromboembolic risk (Class 2a).
7. AF is a common perioperative problem, and it is reasonable to address medical triggers for rapid AF such as anemia and sepsis (Class 2a ). Consideration of postoperative anticoagulation for stroke prevention is reasonable, weighing the risks of bleeding (Class 2a ). AF that is newly diagnosed in the perioperative period should prompt outpatient cardiology follow-up AF surveillance and anticoagulation management (Class 1).
8. Myocardial injury after NCS (MINS), encompassing both type 1 and type 2 myocardial infarction, is associated with increased 30-day postoperative mortality, and outpatient CV follow-up is reasonable (Class 2a).

Μετά από DES-PCI ο χρόνος(timing) να γίνει NCS είναι μετά τους 12 μήνες για τα ΟΣΣ και μετά 6 μήνες για τη ΧΣΝ. Στους 3 μήνες αν η εγχείρηση επείγει(πχ κακοήθεια). ΠΡΟΣΕΧΩΣ περιστατικά

Ο χρόνος διακοπής των αντιΑΜΠ φαίνεται στο table 12 και μόνο σε περιπτώσεις με ιστορικό PCI δεν διακόπτουμε την ασπιρίνη.

ΑΝΤΑΓΩΝΙΣΤΕΣ ΑΛΔΟΣΤΕΡΟΝΗΣ Mineralocorticoid receptor antagonists(ΜRAs):μετά  σπιρονολακτόνη, επλερενόνη  τώρα και η φινερενόνη(Kerendia 10-20 mg 70-80 €)

Tο πρόβλημα με τους ανταγωνιστές της αλδοστερόνης είναι ότι ΥΠΟ χρησιμοποιούνται στη ΚΑ. Στο πρόσφατο ESC παρουσιάσθηκε η μελέτη FINEHEART με ένα νέο μη στεροειδή ανταγωνιστή  τη  φινερενόνη.

Solomon SD,McMurray JJ, Vaduganathan M, et al., for the FINEARTS-HF . Finerenone in Heart Failure With Mildly Reduced or Preserved Ejection Fraction. N Engl J Med 2024;Sep 1:[Epub ahead of print]

Είναι απίστευτο με τις  χρηματοδοτούμενες μελέτες. Δεν πρόφτασε να δημοσιευτεί  η κύρια μελέτη FINE ARTS-HF  που είχε μέση παρακολούθηση 2. 6  χρόνια έχουμε και ανάλυση υποομάδας για τη παρακολούθηση στα 3 χρόνια. JAMA Cardiol. Published online 2024 και μετα ανάλυση: Vaduganathan Μ, Filippatos G , Claggett BL et al. Finerenone in Heart Failure and Chronic Kidney Disease with Type 2 Diabetes: the FINE-HEART pooled analysis of cardiovascular, kidney, and mortality outcomes. Nature Medicine (2024; [Epub ahead of print]). Τhis individual patient level metaanalysis represents an important step forward in the management of HFmrEF and HFpEF, particularly for patients with more advanced disease. However, whether these findings can be extended to the wider population of patients with HFpEF, particularly those with lower NT-proBNP levels who have not yet been hospitalize , remains uncertain.

Jhund PS, Talebi A, Henderson AD, et al. Mineralocorticoid receptor antagonists in heart failure: an individual patient level meta-analysis. Lancet 2024; 404:1119-31

Editorial.  Rutten FH, Amy Groenewegen A. Mineralocorticoid receptor antagonists for every patient with heart failure.  Lancet 2024 404:1080-1

Ταυτόχρονα δημοσιεύτηκε και ανασκόπηση για το ρόλο των MRAs  στη Καρδιακή ανεπάρκεια; Chang J, Ambrosy AP, Vardeny O, Van Spall HG, Mentz RJ, Sauer AJ. Mineralocorticoid Antagonism in Heart Failure: Established and Emerging Therapeutic Role. JACC Heart Fail 2024;Sep 18:[Epublished]

Key points

1. Large RCTs  in HFrEF have demonstrated reduction in CV mortality and HF hospitalizations with MRA. Steroidal MRAs (spironolactone and eplerenone) block other steroid receptors including androgen and progesterone receptors leading to gynecomastia, menstrual irregularities, and impotence in addition to hyperkalemia.

2. Contemporary HF guidelines recommend MRA in patients with HFrEF with NYHA  II-IV symptoms as a Class 1  if GFR  is >30 mL/min/1.73 m² and serum potassium is <5 mEq/L. These guidelines also recommend close monitoring of renal function and potassium level at 1 week, 4 weeks, and then every 6 months after initiating or up-titrating MRA.
3. For HF with mid-range EF (HFmrEF; EF 41-49%), contemporary guidelines recommend MRA in symptomatic patients as a Class 2b  to reduce hospitalization, especially among patients with  LVEF on the lower end of this spectrum.
4. The TOPCAT trial with spironolactone in HFmrEF  HFpEF  showed a reduction in HF hospitalizations αλλά είχε πολλά προβλήματα .
5. Nonsteroidal MRAs (finerenone, esaxerenone, and balcinrenone) offer potential advantages over steroidal MRAs including lower risk for hyperkalemia and lack of antiestrogen and antiprogesterone side effects.
6. Finerenone is currently FDA approved for CKD associated with type 2 diabetes based on trial (FIDELIO-DKD) showing reduction in a composite endpoint for kidney failure. HFrEF patients were excluded in this trial but finerenone also reduced risk for CV events (CV death, MI], and HF hospitalization) in this trial. In a similar cohort, the FIGARO-DKD trial showed reduced CV death, MI, HF hospitalization, and stroke with finerenone.
7. Phase 2 trial data suggest superiority of finerenone compared with eplerenone in chronic HFrEF and/or CKD with type 2 diabetes with a larger decrease in N-terminal pro–B-type natriuretic peptide (NT-proBNP) level at day 90. A secondary analysis also showed a larger reduction in all-cause mortality, CV hospitalizations, and worsening HF leading to ED visits with finerenone compared with eplerenone. The incidence of hyperkalemia was not different between finerenone and eplerenone groups.
8. The FINEARTS-HF trial included HF patients with LVEF >40% randomized to finerenone and placebo. Finerenone was superior to placebo in reducing the composite of CV death and total number of HF hospitalizations/ER visits, without any difference in CV death when considered alone.
9. Trials have demonstrated that esaxerenone is superior to placebo in patients with type 2 diabetes and CKD for renal protection and improves myocardial remodeling in HFpEF patients by decreasing BNP. A phase 2 trial comparing balcinrenone with dapagliflozin versus dapagliflozin alone in symptomatic HF patients with LVEF<60% and CKD showed that combination therapy was superior to dapagliflozin monotherapy in reducing urine-albumin-creatinine ratio at 12 weeks.
10. Although emerging trials are promising for nonsteroidal MRAs, real-world costs limit their use in contemporary practice. The authors suggest using steroidal MRA in treatment of cardiorenal disease due to cost-effectiveness until there are more data with head-to-head comparison of steroidal versus nonsteroidal MRA.
11. Future trials looking at efficacy of nonsteroidal MRA in combination with SGLT-2 inhibitors compared with standard care in hospitalized HF patients across the entire spectrum of EF are ongoing. This is in addition to another trial looking at nonsteroidal MRA in HFrEF patients with previous intolerance to steroidal MRA and other trials re-examining efficacy of spironolactone compared with placebo in HF patients with LVEF >40%.

To ΗΚΓ της εβδομάδας

Τι δείχνει το ΗΚΓ 57 χρονου στα ΤΕΠ με πόνο στο στήθος. KΣ 125/λεπτό, ΑΠ 130/85 mmHg, Osat 99%. Η ΦΕ χωρίς ευρήματα και τα επίπεδα τροπονίνης Ι 35ng/L(ΦΤ 0-34)

1. Προσθιοδιαφραγματικό STEMI
2. Διάχυτη υπενδοκάρδια ισχαιμία
3. Περικαρδίτιδα
4. Οπίσθιο ΕΜ
5. Σύνδρομο Wellens

Kick off  από Τρίτη 1/10  στα

https://www.livemedia.gr/ipo2024 to link παρακολούθησης

Οδυσσέας Ελύτης – «Όλα τα πήρε το καλοκαίρι»

Όλα τα πήρε το καλοκαίρι τ’ άγριο μαλλί σου στην τρικυμία, το ραντεβού μας η ώρα μία

Όλα τα πήρε το καλοκαίρι τα μαύρα μάτια σου, το μαντίλι, την εκκλησούλα με το καντήλι

Όλα τα πήρε το καλοκαίρι με τα μισόλογα τα σβησμένα, τα καραβόπανα τα  σχισμένα

Μες στις αφρόσκονες και τα φύκια όλα τα πήρε τα πήγε πέρα τους όρκους που έτρεμαν στον αέρα

Όλα τα πήρε το καλοκαίρι κι εμάς τους δύο χέρι με χέρι.

Συναδελφικά Γουδέβενος Γιάννης Γιάννινα

Απάντηση στο ΗΚΓ

His ECG showed sinus tachycardia, ST-segment elevations in leads V1 and aVR, and widespread ST-segment depressions – findings indicative of diffuse subendocardial ischemia. This pattern can result from multivessel or left main(LM) complicated by acute plaque rupture or increased myocardial oxygen demand. Εmergency coronary angiography showed greater than 90% stenosis of the proximal LM and 20% stenosis of the bifurcation of the LM. Administration of intracoronary nitroglycerin showed that the stenosis  was fixed and was not attributable to coronary spasm. A diagnosis of high-risk NSTEMI was made.