Motor flexibility to stabilize the toe position during obstacle crossing in older adults: an investigation using an uncontrolled manifold analysis.

Introduction: An age-related decrease in the ability to exploit the abundant degrees of freedom of the body, referred to as motor flexibility, leads to a heightened fall risk. The present study investigated motor flexibility to stabilize the toe position during obstacle crossing in older adults and its correlation with the magnitude of foot elevation. Methods: Twenty-six older adults (70.9 ± 7.4 years old) and 21 younger adults (25.4 ± 5.0 years old) walked and crossed an obstacle, during which the dominant limb was always the leading limb. An uncontrolled manifold (UCM) analysis was used to quantify the flexibility during obstacle crossing as the synergy index, with the vertical toe position being regarded as the performance variable and the segment angles of the lower limbs as the elemental variables. Results and discussion: The results showed that older participants had a significantly lower synergy index for the trailing limb before the moment of obstacle crossing than younger participants, suggesting reduced flexibility in part. The results also showed that, regardless of age, foot elevation was negatively correlated with the synergy index, suggesting that a so-called "conservative strategy" (i.e., a tendency to show extraordinarily high foot elevation to ensure collision avoidance) may be related to their reduced motor flexibility.

Are sub-alpine species' seedling emergence and establishment in the alpine limited by climate or biotic interactions?

One of the ways in which plants are responding to climate change is by shifting their ranges to higher elevations. Early life-history stages are major bottlenecks for species' range shifts, and variation in seedling emergence and establishment success can therefore be important determinants of species' ability to establish at higher elevations. Previous studies have found that warming per se tends to not only increase seedling establishment in alpine climates but it also increases plant productivity, which could limit establishment success through increased competition for light. Here we disentangle the relative importance of several climate-related abiotic and biotic factors on sub-alpine species' seedling emergence and survival in the alpine. Specifically, we test how temperature, precipitation and competition from neighbouring vegetation impacts establishment, and also whether species' functional traits, or strategies impact their ability to colonise alpine locations. We found that our six sub-alpine study species were all able to recruit from seed in alpine locations under the extant alpine climate, but their emergence was limited by competition from neighbouring vegetation. This indicates that biotic interactions can hinder the range shifts expected as a result of climate warming. Species with a resource conservative strategy had higher emergence in the extant alpine climate than species with a resource acquisitive strategy, and they were largely unaffected by changes in temperature. The resource acquisitive species, in contrast, had faster emergence under warming, especially when they were released from competition from neighbouring vegetation. Our results indicate that competition from the established vegetation is limiting the spread of lowland species into the alpine, and as the climate continues to warm, species with resource acquisitive traits might gain an advantage.

Effectiveness of Primary Coronary Intervention for Patients With Delayed ST-Segment Elevation Myocardial Infarction: Insights from Moroccan Cardiology Intensive Care Units.

The benefits of myocardial revascularization in ST-segment elevation acute coronary syndrome after 12 to 24 hours from symptom onset remain a topic of debate, especially in patients who are stable and asymptomatic. We analyzed the benefit of late revascularization by primary coronary intervention in patients admitted to Moroccan cardiac intensive care units (CICUs) with ST-segment elevation myocardial infarction after 12 hours of symptom onset. We included a total of 406 patients who met the inclusion criteria: 262 patients in the invasive strategy group and 144 patients in the conservative strategy group. A total of 74.6% were men, and 25.4% were women. For the primary outcome, 46 all-cause deaths were observed at 1 year, with 33 patients in the conservative strategy arm and 13 patients in the invasive strategy group, with a significant difference between the 2 groups (p <0.001). For secondary outcomes, there was no difference in readmission for acute coronary syndrome or acute heart failure between the 2 groups (p = 0.277, p = 0.205). For in-CICU cardiogenic shock and ejection fraction <35% at discharge, more events are observed in the conservative strategy, with a significant difference for both (p <0.001). In multivariable analysis, 1-year all-cause mortality was independently associated with revascularization between 12 and 48 hours (hazard ratio [HR] 0.372, 95% confidence interval [CI] 0.182 to 0.762, p = 0.007), ejection fraction <35% at discharge (HR 1.92, 95% CI 1.22 to 2.54, p = 0.04), and cardiogenic shock in-CICU (HR 2.69, 95% CI 1.82 to 3.78, p = 0.005).Although no evidence exists to date on the true benefit of late primary coronary intervention revascularization in patients with ST-segment elevation myocardial infarction, this practice remains common, as indicated by the results of most registries.

Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry.

This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.

Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials.

Background: Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes. Methods: The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used. Results: This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies. Conclusions: An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.

The fern economics spectrum is unaffected by the environment.

The plant economics spectrum describes the trade-off between plant resource acquisition and storage, and sheds light on plant responses to environmental changes. However, the data used to construct the plant economics spectrum comes mainly from seed plants, thereby neglecting vascular non-seed plant lineages such as the ferns. To address this omission, we evaluated whether a fern economics spectrum exists using leaf and root traits of 23 fern species living under three subtropical forest conditions differing in light intensity and nutrient gradients. The fern leaf and root traits were found to be highly correlated and formed a plant economics spectrum. Specific leaf mass and root tissue density were found to be on one side of the spectrum (conservative strategy), whereas photosynthesis rate, specific root area, and specific root length were on the other side of the spectrum (acquisitive strategy). Ferns had higher photosynthesis and respiration rates, and photosynthetic nitrogen-use efficiency under high light conditions and higher specific root area and lower root tissue density in high nutrient environments. However, environmental changes did not significantly affect their resource acquisition strategies. Thus, the plant economics spectrum can be broadened to include ferns, which expands its phylogenetic and ecological implications and utility.

Disease Management of Clinical Complete Responders to Neoadjuvant Chemotherapy of Muscle-Invasive Bladder Cancer: A Review of Literature.

Muscle-invasive bladder cancer (MIBC) is an aggressive disease requiring active management. Neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is considered the standard treatment paradigm for MIBC patients, which could result in significant perioperative mortality and morbidity, as well as the significant alteration of the quality of life (QOL). Notably, multimodal bladder-preserving treatment strategies have been recommended for highly selected patients. Pathologic complete response (pCR) after NAC is a powerful prognostic indicator of survival for patients with MIBC. Clinical complete response (cCR) is then introduced as a complementary endpoint for pCR to assess disease status preoperatively. Bladder preservation strategy for patients who achieve cCR following NAC is emerging as a new treatment concept. However, the efficiency of the conservative strategy remains controversial. In this state-of-the-art review, we discuss the advantages and limitations of cCR and the feasibility and safety of bladder preservation strategy in highly selected MIBC patients who achieve cCR following NAC. We conclude that a conservative strategy can be considered a reasonable alternative to RC in carefully selected cCR MIBC patients, leading to acceptable oncological outcomes.

Higher water and nutrient use efficiencies in savanna than in rainforest lianas result in no difference in photosynthesis.

Differences in traits between lianas and trees in tropical forests have been studied extensively; however, few have compared the ecological strategies of lianas from different habitats. Here, we measured 25 leaf and stem traits concerning leaf anatomy, morphology, physiology and stem hydraulics for 17 liana species from a tropical seasonal rainforest and for 19 liana species from a valley savanna in south-west China. We found that savanna lianas had higher vessel density, wood density and lower hydraulically weighted vessel diameter and theoretical hydraulic conductivity than tropical seasonal rainforest lianas. Compared with tropical seasonal rainforest lianas, savanna lianas also showed higher leaf dry matter content, carbon isotope composition (δ13C), photosynthetic water use efficiency, ratio of nitrogen to phosphorus, photosynthetic phosphorus use efficiency and lower leaf size, stomatal conductance and nitrogen, phosphorus and potassium concentrations. Interestingly, no differences in light-saturated photosynthetic rate were found between savanna and tropical seasonal rainforest lianas either on mass or area basis. This is probably due to the higher water and nutrient use efficiencies of savanna lianas. A principal component analysis revealed that savanna and tropical seasonal rainforest lianas were significantly separated along the first axis, which was strongly associated with acquisitive or conservative resource use strategy. Leaf and stem functional traits were coordinated across lianas, but the coordination or trade-off was stronger in the savanna than in the tropical seasonal rainforest. In conclusion, a relatively conservative (slow) strategy concerning water and nutrient use may benefit the savanna lianas, while higher nutrient and water use efficiencies allow them to maintain similar photosynthesis as tropical seasonal rainforest species. Our results clearly showed divergences in functional traits between lianas from savanna and tropical seasonal rainforest, suggesting that enhanced water and nutrient use efficiencies might contribute to the distribution of lianas in savanna ecosystems.

Limited evidence of coupling between above and belowground functional traits in tropical dry forest seedlings / Evidencia limitada de acoplamiento entre rasgos funcionales por encima y por debajo del suelo en plántulas de bosque seco tropical

Abstract Introduction: Water availability is one of the main factors determining the distribution of woody species in the tropics. Although the functional mechanisms that determine the species tolerance to water deficit have been extensively studied in adult individuals, the responses of early ontogenetic stages have been less explored. Objective: To identify functional strategies and trait correlations between different seedlings' dimensions (leaf, stem, and root). We expect limited coordination between above and below-ground functional traits due to a single conservation-acquisition trade-off cannot capture the variability of functions and environmental pressures to which the root system is subjected. Methods: We measured 12 functional traits belonging to 38 seedling species in a tropical dry forest in Colombia. We explored the relationships between pairs of traits using Pearson correlations, and to obtain an integrated view of the functional traits, a principal component analysis (PCA) was performed. Results: The results showed limited evidence of linkage between above- and below-ground traits, but we did find significant correlations between traits for the continuum of conservative and acquisitive strategies. Root traits related to water and nutrient take capacity formed an orthogonal axis to the acquisitive-conservative continuum. Conclusions: Our results showed that dry forest seedlings have different functional strategies to cope with water deficit. The incorporation of root traits helps to explain new functional strategies not reported for leaf and stem traits. This study contributes to understanding the mechanisms that explain species coexistence and is particularly relevant for predicting future forest trajectories.

Resumen Introducción: La disponibilidad de agua es uno de los principales factores que determina la distribución de las especies leñosas en los trópicos. A pesar que los mecanismos funcionales que determinan la tolerancia de las especies al déficit hídrico han sido ampliamente estudiados en los individuos adultos, las respuestas de estados ontogenéticos tempranos han sido menos exploradas. Objetivo: Identificar las estrategias funcionales y las correlaciones de rasgos entre diferentes dimensiones de las plántulas (hoja, tallo y raíz). Nosotros esperamos baja coordinación entre los rasgos funcionales sobre y bajo el suelo debido a que un único trade-off conservación-adquisición de recursos, no puede capturar la variabilidad de funciones y presiones ambientales a las que están expuestas las raíces. Métodos: Medimos 12 rasgos funcionales pertenecientes a 38 plántulas en un bosque seco en Colombia. Exploramos las relaciones entre pares de rasgos usando correlaciones de Pearson, y para tener una visión integrada de los rasgos funcionales, usamos un análisis de componentes principales (ACP). Resultados: Reportamos limitada evidencia de acoplamiento entre los rasgos sobre y bajo el suelo, pero encontramos correlaciones significativas entre el continuo de estrategias conservativas y adquisitivas. Los rasgos de raíz relacionados con la capacidad de absorción de agua y nutrientes formaron un eje ortogonal al continuo adquisitivo-conservativo. Conclusiones: Nuestros resultados mostraron que las plántulas del bosque seco tienen diferentes estrategias funcionales para lidiar con el déficit hídrico. La incorporación de los rasgos de la raíz ayuda a explicar nuevas estrategias funcionales no reportadas por los rasgos de hoja y tallo. Este estudio contribuye al entendimiento de los mecanismos que explican la coexistencia de especies y es particularmente relevante para predecir las trayectorias de los bosques futuros.

Functional analysis of young patients with desmoid-type fibromatosis: Initial surveillance does not jeopardize long term quality of life.

BACKGROUND: With recent conservative strategies, prognosis of patients with desmoid-type fibromatosis (DTF) is about function preservation. We analyzed the long-term quality of life (QoL) of pediatric patients with DTF. METHODS: All French young patients (<21years) treated between 2005 and 2016 for a DTF in the EpSSG NRSTS-05 study were analyzed. A first wait-and-see strategy was recommended. Patients' QoL was analyzed with the internationally validated Child Health Questionnaire (CHQ). We focused on the relevant subscales scores: physical functioning (PF), role social limitations physical (RP), bodily pain (BP), general health perception (GH) and physical (PhS) and psychosocial (PsS) summary measures. RESULTS: Among the 81 patients, 52 families answered the CHQ (median delay since diagnosis = 6.2years; min2.2-max13.3 years). Median age at diagnosis was 11.5 years. Primary site: limbs (52%), head/neck (27%), or trunk (21%). Five year-Progression Free Survival was 39.1% (95%CI: 27.7-50.5%). As initial management for these 52 patients, 30 patients were first observed (57%), 13 had surgery (25%) and 9 received chemotherapy (18%). Total burden of therapy was exclusive surgery (9pts/18%), exclusive chemotherapy (18pts/35%), surgery + chemotherapy (13pts/25%), chemotherapy + radiotherapy (1 pt), surgery + chemotherapy + radiotherapy (1 pt), wait and see (10 pt). Regarding the parent forms, patients have significant lower PF (86.0vs.96.1; p = 0.03), RP (82.0vs.93.6; p = 0.04), GH (60vs.73; p < 0.005) and PhS (46.2 vs.53; p = 0.02) scores compared to healthy population. Comparison of QoL subscales scores according to initial strategy (wait-and-see vs.surgery/chemotherapy) did not reveal any difference (PF = 87.3vs.84.9; p = 0.80/RP = 83.4vs.78.7; p = 0.72/BP = 78.9vs.78.2; p = 0.95/GH = 59.7vs60; p = 0.97). Similar results were found using the children or adult forms. CONCLUSIONS: Initial wait-and-see strategy does not affect long term functional impairment.

Invasive versus conservative strategy in consecutive patients aged 80 years or older with non-ST-segment elevation myocardial infarction: a retrospective study in China.

OBJECTIVE: To investigate whether the very elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) will benefit from an invasive strategy versus a conservative strategy. METHODS: 190 consecutive patients aged 80 years or older with NSTEMI were included in the retrospective study from September 2014 to August 2017, of which 69 patients received conservative strategy and 121 patients received invasive strategy. The primary outcome was death. Multivariate Cox regression models were used to assess the statistical association between strategies and mortality. The survival probability was further analyzed. RESULTS: The primary outcome occurred in 17.4% patients in the invasive group and in 42.0% patients in the conservative group (P = 0.0002). The readmission rate in the invasive group (14.9%) was higher than that in the conservative group (7.2%). Creatinine level (OR = 1.01, 95% CI: 0.10-1.03, P = 0.05) and use of diuretic (OR = 3.65, 95% CI: 1.56-8.53, P = 0.003) were independent influential factors for invasive strategy. HRs for multivariate Cox regression models were 3.45 (95% CI: 1.77-6.75, P = 0.0003), 3.02 (95% CI: 1.52-6.01, P = 0.0017), 2.93 (95% CI: 1. 46-5.86, P = 0.0024) and 2.47 (95% CI: 1.20-5.07, P = 0.0137). Compared with the patients received invasive strategy, the conservative group had remarkably reduced survival probability with time since treatment (P < 0.001). CONCLUSIONS: An invasive strategy is superior to a conservative strategy in reducing mortality of patients aged 80 years or older with NSTEMI. Our results suggest that an invasive strategy is more suitable for the very elderly patients with NSTEMI in China.

Root exudation rate as functional trait involved in plant nutrient-use strategy classification.

Plants adopt a variety of life history strategies to succeed in the Earth's diverse environments. Using functional traits which are defined as "morphological, biochemical, physiological, or phonological" characteristics measurable at the individual level, plants are classified according to their species' adaptative strategies, more than their taxonomy, from fast growing plant species to slower-growing conservative species. These different strategies probably influence the input and output of carbon (C)-resources, from the assimilation of carbon by photosynthesis to its release in the rhizosphere soil via root exudation. However, while root exudation was known to mediate plant-microbe interactions in the rhizosphere, it was not used as functional trait until recently. Here, we assess whether root exudate levels are useful plant functional traits in the classification of plant nutrient-use strategies and classical trait syndromes? For this purpose, we conducted an experiment with six grass species representing along a gradient of plant resource-use strategies, from conservative species, characterized by low biomass nitrogen (N) concentrations and a long lifespans, to exploitative species, characterized by high rates of photosynthesis and rapid rates of N acquisition. Leaf and root traits were measured for each grass and root exudate rate for each planted soil sample. Classical trait syndromes in plant ecology were found for leaf and root traits, with negative relationships observed between specific leaf area and leaf dry matter content or between specific root length and root dry matter content. However, a new root trait syndrome was also found with root exudation levels correlating with plant resource-use strategy patterns, specifically, between root exudation rate and root dry matter content. We therefore propose root exudation rate can be used as a key functional trait in plant ecology studies and plant strategy classification.

Conservative strategy-based ensemble surrogate model for optimal groundwater remediation design at DNAPLs-contaminated sites.

The surrogate-based simulation-optimization techniques are frequently used for optimal groundwater remediation design. When this technique is used, surrogate errors caused by surrogate-modeling uncertainty may lead to generation of infeasible designs. In this paper, a conservative strategy that pushes the optimal design into the feasible region was used to address surrogate-modeling uncertainty. In addition, chance-constrained programming (CCP) was adopted to compare with the conservative strategy in addressing this uncertainty. Three methods, multi-gene genetic programming (MGGP), Kriging (KRG) and support vector regression (SVR), were used to construct surrogate models for a time-consuming multi-phase flow model. To improve the performance of the surrogate model, ensemble surrogates were constructed based on combinations of different stand-alone surrogate models. The results show that: (1) the surrogate-modeling uncertainty was successfully addressed by the conservative strategy, which means that this method is promising for addressing surrogate-modeling uncertainty. (2) The ensemble surrogate model that combines MGGP with KRG showed the most favorable performance, which indicates that this ensemble surrogate can utilize both stand-alone surrogate models to improve the performance of the surrogate model.

The plant economics spectrum is structured by leaf habits and growth forms across subtropical species.

The plant economics spectrum that integrates the combination of leaf and wood syndromes provides a useful framework for the examination of species strategies at the whole-plant level. However, it remains unclear how species that differ in leaf habits and growth forms are integrated within the plant economics spectrum in subtropical forests. We measured five leaf and six wood traits across 58 subtropical plant species, which represented two leaf habits (evergreen vs deciduous) and two growth forms (tree vs shrub) in eastern China. Principal component analysis (PCA) was employed separately to construct the leaf (LES), wood (WES) and whole-plant (WPES) economics spectra. Leaf and wood traits are highly intra- and intercorrelated, thus defining not only the LES and WES, but also a WPES. Multi-trait variations in PCAs revealed that the traits which were representative of the acquisitive strategy, i.e., cheap tissue investment and rapid returns on that investment, were clustered at one end, while traits that represented the conservative strategy, i.e., expensive tissue investment and slower returns, were clustered at other end in each of the axes of the leaf and wood syndromes (PC1-axis) and the plant height strategy (PC2-axis). The local WPES, LES and WES were tightly correlated with each other. Evergreens shaped the conservative side, while deciduous species structured the acquisitive side of the WPES and LES. With respect to plant height strategies, trees formulated the acquisitive side and shrub species made up the conservative side of the WPES, LES and WES. In conclusion, our results suggested that the LES and WES were coordinated to a WPES for subtropical species. The finding of this local spectrum of plant form and function would be beneficial for modeling nutrient fluxes and species compositions in the changing climate, but also for understanding species strategies in an evolutionary context.

A conservative strategy in non-ST-segment elevation myocardial infarction - constraints and prognosis: The situation in Portugal.

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the impact of a conservative strategy in non-ST-segment elevation myocardial infarction in patients in the Portuguese Registry of Acute Coronary Syndromes. METHODS: The 3780 patients included in the study over a three-year period were divided into three groups: group 1, patients treated by a conservative strategy during hospitalization; group 2, patients who underwent coronary angiography without percutaneous coronary intervention (PCI); and group 3, patients who underwent PCI. Clinical and procedural data and in-hospital complications were compared. The primary endpoint was defined as in-hospital or one-year mortality and the secondary endpoint as the presence of at least one of the following in-hospital complications: major bleeding according to the GUSTO criteria, need for blood transfusion, invasive ventilation, heart failure or reinfarction. RESULTS: Of the patients analyzed, 16.5% were treated by a conservative strategy. Patients in this group were older, more often women, and had more high-risk factors. A conservative strategy was associated with a higher rate of the primary endpoint - in-hospital mortality (10.6% vs. 1.1% vs. 0.6% in groups 1, 2 and 3, respectively, p<0.001, odds ratio (OR) 6.974, 95% confidence interval [CI]: 2.775-17.527) and one-year mortality (26.1% vs. 6.8% vs. 4.1%, p<0.001, hazard ratio (HR) 2.925, 95% CI: 1.433 -5.974) - and of the secondary endpoint - 37.2% vs. 18.9% vs. 14.6%, p<0.001; OR 1.471 95% CI: 1.043 -2.076. CONCLUSIONS: In this patient population, a conservative strategy is an independent predictor of in-hospital mortality, in-hospital complications and one-year mortality.

Contemporary antithrombotic strategies in patients with acute coronary syndromes managed without revascularization: insights from the EYESHOT study.

AIMS: Patients with acute coronary syndromes (ACSs) who are managed without coronary revascularization represent a mixed and understudied population that seems to receive suboptimal pharmacological treatment. METHODS AND RESULTS: We assessed patterns of antithrombotic therapies employed during the hospitalization and in-hospital clinical events of medically managed patients with ACS enrolled in the prospective, multicentre, nationwide EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units) registry. Among the 2585 consecutive ACS patients enrolled in EYESHOT, 783 (30.3%) did not receive any revascularization during hospital admission. Of these, 478 (61.0%) underwent coronary angiography (CA), whereas 305 (39.0%) did not. The median GRACE and CRUSADE risk scores were significantly higher among patients who did not undergo CA compared with those who did (180 vs. 145, P < 0.0001 and 50 vs. 33, P < 0.0001, respectively). Antithrombotic therapies employed during hospitalization significantly differ between patients who received CA and those who did not with unfractioned heparin and novel P2Y12 inhibitors more frequently used in the first group, and low-molecular-weight heparins and clopidogrel in the latter group. During the index hospitalization, patients who did not receive CA presented a higher incidence of ischaemic cerebrovascular events and of mortality compared with those who underwent CA (1.6 vs. 0.2%, P = 0.04 and 7.9 vs. 2.7%, P = 0.0009, respectively). CONCLUSION: Almost one-third of ACS patients are managed without revascularization during the index hospitalization. In this population, a lower use of recommended antiplatelet therapy and worse clinical outcome were observed in those who did not undergo CA when compared with those who did. CLINICAL TRIAL REGISTRATION: Unique identifier: NCT02015624, http://www.clinicaltrials.gov.

Outcomes in patients with non-ST-elevation acute coronary syndrome randomly assigned to invasive versus conservative treatment strategies: A meta-analysis

OBJECTIVE: The goal of the present study was to compare the prognoses of patients with non-ST-elevation acute coronary syndromes who were treated with invasive or conservative treatment strategies. METHODS: We performed a meta-analysis of studies of patients with non-ST-elevation acute coronary syndromes to assess the benefits of an invasive strategy vs. a conservative strategy for short- and long-term survival. We searched PubMed for studies published from 1990 to November 2012 that investigated the effects of an invasive vs. conservative strategy in patients with non-ST-elevation acute coronary syndromes. The following search terms were used: “non-ST-elevation myocardial infarction”, “unstable angina”, “acute coronary syndromes”, “invasive strategy”, and “conservative strategy”. The primary endpoints were all-cause mortality at 30 days and 1 year. RESULTS: Seven published studies were included in the present meta-analysis. The pooled analyses show that an invasive strategy decreased the risk of death (risk ratio [0.839] [95% confidence interval {0.648-1.086}; I 2, 86.46%] compared to a conservative strategy over a 30-day-period. Furthermore, invasive treatment also decreased patient mortality (risk ratio [0.276] [95% confidence interval {0.259-0.294}; I 2, 94.58%]) compared to a conservative strategy for one year. CONCLUSION: In non-ST-elevation acute coronary syndromes, an invasive strategy is comparable to a conservative strategy for decreasing short- and long-term mortality rates. .