BACKGROUND:Chest pain (CP) is a common reason for Emergency Department (ED) presentation and may signal life-threatening cardiovascular emergencies (CVE). Sex-related differences in CP management are increasingly recognised, and multimodal sex-neutral assessment and sex-specific troponin thresholds have been proposed to reduce disparities. METHODS:Consecutive adults with haemodynamically stable CP presenting to a tertiary ED (2021-2023) were prospectively enrolled. A sex-neutral triage protocol incorporating symptom severity, physiological parameters, ECG findings, and cardiovascular risk factors was applied, alongside sex-specific troponin thresholds. Clinical characteristics, ED management and 30-day outcomes were recorded. RESULTS:Among 6017 patients, 2703 (44.9%) were women. Median age was 60 years in females vs 59 in males (p < 0.001). Women showed greater clinical heterogeneity, more frequently reporting posterior CP, epigastric pain, dyspnoea, and nausea/vomiting. High-priority triage codes were less often assigned to women (29.2% vs 37.9%, p < 0.001). Female sex independently predicted lower CVE risk (adjusted OR 0.48, 95% CI 0.39-0.59). CVE predictors differed by sex, with dyspnoea, peripheral artery disease, and Q waves associated with CVE in women. Women were hospitalised less frequently but experienced a longer ED stay before admission (19.0 vs 11.9 h, p < 0.001). Females with CVE were more frequently assigned lower-priority triage codes and experienced longer delays to troponin testing and to hospital admission. CONCLUSION:Clinically relevant sex differences persist in CP evaluation, even with sex-neutral, risk-informed triage protocols incorporating ECG findings and cardiovascular risk factors, alongside sex-specific troponin thresholds. Further strategies addressing sex-specific patterns across the entire CP pathway are needed to improve equity in emergency care.
Diabetes mellitus (DM) is increasingly prevalent in people with HIV, with reported prevalence estimates generally ranging from 5% to 15% across contemporary cohorts. It represents a major contributor to both microvascular and macrovascular disease. People with HIV are at increased risk of insulin resistance and type 2 diabetes due to chronic immune activation, antiretroviral therapy-related metabolic effects, and traditional cardiometabolic risk factors. In this context, DM is associated with accelerated atherosclerosis, earlier onset of microvascular injury, and adverse cardiovascular outcomes. Glycaemic screening and management remain suboptimal in this population, and HbA1c may underestimate dysglycaemia in selected patients. This narrative review critically appraises current evidence on diabetes-related vascular complications in people with HIV, identifies key pathophysiological and clinical gaps, and highlights priorities for improved screening, risk stratification, and integrated management.
BACKGROUND:Patients with atrial fibrillation (AF) who are at increased risk of both thrombotic and haemorrhagic events represent a heterogeneous and broad clinical entity, characterized by the presence of several Janus-faced risk factors. We aimed to identify clinical phenotypes and assess the association of ABC pathway adherence with one-year outcomes in patients with AF at high risk of both stroke and bleeding. METHODS:AF patients who had HAS-BLED score ≥3 and CHA2DS2-VASc score ≥2 were included. Hierarchical clustering was applied to identify phenotypic subgroups. We assessed the impact on net adverse clinical event (NACE) of adherence to the integrated care based on the Atrial fibrillation Better Care (ABC) pathway. RESULTS:A total of 2,535 patients (mean age 75.4 ± 7.8 years; 58.3% male) were enrolled. Cluster I had the highest rates of prior thromboembolic and haemorrhagic events with the lowest comorbidity burden; Cluster II comprised the oldest patients with the highest prevalence of dyslipidaemia, heart failure, and peripheral artery disease; Cluster III was the youngest with the highest BMI and alcohol use. Cluster II (aOR 1.93, 95% CI 1.37-2.78), and Cluster III (aOR 1.65, 95% CI 1.10-2.50) were associated with a higher risk of all-cause death compared to Cluster I. Among patients with available ABC pathway data, adherence was associated with lower odds of 1-year MACE (OR 0.39, 95% CI 0.15-0.82). CONCLUSION:Three distinct phenotypic clusters were identified, each with heterogeneous clinical characteristics and outcomes, underscoring the need for more individualised, phenotype-informed management strategies in this complex patient population.
BACKGROUND:Systemic lupus erythematosus (SLE) is associated with increased cardiovascular morbidity, but the long-term prognostic value of subclinical atherosclerosis and circulating biomarkers remains uncertain. We aimed to assess 10-year vascular outcomes and identify clinical and biological predictors of thrombotic events in SLE. METHODS:This prospective cohort study included 97 consecutive female patients with SLE who underwent baseline clinical, laboratory, and carotid ultrasound evaluation and were followed for a mean of 9.7 ± 2.8 years. Carotid intima-media thickness (IMT) and plaque were assessed according to standardized criteria. Traditional cardiovascular risk factors, lupus-related variables, and biomarkers including adipokines, inflammatory mediators, endothelial activation markers, and osteoprotegerin were analyzed. Cardiovascular events were confirmed by medical record review. Logistic and Cox regression models were used to identify predictors. Arterial events were compared with an age-matched population-based cohort. RESULTS:Carotid plaques were present in 44% of patients at baseline. During follow-up, 11 patients (11.3%) experienced thrombotic cardiovascular events, including eight arterial events. Metabolic syndrome (29.4% vs. 6.5%, p = 0.006) and hypertension (22.2% vs. 7.1%, p = 0.036) were associated with increased risk. In Cox analysis, metabolic syndrome independently predicted events (HR 4.3, 95% CI 1.2-15.2, p = 0.012), while age was the strongest independent determinant of both overall and arterial events. Higher IMT, cumulative damage, and reduced renal function were associated with adverse outcomes. An independent prognostic association between most inflammatory and adipokine biomarkers could not be demonstrated within our cohort. Compared with controls, SLE patients showed numerically higher arterial event rates, although differences were not statistically significant. CONCLUSIONS:Long-term cardiovascular risk in SLE appears to be driven mainly by age, metabolic abnormalities, and cumulative organ damage rather than by lupus-specific inflammatory biomarkers.
BACKGROUND:Randomized trials have shown that direct oral anticoagulants (DOACs) are as effective as vitamin K antagonists (VKAs) for treating venous thromboembolism (VTE), with less major bleeding. Whether these findings apply to routine clinical practice remains uncertain. OBJECTIVES:To compare recurrent VTE and bleeding during anticoagulation in patients with symptomatic lower-limb deep vein thrombosis (DVT) treated with DOACs or VKAs, and to assess outcomes according to approximate eligibility for pivotal randomized trials. METHODS:We analyzed consecutive patients with symptomatic lower-limb DVT enrolled in the RIETE registry who received therapeutic-dose VKAs or DOACs. Follow-up was restricted to the treatment period. Outcomes were recurrent VTE, major bleeding, and clinically relevant non-major bleeding (CRNMB). Hazard ratios (HRs) were estimated using Cox proportional hazards models with inverse probability of treatment weighting. RESULTS:Among 24,728 patients (11,349 DOACs; 13,379 VKAs), DOACs were associated with lower risks of recurrent VTE (HR 0.71; 95%CI, 0.58-0.87) and major bleeding (HR 0.78; 95%CI, 0.63-0.97), but a higher risk of CRNMB (HR 1.35; 95%CI, 1.17-1.55). Median times to recurrent VTE, major bleeding, and CRNMB were 105, 88, and 81 days, respectively. Among patients approximating eligibility for randomized trials, DOACs were associated with lower risks of recurrent VTE and major bleeding, whereas no significant reduction was observed in trial-ineligible patients. CONCLUSIONS:In routine clinical practice, DOACs were associated with lower risks of recurrent VTE and major bleeding, but higher CRNMB rates than VKAs. Their safety advantage appeared more evident in patients with characteristics similar to those enrolled in pivotal randomized trials.
The integration of artificial intelligence (AI) and machine learning (ML) into medical practice marks a transformative shift within healthcare delivery, diagnostics, and treatment paradigms. Although AI systems exhibit sophisticated capabilities in image recognition, predictive analytics, and clinical decision support, their implementation introduces fundamental ethical and legal questions requiring thorough examination. This review addresses the primary ethical principles relevant to AI in medicine - including respect for patient autonomy, beneficence, non-maleficence, and justice - alongside key legal frameworks with respect to liability, data protection, regulatory compliance, and algorithmic transparency. It analyzes challenges such as algorithmic bias, patient privacy, informed consent in automated decision-making, and the evolving responsibilities of healthcare professionals in AI-based clinical environments. Additionally, the review investigates emerging regulatory approaches across jurisdictions, considering how existing medical device regulations, data protection laws, and professional liability frameworks are adapting to AI technologies. The paper concludes with recommendations for clinicians, policymakers, and developers to promote ethical AI deployment that strengthens the physician-patient relationship and advances healthcare equity.
