Search

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved., A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

©The European Society of Cardiology 2020. Article reuse guidelines : sagepub.com/journals-permissions, Secondary prevention through comprehensive cardiac rehabilitation has been recognized as the most cost-effective intervention to ensure favourable outcomes across a wide spectrum of cardiovascular disease, reducing cardiovascular mortality, morbidity and disability, and to increase quality of life. The delivery of a comprehensive and ‘modern’ cardiac rehabilitation programme is mandatory both in the residential and the out-patient setting to ensure expected outcomes. The present position paper aims to update the practical recommendations on the core components and goals of cardiac rehabilitation intervention in different cardiovascular conditions, in order to assist the whole cardiac rehabilitation staff in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and patients in the recognition of the positive nature of cardiac rehabilitation. Starting from the previous position paper published in 2010, this updated document maintains a disease-oriented approach, presenting both well-established and more controversial aspects. Particularly for implementation of the exercise programme, advances in different training modalities were added and new challenging populations were considered. A general table applicable to all cardiovascular conditions and specific tables for each clinical condition have been created for routine practice.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021, Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

MRI can assess plaque composition and has demonstrated an association between some atherosclerotic risk factors (RF) and markers of plaque vulnerability in naive patients. We aimed at investigating this association in medically treated asymptomatic patients. This is a cross-sectional interim analysis (August 2013–September 2016) of a single center prospective study on carotid plaque vulnerability (MAGNETIC study). We recruited patients with asymptomatic carotid atherosclerosis (US stenosis > 30%, ECST criteria), receiving medical treatments at a tertiary cardiac rehabilitation. Atherosclerotic burden and plaque composition were quantified with 3.0 T MRI. The association between baseline characteristics and extent of lipid-rich necrotic core (LRNC), fibrous cap (CAP) and intraplaque hemorrhage (IPH) was studied with multiple regression analysis. We enrolled 260 patients (198 male, 76%) with median age of 71-y (interquartile range: 65–76). Patients were on antiplatelet therapy, ACE-inhibitors/angiotensin receptor blockers and statins (196–229, 75–88%). Median LDL-cholesterol was 78 mg/dl (59–106), blood pressure 130/70 mmHg (111–140/65–80), glycosylated hemoglobin 46 mmol/mol (39–51) and BMI 25 kg/m2 (23–28); moreover, 125 out of 187 (67%) patients were ex-smokers. Multivariate analysis of a data-set of 487 (94%) carotid arteries showed that a history of hypercholesterolemia, diabetes, hypertension or smoking did not correlate with LRNC, CAP or IPH. Conversely, maximum stenosis was the strongest independent predictor of LRNC, CAP and IPH (p

Background Discrepant data were reported about hospital admissions for ST-segment elevation myocardial infarction (STEMI) during COVID-19 pandemic. We reviewed studies reporting STEMI hospitalizations during COVID-19 pandemic, investigating whether differences in COVID-19 epidemiology or public health-related factors could explain discrepant findings in different countries. Methods Search through MedLine, Embase, Scopus, Web-of-Science, Cochrane Register of Controlled Trials, of studies comparing STEMI admissions during COVID-19 pandemic with a reference period, without language restrictions, as registered in PROSPERO International Prospective Register of Systematic Reviews. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. Data independently extracted by multiple investigators were pooled using a random-effects model. Health-related metrics were from publicly-available sources. Results We included 79 articles (111,557 STEMI cases, from 57 countries). During peak COVID-19 pandemic, overall incidence rate-ratio (IRR) of STEMI hospitalizations over reference period decreased (0.80; 95% CI 0.76–0.84; p

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com, A proper determination of the exercise intensity is important for the rehabilitation of patients with cardiovascular disease (CVD) since it affects the effectiveness and medical safety of exercise training. In 2013, the European Association of Preventive Cardiology (EAPC), together with the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation, published a position statement on aerobic exercise intensity assessment and prescription in cardiovascular rehabilitation (CR). Since this publication, many subsequent papers were published concerning the determination of the exercise intensity in CR, in which some controversies were revealed and some of the commonly applied concepts were further refined. Moreover, how to determine the exercise intensity during resistance training was not covered in this position paper. In light of these new findings, an update on how to determine the exercise intensity for patients with CVD is mandatory, both for aerobic and resistance exercises. In this EAPC position paper, it will be explained in detail which objective and subjective methods for CR exercise intensity determination exist for aerobic and resistance training, together with their (dis)advantages and practical applications.

The COVID-19 outbreak is having a significant impact on both cardiac rehabilitation (CR) inpatient and outpatient healthcare organization. The variety of clinical and care scenarios we are observing in Italy depends on the region, the organization of local services and the hospital involved. Some hospital wards have been closed to make room to dedicated beds or to quarantine the exposed health personnel. In other cases, CR units have been converted or transformed into COVID-19 units. The present document aims at defining the state of the art of CR during COVID-19 pandemic, through the description of the clinical and management scenarios frequently observed during this period and the exploration of the future frontiers in the management of cardiac rehabilitation programs after the COVID-19 outbreak.

BackgroundIn the last years, the rate of successful pregnancies has significantly increased in Systemic Sclerosis (SSc)1 women. However, the long-term outcome of their children remains an unexplored issue.ObjectivesTo evaluate the neuropsychiatric (NP) outcome of children born to SSc mothers.MethodsAn ad-hoc questionnaire, regarding different aspects of child’s neurodevelopment (ND) (3 sections: childhood [0-5 years]; scholar age [6-11 years]; adolescence [12-18 years]), was created and administered to female SSc patients (ACR/EULAR 2013 criteria) attending our outpatient clinic during 2021 and who had at least 1 child. Children’s NP characteristics were compared between 3 subgroups: A) born >10 years before SSc diagnosis; B) born ≤10 years before SSc diagnosis; C) born after SSc diagnosis. Results below are expressed as number/total number of answers collected for each question.Results100 SSc women reported 189 pregnancies: 152 resulted in 154 live births (2 twin pregnancies).At least one NP alteration was reported in 42/119 (35%) subjects, more frequently in group B (57%), as compared to group A (31%, p:0.07) and group C (30%, p:0.09) although not statistically significant (Figure 1). Sleep irregularities were the most frequently reported disorder (15/42, 36%). Comparisons between the 3 subgroups for every NP outcome evaluated are shown in Table 1: overall, a higher rate of NP alterations were reported in children belonging to group B.Table 1.Analysis of NP outcomes: comparison of the 3 subgroups.A n=103B n=19C n=32N° of subjects evaluated forDISORDERS IN CHILDHOOD103/10319/1932/32Sleep irregularities6/79 (8)*4/13 (31)*5/27 (19)Motor difficulties0/77 (3)°2/13 (15)°2/26 (8)Difficulty in relationships0/78 (0)1/11 (9)2/26 (8)Difficulty in non-verbal communication skills0/78 (0)1/11 (9)2/26 (8)Difficulty in verbal communication skills1/77 (1)1/12 (8)2/26 (8)Difficulty in social integration6/77 (8)3/12 (25)1/25 (4)Cognitive difficulties0/77 (0)1/12 (8)0/26 (0)N° of subjects evaluated forDISORDERS IN SCHOLAR AGE103/10317/1917/32Difficulty in school lessons/homework7/77 (9)3/12 (25)0/15 (0)Behavioral problems during school period4/76 (5)1/12 (8)1/15 (7)School year repetition11/76 (15)2/13 (15)0/15 (0)N° of subjects evaluated forDISORDERS IN ADOLESCENCE101/10314/1911/32Difficulty in managing anger and aggression4/75 (5)0/11 (0)0/10 (0)Behavioral alterations0/75 (0)0/11 (0)0/10 (0)Difficulty in conduct2/73 (3)0/11 (0)2/10 (20)Mood alterations1/73 (1)1/11 (9)0/10 (0)Alterations of the feeding behavior1/75 (1)0/11 (0)0/10 (0)Anxiety problems1/75 (1)1/10 (10)0/10 (0)Results are presented as number/total number (%) of answers collected for each question. Variables were compared with Chi Squared/exact Fisher test. *p=0.03; °p=0.02.Figure 1.Children with ≥1 NP alteration: comparison of the 3 subgroups.In addition, SSc mothers declared that 7/123 (6%) children underwent a NP evaluation leading to a diagnosis in 3 cases: 1 cognitive delay, 1 learning disorder (LD) and 1 autism spectrum disorder (ASD). These children were born 1 and 5 years before and 3 years after SSc diagnosis, respectively. The prevalence of these diagnoses (0.8%) does not differ from general pediatric population.ConclusionChildren born to SSc mothers, had prevalence of major NP alterations (cognitive deficits, LDs, ASDs) similar to general pediatric population. A higher frequency of minor ND disorders, especially sleep irregularities, was observed in children within 10 years before maternal diagnosis, compared to the other groups, possibly suggesting an impact of maternal chronic disease on the relationship with child in the first years of life. To confirm these self-reported preliminary data, the extension of the study will consist in a systematic NP evaluation proposed to all the offspring of SSc mothers aged ≤18 years.References[1]Blagojevic J et al. 2019. J Rheumatol.AcknowledgementsGILS (Gruppo Italiano Lotta Sclerodermia) is kindly acknowledged for supporting the study with a grant.Disclosure of InterestsNone declared

BackgroundInterstitial lung disease (ILD) could be the first and only manifestation of idiopathic inflammatory myopathies (IIMs). Myositis-associated (MAA) or myositis-specific autoantibodies (MSA) are found in 60%-65% of cases [1, 2], but only anti-Jo1 have been included in EULAR 2017 criteria [3].ObjectivesAim of this work is to evaluate the presence of MSA/MAA in patients with ILD on serum analyzed by line blot (LB) immunoassay, the associated clinical diagnoses and the consistency of these diagnoses with antibody specificity.MethodsBetween march 2017 and march 2021, 267 sera were analyzed for MSA/MAA, 84 (31.4%) of which requested after a pneumological evaluation. The search was performed by LB (EUROLINE, Autoimmune Inflammatory Myopathies 16 Ag Profile). Medical records were analyzed for patients with at least one MSA/MAA and diagnosis divided in: connective tissue disease (CTD), interstitial pneumonia with autoimmune features (IPAF) or only pneumological diagnosis.ResultsA positivity for at least one MSA/MAA was found in 37/84 (44%) patients that had the following pneumological diagnosis: 13 non-specific interstitial pneumonia (NSIP, 35.1%), 10 organizing pneumonia (OP, 27%), 10 usual interstitial pneumonia (UIP, 27%), 1 acute interstitial pneumonia (AIP, 2.7%), 1 lymphoid interstitial pneumonia (LIP, 2.7%), 1 iatrogenic ILD for amiodarone (2.7%) and 1 idiopathic pulmonary artery hypertension (IPAH, 2.7%).Distribution of antibodies is reported in Table 1. The most frequent autoantibody was anti-Ro52 (13 sera, 35.2%), while anti-Mi2 was the most frequent MSA (10 sera, 32.4%) followed by anti-Jo1 and anti-SRP with 5 (13.5%) positive sera each. In Figure 1 the heat-map represents the frequency of MSA/MAA and their mutual associations. Multiple autoantibodies were found in 17 (46%) sera. More than one MSA was found in 8 (21.6%) sera of patients with the following diagnosis: 4 only pneumological diseases, 3 ASS and 1 IPAF.Table 1.Distribution of MSA/MAA and associated autoimmune diseasesAutoantibodies distribution N (%)Sera with a single MSA/MAA (N/positive; %)CTD* (N/positive; %)IPAF (N/positive; %)MSAJo-1 = 5 (13.5)2/5 (40)3/5 (60)0PL7 = 4 (10.8)02/4 (50)1/4 (25)PL12 = 6 (16.2)3/6 (50)3/6 (50)0OJ = 3 (8.1)2/3 (66.6)1/3 (33.3)2/3 (66.6)EJ = 1 (2.7)1/1 (100)1/1 (100)0Mi-2 = 10 (32.4)3/10 (30)2/10 (20)0NXP2 = 1 (2.7)001/1 (100)SRP = 5 (13.5)2/5 (40)2/5 (40)0TIF1gamma = 2 (5.4)01/2 (50)0MAARo-52 = 13 (35.2)3/13 (23)9/13 (69.2)1/13 (7.6)PM/Scl = 6 (18.9)4/6 (66.6)01/6 (16.6)For some patients there are multiple positive antibodies.*The following diagnosis were included: antisynthetase syndrome, dermatomyositis, polymyositis and systemic sclerosis.During the diagnostic work-up, at least one MSA/MAA were detected in 13 patients diagnosed with a CTD (35%), 5 with a IPAF (13%), 19 (51%) only a pneumological diagnosis. Of these 19 patients, 11 (57.9%) had a single autoantibody positivity (8 for a MSA, 3 for a MAA) while 8 (42.1%) had multiple positivity (4 with a MSA plus MAA and 4 with multiple MSA positivity).The most frequently diagnosed CTD was ASS with 9 patients (24.3%), followed by 2 polymyositis (5.4%), 1 dermatomyositis (2.7%) and 1 systemic sclerosis (2.7%). Pulmonary involvement in patients with CTD was represented by 9 cases of NSIP (69,3%) and 4 UIP (30,7%).ConclusionDuring the last 4 years about 1/3 of research for MSA/MAA requests to our laboratory had a pneumological indication and MSA/MAA were found in 44% of these patients. In patients with pulmonary involvement and MSA/MAA positivity 35% developed a CTD. Interstitial lung disease could be the first manifestation of a systemic autoimmune disease: research for MSA/MAA and a collaboration between rheumatologist and pneumologist allows a correct diagnostic work-up and therapeutic approach.References[1]Betteridge Z, et al. J Autoimmun 2019;101:48-55[2]Vojinovic T, et al. Clin Rev Allergy Immunol. 2021 Feb;60(1):87-94[3]Lundberg IE, et al. Ann Rheum Dis 2107;76:1955-1964Disclosure of InterestsNone declared

BackgroundIdiopathic Inflammatory Myopathies (IIM) are a group of disorders sharing the common feature of immune-mediated muscle injury. In IIM autoantibodies specific for (MSA) or associated to (MAA) myositis are present in 60-65% of cases (1). Although only anti-Jo-1 (2) are included in the EULAR 2017 criteria, the presence of MSA allows to identify clinical and prognostic phenotypes.ObjectivesAim of the work is to evaluate the positivity rate on sera analyzed by a line blot (LB) immunoassay able to detect MSA or MAA, the associated clinical diagnoses and the consistency with the antibody specificity.Methods267 sera were analyzed using a commercial LB (Autoimmune Inflammatory Myopathies 16 Ag Profile EUROLINE) between March 2017 and March 2021. The diagnosis was identified by analyzing the medical records.ResultsA positivity for at least one MSA/MAA was found in 118/267 sera (44.2%); MAA isolated in 22% of cases and a double/multiple positivity for MSA in 12.7%.The distribution of antibody positivity and the associated clinical diagnoses are shown in Table 1.Table 1.Autoantibody distribution and associated clinical diagnosis; for some patients there are multiple positivityAutoantibody specificityConsistent diagnosisTotal positivity n. (%)Isolated positivity n. (%)Concomitant presence of at least one MAA n. (%)Concomitant presence of MSA +/- MAA n. (%)n. (%)Type of IIMMSAMi-227 (22.9)16 (59.3)2 (7.4)9 (33.3)5 (18.6)2 DM/2 PM/1 ASSTif-1γ12 (10.2)4 (33.3)4 (33.3)4 (33.3)9 (75)5 CAM/4 DMPL-711 (9.4)4 (36.4)3 (27.3)4 (36.4)5 (45.5)ASSNXP-28 (6.8)3 (37.5)1 (12.5)4 (50)3 (37.5)DMSRP8 (6.8)3 (37.5)1 (12.5)4 (50)1 (12.5)PMJo-18 (6.8)2 (25)3 (37.5)3 (37.5)6 (75)ASSPL-127 (5.9)3 (42.9)04 (57.1)4 (57.1)ASSMDA55 (4.2)3 (60)02 (40)4 (80)2 CADM/1 DM/1 ASSOj4 (3.4)3 (75)01 (25)3 (75)ILDSAE3 (2.5)2 (66.7)1 (33.3)02 (66.7)DMEj2 (1.7)1 (50)1 (50)01 (50)ASSMAARo-5233 (28)12 (36.3)2 (6.1)19 (57.6)-PM-Scl19 (16.1)11 (57.9)3 (15.8)5 (26.3)-Ku6 (5.1)3 (50)1 (16.7)2 (33.3)-DM: Dermatoyositis, PM: Polymiositis, ASS: Antisynthetase Syndrome, CAM: Cancer-Associated Myositis, CADM: Clinical Amyopatic Dermatomyositis, ILD: Interstitial Lung DiseaseIn our cohort, the most common antibodies were anti-Ro52kD, positive in 33 sera (28%), while the most frequent MSA were anti-Mi-2, positive in 27 sera (22.9%).MSA most frequently found as an isolated positivity were anti-Oj (75%), while anti-Jo-1 as an isolated positivity were present only in 25% of cases.Considering the 118 sera with at least one MSA/MAA a diagnosis of IIM was made in 52 cases (44%); in 11 cases others systemic autoimmune diseases were identified.The consistency between antibody specificity with the clinical diagnoses was analyzed: for some antibodies, as anti-Jo-1 (80%), anti-MDA5 (75%) and anti-Tif-1gamma (75%), LB results were consistent with clinical diagnoses; while for others, as anti-Mi-2 (18,6%) and anti-SRP (12,5%), the agreement was lower.ConclusionThe use of LB in the diagnostic workout of IIM allowed the detection of MSA previously not found with routine methods. In our court low prevalence of anti-Jo-1 was found. This may be justified by the fact that anti-Jo-1 are included in the assays routinely used to identify anti-ENA antibodies, therefore these sera were not tested with an additional LB.With LB, a higher prevalence of double/multiple MSA positivity was found, compared to the 0.1% described with immunoprecipitation (IP) (3). LB give a semiquantitative result: low, medium or high titer, so the analysis of different titers, according with clinical data or IP, could be helpful in the interpretation of the co-existence of multiple MSA (4).References[1]Betteridge Z, et al. J Autoimmun.2019;101:48-55[2]Lundberg IE, et al. Ann Rheum Dis.2017;76:1955-1964[3]Cavazzana I, et al. J Immunol Methods.2016;433:1-5[4]Cavazzana I, et al. Ann Rheum Dis.2020;79:e152Disclosure of InterestsNone declared

BackgroundSystemic Sclerosis (SSc) can strongly affect the quality of life of affected women. We aimed at designing a SSc-specific, patient-reported questionnaire to explore different aspects of women’s health.ObjectivesThe questionnaire was created together with Obstetricians-Gynecologists (70 questions, 5 sections) and administered to consecutive patients with SSc (2013 ACR/EULAR classification criteria) regularly attending our Clinic in May-December 2021. The Female Sexual Function Index (FSFI) questionnaire was also administered.MethodsThe questionnaire was created together with Obstetricians-Gynecologists (70 questions, 5 sections) and administered to consecutive patients with SSc (2013 ACR/EULAR criteria) regularly attending our Clinic in the period May-December 2021. The Female Sexual Function Index (FSFI) questionnaire was also administered.ResultsQuestionnaires were proposed to 114 patients; among 100 who accepted to participate (median age 59.0 [43.0-67.0], median disease duration 11.0 [6.0-17.0] years), 48% had received SSc diagnosis during reproductive age (Table 1.Results are presented as median [IQR] or number/number available data (%) based on patients answering the question. Continuous variables were compared with Mann-Whitney test; categorical variables with Fisher’s exact test.Total pregnancies (n= 189)Pregnancies after diagnosis (n= 42)Pregnancies before diagnosis (n= 147)p-value OR [95% CI]Maternal age at conception, years28.0 [24.0-32.0]32.0 [28.0-39.0]27.0 [23.0-30.0]< 0.001Live births152/189 (80.4)31/42 (73.8)121/147 (82.3)0.221Cesarean sections36/135 (26.7)17/31 (54.8)19/104 (18.3)< 0.0015.43 [2.30-12.9]Preterm births 32/109 (29.4)7/32 (21.9)25/77 (32.5)0.269Preterm births 7/32 (21.8)2/7 (28.6)5/25 (20.0)0.632Birth weight, kilograms3.3 [2.8-3.6]3.1 [2.5-3.5]3.3 [3.0-3.7]0.049≥ 1 Adverse Pregnancy Outcomes15/113 (13.3)8/31 (25.8)7/82 (8.5)0.0163.73 [1.22-11.39]Gestational hypertension4/113 (3.5)3/31 (9.7)1/82 (1.2)0.062Preeclampsia1/113 (0.9)1/31 (3.2)0/82 (0.0)0.274Eclampsia0/113 (0.0)0/31 (0.0)0/82 (0.0)1.000HELLP syndrome1/113 (0.9)0/31 (0.0)1/82 (1.2)1.000Gestational diabetes3/113 (2.7)2/31 (6.5)1/82 (1.2)0.182Intra Uterine Growth Restriction4/113 (3.5)2/31 (6.5)2/82 (2.4)0.302Perinatal deaths2/134 (1.5)0/32 (0.0)2/102 (1.9)1.000Neonatal Intensive Care Unit Admission11/134 (8.2)6/32 (18.8)5/102 (4.9)0.0224.48 [1.27-15.84]Perinatal infections8/134 (8.2)3/32 (9.4)5/102 (4.9)0.396Breastfeeding92/132 (69.7)22/32 (68.8)70/100 (70.0)0.893ConclusionThe newly created specific questionnaire was instrumental to facilitate physician-patient communication about ‘women’s health’, particularly in the field of sexuality which is characterized by a high frequency of dysfunction. Adverse outcomes are possible during SSc pregnancies and should be discussed during the multidisciplinary preconception counselling, along with measures to possibly reduce their risk.AcknowledgementsGILS (Gruppo Italiano Lotta Sclerodermia) is kindly acknowledged for supporting the study with a grant.Disclosure of InterestsNone declared

A2A Calore e Servizi carries out maintenance programs; one of the main activities is leak detection performed according to different procedures. The first method was based on pressure measurements and then it has evolved in a direct measurement of water loss. A new method has been tested; fixed metering devices have been installed. According to the law of mass conservation, the mass difference is a calculation of the water lost in the area. This procedure allows reliable continuous leak measurements, simplifying operational activities and giving immediate results on field.

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Background Patients who experience a hospital admission for acute coronary syndromes (ACS) exhibit poor prognosis over the years. The purposes of this study were to evaluate the real-world patterns of out-of-hospital practice in the management of ACS patients and to assess their impact on the risk of selected outcomes. Methods The cohort of 87,530 residents in the Lombardy Region (Italy) who were newly hospitalised for ACS during 2011–2015 was followed until 2018. Exposure to medical treatment including use of selected drugs, diagnostic procedures and laboratory tests was recorded. The main outcome of interest was re-hospitalisation for cardiovascular (CV) outcomes. Proportional hazards models were fitted to estimate hazard ratio, and 95% confidence intervals (CI), for the exposure-outcome association. Analyses were stratified according to the ACS type. Results The cumulative incidence of re-hospitalisation for CV disease was 33%, 42% and 38% at 5 years after index discharge among STEMI, NSTEMI and unstable angina patients. Within one year from index discharge, between 70% and 80% of patients had at least a prescription of statins, beta-blockers and renin–angiotensin-system blocking agents, underwent ECG and lipid profile examination, and had a cardiologic examination. One patient in five underwent cardiac rehabilitation. Compared with patients who did not adhere to healthcare recommendations, the risk of CV hospital readmission was reduced from 10% (95% CI: 4%–10%) to 23% (12%–32%) among patients who underwent lipid profile examinations and who experienced cardiac rehabilitation. Conclusion Close out-of-hospital healthcare must be considered the cornerstone for improving the long-term prognosis of ACS patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com., This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from -5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 'for' and 10 'against' respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.

Carotid atherosclerosis is a cause of brain ischemic events. Cardiovascular magnetic resonance (CMR) can assess plaque vulnerability. We investigated atherosclerosis vulnerability in relation to plaque location, eccentricity and vessel remodeling. Methods-Baseline CMR evaluations of the MAGNETIC observational study, were analyzed. We quantitated with MRI-Plaque View™, vessel lumen/wall and vulnerable plaque components of a 32-mm segment of common carotid artery (12 mm), bulb (8 mm) and internal carotid artery (12 mm). Lipid-rich necrotic core [LRNC], fibrous cap [CAP] and intraplaque hemorrhage [IPH] were expressed as percent of wall area. Results-A data-set of 8080 sections of adequate quality in 260 patients (198 male [76%], median age 71 years [65–76]), were analyzed. Patients were on therapy with antiplatelet, ACE-inhibitors/ARB and statins (196–229 out of 260 [75–88%]). We found significant differences in plaque composition according to longitudinal and circumferential location, eccentricity and vessel remodeling (table). At multivariate regression analysis, including classical RF and atherosclerotic burden, we found an independent association of: LRNC and IPH with longitudinal location, eccentricity and positive remodeling, and of CAP with eccentricity (p Lipid-rich necrotic core Fibrous cap Intraplaque hemorrhage Longitudinal distribution Common carotid artery 4% [1–10] p Conclusions Carotid atherosclerotic plaque vulnerability seems to be independently associated with longitudinal location, plaque eccentricity and vessel positive remodeling. Acknowledgement/Funding Bayer AG, Leverkusen, Germany

Presented are the first interferometric images of cool starspots on the chromospherically active giant λ Andromedae. Using the Michigan Infra-Red Combiner coupled to the Center for High Angular Resolution Astronomy Array, 26 interferometric observations were made between 2008 August 17 and 2011 September 24. The photometric time series acquired at Fairborn Observatory spanning 2008 September 20 to 2011 January 20 is also presented. The angular diameter and power-law limb-darkening coefficient of this star are 2.759 ± 0.050 mas and 0.229 ± 0.111, respectively. Starspot properties are obtained from both modeled and SQUEEZE reconstructed images. The images from 2010 through 2011 show anywhere from one to four starspots. The cadence in the data for the 2010 and 2011 data sets is sufficient to measure a stellar rotation period based on apparent starspot motion. This leads to estimates of the rotation period (P 2010 = 61 ± 4.0 days, P 2011 = 54.0 ± 2.4 days) that are consistent with the photometrically determined period of 54.8 days. In addition, the inclination and position angle of the rotation axis are computed for both the 2010 and 2011 data sets; values ( Ψ ¯ = 21.°5, i ¯ = 78.°0) for each are nearly identical between the two years.

Treatment adherence is a key element for (i) improving prognosis in cardiovascular and/or high-risk patients, (ii) reducing the burden of morbidity and mortality associated with cardiovascular disease at a population level, and (iii) decreasing costs due to rehospitalizations.Promotion of adherence should embrace all pharmacological and non-pharmacological interventions in cardiovascular prevention, including lifestyle and behavioral changes. In this perspective, cardiac prevention and rehabilitation programs are the most appropriate and cost-effective setting for delivering structured and multi-component interventions on patient's adherence. In this expert opinion document authored by the Italian Association for Cardiovascular Prevention and Rehabilitation, a modern reappraisal of the adherence issue is provided, together with simple, practical, and feasible suggestions to achieve this goal in the real life as well.

Cardiac rehabilitation (CR) represents a cardiology subspecialty that is devoted to the care of cardiac patients, early and long term after an acute event. CR aims at improving both quality of life and prognosis through risk and prognostic stratification, clinical stabilization and optimization of therapy, management of comorbidities, treatment of disability, and the provision of sustained long-term preventive and rehabilitative services.The mission of CR has changed over time. From being centred on the acute phase, health care of cardiac patients is increasingly involving the long-term chronic phase. The aim of the present position paper is to provide the state of the art of CR in Italy, discussing strengths and weaknesses as well as future perspectives.

AIMS: To undertake an individual patient data (IPD) meta-analysis to assess the impact of exercise-based cardiac rehabilitation (ExCR) in patients with heart failure (HF) on mortality and hospitalisation, and differential effects of ExCR according to patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischaemic aetiology, ejection fraction, and exercise capacity. METHODS AND RESULTS: Randomised trials of exercise training for at least 3weeks compared with no exercise control with 6-month follow-up or longer, providing IPD time to event on mortality or hospitalisation (all-cause or HF-specific). IPD were combined into a single dataset.We used Cox proportional hazards models to investigate the effect of ExCR and the interactions between ExCR and participant characteristics. We used both two-stage random effects and one-stage fixed effect models. IPD were obtained from 18 trials including 3912 patients with HF with reduced ejection fraction. Compared to control, there was no statistically significant difference in pooled time to event estimates in favour of ExCR although confidence intervals (CIs) were wide [all-cause mortality: hazard ratio (HR) 0.83, 95% CI 0.67–1.04; HF-specific mortality: HR 0.84, 95% CI 0.49–1.46; all-cause hospitalisation: HR 0.90, 95% CI 0.76–1.06; and HF-specific hospitalisation: HR 0.98, 95% CI 0.72–1.35]. No strong evidence was found of differential intervention effects across patient characteristics. CONCLUSION: Exercise-based cardiac rehabilitation did not have a significant effect on the risk of mortality and hospitalization in HF with reduced ejection fraction. However, uncertainty around effect estimates precludes drawing definitive conclusions.

Background In cardiovascular prevention and rehabilitation, care activities are carried out by different professionals in coordination, each with their own specific competence. This GICR–IACPR position paper has analysed the interventions performed by the nurse, physiotherapist, dietician and psychologist in order to identify what constitutes minimal care, and it lists the activities that are fundamental and indispensable for each team member to perform in clinical practice. Results In analysing each type of intervention, the following dimensions were considered: the level of clinical care complexity, determined both by the disease and by environmental factors; the ‘area’ complexity, i.e. the specific level of competence required of the professional in each professional section; organisational factors, i.e. whether the care is performed in an inpatient or outpatient setting; duration of the rehabilitation intervention. The specific contents of minimal care have been identified for each professional area together with the specific goals, the assessment tools and the main essential interventions. For the assessments, only a few validated tools have been indicated, leaving the choice of which instrument to use to the individual professional based on experience and usual practice. Conclusion For the interventions, attention has been focused on conditions of major complexity requiring special care, taking into account the different care settings, the clinical conditions secondary to the disease event, and the distinct tasks of each area according to the operator's specific role. The final report performed by each professional has also been included.

Some observational studies raised questions about the need for β-blockers in all patients after a first heart attack. Surprisingly, in some clinical settings, a limited mortality reduction was found in those who received β-blockade.Some studies suggest that patients without heart failure may not need post-MI β-blockers. The lack of data from randomized controlled clinical trials has led to clinical uncertainty and conflicting recommendations. Therefore, there are multiple information to revaluate the value of β-blocker therapy after a heart attack in absence of heart failure or left ventricular dysfunction and the time for new trials of an old group of drugs has arrived.

Recent guidelines on cardiovascular disease prevention suggest multimodal behavioral interventions for psychosocial risk factors and referral for psychotherapy in the case of clinically significant symptoms of depression and anxiety overall. Accordingly, psychologists of the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (GICR-IACPR) have reviewed the key components of psychological activities in cardiovascular prevention and rehabilitation (CPR). The aim of this study was to elaborate a position paper on the best practice in routine psychological activities in CPR based on efficacy, effectiveness and sustainability. The steps followed were: i) a review of the latest international guidelines and position papers; ii) analysis of the evidence-based literature; iii) a qualitative analysis of the psychological services operating in some reference Italian cardiac rehabilitation facilities; iv) classification of the psychological activities in CPR as low or high intensity based on the NICE Guidelines on psychological interventions on anxiety and depression. We confirm the existence of an association between depression, anxiety, social factors, stress, personality and illness onset/outcome and coronary heart disease. Evidence for an association between depression, social factors and disease outcome emerges particularly for chronic heart failure. Some positive psychological variables (e.g., optimism) are associated to illness outcome. Evidence is reported on the impact of psychological activities on ‘new’ conditions which are now indicated for cardiac rehabilitation: pulmonary hypertension, grown-up congenital heart, end-stage heart failure, implantable cardioverter-defribrillator and mechanical ventricular assist devices, frail and oldest-old patients, and end-of-life care. We also report evidence related to caregivers. The Panel divided evidence-based psychological interventions into: i) low intensity (counseling, psycho-education, self-care, self-management, telemedicine, self-help); or ii) high intensity (individual, couples and/or family and group psychotherapy, such as stress management). The results show that psychotherapy is mainly consisting of cognitive-behavior therapy, interpersonal therapy, and short-term psycho-dynamic therapy. The current data further refine the working tools available for psychological activities in CPR, giving clear directions about the choice of interventions, which should be evidence-based and have at least a minimum standard. This document provides a comprehensive update on new knowledge and new paths for psychologists working in the CPR settings.

Whereas exercise training is key in the management of patients with cardiovascular disease (CVD) risk (obesity, diabetes, dyslipidaemia, hypertension), clinicians experience difficulties in how to optimally prescribe exercise in patients with different CVD risk factors. Therefore, a consensus statement for state-of-the-art exercise prescription in patients with combinations of CVD risk factors as integrated into a digital training and decision support system (the EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool) needed to be established. EXPERT working group members systematically reviewed the literature for meta-analyses, systematic reviews and/or clinical studies addressing exercise prescriptions in specific CVD risk factors and formulated exercise recommendations (exercise training intensity, frequency, volume and type, session and programme duration) and exercise safety precautions, for obesity, arterial hypertension, type 1 and 2 diabetes, and dyslipidaemia. The impact of physical fitness, CVD risk altering medications and adverse events during exercise testing was further taken into account to fine-tune this exercise prescription. An algorithm, supported by the interactive EXPERT tool, was developed by Hasselt University based on these data. Specific exercise recommendations were formulated with the aim to decrease adipose tissue mass, improve glycaemic control and blood lipid profile, and lower blood pressure. The impact of medications to improve CVD risk, adverse events during exercise testing and physical fitness was also taken into account. Simulations were made of how the EXPERT tool provides exercise prescriptions according to the variables provided. In this paper, state-of-the-art exercise prescription to patients with combinations of CVD risk factors is formulated, and it is shown how the EXPERT tool may assist clinicians. This contributes to an appropriately tailored exercise regimen for every CVD risk patient. ispartof: SPORTS MEDICINE vol:48 issue:8 pages:1781-1797 ispartof: location:New Zealand status: published

Current evidence shows that cholesterol management either reduces the likelihood of cardiovascular disease (CVD) or slows down its progression. Hence, it is important that all health professionals make appropriate use of all the available intervention strategies to control risk factors: from dietary improvement and positive lifestyle changes to the use of functional foods, food supplements, and drugs. This review examines the effect of the most frequently occurring cholesterol-lowering substances in functional foods or in supplements across Europe, namely plant sterols and stanols, monacolin K found in red yeast rice, berberine and beta-glucans. We conclude that currently available supplements and functional foods can effectively reduce plasma LDL cholesterol levels by about 5 to 25%, either alone or in combination. Suitable candidates for these products are mainly individuals at low absolute cardiovascular risk at a young age or according to classic algorithms. Of note, despite being freely available for purchase, these products should be used following shared agreement between the caring physician and the patient ("concordance").

Cardiac resynchronization therapy (CRT) is a therapeutic option of increasing importance for chronic heart failure (CHF) and criteria for implantation now concern a large amount of patient populations. As a consequence, subjects with ongoing CRT (or immediately after CRT implantation) are more often referred to Cardiac Rehabilitation (CR) programmes, and it has been recently estimated that about one third of CHF patients attending CR in Italy currently have this kind of device. The presence of CRT represents a modulating factor for exercise prescription and monitoring, since CRT patients may be considered per se as a target group for CR. Exercise therapy (ET) increases benefits from CRT on functional capacity, and recent evidence suggests an adjuvant role of ET in improving cardiovascular prognosis also. Both aerobic endurance and resistance training activities may involve CHF patients with CRT, while the potential role of aerobic interval training needs more studies and evidence. Prescription of an ET program should be associated with information regarding device programming and possible limiting factors associated with pacing therapy, tailoring of the basic principles of ET (in terms of type of exercise, intensity and program duration) in this patient group is mandatory.

Background and aims Familial hypercholesterolemia (FH) is a genetic disorder characterized by high levels of low density lipoprotein cholesterol (LDL-C) predisposing to premature cardiovascular disease. Its prevalence varies and has been estimated around 1 in 200–500. The Heredity survey evaluated the prevalence of potential FH and the therapeutic approaches among patients with established coronary artery disease (CAD) or peripheral artery disease (PAD) in which it is less well documented. Methods Data were collected in patients admitted to programs of rehabilitation and secondary prevention in Italy. Potential FH was estimated using Dutch Lipid Clinic Network (DLCN) criteria. Potential FH was defined as having a total score≥6. Results Among the 1438 consecutive patients evaluated, the prevalence of potential FH was 3.7%. The prevalence was inversely related to age, with a putative prevalence of 1:10 in those with 8) had the highest percentages of patients after an ACS (75% vs 52.5% in the whole study population). At discharge, most patients were on high intensity statin therapy, but despite this, potential FH group still had a higher percentage of patients with LDL-C levels not at target and having a distance from the target higher than 50%. Conclusions Among patients with established coronary heart disease, the prevalence of potential FH is higher than in the general population; the results suggest that a correct identification of potential FH, especially in younger patients, may help to better manage their high cardiovascular risk.

BACKGROUND. Uncertainty exists about current delivery levels of exercise training (ET) during Cardiac Rehabilitation (CR) programmes. AIM OF THE STUDY. To evaluate ET modalities in the real world of CR facilities in Italy. METHODS. This was an observational survey of aggregate data, collected from CR facilities on a voluntary basis. Snapshots of a single working day at a local site were made, in terms of characteristics of patients and ET programmes delivered. RESULTS. Overall, 612 patients from 26 CR units were included, with an in-patient vs. out-patient ratio of 3:1. Coronary artery disease (57.6%), heart failure (20.3%), and valve disease/surgery (22.1%) were the most represented target groups. The prevalence of endurance continuous training, interval training, and resistance/strength training was 66.7%, 11.1%, and 9.0%; other non-aerobic endurance and non-resistance training modalities such as respiratory muscle training and calisthenics were reported in 39.9% and 42.9% of cases respectively. Workloads for endurance exercise training were determined by cardiopulmonary test, conventional 12-leads ECG exercise testing, 6min-walking test, theoretical determination of heart rate, and rating of perceived exertion in 9%, 8%, 27%, 9%, and 40% of cases respectively. The average duration of the programmes (on an intention to treat basis) was 25 sessions of 42±11 minutes, with a frequency of >4 sessions/week in 67% of patients. CONCLUSIONS. Despite advances in CR interventions, there is a significant need for improvement of functional evaluation and exercise training prescription, and consideration of a wider range of training modalities in Italy. 

There is currently a lack of consensus on which anticoagulant therapy contraindications should be considered “absolute” and which should be considered “relative”. Guidelines do not clearly identify absolute and relative contraindications to anticoagulant therapy. Recent guidelines on AF of the European Society of Cardiology underline the relevance of several factors and their use in scores, leaving anyway space to the clinical judgment of the physician. A high bleeding risk score should generally not result per se in a contraindication to anticoagulant therapy. Rather, bleeding risk factors should be identified and treatable factors corrected. A combined use of a more hierarchical classification of the different bleeding risk factors and the risk scores probably represents the best approach to maximize the benefit of anticoagulant therapy in various clinical settings.

The number of percutaneous coronary interventions (PCI) is increasing worldwide. Follow-up strategies after PCI are extremely heterogeneous and can greatly affect the cost of medical care. In the present paper, practical advises are provided with respect to a tailored follow-up strategy on the basis of patients' risk profile. Clinical and interventional cardiologists, cardiac rehabilitators, and general practitioners equally contributed to the creation of the present document and defined three follow-up strategies and types and timing of clinical and instrumental evaluations in post-PCI patients.

The number of percutaneous coronary interventions (PCI) is increasing worldwide. Follow-up strategies after PCI are extremely heterogeneous and can greatly affect the cost of medical care. Of note, clinical evaluations and non-invasive exams are often performed to low risk patients. In the present consensus document, practical advises are provided with respect to a tailored follow-up strategy on the basis of patients' risk profile. Three strategies follow-up have been defined and types and timing of clinical and instrumental evaluations are reported. Clinical and interventional cardiologists, cardiac rehabilitators, and general practitioners, who are in charge to manage post-PCI patients, equally contributed to the creation of the present document.

Background Exercise rehabilitation is highly recommended by current guidelines on prevention of cardiovascular disease, but its implementation is still poor. Many clinicians experience difficulties in prescribing exercise in the presence of different concomitant cardiovascular diseases and risk factors within the same patient. It was aimed to develop a digital training and decision support system for exercise prescription in cardiovascular disease patients in clinical practice: the European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and Rehabilitative Training (EXPERT) tool. Methods EXPERT working group members were requested to define (a) diagnostic criteria for specific cardiovascular diseases, cardiovascular disease risk factors, and other chronic non-cardiovascular conditions, (b) primary goals of exercise intervention, (c) disease-specific prescription of exercise training (intensity, frequency, volume, type, session and programme duration), and (d) exercise training safety advices. The impact of exercise tolerance, common cardiovascular medications and adverse events during exercise testing were further taken into account for optimized exercise prescription. Results Exercise training recommendations and safety advices were formulated for 10 cardiovascular diseases, five cardiovascular disease risk factors (type 1 and 2 diabetes, obesity, hypertension, hypercholesterolaemia), and three common chronic non-cardiovascular conditions (lung and renal failure and sarcopaenia), but also accounted for baseline exercise tolerance, common cardiovascular medications and occurrence of adverse events during exercise testing. An algorithm, supported by an interactive tool, was constructed based on these data. This training and decision support system automatically provides an exercise prescription according to the variables provided. Conclusion This digital training and decision support system may contribute in overcoming barriers in exercise implementation in common cardiovascular diseases. The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The realisation of the proof of concept of the EXPERT tool was supported by a UHasselt Industrial Research Fund (IOF) proof of concept (PoC) project.

Background: Pulmonary arterial hypertension (PAH) is a rare disease characterised by a severe impairment of functional status and quality of life (QoL). Use of rehabilitative programmes may help to improve outcomes. The aim of this pre/post test case series was to evaluate the impact of a training program, including sessions of aerobic and resistance exercise, inspiratory muscle reinforcement, slow breathing, relaxation, and psychological support, on functional outcomes. Methods: Fifteen patients affected by PAH, in World Health Organization (WHO) Functional Class (FC) II or III and in stable clinical condition, were included in a 4-week cardiorespiratory training programme conducted in outpatient service. Patients were tested during a routine control visit (T0), one month later at the beginning of the training programme (T1), and at study end (T2). Between T0 and T1, patients continued their normal activities and therapies. At each step, patients underwent respiratory and functional evaluation by spirometry, 6-minute walk test (6-MWT), maximal cardiopulmonary exercise testing (CPET), echocardiography, and levels of brain natriuretic peptide (BNP). QoL was also assessed at T1 and T2 using the Hospital Anxiety and Depression Scale and the EuroQoL-5D questionnaire. The primary endpoint was the effect of training on peak oxygen consumption (peak VO2). Results: There were no significant differences in BNP levels, or in any of the respiratory or echocardiographic parameters measured, between T0 and T1. Between T1 and T2, significant improvements were recorded in QoL (HADS-Anxiety mean change 3.5 ± 3.3 and HADS-Depression mean change 1.6 ± 2.0, all p < 0.01). Significant improvements were also observed in functional capacity with distance walked at 6-MWT increasing from 455 ± 115 to 487 ± 120 (+8%, p < 0.01), workload (WR) of CPET was increased from 22% (from 73 ± 22 to 87 ± 21 watt, p < 0.001), peak VO2 increasing from 17.3 ± 4.2 to 19.9 ± 4.5 mL/kg/min (p < 0.001) and pulse O2 increasing from 7.8 ± 1.8 to 8.8 ± 2.4 mL/beat (p < 0.01). No adverse events or deterioration in clinical status were observed during the training sessions. Conclusion: Cardiorespiratory training in a outpatient service is a suitable option for patients with PAH in WHO FC II/III thanks to improved exercise capacity and QoL, which may allow them to achieve better outcomes.

Cardiovascular disease (CVD) accounts for more than 17 million deaths per year worldwide. It has been estimated that the influence of lifestyle on CVD mortality amounts to 13.7% for smoking, 13.2% for poor diet, and 12% for inactive lifestyle. These results deeply impact both the healthy status of individuals and their skills in working. The impact of CVD on productivity loss accounts for the 24% in total costs for CVD management. Mediterranean diet (MedD) can positively impact on natural history of CVD. It is characterized by a relatively high consumption of inexpensive and genuine food such as cereals, vegetables, legumes, nuts, fish, fresh fruits, and olive oil as the principal source of fat, low meat consumption and low-to-moderate consumption of milk, dairy products, and wine. Its effects on cardiovascular health are related to the significant improvements in arterial stiffness. Peripheral artery disease, coronary artery disease, and chronic heart failure are all positively influenced by the MedD. Furthermore, MedD lowers the risk of sudden cardiac death due to arrhythmias. The present narrative review aims to analyze the effects of MedD on CVD.

The population of elderly adults is constantly increasing and age is a strong determinant of the development of chronic diseases, especially cardiovascular diseases; therefore old subjects represent a very high proportion of cardiac patients. Since cardiology is progressively more and more involved in the care of aged patients, a new area of Cardiology has been identified, the Geriatric Cardiology (GC).On the other hand, Cardiac Rehabilitation (CR) and GC show a wide overlap, and GC seems to be the application in the aged cardiac patient of the core-components that CR has already tested in younger cardiac patients.Now, CR is probably the cardiological area that seems better equipped, both from a cultural and organizational point of view, to care the aged cardiac patients who are often complex and frail, with multimorbidity, and "frequent users" of the health care services.The CR is therefore a concrete response, already ready and operative, to the demographic expansion of chronicity and aging. Beyond the definitions, CR and GC operate according to principles and methods which are in large part common; thus, CR and GC could merge themselves into a new area of cardiology, the Cardiogeriatric Rehabilitation (CGR).La popolazione degli adulti anziani è in continua espansione e l’età rappresenta una condizione fortemente predisponente allo sviluppo delle patologie croniche, in particolare delle malattie cardiovascolari; i pazienti anziani rappresentano quindi una quota crescente della popolazione dei cardiopatici. Ne consegue pertanto che il campo di applicazione della Cardiologia sta progressivamente sempre più interessando l’età avanzata al punto di veder individuato un nuovo settore della Cardiologia, quello della cosiddetta “Cardiologia Geriatrica” (CG). Il contenuto della Cardiologia Riabilitativa (CR) e della nascente CG mostrano ampi margini di sovrapposizione, al punto da poter affermare che la CG è, per molti aspetti, l’applicazione nel paziente cardiopatico anziano di quanto la CR abbia già sviluppato nella sua ormai pluridecennale esperienza. In questo momento storico la CR è probabilmente la “sottospecialità” della Cardiologia più attrezzata, sia da un punto di vista culturale che organizzativo, a sviluppare al meglio la cura del paziente cardiopatico anziano e del paziente cardiopatico cronico “complesso”, comorbido e “multipatologico”, spesso fragile e con minori risorse funzionali, nonché frequente e disordinato utilizzatore (frequent user) dei servizi sanitari. La CR costituisce quindi una risposta concreta, già pronta ed operativa, per far fronte alla espansione demografica della cronicità e dell’invecchiamento. Al di là delle sigle e delle definizioni, CR e CG operano secondo principi comuni e condivisi al punto tale da pensare di potersi fondere in una sorta di Cardiogeriatric Rehabilitation (CGR).

Hospitalized patients after acute cardiovascular events have poorer prognosis if glucose regulation is diagnosed as abnormal. We compared the short and long-term outcome of patients with newly diagnosed altered fasting glycemia (AFG) to that of known diabetic patients and patients with normal glucose regulation (NGR) after admission to cardiac rehabilitation. We retrospectively analyzed 2490 consecutive patients. Three groups were identified: known diabetes mellitus (n = 540, 22%), fasting glycemia above 110 mg/dl (AFG, n = 269, 11%), and fasting glycemia 110 mg/dl or less (NGR, n = 1681, 67%). Clinical variables, complications, and all-cause mortality were evaluated. At follow-up (median 3.1 ± 2.4 years), after adjustment for age, sex, BMI, left ventricular ejection fraction, history of coronary artery disease, AFG had a significantly longer hospital stay versus NGR (21 ± 8 versus 20 ± 8 days; P = 0.019) and higher risk of paroxysmal atrial fibrillation (P = 0.041), pleural/pericardial effusions (P

We present interferometric observations of the Be star Zeta Tau obtained using the MIRC beam combiner at the CHARA Array. We resolved the disk during four epochs in 2007-2009. We fit the data with a geometric model to characterize the circumstellar disk as a skewed elliptical Gaussian and the central Be star as a uniform disk. The visibilities reveal a nearly edge-on disk with a FWHM major axis of ~ 1.8 mas in the H-band. The non-zero closure phases indicate an asymmetry within the disk. Interestingly, when combining our results with previously published interferometric observations of Zeta Tau, we find a correlation between the position angle of the disk and the spectroscopic V/R ratio, suggesting that the tilt of the disk is precessing. This work is part of a multi-year monitoring campaign to investigate the development and outward motion of asymmetric structures in the disks of Be stars., Comment: Accepted for publication in the Astronomical Journal. 27 pages, 7 Figures

This paper is an H band interferometric examination of Arcturus, a star frequently used as a spatial and spectral calibrator. Using the IOTA 3 telescope interferometer, we performed spectro-interferometric observation (R~35) of Arcturus. Atmospheric models and prescriptions were fitted to the data to derive the brightness distribution of the photosphere. Image reconstruction was also obtained using two software algorithms: Wisard and Mira. An achromatic power law proved to be a good model of the brightness distribution, with a limb darkening compatible with the one derived from atmospheric model simulations using our Marcs model. A Rosseland diameter of 21.05+/-0.21 was derived, corresponding to an effective temperature of T_eff=4295+/-26 K. No companion was detected from the closure phases, with an upper limit on the brightness ratio of 8e-4 at 1AU. Dynamic range at such distance from the photosphere was established at 1.5e-4 (1sigma rms). An upper limit of 1.7e-3 was also derived for the level of brightness asymmetries present on the photosphere., 12 pages, 12 figures, accepted in A&A

Giorgio Bertolotti,1 Loretta Moroni,1 Roberto Burro,2 Antonio Spanevello,3 Roberto FE Pedretti,4 Giandomenico Giorgetti5 1Psychology Unit, Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Tradate, 2Department of Human Sciences – University of Verona, Verona, 3Department of Cardiology, 4Division of Pulmonary Disease, 5Department of Neuromotor Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Tradate, Italy Background: A postacute phase needs reliable routine screening instruments in order to identify the patients to be referred for a clinical interview with a psychologist. The aim of this study was to estimate the clinical cutoff scores of the anxiety and depression questionnaires and their clinical validity using a gold standard. Methods: The study involved 177 patients with pulmonary, cardiac, or neurological disease undergoing in-hospital rehabilitation. Receiver operating characteristic curves were used to determine the best concordance between questionnaire’s scores and the gold standards. Results: There was a significant difference (P

Objectives The aim of this study was to assess the prognostic value of T-wave alternans (TWA) in New York Heart Association (NYHA) functional class II/III patients with nonischemic cardiomyopathy and left ventricular ejection fraction (LVEF) ≤40%. Background There is a strong need to identify reliable risk stratifiers among heart failure candidates for implantable cardioverter-defibrillator (ICD) prophylaxis. T-wave alternans may identify low-risk subjects among post-myocardial infarction patients with depressed LVEF, but its predictive role in nonischemic cardiomyopathy is unclear. Methods Four hundred forty-six patients were enrolled and followed up for 18 to 24 months. The primary end point was the combination of cardiac death + life-threatening arrhythmias; secondary end points were total mortality and the combination of arrhythmic death + life-threatening arrhythmias. Results Patients with abnormal TWA (65%) compared with normal TWA (35%) tests were older (60 ± 13 years vs. 57 ± 12 years), were more frequently in NYHA functional class III (22% vs. 19%), and had a modestly lower LVEF (29 ± 7% vs. 31 ± 7%). Primary end point rates in patients with abnormal and normal TWA tests were 6.5% (95% confidence interval [CI] 4.5% to 9.4%) and 1.6% (95% CI 0.6% to 4.4%), respectively. Unadjusted and adjusted hazard ratios were 4.0 (95% CI 1.4% to 11.4%; p = 0.002) and 3.2 (95% CI 1.1% to 9.2%; p = 0.013), respectively. Hazard ratios for total mortality and for arrhythmic death + life-threatening arrhythmias were 4.6 (p = 0.002) and 5.5 (p = 0.004), respectively; 18-month negative predictive values for the 3 end points ranged between 97.3% and 98.6%. Conclusions Among NYHA functional class II/III nonischemic cardiomyopathy patients, an abnormal TWA test is associated with a 4-fold higher risk of cardiac death and life-threatening arrhythmias. Patients with normal TWA tests have a very good prognosis and are likely to benefit little from ICD therapy.

ObjectivesThe purpose of this study was to test the ability of cardiopulmonary exercise testing (CPET)-derived variables as sudden cardiac death (SCD) predictors.BackgroundThe CPET variables, such as peak oxygen uptake (VO2), ventilatory requirement to carbon dioxide (CO2) production (VE/VCO2) slope, and exercise oscillatory breathing (EOB), are strong predictors of overall mortality in chronic heart failure (CHF) patients. Even though up to 50% of CHF patients die from SCD, it is unknown whether any of these variables predicts SCD.MethodsOne hundred fifty-six CHF patients (mean age: 60.9 ± 9.4 years; mean ejection fraction: 34.9 ± 10.6%) underwent CPET. Subjects were tracked for sudden versus pump-failure cardiac mortality over 27.8 ± 25.2 months.ResultsSeventeen patients died from SCD, and 17 died from cardiac pump failure. Survivors showed significantly higher peak VO2(16.8 ± 4.5 ml·kg−1·min−1) and lower VE/VCO2slope (32.8 ± 6.4) and prevalence of EOB (20.3%), compared with subjects who experienced arrhythmic (13.5 ± 3.2 ml·kg−1·min−1; 41.5 ± 11.4; 100%) or nonarrhythmic (14.1 ± 4.7 ml·kg−1·min−1; 38.1 ± 7.3; 47.1%) deaths (p < 0.05). At Cox regression analysis, all variables were significant univariate predictors of both sudden and pump failure death (p < 0.01). Multivariate analysis, including left ventricular (LV) ejection fraction, LV end systolic volume, and LV mass selected EOB, was the strongest predictor of both overall mortality (chi-square: 38.7, p < 0.001) and SCD (chi-square: 44.7, p < 0.001), whereas VE/VCO2slope was the strongest ventilatory predictor of pump failure death (chi-square: 11.8, p = 0.001).ConclusionsExercise oscillatory breathing is an independent predictor of SCD in patients with CHF and might help as an additional marker for prioritization of antiarrhythmic strategies.

The authors report a very unusual case of intermittent and painful rectal bleeding occurring in a two-year-old female. At proctosigmoidoscopy, a bluish mucosal fold was found in the rectal ampulla. Histological examination showed the presence of heterotopic gastric mucosa islands intermingled with normal rectal mucosa. Surgical transanal excision of the lesion was undertaken due to the persistence of rectal bleeding with anemia, notwithstanding a three-month course of pharmacological therapy with a proton pump inhibitor. At a one-year follow-up, the child is well and symptom-free. The international pediatric literature was reviewed.

Non steroid anti-inflammatory drugs (NSAIDs) are largely used for treatment of acute and chronic pain, even for long periods of time (months or years). While it is known that their use is frequently associated with gastrointestinal damage, including major bleedings from peptic ulcer, the risk of cardiovascular events related to NSAID has received much less attention. However, there is a large body of evidence showing that NSAIDs (both “traditional”, such as diclofenac or indobufen, and selective cyclooxygenase inhibitors, COX-2) are associated with a significant increase of risk of cardiovascular events, both fatal and nonfatal. Consequently, several options have been proposed for the treatment of pain, including the use of analgesic drugs with different mechanisms of action, such as the opiates. Of interest, the Italian Drug Agency (AIFA) published a few years ago a warning (Nota 66) on the careful prescription of NSAIDs in patients with overt heart disease, such as coronary artery disease and heart failure. Aim of this paper is to present the current status of knowledge on the proper use of NSAIDs and other analgesic drugs in the management of acute and chronic pain.

Few data are available about the prognostic role of T wave alternans in patients with congestive heart failure. To assess the ability of T wave alternans, used alone or in combination with other risk markers, to predict cardiac death in decompensated patients, we enrolled 46 patients, mean age 59±9, males 89%, ischemic etiology 61%, NYHA class III 35%, left ventricular ejection fraction 29±7%. After 1.6 years follow-up, seven patients died from cardiac death (16%), non-sudden in six (86%) and sudden in one (14%). T wave alternans was positive in 24 (52%), negative in 13 (28%), indeterminate in nine patients (20%). T wave alternans was positive in all patients with events (100%) but only in 16 of 37 patients without (41%) ( P =0.02). Other predictors of cardiac death were O 2 consumption at the peak of exercise ( P =0.03), standard deviation of all NN intervals ( P =0.05) and Wedge pressure ( P =0.03). When receiver operator characteristics curves were calculated, the highest area (0.73) was found for O 2 consumption at the peak of exercise considering the single variables and for O 2 consumption at the peak of exercise plus T wave alternans (0.79) for combination of them; the comparison of the two receiver operator characteristics curves did not reach statistical difference ( P =0.5). In conclusion, this is the first study reporting that T wave alternans can predict cardiac death, with a marginal additional prognostic power when used in combination with measurement of O 2 consumption at the peak of exercise.