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Non-ST-elevation myocardial infarction with multivessel coronary disease is increasing in patients presenting with acute coronary syndrome (ACS) and it is associated with a high rate of mortality. Complete revascularization may reduce major adverse cardiac events in patients with ACS. However, the preferred revascularization strategies (complete vs incomplete) of non-culprit lesions in this setting, as well as the correct timing of revascularization are still matters of debate. This is mostly related to the heterogeneity of patients with this clinical presentation, who are often older and affected by multiple comorbidities. The present review aims to evaluate this topic highlighting the pros and cons of complete revascularization according to anatomical or functional and imaging evaluation and based on timing and patient's clinical phenotype.

With the growing knowledge about the role of inflammatory processes in the pathogenesis of atherosclerotic lesions, inflammation has been identified as a cardiovascular risk factor and therapeutic target to reduce the residual risk in patients with atherosclerotic disease. Several therapeutic agents with anti-inflammatory action have been tested to evaluate their efficacy and safety in the context of atherosclerotic cardiovascular diseases. Among these, colchicine, a drug with multiple therapeutic effects including anti-inflammatory action, in randomized clinical trials conducted in the setting of atherosclerotic cardiovascular disease secondary prevention, significantly reduced the risk of adverse cardiovascular events.This position paper of the Italian Association of Hospital Cardiologists (ANMCO) summarizes the main biological mechanisms through which colchicine contributes to the inhibition of inflammatory processes that increase the atherosclerotic cardiovascular risk. Furthermore, the document reports the available evidence on clinical impact of colchicine treatment in the reduction of residual cardiovascular risk in chronic and acute coronary syndromes. Finally, practical information is provided regarding the use of this drug in this specific clinical setting, emphasizing precautions and possible side effects.

Marijuana consumption is growing up becoming very common especially between young people. 9-THC, the main psychoactive compound in cannabis, acts on the endocannabinoid system having different cardiovascular effects, including arrhythmias, acute coronary syndrome, and sudden cardiac death. We present the case of a young man from Gambia with no cardiovascular risk factors, marijuana consumer, presenting to the emergency department with ST-elevation myocardial infarction. At coronary angiography, thrombotic left anterior descending coronary artery subocclusion was documented. We also describe the association between acute coronary syndrome and cannabis abuse.

Patients suffering from acute coronary syndromes (ACS) present a high risk of recurrence and new adverse cardiovascular events after hospital discharge. Elevated plasma LDL-cholesterol (LDL-C) levels have been shown to be a causal factor for the development of coronary heart disease, and robust clinical evidence has documented that a decrease of LDL-C levels correlates linearly with a reduction in cardiovascular events. Recent studies have also demonstrated the safety and efficacy of an early and significant reduction in LDL-C levels in patients with ACS.In this position paper, ANMCO proposes a decision algorithm on early adoption of lipid-lowering strategies at hospital discharge and short-term follow-up of patients with ACS, in the light of the multiple evidence generated in recent years on the treatment of hypercholesterolemia and the available therapeutic options, considering current reimbursement criteria.

Acute myocardial infarction is an uncommon complication of infective endocarditis, burdened by high mortality and often underdiagnosed. Due to its reduced frequency, current guidelines do not always highlight this condition or provide clear indications regarding treatment. We present a case of acute coronary syndrome induced by the occlusion of the anterior descending artery, due to a septic embolus and treated by aspiration of the embolic material. The clinical-instrumental aspects necessary to raise the suspicion of endocarditis and make the diagnosis are then examined. Subsequently, all the possible therapeutic strategies and any complications of the traditional treatment of acute coronary syndromes during infectious valve disease are analyzed. Since clinical presentation may be extremely variable, the establishment of a multidisciplinary team would allow, in these cases, a more appropriate and complete diagnostic and therapeutic management.

In patients with acute coronary syndrome, total chronic occlusion of a non-culprit vessel is a frequent angiographic finding (10-30%) and it is associated with increased mortality. The effective treatment of these lesions results in better outcomes, and procedural success depends partly on the anatomical features of the lesion. As indicated by current guidelines, the treatment of non-infarct-related artery lesions is not recommended in the acute setting, even in case of hemodynamic instability. We here report the case of a 57-year-old patient suffering from an acute coronary syndrome with double occlusion, acute and chronic, of the left anterior descending artery, both treated in the acute setting with good angiographic and clinical results.

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes and its evaluation remains challenging. The proportion of patients presenting to the emergency department because of acute chest pain appears to be increasing. Nowadays, the essential chest pain-related issues are the missed diagnoses of acute coronary syndromes with a poor short-term prognosis and the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs, but chest pain is never low risk and appropriate diagnosis is always mandatory. The correct diagnosis will guide the treatment strategy. The implementation of networks between hospitals (hub and spoke) with various levels of technology, provide optimal care while minimizing delays, thereby improving clinical outcomes. Cardiologists should actively collaborate with all stakeholders, particularly emergency physicians, in establishing such networks.

Background: The short-term outcomes of acute coronary syndrome (ACS) have been extensively studied; however, the role of post-discharge monitoring, treatment and rehabilitation in the prevention of long-term outcomes remains debated. The aim of this study was to measure the adherence to a therapeutic pathway and to assess its impact on the log-term risk of hospitalization for cardiovascular (CV) causes., Methods: A total of 106 104 incident cases of ACS, in which patients aged 40-90 survived hospitalization, were recorded in the administrative databases between 2009-2015 and were identified as index shelters. Each patient had accumulated person-years from the index hospitalization discharge to the first of the following events: hospitalization for CV events or censorship (death, emigration, June 30, 2018). The association between exposure (drug therapy and rehabilitation) and risk of CV hospitalization was assessed using a Cox model in accordance to the intention-to-treat principle., Results: Compared to untreated patients, those who received prescriptions of beta-blockers, statins, antiplatelet agents or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers in the year after the index discharge experienced a risk reduction of 13% (95% confidence interval [CI] 11-15%), 10% (95% CI 8-12%), 5% (95% CI 2-6%), and 3% (95% CI 1-6%), respectively, whereas rehabilitation within 2 months reduced the risk by 29% (95% CI 26-32%)., Conclusions: Patients undergoing close monitoring with strict adherence to the recommended treatment after admission have a reduced risk of experiencing long-term CV events.

There is limited knowledge on the occurrence of new-onset, transient atrial fibrillation during acute coronary syndromes; compared with patients in sinus rhythm, patients with paroxysmal atrial fibrillation have an increased risk of in-hospital and long-term recurrence of the arrhythmia, all-cause mortality and ischemic stroke. There is a lack of prospective, randomized studies on anticoagulant therapy modalities in this specific subset of patients. In the absence of a widely accepted anticoagulation algorithm, the international guidelines for the management of atrial fibrillation recommend to initiate anticoagulant treatment during acute coronary syndromes estimating in each patient the thrombotic and bleeding risk using the CHA2DS2-VASc and HAS-BLED scores, respectively. In the last updates of the guidelines for the management of atrial fibrillation, non-vitamin K oral anticoagulants are recommended over warfarin and, in patients with atrial fibrillation who have undergone percutaneous coronary intervention with stenting for acute coronary syndromes, dual antiplatelet therapy with rivaroxaban or dabigatran and clopidogrel is reasonable to reduce the risk of bleeding compared with triple therapy. Neither scientific evidences nor recommendations from the guidelines are available about the duration of anticoagulant therapy in case of paroxysmal atrial fibrillation during acute coronary syndromes.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome is a difficult challenge because of the need of taking into consideration three different issues: the cardiac ischemic risk related to coronary artery disease and its treatment with angioplasty and stenting; the thromboembolic risk associated with atrial fibrillation; and the hemorrhagic risk related to the combined use of antiplatelet therapy (with one or two agents) and oral anticoagulant therapy.Data from many trials and meta-analyses currently support a combination therapy with oral anticoagulants (vitamin K antagonists or direct oral anticoagulants) and antiplatelet agents (aspirin and clopidogrel in dual or single antiplatelet therapy).Recently completed and ongoing trials aim to tackle the still controversial issues of this therapy: the choice of the anticoagulant agent and its dosage; the choice of the antiplatelet agent; the use of single or dual antiplatelet therapy and its duration.

Cardiogenic shock (CS) following acute myocardial infarction complicated by severe ventricular dysfunction remains the leading cause of death despite customized pharmacological therapy and optimal revascularization. The use of temporary mechanical circulatory support (MCS) devices during refractory CS might represent the only chance of survival to address the underlying systemic inflammatory response preventing the development of multiorgan failure. We report the case of a patient with a very-high-risk non-ST-elevation acute coronary syndrome and multivessel calcific coronary artery disease complicated by refractory CS undergoing complex percutaneous coronary revascularization. We show a gradual and complementary use of MCS devices tailored on hemodynamic monitoring, clinical and laboratory variables and multidisciplinary collaboration to early recognize the downward spiral that may ensue with multiorgan dysfunction or potential complications leading to death.

Acute coronary syndromes (ACS) are a major health problem both in industrialized countries and in developing ones, and a leading cause of death and disability. The pathogenesis of ACS is multifactorial and complex, with approximately 65-70% of cases caused by the abrupt occlusion of a coronary vessel. This usually occurs as a result of thrombus formation over a vulnerable, lipid-rich atherosclerotic plaque, which undergoes rupture or erosion. High levels of LDL-cholesterol (LDL-C) are a well known risk factor for the development of atherosclerosis, and the reduction in plasma LDL-C is a fundamental treatment both in primary and secondary prevention. Statins are the most extensively used lipid-lowering drugs. They have been associated with reduced progression of coronary atherosclerosis and a decreased incidence of new ACS episodes or post-ACS major cardiovascular events. For ACS patients, the European Society of Cardiology (ESC) has suggested an early treatment - starting with the acute phase - together with a well defined target value of LDL-C level, which should be achieved during the follow-up. While statin therapy has significantly lowered cardiovascular risk, several cardiovascular events are still not prevented and a residual risk remains also after intensive therapy. In addition, a significant proportion of high-risk patients do not achieve the LDL-C target recommended by the ESC guidelines or present with statin intolerance, which does not allow a continuative and effective treatment. This is the main reason why innovative lipid-lowering therapies might become a new opportunity in ACS patients. The recently published results of the IMPROVE-IT trial have shown that the association statin + ezetimibe is superior to statin alone in preventing cardiovascular death, non-fatal myocardial infarction, rehospitalization for unstable angina, coronary revascularization and stroke in a population of medium to high-risk patients stabilized after ACS. Monoclonal antibodies targeting human PCSK9 are currently being tested on top of statins in patients with ACS, to investigate their superiority in reducing major cardiovascular adverse events as compared with statins alone at the maximally tolerated dose. The results, expected for 2017, will hopefully benefit the treatment of patients in secondary prevention and contribute to a better outcome of ACS patients worldwide.

Cardiovascular disease and cancer are the leading causes of mortality worldwide. We report our experience in a cancer patient with acute coronary syndrome successfully treated by hybrid revascularization, i.e. off-pump coronary artery bypass grafting, followed by surgical removal of the tumor and percutaneous coronary intervention. The concomitant presence of cancer and acute coronary syndrome is not rare, ranging from 1.9% to 4.2%. Usually, the most life-threatening disease should be treated first, more frequently coronary artery disease. There are several therapeutic approaches to patients with cancer and coronary artery disease and cancer, including percutaneous coronary intervention, surgical treatment of cancer, or coronary artery bypass grafting. Each of these options should consider the severity of cardiac disease, the stage of malignancy and the clinical conditions of the patient.

Patients with diabetes mellitus (DM) and acute coronary syndromes (ACS) present a significantly higher risk of developing ischemic complications as compared to nondiabetic patients. Multiple mechanisms contribute to DM patients' enhanced prothrombotic status, including impaired fibrinolysis and coagulation, as well as endothelial and platelet dysfunction. Therefore, antithrombotic agents generally, and antiplatelet agents in particular, represent a logical secondary preventive strategy to reduce the risk of recurrent ischemic events in DM patients with ACS. However, DM patients often show attenuated responses to antiplatelet therapies for ACS patients. DM patients benefit from early coronary angiography and revascularization. Although randomized clinical trials have demonstrated that surgical revascularization is associated with an improved prognosis compared to percutaneous coronary intervention, a tailored revascularization strategy should be provided for each patient. The type of revascularization should be decided on the basis of SYNTAX score, surgical risk profile, and feasibility of total arterial revascularization in case of surgery. An accurate diagnosis and prompt treatment of hyperglycemia should also be provided for all patients. The present multidisciplinary document provides practical recommendations regarding diagnosis of DM and the management of hyperglycemia, from the acute phase to discharge. It is aimed at favoring early detection of hyperglycemia and identification of diabetic patients so as to provide adequate glucose control.

Aims: The Chest Pain Unit (CPU) of Policlinico Umberto I, established in 2008, is charged with the management of patients with non-traumatic chest pain transferred from the Emergency Department and aims at: a) an early recognition of patients at high risk of acute coronary syndrome (ACS), in order to perform a primary PCI within 90 minutes; b) an early diagnosis of patients at low risk of ACS in order to discharge them in a short time, and c) the diagnostic performance of clinical tests in patients at intermediate risk of ACS in order to identify those who require either a new PCI or a coronary artery bypass graft (CABG). The purpose is to avoid malpractice which could even imply the risk of legal conflicts., Materials and Methods: We evaluated the total number of admissions to the Emergency Department of Policlinico Umberto I in the period 2010-2011 and selected the patients with non-traumatic chest pain and acute coronary syndrome. In the Chest Pain Unit, patients with non-traumatic chest pain or ACS were recruited through a) the use of the Chest Pain Score to define the typicality or atypicality of chest pain; b) the stratification of the risk of ACS using the modified Braunwald Score; and c) the stratification of patients at intermediate or high risk of ACS using the GRACE ACS Model in order to perform a PCI., Results: In the period 2010-2011, 603 patients were admitted to the CPU with non-traumatic chest pain. Of them, 15.75% (95) were diagnosed with atypical chest pain; 27.03% (163) with chronic stable angina pectoris; 9.3% (56) received a diagnosis of chronic heart failure and 47.92% (289) suffered from non ischemic cardiovascular disease. Other 124 subjects were admitted to the CPU with a diagnosis of ACS, but only in 91.93% of the cases such diagnosis was confirmed, whereas for the remaining 8.06% was discarded. On the whole, 54.2% (394) of the 727 patients admitted to the CPU with non-traumatic chest pain and acute coronary syndrome showed a low cardiovascular risk; 30.12% (219) were at intermediate risk and 15.68% (144) at high risk., Discussion: The aim of the CPU is to accomplish a selection of the subjects at high risk of ACS, to drastically reduce the time of diagnosis and treatment to 24-36 hours and to avoid possible mistakes or adverse events by using both unsophisticated diagnostic tests and a personalized management of diagnosis and treatment.

The 2011 edition of the ESC guidelines on non-ST-segment elevation acute coronary syndromes (NSTE-ACS) maintains the approach strongly based upon risk stratification, following the concept that "the higher the risk of ischemic events, the larger will be the benefit of an aggressive pharmaco-interventional approach". This concept applies both to the indication and timing of angiography/revascularization and to the choice of concomitant pharmacological therapies. The proofs of efficacy of the most recent drug treatments are solid, but the choice among the several available options and the evaluation of the efficacy/safety ratios in patient subsets require clinical wisdom, especially for the management of the most complex and frail patients. The indication for performing coronary angiography within 24h in high-risk patients would imply extending to NSTE-ACS patients the networks already in place for primary percutaneous coronary intervention in ST-elevation myocardial infarction.

Hyperglycaemia in patients with Acute Coronary Syndrome (ACS)is common, and is an independent predictor of mortality and morbidity in patients both with and without diabetes mellitus. Hyperglycaemia may be a marker of pre-existing diabetes or glucose intolerance or may also represent a transient stress response mediated through the autonomic nervous system with release of adrenal corticosteroids and catecholamines. Several evidences suggest that an intensive control of hyperglycaemia results in a significant improvement of the adverse outcomes in the short and long term. In fact, an intensive metabolic treatment can counteract the negative effects of hyperglycaemia. However, the main difficulty to intensive glucose control in patients with ACS remains hypoglycaemia that is associated with an increased risk of mortality and myocardial re-infarction. No definitive data are available about the beneficial effects of insulin intensive treatment. Therefore, randomized multicenter clinical trials will be needed to definitively establish whether intensive glucose control will reduce the associated increased mortality rate and higher rates of complications in hospitalized ACS patients with hyperglycaemia.

The aim of the Chest Pain Unit at Policlinico Umberto I in Rome was to implement simple diagnostic flow-charts in subjects with non-traumatic chest pain for an early identification of patients at high, intermediate and low risk of acute coronary syndrome (ACS). A total of 4.74% of all patients admitted to the Emergency Department were hospitalized in the Chest Pain Unit. 15.72% of them received a diagnosis of atypical chest pain with low risk of ACS; 26,42% were diagnosed of stable angina pectoris; 11.37% were affected by chronic coronary heart disease with medium risk of ACS and 12.83% were at high risk of acute coronary syndrome.

Purpose: The aim of our study was to evaluate the role of magnetic resonance (MR) imaging in identifying the location and extent of acute ischaemic injury to predict reversibility and distinguish areas of acute from chronic ischaemia in patients with acute coronary syndrome non- ST-elevation myocardial infarction (NSTEMI)., Materials and Methods: We evaluated 22 patients with NSTEMI acute coronary syndrome confirmed by coronary angiography (CA). We studied ventricular function indices and segmental changes in wall thickness and kinetics by cine-MR imaging sequences. Subsequently, we evaluated myocardial wall oedema with T2-weighted black-blood short-tau inversion recovery turbo spin echo (T2 BB-STIRTSE) sequences and identified areas of myocardial necrosis using T1-weighted turbo field-echo inversion recovery (T1 TFE-IR) sequences after contrast material administration., Results: The results obtained with the single sequences were as follows: T2 BB-STIR-TSE: 96.8% sensitivity, 100% specificity, 99.7% negative predictive value, 99.7% positive predictive value; T1 TFE-IR: 45.8% sensitivity, 96.9% specificity, 92.3% negative predictive value, 90.3% positive predictive value; systolic wall thickening: 87.5% sensitivity, 91.8% specificity, 98.7% negative predictive value, 50% positive predictive value, 91.4% accuracy., Conclusions: Our study suggests that the sequences used for evaluating oedema and assessing viability allow for precise localisation and differentiation of areas of acute and chronic ischaemia by quantifying the possible mismatch between ischaemia and necrosis.

Secondary prevention after acute coronary syndromes should be aimed at reducing the risk of further adverse cardiovascular events, thereby improving quality of life, and lengthening survival. Despite compelling evidence from large randomized controlled trials, secondary prevention is not fully implemented in most cases after hospitalization for acute coronary syndrome. The Lazio Region (Italy) has about 5.3 million inhabitants (9% of the entire Italian population). Every year about 11 000 patients are admitted for acute coronary syndrome in hospitals of the Lazio Region. Most of these patients receive state-of-the art acute medical and interventional care during hospitalization. However, observational data suggest that after discharge acute coronary syndrome patients are neither properly followed nor receive all evidence-based treatments. This consensus document has been developed by 11 Scientific Societies of Cardiovascular and Internal Medicine in order develop a sustainable and effective clinical approach for secondary cardiovascular prevention after acute coronary syndrome in the local scenario of the Lazio Region. An evidence-based simplified decalogue for secondary cardiovascular prevention is proposed as the cornerstone of clinical intervention, taking into account regional laws and relative shortage of resources. The following appropriate interventions should be consistently applied: smoking cessation, blood pressure control (blood pressure < 130/80 mmHg), optimal lipid management (LDL cholesterol < 80 mmHg), weight and diabetes management, promotion of physical activity and rehabilitation, correct use of antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone system blockers.

Type 2 diabetes and acute coronary syndromes are widely interconnected. Individuals with type 2 diabetes are more likely than non-diabetic subjects to experience silent or manifest episodes of myocardial ischemia as the first presentation of coronary artery disease. Insulin resistance, inflammation, microvascular disease and a tendency to thrombosis are common in these patients. Intensive blood glucose control with intravenous insulin infusion has been demonstrated to significantly reduce morbidity and mortality in critically ill hyperglycemic patients admitted to an intensive care unit. Direct glucose toxicity likely plays a crucial role in explaining the clinical benefits of intensive insulin therapy in such critical patients. However, the difficult implementation of nurse-driven protocols for insulin infusion, able to achieve more rapid and effective blood glucose control without significant episodes of hypoglycemia, has led physicians to consider alternative drugs for this purpose. New intravenous or oral agents include the incretin glucagon-like peptide-1, its analogs, and dipeptidyl peptidase-4 inhibitors, which potentiate the activity of glucagon-like peptide-1 and thus enhance glucose-dependent insulin secretion. Improved glycemic control with protective effects on myocardial and vascular tissue, with lesser side effects and a better therapeutic compliance may represent an important therapeutic potential for this class of drugs in acutely ill patients in general, and in patients with acute coronary syndromes in particular. Such drugs should be known by practicing cardiologists for their possible use in intensive care units in the years to come.