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Background & Aims: Infliximab might prevent postsurgical recurrence of Crohn''s disease. However, it is unclear whether long-term therapy is necessary and whether alternative strategies could be applied to minimize potential side effects and reduce the costs of treatment. Methods: We performed a prospective cohort study in 12 consecutive patients, treated immediately after surgery with maintenance infliximab (5 mg/kg), who did not have clinical or endoscopic evidence of disease recurrence after 24 months; they were followed up for an additional year. Infliximab treatment was then discontinued; patients with disease recurrence, based on endoscopy (Rutgeerts score, ≥2), were given lower doses of infliximab (starting with 1 mg/kg) to re-establish mucosal integrity. Surrogate markers of disease activity (fecal calprotectin [FC], C-reactive protein, and erythrocyte sedimentation rate) were assessed after each infliximab dose. Results: None of the patients had clinical or endoscopic recurrence of Crohn''s disease 3 years after surgery. However, discontinuation of infliximab caused endoscopic recurrence after 4 months in 10 of 12 patients (83%). All 10 patients then were treated again with infliximab, which, at a dose of 3 mg/kg every 8 weeks, restored and maintained mucosal integrity for 1 year. Among the surrogate markers, FC levels correlated with endoscopic scores (Wald test, P < .0001). Conclusions: Long-term maintenance therapy with infliximab is required to maintain mucosal integrity in patients after surgery for Crohn''s disease. However, a dose of 3 mg/kg (a 40% reduction from the standard dose) was sufficient to avoid disease recurrence, determined by endoscopy, in all patients at 1 year. FC levels correlate with mucosal status at different infliximab doses. [Copyright &y& Elsevier]

Abstract: Although infliximab has brought about a major advance in the treatment of Crohn''s disease (CD), several questions remain unanswered. In particular, there is no consensus regarding the best timing to use it in the ideal therapeutic algorithm. Another controversial issue is whether this medication should be given or not for life once proven effective in the individual patient. Therapy with infliximab has also been associated to the development of intestinal strictures in CD: hence, some authors have discouraged its use in their presence. Finally, given its powerful antiinflammatory action, infliximab could in theory be effective in preventing postsurgical recurrence of CD, an as yet almost inescapable consequence of “curative” surgery. This review will focus on and discuss the relevant recent literature related to these issues with special regard to the efficacy and safety of infliximab in the presence of intestinal strictures and the potential role of this medication in preventing recurrence after surgery. [Copyright &y& Elsevier]

The clinical guidelines, while representing an objective reference to perform correct therapeutic choices, contain grey zones, where the recommendations are not supported by solid evidence. In the fifth National Congress Grey Zones held in Bergamo in June 2022, an attempt was made to highlight some of the main grey zones in Cardiology and, through a comparison between experts, to draw shared conclusions that can illuminate our clinical practice. This manuscript contains the statements of the symposium concerning the controversies regarding ischemic cardiomyopathy. The manuscript represents the organization of the meeting, with an initial review of the current guidelines on this topic, followed by an expert presentation of pros (White) and cons (Black) related to the identified "gaps of evidence". For every issue is then reported the "response" derived from the votes of the experts and the public, the discussion and, finally, the highlights, which are intended as practical take home messages to be used in the everyday clinical practice. The first gap in evidence discussed regards the validity of the indication to search for ischemia in light of the data from the ISCHEMIA trial. The second examines the possibility of modifying the algorithm proposed by the European guidelines on anti-ischemic therapy in chronic coronary syndromes. The last gap in evidence evaluates the comparability of long-term antithrombotic strategies in chronic coronary syndromes.

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to most patients affected from AF. Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications, and potential clinical benefit of LAAO and CA in selected older AF patients. Older people carry the greatest burden of AF in real world practice. Within a shared decision-making process, the patient centered approach needs to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.

Principles and processes of comprehensive geriatric assessment (CGA) are increasingly being applied to subspecialties and subspecialty conditions, including cardiovascular patients (i.e., infective endocarditis; considerations of surgery or transcatheter aortic valve replacement, TAVR, for patients with aortic stenosis; vascular surgery) and postoperative mortality risk. In cardiovascular field CGA has mainly the aim to define ideal management according to the different typology of older adult patients (e.g., robust versus intermediate versus physical and cognitively disabled versus end-stage or dying), allowing physicians to select different therapeutic goals according to life expectancy; Aspect to be valued are by CGA are global health status and patient's decision-making capacity: CGA allows the individualized treatment definition and optimize the preprocedure condition.

Recently, transcatheter aortic valve replacement (TAVR) has emerged as established standard treatment for symptomatic severe aortic stenosis, providing an effective, less-invasive alternative to open cardiac surgery for inoperable or high-risk older patients. In order to assess the anticipated benefit of aortic replacement, considerable interest now lies in better identifying factors likely to predict outcome. In the elderly population frailty and medical comorbidities have been shown to significantly predict mortality, functional recovery and quality of life after transcatheter aortic valve replacement. Scientific literature focused on the three items will be discussed. High likelihood of futility is described in patients with severe chronic lung, kidney, liver disease and/or frailty. The addition of frailty components to conventional risk prediction has been shown to result in improved discrimination for death and disability following the procedure and identifies those individuals least likely to derive benefit. Several dedicated risk score have been proposed to provide new insights into predicted "futile" outcome. However, assessment of frailty according to a limited number of variables is not sufficient, while a multi-dimensional geriatric assessment significantly improves risk prediction. A multidisciplinary heart team that includes geriatricians can allow the customization of therapeutic interventions in elderly patients to optimise care and avoid futility.

Over recent years, managing hypertension in older people has gained increasing attention, with reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data. Although limited, available evidence suggests that the association between blood pressure and adverse outcomes significantly varies at advanced age according to frailty status. In particular, the negative prognostic impact of hypertension seems to attenuate or even revert in individuals with older biological age, e.g., patients with disability, cognitive impairment, and poor physical performance. Consequently, "one size does not fit all" and personalized treatment strategies are needed, customized to individuals' frailty and functional status. Similar to other cardiovascular diseases, hypertension management in older people should be characterized by a geriatric approach based on biological rather than chronological age and a geriatric comprehensive evaluation including frailty assessment is required to provide the most appropriate treatment, tailored to patients' prognosis and health care goals. The aim of this review was to illustrate the importance of a patient-centered geriatric approach to hypertension management in older people with the final purpose to promote a wider implementation of frailty assessment in routine practice.

During earliest years, new drug-therapies and novel interventional therapies have been tested to modify the detrimental effect of secondary valve diseases, adverse ventricular remodelling and persistent fluid overload in HF patients. However, the increased prevalence of older or very old patients with HF has made their widespread implementation more problematic due to complex comorbidity, frailty, or overt disability. This growing older population, often excluded by randomized trials, but with elevated risk of hospitalization, required a different clinical and management approach that allows clinicians to take full advantage in reducing mortality and morbidity from these new pharmacological and instrumental therapies. In this perspective, the role of multidisciplinary Heart Team is mandatory for better define a correct decision-making process and tailoring the best pharmacological therapy in each patient and to program a continuum care in a post-acute phase of treatment. In addition, the possibility to plan multicentre registries of several complex cases evaluated by Heart Team could become a very important source of real world data to further refine indications and contraindications of different highly technological therapeutic approach, today based often on randomized clinical trials that do not represent faithfully the current clinical practice population.

The net clinical benefit of aspirin in primary prevention is uncertain as the reduction in occlusive events needs to be balanced against the increase in gastro-intestinal and cerebral bleedings. The meta-analysis of ATT (Anti Thrombotic Trialists) Collaboration in 2009 showed that aspirin therapy in primary prevention was associated with 12% reduction in cardio-vascular events, due mainly to a reduction in non-fatal myocardial infarction (0.18% vs 0.23% per year, p<0.0001). However, the benefit in term of coronary events was almost balanced by the increase in major bleedings. The balance between potential benefit and harm of aspirin differs in each person and appears to be favorable in subjects at higher cardio-vascular risk. Older people have increased risk of hemorrhage as well as increased risk of heart attack and stroke. As a consequence, it is important consider both likelihoods of benefits as well as harm within the lifespan and functioning of the person. The older people who most likely benefit from aspirin in primary prevention are those at higher cardio-vascular risk, with preserved functional abilities, low comorbidity, low risk of bleeding and a prolonged life expectancy.

The serotonin syndrome (SS) represents a life-threatening adverse drug reaction, caused by serotonin overload in the central and peripheral nervous system, producing autonomic instability, neuromuscular and cardiovascular abnormalities, and cognitive alterations. The incidence of SS has been growing over the last few years, as a consequence of population aging and the steadily increasing use of pro-serotoninergic agents in clinical practice, in the presence of various comorbidities, mainly cardiovascular. Cardiologists often use combination therapies including serotoninergic agents, and should therefore consider the risk of serotoninergic adverse events caused by inappropriate drug interactions. SS is often difficult to diagnose and may be life-threatening if not adequately managed. Considering the several published case reports of overdose or not recommended associations, a greater awareness by clinicians about the potential risks associated with inappropriate use of these drugs is needed, as well as better information on the clinical features and therapeutic approaches to SS.

Population aging is associated with an increasing prevalence of chronic diseases (including chronic heart failure) and comorbidities (the presence of one or more diseases in addition to an index disease, potentially contributing to disability) which, in turn, expands the need for healthcare services. Therefore, the already elevated costs in the National Health Services are expected to rise further over the next decades, along with increasing aging of the population. This epidemiologic trend is responsible for the increasing occurrence of polytherapy (multiple medications prescribed to an individual patient) and polypharmacy (multiple medications not directly prescribed by a physician). Owing to often unpredictable interactions, polytherapy and polypharmacy are associated with higher risk of adverse drug reactions with increased mortality and hospitalizations that contribute to increase direct and indirect National Health Services costs. Physicians, patients and caregivers should be instructed in strategies aimed at reducing adverse drug reactions while maintaining optimal management of conditions that, such as chronic heart failure, are at high risk of death, functional impairment and deteriorated quality of life. Strategies consist of a variety of interventions, such as reducing inappropriate medication prescriptions and number of medications and doses taken, avoiding drugs with greater potential of interactions, and increasing patient adherence.

The new Note 13 introduces significant changes in the regulation of statin reimbursement. Although cardiovascular risk assessment still plays a key role, cardiovascular risk estimation has shifted from the "risk charts" to the more simple "sum of risk factors". In addition, the new Note 13 expands drug reimbursement to subjects at intermediate risk, who represent the main source of cardiovascular events because of the size of the population. As a consequence, the general trend of the new Note 13 is to simplify the rules that govern statin reimbursement and to guarantee treatment for all subjects at increased risk of cardiac and vascular events.

Objectives: We have investigated on the levels of homocysteine linked to LDL in acute myocardial infarction patients., Design and Methods: We used capillary electrophoresis to measure LDL-bound thiols in 16 AMI individuals and 32 healthy volunteers., Results: We found a significant increase of apo-B homocysteine and cysteine levels in LDL fraction of AMI subjects., Conclusions: Our findings suggest that also LDL S-homocysteinylation may be considered among the markers for the CVD risk evaluation., (Copyright © 2011 Elsevier Inc. All rights reserved.)

A 65-year-old man with stable angina refractory to medical therapy and with a low-threshold myocardial ischemia at ECG stress testing was referred for coronary angiography. The coronary angiogram showed an ostial subocclusive stenosis of a developed first diagonal branch located just upstream of a subocclusive stenosis of the mid left anterior descending (LAD) coronary artery, occluded distally, and a coronary collateral for LAD from a developed right ventricular branch arising with separate ostia from the right sinus of Valsalva. We discuss the diagnostic interpretation of this coronary anomaly and some aspects regarding the percutaneous treatment of bifurcations.

Anomalies of the coronary artery are incidentally detected during coronary angiography and are seldom found in daily clinical practice. In the reported studies, the incidence ranges from 0.6 to 1.3%, and men are more frequently affected. Among the different types, the detection of a double left anterior descending coronary artery emerging from the right coronary sinus is extremely rare. We describe a case of a 64-year-old male patient admitted to our institution because of ST segment elevation myocardial infarction. After successful systemic lysis, he underwent coronary angiography that showed multivessel coronary disease, a patent infarct-related artery and a double left anterior descending artery. We discuss the clinical relevance of a coronary artery emerging from the opposite Valsalva sinus and its clinical implications.

Objectives: To evaluate the possible role of the active Helicobacter pylori infection as a trigger factor in acute coronary heart disease (CHD)., Methods: Forty patients with acute coronary syndromes, 40 patients with infections other than H. pylori (control group A) and 40 healthy subjects (control group B), pair matched for age, sex and CHD risk factors were studied. In each patient and control subject the presence of H. pylori stool antigen (HpsA) and serum anti-CagA were tested., Results: Twenty-eight of patients with CHD resulted positive for HpSA compared to 14 patients of control group A and 16 subjects of group B (p=0.00095). No significant difference was found in the anti-CagA positivity among patients with CHD and control groups. Concomitant positivity for anti-CagA and HpSA was found in 13 patients with CHD, four controls of group A and five controls of group B (p=0.017), Conclusions: Our findings revealed a higher rate of HpSA positivity and a significantly higher association between HpSA and anti-CagA positivity in patients with acute CHD compared to control groups. These data suggest that active H. pylori infection may play a role as a trigger factor in acute cardiovascular events.