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The SARS-COVID-19 pandemic is bringing to light significant issues that require deliberations on how to manage patients at high cardiovascular risk or with proven heart disease. The evidence that the hospital can be a place where one might contract the infection and spread the disease has drastically reduced non-COVID-19 accesses to emergency rooms (ER) and to elective non-COVID-19 hospital activities. If this, on one hand, results in reducing improper access to the ER and hospital, on the other hand it substantiates the risk of underestimating problems not connected to COVID-19, such as an increased delay in the diagnosis and treatment of acute myocardial infarction and other cardiovascular emergencies. In addition, the need to reorganize hospital activities to treat patients suffering from serious COVID-19 disease forms forces us to reflect on how to safely manage patients who stay at home with milder COVID-19 disease forms and the need to keep the most vulnerable subjects, such as patients with chronic heart failure, away from the hospital. The problem is furtherly amplified by the uncertain trend of the epidemic, by the duration of forced isolation and limited mobility measures and by the inadequate integration between hospital and territory, especially in high-risk areas such as residences for the elderly or in socially and economically fragile environments. Our opinion is that a syndemic approach, which considers the complex interplay between social, economic, environmental and clinical problems, can be the most appropriate and achieved by means the contribution of telemedicine and telecardiology, intended as integration and not as an alternative to traditional management. A flexible use of telematic tools, now available for teleconsultation, and/or remote monitoring adapted to the needs of clinical, family and social-health contexts could allow the creation of integrated and personalized management programs that are effective and efficient for the care of patients.

Acute heart failure (AHF) represents a relevant burden for emergency departments worldwide. AHF patients have markedly worse long-term outcomes than patients with other acute cardiac diseases (e.g. acute coronary syndromes); mortality or readmissions rates at 3 months approximate 33%, whereas 1-year mortality from index discharge ranges from 25% to 50%.The multiplicity of healthcare professionals acting across the care pathway of AHF patients represents a critical factor, which generates the need for integrating the different expertise and competence of general practitioners, emergency physicians, cardiologists, internists, and intensive care physicians to focus on care goals able to improve clinical outcomes.This consensus document results from the cooperation of the scientific societies representing the different healthcare professionals involved in the care of AHF patients and describes shared strategies and pathways aimed at ensuring both high quality care and better outcomes. The document describes the patient journey from symptom onset to the clinical suspicion of AHF and home management or referral to emergency care and transportation to the hospital, through the clinical diagnostic pathway in the emergency department, acute treatment, risk stratification and discharge from the emergency department to ordinary wards or home. The document analyzes the potential role of a cardiology fast-track and Observation Units and the transition to outpatient care by general practitioners and specialist heart failure clinics.The increasing care burden and complex problems generated by AHF are unlikely to be solved without an integrated multidisciplinary approach. Efficient networking among emergency departments, intensive care units, ordinary wards and primary care settings is crucial to achieve better outcomes. Thanks to the joint effort of qualified scientific societies, this document aims to achieve this goal through an integrated, shared and applicable pathway that will contribute to a homogeneous care management of AHF patients across the country.

Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to reduced cardiac output, despite adequate filling status. The development of multiorgan dysfunction is believed to be the major contributor to the high early mortality. Little evidence exists as to which vasopressor or inotrope should best be used for early treatment; however, customized pharmacological therapy, tailored on hemodynamic monitoring, is essential to achieve normal peripheral perfusion. Moreover, an increasing number of mechanical circulatory support devices are available for hemodynamic support in patients with CS but, at present, data derived from randomized clinical trials on the effectiveness, safety, differential indications for mechanical support devices, and optimal implant timing are limited.The aim of this review is to offer an overview of the pharmacological and device options, providing a practical approach to the treatment of patients with CS.

Noninvasive ventilation (NIV), including both continuous and bilevel positive airway pressure, plays a pivotal role in the treatment of acute respiratory failure secondary to acute heart failure. For an appropriate use of NIV, it is essential to consider the underlying pathophysiological principles, the differences between the different modes of ventilation, the main indications, contraindications and complications. The aim of this review is also to give practical guidance on how and when to start NIV at the bedside, how to monitor the response and how to choose the most appropriate interface. A review of the literature supports the use of NIV in terms of efficacy (reduction in intubation and mortality) and safety (in particular, the risk of myocardial infarction associated with its use, suggested by a previous study, has been definitely confuted). Nevertheless, NIV is still largely underused in contemporary clinical practice, as reported by data from real-world registries. This may be due to several factors, including lack of knowledge/confidence, reluctance of application in particular settings (acute coronary syndromes) and the risk of adverse effects (hypotension), which need to be reappraised.

Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics. The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals. The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment. In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.

Changing demographics and an increasing burden of multiple chronic comorbidities in western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of-hospital phases of HF. The needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for hospitalized HF and those followed up at HF clinics.The Working Group on Heart Failure of the Italian Association of Hospital Cardiologists (ANMCO) has drafted a consensus document for the organization of a national HF care network. The aims of this document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among healthcare professionals. In this document, HF clinics are classified into three groups: 1) community HF clinics, devoted to the management of stable patients in strict liaison with primary care, regular re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, 2) hospital HF clinics, that target both new-onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for medicine units and community clinics; 3) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. These different types of HF clinics are integrated in a dedicated network for the management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multiprofessional providers to ensure continuity of care. This consensus document is expected to promote a more efficient organization of HF care, in particular for elderly patients and in transition phases from acute to chronic HF, by networking outpatient cardiology offer and primary care.

Background: The most important limitation in primary percutaneous coronary interventions (PCI) for acute myocardial infarction (AMI) is the small number of catheterization laboratories and their non-homogeneous territorial distribution. The aim of this study was to evaluate the safety and efficacy of an organizational model based on a network including tertiary referral centers and community hospitals for the treatment of AMI with alteplase plus abciximab followed by PCI., Methods: From October to November 2002, 232 patients < or = 75 years with AMI at high risk (84 transferred from four community hospitals and 148 patients admitted directly at the tertiary center) underwent PCI at our Institution. We compared procedural results and clinical outcome in patients with AMI undergoing PCI with or without transfer to tertiary centers., Results: Patient transferal from community hospitals determines a greater door-to-balloon time (120 vs 55 min, p < 0.001), while complications observed during transportation are limited (5.9%). Transferred patients have a greater percentage of infarct-related artery patency (77 vs 22%, p < 0.001) and of ST-segment resolution 90 min post-PCI (77 vs 57%, p < 0.005) in comparison with direct-access patients. The incidence of clinical events (death, reinfarction, angina) was not different between the two groups at 30 days and at 6 months of follow-up., Conclusions: In our experience the integrated model between tertiary centers and community hospitals represents a valid network system offering homogeneous therapeutic (alternatives) options to all patients with AMI regardless of the hospital where they are first admitted.

Background: Ehen refractory to optimal medical treatment cardiogenic pulmonary edema requires mechanical ventilation as a last therapeutic resource. In recent years an increasing number of authors reported their experience in the management of acute or subacute respiratory failure with non-invasive mechanical ventilation by nasal mask., Materials and Methods: Encouraged by the first promising results reported in literature we experimented this new therapeutic tool in a first group of seven elderly patients (mean age: 76.57--range: 65-89); they all had been admitted for severe cardiogenic pulmonary edema unresponsive to maximal doses of the conventional drugs available for treating acute decompensated heart failure. The enrolled patients were treated with intermittent ventilation administered by nasal mask at selected values of inspiratory positive airway pressure (IPAP) that were comprised between 10 and 20 cm H2O. At the same time an expiratory positive airway pressure (EPAP) at values comprised between 3 and 8 cm H2O was applied. Ventilation was continued for variable periods of 3-24 hours until acceptable values of PaO2 and PaCO2 were obtained. The ventilation modality was spontaneous, spontaneous-time or timed depending on the patients' level of consciousness at starting time., Results: A good short-term outcome was achieved in all the patients regardless of the ventilation modality applied. The main blood gas alteration was severe hypercapnia with acidosis in three patients, while the other four presented critical hypoxemia unresponsive to simple oxygen supply even if delivered by high-flow Venturi mask. Four of our seven patients were discharged from hospital in satisfactory haemodynamic conditions; the remaining three died during hospitalization from refractory heart failure., Conclusions: In this our preliminary experience the therapeutic approach with nasal positive pressure ventilation (NPPV) and EPAP proved to be very effective to improve the signs and symptoms of acute refractory cardiogenic pulmonary edema as it avoided the need of invasive mechanical ventilation. It was well tolerated by all our patients; besides it was not difficult to use or time-consuming for physician and nurses. On the other hand it didn't modify our patients' medium or long-time prognosis which was strictly related to their preexisting left ventricular pump derangement.

The case is reported of a 69-year-old man with refractory heart failure due to ischemic cardiomyopathy. All other available treatments having failed and 250 mg doses of furosemide having been administered without success, dobutamine infusion was tried, at first with 72 hours of continuous infusion of 5 mcg/kg/min, followed by intermittent infusion at the same dosage, first with 12-h intervals, subsequently at the rate of 2-3 infusions weekly, and finally, after about 50 days, with a single weekly infusion. Clinical and hemodynamic results were brilliant with the patient passing from grade IV NYHA to grade II and from ejection fraction 21% (Teichholz M-mode measurement) to 55%, 14 months after the start of dobutamine treatment. Discussing the possible mechanisms of this favourable result, the authors stress the possible improvement of the contractility of the "stunned" or "hibernating" myocardial segments. On the basis of their experience and of data in the literature the authors underline the validity of a therapeutic protocol of intermittent dobutamine infusion for severe heart failure.