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To date, the actual prevalence of acute pulmonary embolism (PE) in patients with SARS-CoV-2 infection remains unknown, as systematic screening for PE is cumbersome. We performed a systematic review and meta-analysis on autoptic data to estimate the prevalence of histopathologic findings of acute PE and its relevance as a cause of death on patients with COVID-19. We searched MEDLINE-PubMed and Scopus to locate all articles published in the English language, up to August 10, 2021, reporting the autoptic prevalence of acute PE and evaluating PE as the underlying cause of death in patients with COVID-19. The pooled prevalence for both outcomes was calculated using a random-effects model and presenting the related 95% confidence interval (CI). Statistical heterogeneity was measured using the Higgins I

Introduction: Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure. Materials and methods: We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure. Results: Median (IQR) age and body mass index (BMI) were 14 (13–16) years and 20.1 (17.9–21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7–54.0) s and 89.6 (62.5–143.9) cGy*cm2. The effective dose was 0.19 (0.14–0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26–49) s vs. 36 (31–61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3–4) ml. DAP was higher when SA > 3 mL was used (101.4 (65–183) cGy*cm2 vs. 80.5 (59–119) cGy*cm2; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL. Conclusions: The Tauber procedure is safe and associated with low effective doses. Operative time and the patient’s BMI independently predict a higher radiation dose.

Sacubitril/valsartan reduces heart failure (HF)-related hospitalizations and cardiovascular mortality in PARADIGM-HF and has become a foundational treatment for HF with reduced ejection fraction (HFrEF). However, data of its routine real-world use are limited, and evidence from Italian settings is lacking. The REAL.IT study aimed to characterize the demographics, pharmacotherapy, clinical characteristics and outcomes of sacubitril/valsartan-treated Italian patients with HFrEF. Electronic medical records of patients initiating sacubitril/valsartan from October 2016 to June 2019 at nine specialized hospital outpatient HF centers across Italy were reviewed. Overall, 924 adults (mean age 64.5 years, 84.6% male) were included. At baseline, 38.7% had an ischemic HF etiology, 45.9% hypertension, 23.2% atrial fibrillation, 25.4% diabetes mellitus, 26.1% an implantable cardioverter-defibrillator and 31.9% coronary artery bypass grafting. There were no clear patterns of patient selection over time. During follow-up, NYHA class improved in 37.5% of patients after a mean of 5.3 ± 3.8 months; 36.1% and 16.7% of patients were in NYHA class III during characterization and after one year of follow-up, respectively. Left ventricular ejection fraction (LVEF) improved ≥5% in 56.3% of patients at one year; 39.7% had ≥30% reduction of N-terminal pro-B-type natriuretic peptide; 2.2% had hyperkalemia during characterization and 2.6% during follow-up; and 3.8% had hypotension during characterization and 12% during follow-up. A total of 50 (5.8%) of patients had device implantation (ICD/CRT) during follow-up. HF-related hospitalization was recorded in 19.6% of patients during follow-up; 3.8% of patients died, approximately 1.3% from cardiovascular causes. Our real-world data confirm the favorable effectiveness and tolerability of sacubitril/valsartan observed in pivotal randomized controlled trials.

Aims The current European Society of Cardiology guidelines provide clear indication for the treatment of acute and chronic heart failure (HF).Nevertheless,there is the constant need of real–world evidence concerning the effectiveness,adherence and persistence to drug therapy.We investigated the use of sacubitril/valsartan for the treatment of HF with reduced ejection fraction in real–world clinical practice in Italy. Methods An observational, retrospective,non–interventional cohort study based on electronic medical records from nine specialized hospital heart failure Centers in Italy was carried out on patients prescribed with sacubitril/valsartan. Results Overall,948 patients had a prescription of sacubitril/valsartan, 924 (mean age 64.5 years, 84.6% male) had 6 months of characterization and 12 months of follow–up. The initial dose was 24/26 mg for 548 (59.3%),49/51 mg for 333 (36.0%),97/103 mg for 43 (4.7).The final dose was available for 881 patients and it was:24/26 mg for 254 (28.8%),49/51 mg for 229 (26.0%),97/103 mgfor 398 (45.2).The time to maximal dose prescribed (weeks) was:for 97/103 mg 6.9 ± 6.2 weeks;for 49/51 mg 6.2 ± 6.7 weeks.Blood pressure and hypotension in 65% of the patients, and worsening of chronic kidney disease in 10.6% were the main reasons for not reaching target dose; fifty percent had a change in sacubitril/valsartan dose during follow–up and 70.2% patients were persistent with treatment during the last three months of follow–up, with a sensitivity analysis (persistence during the last four months of follow–up) showing 72.0% persistence. Adherence data, available for 387 patients, showed fully adherence for 53%.Discontinuation (102/387 patients) was mainly due to hypotension and occurred after a mean time of 34.3 ± 28.7 weeks. During follow–up, of the 606 patients with available data, 434 patients (71.6%) had an HF add–on drug or drugs concomitant to sacubitril/valsartan. Although not significantly (p=0.405), HF–related hospitalization during follow–up was higher in not persistent patients (23.9%) versus persistent (19%) to sacubitril/valsartan treatment.Pharmacoutilization data at 1–year expressed as medication possession ratio (MPR) are shown in the Figure. Conclusions Real–world data of sacubitril/valsartan use in clinical practice in Italy show a rapid titration of to target dose, high therapeutic adherence allowing a good level of therapeutic management in line with ESC guidelines in patients with reduced ejection fraction.

Background Thrombocytopenia represents an important issue in patients undergoing Transcatheter aortic valve replacement (TAVR) due to severe aortic stenosis. We performed a systematic review and meta–analysis to establish the pooled prevalence and the in–hospital outcomes of Chronic thrombocytopenia (cTCP) in patients after TAVR. Methods PubMed and Scopus databases were systematically searched for articles, published in any language, from inception through September 15, 2022, reporting the prevalence of cTCP in patients who underwent TAVR and providing data on the hospital outcomes. The pooled prevalence and the outcomes were evaluated pooling the adjusted odds ratio (OR) with the related 95% confidence interval (CI) using a random– effect models. Statistical heterogeneity between groups was measured using the Higgins I2 statistic Results Overall, 1,402,431 patients (mean age 87.2 years, 45.1% females) where hospitalized for TAVR. Among them, cTCP was observed in 7.0% of cases (95% CI: 1.7–24.5%, p Conclusions cTCP is present in about 7% of patients underoing TAVR and was results associated with an increased risk of vascular complications and cardiac tamponade during the periprocedural period.

Introduction In Europe, approximately 29% of the population aged between 15 and 64 have used illicit drugs. Italy is at the top of this ranking. Description 45–year–old female, no previous cardiology events. She enters the Emergency Department for typical chest pain following alcohol and cocaine abuse. EKG (see figure 1) detects sinus tachycardia and mild non–specific changes in ventricular repolarization. Blood tests reveal an increase in Troponin T levels (305 ng/L, NV < 14 ng/L, then decreased with subsequent measurements) and D–dimer (902 mg/mL, NV < 500 mg/mL). Echocardiography reveals a non–dilated right ventricle with severe systolic dysfunction (TAPSE 11 mm). No signs of pulmonary hypertension but a dilated and hypocollapsing inferior vena cava is noted. Abnormal motion of the interventricular septum with systolic d–shape is present (see figure 2). Left ventricle appears normal. Pulmonary angio–Tc was negative for embolic phenomena and coronary angiography detects no lesions on coronary arteries. At discharge, right ventricular systolic dysfunction and septal d–shape were completely regressed (see Figure 3). Discussion Cocaine is a strong systemic adrenergic agonist, which can cause vasospasm of small arterioles of the cardiac microcirculation with possible formation of intracoronary thrombi. Peculiarity of this case is the selective and reversible involvement of the right ventricle, an extremely rare presentation as evidenced by the almost absence of scientific literature on the subject (there is only a similar case report published on the American Journal of Emergency Medicine in 2015). Reversible damage from vasospasm and/or intracoronary thrombosis localized to the marginal branch of the right coronary artery, induced by cocaine use, is conceivable. D–shape of the interventricular septum associated with right ventricular dilatation is likely caused by acute right ventricular failure causing volume overload in the right sections. Take home message Drugs abuse is a widespread problem among the population. Cocaine intake is associated with important adverse cardiovascular effects. A rare presentation can be isolated right ventricular ischemia associated with acute right heart failure.

Introduction This study aims to assess prevalence and prognostic implications of pre-existing peripheral artery disease (PAD) in patients infected by the SARS-CoV-2 by means of a systematic review and meta-analysis. Material and methods We searched MEDLINE and Scopus to locate all the articles published up to 10 December 2021, reporting data on pre-existing PAD among COVID-19 survivors (S) and non survivors (NS). The pooled prevalence of pre-existing PAD in COVID-19 patients was calculated using a random effects model and presenting the related 95% confidence interval (CI), while the mortality risk was estimated using the Mantel–Haenszel random effects models with odds ratio (OR) and related 95% CI. Statistical heterogeneity was measured using the Higgins I2 statistic. Results Eight investigations, enrolling 13,776 COVID-19 patients (mean age: 67.1 years, 3.863 males), met the inclusion criteria and were included in the final analysis. The pooled prevalence of pre-existing PAD was 5.7% of cases (95% CI: 3.8–8.4%, p < 0.0001), with high heterogeneity (I2 = 84.5%), which was directly correlated with age ( p < 0.0001), previous hypertension ( p = 0.003), and dyslipidaemia ( p = 0.02) as demonstrated by the meta-regression. Moreover, pre-existing PAD was significantly associated with higher risk of short-term death in patients with SARS-CoV-2 infection (OR: 2.78, 95% CI: 2.37–3.27, p < 0.0001 I2 = 0%); the sensitivity analysis confirmed yielded results. Conclusions Pre-existing PAD represents a comorbidity in about 1 out of 6 COVID-19 patients, but it is associated with a twofold higher risk of short-term mortality.

Current guidelines on the management of dyslipidemias of the European Society of Cardiology/European Atherosclerosis Society recommend reducing low-density lipoprotein cholesterol (LDL-C) in patients after an acute coronary syndrome (ACS) by ≥50% compared to baseline values with a LDL-C level below 1.4 mmol/l (55 mg/dl) (class I recommendation, level of evidence A). However, in the real world, a low proportion of patients is treated according to the recommended lipid-lowering therapies and, as a consequence, very few people reach these targets. We analyzed seven recent studies reporting data on lipid control in 36 354 patients who were at very high risk because of a previous ACS in Europe. Overall, only 12.1% (95% confidence interval 9.8-13.5) of the patients achieved the recommended LDL-C levels, highlighting the gap between guidelines and current clinical practice. Indeed, the so-called stepwise strategy, although effective from a theoretical point of view, seems hardly applicable in the real world, underlying the need for new therapeutic strategies and algorithms. Based on these observations, a protocol has been proposed for the appropriate management of LDL-C levels in post-ACS patients both in terms of therapeutic choice and timing of treatment use.

Current guidelines on the management of acute pulmonary embolism (PE) of the European Society of Cardiology recommend the administration of systemic thrombolysis in hemodynamically unstable patients (defined as high risk - class I, level of evidence A). However, in the real world, systemic thrombolysis remains underused in hemodynamically unstable PE patients. We systematically reviewed and analyzed all studies published from 2008 to 2022 that evaluated the optimal therapeutic window for systemic thrombolysis in high-risk PE patients, also reporting potential thrombolysis-related adverse events. We identified only two studies enrolling 532 patients (mean age 65.5 years, 251 male). These studies suggested that early administration of systemic thrombolysis was associated with reduced short-term mortality and lower rates of major bleeding events and subsequent clinical deterioration. The identification of a less wide therapeutic window for the administration of systemic thrombolysis may improve the short-term mortality of high-risk PE patients and reduce the incidence of thrombolysis-related adverse events encouraging the use of systemic fibrinolysis, where appropriate.

Patients recovered from COVID-19 have an increased incidence of cardiovascular disease and heart structural changes. The aim of the present manuscript is to assess the risk of incident heart failure (HF) after COVID-19 infection. Data were obtained searching MEDLINE and Scopus for all studies published at any time up to September 1, 2022 reporting the risk of incident HF in COVID-19 recovered patients. The cumulative post-COVID-19 incidence and risk of incident HF were pooled using a random effects model and presented with the corresponding 95% confidence interval (CI). Statistical heterogeneity was measured using the Higgins I

Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disease characterized by high plasma levels of low-density lipoprotein cholesterol (LDL-C) and massive risk of premature atheromasia and cardiovascular events. HoFH is caused by mutations in several genes, such as LDLR, APOB, PCSK9 and LDLRAP1. If untreated, the average age of death is 18 years old, but fatalities within the first 5 years of age have been recorded. Therefore, early diagnosis and treatment are crucial, in order to prevent and/or delay the cardiovascular complications of LDL-C exposure. Because HoFH is a rare disorder, it is not frequently encountered in daily clinical practice at the primary/secondary unspecialized cardiological centers. Then the availability of practical indications helping to identify HoFH patients or to arise a suspect of HoFH is particularly strategic to promptly start the appropriate lipid-lowering therapy. For such a purpose, a group of Italian experts suggests three useful algorithms to identify cases requiring accurate and specialized clinical evaluation as potential HoFH patients. These cases with suspected HoFH should be addressed to specialized centres for the optimal management of these patients.