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Background The Orsiro cobalt-chromium stent platform (Biotronik, Bulach, Switzerland) is one of the first devices in the era of ultrathin struts. However, data regarding the efficacy of Orsiro stent in patients with challenging anatomical conditions obtained from daily clinical practice are scant. Methods We retrospectively reviewed the long-term outcomes, defined as target lesion revascularization (TLR), target vessel revascularization (TVR), stent thrombosis (ST) and cardiovascular (CV) mortality over a six years period, in 1161 consecutive patients (mean age 64.3 ± 11.2 years old, 681 males) treated with 2327 Orsiro stents in our institution who presented with challenging anatomic/angiographic features. Results The mean number of implanted stents was 1.7 ± 2.1 whereas the mean stent diameter and length were 3.6 ± 1.1 and 32.7 ± 15.6 mm, respectively. Mean follow-up duration was 35.6 ± 17 months (range 1–77 months); 923 patients (79.5%) reached the 3-year follow-up. The global rates of TLR, TVR, ST and CV mortality were 0.1%, 1.37%, 0.002%, and 1.9%, respectively with scarce statistically significant differences in multivessel disease, severe calcification, and lesion length > 41 mm. Multivariate regression analysis revealed that age, stent dislodgement , early stent thrombosis (p = 0.001) and lesion length ≥ 41 mm (p = 0.001) were independent predictors of TVR. Similarly, the occurrence of TLR was independently predicted by age, severe calcification, use of IVUS and Rotablator (p = 0.002), early stent thrombosis, LM bifurcation and length ≥ 41 mm (p = 0.001). Conclusions The Orsiro stent confirmed a very high efficacy profile in all anatomical scenarios with very low rates of clinically driven TLR and TVR, CV mortality and ST at 3-years.

The discrimination between heart failure with preserved ejection fraction (HFpEF) and pulmonary arterial hypertension (PAH) requires a multiparametric approach, eventually culminating in right heart catheterization. Solving this differential diagnosis is crucial in order to properly tailor patient treatment, with relevant clinical implications. However, it is not uncommon to be confronted with patients at intermediate or high risk of having HFpEF whose pulmonary artery wedge pressure (PAWP) falls in a grey zone in between 13 and 15 mmHg. In these patients, a provocative test in the cath lab might be considered, with the aim of unmasking an occult form of HFpEF with non-overt hemodynamic manifestations, or to definitely exclude it.Saline load and physical exercise can be viewed as the most suitable provocative tests seeking to help for the differential diagnosis in this specific patient population. Although normative values for the hemodynamic response to these maneuvers have been proposed, supporting evidence is still preliminary or equivocal. In this paper, we will review the pathophysiological background for the application of provocative tests in the cath lab, as well as methodological and interpretative aspects to discriminate between HFpEF and PAH, highlighting strengths and weaknesses of fluid load and physical exercise.

Incidence and prognostic value of new-onset atrial fibrillation after single versus double stent strategy in bifurcation left main disease has not been yet investigated.We retrospectively analyzed the procedural and medical data of patients referred to our center for complex left main bifurcation disease, treated using crossover provisional stenting, T or T-and-Protrusion, Culotte, and Nano-inverted-T techniques between January 1, 2008, and May 1, 2018. Multivariate Cox-regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of new-onset atrial fibrillation during the follow-up period.Five hundred two patients (316 males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. At a mean follow-up of 37.1 ± 10.8 months (range: 22.1- 39.3 months); Target lesion failure rate was 10.1%. Stent thrombosis and cardiovascular mor- tality were observed in 1.2% and 3.6% in of cases, respectively. New-onset atrial fibrillation occurred in 23 out of 502 patients (4.6%). Patients with new-onset atrial fibrillation resulted more frequently female, older, obese, and diabetic and more frequently experienced target lesion failure and cardiovascular death. New-onset atrial fibrillation-free survival favored single versus double stent technique and among double stent techniques nano-inverted-T tech- niques compared to the others. Single stent strategy had a lower risk of new-onset atrial fibril- lation compared to double stent technique on multivariate analysis (Hazard Ratio (HR): 1.14, 95% CI: 1.10-1.19, P.001 vs. HR: 1.28, 95% CI: 1.23-1.32, P.0001).New-onset atrial fibrillation in distal left main bifurcation disease treated with per- cutaneous coronary intervention had a low incidence but resulted more frequently after double than after single stenting technique and was associated with worse outcomes.

Modern ultrathin struts drug eluting stents (DES), due to their constructive characteristics, might be more prone to stent dislodgment than the old thick DES. Our study is aimed to retrospectively analyze and compare the incidence and outcomes of stents dislodgment in thick (TSS) and ultrathin strut stents (USS).We retrospectively analyzed the procedural and medical data of 8,564 consecutive patients (mean age 64.3 ± 11.2 years old, 4442 males) who underwent percutaneous coronary intervention with DES implantation in our Institution between 1st January 2005 to 1st January 2020. Overall, 25,692 (mean of 3.2 stent for patients) have been implanted over the study period (10648 TSS and 15044 and USS, respectively). Stent dislodgment globally occurred in 0.56% of the implanted stents (0.28% vs 0.78%, p0.001 for TTS and USS, respectively). Coronary artery calcifications, ostial lesion, coronary artery tortuosity, and a lesion length25 mm were independent predictors of type I and II USS dislodgments. At 12 months follow up, the rate of target lesion failure was higher in the TTS group (30.7 vs 12.7 %, p0.001). Stent dislodgement is unusual in the modern era but is more frequent using USS than TTS DES.

We sought to examine the impact of gender differences in clinical outcomes at 3 years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Crossover provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT) techniques between January 1st, 2008 and May 1st 2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Five hundred and sixty-seven patients (251 females, mean age 70.0 ± 10 years, mean Syntax score 31.6 ± 6.3) were evaluated. Crossover, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98 (17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri-procedural items among gender. At a mean follow-up of 37.1 ± 10.8 months (range 22.1-39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3-year follow-up either using a single or double stent technique.

Objective: The soluble guanylate cyclase stimulator riociguat is approved for the treatment of adult patients with pulmonary arterial hypertension (PAH) and inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH) following Phase 3 randomized trials. The EXPosurE Registry RiociguaT in patients with pulmonary hypertension (EXPERT) study was designed to monitor the long-term safety of riociguat in clinical practice. Methods: EXPERT was an international, multicenter, prospective, uncontrolled, non-interventional cohort study of patients treated with riociguat. Patients were followed for at least 1 year and up to 4 years from enrollment or until 30 days after stopping riociguat treatment. Primary safety outcomes were adverse events (AEs) and serious adverse events (SAEs) coded using Medical Dictionary for Regulatory Activities preferred terms and System Organ Classes version 21.0, collected during routine clinic visits and collated via case report forms. Results: In total, 956 patients with CTEPH were included in the analysis. The most common AEs in these patients were peripheral edema/edema (11.7%), dizziness (7.5%), right ventricular (RV)/cardiac failure (7.7%), and pneumonia (5.0%). The most common SAEs were RV/cardiac failure (7.4%), pneumonia (4.1%), dyspnea (3.6%), and syncope (2.5%). Exposure-adjusted rates of hemoptysis/pulmonary hemorrhage and hypotension were low and comparable to those in the long-term extension study of riociguat (Chronic Thromboembolic Pulmonary Hypertension Soluble Guanylate Cyclase–Stimulator Trial [CHEST-2]). Conclusion: Data from EXPERT show that in patients with CTEPH, the safety of riociguat in routine practice was consistent with the known safety profile of the drug, and no new safety concerns were identified. © 2020 The Authors Eli Lilly and Company; Pfizer; Bayer; GlaxoSmithKline; Merck; Actelion Pharmaceuticals; Meso Scale Diagnostics; United Therapeutics Corporation; Novartis Pharma; Merck Sharp and Dohme; GlaxoSmithKline Australia; Deutsche Forschungsgemeinschaft; Grupo Ferrer Internacional, S.A The EXPERT registry was funded by Bayer AG (Berlin, Germany) and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co. Inc., Kenilworth, NJ, USA. The authors acknowledge the database administration by Torsten Tille, Dresden, and the project administration of Mrs Romy Hoppenz and Mrs Linda Kottke at GWT-TUD GmbH, Dresden. Medical writing services provided by Richard Murphy PhD of Adelphi Communications Ltd, Macclesfield, UK were funded by Bayer AG in accordance with Good Publication Practice (GPP3) guidelines. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Prof Marius M. Hoeper reports personal fees from Bayer AG, during the conduct of the study; personal fees from Actelion, personal fees from Acceleron, personal fees from MSD, personal fees from Jansen, personal fees from Pfizer, outside the submitted work. Dr Hans Klose reports speaker and consultancy fees from Actelion, Bayer AG, GSK, Novartis, Pfizer, and United Therapeutics and research support from Actelion, Bayer AG, GSK, Pfizer, and MSD. Dr Michael Halank reports personal fees and non-financial support from Actelion, AstraZeneca, Bayer AG, Berlin-Chemie, GSK, OMT, MSD, and Novartis. Dr George Giannakoulas reports speaker and consultancy fees from Actelion, Bayer, ELPEN Pharmaceuticals, GSK, Pfizer, Lilly, and United Therapeutics, and research support from GSK, ELPEN Pharmaceuticals, and Galenica. Dr Henning Gall has received honoraria and/or other support from Actelion, AstraZeneca, Bayer, BMS, GSK, Janssen-Cilag, Lilly, MSD, Novartis, OMT, Pfizer, and United Therapeutics. Dr Pavel Jansa reports consultancy and speaker fees from MSD, AOP Orphan, and Actelion. Prof Ekkehard Grünig reports research grants and speaker honoraria/consultancy fees from Actelion and Bayer/MSD, research grants from GSK, United Therapeutics, Bellerophon, OMT GmbH, Pfizer, Reata, and Novartis, and speaker honoraria from Bial, Medscape, and OrPha Swiss GmbH. Prof David Pittrow reports personal fees from Actelion, Bayer AG, Aspen, Boehringer Ingelheim, Sanofi, Biogen, Shire, and MSD outside the submitted work. Silvia Ulrich reports research grants and personal fees from Actelion, Bayer, MSD, and Orpha Swiss. Tobias J. Lange has received personal fees from Actelion, MSD, Pfizer, and OMT orphan. Dr Iraklis Tsangaris reports speaker and consultancy fees from Actelion, Bayer AG, ELPEN, GSK, MSD, Pfizer, and United Therapeutics. Stephan Rosenkranz reports remunerations for lectures and/or consultancy from Abbott, Actelion, Arena, Bayer, Ferrer, GSK, MSD, Novartis, Pfizer, and United Therapeutics; and research support to his institution from Actelion, Bayer, Novartis, Pfizer, and United Therapeutics. Repke J. Snijder reports grants from Pfizer and Actelion Pharmaceuticals. Prof Iveta Šimková reports consultancy and speaker fees from MSD, AOP Orphan, and Actelion. Dr Marc Humbert reports grants and personal fees from Bayer and GSK, and personal fees from Actelion, Merck, and United Therapeutics. Marion Delcroix has received investigator, speaker, consultant, and steering committee member fees from Actelion, Bayer AG, Bellerophon, Eli Lilly, GlaxoSmithKline, MSD, Pfizer, and Reata, and research grants from Actelion. Joan A. Barberà reports receipt of honoraria for consultation or speaker fees from Actelion and Merck; and research support through his institution from Actelion, Merck, GlaxoSmithKline, and Ferrer. Joanna Pepke-Zaba reports research grants and speaker honoraria/consultancy fees from Actelion, Bayer/MSD, and GSK. Jean-Luc Vachiéry reports ongoing consultancies to Actelion, Sonnivie, Arena Pharma, Bial Portela, and Respira Therapeutics, past consultancies to AstraZeneca, BayerShering, CardioMEMS, GlaxoSmithKline, Pfizer, Merck, and United Therapeutics, and current membership of an advisory board or similar group for Actelion and GlaxoSmithKline. Jean-Luc Vachiéry's institution receives funding from Actelion Pharmaceuticals for performing clinical studies. Regina Steringer-Mascherbauer, Jens Klotsche, and Miguel-Angel Gomez Sanchez have no conflicts of interest relevant to the EXPERT study. Hossein-Ardeschir Ghofrani reports personal fees for advisory board work, and payment for lectures including service on speaker bureaus, from Actelion, Bayer, GSK, Novartis, and Pfizer; consultancy fees from Actelion, Bayer, Bellerophon Pulse Technologies, GSK, MSD, Novartis, and Pfizer; and grants from Deutsche Forschungsgemeinschaft (DFG). Pilar Escribano Subias reports personal fees from Actelion, Bayer AG, GlaxoSmithKline, and Merck Sharp & Dohme, and grants from Actelion, Bayer AG, GlaxoSmithKline, and Ferrer, outside the submitted work. Gérald Simonneau reports personal fees and non-financial support from Actelion, personal fees and non-financial support from Bayer, personal fees and non-financial support from MSD, outside the submitted work. Douglas S. Helmersen reports industry-sponsored research with Bayer AG, United Therapeutics, and Gilead Sciences, Inc., and advisory board/speaker fees from Bayer AG and Actelion. David Langleben reports honoraria, consultation fees, research support, and/or travel expenses from Actelion, Arena, Bayer AG, Northern Therapeutics, PhaseBio, Acceleron, Janssen, and United Therapeutics. Anco Boonstra reports consultancy fees from Pfizer BV and hospitality from Teva Nederland. Lisa M. Mielniczuk reports speaker fees and honoraria from Bayer AG, and speaker fees, consultancy fees, and travel fees from Actelion. Evgenia Williams and Christian Meier are employees of Bayer AG.

Background His bundle pacing (HBP) can be affected by high thresholds and low sensing. Thus, in selected patients including a back-up lead is advisable. Objective Single-centre retrospective analysis of a large HBP experience, focusing on the back-up lead utilization over the years. Methods 677 pts (76±8 years; 433 males) were implanted with HBP from 2004 to 2019 July. The pts received S-HBP (67%) or NS-HBP by the 3830 lead. The pacing indications were AV block 54%, sinus node disease 17%, slow atrial fibrillation 23%, heart failure 6%. Ischemic cardiopathy was found in 26%; hypertension in 83%, diabetes in28% pts. Baseline QRS duration was 123±32 ms and EF 56±12%. Results 266 (39%) pts received the back-up lead. In sinus rhythm we implanted 3-chamber PM (His lead:LV port; VV delay 80 ms: His pulses and apical pacing during the refractory period). 30 pts (11%) received a particular type of 3-chamber PM which provides back-up pacing only if His capture fails, thus saving energy. In atrial fibrillation 2-chamber PM was implanted (His lead: atrial port, DVI). We recorded a significant decrease of back-up lead use over the years, strictly related to operators/centre experience (>70% during the first years, nearly 10% during the last year). The C315 fixed curve sheath, strongly contributed to the rapid reduction of back-up lead use thanks to better lead fixation and stability. Conclusion The back-up lead utilization is progressively decreasing. It is strictly related to the operator/centre experience. The presence of the back-up lead could strengthen the Hisian pacing reliability, potentially impacting pacing indication even in advanced conduction disturbances and saving device longevity. Funding Acknowledgement Type of funding source: None

Background The standard technique to His Bundle Pacing (HBP) based on a fluoroscopic approach might be challenging and fluoro consuming. The electrical signals could lead to a precise and rapid lead implant, thus reducing the fluoroscopy time (FT) and X-ray dose. Objective To evaluate the feasibility, efficacy and safety of the electrogram-guided technique to obtain His Bundle pacing (HBP) with minimal or no fluoroscopy use. Methods Between October and December 2018, 41 consecutive patients with indication for pacing underwent HBP with the electrogram-guided approach. Results Successful HBP was obtained in 39/41 (95%) pts, which is the study population (mean age 78±10 years). S-HBP and NS-HBP were achieved in 23 (59%) and 16 (41%) pts, respectively. Final HBP lead position was achieved in 31/39 (79.4%) pts with zero fluoroscopy, only guided by the electrical signals. In the remaining 8 pts a minimal dose of fluoro (mean 8 sec) has been required to locate the His. Fluoroscopy has been routinely used to remove the sheath and to ensure the slack. The atrial lead has been implanted in a standard fashion. No difference was observed in the FT for HBP lead placement in patients with S-HBP and NS-HBP (mean 8.1±25 sec vs 7.5±20 sec, p=0.8; median value 0 sec vs 0 sec). Moreover, no significant differences were observed in the FT needed for the entire procedure, total Dose Area Product (DAP) and total procedural time among both S-HBP and NS-HBP. The His lead dislodgement occurred in 1 (2.6%) patient one day after the procedure. Conclusion HBP could be performed safely and efficiently using the electrograms, with minimal or no fluoroscopy. Fluoroscopy was required during sheath removal and atrial lead placement. Funding Acknowledgement Type of funding source: None

Pulmonary embolism represents the third leading cause of cardiovascular mortality in developed countries. It requires, in most cases, hospital treatment and always a structured follow-up program. Therefore, at the time of discharge, the communication and the transfer of information from the specialist to the general practitioner, through the discharge letter, represents a crucial opportunity. The aim is to improve the quality of the transmitted content, including information regarding initial assessment, procedures during hospitalization, residual risks, discharge treatments, therapeutic goals and follow-up plan in accordance with the latest guidelines. The discharge letter after hospitalization for pulmonary embolism must include personalized information, especially regarding the anticoagulant regimen in the specific onset setting. Finally, the follow-up program should be accurately described. A standardized discharge letter template, accompanied by some final notes addressed to the general practitioner and patient, could represent a useful tool to improve the quality and time of transmission of information between health professionals after pulmonary embolism.

PurposeIn order to increase the responder rate to CRT, stimulation of the left ventricular (LV) from multiple sites has been suggested as a promising alternative to standard biventricular pacing (BIV). The aim of the study was to compare, in a group of candidates for CRT, the effects of different pacing configurationsBIV, triple ventricular (TRIV) by means of two LV leads, multipoint (MPP), and multipoint plus a second LV lead (MPP + TRIV) pacingon both hemodynamics and QRS duration.MethodsFifteen patients (13 male) with permanent AF (mean age 767years; left ventricular ejection fraction 337%; 7 with ischemic cardiomyopathy; mean QRS duration 178 +/- 25ms) were selected as candidates for CRT. Two LV leads were positioned in two different branches of the coronary sinus. Acute hemodynamic response was evaluated by means of a RADI pressure wire as the variation in LVdp/dtmax.Resultsp id="Par3"Per patient, 2.7 +/- 0.7 veins and 5.2 +/- 1.9 pacing sites were evaluated. From baseline values of 998 +/- 186mmHg/s, BIV, TRIV, MPP, and MPP-TRIV pacing increased LVdp/dtmax to 1200 +/- 281mmHg/s, 1226 +/- 284mmHg/s, 1274 +/- 303mmHg, and 1289 +/- 298mmHg, respectively (p

Available studies have already identified age, heart rate (HR) and systolic blood pressure (SBP) as strong predictors of early mortality in acute pulmonary embolism (PE).One-hundred-seventy patients, with acute PE confirmed on computed tomography angiography (CTA) were enrolled. Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) was calculated using the formula [heart rate (HR) x (AGE/102)/ systolic blood pressure (SBP)]. Study outcomes were 30-day mortality and/or clinical deterioration.Receiver operating characteristics (ROC) curve revealed that a TRI ≥45 was highly specific for both outcomes (AUC 0.91, 95% CI 0.83-0.98, p0.0001) with a positive predictive value (PPV) and negative predictive value (NPV) of 8.3 and 96% for 30-day mortality while PPV and NPV for 30-day mortality and/or clinical deterioration were 21.1 and 98.2%, respectively. Multivariate regression analysis showed that TRI ≥45 was an independent predictor of 30-day mortality (O.R. 22.24, 95% CI 2.54-194.10, p=0.005) independently from positive cTnI and RVD (O.R. 9.57, 95% CI 1.88-48.78, p=0.007; OR 24.99, 95% CI 2.84-219.48, p=0.004). Similarly, 30-day mortality and/or clinical deterioration was predicted by TRI ≥45 (O.R. 11.57, 95% CI 2.36-56.63, p=0.003) and thrombolysis (3.83, 95% CI 1.04-14.09, p=0.043), independently from age, RVD and positive cTnI. Cox regression analysis confirmed the role of TRI as independent predictor for both outcomes. Mantel-Cox analysis showed that after 30-day follow-up there was a statistically significant difference in the distribution of survival between patients with and without TRI ≥45 [log rank (Mantel-Cox) chi-square 17.04, p0.0001].Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) predicted both 30-days mortality (all-causes) and/or clinical deterioration in patients with acute PE.

Bioresorbable vascular scaffolds (BVSs) represent the newest tool in the treatment of coronary artery disease (CAD). Conversely to the previous metal stents and thanks to the polylactate-based backbone, BVSs could be visualized by magnetic resonance imaging (MRI) without artifacts. These properties allow a potential non-invasive assessment of coronary artery patency after percutaneous coronary intervention (PCI), avoiding cardiac catheterization included iodine contrast and radiation exposure, and potentially more sophisticated imaging tool as the optical coherence tomography (OCT). We reviewed the available medical literature on the coronary MRI evaluation of BVS after PCI, also discussing its potential diagnostic role in the long-term follow-up of these patients.

Acute pulmonary embolism (PE) is the third cause of cardiovascular (CV) mortality. We evaluated a new risk index, named Age-Mean Arterial Pressure Index (AMAPI), to predict 30-day CV mortality in patients with acute PE. Data of 209 patients (44.0% male and 56.0% female, mean age 70.58 ± 14.14 years) with confirmed acute PE were retrospectively analysed. AMAPI was calculated as the ratio between age and mean arterial pressure (MAP), which was defined as [systolic blood pressure + (2 × diastolic blood pressure)]/3. To test AMAPI accuracy, a comparison with shock index (SI) and simplified pulmonary embolism severity index (sPESI) was performed. Patients were divided in two groups according their hemodynamic stability, or not, at admission. 30-day mortality rate, in all cases for CV events, was 10.5% (n = 22). Hemodynamically unstable patients had a higher AMAPI compare to those without hypotension at admission (1.28 ± 0.39 vs 0.78 ± 0.27, p

Acute pulmonary embolism (PE) still represents the third leading cause of cardiovascular mortality in developed countries. In this regard, the last European guidelines offer important suggestions on the management of the disease in daily clinical practice but, at the same time, they do not take into account the feasibility of the recommendations according to the local available resources, including the presence or lack of adequate healthcare facilities (cardiological intensive care unit, cath-lab) or specialists (cardiologist available on a 24 h basis, interventional cardiologist, cardiac surgeon, etc.) all over the day. In the real clinical practice, those recommendations should be adapted to the local available resources. The aim of this document is to provide some suggestions regarding the diagnosis and treatment of acute PE, according to the possible available resources in different local circumstances.

Introduction His bundle pacing (HBP) allows physiological ventricular activation and prevents the electrical and mechanical desynchronization generally induced by myocardial stimulation, which can increase the risk of atrial fibrillation and heart failure. On the other hand, reliable HBP capture often requires higher energy than conventional myocardial pacing. This reduces the expected life of the stimulator and might limit the diffusion of HBP in the clinical practice. Purpose Decreasing HBP current drain by careful management of stimulation safety margin and pulse duration. Methods In 28 patients undergoing DDD pacing with HBP, a third lead was implanted in RV apex to provide back-up pacing on demand. HBP and apical leads were connected, respectively, to the V1 and V2 channels of a 3-chamber stimulator. When HBP was effective, apical sensing occurred within the VV delay and prevented V2 stimulation. In contrast, in case of HBP failure, V2 sensing was missing and apical back-up pacing was promptly delivered at the end of the VV delay. The availability of a back-up pulse on demand allowed reducing the HBP safety margin with no risk. Furthermore, the individual HBP strength-duration curve was derived in the aim of optimizing the Hisian pulse parameters, which are the major determinants of the device current drain. Results Correct back-up inhibition by successful HBP and stimulation in the event of capture loss was achieved in all the patients. The latency from Hisian pacing to apical sensing averaged 96±14 ms. According to the pacemaker counters, no back-up pulse was delivered in daily life in 59% of patients. In the remaining, the prevalence of back-up stimulation never exceeded 15% of paced ventricular cycles. The high HBP threshold was essentially due to an increased rheobase (1.2±0.6 V), while the chronaxie ranged from 0.30 to 0.53 ms in 71% of patients (median 0.44 ms), exceeding 0.6 ms only in 29% of the cases. An average current saving of 5.4±3.0 μA was obtained at the expense of a mild reduction in HBP safety margin (from 1.6±0.2 to 1.4±0.1 times). HBP and apical back-up Conclusions Back-up stimulation on demand is a reliable option to decrease HBP current drain and prolong the stimulator service life with full safety. In most of the cases, significant saving can be achieved by pulse shortening, as the chronaxie time is in the same range as with myocardial stimulation and longer pulses are not required. A pulse duration exceeding 0.6 ms is indicated in less than 1/3 of the implants.

Estimating left ventricular electrical delay (Q-LV) from a 12-lead ECG may be important in evaluating cardiac resynchronization therapy (CRT).The purpose of this study was to assess the impact of Q-LV interval on ECG configuration.One hundred ninety-two consecutive patients undergoing CRT implantation were divided electrocardiographically into 3 groups: left bundle branch block (LBBB), right bundle branch block (RBBB), and nonspecific intraventricular conduction delay (IVCD). The IVCD group was further subdivided into 81 patients with left (L)-IVCD and 15 patients with right (R)-IVCD (resembling RBBB, but without S wave in leads I and aVL). The Q-LV interval in the different groups and the relationship between ECG parameters and the maximum Q-LV interval were analyzed.Patients with LBBB presented a long Q-LV interval (147.7 ± 14.6 ms, all exceeding cutoff value of 110 ms), whereas RBBB patients presented a very short Q-LV interval (75.2 ± 16.3 ms, all110 ms). Patients with an IVCD displayed a wide range of Q-LV intervals. In L-IVCD, mid-QRS notching/slurring showed the strongest correlation with a longer Q-LV interval, followed, in decreasing order, by QRS duration150 ms and intrinsicoid deflection60 ms. Isolated mid-QRS notching/slurring predicted Q-LV interval110 ms in 68% of patients. The R-IVCD group presented an unexpectedly longer Q-LV interval (127.0 ± 12.5 ms; 13/15 patients had Q-LV110 ms).Patients with LBBB have a very prolonged Q-LV interval. Mid-QRS notching in lateral leads strongly predicts a longer Q-LV interval in L-IVCD patients. Patients with R-IVCD constitute a subgroup of patients with a long Q-LV interval.

In spite of the evolution of diagnostic and imaging tools, infective endocarditis still remains a challenging diagnostic problem. We report the case of a 77-year-old heart failure patient with a very large mitral vegetative lesion but without fever or any other clinical or microbiological 'endocarditis criteria' except the echocardiographic findings. In this scenario, the second more likely differential diagnosis was neoformation of the mitral valve but despite an exhaustive preoperative diagnostic cardiac imaging, this hypothesis could not be excluded before surgical excision and microbiological examination of the surgical specimen.

Objective The usefulness of stress myocardial perfusion scintigraphy (MPS) for cardiovascular (CV) risk stratification in patients at moderate and high CV risk remains controversial. We tested the hypothesis that different clinical risk profiles influence the test and the likelihood of obtaining a positive coronary angiography (CA) in the following 12 months. Methods We assessed the prognostic value of MPS in 230 patients classified according to the European Society of Cardiology guidelines. Results Patients at high and very-high CV risk had a higher prevalence of positive MPS (25.5 vs. 36.7%, P=0.014 and 9.8 vs. 19.5%, P=0.011, respectively), whereas patients at moderate risk had a higher prevalence of negative MPS (45.1 vs. 38.3, P=NS). Multivariate regression analysis showed that positive MPS was an independent predictor of 12-month positive CA only in patients at high CV risk [odds ratio (OR) 8.03, 95% confidence interval (CI) 1.53-42.03, P=0.014] independent of age>60 and coexistence of obesity and previous percutaneous coronary intervention (OR 3.78, 95% CI 1.18-12.78, P=0.032; OR 1.83, 95% CI 1.03-3.26, P=0.039). The C-statistic showed a good discriminatory power of positive MPS in predicting 12-month positive CA (0.68, 95% CI 0.55-0.80, P=0.015). Mantel-Cox analysis showed that after 12 months of follow-up, in patients at high risk, there was a statistically significant difference in the distribution of patients with positive than those without negative CA (log rank P=0.04). Conclusion CV risk stratification on the basis of MPS is useful only in patients at high and very-high CV risk. In these groups, MPS can aid stratification for the risk of CV events.

Acute myocardial infarction, stroke, peripheral arterial disease and pulmonary embolism share thrombosis as a common mechanism. Some well-known risk factors for arterial thromboembolism are recognized as "weak risk factors" of venous one, too. Arterial and venous thrombosis share also some pathophysiological mechanisms, including inflammation, endothelial damage, and hypercoagulability. It is likely, thus, that any disease related to arterial and venous thrombosis belong to the same "pan-vascular syndrome", that constitutes itself a chronic, recurrent inflammatory disease. According to the available data, there are elements for implementing an omni-comprehensive cardiovascular evaluation after an episode of venous thromboembolism, requiring the investigations, in addition to the known unrecognized prothrombotic conditions, also of indirect signs and risk factors for a possible arterial thromboembolic event. Large, prospective studies are needed to establish the more appropriate therapeutic strategies in this context.The aim of the present statement is to make aware all the physicians involved in the management of arterial and venous diseases and to provide some tools for evaluating the implications of related major risk factors. Thus, it could be possible to lay the foundation for a reduction of total cardiovascular risk, in terms of primary and secondary prevention of arterial and venous thromboembolism.

In clinical practice, acidotic patients with acute cardiogenic pulmonary edema (ACPE) are commonly considered more severe in comparison with nonacidotic patients, and data on the outcome of these patients treated with noninvasive pressure support ventilation (NIV) are lacking.The present investigation was aimed at assessing whether acidosis on admission (pH

Background Spontaneous coronary artery dissection is a rare non-atherosclerotic cause of acute coronary syndromes, often underdiagnosed based on standard coronary angiography. Moreover, features, presentation, and intravascular imaging of recurrent spontaneous dissections have not been assessed. Methods Patients with recurrent spontaneous coronary artery dissection, who were admitted to our catheterization laboratory over a 10-year period, were identified. Demographic, clinical, angiographic, and intravascular imaging data were reviewed and analyzed, comparing patients with a single event with those who had a recurrence. Results Over the study period, 31 (0.2%, mean age 48.1 ± 8.8 years, 24 females) of 10,954 patients who underwent coronary angiography experienced a single spontaneous coronary artery dissection, and 6 (0.05%, mean age 49.3 ± 10.1 years, 4 females) experienced recurrent spontaneous coronary artery dissection. No patient suffered more than 2 dissections. Arterial hypertension ( p = 0.004), a string sign measuring >15 mm on angiography, and hematoma on intravascular ultrasound imaging were more frequently observed in patients with recurrent spontaneous coronary artery dissection. Conclusions Hypertension, length of the string sign on angiography, and hematoma on intravascular ultrasound imaging might identify patients at higher risk of recurrent spontaneous coronary artery dissection despite a lifelong dual antiplatelet regimen.

The Bova score has shown usefulness in the identification of intermediate-high risk patients with acute pulmonary embolism (PE), but lacks prospective validation. The aim of this study was to prospectively validate the Bova score in different settings from the original derivation cohort.Consecutive, normotensive patients with acute PE recruited at 13 academic or general hospitals were stratified, using their baseline data, into the three Bova risk stages (I-III). The primary outcome was the 30-day composite of PE-related mortality, hemodynamic collapse and non-fatal PE recurrences in the three risk categories.In the study period, 639 patients were enrolled. The primary end point occurred in 45 patients (7.0%; 95% Confidence Intervals, 5.2%-9.3%). Risk stage correlated with the PE-related complication rate (stage I, 2.9%; stage II, 17%; stage III, 27%). Patients classified as stage III by the Bova score had a 6.5-fold increased risk for adverse outcomes (3.1-13.5, p 0.001) compared with stages I and II combined. Rescue thrombolysis increased from stage I to stage III (0.6%, 12% and 15% respectively). All-cause mortality (5.3%) did not substantially differ among the stages.The Bova score accurately stratifies normotensive patients with acute PE into stages of increasing risk of 30-day PE-related complications.

Aims Right ventricular apex (RVA) pacing has adverse effects on left atrial (LA) function and may contribute to atrial arrhythmias. The effects of Hisian area (HA) pacing on LA function are still lacking. The objective of this study is to assess the left ventricular (LV) electromechanical activation/relaxation, systolic (S), diastolic (D) phases, and their effects on LA function during pacing from HA and RVA. Methods and results Thirty-seven patients with normal cardiac function underwent permanent HA pacing. In all patients, a RVA backup lead was added. The patients first underwent 3 months of HA pacing, followed by 3 months of RVA pacing. After each 3-month period, we compared by echocardiography: S–D LV electromechanical delay (S–D EMD), S–D intra-LV dyssynchrony, LV S–D phases, and their function evaluated by myocardial performance index (MPI) and mitral annular tissue Doppler early diastolic velocity ( E ′), pulmonary arterial systolic pressure (PASP), and LA function (LA phasic volumes and their emptying fraction). Right ventricular apex compared with HA pacing increased S–D EMD ( P < 0.001) and intra-LV dyssynchrony ( P < 0.001). As a consequence, a significant longer LV isovolumetric contraction time ( P < 0.001) and LV isovolumetric relaxation time ( P = 0.05) were measured during RVA compared with HA pacing, whereas LV ejection time was shorter ( P = 0.033). Moreover, HA pacing resulted in significantly better MPI ( P = 0.039), higher value of E ′ ( P = 0.049), and lower PASP ( P < 0.001). Finally, RVA compared with HA pacing was associated to higher LA volumes pre-atrial contraction ( P = 0.001) and minimal volume ( P = 0.003) with reduction in passive emptying fraction ( P < 0.001) and total emptying fraction ( P = 0.005). Conclusion Hisian area compared with RVA pacing resulted in a more physiological LV electromechanical activation/relaxation and consequently better LA function.

We retrospectively assessed the experience of our tertiary care center on the use of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in 16 adult patients with refractory cardiac arrest. Cardiac arrest was due to acute coronary syndrome in 10 patients (62.5%), Takotsubo Syndrome in 1 patient (6.25%), dilated cardiomyopathy in 4 (25%) patients and massive pulmonary embolism in 1 patient (6.25%). The device was implanted in the catheterization laboratory in 14 patients (87.5%), in the operating room in 1 patient (6.25%) and in the emergency department in 1 patient (6.25%). During support, 7 patients were submitted to percutaneous coronary intervention, while coronary artery bypass grafting was performed in 1 patient, and cardiac surgery for repair of left ventricular wall rupture was performed in 1 patient. The device was successfully weaned in 6 patients (37.5%), among whom 2 patients died and 4 patients (25%) were discharged alive. In our institution 2/16 (12.5%) patients treated with VA-ECMO for refractory cardiac arrest survived to hospital discharge neurologically intact, and a good neurological function was observed in 3/16 (18.8%) at six-month follow-up.

Objective: Assess if acid-base evaluation by Stewart's approach had a clinical role in cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI). SETTING: There are three widely used approaches to investigate metabolic acidosis: base excess (BE), anion gap (AG) and the Stewart's approach or strong ion gap (SIG). Available studies suggest the usefulness of SIG in sepsis and trauma. No data are so far available in CS.Measurements and Results: We enrolled 63 consecutive patients with CS following STEMI submitted to Percutaneous Coronary Intervention (PCI). On admission, the APACHE II (Acute physiology and chronic health evaluation II) score and HOMA (Homeostasis model assessment) index were assessed together with glomerular filtration rate (eGFR), quantitative BE, AG, lactate values and 12 h lactate clearance. Non-survivors showed a higher incidence of PCI failure, higher APACHE II score, lower LVEF, lower eGFR, lower 12 h lactate clearance; a higher admission lactate and more negat...

No data are so far available on the impact of age and obesity in ST-elevation myocardial infarction (STEMI) submitted to percutaneous coronary intervention (PCI).We assessed the impact of age on the prognostic value of body mass index (BMI) in 1268 consecutive STEMI patients admitted to our Intensive Cardiac Care Unit (ICCU). BMI categories were as follows: 37 "lean" patients (37/1268, 2.9%), 403 "normal" patients (403/1268, 31.8%), 656 "overweight" patients (656/1268, 51.7%), 172 "obese" patients (172/1268, 13.6%). Among patients aged75 years, as BMI increased, the number of males and diabetic patients significantly increased (p0.001 and p = 0.004, respectively). Among STEMI patients aged ≥75 years, lean patients showed a higher in-ICCU mortality in respect to the other BMI categories but this did not reach statistical significance. BMI was an independent predictor of In-ICCU mortality in the whole population (lean vs. "normal": OR 3.47, 95%CI 1.08-11.14, p = 0.036) and it was associated with long term mortality only in patients75 years since lean and overweight patients showed lower survival rate (lean vs. "normal": HR 9.25, 95%CI 3.09-27.63, p0.001; overweight vs. "normal": OR 2.10; 95%CI 1.04-4.23, p = 0.039).In our series, underweight is associated with the highest mortality across all age subgroups, while only in patients75 years, overweight patients showed increased in-hospital mortality rate and a poorer long term survival rate. According to our data, the "so called obesity paradox" should be probably age-contextualized.

Purpose The relationships between air pollutant concentration levels and admission for primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) have never been assessed. Methods We retrospectively reviewed 4 consecutive years of medical and instrumental data (1st January 2012 to 1st March 2016) to identify patients admitted with STEMI and subsequently treated with primary PCI in our third referral center. Daily atmospheric pressure data (in hectopascal [hPa]) and air pollutant concentration levels were obtained from the regional meteorological service which had a monitoring site in our city (Rovigo, Italy). Pollutants investigated were nitrogen dioxide (NO 2 ), particulate matter ≤10μm (PM 10 ), ozone (O 3 ), sulfur dioxide (SO 2 ) and carbon monoxide (CO). Safety air concentration levels for the air pollutants were also considered. Results PCI in STEMI patients was more frequent when AP was higher than 1013.15hPa (61.8% vs 38.2%, p 2 , PM 10 and O 3 levels overcame the safe threshold were 83.1%, 52% and 8.5%, respectively. A positive correlation was found between the daily number of STEMI subsequently treated with primary PCI and the air pollutant levels of the same day for NO 2 ( r =0.205, p =0.001), PM 10 ( r =0.349, p 3 ( r =0.191, p =0.002). Conclusions A direct and significant correlation exists between the number of daily STEMI patients and the NO 2 , PM 10 and O 3 air concentration levels of the same day.

Background Approximately one-third of the patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) fail to respond. Positioning the left ventricular (LV) pacing lead in the area of the latest electrical delay may improve the response to CRT. Multipoint pacing (MPP) of the LV has been shown to improve the acute hemodynamic response. Objective The purpose of this study was to test the hypothesis that patients treated with MPP in whom LV pacing location is optimized have better long-term clinical outcomes than do patients treated with conventional CRT. Methods We evaluated the echocardiographic and clinical response of 110 patients with HF treated for nearly 1 year with either conventional CRT (standard [STD] group, n=54, 49%), CRT with hemodynamic and electrical optimization of the LV pacing site (optimized [OPT] group, n=36, 33%), or OPT combined with MPP (OPT + MPP group, n=20, 18%). Responders were classified in terms of reduction in end-systolic volume index ≥15%, reduction in New York Heart Association (NYHA) class ≥1, and Packer score variation (NYHA response with no HF-related hospitalization events or death). Results In STD, OPT, and OPT + MPP groups, 56%, 72%, and 90% of patients, respectively, were end-systolic volume index responders ( P = .004) and 67%, 78%, and 95% were NYHA class responders ( P = .012); 59%, 67%, and 90% of patients exhibited a 1-year Packer score of 0 ( P = .018). These trends remained significant after adjustment for confounding factors by multivariate logistic analysis. Conclusion Combining MPP with optimal positioning of the LV lead on the basis of electrical delay and hemodynamics enhances reverse remodeling and improves clinical outcomes beyond the effect due to conventional CRT.

Computational fluid dynamic analysis (CFD) have recently been applied in study the of cardiovascular system. Since the development of the first blood pumps in the early 1990’s this mathematical technique has been adopted in determining pressure-flow relationship and efficiencies before building left ventricular (LV) assist devices (LVADs) prototypes. Improvements in the functionality of these devices are desirable and for this aim CFD could be a valid tool both in projection and development.

Aim Limited data are available on the safety and outcome of percutaneous coronary intervention (PCI) in elderly patients with ST elevation myocardial infarction (STEMI), as elderly patients are under-represented in randomized trials. Methods We therefore aimed at assessing the trends in mortality rates (both at short-term and at 1-year follow up) in an unselected cohort of 404 STEMI patients aged ≥75 years all submitted to primary PCI and consecutively admitted to our Intensive Cardiac Care Unit from 2004 to 2010. Results In the first period (2004–2006), 202 patients (202/661, 30.6%) were aged ≥75 years, whereas in the second period (2007–2010), 203 patients (203/607, 33.4%) were aged ≥75 years. In the second period, STEMI patients were older (P

Though age is a predictor of adverse events after acute coronary syndrome, including in-hospital and post-hospital mortality rates, elderly patients are under-represented in randomized trials evaluating strategies of early coronary revascularization in acute myocardial infarction. Several factors can account for the unfavorable outcome of the elderly, comprising increased glucose values. Diabetes is more common in the elderly patients with acute myocardial infarction in respect to younger patients and elevated glucose, though common, are rarely treated and associated with increased mortality, particularly in those without recognized diabetes. Age itself is thought to affect the acute glucose response to stress. Human aging is associated with impaired β-cell sensitivity to glucose and impaired β-cell compensation to insulin resistance and older people exhibit an impaired glucose response after injury characterized by a more marked increases in endogenous glucose production. In the early phase of ST elevation myocardial infarction (STEMI), the acute glucose response to stress comprises not only hyperglycemia but also insulin-resistance (assessed by the Homeostatic Model Assessment). Recently it has been documented in 346 STEMI patients submitted to mechanical revascularization that the acute glucose response to myocardial injury differs in respect to age, since older patients showed the highest glucose levels and the poorest glycemic control during ICCU stay in the lack of differences in insulin resistance incidence. Taking into account that aging impairs the acute glucose response to stress in elderly STEMI patients, further studies are needed to establish whether a different (more aggressive) therapeutic regime is needed in this subgroup of patients at higher risk.

Aims The prognostic role (if any) of lactate for early mortality in patients with ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI) is so far not elucidated. We therefore assessed whether lactic acid (LA) was a prognostic predictor for early mortality in 807 patients with STEMI submitted to primary PCI consecutively admitted to our intensive cardiac care unit (ICCU) from January 1, 2006, to December 31, 2009. Result Higher levels of LA were found in older patients ( P = .025) and were associated with a progressive decline in estimated glomerular filtration rate ( P P P P P P = .018, and P = .006, respectively). The in-ICCU mortality rate was highest in the third LA tertile ( P P = .003). In addition, age (OR, 1.11; 95% CI, 1.03-1.19, P = .006) and leukocytes (OR, 1.17; 95% CI, 1.03-1.33, P = .015) were independent predictors for in-hospital mortality when adjusted for PCI failure. Conclusion In patients with STEMI submitted to primary PCI, blood lactate is a prognostic marker for early mortality only in the subgroup with advanced Killip class. The degree of hemodynamic impairment (as indicated by Killip class), of myocardial ischemia (as inferred by troponin I), and glucose values are the main factors influencing lactate concentrations in the early phase of STEMI.

BACKGROUND Chronic obstructive pulmonary disease (COPD) has been reported as a common finding in patients with acute myocardial infarction but data on its prognostic role are still controversial. METHODS The present investigation was aimed at assessing the impact of COPD at short and long terms in 818 consecutive patients with ST-elevation myocardial infarction all submitted to percutaneous coronary intervention. RESULTS Patients with COPD were older (p < 0.001) and more frequently smokers (p = 0.019). They showed a reduced estimated glomerular filtration rate (eGFR; p = 0.004) and a higher incidence of a more advanced coronary artery disease (p = 0.004). Patients with COPD showed higher values of N-terminal pro-brain natriuretic peptide (p = 0.004), uric acid (p = 0.005), erythrocyte sedimentation rate (p = 0.002), fibrinogen (p = 0.004), and C-reactive protein positivity (p = 0.017). Kaplan-Meier survival curve documented a significantly worse outcome in COPD patients. When age was taken into account, COPD patients aged

In the setting of acute myocardial infarction, hyperglycemia and acute insulin resistance may represent a stress response to myocardial injury mainly related to acute catecholamine release. By measuring glucose values and insulin resistance (Homeostatic Model Assessment index-HOMA), we evaluated in 356 non-diabetic patients with ST-elevation myocardial infarction (STEMI) undergone mechanical revascularization: (a) the acute glycometabolic response by evaluating insulin resistance, glucose levels, and their combination and (b) whether insulin resistance and increased glucose values (and their combination) are able to affect in-Intensive Cardiac Care Unit (ICCU) mortality and complications. In the overall population, 226 (63.5%) patients showed glucose values ≤140 mg/dl (group B), while 130 patients had glucose values140 mg/dl (group A) (36.5%). Within group B, insulin resistance (as inferred by positive HOMA index) was present in 125 patients (55.3%), whereas 101 patients (44.7%) exhibited normal values of HOMA index. Within group A, 109 patients (83.8%) were insulin resistant, while 21 patients (16.2%) had normal values of HOMA index. At multivariable analysis, glucose values were independently associated with in-ICCU mortality (OR: 7.387; 95% CI 2.701-20.201; P0.001) and complications (OR: 1.786; 95% CI 1.089-2.928; P = 0.022). In the early phase of STEMI, the acute glycometabolic response to stress is heterogeneous (ranging from no insulin resistance to glucose levels140 mg/dl and, finally, to the combination of increased glucose values and insulin resistance). Increased glucose values are stronger prognostic factors since they are independently associated with in-ICCU mortality and complications.

Controversy still exists about uric acid as a potential prognosticrisk factor for outcomes in patients with acute myocardial infarction. We prospectively assessed, in 856 patients with ST-elevation myocardial infarction (STMI) consecutively admitted to our Intensive Cardiac Care Unit after primary percutaneous coronary intervention (PCI) whether uric acid (UA) levels are associated with in-hospital mortality and complications. Killip classes III-–IV were more frequent in the 3° UA tertile that was associated with the highest values of peak Tn I (p = 0.005), NT-proBNP (p < 0.001), and fibrinogen (p = 0.036). Uric acid was associated with mortality (crude OR: 1.24; 95% CI 1.03–1.51; p = 0.025), but, when adjusted for Tn I and renal failure (as inferred by eGFR

Objectives Previous investigations on microalbuminuria in acute myocardial infarction have been performed in heterogeneous populations of hypetensive/nonhypertensive, diabetic/nondiabetic patients, submitted to either thrombolysis or mechanical revascularization or not revascularized. Therefore, the aim of our investigation was to assess, in 242 consecutive hypertensive patients with ST elevation myocardial infarction without previously known diabetes, all submitted to mechanical revascularization, whether microalbuminuria, in the early phase, has a prognostic role for in-hospital mortality or complications (acute pulmonary edema and arrhythmias). Methods The study population was divided into two groups according to microalbuminuria excretion: group A (microalbuminuria within the normal range); group B (microalbuminuria above the normal range). Results The incidence of microalbuminuria was 52.1% (126/242). No significant difference was detectable in the incidence of in-hospital mortality and complications between the two groups. Patients with microalbuminuria exhibit a larger infarct size as indicated by higher values of troponin I. Microalbuminuria was associated with higher values of glucose and a higher prevalence of insulin resistance. Conclusion In ST elevation myocardial infarction hypertensive patients without previously known diabetes, all submitted to mechanical revascularization, microalbuminuria is a common finding but it does not yield prognostic information about in-hospital mortality or complications. Interestingly it was associated with acute glucose dysmetabolism (as inferred by hyperglycemia and the prevalence of insulin resistance), thus suggesting that it can be considered part of the acute metabolic response to the acute coronary event.

In cardiac acute patients, data on procalcitonin (PCT) are controversial and the clinical interpretation of absolute PCT values represents a major challenge since they may be influenced by several factors. No data are so far available on the dynamics of PCT levels in patients with cardiogenic shock.to evaluate the serum evolution of PCT during intensive cardiac care unit (ICCU) staying in a group of 24 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI) with no laboratory or clinical sign of infection. Furthermore we assessed the kinetics of PCT in a series of 24 patients with septic shock.In septic shock, no significant difference was detectable in PCT kinetics between survivors (R2 = 0.90; P = 0.051) and non-survivors (R2 = 0.63; P = 0.204). In cardiogenic shock, survivors exhibited a significant reduction in PCT values (R2 = 0.94; P = 0.032) while non survivors did not (R2 = 0.68; P = 0.178).differently from septic shock, cardiogenic shock following STEMI was associated with heterogeneous patterns of temporal PCT variations since only patients who survived exhibited a significant PCT reduction during ICCU stay. Our findings support the contention that the 'dynamic' approach may be more reliable that the static one especially in cardiogenic shock.