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Introduction Wearable cardioverter-defibrillators (WCD) have emerged as a valuable tool in the management of patients at risk for life-threatening arrhythmias. These devices offer a non-invasive and temporary solution, providing continuous monitoring and the potential for prompt defibrillation when needed. In this study, we explore the use of WCD and evaluate arrhythmic events through comprehensive monitoring.Methods From November 2022 to May 2024, we conducted an outpatient follow-up of 41 patients receiving WCD. Regular check-ups, remote monitoring and comprehensive echocardiography were performed to optimise a tailored therapy.Results The average age of the patients was 59.2.4±16.5 years, with 78% being male. Among the cohort, 54% had hypertension, 41% were smokers and 66% had dyslipidaemia, while 27% were diabetic. WCD was assigned according to the Italian Association of Hospital Cardiologists position paper focussing on the appropriate use of WCD and European Society of Cardiology guidelines on ventricular arrhythmias and the prevention of sudden cardiac death: 24 (58%) patients had a de novo diagnosis of heart failure with reduced ejection fraction, 11 (27%) patients had a recent acute coronary syndrome and ejection fraction

BackgroundTypical isthmus-dependent atrial flutter (AFL) is traditionally treated through radiofrequency (RF) ablation to create a bidirectional conduction block across the cavo-tricuspid isthmus (CTI) in the right atrium. While this approach is successful in many cases, certain anatomical variations can present challenges, making CTI ablation difficult.MethodsWe enrolled four patients with typical counter-clockwise AFL who displayed an epicardial bridge at the CTI. Patients underwent high-resolution mapping of the right atrium and CTI ablation.ResultsPost-mapping identified areas of early focal activation outside the lesion line which suggested the presence of an epi-endocardial bridge with an endocardial breakthrough, confirmed by recording a unipolar rS pattern on electrograms at that site. A stable CTI block was achieved in all patients only after ablation at the site of the epi-endocardial breakthrough.ConclusionsThe presence of an epicardial bridge at the CTI, allowing conduction to persist despite endocardial ablation, should be considered in challenging cases of CTI-dependent AFL. Understanding this phenomenon and utilizing appropriate mapping and ablation techniques are essential for achieving successful and lasting CTI block.

Abstract Obesity is a complex, chronic disease requiring a multidisciplinary approach to its management. In clinical practice, body mass index and waist-related measurements can be used for obesity screening. The estimated prevalence of obesity among adults worldwide is 12%. With the expected further increase in overall obesity prevalence, clinicians will increasingly be managing patients with obesity. Energy balance is regulated by a complex neurohumoral system that involves the central nervous system and circulating mediators, among which leptin is the most studied. The functioning of these systems is influenced by both genetic and environmental factors. Obesity generally occurs when a genetically predisposed individual lives in an obesogenic environment for a long period. Cardiologists are deeply involved in evaluating patients with obesity. Cardiovascular risk profile is one of the most important items to be quantified to understand the health risk due to obesity and the clinical benefit that a single patient can obtain with weight loss. At the individual level, appropriate patient involvement, the detection of potential obesity causes, and a multidisciplinary approach are tools that can improve clinical outcomes. In the near future, we will probably have new pharmacological tools at our disposal that will facilitate achieving and maintaining weight loss. However, pharmacological treatment alone cannot cure such a complex disease. The aim of this paper is to summarize some key points of this field, such as obesity definition and measurement tools, its epidemiology, the main mechanisms underlying energy homeostasis, health consequences of obesity with a focus on cardiovascular diseases and the obesity paradox. Level of evidence V: report of expert committees.

Cardiac device infections (CDIs) are a serious complication in patients with implanted devices, resulting in increased morbidity, prolonged hospital stay, and increased healthcare costs. The effective management of these infections involves a combination of appropriate antibiotic therapy and preventive strategies aimed at reducing the risk of infection. The role of antibiotic prophylaxis in infection prevention is crucial, including the emerging use of antibiotic-supported tools and other local antibiotic delivery systems, which may reduce the risk of infection at the device implant site. In this contemporary review, we provide an overview of the prophylactic treatment and different antibiotic regimens for the treatment of CDIs, emphasizing early diagnosis, appropriate choice of antibiotics, and individualized treatment.

The exploration of the cardiac conduction system evolved over a century, marked by groundbreaking discoveries in atrioventricular (AV) nodal physiology. Atrioventricular nodal re-entrant tachycardia (AVNRT), the most prevalent regular tachycardia in humans, remains enigmatic despite extensive research. Detailed examinations of AV nodal anatomy and histology reveal variations in location and shape, influencing electrophysiological properties. Variability in AV nodal extensions and their embryological origins contribute to the complexity of the conduction system. Physiologically, the AV node plays a crucial role in modulating AV conduction, introducing delays for ventricular filling and filtering atrial impulses. Dual-pathway physiology involving fast and slow pathways further complicates AVNRT circuitry. Integrated approaches combining pre-procedural imaging with electroanatomical mapping enhance our understanding of AV nodal structures and high-definition mapping improves precision in identifying ablation targets. Electrophysiological–anatomical correlations may unveil the specific roles of conduction axis components, aiding in the optimization of ablation strategies. This review traces the historical journey from Tawara’s pioneering work to recent integrated approaches aimed at unraveling the intricacies of AV nodal structures while emphasizing the importance of a multidimensional approach, incorporating technological advancements, anatomical understanding, and clinical validation in human mapping studies.

Abstract Background Baseline cardiovascular risk factors correction is recommended in all cancer patients undergoing potentially cardiotoxic therapies. Despite available guidelines, real-world data on dyslipidemia prevalence and management in the oncologic population are still sparse. Methods This survey was an Italian, investigator-initiated survey initially designed and drafted by the Cardio-Oncology section of the Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), comprising 10 individual multi-choice questions and spread after validation through the ANMCO mailing list. The survey was sent to cardiologists working in cardio-oncology units and/or managing patients with cancer. Results Our survey included 139 Italian cardiologists. The majority of them routinely ask for the baseline lipidic profile of their patients, regardless of previous clinical history and planned treatment. According to our participants, the estimated prevalence of dyslipidemia in this population is between 20% and 60%. Although this high prevalence, our results highlight that there is poor harmony in terms of scores for CV risk prediction used in clinical practice to guide drug prescription and baseline therapy optimization. On the same line, coronary artery calcium score is poorly used in this setting. At the same time, more than 30% of interrogated physicians do not prescribe adequate statin doses, even though necessary, and have uncertainties on the use of other anti-dyslipidemic drugs in this population. Conclusions Our results highlight the necessity of strong evidences on dyslipidemia screening and management in the cancer population, as well as the need of knowledge diffusion from scientific societies to clinicians treating these patients.

Dear Editor, We thank Dr. Finsterer and Dr. Stollberger for their interest in our published manuscript which is focused on the collected data from patients hospitalized in our multidisciplinary COVID-19 department who experienced a Tako-Tsubo syndrome (TTS) during the second and third wave of the pandemic...

In cancer, a patient is considered a survivor from the time of initial diagnosis until the end of life. With improvements in early diagnosis and treatment, the number of cancer survivors (CS) has grown considerably and includes: (1) Patients cured and free from cancer who may be at risk of late-onset cancer therapy-related cardiovascular toxicity (CTR-CVT); (2) Patients with long-term control of not-curable cancers in whom CTR-CVT may need to be addressed. This paper highlights the importance of the cancer care continuum, of a patient-centered approach and of a prevention-oriented policy. The ultimate goal is a personalized care of CS, achievable only through a multidisciplinary-guided survivorship care plan, one that replaces the fragmented management of current healthcare systems. Collaboration between oncologists and cardiologists is the pillar of a framework in which primary care providers and other specialists must be engaged and in which familial, social and environmental factors are also taken into account.

Growing evidence shows that COVID-19 is associated with an increase in Tako-Tsubo syndrome (TTS) incidence. We collected data from patients hospitalized in our multidisciplinary COVID-19 department who had a diagnosis of TTS during the second and third wave of the pandemic in Italy. We reported four cases of TTS associated with COVID-19. No patient had any classical trigger for TTS except for COVID-19. Mean age was 72 years (67-81) and all patients had a SARS-CoV-2-related interstitial pneumonia confirmed by computed tomography. Typical apical ballooning and transitory reduction in left ventricle (LV) systolic function with a complete recovery before discharge were observed in all patients. The mean LV ejection fraction (LVEF) at TTS onset was 42% (40-48%). ECG showed ST-segment elevation in two cases, while an evolution with negative T waves and QTc prolongation was observed in all patients. Three patients underwent coronary angiography. Two patients had Alzheimer’s disease. The time interval from hospital admission to TTS onset was 4 (2-6) days, and the time interval from COVID-19 symptom onset to TTS diagnosis was 10 (8-12) days. COVID-19 may be a trigger for TTS, though TTS pathophysiology in COVID-19 patients remains unclear, likely due to its multifactorial nature.

Anderson–Fabry disease (AFD) is a lysosome storage disorder resulting from an X-linked inheritance of a mutation in the galactosidase A (GLA) gene encoding for the enzyme alpha-galactosidase A (α-GAL A). This mutation results in a deficiency or absence of α-GAL A activity, with a progressive intracellular deposition of glycosphingolipids leading to organ dysfunction and failure. Cardiac damage starts early in life, often occurring sub-clinically before overt cardiac symptoms. Left ventricular hypertrophy represents a common cardiac manifestation, albeit conduction system impairment, arrhythmias, and valvular abnormalities may also characterize AFD. Even in consideration of pleiotropic manifestation, diagnosis is often challenging. Thus, knowledge of cardiac and extracardiac diagnostic “red flags” is needed to guide a timely diagnosis. Indeed, considering its systemic involvement, a multidisciplinary approach may be helpful in discerning AFD-related cardiac disease. Beyond clinical pearls, a practical approach to assist clinicians in diagnosing AFD includes optimal management of biochemical tests, genetic tests, and cardiac biopsy. We extensively reviewed the current literature on AFD cardiomyopathy, focusing on cardiac “red flags” that may represent key diagnostic tools to establish a timely diagnosis. Furthermore, clinical findings to identify patients at higher risk of sudden death are also highlighted.

Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

Significant maternal and fetal morbidity and mortality risk has been shown to be associated with cardiovascular disease in pregnancy. Several determinants, such as the increasing number of females with corrected congenital heart disease in reproductive age, a more advanced maternal age associated with cardiovascular risk factors, and a greater prevalence of preexisting comorbidities related to cardiac disorders such as cancer and COVID-19), lead to a higher incidence of cardiac complications in pregnancy in the last few decades. However, adopting a multidisciplinary strategy may influence maternal and neonatal outcomes. This review aims at assessing the role of the Pregnancy Heart Team, which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital and other cardiac or metabolic disorders, addressing several emerging aspects in the multidisciplinary team-based approach.

The incidence of atrial fibrillation (AF) during pregnancy increases with maternal age and with the presence of structural heart disorders. Early diagnosis and prompt therapy can considerably reduce the risk of thromboembolism. The therapeutic approach to AF during pregnancy is particularly challenging, and the maternal and fetal risks associated with the use of antiarrhythmic and anticoagulant drugs must be carefully evaluated. Moreover, the currently used thromboembolic risk scores have yet to be validated for the prediction of stroke during pregnancy. At present, electrical cardioversion is considered to be the safest and most effective strategy in women with hemodynamic instability. Beta-selective blockers are also recommended as the first choice for rate control. Antiarrhythmic drugs such as flecainide, propafenone and sotalol should be considered for rhythm control if atrioventricular nodal-blocking drugs fail. AF catheter ablation is currently not recommended during pregnancy. Overall, the therapeutic strategy for AF in pregnancy must be carefully assessed and should take into consideration the advantages and drawbacks of each aspect. A multidisciplinary approach with a “Pregnancy-Heart Team” appears to improve the management and outcome of these patients. However, further studies are needed to identify the most appropriate therapeutic strategies for AF in pregnancy.

Recurrent myocardial infarction (re-MI) is a common event following acute coronary syndrome (ACS), especially during the first year. According to epidemiological studies, patients who experience re-MI are at higher risk of all-cause cardiovascular events and mortality. The cornerstones of re-MI prevention include complete functional coronary revascularization, effective dual antiplatelet therapy and secondary prevention strategies. Notwithstanding this, some controversy still exists on the definition and management of re-MI, and no dedicated studies have been designed or conducted so far in this setting. We here provide an overview of epidemiological and prognostic data on ACS patients experiencing re-MI, along with current available treatment and preventive options.

Objective The aim of the study was to describe the epidemiology and outcome of patients hospitalised during the COVID-19 pandemic in intensive cardiac care units (ICCs).Design Non-interventional, retrospective and prospective, nationwide study.Setting 109 private or public ICCs in Italy.Participants 6054 consecutive patients admitted to Italian ICCs during COVID-19 pandemic.Primary and secondary outcome measures To obtain accurate and up-to-date information on epidemiology and outcome of patients admitted to ICCs during the COVID-19 pandemic, the impact that the COVID-19 infection may have determined on the organisational pathways and in-hospital management of the various clinical conditions being admitted to ICCs.Results Acute coronary syndromes were the most frequent ICC discharge diagnoses followed by heart failure and hypokinetic arrhythmias. The prevalence of COVID-19 positivity was approximately 3%. Most patients with a COVID-19 diagnosis at discharge (52%) arrived to ICC from other wards, in particular 22% from non-cardiology ICCs. The overall mortality was 4.2% during ICC and 5.8% during hospital stay. The cause of in-hospital death was cardiac in 74.4% of the cases, non-cardiovascular in 13.5%, vascular in 5.8% and related to COVID-19 in 6.3% of the patients.Conclusions This study provides a unique nationwide picture of current ICC care during COVID-19 pandemic.Trial registration number NCT04744415.

As cardio-oncology imposed itself as the reference specialty for a comprehensive cardiovascular approach to all patients with cancer, a more specific and careful cardiac evaluation of women entering their journey into cancer care is needed. Gender medicine refers to the study of how sex-based biological and gender-based socioeconomic and cultural differences influence people’s health. Gender-related aspects could account for differences in the development, progression, and clinical signs of diseases as well as in the treatment of adverse events. Gender also accounts for major differences in access to healthcare. As for medicine and healthcare in general, gender-related characteristics have gained significance in cardio-oncology and should no longer be neglected in both clinical practice and research. We aimed to review the most relevant cardiovascular issues in women related to the cardio-oncology approach to offer a specific gender-related point of view for clinicians involved in the care process for both cancer and cardiovascular disease.

It has been consistently demonstrated that circulating lipids and particularly low-density lipoprotein cholesterol (LDL-C) play a significant role in the development of coronary artery disease (CAD). Several trials have been focused on the reduction of LDL-C values in order to interfere with atherothrombotic progression. Importantly, for patients who experience acute coronary syndrome (ACS), there is a 20% likelihood of cardiovascular (CV) event recurrence within the two years following the index event. Moreover, the mortality within five years remains considerable, ranging between 19 and 22%. According to the latest guidelines, one of the main goals to achieve in ACS is an early improvement of the lipid profile. The evidence-based lipid pharmacological strategy after ACS has recently been enhanced. Although novel lipid-lowering drugs have different targets, the result is always the overexpression of LDL receptors (LDL-R), increased uptake of LDL-C, and lower LDL-C plasmatic levels. Statins, ezetimibe, and PCSK9 inhibitors have been shown to be safe and effective in the post-ACS setting, providing a consistent decrease in ischemic event recurrence. However, these drugs remain largely underprescribed, and the consistent discrepancy between real-world data and guideline recommendations in terms of achieved LDL-C levels represents a leading issue in secondary prevention. Although the cost-effectiveness of these new therapeutic advancements has been clearly demonstrated, many concerns about the cost of some newer agents continue to limit their use, affecting the outcome of patients who experienced ACS. In spite of the fact that according to the current recommendations, a stepwise lipid-lowering approach should be adopted, several more recent data suggest a "strike early and strike strong" strategy, based on the immediate use of statins and, eventually, a dual lipid-lowering therapy, reducing as much as possible the changes in lipid-lowering drugs after ACS. This review aims to discuss the possible lipid-lowering strategies in post-ACS and to identify those patients who might benefit most from more powerful treatments and up-to-date management.

Aim: The SAMe-TT2R2 score helps identify patients with atrial fibrillation (AF) likely to have poor anticoagulation control during anticoagulation with vitamin K antagonists (VKA) and those with scores >2 might be better managed with a target-specific oral anticoagulant (NOAC). We hypothesized that in clinical practice, VKAs may be prescribed less frequently to patients with AF and SAMe-TT2R2 scores >2 than to patients with lower scores. Methods and results: We analyzed the Phase III dataset of the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF), a large, global, prospective global registry of patients with newly diagnosed AF and ≥1 stroke risk factor. We compared baseline clinical characteristics and antithrombotic prescriptions to determine the probability of the VKA prescription among anticoagulated patients with the baseline SAMe-TT2R2 score >2 and ≤ 2. Among 17,465 anticoagulated patients with AF, 4,828 (27.6%) patients were prescribed VKA and 12,637 (72.4%) patients an NOAC: 11,884 (68.0%) patients had SAMe-TT2R2 scores 0-2 and 5,581 (32.0%) patients had scores >2. The proportion of patients prescribed VKA was 28.0% among patients with SAMe-TT2R2 scores >2 and 27.5% in those with scores ≤2. Conclusions: The lack of a clear association between the SAMe-TT2R2 score and anticoagulant selection may be attributed to the relative efficacy and safety profiles between NOACs and VKAs as well as to the absence of trial evidence that an SAMe-TT2R2-guided strategy for the selection of the type of anticoagulation in NVAF patients has an impact on clinical outcomes of efficacy and safety. The latter hypothesis is currently being tested in a randomized controlled trial. Clinical trial registration: URL: https://www.clinicaltrials.gov//Unique identifier: NCT01937377, NCT01468701, and NCT01671007.

BackgroundSeveral studies have reported that the combination of high TG and low HDL-C, as simplified by the TG/HDL-C ratio, was a predictor of cardiovascular disease independent of LDL-C level. Nevertheless, poor data are available on the predictive role of TG/HDL-C ratio in very high risk (VHR) patients with chronic coronary syndromes (CCS).MethodsUsing the data from the STable Coronary Artery Diseases RegisTry (START) study, an Italian nationwide registry, we assessed the association between the TG/HDL-C ratio and baseline clinical characteristics, pharmacological treatment, and major adverse cardio-cerebrovascular events (MACCE) at 1 year in a large cohort of CCS patients at VHR.ResultsVHR patients with both TG and HDL-C levels available were grouped in tertiles of TG/HDL-C ratio: low (TG/HDL-C ratio 3.3, n = 1,028). At 1 year from enrolment, 232 (7.6%) patients presented a MACCE, with a higher incidence in the higher tertile, even though not statistically significant (6.0, 8.2, and 8.4% in the low, middle and high tertile, respectively; p = 0.08). At multivariable analysis, the TG/HDL-C ratio in tertiles did not result an independent predictor of the MACCE (p = 0.29) at 1-year follow-up (HR: 1.30; 95% CI: 0.93–1.82; p = 0.12 middle vs. lower tertile, and HR: 1.22; 95% CI: 0.87–1.72; p = 0.25 higher vs. lower).ConclusionsIn the present large, nationwide cohort of CCS patients at VHR a high TG/HD ratio did not emerge as independent predictor of MACCE at 1 year. Further studies with a longer follow-up are needed to better define the prognostic role of TG/HDL ratio in CCS.

Background/Objectives Obesity is associated with an increased risk of noncommunicable diseases, such as diabetes, coronary heart disease, stroke, cancers, and conditions, including obstructive sleep apnea and osteoarthritis. Obesity is largely preventable, and halting its rise is one of the World Health Organization Global Action Plan for the Prevention of Noncommunicable Diseases targets. This study aimed to assess trends of anthropometric measurements in Italy using the data collected within the CUORE Project health examination surveys (HESs) 1998, 2008, and 2018. Subjects/Methods Within the HESs 1998–2002, 2008–2012, and 2018–2019, anthropometric measurements were collected in random samples of the resident population aged 35–74 years, stratified by age and sex, from 10 Italian Regions in Northern, Central, and Southern Italy (2984 men and 2944 women, 2224 men and 2188 women, 1035 men and 1065 women, respectively). Weight, height, and waist and hip circumferences were measured using standardized methodologies. A standardized questionnaire was used to collect data on education. Indicators were age standardized. Results For both men and women, mean body mass index in 2018 was comparable with those in 1998 and 2008 (in 1998, 2008, and 2018—men: 26.7, 27.5, and 27.0 kg/m2; women: 26.2, 26.6, and 26.3 kg/m2). In 1998, 2008, 2018 prevalence of overweight resulted 49%, 47%, 46% in men and 33%, 32%, 28% in women respectively; prevalence of obesity resulted 17%, 24% 20% in men and 19%, 23%, 23% in women respectively. All indicators of excess weight worsen with increasing age and are more severe in persons with a lower educational level. Conclusions Although the overall trend of excess weight over the past two decades appeared to be substantially stable in the Italian adult population, the continuous strengthening of undertaken initiatives should continue since there remains a high proportion of overweight or obesity and a gap between educational levels.

The pathophysiology of some non-communicable diseases (NCDs) such as hypertension, cardiovascular disease (CVD), diabetes, and cancer includes an alteration of the endothelial function. COVID-19 is a pulmonary and vascular disease with a negative impact on patients whose damaged endothelium is particularly vulnerable. The peculiar SARS-CoV-2-induced “endothelitis” triggers an intriguing immune-thrombosis that affects both the venous and arterial vascular beds. An increased liability for infection and an increased likelihood of a worse outcome have been observed during the pandemic in patients with active cancer and in cancer survivors. “Overlapping commonalities” between COVID-19 and Cardio-Oncology have been described that include shared phenotypes of cardiovascular toxicities such as left ventricular dysfunction, ischemic syndromes, conduction disturbances, myocarditis, pericarditis and right ventricular failure; shared pathophysiologic mechanisms such as inflammation, release of cytokines, the renin-angiotensin-aldosterone-pathway, coagulation abnormalities, microthrombosis and endothelial dysfunction. For these features and for the catalyst role of NCDs (mainly CVD and cancer), we should refer to COVID-19 as a “syndemic.” Another challenging issue is the persistence of the symptoms, the so-called “long COVID” whose pathogenesis is still uncertain: it may be due to persistent multi-organ viral attacks or to an abnormal immune response. An intensive vaccination campaign is the most successful pharmacological weapon against SARS-CoV-2, but the increasing number of variants has reduced the efficacy of the vaccines in controlling SARS-CoV-2 infections. After a year of vaccinations we have also learned more about efficacy and side-effects of COVID-19 vaccines. An important byproduct of the COVID-19 pandemic has been the rapid expansion of telemedicine platforms across different care settings; this new modality of monitoring cancer patients may be useful even in a post pandemic era. In this paper we analyze the problems that the cardio-oncologists are facing in a pandemic scenario modified by the extensive vaccination campaign and add actionable recommendations derived from the ongoing studies and from the syndemic nature of the infection.

Background. It is unknown whether patients who survived two or multiple episodes of myocardial infarction (MI) present different clinical characteristics and management than patients at their first MI. Methods. The EYESHOT post-MI was a prospective, observational, nationwide study aimed to evaluate the management of patients presenting to cardiologists 1 to 3 years from the last MI event. In 3 months of enrolment, 165 Italian cardiology centers included 1633 consecutive post-MI patients. In the present analysis, we stratified the study cohort according to the number of prior MI episodes (i.e., 1, 2 or ≥3). Results. Among the 1618 patients enrolled with complete data on MI history, 1335 (82.5%) were at their first MI episode, 209 (12.9%) had a history of 2 MIs, and the remaining 74 (4.6%) had ≥ 3 prior MIs. Patients with a history of multiple MIs were increasingly older and presented a significantly higher rate of risk factors compared to those at their first MI. During the year prior to enrolment, patients with 2 or ≥3 MI episodes more frequently underwent coronary angiography compared to the other group (p

Primary and secondary prevention protocols aim at reducing the plasma levels of lipids - with particular reference to low-density lipoprotein cholesterol (LDL-C) plasma concentrations – in order to improve the overall survival and reduce the occurrence of major adverse cardiovascular events. The use of statins has been widely considered as the first-line approach in lipids management as they can dramatically impact on the cardiovascular risk profile of individuals. The introduction of ezetimibe and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors overcame the adverse effects of statins and ameliorate the achievement of the target lipids levels. Indeed, advances in therapies promote the use of specific molecules – i.e. short strands of RNA named small-interfering RNAs (siRNAs) – to suppress the transcription of genes related to lipids metabolism. Recently, the inclisiran has been developed: this is a siRNA able to block the mRNA of the PCSK9 gene. About 50% reduction in low-density lipoprotein cholesterol levels have been observed in randomized controlled trials with inclisiran. The aim of this review was to summarize the literature regarding inclisiran and its possible role in the general management of patients with lipid disorders and/or in primary/secondary prevention protocols.

Therapeutic approaches based on gene silencing technologies represent a new opportunity to manage hypercholesterolemia. Inclisiran is a small interfering RNA that targets proprotein convertase subtilisin/kexin type 9 (PCSK9) mRNA. Clinical studies have demonstrated that inclisiran is effective, safe, and well-tolerated in reducing low-density lipoprotein cholesterol (LDL-C) in patients with familial hypercholesterolemia, atherosclerotic cardiovascular disease, and atherosclerotic cardiovascular disease risk equivalents. A meta-analysis of phase 3 trials demonstrated a 51% reduction in LDL-C levels at 18 months as compared with placebo. Adverse event incidence was found to be comparable in individuals treated with inclisiran and those receiving placebo, though the reactions at the site of injection were more common in patients receiving inclisiran as compared with those receiving placebo. The recommended inclisiran dose is 284 mg administered as a subcutaneous injection to be repeated after three months with a subsequent 6-month maintenance regimen. Overall, since the pharmacological efficacy of inclisiran in LDL-C reduction is comparable to that of monoclonal antibodies against PCSK9, the longer effect duration and the favorable safety profile may favor this newer approach for hypercholesterolemia management.

Aims: Cardio-oncology has achieved a pivotal role in science, but real world data on its clinical impact are still limited.Methods: A questionnaire was sent out to all cardio-oncology services across Italy (n = 120). The questionnaire was made up of 28 questions divided into four blocks: (A) general information on hospitals and service, (B) the inner organization of cardio-oncology and its relationships with out-of-hospital cardiologists and general practitioners, (C) educational needs and referral guidelines, and (D) activities/specific workload.Results: Ninety-six out of 120 (80%) completed the questionnaire; 9.4% were cancer centers while 90.6% were general hospitals. A cardio-oncology team was present in 56% of the cancer centers and in 20% only of general hospitals, and a cardio-oncology pathway was active in 55% of cancer centers and in just 14% of the general hospitals. Relationships with out-of-hospital cardiologists and general practitioners were lacking. The guidelines of reference were ESC and ANMCO/AIOM. Patients receiving anthracycline chemotherapy underwent scheduled monitoring by means of echocardiography in 58% of cases. Routine use of cardiac damage biomarkers was overall low, ranging from 22 to 33% while the use of global longitudinal strain reached 44%.Conclusions: Italian cardio-oncology showed a growing influence on clinical practice but still has room for improvement. Cardio-oncology teams are still scarce, and the application of dedicated paths is poor. The need for specific training has been highlighted.

Background Evidence regarding the relationships among high plasma triglycerides (TG), all‐cause mortality, and atherosclerotic cardiovascular disease (ASCVD) events in low‐to‐moderate risk individuals is limited. The aim of this study was to determine whether the presence of high TG levels influences the risk of all‐cause mortality and ASCVD events in a population cohort followed in the real‐world clinical setting. Methods and Results A retrospective longitudinal cohort analysis using administrative databases of 3 Italian Local Health Units was performed. All individuals with at least one TG measurement between January 1, 2010 and December 31, 2015 were followed through December 2016. Outcome measures included incident ASCVD events and all‐cause mortality. Individuals with normal TG levels (500 mg/dL). 158 042 individuals (142 289 with normal, 15 558 with high, and 195 with very high TG) were considered. In the whole cohort, the overall incidence rates of ASCVD and all‐cause mortality were 7.2 and 17.1 per 1000 person‐years, respectively. After multivariate adjustment for potential confounders, individuals with high and very high TG showed a significantly increased risk of all‐cause mortality (hazard ratio [HR]=1.49 [95% confidence interval (CI) 1.36–1.63], P

Introduction. The current use of lipid lowering therapies and the eligibility for proprotein convertase subtilisin/kexin-9 (PCSK9) inhibitors of patients surviving a myocardial infarction (MI) is poorly known. Methods. Using the data from two contemporary, nationwide, prospective, real-world registries of patients with stable coronary artery disease, we sought to describe the lipid lowering therapies prescribed by cardiologists in patients with a prior MI and the resulting eligibility for PCSK9 inhibitors according to the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) and the Italian regulatory agency (Agenzia Italiana del Farmaco; AIFA) criteria. The study cohort was stratified according to the following low-density lipoprotein cholesterol (LDL-C) levels at the time of enrolment:

Recent evidence suggests that adding protein convertase subtilisin/kexin type 9 inhibitors to current lipid-lowering therapies may result in unprecedented reductions in low-density lipoprotein cholesterol. The objective of this study was to assess the potential pharmaceutical financial impact of including the protein convertase subtilisin/kexin type 9 inhibitor, alirocumab, in the Italian National Health Service budget. The budget impact of adding alirocumab as a lipid-lowering therapy treatment option was assessed among the population defined by the AIFA reimbursement criteria. Data from the IMS/CEGEDIM national electronic database were used to estimate the size of the potentially eligible population. Drug costs were estimated according to dosing schedule and published prices. Alirocumab annual uptake was assumed at 7%, 9% and 10% for years 1, 2 and 3, respectively, considering a 20% treatment drop-out rate. Sensitivity analyses tested the impact of model inputs on the results. The annual estimated incremental cost of alirocumab treatment was €5106/patient. Treating an eligible population of 843 patients with alirocumab in the first year resulted in a total National Health Service budget impact of €4.30 million. Assuming growth of the alirocumab-treated population of 2105 and 2819 patients in the second and third years, the budgetary impact would be €10.75 and €14.10 million, respectively. Sensitivity analysis suggested that financial impact is most sensitive to the uptake of alirocumab in the population. The uptake of alirocumab results in an overall modest budgetary impact to the Italian National Health Service when added to conventional lipid-lowering therapies in a carefully selected population compared to the total lipid-lowering therapy pharmaceutical expenditure in Italy (€1 billion).

Data on contemporary management patterns of angina in patients with stable coronary artery disease (CAD) are scarce. We sought to describe the current presentation, management, and quality of life of stable CAD patients with or without angina, using the data from the START (STable Coronary Artery Diseases RegisTry) study. START was a prospective, observational, nationwide study aimed to evaluate the presentation, management, treatment and quality of life of stable CAD presenting to cardiologists during outpatient visits or discharged from cardiology wards. Among the 5070 consecutive stable CAD patients enrolled in 183 participating centers over a 3-month period, 3714 (73.2%) had no angina and 1356 (26.8%) presented with angina. Patients with angina underwent more frequently coronary angiography (92.7% vs 84.9%; p

Anticoagulation, reducing the risk of thromboembolic events in patients undergoing cardioversion, is a cornerstone of peri-cardioversion management in patients with atrial fibrillation. We aimed to analyse published data on the efficacy and safety of direct oral anticoagulants (DOACs) in patients undergoing cardioversion. We performed a systematic review of randomized prospective clinical trials (RCTs) comparing DOACs with warfarin and reporting data on post-cardioversion outcomes of interest. Outcomes of interest were stroke, systemic thromboembolic events and major bleeding. We reviewed a total of six RCTs including 3900 cardioversions performed using a DOAC for thromboembolic prophylaxis. These studies reported a low incidence overall of adverse outcomes associated with the use of DOACs (around 1% in all studies, except the ROCKET post-hoc study which included ablation procedures). The incidence rate of adverse events during DOAC treatment was found to be very similar to that observed with warfarin anticoagulation. In RCTs DOAC treatment in patients undergoing cardioversion appears to be effective and safe. However, because evidence in this clinical setting is still weak, observational reports could be useful in providing further data about peri-procedural outcomes.

Despite the wide improvement of diagnostic techniques and the introduction of effective pharmacological and instrumental therapeutic strategies aimed to the treatment of cardiovascular diseases, their incidence and lethality are still elevated, with economic implications increasingly less sustainable by the public medical systems. The modern practice of cardiovascular prevention requires, thus, that diagnostic and therapeutic interventions, both at population level and on the single patient, should be more and more precise, effective, and appropriate. From this point of view, a correct global cardiovascular risk stratification assumes a preponderant relevance, in order to allow an adequate therapeutical response. For this purpose several work instruments, as risk charts and guidelines, namely dedicated to arterial hypertension and dyslipidemias, were developed and offered to clinicians interested in cardiovascular prevention. The aim of this review is to illustrate, in synthesis, those instruments, aiming to facilitate their implementation, thus reducing the actual gap between theoretical indications and the real world.

The measurement of QT dispersion in the surface electrocardiogram has been proposed as a non invasive method for assessing inhomogeneity of myocardial repolarization and has been linked to an increased risk of arrhythmic cardiac death. Several studies have evaluated the use of QTd in a wide variety of cardiac diseases and have reached conflicting conclusions regarding its clinical significance.

The prevention of symptomatic heart failure represents the treatment of patients in the A and B stages of AHA/ACC heart failure classification. Stage A refers to patients without structural heart disease but at risk to develop chronic heart failure. The major risk factors in stage A are hypertension, diabetes, atherosclerosis, family history of coronary artery disease and history of cardiotoxic drug use. In this stage, blockers hypertension is the primary area in which beta blockers may be useful. Beta blockers seem not to be superior to other medication in reducing the development of heart failure due to hypertension. Stage B heart failure refers to structural heart disease but without symptoms of heart failure. This includes patients with asymptomatic valvular disease, asymptomatic left ventricular (LV) dysfunction, previous myocardial infarction with or without LV dysfunction. In asymptomatic valvular disease no data are available on the efficacy of beta blockers to prevent heart failure. In asymptomatic LV dysfunction only few asymptomatic patients have been enrolled in the trials which tested beta blockers. NYHA I patients were barely 228 in the MDC, MERIT and ANZ trials altogether. The REVERT trial was the only trial focusing on NYHA I patients with LV ejection fraction less than 40%. Metoprolol extended release on top of ACE inhibitors ameliorated LV systolic volume and ejection fraction. A post hoc analysis of the SOLVD Prevention trial demonstrated that beta blockers reduced death and development of heart failure. Similar results were reported in post MI patients in a post hoc analysis of the SAVE trial (Asymptomatic LV failure post myocardial infarction). In the CAPRICORN trial about 65% of the patients were not taking diuretics and then could be considered asymptomatic. The study revealed a reduction in mortality and a non-significant trend toward reduction of death and hospital admission for heart failure. Conclusions: beta blockers are not specifically indicated in stage A heart failure. On the contrary, in most of the stage B patients, and particularly after MI, beta blockers are indicated to reduce mortality and, probably, also the progression toward symptomatic heart failure.

Given the limited research on Italian hospital smoking care practices, a cross-sectional survey was undertaken in April-May 2011 to describe the current status of smoking cessation interventions for ACS patients in cardiovascular institutions of the Lazio Region of Italy. Lazio is a region of central Italy with a resident population of about 5,600,000. According to the data of the Regional Health Authority, about 10.000 patients are admitted for ACS every year in this region of Italy. Acute cardiac care in the region is currently provided by 33 Cardiology Divisions. All of these units were considered as eligible for the survey. The eligible respondent for each unit was the director. A self-report questionnaire was developed based on previous studies that examined the specific features of smoking cessation care provided to hospitalised patients. Questionnaires were forwarded by the Lazio Regional Section of the Italian National Association of Hospital Cardiologists (ANMCO). Completed questionnaires were received from 22 of the 33 eligible Divisions (66%). These 22 responding units currently provide acute care to about 70% of all ACS patients of the region. Responding units were more likely to represent public non-teaching hospitals (p=0.002), while non-responders were mostly from private non-teaching institutions (p=0.04). Response rates were not influenced by the presence of either interventional catheterization laboratory (Cathlab)or cardiac surgery within the hospitals. The survey suggest that most of cardiology units fail to provide recommended smoking care interventions to ACS patients. In particular, brief smoking cessation advice before discharge represents the only systematically implemented approach in clinical practice (22 units; 100%). Smoking cessation counselling is provided only in 9 units (40%). Specific pharmacotherapy is prescribed in selected case only in about one third of units (7 units; 32%), with varenicline being the preferred drug. Structural variables and organizational complexity have no influence on smoking care, as hospitals with Cathlab and cardiac surgery do not implement more effective strategies. Overall, this survey shows that the majority of smoking ACS inpatients may receive inadequate smoking care and that hospitals have considerable opportunity for improvement.

A standardized and evidence-based approach to the cardiological management of patients undergoing noncardiac surgery has been recently defined by Task Forces of the American Heart Association (AHA), American College of Cardiology (ACC) and the European Society of Cardiology (ESC) that published their guidelines in 2007 and 2009, respectively. Both the recommendations moved from risk indices to a practical, stepwise approach of the patient, which integrates clinical risk factors and test results with the estimated stress of the planned surgical procedure. In the present paper the main topics of the guidelines are discussed, and moreover, emphasis is placed on four controversial issues such as the use of prophylactic coronary revascularization in patients with myocardial ischemia, the perioperative management of patients with congestive heart failure, the routine use of betablockers and statins, and, finally, the management of antiplatelet therapies in patients with coronary stents. In addition to promoting an improvement of immediate perioperative care, the preoperative cardiological evaluation should be a challenge for identifying subjects with enhanced risk of cardiovascular events, who should be treated and monitored during a long-term follow-up.

Consensus Document of the Regional Chapters of the Italian National Association of Hospital Cardiologists (ANMCO) and of the Italian Society of Emergency Medicine (SIMEU) This document has been developed by the Lazio regional chapters of two scientific associations, the Italian National Association of Hospital Cardiologists (ANMCO) and the Italian Society of Emergency Medicine (SIMEU), whose members are actively involved in the everyday management of Acute Coronary Syndromes (ACS). The document is aimed at providing a specific, practical, evidence-based guideline for the effective management of antithrombotic treatment (antiplatelet and anticoagulant) in the complex and ever changing scenario of ACS. The document employs a synthetic approach which considers two main issues: the actual operative context of treatment delivery and the general management strategy.

Not available.

Atrial fibrillation, whose prevalence is in constant increase, is associated to a noticeably greater thrombo-embolic risk. Various associated factors, such as older age, arterial hypertension, heart failure, previous cerebrovascular events (stroke and transient ischemic attacks), diabetes mellitus, female sex and vascular diseases determine a further increase of the risk of stroke in patients with atrial fibrillation. Robust evidence exists on the efficacy of traditional anticoagulant oral therapy in the prevention of thrombo-embolic risk in these patients, but fears and concerns of hemorrhagic events for the physicians and the logistic difficulties related to the periodic International Normalized Ratio evaluation for the patients are at the basis of a noticeable under-utilization of the therapy with vitamin K antagonists in the real world. Stratification of the thrombo-embolic risk has thus particular importance; for this scope we may use now score systems as CHA2DS2 and, above all, CHA2DS2-Vasc, that allows the identification of truly low risk patients, which do not require an antithrombotic treatment. Novel oral anticoagulants, lastly, will help physicians in order to obtain a better management of trombo-embolic risk in atrial fibrillation.

Objectives. To offer a snapshot of the personal health habits of Italian cardiologists, the Survey on Cardiac Risk Profile and Lifestyle Habits in a Cohort of Italian Cardiologists (SOCRATES) study was undertaken. Background. Cardiologists’ cardiovascular profile and lifestyle habits are poorly known worldwide. Methods. A Web-based electronic self-reported survey, accessible through a dedicated website, was used for data entry, and data were transferred via the web to a central database. The survey was divided in 4 sections: baseline characteristics, medical illnesses and traditional cardiovascular risk factors, lifestyle habits and selected medication use. The e-mail databases of three national scientific societies were used to survey a large and representative sample of Italian cardiologists. Results. During the 3-month period of the survey, 1770 out of the 5240 cardiologists contacted (33.7%) completed and returned one or more sections of the questionnaire. More than 49% of the participants had 1 out of 5 classical risk factors (e.g. hypertension, hypercholesterolemia, active smoking, diabetes and previous vascular events). More than 28% of respondents had 2 to 5 risk factors and only 22.1% had none and therefore, according to age and sex, could be considered at low-intermediate risk. Despite the reported risk factors, more than 90% of cardiologists had a self-reported risk perception quantified as mild, such as low or intermediate. Furthermore, overweight/obesity, physical inactivity and stress at work or at home were commonly reported, as well as a limited use of cardiovascular drugs, such as statins or aspirin. Conclusions. The average cardiovascular profile of Italian cardiologist is unlikely to be considered ideal or even favorable according to recent statements and guidelines regarding cardiovascular risk. Thus, there is a large room for improvement and a need for education and intervention.

Oral anticoagulation is a widely used treatment and atrial fibrillation (AF) is the most frequent indication. We review the therapeutic options on an important clinical challenge: rapid reversal anticoagulation in the setting of an urgent invasive procedure. We report a case of a 71-year-old man treated with warfarin who was over-anticoagulated when presented to the emergency department for syncope due to severe bradiarrhythmia and needed temporary pacing. Intravenous infusion of vitamin-k was not adequate for rapid reversal over anticoagulation whereas the administration of a Prothrombin Complex Concentrate (PCC) was able to quickly reverse anticoagulant activity and allowed the performance of an urgent invasive procedure without hemorrhagic complication. The aim of this paper is to draw attention to possible therapeutic strategies to reduce the risk of bleeding related to over-anticoagulation with vitamin-K antagonists (VKAs) in case of urgent invasive procedure, emphasizing the role of PCC in keeping with national and international guidelines.

Antecedentes: El período inmediato después del inicio del síndrome coronario agudo (SCA) representa un estadio crítico de la cardiopatía coronaria con un alto riesgo de eventos recurrentes y muertes. En los pacientes que presentan SCA los efectos a corto plazo del tratamiento precoz con estati-nas sobre resultados relevantes para el paciente son inciertos. Objetivos: Evaluar los efectos beneficiosos y perjudiciales de las estatinas administradas de forma precoz en pacientes con SCA a partir de ensayos controlados aleatorios (ECA). Estrategia de búsqueda: Se hicieron búsquedas en CENTRAL, MEDLINE, EMBASE y CINAHL (hasta el 1 febrero 2010). No se aplicó ninguna restricción en cuanto al idioma. La búsqueda se complementó al establecer contacto con especialistas en el campo, examinar las listas de referencias de las revisiones y los artículos editoriales sobre el tema y al buscar en los registros de ensayos. Criterios de selección: ECA que compararon estatinas con placebo o atención habitual, iniciaron el tratamiento con estatina en el transcurso de los 14 días después del inicio del SCA, tuvieron un seguimiento de al menos 30 días e informaron al menos un resultado clínico. Obtención y análisis de los datos: Dos autores evaluaron de forma independiente la calidad de los estudios y extrajeron los datos. Con un modelo de efectos aleatorios, se agruparon los efectos del tratamiento y se calcularon los cocientes de riesgos (CR) para todos los resultados en los grupos de tratamiento y control. Resultados principales: Dieciocho estudios (14 303 pacientes) compararon el tratamiento precoz con estatina versus placebo o atención habitual en pacientes con SCA. En comparación con el placebo o la atención habitual, el tratamiento precoz con estatina no redujo el resultado primario combinado de muerte, infarto de miocardio (IM) no mortal y accidente cerebrovascular al mes (cociente de riesgos [cR] 0,93; intervalo de confianza [IC] del 95%: 0,80 a 1,08) ni a los cuatro meses (CR 0,93; IC del 95%: 0,81 a 1,06) de seguimiento. No hubo reducciones estadísticamente significativas en el riesgo de las estatinas para muerte total, IM total, accidente cerebrovascular total, muerte cardiovascular, procedimientos de revascularización e insuficiencia cardíaca aguda al mes ni a los cuatro meses, aunque hubo tendencias favorables relacionadas con el uso de las estatinas para cada una de estas variables de evaluación. La incidencia de episodios de angina inestable se redujo significativamente a los cuatro meses después del SCA (CR 0,76; IC del 95%: 0,59 a 0,96). Hubo nueve pacientes con miopatía (niveles elevados de creatinquinasa > 10 veces el límite superior de lo normal) en los pacientes tratados con estatina (0,13%) versus uno (0,015%) en los grupos control. La toxicidad muscular grave estuvo limitada principalmente a los pacientes tratados con simvastatina 80 mg. Conclusiones de los autores: Según las pruebas disponibles, el inicio del tratamiento con estatinas en el transcurso de 14 días después del SCA no reduce la muerte, el infarto de miocardio ni el accidente cerebrovascular hasta los cuatro meses, pero reduce la ocurrencia de angina inestable a los cuatro meses después del SCA.