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Rivasi G, Coscarelli A, Capacci M, Ceolin L, Turrin G, Tortù V, D'Andria MF, Testa GD, Ungar A. Tolerability of Antihypertensive Medications: The Influence of Age. High Blood Press Cardiovasc Prev 2024:10.1007/s40292-024-00639-z. [PMID: 38658522 DOI: 10.1007/s40292-024-00639-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Despite high prevalence of hypertension, few studies have analysed the adverse effects (AEs) of antihypertensive medications, especially in older patients. AIM To investigate the prevalence and associated factors of antihypertensive-related AEs, focusing on the influence of age on treatment tolerability. METHODS We retrospectively investigated antihypertensive-related AEs in patients evaluated at the Hypertension Clinic of Careggi Hospital, Florence, Italy, between January 2017 and July 2020. Multivariable regression models were generated to analyse variables associated with AEs in the overall sample and in participants ≥75 years. RESULTS Among 622 subjects (mean age 64.8 years, 51.4% female), the most frequently reported AEs were calcium-channel blockers (CCB)-related ankle swelling (26.8%) and ACEi-induced cough (15.1%). Ankle swelling was more common in older patients (35.7% vs 22.3%, p = 0.001; odds ratio [OR] 1.94, 95%CI 1.289-2.912) and was independently associated with Body Mass Index (BMI, adjOR 1.073) and angiotensin-receptor antagonists (adjOR 1.864). The association with BMI was confirmed in older patients (adjOR 1.134). ACEi-induced cough showed similar prevalence in younger and older patients (13.9% vs 15.6%, p = 0.634), being independently associated with female sex (adjOR 2.118), gastroesophageal reflux disease (GERD, adjOR 2.488) and SNRI therapy (adjOR 8.114). The association with GERD was confirmed in older patients (adjOR 3.238). CONCLUSIONS CCB-related ankle swelling and ACEi-induced cough represent the most common antihypertensive-related AEs, also at old age. Older patients showed a two-fold increased risk of ankle swelling, that was also independently associated with BMI. ACEi-induced cough had similar prevalence at younger and old ages, being independently associated with GERD.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.
| | - Antonio Coscarelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Ludovica Ceolin
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Giada Turrin
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Virginia Tortù
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Maria Flora D'Andria
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
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Brignole M, Rivasi G, Fedorowski A. Mechanism-based therapy of non-cardiac syncope: a practical guide. Europace 2024; 26:euae073. [PMID: 38529800 PMCID: PMC10988836 DOI: 10.1093/europace/euae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/08/2024] [Indexed: 03/27/2024] Open
Abstract
The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled out. Reflex syncope and orthostatic hypotension are the most frequent aetiologies of non-cardiac syncope. As no specific therapy is effective for all types of non-cardiac syncope, identifying the underlying haemodynamic mechanism is the essential prerequisite for an effective personalized therapy and prevention of syncope recurrences. Indeed, choice of appropriate therapy and its efficacy are largely determined by the syncope mechanism rather than its aetiology and clinical presentation. The two main haemodynamic phenomena leading to non-cardiac syncope include either profound hypotension or extrinsic asystole/pronounced bradycardia, corresponding to two different haemodynamic syncope phenotypes, the hypotensive and bradycardic phenotypes. The choice of therapy-aimed at counteracting hypotension or bradycardia-depends on the given phenotype. Discontinuation of blood pressure-lowering drugs, elastic garments, and blood pressure-elevating agents such as fludrocortisone and midodrine are the most effective therapies in patients with hypotensive phenotype. Cardiac pacing, cardioneuroablation, and drugs preventing bradycardia such as theophylline are the most effective therapies in patients with bradycardic phenotype of extrinsic cause.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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Tikhonoff V, Casiglia E, Virdis A, Grassi G, Angeli F, Arca M, Barbagallo CM, Bombelli M, Cappelli F, Cianci R, Cicero AFG, Cirillo M, Cirillo P, Dell'oro R, D'elia L, Desideri G, Ferri C, Galletti F, Gesualdo L, Giannattasio C, Iaccarino G, Mallamaci F, Maloberti A, Masi S, Masulli M, Mazza A, Mengozzi A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Pontremoli R, Quarti-Trevano F, Rattazzi M, Reboldi G, Rivasi G, Russo E, Salvetti M, Temporelli PL, Tocci G, Ungar A, Verdecchia P, Viazzi F, Volpe M, Borghi C. Prognostic Value and Relative Cutoffs of Triglycerides Predicting Cardiovascular Outcome in a Large Regional-Based Italian Database. J Am Heart Assoc 2024; 13:e030319. [PMID: 38293920 DOI: 10.1161/jaha.123.030319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Despite longstanding epidemiologic data on the association between increased serum triglycerides and cardiovascular events, the exact level at which risk begins to rise is unclear. The Working Group on Uric Acid and Cardiovascular Risk of the Italian Society of Hypertension has conceived a protocol aimed at searching for the prognostic cutoff value of triglycerides in predicting cardiovascular events in a large regional-based Italian cohort. METHODS AND RESULTS Among 14 189 subjects aged 18 to 95 years followed-up for 11.2 (5.3-13.2) years, the prognostic cutoff value of triglycerides, able to discriminate combined cardiovascular events, was identified by means of receiver operating characteristic curve. The conventional (150 mg/dL) and the prognostic cutoff values of triglycerides were used as independent predictors in separate multivariable Cox regression models adjusted for age, sex, body mass index, total and high-density lipoprotein cholesterol, serum uric acid, arterial hypertension, diabetes, chronic renal disease, smoking habit, and use of antihypertensive and lipid-lowering drugs. During 139 375 person-years of follow-up, 1601 participants experienced cardiovascular events. Receiver operating characteristic curve showed that 89 mg/dL (95% CI, 75.8-103.3, sensitivity 76.6, specificity 34.1, P<0.0001) was the prognostic cutoff value for cardiovascular events. Both cutoff values of triglycerides, the conventional and the newly identified, were accepted as multivariate predictors in separate Cox analyses, the hazard ratios being 1.211 (95% CI, 1.063-1.378, P=0.004) and 1.150 (95% CI, 1.021-1.295, P=0.02), respectively. CONCLUSIONS Lower (89 mg/dL) than conventional (150 mg/dL) prognostic cutoff value of triglycerides for cardiovascular events does exist and is associated with increased cardiovascular risk in an Italian cohort.
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Affiliation(s)
- Valérie Tikhonoff
- Department of Medicine Università degli Studi di Padova Via Giustiniani 8 Padua 35128 Italy
| | - Edoardo Casiglia
- Studium Patavinum, Department of Medicine Università degli Studi di Padova Padua Italy
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine University of Pisa Italy
| | - Guido Grassi
- Department of Medicine and Surgery University of Milano-Bicocca Monza Italy
| | - Fabio Angeli
- Department of Medicine and Surgery University of Insubria Varese Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine Sapienza University of Rome Rome Italy
| | - Carlo M Barbagallo
- Biomedical Department of Internal Medicine and Specialistics University of Palermo Italy
| | - Michele Bombelli
- Department of Medicine and Surgery University of Milano-Bicocca Monza Italy
- Internal Medicine, Pio XI Hospital of Desio, ASST Brianza Desio Italy
| | - Federica Cappelli
- Department of Clinical and Experimental Medicine University of Pisa Italy
| | - Rosario Cianci
- Department of Translational and Precision Medicine Sapienza University of Rome Rome Italy
| | - Arrigo F G Cicero
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department Alma Mater Studiorum University of Bologna Bologna Italy
- IRCCS AOU S.Orsola di Bologna Bologna Italy
| | - Massimo Cirillo
- Department of Medicine "Scuola Medica Salernitana" University of Salerno Baronissi (SA) Italy
| | - Pietro Cirillo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation "Aldo Moro" University of Bari Bari Italy
| | - Raffaella Dell'oro
- Department of Medicine and Surgery University of Milano-Bicocca Monza Italy
| | - Lanfranco D'elia
- Department of Clinical Medicine and Surgery "Federico II" University of Naples Medical School Naples Italy
| | | | - Claudio Ferri
- Department of Life, Health and Environmental Sciences University of L'Aquila Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery "Federico II" University of Naples Medical School Naples Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation "Aldo Moro" University of Bari Bari Italy
| | - Cristina Giannattasio
- Cardiology IV, "A.De Gasperi's" Department Niguarda Ca' Granda Hospital Milan Italy
- School of Medicine and Surgery Milano-Bicocca University Milan Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences "Federico II" University of Naples Naples Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit Reggio Calabria Italy
| | - Alessandro Maloberti
- Cardiology IV, "A.De Gasperi's" Department Niguarda Ca' Granda Hospital Milan Italy
- School of Medicine and Surgery Milano-Bicocca University Milan Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine University of Pisa Italy
| | - Maria Masulli
- Department of Clinical Medicine and Surgery "Federico II" University of Naples Medical School Naples Italy
| | - Alberto Mazza
- Department of Internal Medicine Santa Maria della Misericordia General Hospital, AULSS 5 Polesana Rovigo Italy
| | | | | | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs University of Bari Medical School Bari Italy
| | - Paolo Palatini
- Studium Patavinum, Department of Medicine Università degli Studi di Padova Padua Italy
| | - Gianfranco Parati
- S. Luca Hospital Istituto Auxologico Italiano and University of Milan-Bicocca Milan Italy
| | - Roberto Pontremoli
- Department of Internal Medicine University of Genoa, and Policlinico San Martino Genoa Italy
| | | | - Marcello Rattazzi
- Department of Medicine Università degli Studi di Padova Via Giustiniani 8 Padua 35128 Italy
- Medicina Interna I Ca' Foncello University Hospital Treviso Italy
| | - Gianpaolo Reboldi
- Department of Medical and Surgical Science University of Perugia Italy
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine Careggi Hospital and University of Florence Italy
| | - Elisa Russo
- Department of Internal Medicine University of Genoa, and Policlinico San Martino Genoa Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences University of Brescia Italy
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation Istituti Clinici Scientifici Maugeri, IRCCS, Gattico-Veruno Italy
| | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology University of Rome Sapienza, Sant'Andrea Hospital Rome Italy
| | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine Careggi Hospital and University of Florence Italy
| | | | - Francesca Viazzi
- Department of Internal Medicine University of Genoa, and Policlinico San Martino Genoa Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology University of Rome Sapienza, Sant'Andrea Hospital Rome Italy
- IRCCS San Raffaele Rome Rome Italy
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department Alma Mater Studiorum University of Bologna Bologna Italy
- IRCCS AOU S.Orsola di Bologna Bologna Italy
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Groppelli A, Rivasi G, Fedorowski A, de Lange FJ, Russo V, Maggi R, Capacci M, Nawaz S, Comune A, Bianchi L, Zambon A, Soranna D, Ungar A, Parati G, Brignole M. Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance. Europace 2024; 26:euae026. [PMID: 38262617 PMCID: PMC10849184 DOI: 10.1093/europace/euae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
AIMS Systolic blood pressure (SBP) drops recorded by 24-h ambulatory blood pressure (BP) monitoring (ABPM) identify patients with susceptibility to reflex syncope and orthostatic intolerance. We tested the hypothesis that treatments aimed to increase BP (reassurance, education, and lifestyle measures plus pharmacological strategies) can reduce SBP drops. METHODS AND RESULTS This was a multicentre, observational proof-of-concept study performed in patients with reflex syncope and/or orthostatic intolerance and with SBP drops on a screening ABPM. Among 144 eligible patients, 111 underwent a second ABPM on average 2.5 months after start of treatment. Overall, mean 24-h SBP increased from 114.1 ± 12.1 to 121.4 ± 14.5 mmHg (P < 0.0001). The number of SBP drops <90 and <100 mmHg decreased by 61%, 46% during daytime, and by 48% and 37% during 24-h period, respectively (P < 0.0001 for all). The dose-response relationship between difference in 24-h average SBP increase and reduction in number of SBP drops reached a plateau around ∼15 mmHg increase of 24-h SBP. The reduction in SBP drop rate was consistent and significant in patients who underwent deprescription of hypotensive medications (n = 44) and in patients who received BP-rising drugs (n = 67). CONCLUSION In patients with reflex syncope and/or orthostatic intolerance, an increase in average 24-h SBP, regardless of the implemented strategy, significantly reduced the number of SBP drops and symptom burden. A 13 mmHg increase in 24-h SBP appears to represent the optimal goal for aborting the maximal number of SBP drops, representing a possible target for future interventions. ClincalTrials.gov identifier: NCT05729724.
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Affiliation(s)
- Antonella Groppelli
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Roberto Maggi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sara Nawaz
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Lorenzo Bianchi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Antonella Zambon
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gianfranco Parati
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dei daini 2, 20126 Milan, Italy
| | - Michele Brignole
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
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Rivasi G, Ceolin L, Turrin G, Tortu’ V, D’Andria MF, Testa GD, Montali S, Tonarelli F, Brunetti E, Bo M, Romero-Ortuno R, Mossello E, Ungar A. Prevalence and correlates of frailty in older hypertensive outpatients according to different tools: the HYPER-FRAIL pilot study. J Hypertens 2024; 42:86-94. [PMID: 37698894 PMCID: PMC10713004 DOI: 10.1097/hjh.0000000000003559] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/15/2023] [Accepted: 08/23/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES To date, few studies have investigated frailty in hypertensive individuals. This study aimed at identifying the prevalence of frailty in a sample of hypertensive older outpatients using six different identification tools. Clinical correlates of frailty and agreement between different frailty definitions were also investigated. METHODS The HYPER-FRAIL pilot study recruited hypertensive patients aged at least 75 years from two geriatric outpatient clinics of Careggi Hospital, Florence, Italy. Four frailty scales [Fried Frailty Phenotype, Frailty Index, Clinical Frailty Scale (CFS), Frailty Postal Score] and two physical performance tests [Short Physical Performance Battery (SPPB) and usual gait speed] were applied. The Cohen's kappa coefficient was calculated to assess agreement between measures. Multiple logistic regression was used to identify clinical features independently associated with frailty. RESULTS Among 121 participants (mean age 81, 60% women), frailty prevalence varied between 33 and 50% according to the tool used. Moderate agreement was observed between Fried Frailty Phenotype, Frailty Index and SPPB, and between Frailty Index and CFS. Agreement was minimal or weak between the remaining measures (K < 0.60). Use of walking aids and depressive symptoms were independently associated with frailty, regardless of the definition used. Frailty correlates also included dementia, disability and comorbidity burden, but not office and 24-h blood pressure values. CONCLUSION Frailty is highly prevalent among older hypertensive outpatients, but agreement between different frailty tools was moderate-to-weak. Longitudinal studies are needed to assess the prognostic role of different frailty tools and their clinical utility in the choice of antihypertensive treatment.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Ludovica Ceolin
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Giada Turrin
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Virginia Tortu’
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Maria Flora D’Andria
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Sara Montali
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Francesco Tonarelli
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza, Molinette, Turin, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza, Molinette, Turin, Italy
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology and Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
| | - Enrico Mossello
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
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Groppelli A, Rafanelli M, Testa GD, Agusto S, Rivasi G, Carbone E, Soranna D, Zambon A, Castiglioni P, Ungar A, Brignole M, Parati G. Detection of impending reflex syncope by means of an integrated multisensor patch-type recorder. J Hum Hypertens 2023; 37:1098-1104. [PMID: 37208523 DOI: 10.1038/s41371-023-00840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/20/2023] [Accepted: 05/04/2023] [Indexed: 05/21/2023]
Abstract
We assessed the capability of an integrated multisensory patch-type monitor (RootiRx®) in detecting episodes of reflex (pre)syncope induced by tilt table test (TTT). Firstly, we performed an intrapatient comparison of cuffless systolic blood pressure (SBP), R-R interval (RRI) and variability (power spectrum analysis) obtained by means of the RootiRx® with those obtained with conventional methods (CONV) with validated finger pressure devices at baseline in supine position and repeatedly during TTT in 32 patients affected by likely reflex syncope. Secondly, the LF/HF values obtained with RootiRx® during TTT were analyzed in 50 syncope patients. Compared with baseline supine recordings, during TTT a decrement of median SBP was observed with CONV (-53.5 mmHg) but not with RootiRx® ®(-1 mmHg). Conversely, RRI reduction (CONV: 102 ms; RootiRx®: 127 ms) and RRI Low Frequency/High Frequency powers ratio (LF/HF) increase (CONV: 1.6; RootiRx®: 2.5) were similar. The concordance was good for RRI (0.97 [95% CI 0.96-0.98]) and fair for LF/HF ratio (0.69 [95% CI 0.46-0.83]). During the first 5 min of TTT the LF/HF ratio was higher in patients who later developed syncope than in no-syncope patients. This ratio was significantly different among patients with syncope, presyncope or without symptoms at the time of syncope (p value = 0.02). In conclusion, cuffless RootiRx® was unable to detect rapid drops of SBP occurring during impending reflex syncope and thus cannot be used as a diagnostic tool for hypotensive syncope. On the other hand, RRI mean values and LF/HF power ratios obtained with RootiRx® were consistent with those simultaneously obtained using conventional methods.
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Affiliation(s)
- Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, San Luca Hospital, Milan, Italy
| | - Martina Rafanelli
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Dario Testa
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Samuele Agusto
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Erika Carbone
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Paolo Castiglioni
- IRCCS Fondazione Don C. Gnocchi ONLUS, Milan, Italy
- Department of Biotechnology and Life sciences (DBSV), University of Insubria, Varese, Italy
| | - Andrea Ungar
- Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, San Luca Hospital, Milan, Italy.
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, San Luca Hospital, Milan, Italy
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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Baldasseroni S, Bari MD, Pratesi A, Rivasi G, Stefàno P, Olivo G, Meo MLD, Orso F, Pace SD, Ungar A, Marchionni N. Prediction of worsening postoperative renal function in older candidates to elective cardiac surgery: Choosing the best eGFR formula may not be enough. Heart Lung 2023; 62:28-34. [PMID: 37295187 DOI: 10.1016/j.hrtlng.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Though renal impairment is highly prevalent in older patients and influence post-operative outcomes in cardiac surgery; its prognostic relevance is debated and not fully assessed by surgical risk scores. OBJECTIVE We investigated the predictive role of estimated glomerular filtration rate formulas for in-hospital worsening renal function (WRF) after cardiac surgery. METHODS We prospectively enrolled in single-center cohort study, patients aged ≥ 75 years candidate to elective cardiac surgery. Four creatinine-based equations were used to calculate estimated glomerular filtration rate (eGFR) formulas: Cockroft-Gault, Modification of Diet in Renal Disease, Chronic Kidney Disease Epidemiology, and Berlin Initiative Study 1 formulas. Each patient underwent geriatric and clinical evaluation before surgery with calculation of the Society of Thoracic Surgeons scores. In-hospital WRF was defined as a composite of an increase in SCr ≥0.5 mg/dl or the occurrence of grade III KDIGO acute kidney injury. The association between each eGFR equation, alone and in models including clinical variables, and WRF was analyzed using logistic regressions and ROC analysis. RESULTS WRF occurred in 69 patients (19.8%), and the predictors of WRF were previous acute myocardial infarction, hypertension, 4-mt gait speed performance, and preoperative eGFR, irrespective of the equation used. With all equations, inclusion of these additional variables in the logistic regression models improved the prediction of WRF (AUCs 0.798-0.810). CONCLUSIONS An accurate assessment of renal function and of physical performance should be incorporated into cardiac surgery risk scores to improve prediction of in-hospital WRF and, hence, risk stratification in older adults undergoing elective cardiac surgery.
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Affiliation(s)
- Samuele Baldasseroni
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Mauro Di Bari
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Alessandra Pratesi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Pierluigi Stefàno
- Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Giuseppe Olivo
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Maria Laura Di Meo
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesco Orso
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Del Pace
- Division of General Cardiology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Niccolò Marchionni
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
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8
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Rivasi G, D'Andria MF, Bulgaresi M, Sgrilli F, Casini G, Falzone D, Turrin G, Tortù V, Giordano A, Mossello E, Ungar A. Screening for cognitive impairment in older adults with hypertension: the HYPER-COG study. J Hum Hypertens 2023; 37:1000-1006. [PMID: 36932153 DOI: 10.1038/s41371-023-00817-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 02/07/2023] [Accepted: 03/03/2023] [Indexed: 03/19/2023]
Abstract
Hypertension is a major risk factor for dementia. Yet, the most suitable cognitive screening test for hypertensive patients has yet to be identified. This study investigated cognitive impairment in hypertensive older adults and compared the discriminative ability of the most widely used cognitive screening tests. The study involved hypertensive patients aged 65+ without prior diagnosis of cognitive impairment, from the Hypertension Clinic of Careggi Hospital, Florence, Italy. Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), MiniCog and Clock Drawing Test (CDT) were administered, using a comprehensive neuropsychological assessment as gold standard. The ROC curve analysis and the paired chi-square test were used to compare the discriminative ability, sensitivity and specificity for cognitive impairment of the different screening instruments. Cognitive impairment was diagnosed in 37% of 94 participants (mean age 76, 55% female), mainly involving attention and executive functions. The MoCA (AUC = 0.746), the MMSE (AUC = 0.689) and the MiniCog (AUC = 0.684) showed similar ability in detecting cognitive impairment, while the CDT had a poorer discriminative capacity (AUC = 0.535). The sensitivity of MoCA (80%) and of MMSE/MiniCog combination (74%) was higher in comparison with MiniCog alone (49%, p = 0.007 and 0.004, respectively), while MiniCog achieved the highest specificity (88%, p < 0.001 vs all). Cognitive impairment was detected in more than one-third of hypertensive older adults without prior diagnosis of dementia. MoCA, MMSE and MiniCog showed similar discriminative ability for cognitive impairment, with MoCa and MMSE showing greater sensitivity and MiniCog the highest specificity.
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Affiliation(s)
- Giulia Rivasi
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Maria Flora D'Andria
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Matteo Bulgaresi
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Federica Sgrilli
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Giulia Casini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Daniele Falzone
- Occupational Medicine Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giada Turrin
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Virginia Tortù
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Antonella Giordano
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Enrico Mossello
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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9
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Rivasi G, Fedorowski A. Harm vs. benefit of antihypertensive treatment in very old and frail people - do not miss the forest for the trees. J Hypertens 2023; 41:1551-1553. [PMID: 37642590 DOI: 10.1097/hjh.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Stockholm
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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10
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Maloberti A, Mengozzi A, Russo E, Cicero AFG, Angeli F, Agabiti Rosei E, Barbagallo CM, Bernardino B, Bombelli M, Cappelli F, Casiglia E, Cianci R, Ciccarelli M, Cirillo M, Cirillo P, Desideri G, D'Elia L, Dell'Oro R, Facchetti R, Ferri C, Galletti F, Giannattasio C, Gesualdo L, Iaccarino G, Lippa L, Mallamaci F, Masi S, Masulli M, Mazza A, Muiesan ML, Nazzaro P, Parati G, Palatini P, Pauletto P, Pontremoli R, Pugliese NR, Quarti-Trevano F, Rattazzi M, Reboldi G, Rivasi G, Salvetti M, Tikhonoff V, Tocci G, Ungar A, Verdecchia P, Viazzi F, Volpe M, Virdis A, Grassi G, Borghi C. The Results of the URRAH (Uric Acid Right for Heart Health) Project: A Focus on Hyperuricemia in Relation to Cardiovascular and Kidney Disease and its Role in Metabolic Dysregulation. High Blood Press Cardiovasc Prev 2023; 30:411-425. [PMID: 37792253 PMCID: PMC10600296 DOI: 10.1007/s40292-023-00602-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
The relationship between Serum Uric Acid (UA) and Cardiovascular (CV) diseases has already been extensively evaluated, and it was found to be an independent predictor of all-cause and cardiovascular mortality but also acute coronary syndrome, stroke and heart failure. Similarly, also many papers have been published on the association between UA and kidney function, while less is known on the role of UA in metabolic derangement and, particularly, in metabolic syndrome. Despite the substantial number of publications on the topic, there are still some elements of doubt: (1) the better cut-off to be used to refine CV risk (also called CV cut-off); (2) the needing for a correction of UA values for kidney function; and (3) the better definition of its role in metabolic syndrome: is UA simply a marker, a bystander or a key pathological element of metabolic dysregulation?. The Uric acid Right for heArt Health (URRAH) project was designed by the Working Group on uric acid and CV risk of the Italian Society of Hypertension to answer the first question. After the first papers that individuates specific cut-off for different CV disease, subsequent articles have been published responding to the other relevant questions. This review will summarise most of the results obtained so far from the URRAH research project.
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Affiliation(s)
- Alessandro Maloberti
- Cardiology IV, "A.De Gasperis" Department, Ospedale Niguarda Ca' Granda, Milan, Italy
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich, University of Zurich, Schlieren, Switzerland
| | - Elisa Russo
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico SanMartino, Genoa, Italy
| | - Arrigo Francesco Giuseppe Cicero
- Hypertension and Cardiovascular Risk Research Group, Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna, Italy.
- Cardiovascular Medicine Unit, IRCCS AOU S. Orsola di Bologna, Pad. 25 - 1st Floor, Via Massarenti, 9, 40138, Bologna, Italy.
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate, Varese, Italy
| | - Enrico Agabiti Rosei
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Carlo Maria Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo, Italy
| | - Bruno Bernardino
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Michele Bombelli
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Department of Internal Medicine, Pio XI Hospital of Desio, ASST Brianza, Desio, Italy
| | - Federica Cappelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Rosario Cianci
- Department of Translational and Precision Medicine, University of Rome La Sapienza, Rome, Italy
| | - Michele Ciccarelli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Massimo Cirillo
- Department of Public Health, ''Federico II'' University of Naples, Naples, Italy
| | - Pietro Cirillo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, ''Aldo Moro'' University of Bari, Bari, Italy
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Lanfranco D'Elia
- Department of Clinical Medicine and Surgery, ''Federico II'' University of Naples, Naples, Italy
| | - Raffaella Dell'Oro
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Clinica Medica, San Gerardo Hospital, Monza, Italy
| | - Rita Facchetti
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, ''Federico II'' University of Naples, Naples, Italy
| | - Cristina Giannattasio
- Cardiology IV, "A.De Gasperis" Department, Ospedale Niguarda Ca' Granda, Milan, Italy
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, ''Aldo Moro'' University of Bari, Bari, Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, ''Federico II'' University of Naples, Naples, Italy
| | - Luciano Lippa
- Italian Society of General Medicine (SIMG), Avezzano, L'Aquila, Italy
| | - Francesca Mallamaci
- Reggio Cal Unit, Clinical Epidemiology of Renal Diseases and Hypertension, CNR-IFC, Reggio Calabria, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Masulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari, Italy
| | - Gianfranco Parati
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Paolo Palatini
- Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Pauletto
- Medicina Interna I, Ca' Foncello University Hospital, Treviso, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico SanMartino, Genoa, Italy
| | | | - Fosca Quarti-Trevano
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Clinica Medica, San Gerardo Hospital, Monza, Italy
| | | | - Gianpaolo Reboldi
- Department of Medical and Surgical Science, University of Perugia, 06100, Perugia, Italy
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Sant'Andrea Hospital, Rome, Italy
- Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | | | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico SanMartino, Genoa, Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Sant'Andrea Hospital, Rome, Italy
- IRCCS San Raffaele, Rome, Italy
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Guido Grassi
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- Clinica Medica, San Gerardo Hospital, Monza, Italy
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Research Group, Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Cardiovascular Medicine Unit, IRCCS AOU S. Orsola di Bologna, Pad. 25 - 1st Floor, Via Massarenti, 9, 40138, Bologna, Italy
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11
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Fedorowski A, Kulakowski P, Brignole M, de Lange FJ, Kenny RA, Moya A, Rivasi G, Sheldon R, Van Dijk G, Sutton R, Deharo JC. Twenty-five years of research on syncope. Europace 2023; 25:euad163. [PMID: 37622579 PMCID: PMC10450792 DOI: 10.1093/europace/euad163] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last 25 years, the Europace journal has greatly contributed to dissemination of research and knowledge in the field of syncope. More than 400 manuscripts have been published in the journal. They undoubtedly improved our understanding of syncope. This symptom is now clearly differentiated from other forms of transient loss of consciousness. The critical role of vasodepression and/or cardioinhibition as final mechanisms of reflex syncope is emphasized. Current diagnostic approach sharply separates between cardiac and autonomic pathways. Physiologic insights have been translated, through rigorously designed clinical trials, into non-pharmacological or pharmacological interventions and interventional therapies. The following manuscript is intended to give the reader the current state of the art of knowledge of syncope by highlighting landmark contributions of the Europace journal.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Eugeniavägen 3, 171 76 Solna, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Solnavägen 1, 171 77 Solna, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, 214 28 Malmö, Sweden
| | - Piotr Kulakowski
- Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Ul. Grenadierow 51/59, 04-073 Warsaw, Poland
| | - Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Piazzale Brescia 20, 20149 Milan, Italy
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, 152-160 Pearse St, Dublin, Ireland
- Mercer Institute for Successful Ageing, St. James Hospital, James St, Dublin 8, D08 NHY1Ireland
| | - Angel Moya
- Department of Cardiology, Hospital Universitari Dexeus, Carrer de Sabino Arana 5-19, 08028 Barcelona, Spain
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Robert Sheldon
- Department of Cardiac Sciences, University of Calgary, Libin Cardiovascular Institute, 3310 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Gert Van Dijk
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | - Richard Sutton
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, Du Cane Road, London, W12 0HS, United Kingdom
| | - Jean-Claude Deharo
- Assistance Publique − Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France and Aix Marseille Université, C2VN, 264 Rue Saint-Pierre, 13005 Marseille, France
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12
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Rivasi G, Matteucci G, Ungar A. Antihypertensive treatment targets in older adults: an unsolved dilemma. Eur J Prev Cardiol 2023; 30:1015-1016. [PMID: 37235732 DOI: 10.1093/eurjpc/zwad182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Giulia Rivasi
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Largo Brambilla 3, Florence 50139, Italy
| | - Giulia Matteucci
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Largo Brambilla 3, Florence 50139, Italy
| | - Andrea Ungar
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Largo Brambilla 3, Florence 50139, Italy
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13
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Muiesan ML, Agabiti Rosei C, Paini A, Casiglia E, Cirillo M, Grassi G, Iaccarino G, Mallamaci F, Maloberti A, Mazza A, Mengozzi A, Palatini P, Parati G, Reboldi G, Rivasi G, Russo E, Salvetti M, Tikhonoff V, Tocci G, Borghi C. Serum uric acid and left ventricular mass index independently predict cardiovascular mortality: The uric acid right for heart health (URRAH) project. Eur J Intern Med 2023; 114:58-65. [PMID: 37098447 DOI: 10.1016/j.ejim.2023.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 04/27/2023]
Abstract
A relationship between serum uric acid (SUA) and cardiovascular (CV) events has been documented in the Uric Acid Right for Heart Health (URRAH) study. AIM of this study was to investigate the association between SUA and left ventricular mass index (LVMI) and whether SUA and LVMI or their combination may predict the incidence of CV death. METHODS Subjects with echocardiographic measurement of LVMI included in the URRAH study (n=10733) were part of this analysis. LV hypertrophy (LVH) was defined as LVMI > 95 g/m2 in women and 115 g/m2 in men. RESULTS A significant association between SUA and LVMI was observed in multiple regression analysis in men: beta 0,095, F 5.47, P< 0.001 and women: beta 0,069, F 4.36, P<0.001. During follow-up 319 CV deaths occurred. Kaplan-Meier curves showed a significantly poorer survival rate in subjects with higher SUA (> 5.6 mg/dl in men and 5.1 mg/dl in women) and LVH (log-rank chi-square 298.105; P<0.0001). At multivariate Cox regression analysis in women LVH alone and the combination of higher SUA and LVH but not hyperuricemia alone, were associated with a higher risk of CV death, while in men hyperuricemia without LVH, LVH without hyperuricemia and their combination were all associated with a higher incidence of CV death. CONCLUSIONS Our findings demonstrate that SUA is independently associated with LVMI and suggest that the combination of hyperuricemia with LVH is an independent and powerful predictor for CV death both in men and women.
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Affiliation(s)
- Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, c/o 2 Medicina - ASST Spedali Civili Brescia, Piazzale Spedali Civili 1 Brescia, Italy.
| | - Claudia Agabiti Rosei
- Department of Clinical and Experimental Sciences, University of Brescia, c/o 2 Medicina - ASST Spedali Civili Brescia, Piazzale Spedali Civili 1 Brescia, Italy
| | - Anna Paini
- Department of Clinical and Experimental Sciences, University of Brescia, c/o 2 Medicina - ASST Spedali Civili Brescia, Piazzale Spedali Civili 1 Brescia, Italy
| | - Edoardo Casiglia
- Studium Patavinum, Department of Medicine, University of Padua, Padua, Italy
| | - Massimo Cirillo
- Department of Public Health, "Federico II" University of Naples, Naples, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, ''Federico II'' University of Naples, Naples, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria, Italy
| | - Alessandro Maloberti
- Cardiology IV, ''A.De Gasperi's'' Department, Niguarda Ca' Granda Hospital, Milan, Italy; School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Santa Maria Della Misericordia General Hospital, AULSS 5 Polesana, 11Rovigo, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy; Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Schlieren, Switzerland; Scuola Superiore Sant'Anna, Pisa, Italy
| | - Paolo Palatini
- Studium Patavinum, Department of Medicine, University of Padua, Padua, Italy
| | - Gianfranco Parati
- IRCCS, Istituto Auxologico Italiano, Ospedale San Luca, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianpaolo Reboldi
- Department of Medical and Surgical Science, University of Perugia, Perugia, Italy
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Italy
| | - Elisa Russo
- Department of Internal Medicine, University of Genoa IRCSS Ospedale Policlinico San Martino, Genova, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, c/o 2 Medicina - ASST Spedali Civili Brescia, Piazzale Spedali Civili 1 Brescia, Italy
| | | | - Giuliano Tocci
- Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - Claudio Borghi
- Department Hypertension and Cardiovascular Disease Research Center, Medical and Surgical Sciences Dept., Alma Mater Studiorum University of Bologna, Bologna, Italy; Heart-Chest-Vascular Dept., IRCCS AOU of Bologna, Bologna, Italy
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14
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Bulgaresi M, Rivasi G, Tarantini F, Espinoza Tofalos S, Del Re LM, Salucci C, Turrin G, Barucci R, Bandinelli C, Fattorini L, Borchi D, Betti M, Checchi S, Baggiani L, Collini F, Lorini C, Bonaccorsi G, Ungar A, Mossello E, Benvenuti E. Impact of SARS-CoV2 infection on mortality and hospitalization in nursing home residents during the "Omicron era". Aging Clin Exp Res 2023; 35:1393-1399. [PMID: 37103663 PMCID: PMC10134704 DOI: 10.1007/s40520-023-02415-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Widespread vaccination and emergence of less aggressive SARS-CoV2 variants may have blunted the unfavourable outcomes of COVID-19 in nursing home (NH) residents. We analysed the course of COVID-19 epidemic in NHs of Florence, Italy, during the "Omicron era" and investigated the independent effect of SARS-CoV2 infection on death and hospitalization risk. METHODS Weekly SARS-CoV2 infection rates between November 2021 and March 2022 were calculated. Detailed clinical data were collected in a sample of NHs. RESULTS Among 2044 residents, 667 SARS-CoV2 cases were confirmed. SARS-CoV2 incidence sharply increased during the Omicron era. Mortality rates did not differ between SARS-CoV2-positive (6.9%) and SARS-CoV2-negative residents (7.3%, p = 0.71). Chronic obstructive pulmonary disease and poor functional status, but not SARS-CoV2 infection independently predicted death and hospitalization. CONCLUSIONS Despite that SARS-CoV2 incidence increased during the Omicron era, SARS-CoV2 infection was not a significant predictor of hospitalization and death in the NH setting.
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Affiliation(s)
- Matteo Bulgaresi
- Geriatric Unit, Local Health Unit "Toscana Centro", Santa Maria Annunziata Hospital, Florence, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.
| | - Francesca Tarantini
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Sofia Espinoza Tofalos
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Lorenzo Maria Del Re
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Caterina Salucci
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Giada Turrin
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Riccardo Barucci
- Geriatric Unit, Local Health Unit "Toscana Centro", Santa Maria Annunziata Hospital, Florence, Italy
| | - Chiara Bandinelli
- Geriatric Unit, Local Health Unit "Toscana Centro", Santa Maria Annunziata Hospital, Florence, Italy
| | - Letizia Fattorini
- Department of Health Science, University of Florence, Florence, Italy
| | - Daniele Borchi
- Department of Health Science, University of Florence, Florence, Italy
| | - Marta Betti
- Department of Health Science, University of Florence, Florence, Italy
| | - Saverio Checchi
- Department of Health Science, University of Florence, Florence, Italy
| | - Lorenzo Baggiani
- Department of Community Healthcare Network, Health District "Toscana Centro", Florence, Italy
| | - Francesca Collini
- Quality and Equity Unit, Regional Health Agency of Tuscany, 50141, Florence, Italy
| | - Chiara Lorini
- Department of Health Science, University of Florence, Florence, Italy
| | | | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Enrico Mossello
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Enrico Benvenuti
- Geriatric Unit, Local Health Unit "Toscana Centro", Santa Maria Annunziata Hospital, Florence, Italy
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15
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Sharad B, Rivasi G, Hamrefors V, Johansson M, Ungar A, Sutton R, Brignole M, Parati G, Fedorowski A. Twenty-Four-Hour Ambulatory Blood Pressure Profile in Patients With Reflex Syncope and Matched Controls. J Am Heart Assoc 2023; 12:e028704. [PMID: 37026553 PMCID: PMC10227244 DOI: 10.1161/jaha.122.028704] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 04/08/2023]
Abstract
Background Ambulatory blood pressure (BP) monitoring has long been used to monitor BP in hypertension and lately emerged as a useful tool to detect hypotensive susceptibility in reflex syncope. However, hemodynamic characteristics in reflex syncope have not been sufficiently explored. The present study investigated the differences between ambulatory BP monitoring profiles associated with reflex syncope and normal population. Methods and Results This is an observational study comparing ambulatory BP monitoring data from 50 patients with reflex syncope and 100 controls without syncope, age- and sex-matched 1:2. Mean 24-hour systolic (SBP) and diastolic BP, pulse pressure (24-hour PP), dipping status, and number of daytime SBP drops <90 to 100 mm Hg were analyzed. Variables associated with reflex syncope were investigated using multivariable logistic regression. Patients with reflex syncope displayed significantly lower 24-hour SBP (112.9±12.6 versus 119.3±11.5 mm Hg, P=0.002), higher 24-hour diastolic BP (85.2±9.6 versus 79.1±10.6 mm Hg, P<0.001), and markedly lower 24-hour PP (27.7±7.6 versus 40.3±9.0 mm Hg, P<0.001) compared with controls. Daytime SBP drops <90 mm Hg were more prevalent in patients with syncope (44% versus 17%, P<0.001). Daytime SBP drops <90 mm Hg, 24-hour PP <32 mm Hg, 24-hour SBP ≤110 mm Hg, and 24-hour diastolic BP ≥82 mm Hg were independently associated with reflex syncope, with 24-hour PP <32 mm Hg achieving the highest sensitivity (80%) and specificity (86%). Conclusions Patients with reflex syncope have lower 24-hour SBP but higher 24-hour diastolic BP and more frequent daytime SBP drops <90 mm Hg than individuals without syncope. Our results support the presence of lower SBP and PP in reflex syncope and suggest a role for ambulatory BP monitoring in the diagnostic work-up of this condition.
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Affiliation(s)
- Bashaaer Sharad
- Department of Clinical SciencesLund University, and Skåne University HospitalMalmöSweden
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care MedicineUniversity of Florence and Azienda Ospedaliero Universitaria CareggiFlorenceItaly
| | - Viktor Hamrefors
- Department of Clinical SciencesLund University, and Skåne University HospitalMalmöSweden
- Department of CardiologySkåne University HospitalMalmöSweden
| | - Madeleine Johansson
- Department of Clinical SciencesLund University, and Skåne University HospitalMalmöSweden
- Department of CardiologySkåne University HospitalMalmöSweden
| | - Andrea Ungar
- Division of Geriatric and Intensive Care MedicineUniversity of Florence and Azienda Ospedaliero Universitaria CareggiFlorenceItaly
| | - Richard Sutton
- Department of Clinical SciencesLund University, and Skåne University HospitalMalmöSweden
- Department of Cardiology, National Heart & Lung Institute, Imperial CollegeHammersmith Hospital CampusLondonUnited Kingdom
| | - Michele Brignole
- IRCCS, Istituto Auxologico Italiano, Cardiology UnitS.Luca HospitalMilanItaly
- Department of Cardiovascular, Neural and Metabolic SciencesS.Luca HospitalMilanItaly
| | - Gianfranco Parati
- IRCCS, Istituto Auxologico Italiano, Cardiology UnitS.Luca HospitalMilanItaly
- Department of Cardiovascular, Neural and Metabolic SciencesS.Luca HospitalMilanItaly
| | - Artur Fedorowski
- Department of Clinical SciencesLund University, and Skåne University HospitalMalmöSweden
- Department of CardiologyKarolinska University HospitalStockholmSweden
- Department of MedicineKarolinska InstituteStockholmSweden
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16
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Rivasi G, Ceolin L, Capacci M, Matteucci G, Testa GD, Ungar A. Risks associated with intensive blood pressure control in older patients. Kardiol Pol 2023:VM/OJS/J/94846. [PMID: 36999732 DOI: 10.33963/kp.a2022.0297] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 03/26/2023] [Indexed: 04/01/2023]
Abstract
Hypertension management forms a cornerstone of cardiovascular prevention. Strong evidence is available supporting the benefits of blood pressure (BP) lowering in older adults and recent studies indicate that intensive BP control may provide additional advantages on cardiovascular and mortality risk, also at older ages. Yet, in older adults the cardiovascular benefit of intensive treatment may come at the expense of increase in adverse events. Indeed, advanced age and frailty may modify the risk/benefit ratio of BP lowering due to a greater predisposition to hypotension and more severe consequences deriving from treatment-related adverse effects. This mostly applies to individuals with poor health status and limited life expectancy, in whom aggressive BP lowering may not lead to cardiovascular benefits, but rather increase the risk of short-term treatment-related complications. Furthermore, the potential harms of intensive BP control might be underestimated in clinical trials due to exclusion criteria which preclude patients with frailty and multimorbidity from being eligible. Syncope and falls are the most frequently mentioned antihypertensive-related safety concern, but aggressive BP lowering may negatively affect also renal function, cognitive performance, quality of life and survival. With the growing emphasis on intensive treatment strategies, raising awareness on potential harms associated with aggressive BP lowering might help improve hypertension management in older adults and encourage implementation of clinical research on safety issues. Given these premises, we present a narrative review illustrating the most relevant risk potentially associated with intensive BP control in older patients.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy.
| | - Ludovica Ceolin
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Giulia Matteucci
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
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17
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Russo V, Parente E, Groppelli A, Rivasi G, Tomaino M, Gargaro A, Giacopelli D, Ungar A, Parati G, Fedorowski A, Sutton R, van Dijk JG, Brignole M. Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology. Europace 2023; 25:263-269. [PMID: 36796797 PMCID: PMC10103574 DOI: 10.1093/europace/euac154] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.
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Affiliation(s)
- Vincenzo Russo
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Erika Parente
- Chair of Cardiology, University of the Study of Campania 'Luigi Vanvitelli', Ospedale Monaldi, Via Leonardo Bianchi, 80131 Napoli, Italy
| | - Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Marco Tomaino
- Ospedale Generale Regionale, Via Lorenz Böhler, 5, 39100 Bolzano, Italy
| | - Alessio Gargaro
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Daniele Giacopelli
- Research Clinical Unit, BIOTRONIK Italia S.p.A., Via Alessandro Volta 16, 20093 Cologno, Monzese, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Nobels väg 6, 171 77 Solna, Stockholm, Sweden
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, PO Box 9600, 2300RC Leiden, The Netherlands
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Cardiology Unit and Department of Cardiology, S.Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy
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18
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Mengozzi A, Pugliese NR, Desideri G, Masi S, Angeli F, Barbagallo CM, Bombelli M, Cappelli F, Casiglia E, Cianci R, Ciccarelli M, Cicero AFG, Cirillo M, Cirillo P, Dell’Oro R, D’Elia L, Ferri C, Galletti F, Gesualdo L, Giannattasio C, Grassi G, Iaccarino G, Lippa L, Mallamaci F, Maloberti A, Masulli M, Mazza A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Pontremoli R, Quarti-Trevano F, Rattazzi M, Reboldi G, Rivasi G, Russo E, Salvetti M, Tikhonoff V, Tocci G, Ungar A, Verdecchia P, Viazzi F, Volpe M, Borghi C, Virdis A. Serum Uric Acid Predicts All-Cause and Cardiovascular Mortality Independently of Hypertriglyceridemia in Cardiometabolic Patients without Established CV Disease: A Sub-Analysis of the URic acid Right for heArt Health (URRAH) Study. Metabolites 2023; 13:metabo13020244. [PMID: 36837863 PMCID: PMC9959524 DOI: 10.3390/metabo13020244] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
High serum uric acid (SUA) and triglyceride (TG) levels might promote high-cardiovascular risk phenotypes across the cardiometabolic spectrum. However, SUA predictive power in the presence of normal and high TG levels has never been investigated. We included 8124 patients from the URic acid Right for heArt Health (URRAH) study cohort who were followed for over 20 years and had no established cardiovascular disease or uncontrolled metabolic disease. All-cause mortality (ACM) and cardiovascular mortality (CVM) were explored by the Kaplan-Meier estimator and Cox multivariable regression, adopting recently defined SUA cut-offs for ACM (≥4.7 mg/dL) and CVM (≥5.6 mg/dL). Exploratory analysis across cardiometabolic subgroups and a sensitivity analysis using SUA/serum creatinine were performed as validation. SUA predicted ACM (HR 1.25 [1.12-1.40], p < 0.001) and CVM (1.31 [1.11-1.74], p < 0.001) in the whole study population, and according to TG strata: ACM in normotriglyceridemia (HR 1.26 [1.12-1.43], p < 0.001) and hypertriglyceridemia (1.31 [1.02-1.68], p = 0.033), and CVM in normotriglyceridemia (HR 1.46 [1.23-1.73], p < 0.001) and hypertriglyceridemia (HR 1.31 [0.99-1.64], p = 0.060). Exploratory and sensitivity analyses confirmed our findings, suggesting a substantial role of SUA in normotriglyceridemia and hypertriglyceridemia. In conclusion, we report that SUA can predict ACM and CVM in cardiometabolic patients without established cardiovascular disease, independent of TG levels.
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Affiliation(s)
- Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, 8952 Schlieren, Switzerland
- Scuola Superiore Sant’Anna, 56127 Pisa, Italy
- Correspondence: or or ; Tel.:+39-05-099-2558
| | | | - Giovambattista Desideri
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate, 21100 Varese, Italy
| | - Carlo Maria Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, 90100 Palermo, Italy
| | - Michele Bombelli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Federica Cappelli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Edoardo Casiglia
- Studium Patavinum, Department of Medicine, University of Padua, 35100 Padua, Italy
| | - Rosario Cianci
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Michele Ciccarelli
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, 80133 Naples, Italy
| | - Arrigo F. G. Cicero
- Department Hypertension and Cardiovascular Disease Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy
- Heart-Chest-Vascular Department, IRCCS AOU of Bologna, 40126 Bologna, Italy
| | - Massimo Cirillo
- Department of Public Health, “Federico II” University of Naples, 80133 Naples, Italy
| | - Pietro Cirillo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, 70122 Bari, Italy
| | - Raffaella Dell’Oro
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Lanfranco D’Elia
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, 80133 Naples, Italy
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, 80133 Naples, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, 70122 Bari, Italy
| | - Cristina Giannattasio
- Cardiology IV, “A.De Gasperi’s” Department, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, 80133 Naples, Italy
| | - Luciano Lippa
- Italian Society of General Medicine (SIMG), 67051 Avezzano, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, 89124 Reggio Calabria, Italy
| | - Alessandro Maloberti
- Cardiology IV, “A.De Gasperi’s” Department, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, 80133 Naples, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Santa Maria Della Misericordia General Hospital, AULSS 5 Polesana, 45100 Rovigo, Italy
| | - Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, 25121 Brescia, Italy
| | - Pietro Nazzaro
- Department of Precision and Regenerative Medicine and Jonic Area (DiMePRe-J), Neurosciences and Sense Organs, University of Bari Medical School, 70122 Bari, Italy
| | - Paolo Palatini
- Studium Patavinum, Department of Medicine, University of Padua, 35100 Padua, Italy
| | - Gianfranco Parati
- S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, 20126 Milan, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa; IRCSS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Marcello Rattazzi
- Department of Medicine—DIMED, University of Padova, Medicina Interna 1°, Ca’ Foncello University Hospital, 31100 Treviso, Italy
| | - Gianpaolo Reboldi
- Department of Medical and Surgical Science, University of Perugia, 06100 Perugia, Italy
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, 50121 Florence, Italy
| | - Elisa Russo
- Department of Internal Medicine, University of Genoa; IRCSS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, 25121 Brescia, Italy
| | | | - Giuliano Tocci
- Department of Clinical and Molecular Medicine, University of Rome Sapienza, 00185 Rome, Italy
| | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, 50121 Florence, Italy
| | | | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa; IRCSS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, University of Rome Sapienza, 00185 Rome, Italy
| | - Claudio Borghi
- Department Hypertension and Cardiovascular Disease Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy
- Heart-Chest-Vascular Department, IRCCS AOU of Bologna, 40126 Bologna, Italy
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Abstract
INTRODUCTION Treatment efficacy of reflex syncope is mainly related to the mechanism underlying syncope rather than its etiology or clinical presentation. The predominant mechanism underlying reflex syncope can be assigned to hypotensive or to bradycardic phenotypes. AREAS COVERED Methodology and diagnostic criteria of the most useful tests for the identification of hypotensive and bradycardic phenotypes are discussed. Diagnostic tests for the hypotensive phenotype include office blood pressure measurement with active standing test, home, and wearable blood pressure monitoring, 24-h ambulatory blood pressure monitoring and tilt table test. Diagnostic tests for the bradycardic phenotype include carotid sinus massage, tilt table test and prolonged ECG monitoring. EXPERT OPINION In reflex syncope, the documentation of bradycardia/asystole during a syncopal episode does not rule out the possibility that a preceding or parallel hypotensive reflex plays an important role. Similarly, even when a hypotensive mechanism is established, the possibility of an associated cardioinhibitory reflex should be investigated. Investigating the mechanism of reflex syncope is mandatory in patients with severe recurrent episodes, with the final aim to develop a personalized treatment strategy. Recent trials have demonstrated the benefits of personalized mechanism-based therapy, thus highlighting the importance of a comprehensive assessment of the mechanisms underlying syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Marcus Ståhlberg
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Antonella Groppelli
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Mariotti A, Gallo M, Stracci D, Pecoraro A, Mariottini R, Serni S, Rivasi G, Campi R, Testa G. Preliminary results of a novel uro-geriatric pathways: How good are the scores of frailty to categorize frailty among elderly patients? Eur Urol 2023. [DOI: 10.1016/s0302-2838(23)00372-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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21
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Palatini P, Virdis A, Masi S, Mengozzi A, Casiglia E, Tikhonoff V, Cicero AFG, Ungar A, Parati G, Rivasi G, Salvetti M, Barbagallo CM, Bombelli M, Dell'Oro R, Bruno B, Lippa L, D'Elia L, Masulli M, Verdecchia P, Reboldi G, Angeli F, Mallamaci F, Cirillo M, Rattazzi M, Cirillo P, Gesualdo L, Mazza A, Giannattasio C, Maloberti A, Volpe M, Tocci G, Iaccarino G, Nazzaro P, Galletti F, Ferri C, Desideri G, Viazzi F, Pontremoli R, Muiesan ML, Grassi G, Borghi C. Hyperuricemia increases the risk of cardiovascular mortality associated with very high HdL-cholesterol level. Nutr Metab Cardiovasc Dis 2023; 33:323-330. [PMID: 36642602 DOI: 10.1016/j.numecd.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Whether the association between very high HDL-cholesterol levels and cardiovascular mortality (CVM) is modulated by some facilitating factors is unclear. Aim of the study was to investigate whether the risk of CVM associated with very high HDL-cholesterol is increased in subjects with hyperuricemia. METHODS AND RESULTS Multivariable Cox analyses were made in 18,072 participants from the multicentre URRAH study stratified by sex and HDL-cholesterol category. During a median follow-up of 11.4 years there were 1307 cases of CVM. In multivariable Cox models a J-shaped association was found in the whole population, with the highest risk being present in the high HDL-cholesterol group [>80 mg/dL, adjusted hazard ratio (HR), 1.28; 95%CI, 1.02-1.61; p = 0.031)]. However, a sex-specific analysis revealed that this association was present only in women (HR, 1.34; 95%CI, 1.02-1.77; p = 0.034) but not in men. The risk of CVM related to high HDL-cholesterol was much greater in the women with high uric acid (>0.30 mmol/L, HR 1.61; 95%CI, 1.08-2.39) than in those with low uric acid (HR, 1.17; 95%CI, 0.80-1.72, p for interaction = 0.016). In women older than 70 years with hyperuricemia the risk related to high HDL-cholesterol was 1.83 (95%CI, 1.19-2.80, p < 0.005). Inclusion of BMI in the models weakened the strength of the associations. CONCLUSION Our data indicate that very high HDL-cholesterol levels in women are associated with CVM in a J-shaped fashion. The risk of CVM is increased by concomitant hyperuricemia suggesting that a proinflammatory/oxidative state can enhance the detrimental cardiovascular effects associated with high HDL-cholesterol.
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Affiliation(s)
- Paolo Palatini
- Department of Medicine, Studium Patavinum, University of Padova, Padua, Italy.
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | | | | | | | | | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Italy
| | - Gianfranco Parati
- S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy
| | - Giulia Rivasi
- Department of Medical and Surgical Science, University of Perugia, Perugia, Italy; Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Carlo M Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo, Italy
| | - Michele Bombelli
- Department of Cardiovascular, Neural and Metabolic Sciences, Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Raffaella Dell'Oro
- Department of Cardiovascular, Neural and Metabolic Sciences, Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Berardino Bruno
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Luciano Lippa
- Italian Society of General Medicine (SIMG), Avezzano, L'Aquila, Italy
| | - Lanfranco D'Elia
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples Medical School, Naples, Italy
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples Medical School, Naples, Italy
| | | | - Gianpaolo Reboldi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy; Department of Medicine and Cardiopulmonary Rehabilitation. Maugeri Care and Research Institutes, IRCCS Tradate, Varese, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria, Italy
| | - Massimo Cirillo
- Department of Public Health, "Federico II" University of Naples, Napoli, Italy
| | - Marcello Rattazzi
- Department of Medicine - DIMED, University of Padova, Medicina Interna 1, Ca' Foncello University Hospital, Treviso, Italy
| | - Pietro Cirillo
- Department of Emergency and Organ Transplantation - Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation - Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Hypertension Unit, General Hospital, Rovigo, Italy
| | - Cristina Giannattasio
- Cardiology IV, 'A. De Gasperis' Department, Niguarda Ca' Granda Hospital, Health Science Department, Milano-Bicocca University, Milano, Italy
| | - Alessandro Maloberti
- Cardiology IV, 'A. De Gasperis' Department, Niguarda Ca' Granda Hospital, Health Science Department, Milano-Bicocca University, Milano, Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy; IRCCS Neuromed, Pozzilli (IS), Italy
| | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy; IRCCS Neuromed, Pozzilli (IS), Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, "Federico II" University of Naples, Napoli, Italy
| | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples Medical School, Naples, Italy
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genova, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genova, Italy
| | | | - Guido Grassi
- Department of Cardiovascular, Neural and Metabolic Sciences, Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Claudio Borghi
- Alma Mater Studiorum University of Bologna, Bologna, Italy
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22
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Casiglia E, Tikhonoff V, Virdis A, Grassi G, Angeli F, Barbagallo CM, Bombelli M, Cicero AF, Cirillo M, Cirillo P, Dell’Oro R, D’elia L, Desideri G, Ferri C, Galletti F, Gesualdo L, Giannattasio C, Iaccarino G, Lippa L, Mallamaci F, Masi S, Maloberti A, Masulli M, Mazza A, Mengozzi A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Pontremoli R, Quarti-Trevano F, Rattazzi M, Reboldi G, Rivasi G, Salvetti M, Tocci G, Ungar A, Verdecchia P, Viazzi F, Volpe M, Borghi C. Serum uric acid / serum creatinine ratio as a predictor of cardiovascular events. Detection of prognostic cardiovascular cut-off values. J Hypertens 2023; 41:180-186. [PMID: 36453660 PMCID: PMC9794153 DOI: 10.1097/hjh.0000000000003319] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE In the frame of the Uric Acid Right for Heart Health (URRAH) study, a nationwide multicenter study involving adult participants recruited on a regional community basis from all the territory of Italy under the patronage of the Working Group on Uric Acid and Cardiovascular Risk of the Italian Society of Hypertension, we searched for the cut-off values of the ratio between serum uric acid (SUA) and serum creatinine (sCr) able to predict cardiovascular (CV) events. METHODS Among 20 724 participants followed-up for 126 ± 64 months, after detecting cut-off by the receiver operating characteristic curves, we calculated by Cox models adjusted for confounders having CV events as dependent variable the hazard ratio (HR) of SUA/sCr > cut-off. We also verified if the role of cut-off varied with increasing SUA/sCr. RESULTS A plausible prognostic cut-off of SUA/sCr was found and was the same in the whole database, in men and in women (>5.35). The HR of SUA/sCr > cut-off was 1.159 (95% confidence interval [CI] 1.092-1.131, P < 0.03) in all, 1.161 (95% CI 1.021-1.335, P < 0.02) in men, and 1.444 (95% CI 1.012-1.113, P < 0.03) in women. In increasing quintiles of SUA/sCr the cut-offs were >3.08, >4.87, >5.35, >6.22 and >7.58, respectively. The HRs significantly increased from the 3rd to the 5th quintile (1.21, 95% CI 1.032-1.467, P = 0.018; 1.294, 95% CI 1.101-1.521, P = 0.002; and 1.642, 95% CI 1.405-1.919, P < 0.0001; respectively), that is, over 5.35, whereas the 2nd quintile was not significantly different from the 1st (reference). CONCLUSION Having SUA/sCr >5.35 is an independent CV risk indicator both in men and women. The cut-off is dynamic and significantly increases with increasing SUA/sCr.
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Affiliation(s)
| | | | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese
| | - Carlo M. Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo
| | - Michele Bombelli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Arrigo F.G. Cicero
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna
| | - Massimo Cirillo
- Department of Public Health, “Federico II” University of Naples, Naples
| | - Pietro Cirillo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, Bari
| | - Raffaella Dell’Oro
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Lanfranco D’elia
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples Medical School, Naples
| | | | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples Medical School, Naples
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, Bari
| | - Cristina Giannattasio
- Cardiology IV, “A.De Gasperi's” Department, Niguarda Ca’ Granda Hospital, Milan
- School of Medicine and Surgery, Milano-Bicocca University, Milan
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, Naples
| | - Luciano Lippa
- Italian Society of General Medicine (SIMG), Avezzano, L’Aquila
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Alessandro Maloberti
- Cardiology IV, “A.De Gasperi's” Department, Niguarda Ca’ Granda Hospital, Milan
- School of Medicine and Surgery, Milano-Bicocca University, Milan
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples Medical School, Naples
| | - Alberto Mazza
- Department of Internal Medicine, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo
| | | | | | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari
| | | | - Gianfranco Parati
- S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa, and Policlinico San Martino, Genoa
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Marcello Rattazzi
- Department of Medicine, University of Padua, Padua
- Medicina Interna I, Ca’ Foncello University Hospital, Treviso
| | - Gianpaolo Reboldi
- Department of Medical and Surgical Science, University of Perugia, Perugia
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant’Andrea Hospital, Rome
| | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | | | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa, and Policlinico San Martino, Genoa
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant’Andrea Hospital, Rome
| | - Claudio Borghi
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna
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23
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Fumagalli C, Rafanelli M, Brignole M, Guarducci C, Bettoni N, Rivasi G, Pieragnoli P, Ricciardi G, Checchi L, Gambardella M, Casolaro F, Paolisso G, Marfella R, Signoriello G, Marchionni N, Ungar A, Sardu C. Low incidence of arrhythmic syncope and pacemaker implantation in older patients with bifascicular block and implantable cardiac monitor. Int J Cardiol 2023; 370:215-218. [PMID: 36332751 DOI: 10.1016/j.ijcard.2022.10.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/04/2022] [Accepted: 10/30/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND In patients with unexplained syncope, bifascicular block (BFB) is considered associated with syncope due to either heart block or sinus arrest. Immediate or delayed pacemaker (PM) implantation after ECG documentation of syncopal recurrence by means of implantable cardiac monitors (ICM) is still debated. We aimed to assess the incidence of recurrent syncope and guideline-based PM implantation in patients with syncope and BFB implanted with ICM. METHODS Consecutive patients with syncope and BFB followed at two tertiary care syncope units and implanted with ICM from 2012 to 2020 were retrospectively reviewed. Only patients with ≥2 clinical visits and ≥ 18 years of age were included. Incidence of a Class I indication for PM implantation was the primary outcome. RESULTS Of 635 syncope patients implanted with an ICM, 55 (8.7%) had a BFB and were included. Median age at implantation was 75 [interquartile range, IQR:64-81] years, and 28(49.1%) were women. At 26 [IQR:12-41] months follow-up, 20 (36.3%,16.3%/year) patients experienced syncope: in 6(10.9%) patients syncope was classified 'arrhythmic' with a higher prevalence in older individuals (p = 0.048). PM implantation (N = 14,25.5%) was more frequent in patients ≥75 years (p = 0.024). At survival analysis, patients ≥75 years were at highest risk of arrhythmic syncope and guideline directed PM implantation (Hazard Ratio: 4.5, 95% Confidence Intervals 1.5-13.3). CONCLUSIONS Most older patients with syncope who received an ICM did not have events during follow-up. One-in-three experienced syncope, and an even smaller number had an arrhythmic syncope with indication for PM implantation. Older age was strongly associated with PM implantation.
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Affiliation(s)
- Carlo Fumagalli
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy.
| | - Martina Rafanelli
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy
| | - Michele Brignole
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy; Department of Cardiovascular, Neural and Metabolic Sciences, Faint and Fall Programme, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Caterina Guarducci
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy
| | - Niccolò Bettoni
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy
| | - Giulia Rivasi
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy
| | - Paolo Pieragnoli
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, Italy
| | - Giuseppe Ricciardi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, Italy
| | - Luca Checchi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, Italy
| | - Marco Gambardella
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, Italy
| | - Flavia Casolaro
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, Naples, Italy
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, Naples, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, Naples, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Giuseppe Signoriello
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, Naples, Italy
| | - Niccolò Marchionni
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy
| | - Andrea Ungar
- Syncope Unit, Geriatrics and Intensive Care Unit, University of Florence, Careggi Hospital, Florence, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, Naples, Italy
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24
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Mancusi C, Bisogni V, Maloberti A, Manzi MV, Visco V, Biolcati M, Giani V, Spannella F, Monticone S, Saladini F, Rivasi G, Turrin G, Pucci G, Pengo M, Bertacchini F, Ferri C, Grassi G, Muiesan ML, Fucile I, Sorvillo G, Grieco F, Jacobitti G, Di Costanzo A, Vittoria Govetosa M, D’Avino G, D’Agosto D, Schiavi P, Biondini S, Ristori L. Accuracy of home blood pressure measurement: the ACCURAPRESS study – a proposal of Young Investigator Group of the Italian Hypertension Society (Società Italiana dell’Ipertensione Arteriosa). Blood Press 2022; 31:297-304. [DOI: 10.1080/08037051.2022.2137461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Costantino Mancusi
- Hypertension Research Center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Valeria Bisogni
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Unit of Internal Medicine, Terni University Hospital, Terni, Italy
| | - Alessandro Maloberti
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
- ASST GOM Niguarda Hospital, Milan, Italy
| | - Maria Virginia Manzi
- Hypertension Research Center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Valeria Visco
- Department of Medicine, Surgery and Dentistry, University of Salerno, Fisciano, Italy
| | - Marco Biolcati
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Valentina Giani
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Francesco Spannella
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | - Silvia Monticone
- Department of Clinical and Molecular Sciences, University “Politecnica delle Marche”, Ancona, Italy
| | | | - Giulia Rivasi
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giada Turrin
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giacomo Pucci
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Unit of Internal Medicine, Terni University Hospital, Terni, Italy
| | - Martino Pengo
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Fabio Bertacchini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy and 2a Medicina ASST Spedali Civili di Brescia, Brescia, Italy
| | - Claudio Ferri
- MeSVA Department and San Salvatore Hospital, UOC Internal Medicine and Nephrology, University of L’Aquila, L’Aquila, Italy
| | - Guido Grassi
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy and 2a Medicina ASST Spedali Civili di Brescia, Brescia, Italy
| | - Ilaria Fucile
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Gianmarco Sorvillo
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Fabrizia Grieco
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Giulia Jacobitti
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Anita Di Costanzo
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Maria Vittoria Govetosa
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Giuseppina D’Avino
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
| | - Domenico D’Agosto
- Hypertension Research center and Department of Advanced Biomedical Science, Federico II University of Naples, Napoli, Italy
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25
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Rivasi G, Brignole M, Groppelli A, Soranna D, Zambon A, Sutton R, Kenny RA, Ungar A, Fedorowski A, Parati G. New definition of hypotension in patients with reflex syncope using 24-hour ambulatory blood pressure monitoring (SynABPM Study). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Diagnostic criteria for ambulatory blood pressure monitoring (ABPM) in patients with suspected reflex syncope are lacking.
Purpose
We hypothesized that patients with reflex syncope have a higher prevalence of systolic blood pressure (SBP) drops on ABPM than control subjects and we aimed to define the SBP cut-off values that allow identification of patients with hypotensive susceptibility.
Methods
We compared ABPM data from reflex syncope patients and controls, matched by average 24-hour SBP, age, sex and hypertension. Patients with constitutional hypotension, orthostatic hypotension, predominant cardioinhibition or competing causes of syncope were excluded. Daytime and night-time SBP drops (<110, 100, 90, 80 mmHg) were assessed. Findings were validated in an independent sample.
Results
In the Derivation cohort, daytime SBP drops were significantly more common in 158 syncope patients than 329 controls. One or more daytime drop <90 mmHg provided the best diagnostic yield (91% specificity, 32% sensitivity, Odds Ratio [OR]=4.6, p=0.001). Two or more-daytime drops <100 mmHg achieved 84% specificity and 40% sensitivity (OR=3.5, p=0.001). Results were confirmed in the Validation cohort: one or more daytime SBP drop <90 mmHg provided 94% specificity and 29% sensitivity (OR=6.2, p<0.001), while two or more daytime SBP drops <100 mmHg achieved 83% specificity and 35% sensitivity (OR=2.6, p<0.001) (Figure 1).
Conclusion
SBP drops during ABPM are more common in reflex syncope patients than in controls. Cut-off values that may be applied in clinical practice are defined. This study expands the current indications for ABPM to patients with reflex syncope.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- G Rivasi
- University of Florence , Florence , Italy
| | - M Brignole
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - A Groppelli
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - D Soranna
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - A Zambon
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - R Sutton
- Imperial College London , London , United Kingdom
| | - R A Kenny
- Trinity College Dublin , Dublin , Ireland
| | - A Ungar
- University of Florence , Florence , Italy
| | - A Fedorowski
- Karolinska University Hospital , Stockholm , Sweden
| | - G Parati
- Italian Auxological Institute San Luca Hospital , Milan , Italy
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Groppelli A, Rafanelli M, Testa GD, Agusto S, Rivasi G, Ungar A, Carbone E, Soranna D, Zambon A, Brignole M, Parati G. Feasibility of Blood Pressure Measurement With a Wearable (Watch-Type) Monitor During Impending Syncopal Episodes. J Am Heart Assoc 2022; 11:e026420. [PMID: 35929469 PMCID: PMC9496316 DOI: 10.1161/jaha.122.026420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background We assessed the reliability and feasibility of blood pressure (BP) measurements by means of a new wearable watch‐type BP monitor (HeartGuide) in detecting episodes of hypotensive (pre)syncope induced by tilt table test. Methods and Results An intrapatient comparison between systolic BP (SBP) measured by means of the HeartGuide device and noninvasive finger beat‐to‐beat BP monitoring was undertaken both at baseline in supine position and repeatedly during tilt table test in patients evaluated for reflex syncope. Intrapatient fall of systolic BP from baseline was measured. Eighty‐one patients (mean age, 61±19 years; 46 women) were included. Overall, HeartGuide was able to yield BP values at the time of BP nadir in 58 (72%) patients (average HeartGuide SBP 102±18 mm Hg, versus finger SBP 101±19 mm Hg). Compared with baseline, the maximum SBP decrease was on average −28.5±27.8 and −30.3±33.9 mm Hg respectively (Lin's concordance correlation coefficient=0.78, r=0.79, P=0.001). In the subgroup of 38 patients with tilt table test induced (pre)syncope, the average HeartGuide SBP during symptoms was 97±16 mm Hg, and the finger SBP was 94±18 mm Hg. Compared with baseline, the maximum SBP decrease was on average −35.2±29.3 and −43.3±31.8 mm Hg, respectively (Lin's concordance correlation coefficient=0.83, r=0.87, P=0.001). Conclusions Our data indicate that the HeartGuide BP monitor can detect low BP during presyncope and that its measure of SBP change is consistent with that simultaneously obtained through continuous BP monitoring, despite some intrapatient variability. Thus, this device might be useful in determining the hypotensive nature of spontaneous (pre)syncopal symptoms, a possibility that should be verified by field studies.
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Affiliation(s)
- Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Martina Rafanelli
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Giuseppe Dario Testa
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Samuele Agusto
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Andrea Ungar
- Syncope Unit, Division of Geriatric and Intensive Care Medicine University of Florence and Azienda Ospedaliero Universitaria Careggi Florence Italy
| | - Erika Carbone
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Antonella Zambon
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy.,Department of Statistics University of Milano-Bicocca Milan Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Cardiology Unit and Department of Cardiology San Luca Hospital Milan Italy.,Department of Medicine and Surgery University of Milano Bicocca Milan Italy
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27
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Rivasi G, Groppelli A, Brignole M, Soranna D, Zambon A, Bilo G, Pengo M, Sharad B, Hamrefors V, Rafanelli M, Testa GD, Rice C, Kenny RA, Sutton R, Ungar A, Fedorowski A, Parati G. Association between hypotension during 24 h ambulatory blood pressure monitoring and reflex syncope: the SynABPM 1 study. Eur Heart J 2022; 43:3765-3776. [PMID: 35766175 PMCID: PMC9553097 DOI: 10.1093/eurheartj/ehac347] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/25/2022] [Accepted: 06/15/2022] [Indexed: 01/06/2023] Open
Abstract
AIMS Diagnostic criteria for ambulatory blood pressure monitoring (ABPM) in patients with suspected reflex syncope are lacking. The study hypothesis was that patients with reflex syncope have a higher prevalence of systolic blood pressure (SBP) drops on ABPM. METHODS AND RESULTS ABPM data from reflex syncope patients and controls, matched by average 24 h SBP, age, sex, and hypertension were compared. Patients with constitutional hypotension, orthostatic hypotension, and predominant cardioinhibition during carotid sinus massage or prolonged electrocardiogram monitoring or competing causes of syncope were excluded. Daytime and nighttime SBP drops (<110, 100, 90, 80 mmHg) were assessed. Findings were validated in an independent sample. In the derivation sample, daytime SBP drops were significantly more common in 158 syncope patients than 329 controls. One or more daytime drops <90 mmHg achieved 91% specificity and 32% sensitivity [odds ratio (OR) 4.6, P < 0.001]. Two or more daytime drops <100 mmHg achieved 84% specificity and 40% sensitivity (OR 3.5, P = 0.001). Results were confirmed in the validation sample of 164 syncope patients and 164 controls: one or more daytime SBP drops <90 mmHg achieved 94% specificity and 29% sensitivity (OR 6.2, P < 0.001), while two or more daytime SBP drops <100 mmHg achieved 83% specificity and 35% sensitivity (OR 2.6, P < 0.001). CONCLUSION SBP drops during ABPM are more common in reflex syncope patients than in controls. Cut-off values that may be applied in clinical practice are defined. This study expands the current indications for ABPM to patients with reflex syncope.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Antonella Groppelli
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiology, S.Luca Hospital, 20149 Milan, Italy
| | - Michele Brignole
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiology, S.Luca Hospital, 20149 Milan, Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico Italiano, Biostatistics Unit, 20149 Milan, Italy
| | - Antonella Zambon
- IRCCS Istituto Auxologico Italiano, Biostatistics Unit, 20149 Milan, Italy.,Department of Statistics and quantitative methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Grzegorz Bilo
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiology, S.Luca Hospital, 20149 Milan, Italy
| | - Martino Pengo
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiology, S.Luca Hospital, 20149 Milan, Italy
| | - Bashaaer Sharad
- Department of Clinical Sciences, Lund University, and Skåne University Hospital, 50332 Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, and Skåne University Hospital, 50332 Malmö, Sweden
| | - Martina Rafanelli
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Ciara Rice
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - Rose Anne Kenny
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland.,Department of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, and Skåne University Hospital, 50332 Malmö, Sweden.,Department of Cardiology, National Heart & Lung Institute, Imperial College, Hammersmith Hospital Campus, London W12 0HS, UK
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, and Skåne University Hospital, 50332 Malmö, Sweden.,Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, 171 77 Stockholm, Sweden
| | - Gianfranco Parati
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiology, S.Luca Hospital, 20149 Milan, Italy
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28
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Rivasi G, Menale S, Turrin G, Coscarelli A, Giordano A, Ungar A. The Effects of Pain and Analgesic Medications on Blood Pressure. Curr Hypertens Rep 2022; 24:385-394. [PMID: 35704141 PMCID: PMC9509303 DOI: 10.1007/s11906-022-01205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
Purpose of Review To review the blood pressure (BP) effects of pain and analgesic medications and to help interpret BP changes in people suffering from acute or chronic pain. Recent Findings Acute pain evokes a stress response which prompts a transient BP increase. Chronic pain is associated with impaired regulation of cardiovascular and analgesia systems, which may predispose to persistent BP elevation. Also analgesics may have BP effects, which vary according to the drug class considered. Data on paracetamol are controversial, while multiple studies indicate that non-steroidal anti-inflammatory drugs may increase BP, with celecoxib showing a lesser impact. Hypotension has been reported with opioid drugs. Among adjuvants, tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors could be pro-hypertensive due to potentiation of adrenergic transmission. Summary Pain and analgesics may induce a clinically significant BP destabilization. The implications on hypertension incidence and BP control remain unclear and should be explored in future studies. Graphical abstract ![]()
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Affiliation(s)
- Giulia Rivasi
- Hypertension Clinic, Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy.
| | - Silvia Menale
- Hypertension Clinic, Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Giada Turrin
- Hypertension Clinic, Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Antonio Coscarelli
- Hypertension Clinic, Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Antonella Giordano
- Hypertension Clinic, Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Andrea Ungar
- Hypertension Clinic, Syncope Unit, Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
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29
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Mantovani G, Marozzi I, Rafanelli M, Rivasi G, Volpato S, Ungar A. Supine hypertension: A state of the art. Auton Neurosci 2022; 241:102988. [DOI: 10.1016/j.autneu.2022.102988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/30/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
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30
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Masulli M, D'Elia L, Angeli F, Barbagallo CM, Bilancio G, Bombelli M, Bruno B, Casiglia E, Cianci R, Cicero AFG, Cirillo M, Cirillo P, Dell'Oro R, Desideri G, Ferri C, Gesualdo L, Giannattasio C, Grassi G, Iaccarino G, Lippa L, Mallamaci F, Maloberti A, Masi S, Mazza A, Mengozzi A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Pontremoli R, Quarti-Trevano F, Rattazzi M, Reboldi G, Rivasi G, Salvetti M, Tikhonoff V, Tocci G, Ungar A, Verdecchia P, Viazzi F, Virdis A, Volpe M, Borghi C, Galletti F. Serum uric acid levels threshold for mortality in diabetic individuals: The URic acid Right for heArt Health (URRAH) project. Nutr Metab Cardiovasc Dis 2022; 32:1245-1252. [PMID: 35282979 DOI: 10.1016/j.numecd.2022.01.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIM The URRAH (URic acid Right for heArt Health) Study has identified cut-off values of serum uric acid (SUA) predictive of total mortality at 4.7 mg/dl, and cardiovascular (CV) mortality at 5.6 mg/dl. Our aim was to validate these SUA thresholds in people with diabetes. METHODS AND RESULTS The URRAH subpopulation of people with diabetes was studied. All-cause and CV deaths were evaluated at the end of follow-up. A total of 2570 diabetic subjects were studied. During a median follow-up of 107 months, 744 deaths occurred. In the multivariate Cox regression analyses adjusted for several confounders, subjects with SUA ≥5.6 mg/dl had higher risk of total (HR: 1.23, 95%CI: 1.04-1.47) and CV mortality (HR:1.31, 95%CI:1.03-1.66), than those with SUA <5.6 mg/dl. Increased all-cause mortality risk was shown in participants with SUA ≥4.7 mg/dl vs SUA below 4.7 mg/dl, but not statistically significant after adjustment for all confounders. CONCLUSIONS SUA thresholds previously proposed by the URRAH study group are predictive of total and CV mortality also in people with diabetes. The threshold of 5.6 mg/dl can predict both total and CV mortality, and so is candidate to be a clinical cut-off for the definition of hyperuricemia in patients with diabetes.
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Affiliation(s)
- Maria Masulli
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy
| | - Lanfranco D'Elia
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Varese, Italy and Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate, Varese, Italy
| | - Carlo M Barbagallo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Giancarlo Bilancio
- Department "Scuola Medica Salernitana", Baronissi, SA, University of Salerno
| | - Michele Bombelli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Berardino Bruno
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Edoardo Casiglia
- Studium Patavinum, Department of Medicine, University of Padua, Padua, Italy
| | - Rosario Cianci
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Arrigo F G Cicero
- Hypertension and Cardiovascular Risk Factors Research Center, Medical and Surgical Sciences Department, University of Bologna, Bologna, Italy
| | - Massimo Cirillo
- Department of Public Health, "Federico II" University of Naples, Naples, Italy
| | - Pietro Cirillo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, "Aldo Moro" University of Bari, Bari, Italy
| | - Raffaella Dell'Oro
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, "Aldo Moro" University of Bari, Bari, Italy
| | - Cristina Giannattasio
- Cardiology IV, "A.De Gasperi's" Department, Niguarda Ca' Granda Hospital, Milan, Italy; School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, "Federico II" University of Naples, Naples, Italy
| | - Luciano Lippa
- Italian Society of General Medicine, Avezzano, L'Aquila, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria, Italy
| | - Alessandro Maloberti
- Cardiology IV, "A.De Gasperi's" Department, Niguarda Ca' Granda Hospital, Milan, Italy; School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Santa Maria Della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Pietro Nazzaro
- Department of Biomedical Science and Oncology, University of Bari, Bari, Italy
| | - Paolo Palatini
- Studium Patavinum, Department of Medicine, University of Padua, Padua, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marcello Rattazzi
- Studium Patavinum, Department of Medicine, University of Padua, Padua, Italy; Medicina Interna I, Ca' Foncello University Hospital, Treviso, Italy
| | - Gianpaolo Reboldi
- Department of Medicine and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Perugia, Italy
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | | | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Factors Research Center, Medical and Surgical Sciences Department, University of Bologna, Bologna, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy.
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31
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Ungar A, Rivasi G, Di Bari M, Virdis A, Casiglia E, Masi S, Mengozzi A, Barbagallo CM, Bombelli M, Bruno B, Cicero AF, Cirillo M, Cirillo P, Desideri G, D’elia L, Ferri C, Galletti F, Gesualdo L, Giannattasio C, Iaccarino G, Ciccarelli M, Lippa L, Mallamaci F, Maloberti A, Mazza A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Pontremoli R, Quarti-Trevano F, Rattazzi M, Salvetti M, Tikhonoff V, Tocci G, Cianci R, Verdecchia P, Viazzi F, Volpe M, Grassi G, Borghi C. The association of uric acid with mortality modifies at old age: data from the uric acid right for heart health (URRAH) study. J Hypertens 2022; 40:704-711. [PMID: 34939996 PMCID: PMC10863659 DOI: 10.1097/hjh.0000000000003068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/03/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In older individuals, the role of serum uric acid (SUA) as risk factor for mortality is debated. This study investigated the association of SUA with all-cause and cardiovascular (CV) mortality in older adults participating in the large multicentre observational uric acid right for heart health (URRAH) study. METHODS Eight thousand URRAH participants aged 65+ were included in the analysis. The predictive role of SUA was assessed using Cox regression models stratified according to the cut-off age of 75. SUA was tested as continuous and categorical variable (age-specific quartiles). The prognostic threshold of SUA for mortality was analysed using receiver operating characteristic curves. RESULTS Among participants aged 65-74, multivariate Cox regression analysis adjusted for CV risk factors and comorbidities identified an independent association of SUA with both all-cause mortality (hazard ratio [HR] 1.169, 95% confidence interval [CI] 1.107-1.235) and CV mortality (HR 1.146, 95% CI 1.064-1.235). The cut-off value of 4.8 mg/dl discriminated mortality status. In participants aged 75+, we observed a J-shaped relationship of SUA with all-cause and CV mortality, with risk increasing at extreme SUA levels. CONCLUSIONS These results confirmed the predictive role of SUA for all-cause and CV mortality in older adults, while revealing considerable age-related differences. Mortality risk increased at higher SUA levels in participants aged 65-74, with a prognostic threshold of 4.8 mg/dl. The relationship between SUA and mortality was J-shaped in oldest participants. Large interventional studies are needed to clarify the benefits and possible risks of urate-lowering treatments in older adults.
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Affiliation(s)
- Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Mauro Di Bari
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | | | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | | | - Carlo M. Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo
| | - Michele Bombelli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Bernardino Bruno
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila
| | - Arrigo F.G. Cicero
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna
| | - Massimo Cirillo
- Department of Public Health, “Federico II” University of Naples, Naples
| | - Pietro Cirillo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, Bari
| | | | - Lanfranco D’elia
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples Medical School, Naples
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples Medical School, Naples
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, Bari
| | - Cristina Giannattasio
- Cardiology IV, “A.De Gasperi's” Department, Niguarda Ca’ Granda Hospital, Milan
- School of Medicine and Surgery, Milano-Bicocca University, Milan
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, "Federico II" University of Naples, Naples
| | - Michele Ciccarelli
- Department of Medicine Surgery and Odontology, University of Salerno, Fisciano
| | - Luciano Lippa
- Italian Society of General Medicine (SIMG), Avezzano, L’Aquila
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria
| | - Alessandro Maloberti
- Cardiology IV, “A.De Gasperi's” Department, Niguarda Ca’ Granda Hospital, Milan
- School of Medicine and Surgery, Milano-Bicocca University, Milan
| | - Alberto Mazza
- Department of Internal Medicine, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo
| | | | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari
| | | | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Marcello Rattazzi
- Department of Medicine, University of Padua, Padua
- Medicina Interna I, Ca’ Foncello University Hospital, Treviso
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | | | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant’Andrea Hospital, Rome
- IRCCS Neuromed, Pozzilli
| | | | | | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant’Andrea Hospital, Rome
- IRCCS Neuromed, Pozzilli
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Claudio Borghi
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna
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Ungar A, Ceccofiglio A, Mussi C, Bo M, Rivasi G, Rafanelli M, Martone AM, Bellelli G, Nicosia F, Riccio D, Boccardi V, Tonon E, Curcio F, Landi F, Abete P, Mossello E. Truly unexplained falls after evaluation for syncope: A new diagnostic entity with severe prognosis. Eur J Intern Med 2022; 98:93-97. [PMID: 35172944 DOI: 10.1016/j.ejim.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare one-year mortality risk associated with syncope and unexplained fall in older adults with dementia. METHODS 522 patients (aged >65 years) with dementia and history of transient loss of consciousness and/or unexplained falls were evaluated. The diagnosis of syncope was based on European Society of Cardiology guidelines. A "Syncopal Fall" was defined in patients with an initial clinical presentation of unexplained fall, but a final diagnosis of syncope after complete assessment. A "Truly Unexplained Fall" was defined in patients with an initial clinical presentation of unexplained fall, in whom a diagnosis of syncope had been excluded after the diagnostic work-up. One-year follow-up was assessed by phone interview. RESULTS Follow-up data were available for 501 participants (mean age 83 ± 6 years, 65% female). After a mean follow-up of 324 ± 93 days, death from any cause was reported in 188 participants (24%). Advanced age, male sex, cognitive and functional impairment were associated with a higher mortality rate. Patients with "Truly Unexplained Falls" had a higher mortality risk compared with syncope and "Syncopal Fall". A diagnosis of "Truly Unexplained Falls" remained an independent predictor of one-year all-cause mortality in multivariate model. CONCLUSIONS We propose the novel diagnostic category of "Truly Unexplained Fall", resulting from the application of syncope guidelines to subjects with unexplained falls. This condition in older adults with dementia is a predictor of one-year all-cause mortality. For this new high risk profile, we advice a comprehensive geriatric assessment focused on risk factors for fall, aimed at a possible improvement of prognosis.
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Affiliation(s)
- Andrea Ungar
- Department of Medicine and Geriatrics, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla, Florence 50139, Italy.
| | - Alice Ceccofiglio
- Department of Medicine and Geriatrics, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla, Florence 50139, Italy
| | - Chiara Mussi
- Centro di Valutazione e Ricerca Gerontologica, Chair of Geriatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - Mario Bo
- SCDU Geriatria e Malattie Metaboliche dell'Osso, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giulia Rivasi
- Department of Medicine and Geriatrics, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla, Florence 50139, Italy
| | - Martina Rafanelli
- Department of Medicine and Geriatrics, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla, Florence 50139, Italy
| | - Anna Maria Martone
- Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy; Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Giuseppe Bellelli
- Department of Health Sciences, University of Milano Bicocca and Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - Franco Nicosia
- Medicine and Geriatric Unit - Spedali Civili of Brescia, Brescia, Italy
| | - Daniela Riccio
- Geriatric Department, SS. Trinità Hospital, Cagliari, Italy
| | - Virginia Boccardi
- Department of Medicine, Institute of Gerontology and Geriatrics, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | | | - Francesco Curcio
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Francesco Landi
- Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy; Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Enrico Mossello
- Department of Medicine and Geriatrics, Syncope Unit, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla, Florence 50139, Italy
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Rivasi G, Bulgaresi M, Bandinelli C, Balzi D, Tarantini F, Tognelli S, Lorini C, Buscemi P, Baggiani L, Landini G, Ungar A, Bonaccorsi G, Mossello E, Benvenuti E. Long‐term effects of
SARS‐CoV
‐2 vaccination in the nursing home setting. J Am Geriatr Soc 2022; 70:1336-1341. [PMID: 35347706 PMCID: PMC9115053 DOI: 10.1111/jgs.17773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/02/2022] [Accepted: 03/12/2022] [Indexed: 12/01/2022]
Abstract
Background SARS‐CoV‐2 vaccination has significantly reduced infection, hospitalization, and lethality rates among nursing home (NH) residents, but durability of vaccine effects remains unknown. This study investigated the long‐term impact of BNT162b2 SARS‐CoV‐2 vaccine on breakthrough infection rates in the NHs of Florence, Italy. Methods Participants included residents living in Florence NHs as of April 1st, 2021, who had completed the primary SARS‐CoV2 vaccination course by February 15th, 2021. Weekly rates of breakthrough infection were calculated between April 1st and October 31st 2021, with 7‐day incidence defined as the number of new confirmed SARS‐CoV‐2‐positive residents over the vaccinated resident census. Hospital admissions and deaths were recorded from local administrative and clinical sources. Patients admitted to NHs after April 1st were excluded to avoid confounding effect of different vaccination timing. Results Among 2271 vaccinated residents (mean age 86.6, 74% female), we recorded 105 cases of breakthrough infections. Rates of breakthrough infection remained very low in the 6 months after vaccination, but started to rise over the following months, peaking at 0.94%, and then became stable around 0.2%–0.3%. Over the study period, infection rates remained low as compared to the incidence of SARS‐CoV‐2 infection during pre‐vaccination period. Overall hospitalization and lethality rates were 8%. Conclusions Among vaccinated NH residents, rates of breakthrough SARS‐CoV‐2 infection, hospitalization and lethality remained low up to 9 months following primary vaccination course. A mild resurgence of SARS‐CoV‐2 infection, after 6 months from vaccination, suggests a decline of vaccine effectiveness in preventing transmission.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine Careggi Hospital and University of Florence Florence Italy
| | - Matteo Bulgaresi
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence Italy
| | - Chiara Bandinelli
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence Italy
| | - Daniela Balzi
- Epidemiology Unit, Health District "Toscana Centro", Florence Italy
| | - Francesca Tarantini
- Division of Geriatric and Intensive Care Medicine Careggi Hospital and University of Florence Florence Italy
| | - Silvia Tognelli
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence Italy
| | - Chiara Lorini
- Department of Health Science University of Florence Florence Italy
| | - Primo Buscemi
- Department of Health Science University of Florence Florence Italy
| | - Lorenzo Baggiani
- Department of Community Healthcare Network Health District "Toscana Centro" Florence Italy
| | - Giancarlo Landini
- Department of Internal Medicine Santa Maria Nuova Hospital, Health District "Toscana Centro," Florence Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine Careggi Hospital and University of Florence Florence Italy
| | | | - Enrico Mossello
- Division of Geriatric and Intensive Care Medicine Careggi Hospital and University of Florence Florence Italy
| | - Enrico Benvenuti
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence Italy
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Abstract
Aims Methods and results Conclusion
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Affiliation(s)
| | | | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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Brignole M, Iori M, Strano S, Tomaino M, Rivasi G, Ungar A, Carretta D, Solari D, Napoli P, Deharo JC, Guieu R. Theophylline in patients with syncope without prodrome, normal heart, and normal electrocardiogram: a propensity-score matched study verified by implantable cardiac monitor. Europace 2021; 24:1164-1170. [PMID: 34849728 DOI: 10.1093/europace/euab300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/16/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Syncope without prodromes in subjects with normal heart and normal electrocardiogram (ECG) is classified as non-classical neurally mediated syncope and is characterized by low adenosine plasma levels (APLs) and frequent asystolic syncope. We assessed the efficacy of theophylline, a non-selective adenosine receptor antagonist, in preventing syncopal events. METHODS AND RESULTS Participants received an implantable cardiac monitor, underwent APL measurement, and received oral theophylline at maximum tolerated dose (starting dose 300 mg b.i.d.). They were compared with a historical cohort of untreated patients with implantable cardiac monitor who had the same inclusion criteria and were balanced with the propensity score (PS) method as regard age, sex, lifetime syncopal episodes, APL, and antihypertensive drugs. Primary endpoint was time to first syncopal recurrence at 24 months. There were 76 patients in the theophylline group and 58 in the control group. Syncope recurred in 25 (33%) patients in the theophylline group and in 27 (47%) patients in the control group, with an estimated 2-year recurrence rate of 33% and 60%, respectively, and a hazard ratio of 0.53 [95% confidence interval (CI), 0.30-0.95; P = 0.034]. Most of the benefit of theophylline is derived from reduction of syncope due to asystolic atrioventricular (AV) block (hazard ratio of 0.13; 95% CI, 0.03-0.58; P = 0.008). Thirty (39%) patients discontinued theophylline after a median of 6.4 (interquartile range 1.7-13.8) months due to side effects. CONCLUSION Theophylline was effective in preventing recurrences in patients with syncope without prodromes, normal heart, and normal ECG. The benefit was greater in patients with syncope due to asystolic AV block. CLINICALTRIALS.GOV IDENTIFIER NCT03803215.
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Affiliation(s)
- Michele Brignole
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS, Istituto Auxologico Italiano, Faint & Fall Programme, S. Luca Hospital, Piazzale Brescia 2, 20149 Milan, Italy.,Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy
| | - Matteo Iori
- Department of Cardiology, Ospedale S. Maria Nuova, Reggio Emilia, Italy
| | - Stefano Strano
- Department of Heart and Great Vessels 'A. Reale' Sapienza, University of Rome, Rome, Italy
| | - Marco Tomaino
- Department of Cardiology, Ospedale di Bolzano, Bolzano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Domenico Carretta
- Department of Cardiology, Azienda Ospedaliero-Universitaria Consorziale, Policlinico, Bari, Italy
| | - Diana Solari
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy
| | - Paola Napoli
- Research Clinical Unit, Biotronik Italy, Vimodrone, Italy
| | | | - Regis Guieu
- Laboratory of Biochemistry, Timone Hospital, Marseille, France.,Laboratory of Biochemistry, C2VN INSERM, INRAE, Aix Marseille University, Marseille, France
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36
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Rivasi G, Mossello E, Turrin G, D'Andria MF, Tortù V, Ceolin L, Coscarelli A, Fedeli A, Rafanelli M, Brignole M, Ungar A. Hypotensive episodes revealed by ambulatory blood pressure monitoring in nursing home residents. J Am Geriatr Soc 2021; 70:902-905. [PMID: 34800288 PMCID: PMC9299255 DOI: 10.1111/jgs.17570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/31/2021] [Accepted: 11/05/2021] [Indexed: 01/20/2023]
Affiliation(s)
- Giulia Rivasi
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Enrico Mossello
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Giada Turrin
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Maria Flora D'Andria
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Virginia Tortù
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Ludovica Ceolin
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Antonio Coscarelli
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Angela Fedeli
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Martina Rafanelli
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Michele Brignole
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiovascular Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
| | - Andrea Ungar
- Hypertension Clinic, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
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Campi R, Berni A, Amparore D, Bertolo R, Capitanio U, Carbonara U, Erdem S, Ingels A, Kara O, Klatte T, Kriegmair M, Marchioni M, Minervini A, Mir MC, Papalia R, Pavan N, Pecoraro A, Gomez Rivas J, Rivasi G, Roussel E, Ungar A, Serni S, Esperto F. Impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for renal cancer: a systematic review. Minerva Urol Nephrol 2021; 74:146-160. [PMID: 34714036 DOI: 10.23736/s2724-6051.21.04583-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Frailty has been recognized as a major risk factor for adverse perioperative and oncological outcomes in patients with genitourinary malignancies. Yet, the evidence supporting such an association in patients with renal cell carcinoma (RCC) is still sparse. Herein we provide an updated comprehensive overview of the impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for RCC. EVIDENCE ACQUISITION A systematic review of the English-language literature was conducted using the MEDLINE (Via PubMed), Web of Science and the Cochrane Library databases according to the principles highlighted by the EAU Guidelines Office and the PRISMA statement recommendations. The review protocol was registered on PROSPERO (CRD42021242516). The overall quality of evidence was assessed according to GRADE recommendations. EVIDENCE SYNTHESIS Overall, 18 studies were included in the qualitative analysis. Most of these were retrospective single-centre series including patients undergoing surgery for non-metastatic RCC. The overall quality of evidence was low. A variety of measures were used for frailty assessment, including the Canadian Study of Health and Aging Frailty Index, the five-item frailty index, the Modified Rockwood's Clinical Frailty Scale Score, the Hopkins Frailty score, the Groningen Frailty Index, and the Geriatric nutritional risk index. Sarcopenia was defined based on the Lumbar skeletal muscle mass at cross-sectional imaging, the skeletal muscle index, the total psoas area, or the psoas muscle index. Overall, available studies point to frailty and sarcopenia as potential independent risk factors for worse perioperative and oncological outcomes after surgery or ablation for different RCC stages. Increased patient's frailty was indeed associated with higher risk of perioperative complications, healthcare resources utilization, readmission rates and longer hospitalization periods, as well as potentially lower cancer specific or overall survival. CONCLUSIONS Frailty has been consistently associated with worse outcomes after surgery for RCC, reinforcing the value of preoperative frailty assessment in carefully selected patients. Given the low quality of the available evidence (especially in the setting of tumour ablation), prospective studies are needed to standardize frailty assessments and to identify patients who are expected to benefit most from preoperative geriatric evaluation, aiming to optimize decision-making and postoperative outcomes in patients with RCC.
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Affiliation(s)
- Riccardo Campi
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy - .,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy - .,European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group -
| | - Alessandro Berni
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy
| | - Daniele Amparore
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Riccardo Bertolo
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Department of Urology, San Carlo Di Nancy Hospital, Rome, Italy
| | - Umberto Capitanio
- Department of Urology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Umberto Carbonara
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Department of Emergency and Organ Transplantation-Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Selcuk Erdem
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Division of Urologic Oncology, Department of Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Alexandre Ingels
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Department of Urology, University Hospital Henri Mondor, APHP, Créteil, France.,Biomaps, UMR1281, INSERM, CNRS, CEA, Université Paris Saclay, Villejuif, France
| | - Onder Kara
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Department of Urology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Tobias Klatte
- Department of Surgery, University of Cambridge, Cambridge, UK.,Department of Urology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Maximilian Kriegmair
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Department of Urology, University Medical Centre Mannheim, Mannheim, Germany
| | - Michele Marchioni
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University G D'Annunzio Chieti-Pescara, Chieti, Italy.,Department of Urology, SS Annunziata Hospital, G D'Annunzio University of Chieti, Chieti, Italy
| | - Andrea Minervini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Unit of Urological Oncologic Minimally-Invasive Robotic Surgery and Andrology, Careggi Hospital, University of Florence, Florence, Italy
| | - Maria C Mir
- Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain
| | - Rocco Papalia
- Department of Urology, Campus Bio-Medico University, Rome, Italy
| | - Nicola Pavan
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Angela Pecoraro
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Juan Gomez Rivas
- Department of Urology, La Paz University Hospital, Madrid, Spain.,European Society of Residents in Urology (ESRU), Arnhem, the Netherlands
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Eduard Roussel
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group.,Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | - Sergio Serni
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Esperto
- Department of Urology, Campus Bio-Medico University, Rome, Italy.,European Society of Residents in Urology (ESRU), Arnhem, the Netherlands
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Rivasi G, Ungar A, Moya A, Brignole M, Sutton R, Fedorowski A. Syncope: new solutions for an old problem. Kardiol Pol 2021; 79:1068-1078. [PMID: 34668180 DOI: 10.33963/kp.a2021.0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Indexed: 11/23/2022]
Abstract
Syncope is a frequent event in the general population. Approximately 1%-2% of all emergency department admissions are due to syncope and at least one-third of all people experience fainting in their life. Although consequences of cardiac syncope are generally feared, non-cardiac syncope is much more common and may be associated with severe injuries and quality-of-life impairment, particularly in older adults. Various diagnostic and therapeutic strategies have been created and implemented over decades, leading to significant improvements in diagnostic accuracy and treatment effectiveness. In recent years, diagnosis and treatment have further evolved according to an innovative approach focused on the hemodynamic mechanism underlying syncope, based upon the assumption that knowledge of the syncope mechanism is a prerequisite for effective syncope prevention and treatment. Therefore, a new classification of syncope has been proposed, which defines two main syncope phenotypes with different predominant mechanisms: the hypotensive phenotype, where hypotension or vasodepression prevails, and the bradycardic phenotype, where cardioinhibition prevails. Identification of syncope phenotype - bradycardic or hypotensive/vasodepressive - represents the first step towards personalized management of syncope, characterized by customized interventions for prevention. The present review aims to illustrate these new developments in the diagnosis and therapy of non-cardiac syncope within a mechanism-based perspective. Diagnosis and therapy of bradycardic and hypotensive phenotypes are discussed, with a focus on recent evidence.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Angel Moya
- Cardiology and Arrhythmia Unit, University Hospital Dexeus, Barcelona, Spain
| | - Michele Brignole
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
| | - Richard Sutton
- Department of Cardiology, National Heart & Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Stockholm, Sweden
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39
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Russo E, Viazzi F, Pontremoli R, Barbagallo CM, Bombelli M, Casiglia E, Cicero AFG, Cirillo M, Cirillo P, Desideri G, D'Elia L, Dell'Oro R, Ferri C, Galletti F, Gesualdo L, Giannattasio C, Iaccarino G, Leoncini G, Mallamaci F, Maloberti A, Masi S, Mengozzi A, Mazza A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Rattazzi M, Rivasi G, Salvetti M, Tikhonoff V, Tocci G, Quarti Trevano FAL, Ungar A, Verdecchia P, Virdis A, Volpe M, Grassi G, Borghi C. Serum Uric Acid and Kidney Disease Measures Independently Predict Cardiovascular and Total Mortality: The Uric Acid Right for Heart Health (URRAH) Project. Front Cardiovasc Med 2021; 8:713652. [PMID: 34646871 PMCID: PMC8502977 DOI: 10.3389/fcvm.2021.713652] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Serum uric acid predicts the onset and progression of kidney disease, and the occurrence of cardiovascular and all-cause mortality. Nevertheless, it is unclear which is the appropriate definition of hyperuricemia in presence of chronic kidney disease (CKD). Our goal was to study the independent impact of uric acid and CKD on mortality. Methods: We retrospectively investigated 21,963 patients from the URRAH study database. Hyperuricemia was defined on the basis of outcome specific cut-offs separately identified by ROC curves according to eGFR strata. The primary endpoints were cardiovascular and all-cause mortality. Results: After a mean follow-up of 9.8 year, there were 1,582 (7.20%) cardiovascular events and 3,130 (14.25%) deaths for all causes. The incidence of cardiovascular and all-cause mortality increased in parallel with reduction of eGFR strata and with progressively higher uric acid quartiles. During 215,618 person-years of follow-up, the incidence rate for cardiovascular mortality, stratified based on eGFR (>90, between 60 and 90 and <60 ml/min) was significantly higher in patients with hyperuricemia and albuminuria (3.8, 22.1 and 19.1, respectively) as compared to those with only one risk factor or none (0.4, 2.8 and 3.1, respectively). Serum uric acid and eGFR significantly interact in determining cardiovascular and all-cause mortality. For each SUA increase of 1 mg/dl the risk for mortality increased by 10% even after adjustment for potential confounding factors included eGFR and the presence of albuminuria. Conclusions: hyperuricemia is a risk factor for cardiovascular and all-cause mortality additively to eGFR strata and albuminuria, in patients at cardiovascular risk.
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Affiliation(s)
- Elisa Russo
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Genova, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Genova, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Genova, Italy
| | - Carlo M Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo, Italy
| | - Michele Bombelli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Edoardo Casiglia
- Studium Patavinum, Department of Medicine, University of Padua, Padua, Italy
| | - Arrigo F G Cicero
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Massimo Cirillo
- Department of Public Health, Federico II University of Naples Medical School, Naples, Italy
| | - Pietro Cirillo
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Lanfranco D'Elia
- Department of Clinical Medicine and Surgery, Federico II University of Naples Medical School, Naples, Italy
| | - Raffaella Dell'Oro
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, Federico II University of Naples Medical School, Naples, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Cristina Giannattasio
- Cardiology IV, A. De Gasperis Department, School of Medicine and Sugery, Niguarda Ca' Granda Hospital, Milano-Bicocca University, Milan, Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, Federico II University of Naples Medical School, Naples, Italy
| | - Giovanna Leoncini
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Genova, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria, Italy
| | - Alessandro Maloberti
- Cardiology IV, A. De Gasperis Department, School of Medicine and Sugery, Niguarda Ca' Granda Hospital, Milano-Bicocca University, Milan, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Hypertension Unit, General Hospital, Rovigo, Italy
| | - Maria L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari, Italy
| | - Paolo Palatini
- Studium Patavinum, Department of Medicine, University of Padua, Padua, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Marcello Rattazzi
- Department of Medicine, Ca' Foncello University Hospital, University of Padova, Treviso, Italy
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | | | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Rivasi G, Bulgaresi M, Mossello E, Buscemi P, Lorini C, Balzi D, Barucci R, Del Lungo I, Gangemi S, Giardini S, Piga C, Barghini E, Boni S, Bulli G, Carrai P, Crociani A, Faraone A, Lo Forte A, Martella L, Pupo S, Fortini G, Marozzi I, Bandini G, Cosma C, Stacchini L, Vaccaro G, Baggiani L, Landini G, Bonaccorsi G, Ungar A, Benvenuti E. Course and Lethality of SARS-CoV-2 Epidemic in Nursing Homes after Vaccination in Florence, Italy. Vaccines (Basel) 2021; 9:1174. [PMID: 34696282 PMCID: PMC8537408 DOI: 10.3390/vaccines9101174] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Evidence on the effectiveness of SARS-CoV-2 vaccines in nursing home (NHs) residents is limited. We examined the impact of the BNT162b2 mRNA SARS-CoV-2 vaccine on the course of the epidemic in NHs in the Florence Health District, Italy, before and after vaccination. Moreover, we assessed survival and hospitalization by vaccination status in SARS-CoV-2-positive cases occurring during the post-vaccination period. We calculated the weekly infection rates during the pre-vaccination (1 October-26 December 2020) and post-vaccination period (27 December 2020-31 March 2021). Cox analysis was used to analyze survival by vaccination status. The study involved 3730 residents (mean age 84, 69% female). Weekly infection rates fluctuated during the pre-vaccination period (1.8%-6.5%) and dropped to zero during the post-vaccination period. Nine unvaccinated (UN), 56 partially vaccinated (PV) and 35 fully vaccinated (FV) residents tested SARS-CoV-2+ during the post-vaccination period. FV showed significantly lower hospitalization and mortality rates than PV and UV (hospitalization: FV 3%, PV 14%, UV 33%; mortality: FV 6%, PV 18%, UV 56%). The death risk was 84% and 96% lower in PV (HR 0.157, 95%CI 0.049-0.491) and FV (HR 0.037, 95%CI 0.006-0.223) versus UV. SARS-CoV-2 vaccination was followed by a marked decline in infection rates and was associated with lower morbidity and mortality among infected NH residents.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, 50134 Florence, Tuscany, Italy; (E.M.); (I.M.); (A.U.)
| | - Matteo Bulgaresi
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Enrico Mossello
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, 50134 Florence, Tuscany, Italy; (E.M.); (I.M.); (A.U.)
| | - Primo Buscemi
- Department of Health Science, University of Florence, 50134 Florence, Tuscany, Italy; (P.B.); (C.L.); (C.C.); (L.S.); (G.V.); (G.B.)
| | - Chiara Lorini
- Department of Health Science, University of Florence, 50134 Florence, Tuscany, Italy; (P.B.); (C.L.); (C.C.); (L.S.); (G.V.); (G.B.)
| | - Daniela Balzi
- Epidemiology Unit, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy;
| | - Riccardo Barucci
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Ilaria Del Lungo
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Salvatore Gangemi
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Sante Giardini
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Cecilia Piga
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Eleonora Barghini
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Serena Boni
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Giulia Bulli
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Paolo Carrai
- Department of Internal Medicine, San Giovanni di Dio Hospital, 50134 Florence, Tuscany, Italy; (P.C.); (A.C.); (A.F.); (A.L.F.)
| | - Andrea Crociani
- Department of Internal Medicine, San Giovanni di Dio Hospital, 50134 Florence, Tuscany, Italy; (P.C.); (A.C.); (A.F.); (A.L.F.)
| | - Antonio Faraone
- Department of Internal Medicine, San Giovanni di Dio Hospital, 50134 Florence, Tuscany, Italy; (P.C.); (A.C.); (A.F.); (A.L.F.)
| | - Aldo Lo Forte
- Department of Internal Medicine, San Giovanni di Dio Hospital, 50134 Florence, Tuscany, Italy; (P.C.); (A.C.); (A.F.); (A.L.F.)
| | - Letizia Martella
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Simone Pupo
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Giacomo Fortini
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
| | - Irene Marozzi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, 50134 Florence, Tuscany, Italy; (E.M.); (I.M.); (A.U.)
| | - Giulia Bandini
- Division of Internal Medicine, Careggi Hospital, 50134 Florence, Tuscany, Italy;
| | - Claudia Cosma
- Department of Health Science, University of Florence, 50134 Florence, Tuscany, Italy; (P.B.); (C.L.); (C.C.); (L.S.); (G.V.); (G.B.)
| | - Lorenzo Stacchini
- Department of Health Science, University of Florence, 50134 Florence, Tuscany, Italy; (P.B.); (C.L.); (C.C.); (L.S.); (G.V.); (G.B.)
| | - Gabriele Vaccaro
- Department of Health Science, University of Florence, 50134 Florence, Tuscany, Italy; (P.B.); (C.L.); (C.C.); (L.S.); (G.V.); (G.B.)
| | - Lorenzo Baggiani
- Department of Territorial Health Network, 50134 Florence, Tuscany, Italy;
| | - Giancarlo Landini
- Department of Internal Medicine, Santa Maria Nuova Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy;
| | - Guglielmo Bonaccorsi
- Department of Health Science, University of Florence, 50134 Florence, Tuscany, Italy; (P.B.); (C.L.); (C.C.); (L.S.); (G.V.); (G.B.)
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, 50134 Florence, Tuscany, Italy; (E.M.); (I.M.); (A.U.)
| | - Enrico Benvenuti
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit “Toscana Centro”, 50134 Florence, Tuscany, Italy; (M.B.); (R.B.); (I.D.L.); (S.G.); (S.G.); (C.P.); (E.B.); (S.B.); (G.B.); (L.M.); (S.P.); (G.F.); (E.B.)
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Torabi P, Rivasi G, Hamrefors V, Sutton R, Brignole M, Fedorowski A. Lifelong and mature-onset syncope in older adults may have different mechanisms. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Syncope is a common clinical problem with a sharp rise in the incidence after 70 years. In older patients, syncope is often a diagnostic challenge. It is unclear whether the age at which patients experience syncope for the first time impacts the results of syncope investigation.
Purpose
To study the influence of early-onset vs. mature-onset syncope on clinical characteristics and final head-up tilt (HUT) diagnosis in a large sample of unexplained syncope patients.
Methods
Consecutive patients (n=1928) with unexplained syncope after initial evaluation examined with a standard HUT protocol in a syncope unit were stratified into age groups below and above 60 years. Clinical characteristics and the final HUT diagnosis were analysed in relation to self-reported age at first syncope and age at investigation. The distribution of age at first syncope was bimodal with peaks at 15 and 70 years (Figure 1). In the present analysis, patients aged >60 years (n=836) with early-onset (<30 years) and mature-onset (>60 years) syncope were compared.
Results
Vasovagal syncope (VVS) was more common in early-onset syncope, 39% vs 19% (p<0.001), (Figure 2). Orthostatic hypotension (OH) was more common in mature-onset syncope, 23% vs 7% (p<0.001), as was hypertension, 59% vs 40% (p=0.001). The frequency of carotid sinus syndrome (CSS) was not affected by age at first syncope in patients aged >60 years.Complex syncope etiology (findings suggesting overlap between VVS, OH and/or CSS) was more common among patients with early-onset syncope, 37% vs 26% (p=0.023). No definite HUT-derived diagnosis was more common in mature-onset syncope, 23% vs 13% (p=0.023). Heart failure, 9% vs 2% (p=0.024) and atrial fibrillation, 20% vs 9% (p=0.013) were more common in mature-onset syncope. Prodromes were less common in mature-onset syncope, 26% vs 52% (p<0.001), however there was no significant difference in reported palpitations preceding syncope and dizziness on standing.
Conclusions
Mature-onset syncope was more often associated with absence of prodromes, orthostatic hypotension, inconclusive HUT findings and presence of heart failure and atrial fibrillation suggesting cardiac syncope to be the likely cause. Early-onset syncope was associated with presence of prodromes, vasovagal reflex mechanism and complex syncope diagnosis. Lifelong and mature-onset unexplained syncope may have different pathophysiological mechanisms in older patients and aetiologies other than vasovagal syncope should be carefully considered in patients with first-ever syncope in later life.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish heart and lung foundationCrafoord foundation
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Affiliation(s)
- P Torabi
- Lund University, Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden
| | - G Rivasi
- Careggi University Hospital, Syncope Unit, Division of Geriatrics and Intensive Care Unit, Florence, Italy
| | - V Hamrefors
- Lund University, Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden
| | - R Sutton
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - M Brignole
- Saint Luca Hospital, IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca and Arrhythmolog, Milano, Italy
| | - A Fedorowski
- Lund University, Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden
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Benvenuti E, Rivasi G, Bulgaresi M, Barucci R, Lorini C, Balzi D, Faraone A, Fortini G, Vaccaro G, Del Lungo I, Gangemi S, Giardini S, Piga C, Barghini E, Boni S, Bulli G, Carrai P, Crociani A, Lo Forte A, Martella L, Pupo S, Marozzi I, Bandini G, Buscemi P, Cosma C, Stacchini L, Baggiani L, Ungar A, Mossello E, Bonaccorsi G, Landini G. Caring for nursing home residents with COVID-19: a "hospital-at-nursing home" intermediate care intervention. Aging Clin Exp Res 2021; 33:2917-2924. [PMID: 34417733 PMCID: PMC8378521 DOI: 10.1007/s40520-021-01959-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/09/2021] [Indexed: 01/30/2023]
Abstract
Background Nursing home (NH) residents have been dramatically affected by COVID-19, with extremely high rates of hospitalization and mortality. Aims To describe the features and impact of an assistance model involving an intermediate care mobile medical specialist team (GIROT, Gruppo Intervento Rapido Ospedale Territorio) aimed at delivering “hospital-at-nursing home” care to NH residents with COVID-19 in Florence, Italy. Methods The GIROT activity was set-up during the first wave of the pandemic (W1, March–April 2020) and became a structured healthcare model during the second (W2, October 2020–January 2021). The activity involved (1) infection transmission control among NHs residents and staff, (2) comprehensive geriatric assessment including prognostication and geriatric syndromes management, (3) on-site diagnostic assessment and protocol-based treatment of COVID-19, (4) supply of nursing personnel to understaffed NHs. To estimate the impact of the GIROT intervention, we reported hospitalization and infection lethality rates recorded in SARS-CoV-2-positive NH residents during W1 and W2. Results The GIROT activity involved 21 NHs (1159 residents) and 43 NHs (2448 residents) during W1 and W2, respectively. The percentage of infected residents was higher in W2 than in W1 (64.5% vs. 38.8%), while both hospitalization and lethality rates significantly decreased in W2 compared to W1 (10.1% vs 58.2% and 23.4% vs 31.1%, respectively). Discussion Potentiating on-site care in the NHs paralleled a decrease of hospital admissions with no increase of lethality. Conclusions An innovative “hospital-at-nursing home” patient-centred care model based on comprehensive geriatric assessment may provide a valuable contribution in fighting COVID-19 in NH residents. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-021-01959-z.
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Affiliation(s)
- Enrico Benvenuti
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.
| | - Matteo Bulgaresi
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Riccardo Barucci
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Chiara Lorini
- Department of Health Science, University of Florence, Florence, Italy
| | - Daniela Balzi
- Epidemiology Unit, Local Health Unit "Toscana Centro", Florence, Italy
| | - Antonio Faraone
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Giacomo Fortini
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Gabriele Vaccaro
- Department of Health Science, University of Florence, Florence, Italy
| | - Ilaria Del Lungo
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Salvatore Gangemi
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Sante Giardini
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Cecilia Piga
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Eleonora Barghini
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Serena Boni
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Giulia Bulli
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Paolo Carrai
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Andrea Crociani
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Aldo Lo Forte
- Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | - Letizia Martella
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Simone Pupo
- Geriatric Unit, Santa Maria Annunziata Hospital, Local Health Unit "Toscana Centro", Florence, Italy
| | - Irene Marozzi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Giulia Bandini
- Division of Internal Medicine, Careggi Hospital, Florence, Italy
| | - Primo Buscemi
- Department of Health Science, University of Florence, Florence, Italy
| | - Claudia Cosma
- Department of Health Science, University of Florence, Florence, Italy
| | - Lorenzo Stacchini
- Department of Health Science, University of Florence, Florence, Italy
| | | | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Enrico Mossello
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | | | - Giancarlo Landini
- Department of Internal Medicine, Santa Maria Nuova Hospital, Local Health Unit "Toscana Centro", Florence, Italy
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Fedorowski A, Rivasi G, Torabi P, Johansson M, Rafanelli M, Marozzi I, Ceccofiglio A, Casini N, Hamrefors V, Ungar A, Olshansky B, Sutton R, Brignole M, Parati G. Underlying hemodynamic differences are associated with responses to tilt testing. Sci Rep 2021; 11:17894. [PMID: 34504263 PMCID: PMC8429732 DOI: 10.1038/s41598-021-97503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Aim of this study was to explore whether differences in resting hemodynamic parameters may be associated with tilt test results in unexplained syncope. We analyzed age, gender, systolic (SBP), diastolic blood pressure (DBP) and heart rate (HR) by merging three large databases of patients considered likely to be of vasovagal reflex etiology, comparing patients who had tilt-induced reflex response with those who did not. Tilt-induced reflex response was defined as spontaneous symptom reproduction with characteristic hypotension and bradycardia. Relationship of demographics and baseline supine BP to tilt-test were assessed using logistic regression models. Individual records of 5236 patients (45% males; mean age: 60 ± 22 years; 32% prescribed antihypertensive therapy) were analyzed. Tilt-positive (n = 3129, 60%) vs tilt-negative patients had lower SBP (127.2 ± 17.9 vs 129.7 ± 18.0 mmHg, p < 0.001), DBP (76.2 ± 11.5 vs 77.7 ± 11.7 mmHg, p < 0.001) and HR (68.0 ± 11.5 vs 70.5 ± 12.5 bpm, p < 0.001). In multivariable analyses, tilt-test positivity was independently associated with younger age (Odds ratio (OR) per 10 years:1.04; 95% confidence interval (CI), 1.01–1.07, p = 0.014), SBP ≤ 128 mmHg (OR:1.27; 95%CI, 1.11–1.44, p < 0.001), HR ≤ 69 bpm (OR:1.32; 95%CI, 1.17–1.50, p < 0.001), and absence of hypertension (OR:1.58; 95%CI, 1.38–1.81, p < 0.001). In conclusion, among patients with suspected reflex syncope, younger age, lower blood pressure and lower heart rate are associated with positive tilt-test result.
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Affiliation(s)
- Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Madeleine Johansson
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden
| | - Martina Rafanelli
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Irene Marozzi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Alice Ceccofiglio
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Niccolò Casini
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, Careggi Hospital, University of Florence, Florence, Italy
| | - Brian Olshansky
- Division of Cardiology, Department of Internal Medicine, University of Iowa Hospitals, Iowa City, IA, USA
| | - Richard Sutton
- Department of Cardiology, Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28, Malmö, Sweden.,Department of Cardiology, National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Michele Brignole
- Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Gianfranco Parati
- Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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Rivasi G, Torabi P, Secco G, Ungar A, Sutton R, Brignole M, Fedorowski A. Age-related tilt test responses in patients with suspected reflex syncope. Europace 2021; 23:1100-1105. [PMID: 33564843 DOI: 10.1093/europace/euab024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS Tilt testing (TT) is recognized to be a valuable contribution to the diagnosis and the pathophysiology of vasovagal syncope (VVS). This study aimed to assess the influence of age on TT responses by examination of a large patient cohort. METHODS AND RESULTS Retrospective data from three experienced European Syncope Units were merged to include 5236 patients investigated for suspected VVS by the Italian TT protocol. Tilt testing-positivity rates and haemodynamics were analysed across age-decade subgroups. Of 5236 investigated patients, 3129 (60%) had a positive TT. Cardioinhibitory responses accounted for 16.5% of positive tests and were more common in younger patients, decreasing from the age of 50-59 years. Vasodepressor (VD) responses accounted for 24.4% of positive tests and prevailed in older patients, starting from the age of 50-59. Mixed responses (59.1% of cases) declined slightly with increasing age. Overall, TT positivity showed a similar age-related trend (P = 0.0001) and was significantly related to baseline systolic blood pressure (P < 0.001). Tilt testing was positive during passive phase in 18% and during nitroglycerine (TNG)-potentiated phase in 82% of cases. Positivity rate of passive phase declined with age (P = 0.001), whereas positivity rate during TNG remained quite stable. The prevalence of cardioinhibitory and VD responses was similar during passive and TNG-potentiated TT, when age-adjusted. CONCLUSIONS Age significantly impacts the haemodynamic pattern of TT responses, starting from the age of 50. Conversely, TT phase-passive or TNG-potentiated-does not significantly influence the type of response, when age-adjusted. Vagal hyperactivity dominates in younger patients, older patients show tendency to vasodepression.
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Affiliation(s)
- Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Parisa Torabi
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Gianmarco Secco
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy.,Emergency Medicine Unit, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital, London, UK.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milano, Italy.,Arrhythmology Centre and Syncope Unit, Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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45
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Brignole M, Rivasi G, Sutton R, Kenny RA, Morillo CA, Sheldon R, Raj SR, Ungar A, Furlan R, van Dijk G, Hamdan M, Hamrefors V, Engström G, Park C, Soranna D, Zambon A, Parati G, Fedorowski A. Low-blood pressure phenotype underpins the tendency to reflex syncope. J Hypertens 2021; 39:1319-1325. [PMID: 33560050 PMCID: PMC8183486 DOI: 10.1097/hjh.0000000000002800] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/04/2020] [Accepted: 12/30/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND We hypothesized that cardiovascular physiology differs in reflex syncope patients compared with the general population, predisposing such individuals to vasovagal reflex. METHODS In this multicohort cross-sectional study, we compared aggregate data of resting SBP, DBP, pulse pressure (PP) and heart rate (HR), collected from six community-based cohort studies (64 968 observations) with those from six databases of reflex syncope patients (6516 observations), subdivided by age decades and sex. RESULTS Overall, in male individuals with reflex syncope, SBP (-3.4 mmHg) and PP (-9.2 mmHg) were lower and DBP (+2.8 mmHg) and HR (+5.1 bpm) were higher than in the general population; the difference in SBP was higher at ages above 60 years. In female individuals, PP (-6.0 mmHg) was lower and DBP (+4.7 mmHg) and HR (+4.5 bpm) were higher than in the general population; differences in SBP were less pronounced, becoming evident only above 60 years. Compared with male individuals, SBP in female individuals exhibited slower increase until age 40 years, and then demonstrated steeper increase that continued throughout remaining life. CONCLUSION The patients prone to reflex syncope demonstrate a different resting cardiovascular haemodynamic profile as compared with a general population, characterized by lower SBP and PP, reflecting reduced venous return and lower stroke volume, and a higher HR and DBP, suggesting the activation of compensatory mechanisms. Our data contribute to a better understanding why some individuals with similar demographic characteristics develop reflex syncope and others do not. VIDEO ABSTRACT http://links.lww.com/HJH/B580.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milan
| | - Giulia Rivasi
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Richard Sutton
- National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, Ducane Road, London, UK
| | - Rose Anne Kenny
- Chair Medical Gerontology, Syncope and Falls Unit, School of Medicine, St James Hospital and Trinity College, Dublin, Ireland
| | - Carlos A. Morillo
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Robert Sheldon
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Satish R. Raj
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Ungar
- Syncope Unit, Division of Geriatrics and Intensive Care Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Raffaello Furlan
- Internal Medicine, Humanitas Clinical and Research Center-IRCCS, Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Gert van Dijk
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mohamed Hamdan
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Viktor Hamrefors
- Department of Clinical Sciences, Lund University
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Chloe Park
- MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College, London, UK
| | | | - Antonella Zambon
- IRCCS Istituto Auxologico Italiano, Biostatistics Unit
- Department of Statistics and quantitative methods, University of Milano-Bicocca
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, Faint & Fall Programme, Ospedale San Luca, Milan
- Department of Medicine and Surgery, University of Milano Bicocca and IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milan, Italy
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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46
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Brignole M, Kessisoglu F, Croci F, Solano A, Donateo P, Maggi R, Solari D, Bertolone C, Fontana D, Oddone D, Rivasi G, Rafanelli M, Casini N, Ungar A. Complementary effectiveness of carotid sinus massage and tilt testing for the diagnosis of reflex syncope in patients older than 40 years: a cohort study. Europace 2021; 22:1737-1741. [PMID: 33078193 DOI: 10.1093/europace/euaa204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/23/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Indications, methodology, and diagnostic criteria for carotid sinus massage (CSM) and tilt testing (TT) have been standardized by the 2018 Guidelines on Syncope of the European Society of Cardiology. Aim of this study was to assess their effectiveness in a large cohort which reflects the performance under 'real-world' conditions. METHODS AND RESULTS We analysed all patients who had undergone CSM and TT in the years 2003-2019 for suspected reflex syncope. Carotid sinus massage was performed according to the 'Method of Symptoms'. Tilt testing was performed according to the 'Italian protocol' which consists of a passive phase followed by a sublingual nitroglycerine phase. For both tests, positive test was defined as reproduction of spontaneous symptoms in the presence of bradycardia and/or hypotension. Among 3293 patients (mean age 73 ± 12 years, 48% males), 2019 (61%) had at least one test positive. A bradycardic phenotype was found in 420 patients (13%); of these, 60% were identified by CSM, 37% by TT, and 3% had both test positive. A hypotensive phenotype was found in 1733 patients (53%); of these, 98% were identified by TT and 2% had both TT and CSM positive. CONCLUSION The overall diagnostic yield of the tests in patients >40-year-old with suspected reflex syncope was 61%. Both CSM and TT are useful for identifying those patients with a bradycardic phenotype, whereas CSM has a limited value for identifying the hypotensive phenotype. Since the overlap of responses between tests is minimal, both CSM and TT should be performed in every patient over 40 years receiving investigation for unexplained but possible reflex syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Faint & Fall programme, Ospedale San Luca, Milano, Italy
| | | | - Francesco Croci
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Alberto Solano
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Paolo Donateo
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Roberto Maggi
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Diana Solari
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Cristina Bertolone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Fontana
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Daniele Oddone
- Department of Cardiology, Arrhythmology Centre and Syncope Unit, Ospedali del Tigullio, via don Bobbio 25, 16033 Lavagna, Italy
| | - Giulia Rivasi
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Martina Rafanelli
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Niccolò Casini
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
| | - Andrea Ungar
- Division of Geriatrics and Intensive Care Unit, Syncope Unit, University of Florence and Careggi Hospital, Florence, Italy
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47
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Rafanelli M, Testa GD, Rivasi G, Ungar A. Evaluation of Patients with Syncope in the Emergency Department: How to Adjust Pharmacological Therapy. Medicina (B Aires) 2021; 57:medicina57060603. [PMID: 34208045 PMCID: PMC8231040 DOI: 10.3390/medicina57060603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/05/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022] Open
Abstract
The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional or drug induced. Consequently, obtaining an accurate drug history is an important step of the initial assessment of syncope. As anti-hypertensive medication might be responsible for orthostatic hypotension, managing hypertension in patients with syncope requires finding an ideal balance between hypotensive and cardiovascular risks. The choice of anti-hypertensive molecule as well as the therapeutic regimen and dosage, influences the risk of syncope. Not only could anti-hypertensive drugs have a hypotensive effect but opioids and psychoactive medications may also be involved in the mechanism of syncope. Proper drug management could reduce syncope recurrences and their consequences.
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48
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Abstract
Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and post-prandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy and quality of life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy -
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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49
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Ungar A, Rivasi G, Coscarelli A, Boccanelli A, Marchionni N, Alboni P, Baldasseroni S, Bo M, Palazzo G, Rozzini R, Terrosu P, Vetta F, Zito G, Desideri G. Hypertension in older persons: why one size does not fit all. Minerva Med 2021; 113:616-625. [PMID: 33832215 DOI: 10.23736/s0026-4806.21.07502-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over recent years, managing hypertension in older people has gained increasing attention, with particular reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data. Although limited, available evidence suggests that the association between blood pressure and adverse outcomes significantly varies at advanced age according to frailty status. In particular, the negative prognostic impact of hypertension seems to attenuate or even revert in individuals with older biological age, e.g. patients with disability, cognitive impairment, and poor physical performance. Consequently, one size doesn't fit all and personalized treatment strategies are needed, customized to individuals' frailty and functional status. Similar to other cardiovascular diseases, hypertension management in older people should be characterized by a geriatric approach based on biological rather than chronological age and a geriatric comprehensive evaluation including frailty assessment is required to provide the most appropriate treatment, tailored to patients' prognosis and health care goals. This review illustrates the importance of a patient-centered geriatric approach to hypertension management in older people with the final purpose to promote a wider implementation of frailty assessment in routine practice.
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Affiliation(s)
- Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy - .,SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy -
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy
| | - Antonio Coscarelli
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy
| | | | | | - Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giuseppe Palazzo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovambattista Desideri
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy.,Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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50
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Russo E, Viazzi F, Pontremoli R, Barbagallo CM, Bombelli M, Casiglia E, Cicero AFG, Cirillo M, Cirillo P, Desideri G, D'Elia L, Ferri C, Galletti F, Gesualdo L, Giannattasio C, Iaccarino G, Leoncini G, Mallamaci F, Maloberti A, Masi S, Mengozzi A, Mazza A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Rattazzi M, Rivasi G, Salvetti M, Tikhonoff V, Tocci G, Ungar A, Verdecchia P, Virdis A, Volpe M, Grassi G, Borghi C. Association of uric acid with kidney function and albuminuria: the Uric Acid Right for heArt Health (URRAH) Project. J Nephrol 2021; 35:211-221. [PMID: 33755930 PMCID: PMC8803667 DOI: 10.1007/s40620-021-00985-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperuricemia is commonly observed in patients with chronic kidney disease (CKD). However, a better understanding of the relationship among uric acid (UA) values, glomerular filtration rate (GFR) and albuminuria may shed light on the mechanisms underlying the excess of cardiovascular mortality associated with both chronic kidney disease and hyperuricemia and lead to better risk stratification. Our main goal was to study the relationships between serum uric acid and kidney disease measures (namely estimated GFR [eGFR] and albuminuria) in a large cohort of individuals at cardiovascular risk from the URic acid Right for heArt Health (URRAH) Project database. METHODS Clinical data of 26,971 individuals were analyzed. Factors associated with the presence of hyperuricemia defined on the basis of previously determined URRAH cutoffs for cardiovascular and all-cause mortality were evaluated through multivariate analysis. Chronic kidney disease was defined as eGFR < 60 ml/min per 1.73 m2 and/or abnormal urinary albumin excretion diagnosed as: (i) microalbuminuria if urinary albumin concentration was > 30 and ≤ 300 mg/L, or if urinary albumin-to-creatinine ratio (ACR) was > 3.4 mg/mmol and ≤ 34 mg/mmol; (ii) macroalbuminuria if urinary albumin concentration was > 300 mg/L, or if ACR was > 34 mg/mmol. RESULTS Mean age was 58 ± 15 years (51% males, 62% with hypertension and 12% with diabetes), mean eGFR was 81 ml/min per 1.73m22with a prevalence of eGFR < 60 and micro- or macroalbuminuria of 16, 15 and 4%, respectively. Serum uric acid showed a trend towards higher values along with decreasing renal function. Both the prevalence of gout and the frequency of allopurinol use increased significantly with the reduction of eGFR and the increase in albuminuria. Hyperuricemia was independently related to male gender, eGFR strata, and signs of insulin resistance such as body mass index (BMI) and triglycerides. CONCLUSIONS The lower the eGFR the higher the prevalence of hyperuricemia and gout. In subjects with eGFR < 60 ml/min the occurrence of hyperuricemia is about 10 times higher than in those with eGFR > 90 ml/min. The percentage of individuals treated with allopurinol was below 2% when GFR was above 60 ml/min, it increased to 20% in the presence of CKD 3b and rose further to 35% in individuals with macroalbuminuria.
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Affiliation(s)
- Elisa Russo
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genoa, Italy.
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Carlo Maria Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo, Italy
| | - Michele Bombelli
- Department of Medicine and Surgery, Clinica Medica, University of Milano-Bicocca, Monza, Italy
| | - Edoardo Casiglia
- Department of Medicine, Studium Patavinum, University of Padua, Padua, Italy
| | | | - Massimo Cirillo
- Department of Public Health, Federico II University of Naples Medical School, Naples, Italy
| | - Pietro Cirillo
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Giovambattista Desideri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Lanfranco D'Elia
- Department of Clinical Medicine and Surgery, Federico II University of Naples Medical School, Naples, Italy
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, Federico II University of Naples Medical School, Naples, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, Aldo Moro University of Bari, Bari, Italy
| | - Cristina Giannattasio
- Cardiology IV, A. De Gasperis Department, Health Science Department, Niguarda Ca' Granda Hospital, Milano-Bicocca University, Milan, Italy
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, Federico II University of Naples Medical School, Naples, Italy
| | - Giovanna Leoncini
- Department of Internal Medicine, University of Genoa and IRCCS Ospdedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Francesca Mallamaci
- Reggio Cal Unit, CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Alessandro Maloberti
- Cardiology IV, A. De Gasperis Department, Health Science Department, Niguarda Ca' Granda Hospital, Milano-Bicocca University, Milan, Italy
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Hypertension Unit, General Hospital, Rovigo, Italy
| | - Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari, Italy
| | - Paolo Palatini
- Department of Medicine, Studium Patavinum, University of Padua, Padua, Italy
| | - Gianfranco Parati
- S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy
| | - Marcello Rattazzi
- Department of Medicine, Medicina Interna 1°, Ca' Foncello University Hospital, University of Padova, Treviso, Italy
| | - Giulia Rivasi
- Department of Medicine, University of Padua, Padua, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy
| | | | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Guido Grassi
- Department of Medicine and Surgery, Clinica Medica, University of Milano-Bicocca, Monza, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna, Italy
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