[ANMCO Position paper: States General 2023 - Scientific societies and training: the role of ANMCO]

Scientific societies promote numerous activities, including the training of professionals. With the continuous growing of knowledge and the availability of new evidence in the cardiological field, the achievement and maintenance of knowledge and know-how is difficult. The evolving educational needs of professionals in cardiology have been analyzed during the 2023 ANMCO General States. Furthermore, the initiatives implemented to meet professionals' needs after the university medical training have been discussed. In this document, we report the main and most innovative training activities promoted by ANMCO, from distance training to simulation training, including courses for master's degree, training to and through clinical research and the potential role of teaching hospitals.

Impact of age on the predictive value of NT-proBNP in patients with diabetes mellitus stabilised after an acute coronary syndrome

AIMS

To assess the impact of age on the prognostic value of NT-proBNP concentration in patients with type-2 diabetes mellitus (T2DM) stabilised after an Acute Coronary Syndrome (ACS).

METHODS

The AleCardio study compared aleglitazar with placebo in 7226 patients with T2DM and recent ACS. Patients with heart failure were excluded. Median follow-up was 104 weeks. Baseline NT-proBNP plasma concentration was measured centrally. Multivariable Cox regression was used to determine the mortality predictive information provided by NT-proBNP across age groups.

RESULTS

Median age was 61y (IQR 54, 67). NT-proBNP concentration increased by quartile (Q) of age (median 264, 318, 391, and 588 pg/ml). Compared to Q1, patients in Q4 of NT-proBNP had higher (p < 0.001) adjusted HR for all-cause (aHR 6.9; 95 % CI 4.0-12) and cardiovascular (11; 5.4-23) death. Within each age Q, baseline NT-proBNP in patients who died was 3 times higher than in survivors (all p < 0.001). When age and NT-proBNP levels were modeled as continuous variables, their interaction term was nonsignificant. The relative prognostic information provided by NT-proBNP (percent of total X2) increased from 38 % in age Q1 to 75 % in age Q4 for mortality, and from 50 % to 88 % for CV death.

CONCLUSIONS

Among patients with T2DM stabilised after an ACS, NT-proBNP level predicts death irrespective of age.

Catheter-based renal artery denervation: facts and expectations

Catheter-based renal artery denervation (RAD) is entering a new era. After the disappointing results of SYMPLICITY-HTN 3 trial in year 2014, several technical and methodological advancements led to execution of important SHAM-controlled randomized trials with promising results. Now, the 2023 ESH Guidelines give RAD a class of recommendation II with a Level of Evidence B. Currently, catheter-based RAD has two main areas of application: (a) Hypertensive patients who are still untreated, in whom RAD is a sort of a first-line treatment; (b) Difficult-to-control or true resistant hypertensive patients. Notably, randomized SHAM-controlled trials met their primary end-point in both these conditions. So far, we do not dispose of established predictors of the antihypertensive response to RAD. Some data suggest that younger patients with systo-diastolic hypertension, absence of diffuse atherosclerosis and evidence of sympathetic nervous system overactivity experience a better BP response to the procedure. We reviewed the available data on catheter-based RAD and included an updated meta-analysis of the results of the available SHAM-controlled trials. Overall, the reduction in 24-h systolic blood pressure (BP) after RAD exceeded that after SHAM by 4.58 mmHg (95% CI 3.07-6.10) in untreated patients, and by 3.82 mmHg (95% CI 2.46-5.18) in treated patients, without significant heterogeneity across trials, patient phenotype (untreated versus treated patients) and technique (radiofrequency versus ultrasound). There were no important safety signals related to the procedure. Notably, some data suggest that RAD could be an effective additional approach in patients with atrial fibrillation and other conditions characterized by sympathetic nervous system overactivity.

Use of Oral Anticoagulants in Patients with Atrial Fibrillation: Preliminary Data from the Italian Atrial Fibrillation (ITALY-AF) Registry

BACKGROUND

Atrial fibrillation (AFIB), the most frequent cardiac arrhythmia, is a major risk factor for stroke, heart failure, and death. Because of the recent advances in AFIB management and the availability of new oral anticoagulants (OACs), there is a need for a systematic and predefined collection of contemporary data regarding its management and treatment.

METHODS

The objective of the ongoing ITALY-AFIB registry is to evaluate the long-term morbidity and mortality in patients with AFIB and to verify the implementation of the current guidelines for stroke prevention in these patients. The registry includes consecutive in- and out-patients with first diagnosed, paroxysmal, persistent, or permanent AFIB. In patients in sinus rhythm at entry, the qualifying episode of AFIB, confirmed by ECG diagnosis, had to have occurred within 1 year before entry. The clinical record form is web-based and accessible by personal keyword.

RESULTS

Enrolment into the registry started in the year 2013. In a current cohort of 2470 patients (mean age 75 ± 11 years, males 56%), the mean CHA2DS2-VASc score was 3.7 ± 1.8, and the mean HAS-BLED was 1.6 ± 0.9. There were no significant sex differences in the AFIB subtypes. At the end of the inclusion visit and after receiving knowledge of the web-based electronic estimate of risk for stroke and bleeding, the proportion of patients discharged with OACs was 80%. After exclusion of patients with first diagnosed AFIB (n = 397), the proportion of patients with prescription of OACs rose from 66% before the visit to 82% on discharge (p < 0.0001). Prescription of aspirin or other antiplatelet drugs fell from 18% before the visit to 10% on discharge (p < 0.0001).

CONCLUSIONS

A web-based management of AFIB with automated estimation of risk profiles appears to favorably affect adherence to AFIB guidelines, based on a high proportion of patients treated with OACs and a substantial decline in the use of antiplatelet drugs.

Secondary prevention and follow-up of patients with ACS and not-at-target LDL: An Italian real-world retro-prospective analysis by the inertia group

Background

In patients with recent ACS, the latest ESC/EAS guidelines for management of dyslipidaemia recommend intensification of LDL-C-lowering therapy.

Objective

Report a real-world picture of lipid-lowering therapy prescribed and cholesterol targets achieved in post-ACS patients before and after a specific educational program.

Methods

Retrospective data collection prior to the educational course and prospective data collection after the course of consecutive very high-risk patients with ACS admitted in 2020 in 13 Italian cardiology departments, and with a non-target LDL-C level at discharge.

Results

Data from 336 patients were included, 229 in the retrospective phase and 107 in the post-course prospective phase. At discharge, statins were prescribed in 98.1% of patients, alone in 62.3% of patients (65% of which at high doses) and in combination with ezetimibe in 35.8% of cases (52% at high doses). A significant reduction was obtained in total and LDL cholesterol (LDL-C) from discharge to the first control visit. Thirty-five percent of patients achieved a target LDL-C <55 mg/dL according to ESC 2019 guidelines. Fifty percent of patients achieved the <55 mg/dL target for LDL-C after a mean of 120 days from the ACS event.

Conclusions

Our analysis, though numerically and methodologically limited, suggests that management of cholesterolaemia and achievement of LDL-C targets are largely suboptimal and need significant improvement to comply with the lipid-lowering guidelines for very high CV risk patients. Earlier high intensity statin combination therapy should be encouraged in patients with high residual risk.

Therapy of Type 2 diabetes: more gliflozines and less metformin?

Metformin is a frequently used anti-diabetic drug. In addition to the well-known modulating properties on glyco-metabolic control, metformin reduces cardiovascular (CV) risk partly independently of its anti-hyperglycaemic effect. The use of 'new' anti-diabetic drugs, inhibitors of the renal Na-glucose co-transporter (SGLTs-I or 'gliflozines') and GLP-1 receptor agonists (GLP1-RAs), has further contributed to challenge the strictly 'gluco-centric' view of diabetic CV disease. Several controlled trials have demonstrated that the cardio-renal benefits of gliflozines and GLP1-RAs are present regardless of the presence of metformin as 'background' therapy. The impact on the 'cardio-renal continuum' exerted by SGLTs-I was also noted in non-diabetic patients with heart failure and reduced or preserved ventricular function and different levels of renal function. These drugs reduced re-hospitalization, CV mortality, and progression to end-stage renal disease. These clinical acquisitions, implemented by Scientific Societies, have led to a change in the therapeutic approach to diabetic cardio-renal disease. Although metformin still represents a valid therapeutic option to be offered particularly to 'naïve' diabetic patients without previous cardio-renal events, SGLTs-I and/or GLP1-RAs emerge as 'first-line' drugs in diabetic patients with previous CV events, or at high CV risk, without having to request 'on board' metformin therapy.

662 A CASE OF MILIARY TBC WITH PERICARDIAL INVOLVEMENT

Introduction

Miliary TBC represents a complex disease, quite rare at our latitudes. We present a case with severe pericardial involvement.

Case report

a 25-year-old Pakistani male, recently come in Italy, presented for fever and orthopnea. Anamnesis was difficult because of linguistic barrier. Echocardiogram revealed a large pericardial effusion with signs of tamponade, so a pericardiocentesis was promptly performed and exudative fluid was drained out and sent to laboratory. Blood tests showed anemia, mild hyponatremia, VES elevation and several vitamin deficiencies. Few days after the procedure the patient developed fever with chills, so blood samples for cultural tests were taken, but resulted negative. To better understand the etiology of pericardial effusion and fever a thoraco-abdominal CT was performed and bared multiple micronodular lesions disseminated to lungs, spleen and lever and pleural and peritoneal effusion. At the same time, the DNA search for Koch's bacillus in the pericardial fluid resulted positive for Mycobacterium TBC complex. So, a diagnosis of miliary TBC with pericardial involvement was done and corticosteroid therapy together with antitubercular drugs were started. Encephalic MRI excluded neurological involvement. Patient was isolated and moved to the infectious disease ward, where therapy was continued until recovery.

Discussion

Miliary TBC is a disseminated form due to the hematogenous spread of tubercle bacilli resulting in the formation of multiple tuberculous foci. This manifestation is more frequent in countries where TBC is still endemic (Pakistan, India, Philippines). The disease can progress slowly with few symptoms or acutely (typical of younger) and the identification may be challenging due to its rarity in developed countries and the lack of uniform criteria. Diagnosis is mainly based on the isolation mycobacterial from a specimen or molecular methods such as PCR. Treatment is based on standard antitubercular drugs regimen. The role of corticosteroids is still controversial.

Conclusions

Miliary TBC is a rare disease in developed countries with not well-defined diagnosis criteria and different clinical presentations. However, because of the increase of migration flows, is important to recognize this manifestation, especially when it develops acutely and with life-treating conditions such as pericardial tamponade.

558 BIVENTRICULAR PERIOPERATIVE TAKOTSUBO CARDIOMIOPATHY

Introduction

Perioperative Takotsubo cardiomyopathy (pTC) represents a rare and still not well characterized disease. Biventricular involvement is an uncommon manifestation of TC and is associated with a more severe clinical presentation.

Case report

A 72-year-old male, hospitalized for a laparoscopic left hemicolectomy, was transferred to ICU after having developed severe bradycardia, treated with Adrenalin, and cardiogenic shock during induction of general anesthesia. EKG showed complete atrio-ventricular block, so a temporary PMK was placed. Troponin was raised. Echocardiogram showed severe biventricular disfunction (LVEF 25%, TAPSE 12 mm) with akinesia of medio-apical segments, suggesting a biventricular pTC. Also, there was a reduction of 3D LV longitudinal strain (- 5,8%), particularly of the medio-apical portion, and RV free wall longitudinal strain (- 11%). Coronary angiography resulted negative. Patient's hemodynamic was supported with Noradrenalin and a cycle of Levosimendan, allowing to reach stability. Further echocardiogram showed improvement of biventricular function and longitudinal strain values. Due to the persistency of atrio-ventricular block, a definitive PMK was placed. Patient was discharged after therapy optimization.

Discussion

pTC is a little-known disease, as incidence and etiology are not well definite. Literature suggests a relation between pTC and physical or emotional stress due to surgery to promote an increase of catecholamine release. Other potential factors may be inadequate depth of anesthesia or tracheal manipulation during intubation and catecholaminergic drugs administration. On the other hand, the use of anesthetic volatile agents seems to have a cardioprotective effect. PTC is more common during general anesthesia and when occurs intraoperatively has a worse clinical presentation. Biventricular involvement, which is a rare and severe manifestation of TC, has been reported frequently among pTC patients. To date, due to the lack of a systematic review, there is little knowledge about potential risk factors, prevention strategies and management of pTC.

Conclusions

Despite multiple cases of pTC have been reported, several characteristics of this entity are not fully understood. However, it must be considered as a part of differential diagnosis in patients with anaesthesia-related decompensation. Biventricular involvement represents an infrequent presentation and its commonly associated with life-threating hemodynamic impairment.

Impact of hemoglobin levels at admission on outcomes among elderly patients with acute coronary syndrome treated with low-dose Prasugrel or clopidogrel: A sub-study of the ELDERLY ACS 2 trial

Hemoglobin (Hb) levels have emerged as a useful tool for risk stratification and the prediction of outcome after myocardial infarction. We aimed at evaluating the prognostic impact of this parameter among patients in advanced age, where the larger prevalence of anemia and the higher rate of comorbidities could directly impact on the cardiovascular risk.

METHODS

All the patients in the ELDERLY-2 trial, were included in this analysis and stratified according to the values of hemoglobin at admission. The primary endpoint of this study was cardiovascular mortality within one year. The secondary endpoints were all-cause mortality, MI, Bleeding Academic Research Consortium (BARC) type 2-3 or 5 bleeding, any stroke, re-hospitalization for cardiovascular event or stent thrombosis (probable or definite) within 12 months after index admission.

RESULTS

We included in our analysis 1364 patients, divided in quartiles of Hb values (&lt;12.2; 12.2-13.39; 13.44-14.49; ≥ 4.5 g/dl). At a mean follow- up of 330.4 ± 99.9 days cardiovascular mortality was increased in patients with lower Hb (HR[95%CI] = 0.76 [0.59-0.97], p = 0.03). Results were no more significant after correction for baseline differences (adjusted HR[95%CI] = 1.22 [0.41-3.6], p = 0.16). Similar results were observed for overall mortality. At subgroup analysis, (according to Hb median values) a significant interaction was observed only with the type of antiplatelet therapy, but not with major high-risk subsets of patients.

CONCLUSIONS

Among elderly patients with acute coronary syndrome managed invasively, lower hemoglobin at admission is associated with higher cardiovascular and all-cause mortality and major ischemic events, mainly explained by the higher risk profile.

The myocardial bridge: incidence, diagnosis, and prognosis of a pathology of uncertain clinical significance

The myocardial bridge (MB) is a common anomaly of the coronary tree, very often clinically silent. The artery typically involved is the left anterior descending in its proximal and/or middle portion. MB can cause ischaemia with various mechanisms, directly proportional to the degree of compression of the intra-myocardial tract, which impairs the coronary flow. It is a dynamic phenomenon that is affected by the adrenergic tone and is therefore often brought by physical exercise. MB, when symptomatic, often begins with angina from exertion; some patients have more severe conditions such as unstable angina or myocardial infarction. Coronary vasospasm related to MB-induced endothelial dysfunction can explain a number of cases that come to observation even with catastrophic pictures such as ventricular fibrillation caused by ischaemia. The diagnostic workup includes the non-invasive study using computed tomography angiography and the invasive study of the haemodynamic impact using pressure and Doppler guides. In symptomatic cases, drug therapy with a beta-blocker is enough to manage angina. When it fails, there is the option of coronary angioplasty or surgical treatment techniques.

Typical Atrial Flutter Mapping and Ablation

Isthmus-dependent flutter represents a defeated arrhythmia. Possibly one of the most outstanding successes in terms of understanding the mechanism behind it has led to an effective, relatively simple, and safe targeted therapy. Technology, fulfilling a number of the clinical electrophysiologist's dreams, has linked diagnosis and therapy in computerized systems showing real-time imagines of the right atrium, the arrhythmia circuit, and the ablation target. The entire history of clinical electrophysiology is contained in its path and atrial flutter needs to be regarded with immense respect for a large amount of knowledge that its study always engenders."

[Diagnostic, therapeutic and prognostic aspects of type 2 myocardial infarction]

Type 2 myocardial infarction is the ischemic necrosis of cardiomyocytes due to oxygen supply/demand imbalance. The most common causes are surgery, sepsis, arrhythmias, hypo/hypertension. Patients with type 2 myocardial infarction, a disease that accounts for about 25% of total myocardial infarctions, have more comorbidities and are older than patients with type 1 myocardial infarction. Coronary angiography is not mandatory, but it may be useful for the differential diagnosis with acute coronary syndrome. The prognosis in these patients is severe and burdened by high non-cardiovascular and cardiovascular mortality. Treatment is poorly codified and involves the management of trigger events and/or treatment of the underlying coronary artery disease, which is often present; revascularization has an uncertain benefit. Ongoing studies will provide insight on this complex disease.

Association of statin pretreatment with presentation characteristics, infarct size and outcome in older patients with acute coronary syndrome: the Elderly ACS-2 trial

BACKGROUND

prior statin treatment has been shown to have favourable effects on short- and long-term prognosis in patients with acute coronary syndrome (ACS). There are limited data in older patients. The aim of this study was to investigate the association of previous statin therapy and presentation characteristics, infarct size and clinical outcome in older patients, with or without atherosclerotic cardiovascular disease (ASCVD), included in the Elderly-ACS 2 trial.

METHODS

data on statin use pre-admission were available for 1,192 of the 1,443 patients enrolled in the original trial. Of these, 531 (44.5%) were already taking statins. Patients were stratified based on established ASCVD and statin therapy. ACS was classified as non-ST elevation or ST elevation myocardial infarction (STEMI). Infarct size was measured by peak creatine kinase MB (CK-MB). All-cause death in-hospital and within 1 year were the major end points.

RESULTS

there was a significantly lower frequency of STEMI in statin patients, in both ASCVD and No-ASCVD groups. Peak CK-MB levels were lower in statin users (10 versus 25 ng/ml, P < 0.0001). There was lower all-cause death in-hospital and within 1 year for subjects with ASCVD already on statins independent of other baseline variables. There were no differences in all-cause death for No-ASCVD patients whether or not on statins.

CONCLUSIONS

statin pretreatment was associated with more favourable ACS presentation and lower myocardial damage in older ACS patients both ASCVD and No-ASCVD. The incidence of all-cause death (in-hospital and within 1 year) was significantly lower in the statin treated ASCVD patients.

P34 ASYMPTOMATIC VENTRICULAR PRE–EXCITATION WITH DISAPPEARANCE DURING EXERTION: ALWAYS AN INDEX OF BENIGNITY?

Introduction

The disappearance of pre–excitation at high heart rates points to a low arrhythmic risk: why resort to electrophysiological studies anyway?

Clinical Case

L.S., a 12–year–old patient, performed an ECG for sports examination with evidence of ventricular pre–excitation from an asymptomatic left lateral accessory route (Fig. A). A 24 h ECG–Holter during training showed the disappearance of the pre–excitation at high frequencies (Fig. B) which is considered a low risk index. The patient underwent a transesophageal electrophysiological study (SETE) during which an effective refractory antegrade period of 228 ms of the pathway was objectified through atrial extrastimuli (*) (Fig. C: drive of atrial stimuli (*) followed by extrastimulus with conduction on an accessory route (E)). In addition, a 1: 1 conduction was observed on the atrial pathway up to at least 270 bpm (222 ms). The antegrade refractory period of the resting path was &lt;250 ms and therefore identified a high–risk condition to be treated with ablation.

Discussion

The disappearance of pre–excitation at high heart rates is usually considered indicative of an accessory pathway with a long refractory period and therefore at low risk, however it must be sudden. According to European guidelines, the execution of invasive studies in asymptomatic patients who are employed in high–risk jobs or competitive sports has a class I B indication, but in the remaining asymptomatic cases the indication is IIa B. The Holter ECG alone or the stress test, with a careless evaluation of the disappearance of the pre–excitation (sudden vs progressive with minimal residual pre–excitation) would have erroneously led to labeling this accessory pathway at low risk. In the left lateral accessory pathways, with the increase of the HR, there can be a disappearance or pseudo–disappearance of the pre–excitation for anatomical reasons (being further away from the SA node) and for an increase in the AV conduction speed, not therefore for a long refractory period of the pathway. SETE is closer to the atrial side of the left accessory pathway and allows to correctly classify the risk.

Conclusion

SETE is a low–cost and minimally invasive method that should be considered as an integral part of the study of patients with asymptomatic ventricular pre–excitation even if non–invasive stratification indicates low risk.

Soluble CD40 ligand and outcome in patients with coronary artery disease undergoing percutaneous coronary intervention

OBJECTIVES

CD40 ligand (CD40L), a transmembrane glycoprotein belonging to the tumor necrosis factor family and expressed by a variety of cells, is involved in the basic mechanisms of inflammation, atherosclerosis and thrombosis. Some studies suggest that the soluble form of CD40L (sCD40L) is a predictor of major cardiovascular events and mortality in a variety of clinical settings, but data from literature are conflicting.

METHODS

We studied consecutive patients with acute (ACS) or chronic (CCS) coronary syndrome who underwent percutaneous coronary artery intervention (PCI). Blood samples for sCD40L dosage were taken at baseline immediately before PCI. We tested the relation between sCD40L and pre-specified outcome measures consisting of new ACS, clinical restenosis and all-cause mortality. We recruited 3,841 patients (mean age 64 ± 11 years, 79% men) with ACS (n=2,383) or CCS (n=1,458).

RESULTS

During a mean follow-up of two years (±0.6 years), 642 patients developed ACS, 409 developed restenosis (≥70% of at least one of the previously treated coronary segments) and 175 died. For each 1-standard deviation increase in sCD40L (0.80 ng/mL), the hazard ratios (HRs) for ACS, restenosis, and mortality were 1.11 (95% confidence interval [CI]: 1.05 to 1.18, p<0.0001), 1.10 (95% CI: 1.02 to 1.19, p=0.010), and 1.00 (95% CI: 0.86 to 1.16, p=0.983), respectively. In multivariable Cox regression models with adjustment for several potential confounders including age, acute or chronic coronary syndrome, multi-vessel disease, stent placement, diabetes, previous coronary events and dyslipidemia, sCD40L remained an independent predictor of ACS and coronary restenosis. There were no interactions between sCD40L and acute or chronic coronary syndrome or stent placement.

CONCLUSIONS

Among patients with ACS or CCS who undergo PCI, higher levels of sCD40L predict an increased risk of acute coronary events and coronary restenosis, but not of mortality.

Unattended compared to traditional blood pressure measurement in patients with rheumatoid arthritis: a randomised cross-over study

BACKGROUND

Hypertension is characterised by a high prevalence, low awareness and poor control among rheumatoid arthritis (RA) patients. Correct blood pressure (BP) measurement is highly important in these subjects. The "unattended" BP measurement aims to reduce the "white-coat effect," a phenomenon associated with cardiovascular risk. Data on "unattended" BP measurement in RA and its impact on hypertensive organ damage are very limited.

METHODS

BP was measured in the same patient both traditionally ("attended" BP) and by the "unattended" protocol (3 automated office BP measurements, at 1-min intervals, after 5 min of rest, with patient left alone) by a randomised cross-over design. Patients underwent clinical examination, 12-lead electrocardiography and trans-thoracic echocardiography to evaluate cardiac damage.

RESULTS

Sixty-two RA patients (mean age 67 ± 9 years, 87% women) were enrolled. Hypertension was diagnosed in 79% and 66% of patients according to ACC/AHA and ESC/ESH criteria, respectively. Concordance correlation coefficients between the two techniques were 0.55 (95%, CI 0.38-0.68) for systolic BP and 0.73 (95%, CI 0.60-0.82) for diastolic BP. "Unattended" (121.7/68.6 mmHg) was lower than "attended" BP (130.5/72.8 mmHg) for systolic and diastolic BP (both p < .0001). Among the two techniques, only "unattended" systolic BP showed a significant association with left ventricular mass (r = 0.11; p = .40 for "attended" BP; r = 0.27; p = .036 for unattended BP; difference between slopes: z = 3.92; p = .0001).

CONCLUSIONS

In RA patients, "unattended" BP is lower than traditional ("attended") BP and more closely associated with LV mass. In these patients, the "unattended" automated BP measurement is a promising tool which requires further evaluation.KEY MESSAGES"Unattended" automated blood pressure registration, aimed to reduce the "white-coat effect" is lower than "attended" value in rheumatoid arthritis patients."Unattended" blood pressure is more closely associated with left ventricular mass than "attende" registration.

Intensive cardiac care unit admission trends during the COVID-19 outbreak in Italy: a multi-center study

A significant decline in the admission to intensive cardiac care unit (ICCU) has been noted in Italy during the COVID-19 outbreak. Previous studies have provided data on clinical features and outcome of these patients, but information is still incomplete. In this multicenter study conducted in six ICCUs, we enrolled consecutive adult patients admitted to ICCU in three specific time intervals: from February 8 to March 9, 2020 [before national lockdown (pre-LD)], from March 10 to April 9, 2020 [during the first period of national lockdown (in-LD)] and from May 18 to June 17, 2020 [soon after the end of all containment measures (after-LD)]. Compared to pre-LD, in-LD was associated with a significant drop in the admission to ICCU for all causes (- 35%) and acute coronary syndrome (ACS; - 49%), with a rebound soon after-LD. The in-LD reduction was greater for women (- 49%) and NSTEMI (- 61%) compared to men (- 28%) and STEMI (- 33%). Length-of-stay, and in-hospital mortality did not show any significant change from to pre-LD to in-LD in the whole population as well as in the ACS group. This study confirms a notable reduction in the admissions to ICCUs from pre-LD to in-LD followed by an increment in the admission rates after-LD. These data strongly suggest that people, particularly women and patients with NSTEMI, are reluctant to seek medical care during lockdown, possibly due to the fear of viral infection. Such a phenomenon, however, was not associated with a rise in mortality among patients who get hospitalization.

The ISCHEMIA trial: optimal medical therapy against PTCA in the stable patient: the endless story

In patients with acute coronary syndrome, an aggressive approach with coronary angiography and revascularization leads to important benefits compared to medical therapy alone. On the contrary, the prognostic impact of coronary revascularization in patients suffering from stable coronary artery disease has long been the subject of debate. The pivotal study in this area is COURAGE, published in 2007, in which coronary revascularization showed no benefit about the combined endpoint of death from all causes and acute myocardial infarction (AMI), compared to medical therapy. The ISCHEMIA study, published in 2020, compared selective coronary angiography and revascularization vs. a non-invasive approach. By protocol, the patients were initially evaluated with coronary computed axial tomography angiography: in case of coronary stenosis >50%, they were then randomized to the two strategies. While in the invasive arm patients were revascularized, in the non-invasive arm revascularization was used only in case of patient destabilization. As in COURAGE, the results of ISCHEMIA did not demonstrate superiority of revascularization over medical therapy alone for a combined endpoint of cardiovascular death, AMI, or hospitalization for unstable angina, heart failure, or cardiac arrest. Based on recent evidence from ISCHEMIA, it is therefore confirmed that coronary revascularization in stable patients does not seem to improve the prognosis compared to medical therapy alone.

Certainties fading away: β-blockers do not worsen chronic obstructive pulmonary disease

For many years, β-blockers have been considered contraindicated in patients with heart failure (HF) and in those with bronchial asthma or even chronic obstructive pulmonary disease (COPD) although without clear evidence of asthma. Today, despite overwhelming evidence of the usefulness of β-blockers, especially in HF with reduced left ventricular ejection fraction (HFrEF), and in ischaemic heart disease, some reluctance persists in using these drugs when COPD coexists. Such resistance is due to the fear that a possible worsening of bronchospasm induced by β-blockers could induce negative effects greater than the benefits. The Guidelines of the European Society of Cardiology clearly suggest that: (i) implantation of a cardiac defibrillator (ICD) are not contraindicated in COPD without clear evidence of bronchial asthma; (ii) β-blockers are only ‘relatively’ contraindicated when there is certainty of bronchial asthma with a documented bronchodilator response to the β2 stimulant. Therefore, bronchial asthma is not an absolute contraindication to β-blockers. The cardiologist should not limit the diagnosis of COPD to clinical suspicion, but should rely on a spirometry examination associated with any bronchodilation tests. In any case, selective β1 blockers are preferred, starting at a basic dose, which ensure a better dilator response to bronchodilators and in any case cause less bronchospasm than non-selective β-blockers. Unfortunately, there is still some reluctance to the use of β-blockers in patients with COPD associated with HF, which should be eliminated.

Unprotected left main coronary artery stenting: true vs. non true bifurcation lesions; a single-centre experience

Aims

We investigated the impact of bifurcation lesions involving a side branch lesion combined with a main branch stenosis on clinical outcomes after percutaneous coronary intervention (PCI) on unprotected left main coronary artery (ULM).

Methods and results

We defined “true” bifurcation lesions as significant (&gt;50%) side branch stenosis associated with a significant main branch lesion, either proximal or distal, according to the Medina classification (1.1.1, 1.0.1 or 0.1.1 lesions). “Non true” lesions were defined by absence of significant side lesions, or significant side lesions without concomitant main branch stenosis. We compared patients with “non-true” bifurcation lesions (N=132; 56%) with those with “true” bifurcation lesions (N=105; 44%) in their 12-month incidence of target vessel failure (TVF) (composite of (i) cardiac death related to target vessel; (ii) myocardial infarction related to target vessel, or (iii) ischemia-driven target vessel revascularization), death from any cause, target lesion revascularization (TLR) and stent thrombosis (ST). TVF occurred in 56 patients (24%) (figure 1). Patients with “true” bifurcation lesions had a significantly higher risk of TVF than those with “non-true” bifurcation lesions (HR 2.39; 95% CI 1.39–4.11, P=0.002). “True” bifurcation lesions were also associated with a higher risk of all cause of death (HR, 2.54; 95% CI, 1.09–5.94; P=0.031) and TLR (HR, 2.33; 95% CI, 1.1–4.94, P=0.027). 'True' bifurcation lesions, diabetes mellitus, as well as cardiogenic shock, were independently associated with an increased risk of TVF (figure 2). Of note, the SYNTAX score I was not identified as an independent predictor of TVF. The stenting strategy (1 vs 2 stents) did not show any significant association with the outcome.

Conclusions

Patients with ULM and “true” bifurcation lesions who undergo PCI have a worse clinical outcome than those with “non-true” bifurcation lesions.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier curves for TVFFigure 2. Independent predictors of TVF

Acute Myocarditis Associated with Legionella Infection: Usefulness of Layer-specific Two-dimensional Longitudinal Speckle-tracking Analysis

Pneumonia is the most commonly described manifestation of Legionella pneumophila infection (legionellosis), and extrapulmonary manifestations are uncommon. There are a few descriptions of acute myocarditis associated with legionellosis. We present a case of acute myocarditis in a patient admitted for legionellosis with multisystemic involvement (lung, heart, and kidney). Left ventricular (LV) dysfunction was documented by cardiac magnetic resonance (CMR) and two-dimensional speckle-tracking echocardiography; layer-specific strain analyses were performed, which allowed to differentiate subendocardial or subepicardial contractile impairment. Layer-specific strain analyses by echocardiography demonstrated impairment of subepicardial deformation in the inferolateral wall, which mirrored CMR findings, showing late gadolinium enhancement in the subepicardium of the same LV segments. After initiation of appropriate antibiotic therapy with levofloxacin, LV systolic function rapidly improved as assessed by both CMR and strain analyses, with concomitant normalization of both clinical and biochemical abnormalities. The basic mechanisms of myocardial involvement during legionellosis are unclear; we discussed our findings according to the limited available evidence.

Association of Sex with Outcome in Elderly Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

BACKGROUND

Worse outcomes have been reported for women, compared with men, after an acute coronary syndrome (ACS). Whether this difference persists in elderly patients undergoing similar invasive treatment has not been studied. We investigated sex-related differences in 1-year outcome of elderly acute coronary syndrome patients treated by percutaneous coronary intervention (PCI).

METHODS

Patients 75 years and older successfully treated with PCI were selected among those enrolled in 3 Italian multicenter studies. Cox regression analysis was used to assess the independent predictive value of sex on outcome at 12-month follow-up.

RESULTS

A total of 2035 patients (44% women) were included. Women were older and most likely to present with ST-elevation myocardial infarction (STEMI), diabetes, hypertension, and renal dysfunction; men were more frequently overweight, with multivessel coronary disease, prior myocardial infarction, and revascularizations. Overall, no sex disparity was found about all-cause (8.3% vs 7%, P = .305) and cardiovascular mortality (5.7% vs 4.1%, P = .113). Higher cardiovascular mortality was observed in women after STEMI (8.8%) vs 5%, P = .041), but not after non ST-elevation-ACS (3.5% vs 3.7%, P = .999). A sensitivity analysis excluding patients with prior coronary events (N = 1324, 48% women) showed a significantly higher cardiovascular death in women (5.4% vs 2.9%, P = .025). After adjustment for baseline clinical variables, female sex did not predict adverse outcome.

CONCLUSIONS

Elderly men and women with ACS show different clinical presentation and baseline risk profile. After successful PCI, unadjusted 1-year cardiovascular mortality was significantly higher in women with STEMI and in those with a first coronary event. However, female sex did not predict cardiovascular mortality after adjustment for the different baseline variables.

Prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions: a Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

A substantial number of chronic coronary syndrome (CCS) patients undergoing percutaneous coronary intervention (PCI) experience periprocedural myocardial injury or infarction. Accurate diagnosis of these PCI-related complications is required to guide further management given that their occurrence may be associated with increased risk of major adverse cardiac events (MACE). Due to lack of scientific data, the cut-off thresholds of post-PCI cardiac troponin (cTn) elevation used for defining periprocedural myocardial injury and infarction, have been selected based on expert consensus opinions, and their prognostic relevance remains unclear. In this Consensus Document from the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI), we recommend, whenever possible, the measurement of baseline (pre-PCI) cTn and post-PCI cTn values in all CCS patients undergoing PCI. We confirm the prognostic relevance of the post-PCI cTn elevation >5× 99th percentile URL threshold used to define type 4a myocardial infarction (MI). In the absence of periprocedural angiographic flow-limiting complications or electrocardiogram (ECG) and imaging evidence of new myocardial ischaemia, we propose the same post-PCI cTn cut-off threshold (>5× 99th percentile URL) be used to define prognostically relevant ‘major’ periprocedural myocardial injury. As both type 4a MI and major periprocedural myocardial injury are strong independent predictors of all-cause mortality at 1 year post-PCI, they may be used as quality metrics and surrogate endpoints for clinical trials. Further research is needed to evaluate treatment strategies for reducing the risk of major periprocedural myocardial injury, type 4a MI, and MACE in CCS patients undergoing PCI.

Syncope and Cardiac Tamponade: Multimodality Imaging of Primary Cardiac Lymphoma

Primary cardiac lymphoma (PCL) is among the rarest heart neoplasms. Its estimated incidence is about 1%-2% among primary cardiac tumor and 0.5% of extranodal lymphoma. It usually causes heart failure, pericardial effusion, tamponade, and arrhythmias. Prognosis is poor; treatment is combined medical and surgical. We described the case of a 62-year-old male with PLC that presented with syncope and cardiac tamponade, submitted to R-CHOP therapy because of failure of surgery. Clinical state is stable 3 months after diagnosis and first chemotherapy cycle.

Procedural myocardial injury, infarction and mortality in patients undergoing elective PCI: a pooled analysis of patient-level data

AIMS

The prognostic importance of cardiac procedural myocardial injury and myocardial infarction (MI) in chronic coronary syndrome (CCS) patients undergoing elective percutaneous coronary intervention (PCI) is still debated.

METHODS AND RESULTS

We analysed individual data of 9081 patients undergoing elective PCI with normal pre-PCI baseline cardiac troponin (cTn) levels. Multivariate models evaluated the association between post-PCI elevations in cTn and 1-year mortality, while an interval analysis evaluated the impact of the size of the myocardial injury on mortality. Our analysis was performed in the overall population and also according to the type of cTn used [52.0% had high-sensitivity cTn (hs-cTn)]. Procedural myocardial injury, as defined by the Fourth Universal Definition of MI (UDMI) [post-PCI cTn elevation ≥1 × 99th percentile upper reference limit (URL)], occurred in 52.8% of patients and was not associated with 1-year mortality [adj odds ratio (OR), 1.35, 95% confidence interval (CI) (0.84-1.77), P = 0.21]. The association between post-PCI cTn elevation and 1-year mortality was significant starting ≥3 × 99th percentile URL. Major myocardial injury defined by post-PCI ≥5 × 99th percentile URL occurred in 18.2% of patients and was associated with a two-fold increase in the adjusted odds of 1-year mortality [2.29, 95% CI (1.32-3.97), P = 0.004]. In the subset of patients for whom periprocedural evidence of ischaemia was collected (n = 2316), Type 4a MI defined by the Fourth UDMI occurred in 12.7% of patients and was strongly associated with 1-year mortality [adj OR 3.21, 95% CI (1.42-7.27), P = 0.005]. We also present our results according to the type of troponin used (hs-cTn or conventional troponin).

CONCLUSION

Our analysis has demonstrated that in CCS patients with normal baseline cTn levels, the post-PCI cTn elevation of ≥5 × 99th percentile URL used to define Type 4a MI is associated with 1-year mortality and could be used to detect 'major' procedural myocardial injury in the absence of procedural complications or evidence of new myocardial ischaemia.

Cardiac procedural myocardial injury, infarction and mortality in patients undergoing elective PCI: a pooled analysis of patient-level data

Background

The prognostic implications of cardiac procedural myocardial injury and infarction (MI) in chronic coronary syndrome patients undergoing elective percutaneous coronary intervention (PCI) is still debated.

Objective

To determine the optimal cardiac troponin threshold for identifying prognostically important events.

Methods

Using a pooled dataset of nine registries and one randomized trial, we analysed individual data of 14,433 patients undergoing elective PCI with a normal or moderately elevated baseline pre-PCI cardiac troponin (cTn). A multivariate model was performed to evaluate the associations between post-PCI cTn elevation and 1-year mortality after PCI, including thresholds used by existing procedural myocardial injury definitions (Fourth Universal Definition of MI [UDMI] and Academic Research Consortium 2 [ARC-2] / Society for Cardiovascular Angiography and Interventions (SCAI)). The association between type 4a MI and 1-year mortality was also evaluated.

Results

Procedural myocardial injury defined by the Fourth UDMI occurred in 52.5% of patients and was not associated with 1-year mortality (adjOR 1.27, 95% CI [0.90–1.81] p=0.18). The association between post-PCI cTn elevation and 1-year mortality was significant above a 3-fold increase above the upper reference limit, and was optimal for a 5.2-fold increase which corresponded to an 18.3% rate of event, and an adjOR of 2.03 (95% CI [1.31–3.14], p=0.002) (figure). Procedural myocardial injury defined by the ARC-2/SCAI definition occurred in 1.3% of the patients, had a strong association with 1-year mortality (adjOR 4.15, 95% CI [1.62–10.64], p&lt;0.01) but lacked sensitivity (5.2% sensitivity). Type 4a MI occurred in 12.7% of patients, was strongly associated with 1-year mortality (adjOR 3.18, 95% CI [1.47–6.90], p=0.002), but could only be evaluated in a subset of patients (n=3 084) with available data on new myocardial ischaemia post-PCI.

Conclusions

We have demonstrated that a post-PCI cTn elevation ≥5x the 99th percentile URL in CCS patients with normal baseline cTn, represents the optimal threshold for defining prognostically important or “Major” procedural myocardial injury in the absence of evidence for new myocardial ischaemia. Major procedure related myocardial injury and type 4a MI should be considered as a quality metric and endpoints in clinical trials.

Adjusted OR of mortality at 1 year

Funding Acknowledgement

Type of funding source: None

Ventricular Preexcitation: An Anomalous Wave Interfering with the Ordered Ventricular Activation

Ventricular preexcitation is a depolarization of the ventricles that occurs before the conventional sequence, and the electrocardiogram is the specific test for diagnosis. A Kent bundle is the paradigm of ventricular preexcitation, and it is associated with short PR, wide QRS and delta wave. This finding is not always very evident, as it can have different degrees of pre-eccitazione; therefore great diagnostic care must be taken in this field. If not properly identified, the pattern of ventricular preexcitation may lead to an incorrect diagnosis. The methodology of precision electrocardiology is able to confront all these aspects.

Atrial fibrillation recurrence after transcatheter ablation worsens left atrial strain

Introduction

Left atrial strain (LAs) shows correlation with atrial fibrosis and is a predictor of atrial fibrillation (AF) recurrence after transcatheter ablation. Little is known about LAs evolution after ablation.

Purpose

We sought to evaluate the atrial function with echocardiographic strain before and 6 months after AF ablation.

Methods

65 consecutive patients undergoing radiofrequency or cryoballoon ablation for atrial fibrillation at our centre were enrolled. They underwent a transthoracic echocardiography before the procedure and at 6 months follow-up. 5 patients were excluded because of low quality images. Global left atrial strain during the reservoir phase (LASr) was calculated as a mean of the values obtained in 4 and 2 chamber apical view; the ventricular end-diastole was set as reference to allow the calculation both in patients in AF and sinus rhythm during the echocardiography. Recurrence was defined as any atrial arrhythmia episode lasting more than 30 seconds recorded on an EKG strip after the 3 months blanking period; all patients underwent a 24 hours EKG Holter after the blanking period to detect asymptomatic recurrence. Quality of life was assessed before the procedure and at follow-up with the EQ-5D-3L model.

Results

At 6 months 14 patients (13%) had AF recurrence. Patients with recurrence (AF-R) had similar baseline characteristics compared to those without recurrence (AF-NR) but the former had a longer history of AF (39±53 vs 85±94 months, p=0,018). LASr, LA volume and left ventricle ejection fraction (EF) were similar at baseline between groups. At follow-up LASr was significantly impaired in the AF-R group compared to AF-NR (14±6% vs 26±10% respectively, p&lt;0,0001) whereas LA volume, LV end systolic volume and EF remained similar. Compared to baseline LASr worsened in patients experiencing AF recurrence (22±11% vs 14±6%, p=0.016) and this finding was consistent also in patients in sinus rhythm during both examinations (29±8 vs 17±7, p=0,005). Compared to baseline LASr (22±10% vs 26±10%, p=0.024), LV end-systolic volume (29±15 ml vs 22±6 ml, p=0,006) and EF (51±9% vs 58±18%, p=0,038) improved in the AF-NR group but the effect was driven mainly by patients restoring sinus rhythm. Both groups showed a significant improvement of the quality of life (55±23 vs 85±13, p&lt;0,0001 AF-NR; 63±17 vs 80±12, p=0,012 AF-R).

Conclusions

Atrial fibrillation recurrence after transcatheter ablation is associated with significant left atrial strain worsening which indicates disease progression and may predispose to further long-term recurrences whereas a successful ablation has a protective effect on atrial function.

Funding Acknowledgement

Type of funding source: None

Post-traumatic Aortopulmonary Fistula after Bentall Procedure

Pseudoaneurysm complicated by aortopulmonary fistula (APF) after a Bentall procedure is extremely rare but potentially fatal, so timely diagnosis and treatment are critical. We present a subacute case of a post-traumatic APF which has had initial aspecific symptoms and later an acute worsening heart failure with chest pain not responding to medical treatment and requiring emergency surgery.

The pivotal link between ACE2 deficiency and SARS-CoV-2 infection

Angiotensin converting enzyme-2 (ACE2) receptors mediate the entry into the cell of three strains of coronavirus: SARS-CoV, NL63 and SARS-CoV-2. ACE2 receptors are ubiquitous and widely expressed in the heart, vessels, gut, lung (particularly in type 2 pneumocytes and macrophages), kidney, testis and brain. ACE2 is mostly bound to cell membranes and only scarcely present in the circulation in a soluble form. An important salutary function of membrane-bound and soluble ACE2 is the degradation of angiotensin II to angiotensin_1-7. Consequently, ACE2 receptors limit several detrimental effects resulting from binding of angiotensin II to AT1 receptors, which include vasoconstriction, enhanced inflammation and thrombosis. The increased generation of angiotensin_1-7 also triggers counter-regulatory protective effects through binding to G-protein coupled Mas receptors. Unfortunately, the entry of SARS-CoV2 into the cells through membrane fusion markedly down-regulates ACE2 receptors, with loss of the catalytic effect of these receptors at the external site of the membrane. Increased pulmonary inflammation and coagulation have been reported as unwanted effects of enhanced and unopposed angiotensin II effects via the ACE→Angiotensin II→AT1 receptor axis. Clinical reports of patients infected with SARS-CoV-2 show that several features associated with infection and severity of the disease (i.e., older age, hypertension, diabetes, cardiovascular disease) share a variable degree of ACE2 deficiency. We suggest that ACE2 down-regulation induced by viral invasion may be especially detrimental in people with baseline ACE2 deficiency associated with the above conditions. The additional ACE2 deficiency after viral invasion might amplify the dysregulation between the 'adverse' ACE→Angiotensin II→AT1 receptor axis and the 'protective' ACE2→Angiotensin_1-7→Mas receptor axis. In the lungs, such dysregulation would favor the progression of inflammatory and thrombotic processes triggered by local angiotensin II hyperactivity unopposed by angiotensin_1-7. In this setting, recombinant ACE2, angiotensin_1-7 and angiotensin II type 1 receptor blockers could be promising therapeutic approaches in patients with SARS-CoV-2 infection.

P1187Pocket-Hematoma after cardiac implantable electronic devices surgery: a single centre study

Intro

Pocket hematoma is a common complication after pacemaker (PMK) or implantable cardioverter defibrillator (ICD) surgery. In this clinical setting anticoagulant and antiplatelet therapy are associated with an increased risk of hemorrhagic complications, but data are sparse.

Purpose

We examined  the impact of antiplatelet therapy and anticoagulation with vitamin K antagonists (VKA) or heparin on the risk of pocket hematoma. Materials and method: between august 2017 and june 2019, a total of 639 devices were implanted or replaced at our centre. Predictors of hematoma occurrence were determined by multivariate regression analysis. We used a specific definition of pocket hematoma: a) any palpable swelling in the pocket area requiring an unscheduled visit or prolonged hospitalization &gt; 24 h or re-hospitalization for hematoma, b) interruption of antithrombotics, c) reoperation, d) hemoglobin drop &gt; 2 g/dl or blood transfusion. The above criteria were assessed during hospitalization and up to 10 days after discharge. Results: the incidence of pocket hematoma was 7.5%. Among 639 patients (pts) including in the study 33.5% (214 pts) didn’ t take any antithrombotic therapy, 40.2 % (257 pts) were on single antiplatelet therapy (SAPT), 8.8 % (56 pts) were on dual antiplatelet therapy, 11.1 % (71 pts) were on uninterrupted VKA (mean INR 2). Heparin bridging was administered in 6.4% (41 pts). Ejection fraction (43 ±13 %) and  hemoglobin value before implantation (12.3 ±2.6 g/dL) in patients who developed hematoma were significantly lower compared with whose without hematoma. Patients with hematoma had a higher prevalence of congestive heart failure, ischemic cardiomyopathy and intake antithrombotic therapy. After adjusting for confounding factors with multivariate logistic regression only the use of dual antiplatelet therapy (OR 5.9 95% CI 1.5-21 p = 0.008) and the bridging with enoxaparin (OR 5.6 95% CI 1.4-22 p = 0.013) increased the risk of pocket hematoma. Single antiplatelet therapy (OR 2.6 95% CI 0.8-8.4 p = ns) and uninterrupted VKA (OR 0.9 95% CI 0.7-11 p = ns) did not increased the risk of pocket hematoma compared to no antithrombotic therapy. Pulse generator change and new device implant/upgrading (OR 1.8 95% CI 0.6-5.2 p = ns) carried the same haemorrhagic risk.

Conclusion

the use of DAPT or bridging with enoxaparin are highly predictive for the occurrence of perioperative pocket hematoma in patients scheduled for pmk/icd surgery. In contrast, single antiplatelet therapy and uninterrupted VKA  did not increase the risk of hematoma.

COVID-19: ACE2centric Infective Disease?

Diffuse pulmonary inflammation, endothelial inflammation, and enhanced thrombosis are cardinal features of coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2. These features are reminiscent of several adverse reactions triggered by angiotensin II and opposed by angiotensin_1-7, in many experimental models. Severe acute respiratory syndrome coronavirus 2 binds to ACE2 (angiotensin-converting enzyme 2) receptors and entries into the cell through the fusion of its membrane with that of the cell. Hence, it downregulates these receptors. The loss of ACE2 receptor activity from the external site of the membrane will lead to less angiotensin II inactivation and less generation of antiotensin_1-7. In various experimental models of lung injury, the imbalance between angiotensin II overactivity and of antiotensin_1-7 deficiency triggered inflammation, thrombosis, and other adverse reactions. In COVID-19, such imbalance could play an important role in influencing the clinical picture and outcome of the disease. According to this line of thinking, some therapeutic approaches including recombinant ACE2, exogenous angiotensin_1-7, and angiotensin receptor blockers seem particularly promising and are being actively tested.

Impact of diabetes on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: insights from the ELDERLY ACS 2 trial

BACKGROUND

Despite recent improvements in percutaneous coronary revascularization and antithrombotic therapies for the treatment of acute coronary syndromes, the outcome is still unsatisfactory in high-risk patients, such as the elderly and patients with diabetes. The aim of the current study was to investigate the prognostic impact of diabetes on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study carried out at 32 centers in Italy.

METHODS

Our population is represented by 1443 patients included in the Elderly-ACS 2 trial. Diabetes was defined as known history of diabetes at admission. The primary endpoint of this analysis was cardiovascular mortality, while secondary endpoints were all-cause death, recurrent myocardial infarction, Bleeding Academic Research Consortium type 2 or 3 bleeding, and rehospitalization for cardiovascular event or stent thrombosis within 12 months after index admission.

RESULTS

Diabetes was present in 419 (29%) out of 1443 patients. Diabetic status was significantly associated with major cardiovascular risk factors and history of previous coronary disease, presentation with non-ST segment elevation myocardial infarction (P = 0.01) more extensive coronary disease (P = 0.02), more advanced Killip class at presentation (P = 0.003), use at admission of statins (P = 0.004) and diuretics at discharge (P < 0.001). Median follow-up was 367 days (interquartile range: 337-378 days). Diabetic status was associated with an absolute increase in the rate of cardiovascular mortality as compared with patients without diabetes [5.5 vs. 3.3%, hazard ratio (HR) 1.7 (0.99-2.8), P = 0.054], particularly among those treated with clopidogrel [HR (95% confidence interval (CI)) = 1.89 (0.93-3.87), P = 0.08]. However, this difference disappeared after correction for baseline differences [Adjusted HR (95% CI) 1.1(0.4-2.9), P = 0.86]. Similar findings were observed for other secondary endpoints, except for bleeding complications, significantly more frequent in diabetic patients [HR (95% CI) 2.02 (1.14-3.6), P = 0.02; adjusted HR (95% CI) = 2.1 (1.01-4.3), P = 0.05]. No significant interaction was observed between type of dual antiplatelet therapy, diabetic status and outcome.

CONCLUSION

Among elderly patients with acute coronary syndromes, diabetic status was associated with higher rates of comorbidities, more severe cardiovascular risk profile and major bleeding complications fully accounting for the absolute increase in mortality. In fact, diabetes mellitus did not emerge as an independent predictor of survival in advanced age.

Impact of body mass index on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: Insights from the ELDERLY ACS 2 trial

BACKGROUND AND AIM

Elderly patients are at increased risk of hemorrhagic and thrombotic complications after an acute coronary syndrome (ACS). Frailty, comorbidities and low body weight have emerged as conditioning the prognostic impact of dual antiplatelet therapy (DAPT). The aim of the present study was to investigate the prognostic impact of body mass index (BMI) on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study comparing low-dose (5 mg) prasugrel vs clopidogrel among elderly patients with ACS.

METHODS AND RESULTS

Our population is represented by 1408 patients enrolled in the Elderly-ACS 2 trial. BMI was calculated at admission. The primary endpoint of this analysis was cardiovascular (CV) mortality. Secondary endpoints were all-cause death, recurrent MI, Bleeding Academic Research Consortium (BARC) type 2 or 3 bleeding, and re-hospitalization for cardiovascular reasons or stent thrombosis within 12 months after index admission. Patients were grouped according to median values of BMI (<or ≥ 25.7 kg/m2). BMI was associated with hypertension, diabetes, hypercholesterolemia, estimated glomerular filtration rate and hemoglobin (p < 0.001), and inversely with age (p = 0.005). Overweight patients displayed larger use of diuretics at admission (p = 0.03), aspirin pre-randomization (p = 0.01) and radial access (p = 0.04). At a median follow-up of 367 [337-378] days, BMI did not affect CV mortality in the overall population 4% vs 3.8%; adjusted HR [95%CI] = 2.3 [0.8-6.5], p = 0.12. Similar findings were observed for our secondary efficacy and safety endpoints. Results did not change when considering separately higher risk subsets of patients, (female gender, diabetics, ST-segment elevation myocardial infarction or the type of DAPT treatment allocation), with no significant interaction between these population characteristics and BMI.

CONCLUSIONS

Among elderly patients with ACS, BMI did not condition the survival or the risk of major cardiovascular and bleeding complications. The results were consistent across several patient risk categories.

[ACE-inhibitors, angiotensin receptor blockers and severe acute respiratory syndrome caused by coronavirus]

Some Authors recently suggested that angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should be discontinued, even temporarily, given the current pandemic of SARS-CoV-2 virus. The suggestion is based on the hypothesis that ACE-inhibitors and ARBs may favor the entry and diffusion of SARS-CoV-2 virus into the human cells. ACE-inhibitors and ARBs may increase the expression of ACE2 receptors, which are the sites of viral entry into the human organism. ACE2 receptors are ubiquitous, although they are extremely abundant on the cell surface of type 2 pneumocytes. Type 2 pneumocytes are small cylindrical alveolar cells located in close vicinity to pulmonary capillaries and responsible for the synthesis of alveolar surfactant, which is known to facilitate gas exchanges. The increased expression of ACE2 for effect of ACE-inhibitors and ARBs can be detected by increased production of angiotensin1-7 and mRNA related to ACE2. There is the fear that the increased expression of ACE2 induced by ACE-inhibitors and ARBs may ultimately facilitate the entry and diffusion of the SARS-CoV-2 virus. However, there is no clinical evidence to support this hypothesis. Furthermore, available data are conflicting and some counter-intuitive findings suggest that ARBs may be beneficial, not harmful. Indeed, studies conducted in different laboratories demonstrated that ACE2 receptors show a down-regulation (i.e. the opposite of what would happen with ACE-inhibitors and ARBs) for effect of their interaction with the virus. In animal studies, down-regulation of ACE2 has been found as prevalent in the pulmonary areas infected by virus, but not in the surrounding areas. In these studies, virus-induced ACE2 down-regulation would lead to a reduced formation of angiotensin1-7 (because ACE2 degrades angiotensin II into angiotensin1-7) with consequent accumulation of angiotensin II. The excess angiotensin II would favor pulmonary edema and inflammation, a phenomenon directly associated with angiotensin II levels, along with worsening in pulmonary function. Such detrimental effects have been blocked by ARBs in experimental models. In the light of the above considerations, it is reasonable to conclude that the suggestion to discontinue ACE-inhibitors or ARBs in all patients with the aim of preventing or limiting the diffusion of SARS-CoV-2 virus is not based on clinical evidence. Conversely, experimental studies suggest that ARBs might be useful in these patients to limit pulmonary damage through the inhibition of type 1 angiotensin II receptors. Controlled clinical studies in this area are eagerly awaited. This review discusses facts and theories on the potential impact of ACE-inhibitors and ARBs in the setting of the SARS-CoV-2 pandemic.

The revolution of the anti-diabetic drugs in cardiology

Beginning in December 2008, under the auspices of Food and Drug Administration, numerous controlled clinical trial were planned, and in part completed, concerning the cardiovascular (CV) effects of hypoglycaemic drug in patients with Type 2 diabetes mellitus. At least 9 studies have been concluded, 13 are still open, and 4 have been initiated and closed ahead of time. Of the nine completed studies, three concerned inhibitor of the dipeptidyl peptidase 4 (inhibitors of DPP-4), four the glucagon-like peptide 1 agonist (GLP-1 agonist), and two the inhibitor of sodium-glucose co-transporter-2 (inhibitors of SGLT-2). Only four studies demonstrated the superiority, and not the mere ‘non-inferiority’, of the anti-diabetic drugs compared to placebo, in addition to standard treatment, in terms of reduction of the primary endpoint (CV death, non-fatal myocardial infarction, and non-fatal stroke). Two of the four studies regarded GLP-1 analogues (liraglutide and semaglutide), and two inhibitors of SGLT-2 (empaglifozin and canaglifozin). As a whole, these studies provided solid data supporting major beneficial CV effects of anti-diabetic drugs. During the next 3–4 years, an equal number of studies will be completed and published, so we will soon have the ‘final word’ on this issue. In the meantime, the clinical cardiologist should become familiar with these drugs, selecting the patients able to gain the best clinical advantage from this treatment, also by establishing a close relationship with the diabetologist.

Treatment of stable ischaemic heart disease: the old and the new

Stable ischaemic heart disease is a frequent and very heterogeneous condition. Drug therapy is important, in these patients, for improving their prognosis and controlling their symptoms. The typical clinical manifestation of obstructive coronary disease is angina pectoris. This symptom can be improved by various classes of compounds, namely beta-blockers (BBs), calcium antagonist, and nitrates. More recently, ranolazine and ivabradine have been introduced. All these drugs have been proven to reduce significantly angina. On the other hand, there are no evidences supporting improvement in prognosis, besides for the use of BBs, in patients with previous myocardial infarction (MI) or systolic dysfunction. Besides drugs for symptoms control, these patients also receive antiplatelet drugs, specifically aspirin, and lipid lowering compounds such as statins. Furthermore, recent evidences supported the use of low doses direct anticoagulant, or a second antiplatelet agent in patients with previous MI. Similarly, a very low LDL cholesterol level, such as obtained with PCKS9 inhibitors, seems very beneficial in these patients. It is possible that in the near future a specific role for neo-angiogenesis factors and cellular therapies, could be proven, albeit, presently these treatments are not supported by solid evidences.