[The pulmonary artery catheter in the intensive cardiac care unit]. / Il catetere arterioso polmonare in terapia intensiva cardiologica.

More than 50 years after its introduction in clinical practice, the increase in the intensity of care offered by the cardiac intensive care units, the shift in the population of patients treated and the wider availability of circulatory supports, still makes the pulmonary artery catheter (PAC) an essential tool for diagnosis, monitoring and prognosis in patients suffering from cardiogenic shock. In this review, we will discuss how to identify those patients who can benefit most from its use, the configuration and the correct insertion technique of a PAC. A pragmatic guide will also be provided for the interpretation of the hemodynamic indexes (direct and calculated) that the PAC is able to reveal as well as a summary of the most common errors in reading or interpreting the pressure curves provided by the PAC. In this article, we will then present a practical guide on how to use the PAC in a modern cardiac intensive care unit.

Takotsubo Syndrome and Gender Differences: Exploring Pathophysiological Mechanisms and Clinical Differences for a Personalized Approach in Patient Management.

Takotsubo syndrome (TTS), also known as the broken-heart syndrome, is a reversible condition typically observed in female patients presenting for acute coronary syndromes (ACS). Despite its increasing incidence, TTS often remains undiagnosed due to its overlap with ACS. The pathophysiology of TTS is complex and involves factors such as coronary vasospasm, microcirculatory dysfunction, increased catecholamine levels, and overactivity of the sympathetic nervous system. Diagnosing TTS requires a comprehensive approach, starting with clinical suspicion and progressing to both non-invasive and invasive multimodal tests guided by a specific diagnostic algorithm. Management of TTS should be personalized, considering potential complications, the presence or absence of coronary artery disease (CAD), diagnostic test results, and the patient's clinical course. The current data primarily derive from case series, retrospective analyses, prospective registries, and expert opinions. In recent years, there has been growing recognition of gender differences in the pathophysiology, presentation, and outcomes of TTS. This review provides an updated overview of gender disparities, highlighting the importance of tailored diagnostic and management strategies.

Aspirin in Primary Prevention: Looking for Those Who Enjoy It.

Based on a wealth of evidence, aspirin is one of the cornerstones of secondary prevention of cardiovascular disease. However, despite several studies showing efficacy also in primary prevention, an unopposed excess risk of bleeding leading to a very thin safety margin is evident in subjects without a clear acute cardiovascular event. Overall, the variability in recommendations from different scientific societies for aspirin use in primary prevention is a classic example of failure of simple risk stratification models based on competing risks (atherothrombosis vs. bleeding), perceived to be opposed but intertwined at the pathophysiological level. Notably, cardiovascular risk is dynamic in nature and cannot be accurately captured by scores, which do not always consider risk enhancers. Furthermore, the widespread use of other potent medications in primary prevention, such as lipid-lowering and anti-hypertensive drugs, might be reducing the benefit of aspirin in recent trials. Some authors, drawing from specific pathophysiological data, have suggested that specific subgroups might benefit more from aspirin. This includes patients with diabetes and those with obesity; sex-based differences are considered as well. Moreover, molecular analysis of platelet reactivity has been proposed. A beneficial effect of aspirin has also been demonstrated for the prevention of cancer, especially colorectal. This review explores evidence and controversies concerning the use of aspirin in primary prevention, considering new perspectives in order to provide a comprehensive individualized approach.

A case report of cardiac tamponade after a road accident: think beyond trauma.

Background: Cardiac tamponade is a life-threatening compression of the heart caused by the accumulation of fluid in the pericardial sac. Although central venous catheters (CVCs) are essential in modern medicine, they carry a certain risk of complications including cardiac tamponade. Case summary: A 12-year-old female was involved in a road accident reporting multiple severe traumatic injuries, including a left humerus fracture and subdural haemorrhage. After 2 days in the intensive care unit, she suddenly developed hypotension and cardiac tamponade was diagnosed. Analysis of the pericardial fluid showed high glucose levels comparable to the parenteral nutrition that she was receiving. Retraction of the CVC allowed resolution of the effusion. Discussion: Cardiac tamponade is a rare but serious adverse event after CVC insertion, mostly among younger patients. Awareness of this risk allows physicians to promptly recognize and treat this dangerous complication.

Successful Recovery of Cardiac Function Following 20 min of a No-touch Period in a Donation After Circulatory Death: A Case Report.

BACKGROUND: Withdrawal of life-sustaining therapy (WLST) performed in the circulatory determination of death (DCD) donors leads to cardiac arrest, challenging the utilization of the myocardium for transplantation. The rapid initiation of normothermic regional perfusion or extracorporeal membrane oxygenation after death helps to optimize organs before implantation. However, additional strategies to mitigate the effects of stress response during WLST, hypoxic/ischemic injury, and reperfusion injury are required to allow myocardium recovery. METHODS: To this aim, our team routinely used a preconditioning protocol for each DCD donation before and during the WLST and after normothermic regional perfusion/extracorporeal membrane oxygenation. The protocol includes pharmacological treatments combined to reduce oxidative stress (melatonin, N -acetylcysteine, and ascorbic acid), improve microcirculation (statins), and mitigate organ's ischemic injury (steroids) and organ ischemia/reperfusion injury (remifentanil and sevoflurane when the heart is available for transplantation). RESULTS: This report presents the first case of recovery of cardiac function, with the only support of normothermic regional reperfusion, following 20 min of a no-touch period and 41 min of functional warm ischemic time in a DCD donor after the preconditioning protocol. CONCLUSIONS: Our protocol seems to be effective in abolishing the stress response during WLST and, on the other hand, particularly organ protective (and heart protective), giving a chance to donate organs less impaired from ischemia/reperfusion injury.

[Practical approach to the patient with fever in the intensive cardiac care unit: diagnostic framework and therapy notes]. / Approccio pratico al paziente con febbre in terapia intensiva cardiologica: inquadramento diagnostico e cenni di terapia.

The management of the patient with fever in the intensive cardiac care unit begins with a thorough evaluation of the patient, particularly symptoms, clinical history and physical examination, to provide information regarding the origin of the fever. The global evaluation of the patient should be integrated with blood and microbiological tests, in particular blood culture and swab. The laboratory, microbiologic or radiologic tests could be more or less detailed and targeted depending on the type of suspected infection and clinical conditions of the patient. When therapy is necessary, it is crucial to switch, as soon as possible, from broad spectrum antibiotic therapy to antibiotic therapy based on the results of the microbiological exams. Antibiotic therapy could be associated with antipyretic and specific organ support therapy when necessary.

[Management of elderly patients in the cardiac intensive care unit: how to balance between appropriateness and futility]. / Gestione del paziente anziano in unità di terapia intensiva cardiologica: tra appropriatezza diagnostico-terapeutica e futilità.

The number of elderly patients admitted to cardiac intensive care units (CICU) is significantly increasing. Nowadays, novel diagnostic and therapeutic tools allow to treat the vast majority of cardiac acute diseases, nonetheless care of elderly patients requires a careful clinical evaluation. A favorable proportion of cost-effectiveness is warranted, aimed at avoiding futile procedures or treatments. On the other hand, the availability of minimally invasive procedures carries forward old limits to treatments in elderly patients in CICU. It appears evident that age cannot per se represent a limit in the care of elderly people. The present review gives insights in the management of the most common cardiovascular disease settings in elderly patients in the CICUs, thus providing important tools in complex decision-making.

ANMCO POSITION PAPER: Role of intra-aortic balloon pump in patients with acute advanced heart failure and cardiogenic shock.

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.

[ANMCO Position paper: Current evidence on intra-aortic balloon pump in advanced acute heart failure]. / Position paper ANMCO: Ruolo del contropulsatore aortico nel paziente con insufficienza cardiaca acuta avanzata.

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists (ANMCO), reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure. Data deriving from a national survey in Italian hospitals about IABP use are also provided.

Transfemoral transcatheter aortic valve implantation for treatment of severe aortic regurgitation in a patient with previous aortic valve-sparing operation according to David.

The regurgitation of the native aortic valve in patient with previous David operation may represent a clinical challenge because the morbidity and mortality risk of re-operation is not negligible. Here we describe the case of a patient suffering from late severe aortic regurgitation, many years after David operation, efficaciously treated with transfemoral transcatheter aortic valve implantation. To the best of our knowledge, this is the first description of such treatment in a patient with aortic regurgitation and previous David operation.

[The use of mechanical chest compression devices for both out-of-hospital and in-hospital refractory cardiac arrest]. / Utilizzo del massaggiatore automatico esterno nell'arresto cardiaco refrattario sul territorio e in ospedale.

The purpose of cardiopulmonary resuscitation after sudden cardiac arrest is to restore minimal blood flow to provide oxygen to the brain and other vital organs. Chest compressions and external defibrillation are the first line for circulatory support. Although early defibrillation is the main factor influencing survival, cardiopulmonary resuscitation must be characterized by high-quality external chest compressions. Unfortunately, the performance of manual chest compressions decreases during time and in hostile conditions. For these reasons, mechanical devices for chest compression are able to support rescuers during cardiopulmonary resuscitation. Commonly used mechanical chest compression devices in Europe include LUCAS and Autopulse. Routine utilization of mechanical chest compression devices cannot be recommended because randomized controlled trials, such as LINC and PARAMEDIC for LUCAS and CIRC for Autopulse, have not demonstrated their superiority compared with manual chest compressions. The aim of this review is to analyze recent data regarding utilization of mechanical chest compression devices, and to clarify advantages and limitations.

Life-threatening ventricular tachyarrhythmias in the cardiology department: Implications for appropriate prescription of telemetry monitoring.

BACKGROUND: in-hospital life-threatening ventricular arrhythmias (LT-VA) may complicate the course of cardiovascular patients. We aimed to assess the incidence, circumstances, determinants, and outcome of in-hospital LT-VA in order to help clinicians in prescribing appropriate levels of monitoring. METHODS: the study population consisted of all 10,741 consecutive patients (65 ± 15 years, 67.7% males) admitted to a cardiology department in 2009-2014. Terminally ill patients and those with primary arrhythmia diagnosis were excluded. The composite end-point included sudden arrhythmic death, ventricular fibrillation, unstable ventricular tachycardia and appropriate ICD shock unrelated to invasive interventions. RESULTS: the incidence of LT-VA was 0.6%, with no differences regarding age, gender and primary diagnosis of coronary artery disease between patients with and without LT-VA. The incidence of LT-VA was significantly higher (1.2% versus 0.1%, p<0.001) among urgent compared with elective admissions and among patients with left ventricular ejection fraction (LV-EF) <45% (1.7% versus 0.2%, p<0.001). At multivariable analysis, urgent admission and LV-EF <45%, but not primary diagnosis of coronary artery disease, remained independent predictors of LT-VA. At the time of the event, 97.1% fulfilled either class I or class II indications for telemetry monitoring according to the American Heart Association guidelines. Survival to discharge with good neurological status was 70.6%. CONCLUSIONS: acutely ill patients with heart failure and LV systolic dysfunction showed the highest rate of LT-VAs, regardless of the underlying cardiac disease (ischemic or non-ischemic). Current guidelines demonstrated high sensitivity in identifying patients at risk. These findings may favor proper utilization of telemetry monitoring resources.

Surviving out-of-hospital cardiac arrest: just a matter of defibrillators?

Out-of-hospital sudden cardiac arrest (OHCA) is a leading cause of death all over the world. Although the outcome of OHCA resulting from 'nonshockable' rhythms (asystole and pulseless electrical activity) is poor regardless of resuscitation efforts, 'shockable' rhythms such as ventricular tachycardia or fibrillation may carry a good prognosis if early defibrillation is performed. At present, simplified cardiopulmonary resuscitation techniques (hands-only cardiopulmonary resuscitation) and automated external defibrillators (AEDs) offer lay people the possibility to provide lifesaving treatment to OHCA victims in the critical minutes before the arrival of the emergency medical system. Programs aimed at increasing provision of cardiopulmonary resuscitation and use of AEDs by lay people have been set up in different countries, including Italy, and have contributed to improve survival rates. However, success of these programs critically depends on appropriate planning and design, and on cultural predisposition of witnesses to undertake immediate measures of resuscitation in the case of OHCA. Placement of a large number of AEDs may carry high costs and little benefits if it is uncoordinated and not preceded by educational campaigns to spread widely the 'culture of resuscitation' in the population.

At-admission risk stratification for in-hospital life-threatening ventricular arrhythmias and death in non-ST elevation myocardial infarction patients.

AIMS: Identification of patients with non-ST elevation acute myocardial infarction (NSTEMI) at higher risk of in-hospital life-threatening ventricular arrhythmias (LT-VA) and death is crucial for determining appropriate levels of care/monitoring during hospitalisation. We assessed predictors of in-hospital LT-VA and all-cause mortality in a consecutive series of NSTEMI patients. METHODS AND RESULTS: We prospectively studied 1325 consecutive patients (69.7% males, median age 70 (61-79) years) presenting with NSTEMI and undergoing continuous electrocardiographic monitoring. The primary study end-point was the occurrence of spontaneous (unrelated to coronary interventions) in-hospital LT-VA, including sustained ventricular tachycardia and ventricular fibrillation; the secondary end-point was in-hospital mortality from all causes. Of 1325 patients, 21 (1.5%) experienced LT-VA and 62 (4.7%) died from either arrhythmias (n=1) or other causes (n=61). Seven of the 20 patients who survived LT-VA subsequently died of heart failure. Independent predictors of in-hospital LT-VA were the Global Registry of Acute Coronary Events (GRACE) score >140 (odds ratio (OR)=7.5; 95% confidence interval (CI) 1.7-33.3; p=0.008) and left ventricular ejection fraction (LV-EF)<35% (OR=4.1; 95% CI 1.7-10.3; p=0.002). GRACE score >140 (OR=14.6; 95% CI 3.4-62) and LV-EF <35% (OR=4.4; 95% CI 1.9-10) also predicted in-hospital all-cause death. The cumulative probability of in-hospital LT-VA and death was respectively 9.2% and 23% in the 98 (7.4%) patients with GRACE score >140 and LV-EF<35%, while it was respectively 0.2% and 0% among the 627 (47.3%) with GRACE score ≤140 and LV-EF ≥35%. CONCLUSIONS: Simple risk stratification at admission based on GRACE score and echocardiographic LV-EF allows early identification of NSTEMI patients at higher risk of both in-hospital LT-VA and all-cause mortality.

Therapeutic hypothermia in Italian Intensive Care Units after 2010 resuscitation guidelines: still a lot to do.

BACKGROUND: Therapeutic hypothermia (TH) is one of three interventions that have demonstrated to improve patients' neurological outcome after cardiac arrest. The aim of this study was to investigate the effect of the 2010 resuscitation guidelines on TH implementation in various Italian Intensive Care Units (ICU). METHODS: A structured questionnaire was submitted to Italian ICU. The questionnaire was addressed to determine the procedures of TH in each ICU or, on the contrary, the reason for not employing the therapy. RESULTS: We obtained complete information from 770 of 847 Italian ICU (91%). Out of 405 Units included in the analysis only 223 (55.1%) reported to use TH in comatose patients after return of spontaneous circulation. The trend of TH implementation shows a stable increase, particularly after 2006 but there is no evident acceleration after the strong indication of the 2010 guidelines. There was a rise of about 3.4 times in the number of Italian ICU using TH as compared to the 2007 survey (an increase of 68% per year). One hundred and eighty-two (44.9%) units did not use TH mainly because of lack of equipment, economic issues or the conviction of the difficulty of execution. CONCLUSIONS: TH is still under-used in Italy (55.1%) even though the therapy is strongly recommended in the 2010 guidelines. However, the increase in the adoption of hypothermia has been significant in the past 5 years (68%/years) and the awareness of the efficacy is almost consolidated among intensivists, being logistic problems the leading cause for non-adoption.