Correlation between epicardial fat and cigarette smoking: CT imaging in patients with metabolic syndrome.

BACKGROUND: The aim of our study was to assess the relationship between cigarette smoking and epicardial fat in a cohort of patients with metabolic syndrome (MetS) at risk for coronary artery disease. METHODS: We studied, in primary prevention, 54 subjects diagnosed with MetS. According to their smoking habits, the subjects were divided into two groups: smokers and non-smokers. Besides anthropometric characterization and screening laboratory tests, the subjects had a multidetector computerized tomography scan, which allowed epicardial fat quantification and calcium score (CS) evaluation. RESULTS: Compared with non-smokers, smokers showed older age (61.6 ± 1.8 vs 56.8 ± 1.2 yrs; p < 0.05). Also, the smokers displayed increased epicardial fat volume (138 [123; 150] vs 101[79; 130] ml; p < 0.01) as well as higher CS (94 [3; 301.5] vs 0 [0;10.2]; p < 0.001), in comparison with non-smokers. Notably, CS was positively correlated with smoking habit (rs 0.469; p < 0.01), epicardial fat (rs 0.377; p < 0.01), age (rs 0.502; p < 0.001) and uric acid (rs 0.498; p < 0.01). Accordingly, the associations between both CS or epicardial fat and cigarette smoking were still maintained after adjustment for age (r 0.317; p < 0.05; r 0.427; p < 0.01). Finally, multiple regression analysis showed that smoke was the variable that best predicted CS (R(2) 0.131; ß 0.362; p < 0.05) and epicardial fat (R(2) 0.177; ß 0.453; p = 0.01). CONCLUSIONS: Our findings suggest that, in subjects with MetS, cigarette smoking is an independent predictor of increased epicardial fat volume and higher CS.

[Management strategies and choice of antithrombotic treatment in patients admitted with acute coronary syndrome--executive summary for clinical practice. Consensus Document of the Regional Chapters of the Italian National Association of Hospital Cardiologists (ANMCO) and of the Italian Society of Emergency Medicine (SIMEU)]. / Strategie Assistenziali e Scelta della Terapia Antitrombotica nei Pazienti Ricoverati con Diagnosi di Sindrome Coronarica Acuta--Sintesi Operativa per la Pratica Clinica. Documento congiunto delle Sezioni Regionali del Lazio dell'Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) e della Società Italiana di Medicina di Emergenza-Urgenza (SIMEU).

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

Dopamine receptor subtypes in the human coronary vessels of healthy subjects.

OBJECTIVE: Dopamine D(1)-D(5) receptors subtypes were studied in human coronary vessels of healthy subjects to assess their localization and their expression. METHODS: Samples of intraparenchymal and extraparenchymal branches of human coronary arteries and veins were harvested from four normal native hearts explanted from four young brain dead heart donors in case of orthoptic transplant, not carried out for technical reasons. In all the samples morphological, biochemical, immunochemical, and morphometrical studies were performed including quantitative analysis of images and evaluation of data. RESULTS: Microanatomical section showed healthy coronary vessels, which expressed all dopamine receptors (from D(1) to D(5)) with a different pattern of distribution between the different layers, in the intra and in the extraparenchymal branches.D(1) and D(5) (with a prevalence D(1) over D(5)) were distributed in the adventitia and to a lesser extent in the outer media but they were absent in arterioles, capillaries and venules. Endothelial and the middle layer showed D(2), D(3) and D(4) receptors, with a greater expression of D(2). Immunoblot analysis of dopamine monoclonal antibodies and dopamine receptors showed a different migration band for each receptor: D(1) (45 KDa); D(2) (43 KDa); D(3) (42 kDa); D(4) (40-42 KDa); D(5) (38-40 KDa) CONCLUSION: These findings demonstrate the presence of all dopamine receptor subtypes in the wall of human coronary vessels of healthy subjects. Dopamine D(1) and D(2) receptor subtypes are the most expressed, suggesting their prominent role in the coronary vasoactivity.

[Cardiac abnormalities in patients with systemic lupus erythematosus: the role of antiphospholipid antibodies]. / Alterazioni cardiologiche in pazienti affetti da lupus: il ruolo degli anticorpi antifosfolipidi.

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic inflammatory disease that has protean manifestations and follows a relapsing and remitting course. More than 90% of cases of SLE occur in women, frequently starting at childbearing age. It is characterized by the presence of autoantibodies potentially directed toward every organ or apparatus. Cardiac alterations are frequent in patients affected by SLE and the simultaneous presence of antiphospholipid antibodies (aPL), able to cause arterial thrombosis in any vascular district, is considered a possible risk factor for cardiac damage in SLE patients. The aim of this study is to correlate the main cardiac disorders, estimable through transthoracic echocardiography, in SLE patients as well as the typical autoantibody pattern of the disease. METHODS: Our study included 76 patients: 38 SLE and 38 controls patients. Control patients have been properly selected to be comparable in gender, age and risks factors for cardiovascular disease. We performed autoantibody panel to assess the prevalence of various autoantibodies during SLE development (antinuclear antibody [ANA], double-stranded DNA [dsDNA], extractable nuclear antigen antibodies [ENA], aPL). In the study, the determination of the IgG and IgM isotypes for aPL (cardiolipin, phosphatidylinositol [aPI], phosphatidylserine, phosphatidic acid [aPA], and anti-ß2-glycoprotein I antibodies) were checked. Echocardiography was performed in all patients. RESULTS: In patients affected by SLE, 94.7% was positive to ANA (relative risk 20; 95% confidence interval 4.9-340; p<0.0001) whereas 60.5% was positive for aPL. In patients with SLE, valvular alterations were observed, with a statistically significant correlation between mitral and aortic insufficiency (p=0.01 and p=0.02, respectively). Among aPL-positive patients, 68% (17/25) exhibited at least one hemodynamically significant echocardiographic alteration, vss 3/13 (23%) of patients with negative aPL, with a statistically significant correlation (relative risk 2; 95% confidence interval 1.0-29.8; p=0.01). Among positive-aPL patients, a statistically significant correlation was also observed between mitral insufficiency and aPI-IgG positivity (p=0.01) and, regarding non-valvular alterations, between left atrial enlargement and aPI-IgG positivity (p=0.01) and between left ventricular hypertrophy and aPA-IgG positivity (p=0.03). CONCLUSIONS: The present study confirms that SLE is an important risk factor for the presence of cardiac alterations, especially for valvular damage. Moreover, the presence of aPL antibodies in patients with SLE is significantly associated with an increased risk of heart disease, and some specific cardiac alterations are correlated with the positivity of some subclasses of aPL.

Perception of Thromboembolism Risk: Differences between the Departments of Internal Medicine and Emergency Medicine.

The latest developments in emergency medicine (EM) have introduced new typologies of patients that have not been taken into account in previous studies of venous thromboembolism (VTE) risk. The aim of the current study was to evaluate by comparing the main international risk scores whether different perceptions of VTE risk exist in internal medicine (IM) departments and in EM departments. This cross-sectional observational study involved 23 IM and 10 EM departments of 21 different hospitals. The patient data were collected by physicians who were blinded to the purpose of the study. The data were analyzed using the main international risk scores. We analyzed 742 patients, 222 (30%) hospitalized in EM departments and the remaining 520 (70%) in IM departments. We found that fewer patients at risk for VTE were treated with low-molecular-weight heparin (LMWH) in EM departments than in IM departments. Moreover, there was significant statistical difference in the use of LMWH between IM and EM departments when the Padua score and immobilization criteria were used to assess the risk. The infrequent use of LMWH in EM patients may have several causes. For example, in EM departments, treatment of acute illness often takes higher priority than VTE risk evaluation. Moreover, immobilization criteria cannot be evaluated for all EM patients because of the intrinsic time requirements. For the aforementioned reasons, we believe that a different VTE risk score is required that takes into account the peculiarities of EM, and establishing such a score should be the object of future study.

[Venous thromboembolism in critically ill patients: analysis of the main age-related risk factors and definition of specific scores.] / Il tromboembolismo venoso nei pazienti critici: studio dei principali fattori di rischio correlati all'età e proposta di punteggi specifici.

INTRODUCTION: Venous thromboembolism (VTE) is the third most common cardiovascular illness after acute coronary syndrome and stroke and and the most common preventable cause of hospital-related death. Several studies have demonstrated a significant reduction of fatal pulmonary embolism attributed to the introduction of thromboprophylactic measures and changes in hospital practices. However, the influence of some demographical variables, especially age, has largely been under appreciated. METHODS: Using the date of the TEVere study, we have studied 187 patients with VTE and 350 case-control, and we proceeded to analyze the major risk factors for venous thromboembolism, separately for three age groups (≤60 years, 60-75 years, >75 years). Patients came from the departments of internal medicine and emergency medicine for 21 hospitals. In this subgroup, we have examined the main risk factors for the individual classes of age and have proposed, through a logistic regression analysis, 3 different types of scores, specific for each age class. We then compared the individual scores obtained with the Kucher's score. RESULTS: It was found that in the class of patients with a lower age of 60, the main risk factors found to be estrogen-progestagen treatment (p=0.004) and family history of VTE (p=0.047), while in older patients (>75 years) the main risk factors were immobilization (p=0.005) and chronic venous insufficiency (p=0.001). In common for the three classes the presence of an evolutionary malignancy and previous episodes of VTE. Through the ROC curve analysis, it was found that the results for the three proposed scores improved sensitivity compared to Kucher's score. However our results showed that the only score of the intermediate class showed a statistically significant difference for prediction of the thromboembolic risk (p=0.0264 (AUROC 0.7946; 95% CI, 0.75 to 0.80, AUROC 0.7042; 95% CI, 0.68. to 0.72). DISCUSSION: Our study emphasizes the importance of carrying a correct stratification, which also consider the patient's age and therefore the concomitant pathologies. In fact, although the age of the patient cannot be considered as the only criterion to start the thromboprophylaxis, as highlighted in literature, you need to consider each individual patient, with its own peculiarities. CONCLUSION: This study showed the difficulty in identifying the key risk factors that are responsible for thromboembolic disease and has emerged the opportunity to be evaluated by larger studies, the use of specific scores by age groups.

[The overuse of thromboprophylaxis in medical patients: main clinical aspects]. / L'uso eccessivo della tromboprofilassi in pazienti medici: i principali aspetti clinici.

BACKGROUND: Overuse of thromboprophylaxis is not an infrequent behavior in internal medicine. However, differently from underuse, overuse of thromboprophylaxis is rarely taken into account, and only few studies have addressed this issue. The purpose of our study was to try to understand the reasons behind this phenomenon. METHODS: Using data from the TEVERE study, we evaluated 279 patients hospitalized in 21 hospitals of the Lazio Region in Italy. Only patients who were negative to major risk scores as established in the scientific literature were included. We assessed the frequency of thromboprophylaxis in acutely ill medical patients hospitalized in emergency and internal medicine wards, and we performed a comparative analysis for each risk factor among patients who received or not received thromboprophylaxis. RESULTS: Forty-seven patients (16.5%) with negative risk scores were given thromboprophylaxis during hospitalization. On backward stepwise logistic regression analysis, severe infection (odds ratio [OR] 2.31; 95% confidence interval [CI] 1.25-4.35) and chronic venous insufficiency (OR 3.02; 95% CI 1.96-4.67) were found to be the strongest predictors of the use of thromboprophylactic treatment with heparin. The subgroup of patients who did not exhibit risk factors was also analyzed, and age was found to be the main factor in the decision-making process regarding heparin administration in the absence of other risk factors (74.9 ± 11.8 vs 63.7 ± 18.1, p=0.002). CONCLUSIONS: Our findings suggest that thromboprophylaxis is associated with considerable uncertainty, which results in its overuse. Further research is needed to better understand thromboembolic risk factors in hospitalized medical patients.

Cognitive impairment in elderly ED patients: need for multidimensional assessment for better management after discharge.

We describe the prevalence of cognitive impairment in a population aged 65 and older requiring urgent medical services and to propose global evaluation, involving cognitive, functional and social aspects, during the emergency department (ED) visit to define an individualized care protocol. A total of 150 patients aged 65 and older attended at the ED were screened for cognitive impairment using the Mini-Mental State Examination (MMSE). Patients with an MMSE score lower or equal to 23 were included in the second step of the study, namely evaluation involving neuropsychological instruments to assess cognitive and functional status and a questionnaire exploring socioeconomic conditions and type of support need. Cognitive impairment was detected in 24 patients (16%). In no case of mild impairment had a cognitive deficit already been diagnosed. The functional and socioeconomic profile enabled proposing a strategy for better management of the patients discharged by the ED.