Incremental Value of Renal Dysfunction Addition to the CHA2DS2-Vasc Score for Mortality Prediction in Patients with Acute Coronary Syndrome.

INTRODUCTION: This study analyzes the usefulness of the CHA2DS2-VASc score for mortality prediction in patients with acute coronary syndromes (ACSs) and evaluates if the addition of renal functional status could improve its predictive accuracy. METHODS: CHA2DS2-VASc score was calculated by using both the original scoring system and adding renal functional status using 3 alternative renal dysfunction definitions (CHA2DS2-VASc-R1: eGFR <60 mL/min/1.73 mq = 1 point; CHA2DS2-VASc-R2: eGFR <60 mL/min/1.73 mq = 2 points; and CHA2DS2-VASc-R3: eGFR <60 mL/min/1.73 mq = 1 point, <30 mL/min/1.73 mq = 2 points). Inhospital mortality (IHM) and post-discharge mortality (PDM) were recorded, and discrimination of the various risk models was evaluated. Finally, the net reclassification index (NRI) was calculated to compare the mortality risk classification of the modified risk models with that of the original score. RESULTS: Nine hundred and eight ACS patients (median age 68 years, 30% female, 51% ST-elevation) composed the study population. Of the 871 patients discharged, 865 (99%) completed a 12-month follow-up. The IHM rate was 4.1%. The CHA2DS2-VASc score demonstrated a good discriminative performance for IHM (C-statistic 0.75). Although all the eGFR-modified risk models showed higher C-statistics than the original model, a statistically significant difference was observed only for CHA2DS2-VASc-R3. The PDM rate was 4.5%. The CHA2DS2-VASc C-statistic for PDM was 0.75, and all the modified risk models showed significantly higher C-statistics values than the original model. The NRI analysis showed similar results. CONCLUSIONS: CHA2DS2-VASc score demonstrated a good predictive accuracy for IHM and PDM in ACS patients. The addition of renal dysfunction to the original score has the potential to improve identification of patients at the risk of death.

Utility of the HAS-BLED score for risk stratification of patients with acute coronary syndrome.

HAS-BLED score was developed for bleeding prediction in patients with atrial fibrillation (AF). Recently, it was also used in patients undergoing percutaneous coronary interventions (PCI). This study analyzes the HAS-BLED predictivity for bleedings and mortality in patients with acute coronary syndromes (ACS) without AF, and evaluates the utilization of alternative criteria for renal dysfunction. The study population was composed of 704 patients with ACS. Six-hundred and eleven patients completed the follow-up. The HAS-BLED score was calculated both using the original definition of renal dysfunction, both using three alternative eGFR thresholds (< 30, < 60 and ≤ 90 ml/min/1.73 mq). In-hospital and post-discharge bleedings and mortality were recorded, and calibration and discrimination of the various risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic. In-hospital bleedings were 4.7% and mortality was 2.7%. Post-discharge bleedings were 3.1% and mortality was 4.4%. Regarding bleeding events and in-hospital mortality, the HAS-BLED original risk model demonstrated a moderate-to-good discriminative performance (C-statistics from 0.65 to 0.76). No significant differences were found in predictive accuracy when applying alternative definitions of renal dysfunction based on eGFR, with the exception of post-discharge mortality, for which HAS-BLED model assuming an eGFR value < 60 ml/min/1.73 mq showed a discriminative performance significantly higher in comparison to the other risk models (C-statistic 0.71 versus 0.64-0.66). In conclusion, in our ACS population, the HAS-BLED risk score showed a fairly good predictive accuracy regarding in-hospital and follow-up bleeding events and in-hospital mortality. The use of renal dysfunction alternative criteria based on eGFR values resulted in out-of hospital mortality predictive accuracy enhancement.

Comparison of CRUSADE and ACUITY-HORIZONS Bleeding Risk Scores in Patients With Acute Coronary Syndromes.

BACKGROUND: Compare the discriminative performance of two validated bleeding risk models for in-hospital bleeding events in a non-selected cohort of acute coronary syndrome (ACS) patients. METHODS: CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) scores were calculated in 501 consecutive patients (median age 68 years (IQR 57-77), 31% female) admitted for ACS to the coronary care unit (CCU) of San Paolo Hospital in Milan (Italy). In-hospital haemorrhagic events and mortality were recorded and calibration and discrimination of the two risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic, respectively. RESULTS: Overall bleeding events were observed in 32 patients and major bleedings in 11 (with an incidence of 6.4% and 2.2%, respectively). In-hospital mortality was 2.6%. Regarding major bleedings both risk scores demonstrated an adequate calibration (H-L test p>0.20) and a moderate discrimination with no significant difference in predictive accuracy between the two models (C-statistic 0.69 for CRUSADE and 0.73 for ACUITY-HORIZONS). We also tested the performance of the two risk models in predicting in-hospital mortality, showing an adequate calibration and a very good discrimination (C-statistic 0.88 and 0.89 for the CRUSADE and ACUITY-HORIZONS scores, respectively), with no significant difference in predictive accuracy. CONCLUSIONS: In our ACS population the CRUSADE and the ACUITY-HORIZONS risk scores showed a fairly good and comparable predictive accuracy regarding in-hospital bleeding events and they appeared to be very good predictors of in-hospital mortality.

Cardiovascular magnetic resonance characterization of peri-infarct zone remodeling following myocardial infarction.

BACKGROUND: Clinical studies implementing late gadolinium-enhanced (LGE) cardiovascular magnetic resonance (CMR) studies suggest that the peri-infarct zone (PIZ) contains a mixture of viable and non-viable myocytes, and is associated with greater susceptibility to ventricular tachycardia induction and adverse cardiac outcomes. However, CMR data assessing the temporal formation and functional remodeling characteristics of this complex region are limited. We intended to characterize early temporal changes in scar morphology and regional function in the PIZ. METHODS AND RESULTS: CMR studies were performed at six time points up to 90 days after induction of myocardial infarction (MI) in eight minipigs with reperfused, anterior-septal infarcts. Custom signal density threshold algorithms, based on the remote myocardium, were applied to define the infarct core and PIZ region for each time point. After the initial post-MI edema subsided, the PIZ decreased by 54% from day 10 to day 90 (p = 0.04). The size of infarct scar expanded by 14% and thinned by 56% from day 3 to 12 weeks (p = 0.004 and p < 0.001, respectively). LVEDV increased from 34.7. ± 2.2 ml to 47.8 ± 3.0 ml (day 3 and week 12, respectively; p < 0.001). At 30 days post-MI, regional circumferential strain was increased between the infarct scar and the PIZ (-2.1 ± 0.6 and -6.8 ± 0.9, respectively;* p < 0.05). CONCLUSIONS: The PIZ is dynamic and decreases in mass following reperfused MI. Tensile forces in the PIZ undergo changes following MI. Remodeling characteristics of the PIZ may provide mechanistic insights into the development of life-threatening arrhythmias and sudden cardiac death post-MI.

Access-site hematoma in distal and conventional transradial access: a randomized trial.

BACKGROUND: Distal transradial access (dTRA) has been recently proposed as an innovative access for coronary procedures and a valuable alternative to conventional transradial access (cTRA). The aim of this study was to assess the safety of dTRA versus cTRA in patients undergoing percutaneous coronary angiography and intervention. METHODS: In this single-center randomized trial, consecutive patients admitted for stable cardiac condition or acute coronary syndrome (ACS) were assigned to dTRA or cTRA. The primary endpoint was an early discharge after transradial stenting of coronary arteries (EASY) grade ≥II access-site hematoma (ASH). Vascular access failure, radial artery occlusion (RAO) at hospital discharge, 30-day rates of death, myocardial infarction, stroke and bleeding not related to coronary artery bypass grafting were considered as secondary endpoints. RESULTS: A total of 204 patients were included and randomized to dTRA (N.=100) or cTRA (N.=104). The two populations were similar, except for a higher percentage of ACS in the dTRA than in the cTRA group (38% versus 24%, P=0.022). The rate of EASY grade ≥II ASH was lower in dTRA than in cTRA patients, but the difference was not statistically significant (4% versus 8.4%, respectively, P=0.25). Vascular access failure was more frequent in dTRA patients than in cTRA patients (34% versus 8.7%, P<0.0001). We detected no case of RAO at hospital discharge and similar rates of 30-day adverse events in both groups. CONCLUSIONS: DTRA is safe and feasible. When compared to cTRA, dTRA is technically more demanding and limited by more frequent crossover to an alternative vascular access.

Uric acid associated with acute heart failure presentation in Acute Coronary Syndrome patients.

We focused on the role of Uric Acid (UA) as a possible determinant of Heart Failure (HF) related issues in Acute Coronary Syndromes (ACS) patients. Main outcomes were acute HF and cardiogenic shock at admission, secondary outcomes were the use of Non Invasive Ventilation (NIV) and the admission Left Ventricular Ejection Fraction (LVEF). We consecutively enrolled 1269 ACS patients admitted to the cardiological Intensive Care Unit of the Niguarda and San Paolo hospitals (Milan, Italy) from June 2016 to June 2019. Median age was 68 (first-third quartile 59-77) years and males were 970 (76%). All the evaluated outcomes occurred more frequently in the hyperuricemic subjects (UA higher than 6 mg/dL for females and 7 mg/dL for males, n = 292): acute HF 35.8 vs 11.1% (p < 0.0001), cardiogenic shock 10 vs 3.1% (p < 0.0001), NIV 24.1 vs 5.1% (p < 0.0001) and lower admission LVEF (42.9±12.8 vs 49.6±9.9, p < 0.0001). By multivariable analyses, UA was confirmed to be significantly associated with all the outcomes with the following Odds Ratio (OR): acute HF OR = 1.119; 95% CI 1.019;1.229; cardiogenic shock OR = 1.157; 95% CI 1.001;1.337; NIV use OR = 1.208; 95% CI 1.078;1.354; LVEF ß = -0.999; 95% CI -1.413;-0.586. We found a significant association between UA and acute HF, cardiogenic shock, NIV use and LVEF. Due to the cross-sectional nature of our study no definite answer on the direction of these relationship can be drawn and further longitudinal study on UA changes over time during an ACS hospitalization are needed.

Predictors of Mortality and Long-Term Outcome in Patients with Anterior STEMI: Results from a Single Center Study.

Anterior ST segment elevation myocardial infarction (A-STEMI) has the worst prognosis among all infarct sites due to larger infarct size and the higher cardiac enzyme release. We retrospectively analyzed 584 A-STEMI undergoing urgent coronary angiography from October 2008 to April 2019. The median follow-up time was 1774 days with a minimum of a 1-year follow-up for 498 patients. In-hospital mortality was 8.6%, while long-term, all-cause mortality and 1-year mortality were 18.8% and 6.8%, respectively. The main predictors for in-hospital mortality were ejection fraction (LV-EF), baseline estimated glomerular filtration rate (eGFR), female gender and cardiogenic shock (CS) at admission, while long-term predictors of mortality were age, coronary artery disease (CAD) extension and LV-EF. Patients presenting with CS (6.5%) showed a higher mortality rate (in-hospital 68.4%, long term 41.7%). Among 245 patients (42%) with multivessel disease (MVD), complete revascularization (CR) during the index procedure was performed in 42.8% of patients and more often in patients with CS at admission (19.1% vs. 6.1%, p = 0.008). Short- and long-term mortality were not significantly influenced by the revascularization strategy (CR/culprit only). Our study confirmed the extreme fragility of A-STEMI patients, especially in case of CS at admission. LV-EF is a powerful predictor of a poor outcome. In MVD, CR during p-PCI did not show any advantage for either long- or short-term mortality compared to the culprit-only strategy.

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.

Autologous mesenchymal stem cells produce reverse remodelling in chronic ischaemic cardiomyopathy.

AIMS: The ability of mesenchymal stem cells (MSCs) to heal the chronically injured heart remains controversial. Here we tested the hypothesis that autologous MSCs can be safely injected into a chronic myocardial infarct scar, reduce its size, and improve ventricular function. METHODS AND RESULTS: Female adult Göttingen swine (n = 15) underwent left anterior descending coronary artery balloon occlusion to create reproducible ischaemia-reperfusion infarctions. Bone-marrow-derived MSCs were isolated and expanded from each animal. Twelve weeks post-myocardial infarction (MI), animals were randomized to receive surgical injection of either phosphate buffered saline (placebo, n = 6), 20 million (low dose, n = 3), or 200 million (high dose, n = 6) autologous MSCs in the infarct and border zone. Injections were administered to the beating heart via left anterior thoracotomy. Serial cardiac magnetic resonance imaging was performed to evaluate infarct size, myocardial blood flow (MBF), and left ventricular (LV) function. There was no difference in mortality, post-injection arrhythmias, cardiac enzyme release, or systemic inflammatory markers between groups. Whereas MI size remained constant in placebo and exhibited a trend towards reduction in low dose, high-dose MSC therapy reduced infarct size from 18.2 +/- 0.9 to 14.4 +/- 1.0% (P = 0.02) of LV mass. In addition, both low and high-dose treatments increased regional contractility and MBF in both infarct and border zones. Ectopic tissue formation was not observed with MSCs. CONCLUSION: Together these data demonstrate that autologous MSCs can be safely delivered in an adult heart failure model, producing substantial structural and functional reverse remodelling. These findings demonstrate the safety and efficacy of autologous MSC therapy and support clinical trials of MSC therapy in patients with chronic ischaemic cardiomyopathy.

Impact of COVID-19 on STEMI: Second youth for fibrinolysis or time to centralized approach?

On March 11th 2020 the World Health Organization declared the pandemic infection of SARS-CoV-2 (COVID-19) and Italy was one of the most affected country. The regional Emergency Medical System (EMS) founded itself facing an exponential increase in hospitalizations with a consequent organizational system crisis. Experts from Cina, UK and US suggested to reconsider thrombolysis as the best treatment in term of balance between time consumption and operators safety for ST-segment elevation myocardial infarction (STEMI) patients respect to primary PCI (pPCI). The system reorganization consisted in a centralization of all the emergency nets: from 55 hospitals with cardiac catheterization laboratories distributed within our region offering a 24/7 service we passed to 13 Hub and 42 Spoke centres. Dedicated in-hospital paths for patients COVID positive or suspected (pCOV+) and COVID negative (pCOV-) were instituted. We analysed all consecutive patients undergoing emergency coronary angiogram from March 14 to April 14, 2020 at San Carlo Hospital in Milan comparing the two different in-hospital paths. We collected 30 STEMI patients. Eighteen patients (60%) were treated in pCOV-, while twelve patients (40%) in pCOV+. No significant differences were found among the two groups regarding key time points of STEMI care and interestingly we didn't find any treatment delay in pCOV+. In conclusion, a focused overhaul of the EMS may allow to maintain pPCI as the treatment of choice for patients and operators.

Predictors of procedural and clinical outcome in rotational atherectomy: analysis of a single center registry.

BACKGROUND: Heavy calcified lesions can decrease effectiveness of drug eluted stents in preventing restenosis. Rotational atherectomy (RA) demonstrated to improve outcomes in patients with severely calcified lesions pretreated with debulking. However, its feasibility and its safety are continuously on stage. Our aim has been to identify predictors of clinical and procedural outcome in RA. METHODS: We retrospectively analyzed a population of patients referred to our cath lab for urgent or elective coronary catheterization treated with RA. The associations between clinical variables and clinical or procedural events were evaluated using logistic regression. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) from procedure date to last day of follow-up. MACE have been defined as follows: cardiovascular death, heart failure hospitalization and target lesion revascularization. RESULTS: The registry included 68 of the 1908 (3.6%) patients that underwent percutaneous coronary intervention. Procedural success was as high as 94% and more than 90% of cases were treated without any complication. The most common complication during PCI with RA was vessel dissection (8.8%) and no procedural death occurred. None of the clinical nor procedural characteristics were associated with burr entrapment or vascular access hematoma. We identified as independent predictor of treated vessel dissection the female sex (OR 16.9, 95% CI 1.55-183.77, P<0.05). Logistic regression revealed age (OR 1.17, 95% CI: 1.02-1.33, P<0.02) as the only independent predictor of MACE. We therefore calculated the ROC curve on age in predicting MACE, that showed a C-statistics of 0.75 (95% CI 0.628 to 0.852, P=0.02), with 80 years old as the best threshold in defining high risk population. CONCLUSIONS: RA is a feasible and safe procedure. Females and elderly patients must be carefully selected in order to balance the risk/benefit ratio in these high-risk populations.

Impact of admission serum acid uric levels on in-hospital outcomes in patients with acute coronary syndrome.

BACKGROUND: To assess the association between admission serum uric acid (SUA) levels and in-hospital outcomes in a real-world patients population with acute coronary syndrome (ACS) and to investigate the potential incremental prognostic value of SUA added to GRACE score (GRACE-SUA score). METHODS: The data of consecutive ACS patients admitted to Coronary Care Unit of San Paolo and Niguarda hospitals in Milan (Italy) were retrospectively analyzed. RESULTS: 1088 patients (24% female) were enrolled. Mean age was 68 years (IQR 60-78). STEMI and NSTE-ACS patients were 504 (46%) and 584 (54%) respectively. SUA (OR 1.72 95%CI 1.33-2.22, p < 0.0001) and GRACE score (OR 1.04 95%CI 1.02-1.06, p < 0.0001) were significantly associated with an increased risk of in-hospital death at the multivariate analysis. Admission values of SUA were stratified in four quartiles. Rates of acute kidney injury, implantation of intra-aortic balloon pump and non-invasive ventilation use were significantly higher in the last quartile compared to Q1, Q2 and Q3 (p < 0.01). The areas under the ROC curve (AUC) for GRACE score and for SUA were 0.91 (95% CI 0.89-0.93, p < 0.0001) and 0.79 (95% CI 0.76-0.81, p < 0.0001) respectively. The AUC was larger for predicting in-hospital mortality with the GRACE-SUA score (0.94; 95% CI 0.93-0.95). CONCLUSIONS: High admission levels of SUA are independently associated with in-hospital adverse outcomes and mortality in a contemporary population of ACS patients. The inclusion of SUA to GRACE risk score seems to lead to a more accurate prediction of in-hospital mortality in this study population.

Chest pain and a left parasternal soft tissue swelling in an immunocompetent refugee with disseminated tuberculosis.

An immunocompetent migrant with chest pain was admitted to an Italian hospital. Computed tomography showed a left pectoral abscess and osteomyelitis of the sternum. The infection had spread into the anterior mediastinum near to the pericardium and the heart, where an atrial mass was confirmed by echocardiography. Disseminated tuberculosis was diagnosed.

[Role of ACE-inhibitors in preventing atrial fibrillation relapses in normotensive patients]. / Il ruolo degli ACE-inibitori nella prevenzione delle recidive di fibrillazione atriale isolata in pazienti normotesi.

Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia and a major public health problem, leading to high rates of morbidity and mortality. The most prevalent cause of AF in the western world is hypertensive heart disease. Blood pressure increase leads to hemodynamic modifications which usually have direct effects on left ventricular and atrial structure and function. The renin-angiotensin-aldosterone system (RAAS) plays an important role in regulating blood volume and systemic vascular resistance. Furthermore, recent studies showed that RAAS plays a key role in left atrial and ventricle structural and functional remodeling. Experimental studies and clinical trials have shown that angiotensin-II converting enzyme (ACE) inhibitors and angiotensin-II receptor blockers are effective in preventing atrial fibrillation in patients with arterial hypertension or several forms of heart disease. In our study, we showed that ramipril is effective in preventing AF relapses in patients with lone AF (LAF: i.e AF in the absence of clinical and echocardiographic evidence of cardiovascular, pulmonary, or endocrine disease), independently of any sizeable effect on cardiac echocardiographic anatomy when compared with baseline data. In this paper, we briefly discuss: 1) the role of ACE inhibitor ramipril in preventing AF relapses in LAF patients; 2) the underlying mechanisms by which it can potentially act; 3) the possibility of considering the occurrence of LAF as a marker of subclinical organ damage in subjects with blood pressure values in the 130 to 139 mm Hg range, that is in the pre-hypertension classification according to the JNC-7 Report, of high normal blood pressure levels according to the 2007 ESC/ESH guidelines.

The adult Göttingen minipig as a model for chronic heart failure after myocardial infarction: focus on cardiovascular imaging and regenerative therapies.

Porcine models have become increasingly popular in cardiovascular research. The standard farm pig rapidly increases in body weight and size, potentially confounding serial measurements of cardiac function and morphology. We developed an adult porcine model that does not show physiologic increases in heart mass during the study period and is suitable for long-term study. We compared adult minipigs with the commonly used adolescent Yorkshire swine. Myocardial infarction was induced in adult Göttingen minipigs and adolescent Yorkshire swine by occlusion of the left anterior descending coronary artery followed by reperfusion. At 8 wk after infarction, the left ventricular ejection fraction was 34.1 +/- 2.3% in minipigs and 30.7 +/- 2.0% in Yorkshire swine. The left ventricular end-diastolic mass in Yorkshire pigs assessed by magnetic resonance imaging increased 17 +/- 5 g, from 42.6 +/- 4.3 g at week 1 after infarction to 52.8 +/- 6.6 g at week 8, whereas it remained unchanged in minipigs. Cardiac anatomy and physiology in adult minipigs were evaluated invasively by angiography and noninvasively by Multidetector Computed Tomography and by Magnetic Resonance Imaging at 1.5 T and 3 T prior to myocardial infarction and during folow-up. This porcine heart failure model is reproducible, mimics the pathophysiology in patients who have experienced myocardial infarction, and is suitable for imaging studies. New heart failure therapies and devices can be tested preclinically in this adult animal model of chronic heart failure.

Real-world clopidogrel utilization in acute coronary syndromes: patients selection and outcomes in a single-center experience.

BACKGROUND: With this study, we sought to identify patient characteristics associated with clopidogrel prescription and its relationship with in-hospital adverse events in an unselected cohort of ACSs patients. MATERIALS AND METHODS: We studied all consecutive patients admitted at our institution for ACSs from 2012 to 2014. Patients were divided into two groups based on clopidogrel or novel P2Y12 inhibitors (prasugrel or ticagrelor) prescription and the relationship between clopidogrel use and patient clinical characteristics and in-hospital adverse events was evaluated using logistic regression analysis. RESULTS: The population median age was 68 years (57-77 year) and clopidogrel was prescribed in 230 patients (46%). Patients characteristics associated with clopidogrel prescription were older age, female sex, non-ST-elevation ACS diagnosis, the presence of diabetes mellitus and anemia, worse renal and left ventricular functions and a higher Killip class. Patients on clopidogrel demonstrated a significantly higher incidence of in-hospital mortality (4.8%) than prasugrel and ticagrelor-treated patients (0.4%), while a nonstatistically significant trend emerged considering bleeding events. However, on multivariable logistic regression analysis female sex, the presence of anemia and Killip class were the only variables independently associated with in-hospital death. CONCLUSION: Patients treated with clopidogrel showed a higher in-hospital mortality. However, clinical variables associated with its use identify a population at high risk for adverse events and this seems to play a major role for the higher in-hospital mortality observed in clopidogrel-treated patients.

[Follow-up strategies after percutaneous coronary intervention: prognostic stratification and multidisciplinary management based on patient risk profile]. / Paziente sottoposto a rivascolarizzazione coronarica per via percutanea: percorsi di stratificazione prognostica e di gestione multidisciplinare in relazione al profilo di rischio.

The number of percutaneous coronary interventions (PCI) is increasing worldwide. Follow-up strategies after PCI are extremely heterogeneous and can greatly affect the cost of medical care. In the present paper, practical advises are provided with respect to a tailored follow-up strategy on the basis of patients' risk profile. Clinical and interventional cardiologists, cardiac rehabilitators, and general practitioners equally contributed to the creation of the present document and defined three follow-up strategies and types and timing of clinical and instrumental evaluations in post-PCI patients.

A rare case of large intracoronary thrombosis in advanced breast cancer patient treated with epirubicin and cisplatin.

: Cancer is associated with a prothrombotic or hypercoagulable state. Intracoronary thrombosis is a rare and potentially life-threatening complication in cancer patients. We describe a rare case of large nonocclusive intracoronary thrombosis successfully treated by means of medical therapy.

A comparison between two different definitions of contrast-induced acute kidney injury in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is associated with significantly increased mortality after primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). The prognostic value of CI-AKI depends on the definitions used to define it. We compare the predictive accuracy of long-term mortality of two definitions of CI-AKI on consecutive patients undergoing pPCI for STEMI. METHODS: Incidence, risk factors and long-term prognosis of CI-AKI were assessed according to two different definitions: the first as an increase in serum creatinine ≥ 25% or ≥ 0.5 mg/dl from baseline within 72 h after pPCI (contrast-induced nephropathy (CIN) criteria), the second one according to Acute Kidney Injury Network (AKIN) classification system. RESULTS: A total of 402 patients were enrolled. The median follow-up period was 12 ± 4 months. Long-term mortality rate was 9.5%. Independent predictors of long-term mortality were: older age, basal renal impairment, left ventricular ejection fraction <40%, in-hospital major bleedings and CI-AKI. A significant correlation was found between mortality and CI-AKI as assessed by both CIN (HR 4.84, 95% CI: 2.56-9.16, p=0.000) and AKIN (HR 9.70, 95% CI: 5.12-18.37, p=0.000) definitions. The area under the receiver operating curve was significantly larger for predicting mortality with AKIN classification than with CIN criteria (0.7984 versus 0.7759; p=0.0331). CONCLUSIONS: In patients with STEMI treated by pPCI, CI-AKI is a frequent complication irrespective of the criteria used for its definition. AKIN, however, seems to provide a better accuracy in predicting long-term mortality than CIN criteria.