ALLiance for sEcondary PREvention after an acute coronary syndrome. The ALLEPRE trial: A multicenter fully nurse-coordinated intensive intervention program.

The main objective of cardiovascular disease prevention is to reduce morbidity and mortality by promoting a healthy lifestyle, reducing risk factors, and improving adherence to medications. Secondary prevention after an acute coronary syndrome has proved to be effective in reducing new cardiovascular events, but its limited use in everyday clinical practice suggests that there is considerable room for improvement. The short-term results of evidence-based studies of nurse-coordinated secondary prevention programs have been positive, but there is a lack of long-term outcome data. The Alliance for the Secondary Prevention of Cardiovascular Disease in the Emilia-Romagna region (ALLEPRE) is a multicenter, randomized, controlled trial designed to compare the effects of a structured nurse-coordinated intensive intervention on long-term outcomes and risk profiles after an acute coronary syndrome with those of the standard of care. All of the patients randomized to the intervention group take part in 9 one-to-one sessions with an experienced nurse from the participating centers with the aim at promoting healthy lifestyles, reducing risk factors, and increasing adherence to medication over a mean period of 5 years. The primary clinical end point is the reduction in the risk of the 5-year occurrence of major adverse events (a composite of cardiovascular mortality, nonfatal reinfarction, and nonfatal stroke). The primary surrogate end point is the achievement of prespecified targets relating to classical risk factors, lifestyle modifications, and adherence to pharmacological therapy after 2 years of follow-up. Coronary heart disease is a chronic degenerative disease, and patients who recover from an acute coronary syndrome (ACS) are at high risk of developing recurrent events.1 Although secondary prevention measures have proved to be effective and are strongly recommended by all of the international guidelines,2., 3. the 4 EUROASPIRE surveys4., 5., 6., 7., 8. showed that there was still a high prevalence of conventional risk factors, that secondary prevention measures were inadequately implemented, and that their main goals were often not reached. In addition, there were considerable discrepancy in secondary prevention practices between centers and countries, and a widespread underuse of cardiac prevention and rehabilitation programs despite their demonstrated effectiveness in reducing cardiovascular risk over time.9., 10. Over the last 10 years, nurses have been increasingly involved in successful cardiovascular risk management,11., 12., 13. but although this has improved levels of cardiovascular risk, no clear reduction in hard end points such as major cardiovascular adverse events and mortality has been demonstrated.10 The aim of the ALLEPRE trial is to evaluate the benefit of a homogeneous, structured, secondary prevention intervention program, fully coordinated by nurses from in- and outpatient clinics, in terms of cardiovascular risk profiles and major clinical events in ACS patients living in the large Emilia-Romagna region of Italy.

Long-Term Outcome After Out-of-Hospital Cardiac Arrest: An Utstein-Based Analysis.

Background: No data are available regarding long-term survival of out-of-hospital cardiac arrest (OHCA) patients based on different Utstein subgroups, which are expected to significantly differ in terms of survival. We aimed to provide the first long-term survival analysis of OHCA patients divided according to Utstein categories. Methods: We analyzed all the 4,924 OHCA cases prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 2015 to 2019. Pre-hospital data, survival, and cerebral performance category score (CPC) at 1, 6, and 12 months and then every year up to 5 years after the event were analyzed for each patient. Results: A decrease in survival was observed during the follow-up in all the Utstein categories. The risk of death of the "all-EMS treated" group exceeded the general population for all the years of follow-up with standardized mortality ratios (SMRs) of 23 (95%CI, 16.8-30.2), 6.8 (95%CI, 3.8-10.7), 3.8 (95%CI, 1.7-6.7), 4.05 (95%CI, 1.9-6.9), and 2.6 (95%CI, 1.03-4.8) from the first to the fifth year of follow-up. The risk of death was higher also for the Utstein categories "shockable bystander witnessed" and "shockable bystander CPR": SMRs of 19.4 (95%CI, 11.3-29.8) and 19.4 (95%CI, 10.8-30.6) for the first year and of 6.8 (95%CI, 6.6-13) and 8.1 (95%CI, 3.1-15.3) for the second one, respectively. Similar results were observed considering the patients discharged with a CPC of 1-2. Conclusions: The mortality of OHCA patients discharged alive from the hospital is higher than the Italian standard population, also considering those with the most favorable OHCA characteristics and those discharged with good neurological outcome. Long-term follow-up should be included in the next Utstein-style revision.

[Heart failure and iron deficiency]. / Scompenso cardiaco e carenza marziale.

Heart failure with reduced ejection fraction (HFrEF) is a clinical reality with an incidence of >10% in the population over 65 years of age, expected to increase in the coming years. Alongside the well-known pharmacological options (e.g. angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, neprilysin inhibitors, beta-blockers, aldosterone antagonists), which have significantly improved the clinical and prognostic outcomes of HFrEF patients, we now have a new therapeutic target: iron deficiency, defined as a ferritin concentration <100 µg/l or between 100-300 µg/l in the presence of a transferrin saturation <20%. Iron plays a major role in the transport of oxygen as a component of hemoglobin, as an oxygen reservoir, and as a component of myoglobin, as well as in the formation of energy, as a constituent of respiratory chain enzymes. Iron deficiency can therefore lead to anemia, changes in cognitive performance, behavior, emotions, reduced exercise capacity and myocardial structural and functional changes. Several clinical studies have shown that intravenous iron carboxymaltose supplementation can improve anemia, NYHA class, quality of life and exercise capacity of HFrEF patients. There are no randomized studies of adequate sample size that positively correlate iron supplementation with the higher endpoints of mortality and morbidity both in chronic and acute heart failure. Several studies are ongoing to answer these questions in the next few years.

[From vulnerable plaque to vulnerable patient]. / Dalla placca vulnerabile al paziente vulnerabile.

Atherosclerotic plaque instability is directly involved in triggering acute coronary syndromes, including unstable angina, acute myocardial infarction, and sudden coronary death. Different and not completely unknown mechanisms are involved in the pathogenesis of the destabilisation of the vulnerable plaque; currently three mechanisms are considered to play a causal role in this process: embolization, vasoconstriction and plaque rupture that only in a few cases lead to thrombosis; in most cases it is repaired spontaneously. Therefore only some plaques lead to clinical manifestations whereas many others remain asymptomatic. It is possible formulate two hypothesis: in the first case there are different types of plaques, some with strong thrombogenic stimulus; in the second case all the plaques are considered to be equal and instead is the patient who in particular situations has an hypercoagulable state that leads to an high risk of acute coronary syndromes. The aim of this review is to analyze the complex mechanisms leading to plaque and patient vulnerability.