ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain.

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

Impact of associated significant aortic regurgitation on left ventricular remodeling and hemodynamic impairment in severe aortic valve stenosis.

OBJECTIVES: The left ventricular (LV) response to combined pressure and volume overload [aortic stenosis (AS) and aortic regurgitation (AR)] versus pressure overload (isolated AS)has not been systematically studied. We aimed to assess LV remodeling, functional and hemodynamic consequences inpatients with mixed aortic valve disease versus patients with isolated AS. METHODS: We enrolled 181 patients (67 ± 9 years,109 men) with severe AS (aortic valve area indexed to body surface area <0.6 cm 2 /m 2 ) who underwent preoperative cardiac catheterization and a complete echocardiogram. Pulmonary capillary wedge pressure (PCWP), LV end-diastolic pressure (LVEDP) and pulmonary artery pressure (PAP) were measured. RESULTS: One hundred and ten patients (group A)had isolated severe AS (AR 0­1) and 71 patients (group B)had mixed aortic valve disease (severe AS plus AR 2­3). Patients in group B were younger and in a higher New York Heart Association class (p < 0.01). Severity of AS was similar in both groups. Patients in group B had a higher indexed LV mass, a lower LV ejection fraction, and higher PCWP, LVED Pand PAP (all p ≤ 0.01). CONCLUSIONS: Patients with severe AS and significant AR are more symptomatic than patients with isolated severe AS. The increased burden due to the combined lesion induces pronounced LV remodeling and more severe hemodynamic consequences.

Heterogeneity of clinical presentation in Tako-Tsubo syndromes: the prevalence of normal segmental wall motion and normal ECG pattern.

AIM: The aim of this study is to report the heterogeneity of clinical presentation in Tako-Tsubo syndrome (TTS), including a significant prevalence of normal ECG and echocardiographic patterns in a series of consecutive patients from a single center. METHODS AND RESULTS: From our database we selected a total of 168 cases of TTS. A total of 140 of these (Group A); 14 men (10%), mean age 60.3 years, range 39-87; 126 women (90%), mean age 66.1 years, range 43-93; matched the following reported criteria: typical stenocardic pain immediately following an emotional acute stress, or acute medical or surgical event within the preceding 12 h; acute rise and fall of troponin release; absence of significant coronary disease at coronary angiography. ECG findings at presentation ranged from T wave abnormalities (41 cases, 29.3%) to ST elevation (52 cases, 37.1%) and ST depression (11 cases, 7.9%), whereas in 36 cases (25.7%) the ECG was normal. Echocardiography at presentation showed akinesia of the total apical or medium-apical segments in 74 patients (53%), whereas it showed akinesia of left ventricular wall segments in other locations in 30 patients (21%) and even normal regional wall motion and thickening in 36 patients (26%). We described also a series of 13 female patients (mean age 70.2 years; age range 45-85 years) (Group B) who did not complain of chest pain at presentation, but showed a classical Tako-Tsubo evolution of wall motion abnormalities at echocardiography. Finally we selected 15 female patients (mean age 69.3 years; age range 49-89 years) (Group C) who formally did not report acute stress immediately preceding their presentation to the hospital for chest pain. They showed a classical Tako-Tsubo evolution of wall motion abnormalities at echocardiography and only one case of normal ECG pattern at presentation. CONCLUSION: In this series of acute TTS, a wide variability of ECG and echocardiographic patterns are observed, ranging from ST elevation with coexisting segmental wall motion abnormalities of the typical TTS to a clinical presentation characterized by normal ECG and normal segmental wall motion pattern.

Clinical and echocardiographic predictors of long-term outcome of a large cohort of patients with bicuspid aortic valve.

BACKGROUND AND OBJECTIVES: Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation. The aim of the present article is to determine clinical and echocardiographic prognostic factors and provide a predictive model of outcome of a large cohort of patients with BAV. METHODS: We retrospectively enrolled 337 patients consecutively assessed for echocardiography at our Cardiology Department from 1993 to 2014. We considered aortic valve replacement, aortic surgery and cardiovascular death as a clinical combined end-point. Predictors of outcome were determined by Cox regression. RESULTS: Mean age was 29.2 ±â€Š19.8 years, median 27.1 years. A total of 38.4% patients presented a history of hypertension. Mean duration of follow-up was 8.4 ±â€Š6.1 years, range 0-21 years. A total of 73 patients underwent aortic valve replacement and/or aortic surgery during follow-up. Age at surgery was 45.2 ±â€Š15.6 years. Seven patients died because of cardiovascular causes. At multivariate analysis, baseline clinical predictors were history of hypertension [hazard ratio (HR) 2.289, 95% confidence interval (CI) 1.350-3.881, P = 0.002], larger ascending aortic diameter (HR 2.537, 95% CI 1.888-3.410, P < 0.001), moderate-to-severe aortic regurgitation (HR 2.266, 95% CI 1.402-3.661, P = 0.001) and moderate-to-severe aortic stenosis (HR 2.807, 95% CI 1.476-5.338, P = 0.002). A predictive model was created by integrating these four independent covariates. It allows the calculation of calculate a risk score for each patient, which helps better tailor appropriate treatment in BAV patients. CONCLUSION: At enrolment, history of hypertension, a wider aortic diameter, moderate-to-severe aortic regurgitation and aortic stenosis were independently correlated to combined end-point. Long-term follow-up showed low cardiovascular mortality (2.1%) and a high prevalence of cardiac surgery (21.6%).

[ANMCO/SIMEU Consensus document: In-hospital management of patients presenting with chest pain]. / Documento di consenso ANMCO/SIMEU: Gestione intraospedaliera dei pazienti che si presentano con dolore toracico.

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: 1) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; 2) the increasing percentage of hospitalizations of low-risk cases.It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

Postoperative Takotsubo cardiomyopathy triggered by intraoperative fluid overload and acute hypertensive crisis.

The Takotsubo cardiomyopathy is a rare haemodynamic dysfunction, only recently reported perioperatively. While the diagnostic criteria have been established and the outcome is known as favorable, the pathophysiological mechanisms are not entirely understood. Here we present the case of a patient scheduled for laparoscopic hysterectomy and adnexectomy, who early postoperatively developed a Takotsubo cardiomyopathy supposedly triggered by an acute hypertensive crisis due to intraoperative fluid overload.

Thrombus in the right atrial appendage during pulmonary and paradoxical embolism: a case report.

We report the case of a 56-year-old woman who was admitted because of left pulmonary embolism. An episode of ischemic stroke occurred during hospitalization. Transesophageal echocardiography revealed a right atrial appendage thrombus and a patent foramen ovale with right to left shunting. This suggested paradoxical embolism across a patent foramen ovale as the most reasonable explanation of the ischemic stroke in this patient, in the presence of right cardiac overload secondary to the hemodynamically significant pulmonary embolism. The patient's clinical conditions dramatically improved after anticoagulant therapy.

Spontaneous closure of postinfarction ventricular septal rupture. A case report.

Spontaneous closure of a postinfarction ventricular septal rupture is extremely rare. We present such a case in which the postinfarction ventricular septal rupture closed spontaneously during follow-up. We postulate that the spontaneous closure of the ventricular septal rupture was probably due to thrombosis in the apical and septal aneurysm.

Transesophageal electrical cardioversion of persistent atrial fibrillation: a new approach for an old technology.

BACKGROUND: Low energy intracardiac cardioversion may be considered the elective, alternative method for the acute restoration of sinus rhythm when direct current cardioversion fails or is contraindicated. Transesophageal cardioversion is a further alternative method for the recovery of sinus rhythm and obviates the potential complications of the low energy intracardiac cardioversion venous approach. METHODS: The present prospective study including 30 patients (21 males, 9 females, mean age 65.1 years, range 52-76 years), with persistent atrial fibrillation (mean duration 4.3 months), was undertaken in order to further evaluate, with regard to transesophageal cardioversion: 1) the acute efficacy, 2) the patient acceptance of the procedure, 3) the preferable choice among direct current cardioversion, low energy intracardiac cardioversion and transesophageal cardioversion, 4) the time required to perform the procedure, 5) the incidence of complications, and 6) the persistence of sinus rhythm after 1 month. RESULTS: Sinus rhythm was acutely restored in 29 patients (96.7%). Discomfort induced by the electrical shock was minimal or mild in most patients (75.8%). Transesophageal cardioversion was usually preferred by patients who had been previously submitted to direct current cardioversion or low energy intracardiac cardioversion. The mean total time required to perform the procedure was 107.9 min. No complications related to the procedure occurred. In spite of adequate pharmacological prophylaxis of atrial fibrillation only 41.4% of patients were in sinus rhythm 1 month after successful transesophageal cardioversion. CONCLUSIONS: Transesophageal cardioversion may be considered a very effective, well accepted and non-time consuming procedure for the short-term restoration of sinus rhythm. The incidence of complications is low.

Reliability of new and old Doppler echocardiographic indexes of the severity of aortic stenosis in patients with a low cardiac output.

BACKGROUND: In addition to the conventional "flow-corrected" parameters (continuity equation and aortic valve resistance), new and simpler Doppler echocardiographic indexes of the severity of aortic stenosis have recently been introduced. These measures can be classified as "function-corrected" indexes (fractional shortening-velocity ratio and ejection fraction-velocity ratio) and "pressure-corrected" indexes (percent stroke work loss). Little information however is available about the diagnostic accuracy of each of these parameters in identifying patients with severe aortic stenosis in low-flow states, in which the diagnosis and clinical decision-making are more difficult and challenging. METHODS: We analyzed 161 patients with aortic stenosis (96 males, 65 females, mean age 68 +/- 9 years) and a low cardiac output (thermodilution cardiac index < or = 2.5 l/min/m2). All patients underwent both cardiac catheterization and echocardiography within 48 hours one of the other. The invasive Gorlin valve area was used as gold standard (severe aortic stenosis = Gorlin < or = 0.8 cm2). Echocardiographic indexes were assessed by an investigator who was unaware of the hemodynamic findings. RESULTS: The mean Gorlin aortic valve area was 0.7 +/- 0.3 cm2; cardiac catheterization allowed the identification of 129 patients with severe aortic stenosis and of 32 with mild-to-moderate aortic stenosis. The diagnostic accuracy of the Doppler gradient alone was low (sensitivity 55%). The best linear correlation with the Gorlin value was found using the "function-corrected" ejection fraction-velocity ratio (r = 0.85). Similarly, the best combination of sensitivity and specificity in identifying patients with severe aortic stenosis, as assessed by cardiac catheterization, was observed using the ejection fraction-velocity ratio (sensitivity 87%, specificity 88%). CONCLUSIONS: In patients with aortic stenosis and a low cardiac output, the "function-corrected" ejection fraction-velocity ratio offers the better diagnostic accuracy, as compared with the cardiac catheterization valve area calculation.

Usefulness of exercise test in selected patients coming to the emergency department for acute chest pain.

BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge for clinicians. In our emergency department (ED) a systematic protocol that involves the use of the exercise test for the management of patients with chest pain of suspected cardiac origin is presently running. The aim of the present study was to evaluate the feasibility of such a test in this setting, in terms of the safety and satisfactory follow-up of these patients discharged home. METHODS: Patients with chest pain lasting < or = 24 hours, aged > 18 years, without a history of trauma or of any other evident medical cause of chest pain and without high-risk characteristics were included in the present study. These patients, defined as low-risk patients for acute coronary events on admission, were evaluated in the ED area and submitted to serial ECG and blood sampling for the determination of the creatine kinase-MB mass and troponin I serum levels on admission and at 6 and 12 hours after admission. A symptom-limited maximal exercise was performed in the patients with a negative clinical observation and typical chest pain or atypical chest pain but multiple coronary risk factors. RESULTS: In the year 2000, 1370 patients were evaluated in the ED for chest pain. In 150 (11%) an exercise test was performed. The test was positive in 24 patients (16%). The criteria for a positive test were only clinical in 3 patients, only ECG in 13 patients, and both in 8 patients. Inconclusive tests were observed in 27 patients (18%) and the test was negative in 99 patients (66%). There were no complications during the exercise test. At a median follow-up of 237 days (range 11-443 days), 11 clinical events were recorded (4 acute coronary syndromes and 7 revascularization procedures). Patients with a non-negative exercise test had a significantly shorter event-free survival (p < 0.005). CONCLUSIONS: The exercise test performed in selected patients coming to the ED with acute chest pain is safe and useful for further risk assessment.

Management of patients with low-risk chest pain at the time of admission: a prospective study on a non-selected population from the Emergency Department.

BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge from the epidemiological, clinical, organizational and malpractice points of view. Our purpose was to test and implement a simple clinical protocol for the management of patients with acute chest pain and at low-risk for an acute coronary syndrome (ACS) at the time of admission to the Emergency Department (ED). METHODS: During a 5-month study period, 570 consecutive patients were admitted to the ED with acute chest pain: 224 patients were excluded owing to the presence of a clear diagnosis of an ACS or of high-risk factors. The remaining 346 were considered, at the time of admission, as being at low risk for an ACS and constituted the study group (208 males, 138 females, mean age 65 years). These 346 patients were evaluated in the ED area by means of multiple ECGs and multiple blood sampling for the creatine kinase-MB mass and troponin I serum levels at the time of admission and 6 and 12 hours later. In selected cases a treadmill stress test was requested in order to further clarify the diagnosis. RESULTS: The ECG at the time of admission was normal or nearly normal in 79% of the patients. Stress testing was performed in 79 patients (25%). Sixty-six/346 low-risk patients (19%) were admitted to the coronary care unit during ED observation: 38 patients because of positive markers, 10 because of a positive ECG, 13 because of positive markers and ECG, and 5 because of a positive stress test. Two hundred and eighty low-risk patients without evidence of acute ischemia were definitively discharged and classified as having non-ischemic chest pain. At 1 month of follow-up, 1 patient underwent coronary artery bypass grafting, 1 patient was again admitted to the ED for acute pulmonary edema, and 2 patients had acute extracardiac events. Within 1 year of follow-up 4 deaths occurred: 2 were cancer-related and 2 were sudden deaths. CONCLUSIONS: The tested strategy, based on integrated clinical, ECG and multimarker data, and on a short "test of time" period of low-risk patient observation, can allow the identification of patients having an ACS on the one hand and of those for whom a safe, rapid and early discharge is possible on the other, in a low-cost environment.

[Anterior myocardial infarction in a chronic alcoholic man on disulfiram therapy: a case report]. / Infarto miocardico anteriore in etilista cronico in trattamento con disulfiram: descrizione di un caso.

Disulfiram is a drug used since 1940 in the treatment of alcohol dependence. However, it is not a completely safe drug; there are in the literature some case reports of more severe reaction than the usual "acetaldehyde syndrome" secondary to ingestion of disulfiram and alcohol. We describe a case of a 45-year-old, chronic alcoholic man in treatment with disulfiram, who suffered an acute anterior myocardial infarction, successfully treated with thrombolysis. The possible factors precipitating acute myocardial infarction in this patient are discussed.

[Two cases of false troponin I increase in patients with heterophile antibodies]. / Due casi di incremento spurio di troponina I in pazienti con anticorpi eterofili.

Cardiac troponin T and I are highly sensitive and specific biochemical markers for the detection of myocardial damage and they are now considered the preferred markers for the diagnosis of myocardial infarction. Despite this, in some cases elevations in the serum levels of cardiac troponin T and I are not associated with a final diagnosis of cardiac necrosis. These false-positive results are to be related to different interferences in immunometric assays. We report 2 cases of false-positive troponin I results due to heterophilic antibodies. Two women admitted to the Emergency Department with acute chest pain persistently showed, in serial blood samples, elevated and constant values of troponin I serum levels. The results were confirmed as being false positives by treatment of the samples with heterophilic blocking reagent (Scantibodies Laboratory, Santee, CA, USA). Coronary artery disease was excluded at coronary angiography and at stress testing in the first case and at stress myocardial perfusion imaging in the second case. In clinical practice, in case of persistently elevated but constant values of cardiac troponin without the time interval of release characteristic of acute syndromes, it is important to bear in mind the possible occurrence of false-positive cardiac troponin results due to the presence of heterophilic antibodies.

[Proarrhythmic effects of propafenone in a woman with hepatopathy: is it always a simple drug in clinical practice?]. / Effetto proaritmico del propafenone in donna con epatopatia: è sempre un farmaco di semplice utilizzo nella pratica clinica?

A 65-year-old woman with a history of alcoholic liver disease and presenting with fever and vomiting was admitted to an internal medicine unit. In view of recent atrial fibrillation with inadequate heart rate control, digoxin and propafenone were included in the therapeutic regimen. After a few days sinus rhythm was restored but suddenly ventricular arrhythmias with the characteristics of a non-responsive electrical storm arose shortly following the appearance of clinical symptoms of drug intoxication.

[Long QT and torsade de pointes in a patient with acquired human immunodeficiency virus infection in multitherapy with drugs affecting cytochrome P450]. / Allungamento del QT e torsione di punta in un paziente con immunodeficienza virale acquisita in multiterapia con farmaci utilizzatori del citocromo P450.

In acquired human immunodeficiency virus (HIV) infection, a long depolarization period at ECG may be the consequence of cardiac complications due to viral myocarditis or cardiomyopathy or indirectly due to autonomic neuropathy, or sometimes resulting from pharmacological treatments. Several drugs administered for direct treatment of HIV disease or its complications, such as antiretrovirus, fluconazole, and antibiotics, may induce ventricular arrhythmias due to long QT prolonged depolarization period. Also methadone, frequently associated with HIV therapy to treat patients with opiate addiction, is described in the literature to have cardiac inotropic effects. It has also the potential to increase the QT period and to develop ventricular torsade de pointes, primarily through interference with the rapid component of the delayed rectifier potassium ion current. Moreover, the use of methadone associated with other inhibitors of cytochrome P450 might increase plasma concentrations and contribute to methadone cardiac toxicity. We report the case of an HIV patient receiving antiretroviral treatment, fluconazole and high-dose methadone, who suddenly complained of vertigo, dizziness, pre-syncope and syncope due to severe ventricular arrhythmias that disappeared after discontinuation of all treatments.

[Patent foramen ovale and cardiovascular stroke: the eternal dilemma]. / Forame ovale pervio e ictus cardioembolico: l'eterno dilemma.

Ischemic stroke is one of the leading causes of mortality and the most important determinant of disability in developed countries. Its association with patent foramen ovale is one of the more controversial issues of the literature, also because paradoxical embolism is frequently a diagnosis of suspicion. Up to now, no clinical randomized studies unequivocally demonstrated the causality of this association. Comparing international guidelines there are substantial differences in clinical recommendations among scientific societies, which confirm the uncertainty surrounding this field. Actually, the superiority of transcatheter percutaneous closure over medical therapy alone is not confirmed, partially as a consequence of significant variability in the inclusion criteria, technical approach, peri- and post-procedural therapy among different studies. Moreover, the procedure is very recent and very few studies report prospective data about the safety and effectiveness of patent foramen ovale closure at long-term follow-up. A careful assessment of both clinical characteristics of patients and anatomical features of patent foramen ovale is very helpful to drive a personalized choice for the individual patient. On the basis of the available evidence, this review re-examines the impact of patent foramen ovale in the etiology of cryptogenic cerebrovascular events as well as the advantages and disadvantages of different treatment modalities, waiting for more scientific consensus.

[Heart failure in Italian intensive cardiac care units: data from the BLITZ-3 survey]. / I pazienti con scompenso cardiaco nelle unità di terapia intensiva cardiologica italiane: i dati dello studio BLITZ-3.

BACKGROUND: Only limited information about clinical characteristics, diagnostic procedures and therapeutic options is available in patients admitted to an intensive cardiac care unit (ICCU) for heart failure. The aim of this study was to evaluate causes of admission, clinical characteristics, diagnostic and therapeutic options, and outcome of patients admitted for heart failure in the ICCU network. METHODS: The BLITZ-3 Registry prospectively included patients admitted by 332 Italian ICCUs. Data of the patients admitted with a principal diagnosis of heart failure are analyzed. RESULTS: From April 7 to 20, 2008, 6986 consecutive patients with acute cardiac conditions were admitted to ICCUs; 966 (14%) out of 6986 patients were admitted for acute heart failure. Heart failure was the second cause of admission after acute coronary syndromes (52%). Mean age of patients admitted for heart failure was 73 years, 42% were female, and diabetes accounted for 32% of heart failure patients. Most patients were admitted to the emergency department (62%), and were discharged by the cardiology ward (65%). Median length of stay in the ICCU was 4 days, and during the stay in ICCU 5% of the patients with heart failure died. Advanced age and elevated creatinine values were associated with a higher risk of death. Echocardiography was performed in 79% of heart failure patients, coronary angiography in 10%, assisted ventilation in 15%, ultrafiltration in 3%, and right catheterization in 1%. Diuretics were administered in 93% of patients admitted for acute heart failure, intravenous nitrates in 41%, inotropes in 22%, beta-blockers in 42%, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 66%. CONCLUSIONS: In a nationwide survey, acute heart failure accounted for 14% of hospital admissions in ICCUs. Patients admitted for heart failure are usually old, with frequent comorbidities. Diagnostic and therapeutic procedures are rarely used, with the exception of echocardiography.

Elderly patients with acute coronary syndromes admitted to Italian intensive cardiac care units: a Blitz-3 Registry sub-analysis.

BACKGROUND: Guideline-recommended therapies for acute coronary syndromes (ACS) derive from randomized trials in which elderly patients are underrepresented. Although numbers of this population are increasing, they are largely undertreated in the real world. OBJECTIVE: The study evaluates the impact of older age on care for patients with ACS admitted to the Italian Intensive Cardiac Care Units (ICCUs) network. METHODS: We analyzed data from the BLITZ-3 Registry in order to assess in-hospital care among unselected elderly patients (≥75 years). RESULTS: From 7-20 April 2008, 6986 consecutive patients with acute cardiac conditions were admitted to ICCUs and prospectively enrolled; 3636 (52%) had ACS and 38% of them were elderly. Elderly patients had a higher risk profile, their median length of stay in ICCU was longer [4 days, interquartile range (IQR): 3-6 vs. 3 days, IQR: 2-5; P < 0.0001] and guideline-recommended care was applied less often. At multivariable analysis, elderly patients were less likely to receive reperfusion [odds ratio (OR) = 0.53, 95% confidence interval (CI) = 0.42-0.67] for ST-elevation, or early coronary angiography (OR = 0.45, 95% CI = 0.37-0.56) for non-ST elevation ACS. Besides, unadjusted in-ICCU total mortality was higher for elderly patients with ST-elevation (11.8% elderly vs. 1.8% younger patients; P < 0.0001) or non-ST-elevation (3.9% elderly vs. 0.6% younger patients; P < 0.0001) ACS. CONCLUSION: In a nationwide survey, age impacts on care. The elderly with ACS have a higher risk profile but receive less guideline-recommended care than younger patients. Thus, further improvements in care of this population should be pursued.

[Distribution and appropriateness of hospital admissions, resource utilization in the Italian intensive cardiac care units. The BLITZ-3 study]. / Distribuzione e appropriatezza dei ricoveri ed utilizzo di risorse nelle unità di terapia intensiva cardiologica italiane. Lo studio BLITZ-3.

BACKGROUND: The BLITZ-3 study prospectively evaluated the epidemiology of hospital admissions, the patterns of care and the most important comorbidities in intensive cardiac care unit (ICCU) patients. METHODS: Distribution and level of appropriateness of hospital admissions in relation to type of ICCU were analyzed (type A, 32%, without cardiac cath lab or cardiac surgery; type B, 49%, with cath lab; type C, 19%, with both cath lab and cardiac surgery). The caseload was estimated on the basis of different levels of mortality risk during the ICCU stay: high (>5.1%), intermediate (0.7-5.1%), low (< or = 0.7%). RESULTS: A total of 6986 consecutive patients admitted to 332 ICCUs were enrolled. A median number of 19 patients (interquartile range 15-26) was admitted to each center during the 14 days of enrollment; 28% of the ICCUs admitted more than 25 patients, 48% between 15 and 25, and 24% less than 15. A higher number of type A ICCUs admitted less than 15 patients (p<0.0001), whereas a higher number of type C ICCUs admitted more than 25 patients (p<0.0001). Hospital admissions for ST-elevation myocardial infarction occurred more frequently in type B or C ICCUs (p<0.0001), whereas hospital admission for heart failure mostly occurred in type A ICCUs (p<0.0001). The number of patients not undergoing reperfusion (p<0.0001) or treated with thrombolytic therapy (p<0.0001) was higher in the type A ICCUs. Coronary revascularization with primary percutaneous coronary intervention was performed more frequently in type B and C ICCUs (p<0.0001). Similarly, patients hospitalized for acute coronary syndrome underwent coronary angiography (p<0.0001) and percutaneous coronary intervention more frequently in type B and C ICCUs (p<0.0001). Prevalence of low-risk rather than intermediate- or high-risk patients was higher in type A ICCUs (p<0.05), and prevalence of high- or intermediate-risk patients was higher in type C ICCUs (p<0.05). CONCLUSIONS: The results of the BLITZ-3 study should lead the Italian cardiological community to reflect upon the needed number of ICCUs, the role of Spoke centers for their integration in the interhospital network, and inappropriate hospital admissions for low-risk conditions.