Multi-domain lifestyle intervention in older adults after myocardial infarction: rationale and design of the PIpELINe randomized clinical trial.

BACKGROUND: Traditional cardiac rehabilitation (CR) is effective in improving physical performance and prognosis after myocardial infarction (MI). Anyway, it is not consistently recommended to older adults, and its attendance rate is low. Previous studies suggested that alternative, early and tailored exercise interventions are feasible and effective in improving physical performance in older MI patients. Anyway, the demonstration that they are associated also with a significant reduction of hard endpoints is lacking. AIM: To describe rationale and design of the "Physical activity Intervention in Elderly patients with myocardial Infarction" (PIpELINe) trial. METHODS: The PIpELINe trial is a prospective, randomized, multicentre study with a blinded adjudicated evaluation of the outcomes. Patients aged ≥ 65 years, admitted to hospital for MI and with a low physical performance one month after discharge, as defined as short physical performance battery (SPPB) value between 4 and 9, will be randomized to a multi-domain lifestyle intervention (including dietary counselling, strict management of cardiovascular and metabolic risk factors, and exercise training) or health education. The primary endpoint is the one-year occurrence of the composite of cardiovascular death or re-hospitalization for cardiovascular causes. RESULTS: The recruitment started in March 2020. The estimated sample size is 456 patients. The conclusion of the enrolment is planned for mid-2023. The primary endpoint analysis will be available for the end of 2024. CONCLUSIONS: The PIpELINe trial will show if a multi-domain lifestyle intervention is able to reduce adverse events in older patients with reduced physical performance after hospitalization for MI. TRIAL REGISTRATION: ClinicalTrials.gov NCT04183465.

Association between Epicardial Adipose Tissue and Atrial Fibrillation in Patients with Transfusion-Dependent ß-Thalassemia.

Background: Modern treatments for transfusion-dependent ß-thalassemia (TDßT) have allowed patients to reach high life expectancy with no iron overload. Despite survival improvement, atrial fibrillation (AF) has emerged as a relevant issue. AF pathophysiology and characteristics in TDßT are different than in the general population. Epicardial adipose tissue (EAT) may play a role but its relationship with AF in patients with TDßT has not been explored. Methods: A monocentric, cross-sectional study, enrolling consecutive patients with TDßT. Epicardial adipose tissue (EAT) was evaluated at magnetic resonance. Characteristics of patients with and without history of AF were investigated. Factors independently associated with AF prevalence were analyzed. Results: A total of 116 patients were enrolled. All patients were treated with regular chelation therapy. The prevalence of AF was 29.3% (34/116). Cardiac T2* and liver iron concentration were no different between patients with and without AF. EAT thickness was significantly higher in patients with AF at left atrium, right atrium and right ventricle (5.0 vs. 4.0 mm, p < 0.01, 4.4 vs. 4.0, p = 0.02 and 5.0 vs. 4.3, p = 0.04). Patients with AF presented with older age, (53 vs. 49 years, p < 0.01), more hypothyroidism (44.1 vs. 20.7%, p = 0.01), pulmonary hypertension (23.5 vs. 2.4% p < 0.01), splenectomy (88.2 vs. 64.6%, p = 0.01), higher right and left atrial volume (61 vs. 40 and 74 vs. 43 mL, both p < 0.01). At multivariable analysis, hypothyroidism, left atrial volume and left atrial EAT were independently associated with AF (odds ratio 9.95, 1.09 and 1.91, respectively). Conclusions: In a contemporary cohort of patients with TDßT, treated with regular chelation therapy, prevalence of AF was unrelated to iron overload. EAT was independently associated with AF.

Cardiac Computed Tomography in Monitoring Revascularization.

The use of coronary computed tomography angiography (CCTA) in the setting of stable coronary artery disease is highly recommended for low-risk patients. High-risk patients, such as symptomatic subjects with prior revascularization, are suggested to be investigated with noninvasive functional tests or invasive coronary angiography. CCTA is not considered for these patients because of some well-known CCTA artifacts, such as blooming and motion artifacts. However, new technology has allowed us to obtain images with high spatial resolution, overcoming these well-known limitations of CCTA. Furthermore, the introduction of CT-derived fractional flow reserve and stress CT perfusion has made CCTA a comprehensive examination, including anatomical and functional assessments of coronary plaques. Additionally, CCTA allows for plaque characterization, which has become a cornerstone for the optimization of medical therapy, which is not possible with functional tests. Recent evidence has suggested that CCTA could be used with the aim of monitoring revascularization, both after coronary bypass grafts and percutaneous coronary intervention. With this background information, CCTA can also be considered the exam of choice in subjects with a history of revascularization. The availability of a noninvasive anatomic test for patients with previous coronary revascularization and its possible association with functional assessments in a single exam could play a key role in the follow-up management of these subjects, especially considering the rate of false-positive and negative results of noninvasive functional tests. The present review summarizes the main evidence about CCTA and coronary artery bypass grafts, complex percutaneous coronary intervention, and bioresorbable stent implantation.