One-year results from the Assessing MICRO-vascular resistances via IMR to predict outcome in ST-elevation myocardial infarction patients with multivessel disease undergoing primary PCI (AMICRO) trial.

Background: In ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary angioplasty (PPCI) the index of microcirculatory resistance (IMR) correlates to the extent of myocardial damage and left ventricular (LV) function recovery. Data on the IMR time-course and impact on clinical outcome in STEMI patients with multi-vessel disease (MVD) are scarce. Aims: We designed a prospective, multicenter clinical trial to assess the infarct-related artery (IRA)-IMR in STEMI patients with MVD undergoing PPCI and to explore its potential in relationship with outcome and LV remodeling. Methods: The study enrolled 242 STEMI patients with MVD. Both fractional flow reserve (FFR) and IMR of the IRA were assessed after successful PPCI. Then, FFR/IMR measurements were repeated in the IRA at a staged angiography, and FFR-guided angioplasty was performed in non-IRA lesions. The primary endpoint was the composite of cardiovascular death, re-infarction, re-hospitalization for heart failure, resuscitation or appropriate ICD shock at 1-year follow-up. Results: A significant improvement of IRA-IMR values (from 47.9 to 34.2, p < 0.0001) was observed early after PPCI. Staged FFR-guided angioplasty was performed in 102 non-IRA lesions. We failed to find a correlation between IRA-IMR, clinical events and LV remodeling. Notwithstanding, in patients with anterior STEMI an inverse correlation between initial IMR values and LV function at follow-up was observed. Conclusion: After successful PPCI, a significant proportion of patients with STEMI and MVD had coronary microvascular dysfunction as assessed by IMR that recovered early after reperfusion. Higher IMR values predicted lack of improvement of LV function only in anterior STEMI. Clinical trial registration: https://clinicaltrials.gov/, identifier [NCT02325973].

Decline of Admission for Acute Coronary Syndromes and Acute Cardiovascular Conditions during COVID-19 Pandemic in Veneto Region.

Background: The present study aimed to examine longitudinal trends in hospitalizations for acute coronary syndrome (ACS) before and during the COVID-19 pandemic, by reviewing the data from 13 hospitals of the Veneto Region, in the north-east of Italy. Methods: We performed a multicenter, retrospective analysis including all the consecutive patients presenting with ACS and other acute cardiovascular (CV) conditions (defined as heart failure, arrhythmias, cardiac arrest and venous thromboembolism) hospitalized in 13 different hospitals of the Veneto Region covering a population of 2,554,818 inhabitants, during the first (between 15 March 2020 and 30 April 2020) and second (between 15 November 2020 and 30 December 2020) COVID-19 pandemic waves (the 2020 cohort). Data were compared with those obtained at the same time-windows of years 2018 and 2019 (the historical cohorts). Results: Compared to the historical cohorts, a significant decrease in the number of ACS cases was observed in 2020 (−27.3%, p = 0.01 and −32%, p < 0.001, comparing 2018 versus 2020 and 2019 and 2020, respectively). The proportion of patients hospitalized for acute CV conditions decreased during the first and second wave COVID-19 pandemic when compared to the historical cohorts (−36.5%, p < 0.001 and −40.6%, p < 0.001, comparing 2018 versus 2020 and 2019 and 2020, respectively). Pearson's correlation evidenced a significant inverse relationship between the number of COVID-19 cases and both ACS hospital admissions (r = −0.881, p = 0.005) and hospitalizations for acute CV conditions (r = −0.738, p = 0.01), respectively. Conclusions: The decrease in hospitalizations for ACS and other acute CV conditions will strongly affect future patients' management since undiagnosed nonfatal CV events represent a source of increased (and unknown) CV morbidity and mortality.

Takotsubo Syndrome during COVID-19 Pandemic in the Veneto Region, Italy.

Background: During the COVID-19 pandemic, the risk of SARS-CoV-2 infection, the public health measures of social distancing, the freedom limitations, quarantine, and the enforced homeworking under the lockdown period, as well as medical causes including COVID-19 infection per se, may have caused major emotional distress, especially in the most vulnerable patients. We aimed to evaluate the variations in the number of admissions due to Takotsubo syndrome (TTS) during the COVID-19 pandemic in the Veneto region. Methods: We retrospectively reviewed and analyzed the number of admissions because of TTS in 13 Divisions of Cardiology located in the Veneto region, the northeastern area of Italy, covering a population of more than 2.5 million inhabitants, during the two major pandemic waves of COVID-19 (the first between 15 March and 30 April 2020 and the second between 15 November and 30 December 2020) that occurred in 2020. Results: In total, 807 acute coronary syndromes were admitted in the 13 enrolling hospitals. Among these, 3.9% had TTS. Compared to the corresponding 2018 and 2019 time periods, we observed a significant increase in the number of TTS cases (+15.6%, p = 0.03 and +12.5%, p = 0.04, comparing 2018 to 2020 and 2019 to 2020, respectively). Geographical distribution of the TTS cases reflected the broad spread of the SARS-CoV-2 infection with a significant direct relationship between TTS incidence and the number of COVID-19 infections according to Pearson's correlation (r = 0.798, p < 0.001). Conclusions: The higher incidence of TTS during the 2020 COVID-19 pandemic waves, especially in the areas that were hit hardest in terms of morbidity and mortality by the SARS-CoV-2 infection, suggest a strong direct and/or indirect role of COVID-19 in the pathogenesis of TTS.

Clinical and Prognostic Significance of Idiopathic Left Bundle-Branch Block in Young Adults.

AIMS: LBBB is rare in healthy young adults, and its long-term prognosis is uncertain. METHODS: 56 subjects (aged <50 years), in whom an LBBB was discovered by chance in the absence of clinical and echocardiographic evidence of heart disease, were collected in a multicenter registry. RESULTS: 69% were males. Mean age at the time of discovery of LBBB was 37 ± 11 years. Mean QRS duration was 149 ± 17 m sec and 35% had left axis deviation. All patients had a normal echocardiogram, except for left ventricular dyssynchrony; 37 patients underwent coronary angiography (30) or myocardial scintigraphy during effort Eriksson and Wilhelmsen (2005), and in all cases obstructive coronary artery disease was excluded. In 2/30 patients who underwent coronary angiography, an anomalous origin of the CX artery from the right coronary sinus was found. Thirty patients underwent cardiac magnetic resonance; in 60% it was normal, while in 40% it revealed late enhancement, which in 33% was localized in the basal septum, suggesting fibrosis of the left bundle branch. During follow-up (12+/10 years, median 10 years) no sudden death occurred. At the end of follow-up, all patients were alive, except for one who suffered accidental death. Two patients (3.5%) underwent PM implantation owing to syncope. The echocardiogram at the end of follow-up revealed LV dysfunction in only one patient. CONCLUSIONS: In young adults without apparent heart disease, LBBB is a heterogeneous condition. In the vast majority of cases, the prognosis is good and no ventricular dysfunction occurs over time. However, as only 18% of our patients were aged >60 years at the end of follow-up, we cannot establish the prognosis in older age-groups.

[Being cardiologist at the time of SARS-CoV-2: what do not forget during the post-pandemic phase?] / Essere cardiologo ai tempi del SARS-CoV-2: cosa non dimenticare nella fase post-pandemia?

In Italy, the epidemic explosion stage of COVID-19 seems to have been overcome; however, the virus has not been eradicated and the re-emergence of some outbreaks of infection substantiates the danger that the disease may persist. It is therefore necessary to keep the level of surveillance high, to maintain social distancing measures and to act in the control of disease risk factors of a serious or complicated course. Among the risk factors of severe COVID-19 in addition to age, male gender, hypertension and cardiovascular diseases, a major role seems to be played by other cardiovascular risk factors conditioned by an unhealthy lifestyle such as obesity, metabolic syndrome, diabetes and smoking. The new phase requires the maintenance of measures that avoid crowding and close interpersonal contact especially during exercise, in addition to controlled access to hospitals. This will require the reorganization of the traditional methods of cardiovascular prevention and rehabilitation activities, such as gyms and collective educational sessions, and the dilution of outpatient checks. The risk that this scenario may worsen the already suboptimal control of cardiovascular risk factors is therefore real. We do not currently know how long this new phase will last, therefore it is necessary to give impetus to new tele-health initiatives to stimulate the adoption of a healthy lifestyle in primary prevention and tele-monitoring and tele-rehabilitation programs in secondary prevention.

[Being a cardiologist at the time of SARS-COVID-19: is it time to reconsider our way of working?] / Essere cardiologo ai tempi del SARS-COVID-19: è tempo di riconsiderare il nostro modo di lavorare?

The SARS-COVID-19 pandemic is bringing to light significant issues that require deliberations on how to manage patients at high cardiovascular risk or with proven heart disease. The evidence that the hospital can be a place where one might contract the infection and spread the disease has drastically reduced non-COVID-19 accesses to emergency rooms (ER) and to elective non-COVID-19 hospital activities. If this, on one hand, results in reducing improper access to the ER and hospital, on the other hand it substantiates the risk of underestimating problems not connected to COVID-19, such as an increased delay in the diagnosis and treatment of acute myocardial infarction and other cardiovascular emergencies. In addition, the need to reorganize hospital activities to treat patients suffering from serious COVID-19 disease forms forces us to reflect on how to safely manage patients who stay at home with milder COVID-19 disease forms and the need to keep the most vulnerable subjects, such as patients with chronic heart failure, away from the hospital. The problem is furtherly amplified by the uncertain trend of the epidemic, by the duration of forced isolation and limited mobility measures and by the inadequate integration between hospital and territory, especially in high-risk areas such as residences for the elderly or in socially and economically fragile environments. Our opinion is that a syndemic approach, which considers the complex interplay between social, economic, environmental and clinical problems, can be the most appropriate and achieved by means the contribution of telemedicine and telecardiology, intended as integration and not as an alternative to traditional management. A flexible use of telematic tools, now available for teleconsultation, and/or remote monitoring adapted to the needs of clinical, family and social-health contexts could allow the creation of integrated and personalized management programs that are effective and efficient for the care of patients.

Assessing MICRO-vascular resistances via IMR to predict outcome in STEMI patients with multivessel disease undergoing primary PCI (AMICRO): Rationale and design of a prospective multicenter clinical trial.

BACKGROUND: In STEMI patients treated with primary percutaneous coronary angioplasty (PPCI) the evaluation of coronary microcirculatory resistance index (IMR) predict the extent of microvascular damage and left ventricular (LV) remodeling. However, the impact of IMR on the clinical outcome after PPCI in patients with multivessel disease (MVD) remains unsettled. AIM: We designed a prospective multicenter controlled clinical trial to evaluate the prognostic value of IMR in terms of clinical outcome and left ventricular remodeling in STEMI patients with MVD undergoing PPCI. METHODS AND DESIGN: The study will involve 242 patients with MVD defines as the presence of at least a non-culprit lesion of >50% stenosis at index coronary angiography. Both fractional flow reserve (FFR) and IMR will be measured in the infarct-related artery (IRA) after successful PPCI. Measurements of FFR and IMR will be repeated in the IRA and performed in the non-culprit vessels at staged angiography. The non-culprit vessel lesions will be treated only in the presence of a FFR<0.75. A 2D echocardiographic evaluation of the left ventricular (LV) volumes and ejection fraction will be performed before hospital discharge and at 1-year follow-up. The primary end-point of the study will be the composite of cardiovascular death, re-hospitalization for heart failure and resuscitation or appropriate ICD shock during 1-year of follow-up. Secondary end-points will be the impact of IMR in predicting LV remodeling during follow-up and correlations between IMR and ST-segment resolution. Other secondary endpoints will be need for new revascularization, stent thrombosis and re-infarction of the non-culprit vessels territory. IMPLICATIONS: If IMR significantly correlates with differences in outcome and LV remodeling, it will emerge as a potential prognostic index after PPCI in patients with MVD.

Early assessment of coronary flow reserve by transthoracic Doppler echocardiography predicts late remodeling in reperfused anterior myocardial infarction.

BACKGROUND: Microvascular integrity is an essential determinant of favorable late outcome in reperfused myocardial infarction. Coronary flow reserve (CFR) can be assessed by transthoracic Doppler echocardiography and provides a functional estimate of microvascular integrity downstream from the patent infarct-related vessel. OBJECTIVE: We sought to assess the effects of CFR in predicting late left ventricular (LV) remodeling in patients with reperfused acute anterior myocardial infarction treated with primary angioplasty. METHODS: In all, 31 patients admitted with acute anterior myocardial infarction underwent primary angioplasty of the infarct-related vessel. After angioplasty, angiographic thrombosis in myocardial infarction (TIMI) grade and myocardial blush were scored. On the first day, all underwent stress echocardiography and CFR evaluation of left anterior descending coronary artery by transthoracic Doppler. All patients had resting 2-dimensional echocardiography at 1, 3, and 6 months for assessment of LV function. RESULTS: CFR could be successfully assessed in 31 patients. After 6 months 5 patients showed LV dilatation (group I), whereas 26 patients did not show significant variation (group II). On day 1, CFR was higher (group I = 1.43 +/- 0.11 vs group II = 1.67 +/- 0.26, P =.005) and the deceleration time of diastolic left anterior descending coronary artery flow velocity was longer (group I = 212 +/- 41.4 milliseconds vs group II = 286 +/- 106.7 milliseconds, P <.02) in patients without, compared with those with LV remodeling, whereas there was no difference in angiographic parameters. CONCLUSION: Early assessment of CFR and the pattern of baseline diastolic coronary flow velocity by transthoracic Doppler echocardiography is feasible, safe, and more useful than angiographic indices in identifying patients at high risk of remodeling in spite of successful primary angioplasty.