Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe.

AIM: To evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)]. METHODS: Prevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation. RESULTS: Overall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08-4.44, p < 0.001). CONCLUSIONS: Patients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.

Aortic Valve Stenosis and Cancer: Problems of Management.

Aortic valve stenosis and malignancy frequently coexist and share the same risk factors as atherosclerotic disease. Data reporting the prognosis of patients with severe aortic stenosis and cancer are limited. Tailoring the correct and optimal care for cancer patients with severe aortic stenosis is complex. Cancer patients may be further disadvantaged by aortic stenosis if it interferes with their treatment by increasing the risk associated with oncologic surgery and compounding the risks associated with cardiotoxicity and heart failure (HF). Surgical valve replacement, transcatheter valve implantation, balloon valvuloplasty, and medical therapy are possible treatments for aortic valve stenosis, but when malignancy is present, the choice between these options must take into account the stage of cancer and associated treatment, expected outcome, and comorbidities. Physical examination and Doppler echocardiography are critical in the diagnosis and evaluation of aortic stenosis. The current review considers the available data on the association between aortic stenosis and cancer and the therapeutic options.

Infective Endocarditis in People Who Inject Drugs: Report from the Italian Registry of Infective Endocarditis.

Intravenous drug use is a predisposing condition for infective endocarditis (IE). We report the clinical features of IE, taken from the Italian Registry of IE, in people who inject drugs (PWIDs). The registry prospectively collected epidemiological, clinical, in-hospital, and follow-up data on patients with IE from 17 Italian centers. A total of 677 patients were enrolled, and 61 (9%) were intravenous drug users (IDUs). Most PWIDs were male (78.6%), and aged between 41 and 50 years old (50%). The most frequent comorbidities were HIV (34.4%) and chronic liver disease (32%). Predisposing factors for IE were present in 6.5% of the patients, and 10% had minor valvular abnormalities. IE had occurred previously in 16.4% of the patients, and 50% of them had undergone heart surgery. Overall mortality was 9.8% in IDUs and 20% in patients with recurrent IE. IE in PWIDs mostly affected the native valves (90%). The echocardiographic diagnosis of IE was based on the detection of vegetation in 91.82% of cases. Staphylococcus aureus was the main microorganism isolated (70%) from blood cultures. Thirty patients (49%) underwent heart surgery: thirteen had aortic valves, eleven had mitral valves, and six had tricuspid valve interventions. IE in PWIDs was relatively common, and patients with native valve right-sided IE had a better prognosis, with a low rate of surgical interventions.

Cardiac lymphoma with early response to chemotherapy: A case report and review of the literature.

Cardiac tumors are rare and benign masses account for the most part of the diagnosis. When malignant cancer is detected, primary or secondary cardiac lymphoma are quite frequent. Cardiac lymphoma may present as an intra or peri-cardiac mass or, rarely, it may diffusely infiltrate the myocardium. Although often asymptomatic, patients can have non-specific symptoms. Acute presentations with cardiogenic shock, unstable angina, or acute myocardial infarction are also described. Modern imaging techniques can help the clinicians not only in the diagnostic phase but also during administration of chemotherapy. A multidisciplinary counseling and serial multi-parametric assessment (echocardiography, cardiac troponin) seem to be the most effective approach to prevent possible fatal complications (i.e., cardiac rupture). Currently, only chemo- and radiotherapy are available options for treatment, but the prognosis remains poor. This is a case of secondary cardiac lymphoma presenting as a mediastinal mass with large infiltration of the heart and the great vessels with a good improvement after only one cycle of chemotherapy. It demonstrates the importance of an early diagnosis to modify the natural history of the disease.

Risk of cardiovascular complications during non-cardiac surgery and preoperative cardiac evaluation.

The preoperative evaluation of candidates to non-cardiac surgery requires a knowledge of factors related both to the type of surgery and to the risk of each patient, in order to predict the potential cardiovascular complications. Over the past several decades, the field of preoperative cardiac evaluation before non-cardiac surgery has evolved substantially on the basis of the current guidelines of international medical societies. The aim of this paper is to summarize available evidence on the risk of non-cardiac surgery, focusing on appropriate cardiovascular assessment prior to surgery.

Lipoprotein(a) and aortic valve stenosis: A casual or causal association?

AIMS: This review aims to provide an update of available methods for imaging calcification activity and potential therapeutic options. DATA SYNTHESIS: Aortic valve calcification represents the most common heart valve condition requiring treatment among adults in Western societies. No medical therapies are proven to be effective in treating symptoms or reducing disease progression. Therefore, surgical or transcatheter aortic valve replacement remains the only available treatment option. Elevated circulating concentrations of lipoprotein(a) is strongly associated with degenerative aortic stenosis. This relationship was first observed in prospective observational studies, and the causal relationship was confirmed in genetic studies. CONCLUSIONS: New therapeutic targets have been identified and new imaging techniques could be used to test the effectiveness of new agents and further clarify the pathophysiology of AVS. No therapy that specifically lowers Lp (a) levels has been approved for clinical use.

Aortic Valve Stenosis and Cardiac Amyloidosis: A Misleading Association.

The association between aortic stenosis (AS) and cardiac amyloidosis (CA) is more frequent than expected. Albeit rare, CA, particularly the transthyretin (ATTR) form, is commonly found in elderly people. ATTR-CA is also the most prevalent form in patients with AS. These conditions share pathophysiological, clinical and imaging findings, making the diagnostic process very challenging. To date, a multiparametric evaluation is suggested in order to detect patients with both AS and CA and choose the best therapeutic option. Given the accuracy of modern non-invasive techniques (i.e., bone scintigraphy), early diagnosis of CA is possible. Flow-charts with the main CA findings which may help clinicians in the diagnostic process have been proposed. The prognostic impact of the combination of AS and CA is not fully known; however, new available specific treatments of ATTR-CA have changed the natural history of the disease and have some impact on the decision-making process for the management of AS. Hence the relevance of detecting these two conditions when simultaneously present. The specific features helping the detection of AS-CA association are discussed in this review, focusing on the shared pathophysiological characteristics and the common clinical and imaging hallmarks.

Aortic valve stenosis and cancer: a common and complex association.

Introduction. The prevalence of aortic valve stenosis (AS) and malignancy are both high, especially in elderly people and in developed countries. These two conditions frequently coexist and share the same risk factors as atherosclerotic disease.Area covered. The progression of calcified AS may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy. The standard treatment for symptomatic severe AS is surgical aortic valve replacement; however, in cancer patients, transcatheter implantation may be preferred as they are often at high-risk for cardiac surgery. In patients with AS and cancer, physicians may face difficult treatment decisions.To date, there is limited information on the impact of malignancy on outcomes in patients with severe AS; hence, there is no established treatment policy.Expert Opinion. Treating clinicians must integrate complex information about the severity of valve disease and expected cardiac outcomes with information regarding the cancer prognosis and the need for specific treatment, including surgery. Other comorbidities, age and frailty also contribute to decision-making about whether, when, and how to perform aortic valve replacement.

Heart valve calcification and cardiac hemodynamics.

PURPOSE: Heart valve calcification (VC) is associated with increased cardiovascular risk, but the hemodynamic and functional profile of patients affected by VC has not been fully explored. METHODS: The study population was formed by consecutive unselected patients included in seven echocardiographic laboratories in a 2-week period. A comprehensive echocardiographic examination was performed. VC was defined by the presence of calcification on at least one valve. RESULTS: Population was formed of 1098 patients (mean age 65 ± 15 years; 47% female). VC was present in 31% of the overall population. Compared with subjects without VC, VC patients were older (60 ± 14 vs 75 ± 9; P < .0001), had more hypertension (40% vs 57%; P = .0005), diabetes (11% vs 18%; P = .002), coronary artery disease (22% vs 38%; P = .04), and chronic kidney disease (4% vs 8%; P = .007). Furthermore, VC patients had lower ejection fraction (55 ± 14 vs 53 ± 25; P < .0001), worse diastolic function (E/e' 8.5 ± 4.6 vs 13.0 ± 7.1; P < .0001) and higher pulmonary artery pressure (29 ± 9 vs 37 ± 12; P < .0001). The association between VC and EF was not independent of etiology (p for VC 0.13), whereas the association with E/e' and PASP was independent in a full multivariate model (P < .0001 and P = .0002, respectively). CONCLUSION: Heart valve calcification patients were characterized by a worse functional and hemodynamic profile compared to patients with normal valve. The association between VC and diastolic function and PASP were independent in comprehensive multivariate models.

Active cancer and cardiac surgery: Possible scenarios in patient decision-making.

Heart disease and cancer are often found simultaneously in the same patient, and may require cardiac and non-cardiac surgery. Cancer may be part of the past medical history; in other cases the presence of an active malignancy makes the clinical management more complex. No general evidence-based recommendations are available to help in the decision-making process. Because of the lack of specific guidelines we provided a series of possible scenarios describing not unusual cases. We focused on cases where the concomitant presence of heart disease and active malignancies involved a multidisciplinary team. Four real patients with active cancer referred to our Center were assessed. Three of them had valve disease requiring cardiac surgery. Defining the timing of surgery and choosing the surgical approach required a careful and comprehensive evaluation. In the last case, the complicated balance between the thrombotic and the hemorrhagic risk involved difficult decision. Several critical points, which characterized the management of this kind of patients, were identified. In particular, the hemodynamic status, the type and stage of the tumor, the need for cancer therapy, as well as the comorbidities of the patient, had to be taken into account. This narrative review shows the importance of submitting every challenging case to the assessment of a multidisciplinary team, which involves different clinical figures, in order to guarantee the most comprehensive evaluation. When clinical management deviates from the general recommendations, an individualized approach should be used.

Rate of venous thromboembolism and atrial fibrillation in a real-world case series of advanced cancer patients: the CaTEV Study.

BACKGROUND: Venous thromboembolism is the second leading cause of death in cancer patients and its incidence seems underestimated. In addition, cancer patients have an increased risk of developing atrial fibrillation, which may be the first presentation of cancer itself. The primary aim of this study was to define the incidence of venous thromboembolism (VTE) and atrial fibrillation in a real-word series of advanced cancer patients. METHODS: We performed a retrospective single-institution study on patients diagnosed with stage IV solid neoplasia at the outpatient clinic of the Medical Oncology Unit (Spedali Civili Brescia, Italy), from January to December 2018. RESULTS: A total of 403 patients were enrolled, with a mean age at presentation of 63 years (range 18-85 years). A VTE was observed in 24% of cases, half of which occurred after diagnosis of metastatic neoplasia, with a median time of onset of 5.5 months (range 0-84). About 3% of patients developed atrial fibrillation after cancer diagnosis. In this patient series, no statistically significant differences were found when comparing Khorana and PROTECHT thromboembolic risk scores, both before and after the start of chemotherapy. Overall, about 25% of the patients received anticoagulant therapy; in most cases, the drug of choice was low-molecular-weight heparin (LMWH). CONCLUSION: This study showed for cancer patients a considerably higher incidence of VTE and a comparable incidence of atrial fibrillation than reported in literature. Validated thromboembolic risk scores appear to be poorly predictive, and LMWH remains the most widely used anticoagulant drug.

[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.

Cardio-oncology: the new frontier of clinical and preventive cardiology.

Even if cancer and cardiovascular diseases are considered two distinct diseases, an intricate interconnection between these conditions has been established. Increased risk of malignancy has been identified in patients with cardiovascular disease, as well as a greater propensity to the development of cardiovascular diseases has been observed in patients with cancer. The development of cardiotoxicity following exposure to certain anticancer drugs only partially explains this relationship. Shared risk factors and common pathogenic mechanisms suggest the existence of a common biology and a complex interplay between these two conditions. Due to improving longevity and therapeutic advances, the number of patients affected or potentially at risk of developing these two diseases is constantly increasing and currently, several drugs against cancer from anthracyclines to checkpoint inhibitors, can also cause a wide range of unexpected cardiovascular side effects. Management of these issues in clinical practice is an emerging challenge for cardiologists and oncologists, and led to the development of a new dedicated discipline called cardio-oncology. Surveillance and prevention strategies as well as interventions to reduce cardiovascular risk and prevent cardiotoxicities are the primary objectives of cardio-oncology. In this review, we explore the etiopathogenesis common to cardiovascular disease and cancer and the complex interplay between them. We also report the main characteristics of the drugs responsible for cardiotoxicity, highlighting the available strategies for optimal patient management based on a multidisciplinary approach in the cardio-oncology setting.

[Clinical and diagnostic key points of left ventricular hypertrophy in adults: insights from the ANMCO Lombardy experience]. / I punti chiave nell'approccio clinico e diagnostico dell'ipertrofia ventricolare sinistra nell'adulto. Spunti dall'esperienza di ANMCO Lombardia.

Left ventricular hypertrophy is a common complication of different diseases. Among these, cardiac involvement of amyloidosis or Anderson-Fabry disease are often unrecognized. Early diagnosis is therefore crucial because new therapies can impact the progression of these diseases. Different specific signs unmasked by clinical, laboratory, and non-invasive diagnostic tests such as echocardiography or cardiac magnetic resonance could guide clinicians towards an appropriate diagnosis. The aim of this review is to underline the major diagnostic clues of different forms of left ventricular hypertrophy in adult patients, guiding clinicians towards a more appropriate diagnosis.

Preoperative assessment of cardiovascular risk in patients undergoing noncardiac surgery: the Orion study.

In patients undergoing noncardiac surgery risk indices can estimate patients' perioperative risk of major cardiovascular complications. The indexes currently in use were derived from observational studies that are now outdated with respect to the current clinical context. We undertook a prospective, observational, cohort study to derive, validate, and compare a new risk index with established risk indices. We evaluated 7335 patients (mean age 63±13 years) who underwent noncardiac surgery. Based on prospective data analysis of 4600 patients (derivation cohort) we developed an Updated Cardiac Risk Score (UCRS), and validated the risk score on 2735 patients (validation cohort). Four variables (i.e. the UCRS) were significantly associated with the risk of a major perioperative cardiovascular events: high-risk surgery, preoperative estimate glomerular filtration rate <30 ml/min/1.73 m2, age ≥75 years, and history of heart failure. Based on the UCRS we created risk classes 1,2,3 and 4 and their corresponding 30-day risk of a major cardiovascular complication was 0.8% [95% confidence interval (CI) 0.5-1.7], 2.5 (95% CI 1.6-5.6), 8.7 (95% CI 5.2-18.9) and 27.2 (95% CI 11.8-50.3), respectively. No significant differences were found between the derivation and validation cohorts. Receiver operating characteristic (ROC) curves demonstrate a high predictive performance of the new index, with greater power to discriminate between the various classes of risk than the indexes currently used. The high predictive performance and simplicity of the UCRS make it suitable for wide-scale use in preoperative cardiac risk assessment of patients undergoing noncardiac surgery.

Referral from vascular surgery to cardiovascular rehabilitation and related outcomes in patients with peripheral arterial disease: the THINKPAD-RELOADED survey.

The utilization of cardiovascular rehabilitation (CR) programmes in patients with Lower Extremity Peripheral Artery Disease (LEPAD) is generally poor, with limited evidence of current policies for referral. The aim of the study was to evaluate, within a cohesive network of CR and vascular surgery facilities with facilitated referral process, the clinical characteristic of LEPAD patients referred to CR and related outcomes, as compared to patients not referred. The present is an observational prospective study of consecutive patients recruited at vascular surgery facilities. Out of 329 patients observed, the average referral rate to CR was 34% (28% and 39% in patients with and without recent peripheral revascularization, p<0.05). LEPAD patients entering the CR programme were similar to those who did not according to sex, age, the vascular surgery setting of evaluation, and localization of arterial lesions. Patients with moderate intermittent claudication and patients with acute limb ischemia as index event were more represented among those who attended CR (41% vs 21% and 9% vs 2% respectively, p<0.05). Patients referred to CR had five times more episodes of acute coronary syndrome and heart failure as complication of the index event. The cardiovascular risk profile (obesity 29.5% vs 11%, p<0.05; hypercholesterolemia 80% vs 61%, p<0.05) was much worse in LEPAD patients referred to CR, but conversely, they better achieved secondary prevention targets, particularly for blood pressure control (97% vs 57%, p<0.05). All-cause 2-year mortality in the whole patients' population was 6%. Patients entering the CR programme displayed less events (13.5% vs 37.7%, p<0.05), mainly death (3.1% vs 11.3%, p<0.05) and limb-related events (4.2% vs 15.2%, p<0.05). The results of our study suggest that when a cohesive network of vascular surgery and CR facilities becomes available, the referral rate to rehabilitation may increase up to one third of eligible patients. Patients with higher comorbidity and cardiovascular risk seem to have priority in the referral process, nevertheless those with peripheral revascularization are still underestimated. Entering CR may ensure better cardiovascular risk profile and cardiovascular prognosis in LEPAD patients, and consequently the systematic adoption of this care model needs to be strongly recommended and facilitated.

Iron deficiency from the standpoint of cardiac rehabilitation: novel therapeutic opportunities.

Anemia is one of the most frequent comorbidities found in patients with coronary artery disease and chronic heart failure (CHF) who are being followed in cardiac rehabilitation facilities. The more frequent type of anemia is caused by iron deficiency (IDA, iron-deficiency anemia): this review summarizes the state of the art of this topic. First of all, the mechanisms of IDA will be analyzed. Subsequently, a description of the main conditions where IDA can unfavorably affect the clinical course, and of its more frequent complications, will be presented (percutaneous interventions, heart surgery, CHF). Special attention will be paid in the description of anemia in the setting of CHF. To this regard, in recent years a relevant amount of research has been carried out, to determine whether treating anemia (either by directly stimulating erythropoiesis or by correcting iron deficiency by oral or intravenous route) is of any clinical and prognostic relevance in patients with CHF. The results of this research will, therefore, be summarized and critically discussed. Finally, we will outline the promising role of cardiac rehabilitation facilities and of its network of experts in the diagnosis, prognostic stratification, and treatment of anemia and iron deficiency.

Practical implementation of the Endocarditis Team in 'functional' reference centres: the Italian hospital network experience and recommendations of the Italian Society of Echocardiography and Cardiovascular Imaging.

: The 2015 European Society of Cardiology (ESC) guidelines for the management of infective endocarditis recommend the use of a multidisciplinary team in the care of patients with infective endocarditis. A standardized collaborative approach should be implemented in centres with immediate access to different imaging techniques, cardiac surgery and health professionals from several specialties. This position paper has been produced by the Task Force for Management of Infective Endocarditis of Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) with the aim of providing recommendations for the implementation of the Endocarditis Team within the Italian hospital network. On the basis of the Italian hospital network with many cardiology facilities encompassing a total of 405 intensive cardiac care units (ICCUs) across the country, 224 (3.68 per million inhabitants) of which have on-site 24-h PCI capability, but with relatively few centres equipped with cardiac surgery and nuclear medicine, in the present article, the SIECVI Task Force for Management of Infective Endocarditis develops the idea of a network where 'functional' reference centres act as a link with the periphery and with 'structural' reference centres. A number of minimum characteristics are provided for these 'functional' reference centres. Outcome and cost analysis of implementing an Endocarditis Team with functional referral is expected to be derived from ongoing Italian and European registries.

Choosing wisely in cardiology: Five proposals from the Italian Association for Cardiovascular Prevention and Rehabilitation.

We do not always accomplish what is best for our patients. Is "more procedures, more drugs" a real synonym of good and always useful medicine? Probably not. Indeed, it has been highlighted that many tests and treatments, widely used in medical practice, do not bring benefits to patients, but they can be harmful. So, why do we keep performing them? Many reasons, surely one of the main is the constant fear of malpractice legal-medical consequences; this led to the development of a defensive medicine, no longer focused on the health of the patient. For this reason, the Italian Association of Cardiac Prevention and Rehabilitation (GICR-IACPR) joined an international project "Choosing Wisely", supported by the Slow Medicine Initiative, a network which states that "Less is more". The purpose of "Choosing Wisely " project is to improve the quality and safety of health services through the reduction of practices that, according to available scientific knowledge, do not bring significant benefits to the patients, but can, on the contrary, expose them to risks. This GICR-IACPR paper proposes to avoid five widespread practices in cardiology, at risk for inappropriateness and lacking of clinical evidence of benefit: • Do not perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery • Do not perform Computed Tomography for coronary calcium score in patients at high cardiovascular risk • Do not perform Holter electrocardiographic monitoring in patients suffering from syncope, near syncope or dizziness, in whom a non-arrhythmic origin has been documented • Do not routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding prophylaxis in patient with single drug antiplatelet therapy in absence of additional risk factors. • Avoid routine use of infective endocarditis prophylaxis in mild to moderate native valve disease.

Secondary prevention advices after cardiovascular index event: From drug prescription to risk factors control in real world practice.

The present study aims at evaluating the achievement of blood pressure, lipid and blood glucose targets, healthy lifestyle changes and appropriate drug prescription/adherence in patients attending secondary prevention/CR ambulatory visit after index cardiovascular event in a time period ranging 1 to 5 year. At ambulatory visit, a predetermined set of data collection was used, including demographic data, cardiovascular risk factors and lifestyle habits, type and time of index event, current symptoms, physical sign, biochemistry and current medical treatment (including type and dosage). Cardiovascular risk profile (smoking habits, physical activity and body weight), secondary prevention goals (LDL-cholesterol, blood pressure, resting heart rate, glycated haemoglobin level) and the use of recommended drugs were also evaluated and categorized. Study population consisted of 800 patients [644 men (84.5%), aged 69±10.9 years)]. Cardiovascular index events were coronary artery bypass graft (CABG) (20%) ST segment elevation myocardial infarction (STEMI) (28%), non-ST segment elevation myocardial infarction (NSTEMI) (21%) and stable angina (13%) by unstable angina (13%) and stroke (5%). About 30% of patients was symptomatic (angina or dyspnoea) at the time of ambulatory visit. Major comorbidities were hypertension (73%), dyslipidaemia (64%) and diabetes (40%). More than 80% of patients achieved target levels for blood pressure. Patients that have participated to cardiac rehabilitation programmes after cardiovascular index event showed best achievement in blood pressure target (83.8% vs 76.8%, p=0.02). LDL-cholesterol target (<70 mg/dl) was achieved in about 2/3 of patients; HbA1c target (<7%) was achieved in 56.4% of diabetic population. About 75% of study cohort was treated with RAAS inhibitors, 85% with beta-blockers, 92% with statins and 87% with acetylsalicylic acid. All drugs were increasingly adopted from index event. Implementing secondary prevention guidelines into the 'real world' clinical practice in "late" interval from 1 to 5 years after a cardiovascular event improved risk factors control and appropriate drug prescription. Whether these improvements translated into prognostic advantages remains to be elucidated.