[Appropriateness of diagnostic tests in cardiovascular prevention: what can we skip?]. / Appropriatezza delle procedure diagnostiche in prevenzione cardiovascolare: di che cosa possiamo fare a meno?

In recent years, a huge increase in the use of cardiac procedures, both invasive and non-invasive, was observed. Diagnostic tests, mainly non-invasive tests, are often prescribed inappropriately, in most cases replacing the clinical evaluation. The rate of inappropriate tests in cardiology is largely variable, depending on regional issues and different medical approach. When the test entails radiation exposure, the biological risk for both the patient and the environment must be taken into account. For this reason, the test that results in less biological risk should always be preferred as a first step.Moreover, it has not been clearly demonstrated that some diagnostic tests help to improve the outcome, that is to prevent cardiovascular events. As many as one sixth of the patients who undergo stress imaging are not taking proper medication, and very frequently no change in therapy is made after the test, regardless of the outcome. Since the appropriateness of diagnostic evaluation requests is mandatory, we focused on the diagnostic tests usually performed in primary and secondary prevention that carry no contribution to the clinical management of patients. This review addresses the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models.

Similarities and differences between renal sympathetic denervation and carotid baroreceptor stimulation.

The two novel approaches recently introduced for the treatment of resistant hypertension, i.e. carotid baroreceptor stimulation and renal denervation, share a number of similarities but are also characterized by important differences. The similarities include the evidence that both interventions have as common pathophysiological background the state of sympathetic overdrive characterizing essential hypertension. In addition both procedures 1) are invasive, 2) exert in the short-term period clearcut blood pressure lowering effects and 3) still face a number of open questions, particularly related to the long-term blood pressure lowering effects, impact on end-organ damage and on cardiovascular events. The differences include the fact that two procedures act on distinct targets that trigger sympathetic activation and consequently blood pressure increase. In addition, only in the case of carotid baroreceptor stimulation the blood pressure effects can be easily assessed immediately following the implantation. Finally, the economic costs, metabolic effects and impact on vagal modulation of heart rate are different between the two interventions. This paper will provide a comparison of the background, effects and outcome of renal denervation and carotid baroreceptor stimulation, stressing whenever possible the clinical implications of the main features of the two interventions.

Comparison of echotracking and magnetic resonance assessment of abdominal aorta distensibility and relationships with pulse wave velocity.

Arterial distensibility can be measured either by echotracking or by nuclear magnetic resonance (MRI). Little information, however, is available on the comparison between the two methods and on the relationships between the results obtained with the two approaches and the arterial stiffness gold standard measurement, i.e., pulse wave velocity (PWV). In 28 normotensive subjects (age 33.0 ± 10.4 years, mean ± SD) we measured aortic diameter 1 cm above iliac bifurcation, aortic pulse pressure by tonometry and calculated arterial distensibility via the Reneman formulae for both methods. Aortic diameter and aortic distensibility were not superimposable and higher values were systematically detected with the MRI approach than with the ultrasound one. However, PWV showed a significant correlation with aortic distensibility values obtained by both methods (r = 0.50 and r = 0.49, p < 0.05). These data provide evidence that MRI-measured distensibility value is higher than that obtained via echotracking. The significant correlation with PWV, however, suggests that both methods can be regarded as valuable approaches. Considering the greater economic cost and the lower availability in daily clinical and research practice of MRI, echotracking ultrasonography can be regarded as a reliable and feasible method to assess aortic distensibility.