RESUMO
Despite improvements in the treatment and prevention of risk factors (i.e. dyslipidemia), cardiovascular disease (CVD) remains one of the leading causes of morbidity and mortality in countries with a high degree of socio-economic development. As a matter of fact, in the last decades, several trials and meta-analysis highlighted the impact of treatments targeted to lowering cholesterol levels (particularly LDL-cholesterol) on outcomes of patients affected by CVD, both in terms of primary and secondary prevention. The main international CVD guidelines recommend lifestyle modifications and optimal lipid-lowering therapy in individuals with established CVD. The aim of the present document is to describe the dimension of the problem and the available therapies, offering a practical pharmacological flow-chart useful for accurate monitoring and intensive treatment of dyslipidemias in this patient population.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Dislipidemias/terapia , Prevenção Secundária , Doenças Cardiovasculares/etiologia , Árvores de Decisões , Dislipidemias/complicações , Humanos , Guias de Prática Clínica como AssuntoRESUMO
OBJECTIVES: The aims of the ERIS (Evolving Routine Standards of FFR Use) study are to describe the current use of invasive coronary physiology assessment and discern the reasons for its nonuse in daily practice. BACKGROUND: Adoption of coronary physiology guidance in the catheterization laboratory varies among countries, centers, and operators. METHODS: ERIS is an investigator-driven, nationwide, prospective, cross-sectional study involving 76 Italian catheterization laboratories. Each center had a 60-day window to include consecutive cases that fulfilled the inclusion and exclusion criteria. Two pre-specified groups were enrolled: 1) patients who had operators apply fractional flow reserve or instantaneous wave-free ratio assessment (physiology assessment group); and 2) patients who had operators decide not to perform fractional flow reserve or instantaneous wave-free ratio assessment, although the patients met the inclusion and exclusion criteria (visual estimation group). RESULTS: Overall, 1,858 cases were included (physiology assessment group, n = 1,177; visual estimation group, n = 681). Physiology-based guidance was used in 7% and 13% of the total volume of angiographic and percutaneous coronary interventions, respectively. Its use was in line with European and American guidelines in 48% of the cases (n = 569). Physiology guidance was used in a consistent number of patients with acute coronary syndromes (n = 529 [45%]). The main reason for not using physiology guidance was the operator's confidence that clinical and angiographic data alone were sufficient. CONCLUSIONS: Use of coronary physiology assessment in daily practice meets the current guideline indications in approximately 50% of cases. The major limiting factor for the adoption of physiology guidance was the operator's confidence in visual assessment alone. (Evolving Routine Standards of FFR Use [ERIS]; NCT03082989).
Assuntos
Cateterismo Cardíaco/normas , Estenose Coronária/diagnóstico , Reserva Fracionada de Fluxo Miocárdico , Padrões de Prática Médica/normas , Idoso , Competência Clínica/normas , Tomada de Decisão Clínica , Angiografia Coronária , Estenose Coronária/fisiopatologia , Estenose Coronária/terapia , Estudos Transversais , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Intervenção Coronária Percutânea , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Mitral regurgitation is the most common valvular heart disease in western world, with moderate to severe mitral regurgitation having a deep impact on prognosis, mortality and rehospitalizations. Advanced congestive heart failure is frequently complicated by mitral regurgitation, a pathologic condition that is often under-diagnosed. A significant proportion of patients with severe mitral regurgitation is not eligible for surgery (mitral valve repair or replacement) because of contraindications or excessive surgical risk. Therefore, the need for a less invasive treatment has led to the development of endovascular techniques; among them the MitraClip system, which mimics Alfieri's edge-to-edge surgical technique introduced in 2003, has gained widespread acceptance. More than 35 000 patients have been treated using this technique. Evidence from clinical studies suggests that the MitraClip system is effective in improving survival and quality of life in patients with severe mitral regurgitation, also reducing rehospitalization rates with substantial social and economic advantages. At present, in Italy, undertreatment of patients with severe mitral regurgitation not amenable to surgical correction is still significantly high, and remarkable inhomogeneity among regions is observed in the availability of the MitraClip procedure.
Assuntos
Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/cirurgia , Cateterismo Cardíaco , Acessibilidade aos Serviços de Saúde , Implante de Prótese de Valva Cardíaca/economia , Humanos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/epidemiologiaRESUMO
OBJECTIVES: The authors conducted a systematic pairwise and network meta-analysis to assess optimal treatment strategies in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MV-CAD) undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: Patients with STEMI and MV-CAD have a worse prognosis than those with single-vessel CAD. The optimal revascularization strategy for these patients is uncertain. METHODS: Studies of revascularization strategies for MV-CAD in STEMI patients undergoing primary PCI published between 2001 and 2015 were identified using an electronic search. Pairwise and network meta-analyses were performed for 3 PCI strategies in prospective and retrospective studies: 1) infarct-related artery (IRA)-only PCI; 2) single procedure MV-PCI; and 3) staged MV-PCI. Information on study design, inclusion and exclusion criteria, and clinical outcomes was extracted. The outcomes of interest were short-term and long-term mortality. RESULTS: Thirty-two studies (13 prospective and 19 retrospective) with 54,148 patients (IRA-only PCI [n = 42,112], single procedure MV-PCI [n = 8,138], and staged MV-PCI [n = 3,898]) were included in the analysis. Pairwise meta-analyses showed that staged MV-PCI was associated with lower short-term and long-term mortality compared with both IRA-only PCI and single stage MV-PCI, whereas IRA-only PCI was associated with lower mortality compared with single stage MV-PCI. Staged MV-PCI was also associated consistently with improved survival in network analyses. CONCLUSIONS: The present systematic review and meta-analysis supports the hypothesis that in patients with MV-CAD presenting with STEMI undergoing primary PCI, a staged multivessel revascularization strategy may improve early and late survival.
Assuntos
Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Teorema de Bayes , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Medicina Baseada em Evidências , Humanos , Cadeias de Markov , Método de Monte Carlo , Metanálise em Rede , Razão de Chances , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The implementation of the latest medical innovations can vary widely within the same geographic area. This study aimed to describe the current status of recent innovations in the field of coronary interventional cardiology in 4 regions of Northern Italy. METHODS: From April to May 2014, 4 regional delegations of the Italian Society of Invasive Cardiology (SICI-GISE) have promoted a multicenter survey. By means of a web-based methodology, a focused questionnaire was administered to head physicians of 97 cath-labs in 4 Italian regions within the "GISE TOLOVE" area (Lombardy, Veneto, Tuscany, Emilia-Romagna). RESULTS: Pharmacological and technological innovations in coronary interventional cardiology appear to be widely used in the area covered by this survey, with uniformity in application and availability of therapeutic devices and drugs within the 4 regions involved. The main limiting factors to the adoption of new technologies and drugs were economic factors or lack of scientific evidence for some specific devices or drugs. CONCLUSIONS: This survey showed widespread and consistent application of the main latest innovations in coronary interventional cardiology across 4 Italian regions of Northern Italy.