Left Ventricular Diastolic Dysfunction in ß-Thalassemia Major with Heart Failure.

We studied the clinical, electrocardiographic, echocardiographic, Doppler and T2* cardiac magnetic resonance (CMR) data of all adult ß-thalassemia major (ß-TM) patients with heart failure (HF) consecutively observed at our referral center of the Sicilian region between 2008 and 2016. There were 16 patients enrolled in the study. Echocardiographic examination showed that only one patient had HF with systolic dysfunction of the left ventricle (HFrEF), whereas the others had HF with preserved systolic function of the left ventricle (HFpEF). Systolic dysfunction of the right ventricle (RV) was observed in 13 cases. Furthermore, 30.0% of the patients presented T2* CMR values consistent with intermediate risk of systolic dysfunction of the left ventricle (LV) due to iron overload, whereas 70.0% had normal values. Typical electrocardiographic abnormalities (wide T wave inversion and low voltages) were observed in 11 out of 16 patients. In conclusion, in the adult ß-TM patients with HF recently observed at our center, the predominant form was that with diastolic dysfunction of the LV, and with systolic dysfunction of the RV. Only 30.0% had low values of T2* CMR. Typical electrocardiographic abnormalities were found in 69.0%.

Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Association of Interventional Cardiology (SICI-GISE) and Italian Society of Cardiac Surgery (SICCH): clinical approach to pharmacologic pre-treatment for patients undergoing myocardial revascularization procedures.

The wide availability of effective drugs in reducing cardiovascular events together with the use of myocardial revascularization has greatly improved the prognosis of patients with coronary artery disease. The combination of antithrombotic drugs to be administered before the knowledge of the coronary anatomy and before the consequent therapeutic strategies, can allow to anticipate optimal treatment, but can also expose the patients at risk of bleeding that, especially in acute coronary syndromes, can significantly weigh on their prognosis, even more than the expected theoretical benefit. In non ST-elevation acute coronary syndromes patients in particular, we propose a 'selective pre-treatment' with P2Y12 inhibitors, based on the ischaemic risk, on the bleeding risk and on the time scheduled for the execution of coronary angiography. Much of the problems concerning this issue would be resolved by an early access to coronary angiography, particularly for patients at higher ischaemic and bleeding risk.

Impact of eGFR rate on 1-year all-cause mortality in patients with stable coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is a leading cause of mortality and is often complicated by chronic kidney disease. We sought to investigate the prevalence of different degree of estimated glomerular filtration rate (eGFR) reduction, the clinical and bio-humoral correlates, its relationship with therapeutic management, and its predictive role on 1-year all-cause mortality, in patients with stable CAD. METHODS: We studied 4,130 patients with stable CAD recruited in a prospective, observational, nationwide study (START, STable coronary Artery diseases RegisTry) in Italy. Baseline clinical characteristics, pharmacological treatment, and all-cause 1-year mortality were evaluated according to groups of eGFR (<30; 30-59; 60-89; ≥90 ml/min/1.73 m2) at baseline. RESULTS: The presence and the degree of chronic kidney disease entailed an unfavorable risk profile, since it was gradually associated with more comorbidities. Furthermore, progressively lower eGFR values were associated to lower diastolic blood pressure and hemoglobin values. As eGFR lowers, optimal medical treatment and its persistence overtime is reduced. Multivariate analysis showed that progressively lower eGFR significantly correlated with all-cause 1-year mortality [hazard ratio (HR): 1.02; 95% confidence intervals (CI): 1.01-1-03; p = 0.0001]. CONCLUSIONS: Low eGFR is associated with an increasing risk of all-cause mortality in patients with stable CAD. Chronic kidney disease may hamper the optimization of treatment limiting the use of drugs which may favorably impact cardiovascular and renal outcomes.

Post-discharge antithrombotic management and clinical outcomes of patients with new-onset or pre-existing atrial fibrillation and acute coronary syndromes undergoing coronary stenting: Follow-up data of the MATADOR-PCI study.

BACKGROUND: . Patients with concomitant atrial fibrillation (AF) and acute coronary syndromes (ACS) do not seem to receive proper antithrombotic therapies and present high rates of adverse clinical events. METHODS: . We analyzed the follow-up data of the prospective, nationwide MATADOR-PCI registry. We assessed the use of antithrombotic strategies and the incidence of major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) at 6 months, in patients with new-onset or pre-existing AF admitted for ACS and treated with percutaneous coronary intervention (PCI). RESULTS: . Out of the 588 patients enrolled in the registry and discharged alive (287 with pre-existing and 301 with new-onset AF), data at 6 months were obtained for 579 (98.5%) patients. Compared to hospital discharge, the rate of triple antithrombotic therapy was significantly reduced (from 76.4% to 23.6% and from 53.8% to 23.6%; both p<0.0001) while dual antithrombotic therapy (DAT) increased (from 11.8% to 56.3% and from 5.8% to 30.9%; both p<0.0001) at follow-up, in patients with pre-existing and new-onset AF, respectively. Among patients with a class IA indication to receive oral anticoagulation therapy (OAT), it was prescribed in 91% and 88% of patients with pre-existing and 64% and 62% of new-onset AF, at discharge and follow-up, respectively. At 6 months from discharge the overall rate of MACE was 8.4% and 7.6% (p=0.75), while NACE occurred in 10.8% vs 10.0% (p=0.74) of patients with pre-existing or new-onset AF, respectively. CONCLUSIONS: . At follow-up, DAT was the most used antithrombotic strategy for both patients with pre-existing and new-onset AF with concomitant ACS. These two groups of patients presented comparable rates of MACE and NACE at 6 months.

Glomerular filtration rate: A prognostic marker in atrial fibrillation-A subanalysis of the AntiThrombotic Agents Atrial Fibrillation.

OBJECTIVE: An increased cardiovascular mortality and morbidity has been widely reported in patients with atrial fibrillation (AF). In this study, a subanalysis of the AntiThrombotic Agents Atrial Fibrillation (ATA-AF) is performed with the aim to evaluate estimated glomerular filtration rate (eGFR) as an independent prognostic marker of cardiovascular mortality and morbidity in patients with AF. METHODS AND RESULTS: The ATA-AF study enrolled 7148 patients with AF, in 360 Italian centers. The eGFR was calculated from data reported in patient notes or hospital database. This post-hoc analysis included 1097 AF patients with eGFR data available and 1-year clinical follow-up. The endpoint was assessed as cardiovascular mortality and/or hospital admission for cardiovascular causes at follow-up. Patients were also divided in two groups according to the eGFR (<60 and ≥60 mL/min/1.73 m2 ). The Kaplan-Meyer curve for the mentioned endpoint showed a higher endpoint incidence in the group of patient with eGFR below 60 mL/min/1.73 m2 (P < 0.001). Using multivariate analysis (Cox regression), a trend toward a higher rate of occurrence of the primary endpoint was observed for eGFR below 60 mL/min/1.73 m2 without reaching the conventional level of statistical significance (hazard ratio [HR] 1.40; 95% confidence interval [CI] 0.99-1.99; P = 0.0572). When eGFR was included in the analysis as continuous variable a significant correlation was observed with the combined endpoint at the Cox regression (HR 0.99, 95% CI 0.98-0.99, P = 0.04). CONCLUSION: The result of this post-hoc analysis indicates that an impaired eGFR is independently associated with worse prognosis among patients with AF.

[ANMCO/SIC/SICI-GISE/SICCH Consensus document: Clinical approach to pharmacological pretreatment for patients undergoing myocardial revascularization]. / Documento di consenso ANMCO/SIC/SICI-GISE/SICCH: Approccio clinico al pretrattamento farmacologico in pazienti candidati a procedure di rivascolarizzazione miocardica.

The wide availability of drugs effective in reducing cardiovascular events and the use of myocardial revascularization have greatly improved the prognosis of patients with coronary artery disease. However, the combination of antithrombotic drugs to be administered before the exact knowledge of the coronary anatomy and before the consequent therapeutic strategy can, on one hand, allow to anticipate an optimal treatment but, on the other hand, may expose the patient to a bleeding risk not always necessary. In patients with ST-elevation acute coronary syndrome with an indication to primary angioplasty, the administration of unfractionated heparin and aspirin is considered the pre-procedural standard treatment. The upstream administration of an oral P2Y12 inhibitor, even if not supported by randomized controlled trials, appears reasonable in view of the very high likelihood of treatment with angioplasty. In patients with non-ST elevation acute coronary syndrome, in which it is not always chosen an invasive strategy, the occurrence of bleeding can significantly weigh on prognosis, even more than the theoretical benefit of pretreatment. Fondaparinux is the anticoagulant with the most favorable efficacy/safety profile. Antiplatelet pretreatment must be selective, guided by the ischemic risk conditions, the risk of bleeding and the time schedule for coronary angiography.In patients with stable coronary artery disease, generally treated with aspirin, pretreatment with clopidogrel is advisable in case of already scheduled angioplasty, and it appears reasonable in case of high likelihood, at least in patients at low bleeding risk. In patients candidate to surgical revascularization, aspirin is typically maintained and the oral P2Y12-inhibitor discontinued, with i.v. antiplatelet drug bridging in selected cases.Anti-ischemic drugs are useful in controlling symptoms, but they have no specific indications with regard to revascularization procedures. Statins showed protective effects on periprocedural damage and late clinical events, when administered early. Although randomized data are lacking, it seems reasonable their pre-procedural administration, due to potential advantages without significant adverse effects.