PSYChosomatic Medicine in ONcologIc and Cardiac Disease (PSYCHONIC) Study-A Retrospective and Prospective Observational Research Protocol.

Psychosocial factors play an important role in non-communicable diseases (NCDs). This observational study is primarily aimed at assessing the relationship of psychological characteristics of patients with the outcomes of different NCDs, and to assess short-term psychotherapy (STP) efficacy in the real world. Methods: One hundred and forty patients with recent acute myocardial infarction, Takotsubo syndrome, or non-metastatic breast cancer and a control group of 140 age and sex-matched healthy subjects, will be enrolled. All subjects will be administered psychometric tests, quality of life tests, a specific body perception questionnaire, a dream questionnaire, and a projective test, the Six Drawing test at baseline and follow-up. All subjects with medical conditions will be asked to freely choose between an ontopsychological STP along with standard medical therapy and, whenever indicated, rehabilitation therapy or medical therapy plus rehabilitation alone. The study endpoints will be to evaluate: the relationship of the psychological characteristics of enrolled subjects with the outcomes of different NCDs, predictors of the choice of psychotherapy, and the efficacy of ontopsychological intervention on psychological and medical outcomes. Conclusion: This study will generate data on distinctive psychological characteristics of patients suffering from different CDs and their relationship with medical outcomes, as well as explore the efficacy of ontopsychological STP in these patients in the real world. (Number of registration: NCT03437642).

[ANMCO Position paper: Reorganization of cardiology in the era of the COVID-19 pandemic]. / Position paper ANMCO: Riorganizzazione della cardiologia in epoca di pandemia COVID-19.

The COVID-19 pandemic represents an unprecedented event that has brought deep changes in hospital facilities with reshaping of the health system organization, revealing inadequacies of current hospital and local health systems. When the COVID-19 emergency will end, further evaluation of the national health system, new organization of acute wards, and a further evolution of the entire health system will be needed to improve care during the chronic phase of disease. Therefore, new standards for healthcare personnel, more efficient organization of hospital facilities for patients with acute illnesses, improvement of technological approaches, and better integration between hospital and territorial services should be pursued. With experience derived from the COVID-19 pandemic, new models, paradigms, interventional approaches, values and priorities should be suggested and implemented.

[Opportunities and perspectives for bempedoic acid use in clinical practice]. / Opportunità e prospettive per l'impiego dell'acido bempedoico nella pratica clinica.

Bempedoic acid is a new lipid-lowering drug that inhibits cholesterol biosynthesis in liver cells selectively. Results from phase 2 and phase 3 studies showed a complementary effect on LDL-cholesterol lowering when combining bempedoic acid and ezetimibe without increasing side effects. Moreover, bempedoic acid seems to represent a good treatment option for the management of hypercholesterolemia, especially in patients at increased risk of cardiovascular events, such as patients with impaired glucose metabolism, elderly patients, patients with prior acute coronary syndrome, and patients with familial hypercholesterolemia. Based on the scientific evidence, this paper provides practical recommendations on the management of hypercholesterolemia with bempedoic acid.

Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO).

Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.

ANMCO POSITION PAPER: The management of suspect or confirmed COVID-19 patients needing urgent electrophysiology and/or electrostimulation procedures.

The aim of this document is the management and organization of patients in need of urgent access to electrophysiology (EP) and pacing procedures during the COVID-19 emergency. Specifically, non-deferrable procedures or irreplaceable with a drug therapy prior to the resolution of the COVID-19 virus emergency [pacemaker (PM) implant/replacement/urgent defibrillator (implantable cardioverter-defibrillator, ICD) or arrhythmic storm or other indication of non-deferrable ablation]. The pacing and electrophysiological procedures urgent as they may be, less and less frequently represent situations of emergency, therefore for almost all cases, it is possible to perform a swab test to determine the positivity to COVID-19 of the patient. In cases where this is not possible, due to situations of emergency, the recommendations and procedures we have indicated are advisable, if not mandatory, in order to avoid the spreading of the virus to healthcare personnel and other patients.

[ANMCO Position paper: New perspectives on the role of n-3 polyunsaturated fatty acids in cardiovascular prevention]. / Position paper ANMCO: Nuove prospettive sul ruolo degli acidi grassi polinsaturi n-3 nella prevenzione cardiovascolare.

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the most important long-chain polyunsaturated fatty acids of the n-3 series (n-3 PUFA). Recent studies have clarified that EPA and DHA have different tissue distribution and influence target organs in a distinct way. In addition to the main effect of reducing triglycerides (TG), they exert antithrombotic, antiarrhythmic, anti-inflammatory, anti-atherogenic, and hemodynamic effects. The different action of PUFA n-3 depends on the dosage and duration of treatment: the effect on TG requires high doses and a few weeks/months of treatment.Several epidemiological studies have shown a relationship between hypertriglyceridemia and cardiovascular risk, confirmed by post-hoc analysis of statin trials and by recent genetic linkage studies. Moreover in secondary prevention, the evidence of a significant "residual risk", even in the presence of an adequate control of LDL-cholesterol, has led the scientific community to consider further intervention objectives in the context of the individual lipid profile, the most promising of which is certainly hypertriglyceridemia.The recent landmark REDUCE-IT study is the first major lipid intervention study to demonstrate a benefit deriving from an approach not based on the LDL target, focusing on a determinant factor of residual risk such as hypertriglyceridemia and treating it with high doses of n-3 PUFA (4 g/day).Overall, the "lipid residual risk" approach involves two integrated actions: (i) the achievement of the LDL-cholesterol target (<70 mg/dl) by using statins, ezetimibe, PCSK9 inhibitors; (ii) checking TG levels in order to start n-3 PUFA in case of TG values >150 mg/dl, at an initial dosage of 2-3 g/day (up to 4 g/day after 10-12 weeks).

Management of atrial fibrillation in the emergency room and in the cardiology ward: the BLITZ AF study.

AIMS: To assess the number of admissions to the emergency room (ER) of patients with atrial fibrillation (AF) or atrial flutter (af) and their subsequent management. To evaluate the clinical profile and the use of antithrombotics and antiarrhythmic therapy in patients with AF admitted to cardiology wards. METHODS AND RESULTS: BLITZ-AF is a multicentre, observational study conducted in 154 centres on patients with AF/af. In each centre, data were collected, retrospectively for 4 weeks in ER and prospectively for 12 weeks in cardiology wards. In ER, there were 6275 admissions. Atrial fibrillation was the main diagnosis in 52.9% of the cases, af in 5.9%. Atrial fibrillation represented 1.0% of all ER admissions and 1.7% of all hospital admissions. A cardioversion has been performed in nearly 25% of the cases. Out of 4126 patients, 52.2% were admitted in cardiology ward; mean age was 74 ± 11 years, 41% were females. Patients with non-valvular AF were 3848 (93.3%); CHA2DS2-VASc score was ≥2 in 87.4%. Cardioversion was attempted in 38.8% of the patients. In-hospital mortality was 1.2%. At discharge, 42.6% of the patients were treated with vitamin K antagonists, 39.5% with direct oral anticoagulants, 13.6% with other antithrombotic drugs, and 4.2% did not take any antithrombotic agent. Rate control strategy was pursued in 47.2%, rhythm control in 44.0%, 45.6% were discharged in sinus rhythm. CONCLUSION: Atrial fibrillation still represents a significant burden on health care system. Oral anticoagulant use increased over time even if compliance with guidelines, with respect to prevention of the risk of stroke, remains suboptimal.

N-3 Fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: a randomized, controlled trial.

OBJECTIVES: The aim of this study was to assess the efficacy of preoperative and postoperative treatment with n-3 polyunsaturated fatty acids (PUFAs) in preventing the occurrence of atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG). BACKGROUND: Postoperative AF is a common complication of CABG. There is growing clinical evidence that PUFAs have cardiac antiarrhythmic effects. METHODS: A total of 160 patients were prospectively randomized to a control group (81 patients, 13 female, 64.9 +/- 9.1 years) or PUFAs 2 g/day (79 patients, 11 female, 66.2 +/- 8.0 years) for at least 5 days before elective CABG and until the day of discharge from the hospital. The primary end point was the development of AF in the postoperative period. The secondary end point was the hospital length of stay after surgery. All end points were independently adjudicated by two cardiologists blinded to treatment assignment. RESULTS: The clinical and surgical characteristics of the patients in the two groups were similar. Postoperative AF developed in 27 patients of the control group (33.3%) and in 12 patients of the PUFA group (15.2%) (p = 0.013). There was no significant difference in the incidence of nonfatal postoperative complications, and postoperative mortality was similar in the PUFA-treated patients (1.3%) versus controls (2.5%). After CABG, the PUFA patients were hospitalized for significantly fewer days than controls (7.3 +/- 2.1 days vs. 8.2 +/- 2.6 days, p = 0.017). CONCLUSIONS: This study first demonstrates that PUFA administration during hospitalization in patients undergoing CABG substantially reduced the incidence of postoperative AF (54.4%) and was associated with a shorter hospital stay.

Transseptal activation during left atrial pacing in humans: electroanatomic mapping using a noncontact catheter and the intracardiac echocardiography.

BACKGROUND: A better understanding of transseptal activation may be important for the treatment of atrial fibrillation, but little is known about preferential routes of conduction from the left atrium (LA) to the right atrium (RA) in humans. METHODS AND RESULTS: Twelve patients were studied. A noncontact mapping system was used to map the RA during pacing from several sites of LA at different cycle lengths. The location of the Bachmann's bundle (BB), the fossa ovalis (FO) and the coronary sinus (CS) ostium were determined using intracardiac echocardiography. The BB was the earliest area of right atrial activation during pacing from the atrial appendage, roof and postero-superior wall in 94% of cases. The FO was the area of earliest activation during pacing from the septum and the right superior pulmonary veins (PV) in 95% of cases. The CS ostium (alone or associated with the FO) was the region of transseptal breakthrough in all patients during pacing from the right inferior PV, postero-inferior wall and distal CS. Various patterns of activation with 2 or 3 distinct areas of transseptal breakthrough were observed during pacing from the lateral wall and the left superior PV. The pacing cycle length did not influence the modality of transseptal activation. CONCLUSIONS: Different patterns of transseptal activation were found during pacing from LA. The preferential routes of conduction from the LA to the RA were related to the sites of stimulation and were not influenced by the pacing cycle length.