Lights and shadows of long-term dual antiplatelet therapy in "real life" clinical scenarios.

Dual antiplatelet therapy (DAPT) is a cornerstone of treatment for patients with acute coronary syndromes (ACS). Mounting evidences have opened the debate about the optimal DAPT duration. Considering the ACS-pathophysiology, the most recent guidelines recommend DAPT in all ACS patients for at least 12 months unless there are contraindications such as excessive risk of bleeding. Thus, it can be considered acceptable earlier discontinuation if the risk of morbidity from bleeding outweighs the anticipated benefit. On the other hand, several studies have clearly indicated that a significant burden of platelet related-events, such as stroke and new ACS might occur after this period, suggesting that potential benefits might derive by prolonging DAPT beyond 12 months (Long DAPT). Indeed, although current guidelines give some indications about patients eligible for Long DAPT, they do not embrace several real-life clinical scenarios. Thus, in such scenarios, how to decide whether a patient is eligible for Long DAPT or not might be still challenging for clinicians. This position paper presents and discusses various "real-life" clinical scenarios in ACS patients, in order to propose several possible recommendations to overcome guidelines potential limitations.

[Home hemodialysis and peritoneal dialysis compared]. / Dialisi domiciliare sì, ma quale? Emodialisi domiciliare e dialisi peritoneale a confronto: una controversia non controversa.

The evolution of home dialysis marked the main steps in the progress of renal replacement therapy. From the origins when home hemodialysis was often the only alternative to death, to the advent and widespread use of peritoneal dialysis, the dream of kidney transplant as a solution to all problems (at least in the young), and ultimately the profound social and organizational changes that have led to a drastic reduction of home hemodialysis, we arrive at the present with the rediscovery of the clinical, rehabilitative and economic advantages of home dialysis. Seven experts from five different centers with different expertise in home dialysis report their opinions on the future of home dialysis in a ''noncontroversial controversy''. Beyond the sterile competition between peritoneal dialysis and home hemodialysis, the shared opinion is that the two methods may complement each other, allowing a tailored treatment for each patient and a tailored organization in each setting. The organizational solutions are many; the authors underline the importance of longer survival and better rehabilitation, and the ethical need of offering each patient a choice among all available treatments. Add to this the importance of dedicated educational programs targeted to physicians, nurses and patients alike and focused on self-care and patient empowerment. A new generation of dialysis machines, easier technical solutions, and financial incentives may strengthen motivations and simplify problems; all these elements may in the near future be combined in a joint effort to increase peritoneal dialysis and revive home hemodialysis in Italy.

Characteristics, treatment and quality of life of stable coronary artery disease patients with or without angina: Insights from the START study.

Data on contemporary management patterns of angina in patients with stable coronary artery disease (CAD) are scarce. We sought to describe the current presentation, management, and quality of life of stable CAD patients with or without angina, using the data from the START (STable Coronary Artery Diseases RegisTry) study. START was a prospective, observational, nationwide study aimed to evaluate the presentation, management, treatment and quality of life of stable CAD presenting to cardiologists during outpatient visits or discharged from cardiology wards. Among the 5070 consecutive stable CAD patients enrolled in 183 participating centers over a 3-month period, 3714 (73.2%) had no angina and 1356 (26.8%) presented with angina. Patients with angina underwent more frequently coronary angiography (92.7% vs 84.9%; p<0.0001) and other diagnostic imaging procedures compared to those without angina. In addition, patients with angina received more frequently different combinations of first line therapies and angina relief drugs compared to patients without angina. The quality of life, assessed with the EQ 5D-5L questionnaire, did not differ between the two groups, with the exception of the 'pain or worry' domain that was higher in patients with compared to those without angina (p<0.0001). Current management and treatment of stable CAD patients with angina is still suboptimal and different compared to those without angina. Our findings highlight the need for disseminating best-practice patterns and improving guidelines adherence for the management of angina even among cardiologists.

Contemporary management of patients referring to cardiologists one to three years from a myocardial infarction: The EYESHOT Post-MI study.

AIMS: To describe the contemporary management by cardiologists of patients after an episode of myocardial infarction (MI). METHODS: The EYESHOT Post-MI was a prospective, observational, nationwide study aimed to evaluate the management of patients referring to cardiologists 1 to 3 years from the last MI event. RESULTS: Over a 3-month period, 1633 consecutive patients [median 22 (IQR 15-28) months from MI] were enrolled: 1028 (63.0%) at the second and 605 (37.0%) at the third year from MI. During the 12 months prior to enrolment, the majority of patients received a transthoracic echocardiogram (60% and 54%), followed by coronary angiography (24% and 16%, in the second and third year from MI groups, respectively). At the time of enrolment, the majority of patients were prescribed on statins (93%) and beta-blockers (82%), without significant differences between the 2 groups. A dual antiplatelet therapy (DAPT) was used more frequently among patients presenting during the second compared to the third year from MI (40% vs 24%; p < 0.0001). At multivariable analysis, the time interval from last MI (2 vs 3 years: OR 2.27; 95% CI 1.79-2.88; p < 0.0001) and a previous percutaneous coronary intervention with multiple stents (OR 3.46; 95% CI 2.19-5.47; p < 0.0001) resulted as the major independent predictors of DAPT persistence at the time of enrolment. CONCLUSIONS: This contemporary registry provides unique insights into the current management of post-MI patients and represents an opportunity to further improve the long-term treatment of this high-risk population.

Antiplatelet Therapy for Non-ST-Segment Elevation Myocardial Infarction in Complex "Real" Clinical Scenarios: A Consensus Document of the "Campania NSTEMI Study Group".

The incidence of ST-segment elevation myocardial infarction (STEMI) has significantly decreased. Conversely, the rate of non-STEMI (NSTEMI) has increased. Patients with NSTEMI have lower short-term mortality compared to patients with STEMI, whereas at long-term follow-up, the mortality becomes comparable. This might be due to the differences in baseline characteristics, including older age and a greater prevalence of comorbidities in the NSTEMI population. Although antithrombotic strategies used in patients with NSTEMI have been well studied in clinical trials and updated guidelines are available, patterns of use and outcomes in clinical practice are less well described. Thus, a panel of Italian cardiology experts assembled under the auspices of the "Campania NSTEMI Study Group" for comprehensive discussion and consensus development to provide practical recommendations, for both clinical and interventional cardiologists, regarding optimal management of antithrombotic therapy in patients with NSTEMI. This position article presents and discusses various clinical scenarios in patients with NSTEMI or unstable angina, including special subsets (eg, patients aged ≥85 years, patients with chronic renal disease or previous cerebrovascular events, and patients requiring triple therapy or long-term antithrombotic therapy), with the panel recommendations being provided for each scenario.

Cardiac resynchronization therapy improves functional status and cognition.

BACKGROUND: Many trials demonstrated the beneficial effects on hospitalizations and mortality of cardiac resynchronization therapy (CRT). The purpose of this study was to evaluate CRT effects on functional performance and cognition, two determinants of disability, frailty development and survival. METHODS: All consecutive patients receiving a CRT device were evaluated at baseline and at the 6-month follow-up. Functional profile was assessed with the Short Physical Performance Battery (SPPB), a measure exploring balance, gait, strength and endurance, highly predictive of incident disability and mortality. The Mini-Mental State Examination (MMSE) was used to study the cognitive profile. RESULTS: We enrolled 54 patients; two of them died during the follow-up, two refused to continue the study. Age was 67±10years (men: 80%, LVEF: 28±5%); medical therapy was optimized (ACE-I/ARB: 84%, beta-blockers: 80%). After 6months, CRT was associated with the improvement of LVEF (35±8 vs. 28±5%, p<0.001) and NYHA Class (1.8±0.6 vs. 2.6±0.5, p<0.001), and with the reduction of left ventricular end-systolic diameter (50±9 vs. 57±9mm, p<0.001). SPPB improved in its total score (10.3±2.0 vs. 9.1±2.7, p<0.001) and in the scores exploring gait speed and strength and endurance. These changes were associated with a better cognitive profile (MMSE score: 27.0±3.5 vs. 25.9±4.8, p=0.009). Advanced age was an independent predictor of improved functional performance and cognition. CONCLUSIONS: CRT is associated with higher functional and cognitive profile after only 6months of therapy. These findings let us hypothesize a powerful effect of treatment to slow disability and frailty development in heart failure.

The role of blood volume reduction in the genesis of intradialytic hypotension.

BACKGROUND: The aim of this multicenter prospective study was to investigate the role of relative blood volume (RBV) reduction on intradialytic hypotension. METHODS: One hundred twenty-three patients on chronic hemodialysis therapy were considered a priori normotensive (reference group A), intradialytic hypotension prone (group B), and hypertensive (group C). RBV was continuously monitored, and diastolic and systolic blood pressure (SBP) and heart rate (HR) were measured at 20-minute intervals during three dialysis sessions. RESULTS: Intradialytic RBV reduction was -13.8% +/- 7.0% and similar in the three groups (P = 0.841). SBP and RBV decreased during dialysis, with a sharp initial decrease (in the first 20 minutes for SBP and the first 40 minutes for RBV), followed by a slower decrease. The lying bradycardic response before dialysis was less in group B than group A (a decrease of 3 +/- 7 versus 9 +/- 9 beats/min; P < 0.001). When symptomatic hypotension occurred, RBV reduction was not significantly different from that recorded at the same time during hypotension-free sessions (-13.9% +/- 6.4% versus -12.7% +/- 5.2%; P = 0.149). Group, baseline plasma-dialysate sodium gradient, RBV line irregularity, and early RBV and HR reduction during dialysis influenced the relative risk for symptomatic hypotension with a sensitivity of 80% versus 30% for RBV alone. CONCLUSION: We found no difference in reduction in RBV in the three groups and no critical RBV level for the appearance of symptomatic hypotension. With variables easily available within 40 minutes of dialysis, RBV monitoring increases the prediction of symptomatic hypotension.

Methods for testing automatic mode switching in patients implanted with DDD(R) pacemakers.

The assessment of automatic mode switching (AMS) algorithms is impossible in vivo, due to a low chance of seeing the patient at the onset of a spontaneous episode of atrial fibrillation (AF). As the induction of AF to test AMS has clinical concerns, three alternative and non-invasive techniques may be proposed for this purpose: myopotentials, chest wall stimulation, and an external supraventricular arrhythmia simulator. The first method is simple and does not require additional equipment, even though in some patients adequate signals cannot be generated with a soft effort such as handgrip or hand compression. The main advantage of the chest wall stimulation method is the possibility that it be performed in every implanting center, since it is based on the use of standard devices for cardiac stimulation. The method based on the external supraventricular arrhythmia simulator allows the most detailed of the ECG traces, but it needs a dedicated electronic device.

[Variations in QRS duration and axis with different sites and intervals of right ventricular pacing]. / Variazioni della durata e dell'asse del QRS con differenti siti ed intervalli di stimolazione in ventricolo destro.

BACKGROUND: The aim of this study was to achieve left ventricular resynchronization by means of right ventricular pacing. METHODS: We studied 12 patients (9 males, 3 females, mean age 61.7 +/- 19.5 years), with syncope, II degree atrioventricular block or ventricular arrhythmias, without intraventricular conduction disturbances. Single and dual site pacing, synchrony or at different delay, was made in the right ventricular, outflow tract from the apex, and midseptal areas. RESULTS: In all patients we obtained the shortest QRS duration with synchrony or delayed bisite pacing (standard ventricular apex pacing 170 +/- 20 ms; bisite pacing 137 +/- 13 ms). CONCLUSIONS: Our data demonstrate that appropriate right ventricular pacing can lead to left ventricular resynchronization.

A randomized study to compare ramp versus burst antitachycardia pacing therapies to treat fast ventricular tachyarrhythmias in patients with implantable cardioverter defibrillators: the PITAGORA ICD trial.

BACKGROUND: In patients with implantable cardioverter-defibrillators (ICDs), antitachycardia pacing (ATP) is highly effective in terminating fast ventricular tachycardias (FVTs) and lowers the use of high-energy shocks, without increasing the risk of arrhythmia acceleration or syncope. METHODS AND RESULTS: The aim of the PITAGORA ICD trial was to randomly compare 2 ATP strategies (88% coupling interval burst versus 91% coupling interval ramp, both 8 pulses) in terms of ATP efficacy, arrhythmia acceleration, and syncope. Two hundred six ICD patients (83% male, 67+/-11 years) were enrolled. FVT episodes with cycle lengths between 240 and 320 ms were treated by 1 ATP sequence and, in the event of failure, by shocks. Over a median follow-up of 36 months, 829 spontaneous ventricular tachyarrhythmia episodes were detected in 79 patients. Episode review identified 595 episodes as true ventricular arrhythmias in 72 patients; devices classified 111 (18.7%) episodes as VF, 216 (36.3%) as FVT, and 268 (45.0%) as VT. Fifty-six patients had 214 treated FVT episodes-2 FVTs self-terminated before ATP release; 44 (79%) of these had at least 1 effective ATP intervention, and 34 (61%) were spared ICD shocks. Burst terminated 100 of 133 (75.2%) FVT episodes, whereas ramp terminated 44 of 81 (54.3%; P=0.015). Acceleration occurred in 9 of 214 (4.2%) FVT episodes treated: 6 episodes in 3 ramp patients and 3 episodes in 3 burst patients. Two patients-1 in each group-suffered 1 syncopal event associated to a nonterminated FVT episode. CONCLUSIONS: Burst is significantly more efficacious than ramp in terminating FVT episodes. As the first therapy for FVT episodes, ATP carries a low risk of acceleration or syncopal events.