Response to a massive SARS-CoV-2 infection in a nursing home transformed into a caring center.

BACKGROUND: The best policy to follow when nursing homes are massively hit by SARS-CoV2 is unclear. AIM: To describe COVID-19 containment in a nursing home transformed into a caring center. METHODS: Physicians and nurses were recruited. The facility was reorganized and connected with the laboratory of the reference hospital. Ultrasound was used to diagnose pneumonia. Patients needing intensive care were transferred to the reference hospital. Hydroxychloroquine/azithromycin/enoxaparin were used initially, while amiodarone/enoxaparin were used at a later phase. Under both regimens, methylprednisolone was added for severe cases. Prophylaxis was done with hydroxychloroquine initially and then with amiodarone. PERIOD COVERED: March 22-July 31, 2020. RESULTS: The facility was reorganized in two days. Ninety-two guests of the 121 (76%) and 25 personnel of 118 (21.1%) became swab test positive. Seven swab test negative patients who developed symptoms were considered to have COVID-19. Twenty-seven patients died, 23 swab test positive, 5 of whom after full recovery. Four patients needing intensive care were transferred (3 died). Mortality, peaking in April 2020, was correlated with symptoms, comorbidities, dyspnea, fatigue, stupor/coma, high neutrophil to lymphocyte ratio, C-reactive protein, interleukin-6, pro-calcitonin, and high oxygen need (p ≤ 0.001 for all). Among swab-positive staff, 3 had pneumonia and recovered. Although no comparison could be made between different treatment and prophylaxis strategies, potentially useful suggestions emerged. Mortality compared well with that of nursing homes of the same area not transformed into care centers. CONCLUSION: Nursing homes massively hit by SARS-CoV-2 can become caring centers for patients not needing intensive care.

Introducing Virtual Reality in a STEMI Coronary Syndrome Course: Qualitative Evaluation with Nurses and Doctors.

In the increasing number of medical education topics taught with virtual reality (VR), the prehospital management of ST-segment elevation myocardial infarction (STEMI) had not been considered. This article proposes an implemented VR system for STEMI training and introduces it in an institutional course addressed to emergency nurses and case manager (CM) doctors. The system comprises three different applications to, respectively, allow (a) the course instructor to control the conditions of the virtual patient, (b) the CM to communicate with the nurse in the virtual field and receive from him/her the patient's parameters and electrocardiogram, and (c) the nurse to interact with the patient in the immersive VR scenario. We enrolled 17 course participants to collect their perceptions and opinions through a semistructured interview. The thematic analysis showed the system was appreciated (n = 17) and described as engaging (n = 4), challenging (n = 5), useful to improve self-confidence (n = 4), innovative (n = 5), and promising for training courses (n = 10). Realism was also appreciated (n = 13), although with some drawbacks (e.g., oversimplification; n = 5). Overall, participants described the course as an opportunity to share opinions (n = 8) and highlight issues (n = 4) and found it useful for novices (n = 5) and, as a refresh, for experienced personnel (n = 6). Some participants suggested improvements in the scenarios' type (n = 5) and variability (n = 5). Although most participants did not report usage difficulties with the VR system (n = 13), many described the need to get familiar with it (n = 13) and the specific gestures it requires (n = 10). Three suffered from cybersickness.

Effectiveness of home-rehabilitation in patients after an acute coronary syndrome and myocardial revascularization.

Physical activity is a mainstay (class IA) of rehabilitation programme after an acute coronary syndrome, but less than 40% of patients is physically active at one year. Home-rehabilitation, initially designed to manage the increasing number of patients in rehabilitation programmes, could result in a better strategy to increase adherence and persistence to physical activity. Objectives: To test such hypothesis, At Cardiac Rehabilitation Centre (Institute of Physical Medicine and Rehabilitation, Udine, Italy), physical activity adherence was compared between patients treated with a standard in-office rehabilitation programme and a cohort where home rehabilitation programme was added. Methods: From February 2017 to February 2019, 372 patients after an acute coronary syndrome (72 were excluded according to study criteria) were included, 193 patients in standard rehabilitation and 179 in home rehabilitation. At the end of follow-up, patients of both groups were called on the telephone to collect physical activity items according to a standardized questionnaire. Results: At a medium follow-up of 30.1 months, there are more physically active patients in home rehabilitation than in standard, respectively 139 vs 108 patients (77,1% vs. 56%, p < 0,0001).At multivariate analysis, including age, gender, and rehabilitation model, the probability to be fully physically active at the end of the rehabilitation programme, is 3 times higher (OR 3.0 CI 1,9-6,0 p < 0,0001) for home rehabilitation programme compared to standard one. Conclusions: Home rehabilitation, when applied to selected populations, resulted in a feasible and effective strategy to promote long term physical activity in secondary prevention after an acute coronary syndrome.

Detection of severe acute respiratory syndrome coronavirus 2 in nasopharynx according to clinical phenotype of affected patients.

OBJECTIVES: Duration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the upper respiratory tract is extremely variable, but its relation to disease severity is unknown. We investigated this relation in the 530 000 inhabitants of the northeastern Italian province of Udine. METHODS: We analysed real-time RT-PCR tests for SARS-CoV-2 in upper respiratory specimens conducted at the Virology Laboratory of the University Hospital of Udine, Italy (which serves the whole province) from 1 March to 30 April 2020 Specimens were from positive individuals in four groups characterized by different disease severity (critically ill patients admitted to intensive care units, patients admitted to infectious disease units, symptomatic patients visiting the emergency department and not hospitalized, and asymptomatic individuals tested during contact tracing or screening activities). Duration of viral positivity was assessed from the first positive test to the day of the first of two consecutive negative tests. Univariate and multivariate analyses were conducted to investigate differences in the four groups. RESULTS: From 1 March to 30 April, 39 483 RT-PCR tests for SARS-CoV-2 were conducted on 23 778 individuals, and 974 individuals had a positive test result. Among those with multiple tests (n = 878), mean time to negativity was 23.7 days (standard error 0.3639; median 23, interquartile range 16-30 days). Mean time to negativity was longer in the group admitted to the intensive care unit than in the others, whereas no difference was observed between asymptomatic patients and those with mild disease. CONCLUSIONS: Disease control measures should not be adjusted to account for differences in viral shedding according to symptomatic status.

Epidemiology and mortality in an Italian region after the adoption of the universal definition of myocardial infarction.

AIMS: The aim of the study is to validate at the biochemical level (presence of myocardial damage) the discharge diagnosis code ICD-9-CM 410.x1, and to compare the acute myocardial infarction (AMI) epidemiology based on pure administrative data with the epidemiology based on troponin and clinical data. METHODS: The health-related administrative databases of the Italian Region Friuli Venezia Giulia were used as the source of information. All the databases are anonymous and can be linked with each other at the individual patient level through a univocal stochastic key. Two methods were used to assess incidence in 2017: the first used the main hospital discharge diagnosis, validated by biochemical myocardial necrosis; the second identified from the cohort of all patients with any myocardial injury those with ischemic origin. RESULTS: The positive-predictive value of the clinical diagnosis of AMI (410.x1), validated at the biochemical level, was 96.2%.About 40% of patients with a not trivial biochemical myocardial injury and an ischemic heart disease diagnosis (e.g. 411) were discharged without either ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI) diagnosis, leading to a sensitivity of clinical discharge diagnosis of 47.6%.Thirty-day and 90-day mortality at multivariate analysis resulted respectively, 1.8 and 4.0% in NSTEMI, 6.6 and 9.8% in STEMI, 8.8 and 12.2% in patients with biochemical AMI and discharge diagnosis other than 410.x1. CONCLUSION: Pure administrative data (clinical discharge diagnosis) are today insufficient to catch the whole hospital epidemiology of myocardial infarction missing an important proportion of AMI with an adverse prognosis comparable with STEMI.

Fifteen-Year Trends of Cardiogenic Shock and Mortality in Patients with Diabetes and Acute Coronary Syndromes.

PURPOSE: Our study was intended to examine time trends of management and mortality of acute coronary syndrome patients with associated diabetes mellitus. METHODS: We analyzed data from 5 nationwide registries established between 2001 and 2014, including consecutive acute coronary syndrome patients admitted to the Italian Intensive Cardiac Care Units. RESULTS: Of 28,225 participants, 8521 (30.2%) had diabetes: as compared with patients without diabetes, they were older and had significantly higher rates of prior myocardial infarction and comorbidities (all P < .0001). Prevalence of diabetes and comorbidities increased over time (P for trend < .0001). Cardiogenic shock rates were higher in patients with diabetes, as compared with those without diabetes (7.8% vs 2.8%, P < .0001), and decreased significantly over time only in patients without diabetes (P = .007). Revascularization rates increased over time in patients both with and without diabetes (both P for trend < .0001), although with persistingly lower rates in patients with diabetes. All-cause in-hospital mortality was higher in patients with diabetes (5.4 vs 2.5%, respectively, P < .0001) and decreased more consistently in patients without diabetes (P for trend = .007 and < .0001, respectively). At multivariable analysis, diabetes remains an independent predictor of both cardiogenic shock (odds ratio 2.03; 95% confidence interval, 1.77-2.32; P < .0001) and mortality (odds ratio 1.95; 95% confidence interval, 1.69-2.26; P < .0001). CONCLUSIONS: Despite significant mortality reductions observed over 15 years in acute coronary syndromes, patients with diabetes continue to show threefold higher rates of cardiogenic shock and lower revascularization rates as compared with patients without diabetes. These findings may explain the persistingly higher mortality of patients with diabetes and acute coronary syndromes.

Trends in management and outcome of patients with non-ST elevation acute coronary syndromes and peripheral arterial disease.

OBJECTIVE: Patients with non ST-segment elevation acute coronary syndromes (NSTE-ACS) and peripheral arterial disease (PAD) present a worse prognosis compared to those without PAD. We sought to describe contemporary trends of in-hospital management and outcome of patients admitted for NSTE-ACS with associated PAD. METHODS: We analyzed data from 6 Italian nationwide registries, conducted between 2001 and 2014, including consecutive NSTE-ACS patients. RESULTS: Out of 15,867 patients with NSTE-ACS enrolled in the 6 registries, 2226 (14.0%) had a history of PAD. As compared to non-PAD patients, those with PAD had significantly more risk factors and comorbidities (all p < 0.0001) that increased over time. Patients with PAD underwent less frequently coronary angiography (72.0% vs 79.2%, p < 0.0001) and percutaneous coronary intervention (PCI, 42.9% vs 51.8%, p < 0.0001), compared to patients without PAD. Over the years, a progressive and similar increase occurred in the rates of invasive procedures both in patients with and without PAD (both p for trend <0.0001). The crude in-hospital mortality rate did not significantly change over time (p for trend = 0.83). However, as compared to 2001, the risk of death was significantly lower in all other studies performed at different times, after adjustment for multiple comorbidities.. At multivariable analysis, PAD on admission was an independent predictor of in-hospital mortality [odds ratio (OR): 1.75; 95% confidence intervals (CI): 1.35-2.27; p < 0.0001]. CONCLUSIONS: Over the 14 years of observation, patients with PAD and NSTE-ACS exhibited worsening baseline characteristics and a progressive increase in invasive procedures. Whereas crude in-hospital mortality did not change over time, we observed a significant reduction in comorbidity-adjusted mortality, as compared to 2001.

Recent trends in management and outcome of patients with acute coronary syndromes and atrial fibrillation.

AIMS: To describe the clinical characteristics, contemporary trends of in-hospital management and outcome of patients admitted for an acute coronary syndrome (ACS) with associated atrial fibrillation (AF). METHODS: We analyzed data from four Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive ACS patients. RESULTS: Out of 16,803 ACS patients, 1019 (6.1%) presented with concomitant AF: 668 with non-ST elevation (NSTE)-ACS and 351 with ST-elevation myocardial infarction (STEMI). As compared to no-AF patients, those with AF were older and had significantly more prior cardiac events and comorbidities (all p<0.005). A progressive increase occurred over time in the rates of coronary angiography and percutaneous coronary intervention, both in NSTE-ACS (p for trend=0.0002 and 0.0008, respectively) and STEMI patients with AF at admission (both p for trend <0.0001), with trends similar to those observed in non-AF patients. Among STEMI patients, in-hospital mortality decreased by 50% in those without AF (7.5% in 2001 to 3.3% in 2014, p<0.0001), with a similar decrease in those with AF (20% vs 10.7%, p=0.20), even though not statistically significant. At multivariable analysis, AF on admission was not an independent predictor of in-hospital mortality [odds ratio (OR): 0.82; 95% confidence intervals (CI): 0.52-1.30; p=0.41 for NSTE-ACS, and OR: 1.07; 95% CI: 0.73-1.57; p=0.74 for STEMI]. CONCLUSIONS: Over the last 14years, the in-hospital management of ACS patients with AF has significantly improved as for patients without AF, with comparable effect in terms of outcome.

[Bundle-branch block in the course of myocardial infarction. Recent advances]. / I blocchi di branca in corso di infarto miocardico. Recenti acquisizioni di fisiopatologia e clinica.

In case of acute myocardial infarction and a bundle-branch block (BBB) major diagnostic and prognostic issues should be addressed with different considerations, depending on the presence of a left BBB (LBBB) or a right BBB (RBBB), distinguishing new or presumably new BBB, considering the possibility that the BBB masks electrocardiographic features of MI with ST-segment elevation. In this paper we briefly discuss the results of published trials that assessed the prognostic difference between different types of BBB during the early phase of acute myocardial infarction. The Wong et al. analysis of HERO-2 trial demonstrates that in the setting of an anterior STEMI, the presence of an RBBB, whatever its onset, is associated with a higher risk of death. The same analysis shows as RBBB associated with an inferior infarction does not portend a worse prognosis independently of its onset. Patients with LBBB already present at randomization were found to have worse pre-infarction characteristics, responsible, by itself, for the worst prognosis. However, the occurrence of an LBBB after randomization indicates a 'true' ischaemic conduction damage, thus carrying an independent negative prognostic value due to the large percentage of myocardium involved. HERO-2 trial, showing prognostic differences between different clinical presentations, underlines the importance to be familiar with the mechanisms related to BBBs and with the prognostic implications of BBBs in the setting of an acute myocardial infarction.

Contemporary Trends and Age-Specific Sex Differences in Management and Outcome for Patients With ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Age- and sex-specific differences exist in the treatment and outcome of ST-elevation myocardial infarction (STEMI). We sought to describe age- and sex-matched contemporary trends of in-hospital management and outcome of patients with STEMI. METHODS AND RESULTS: We analyzed data from 5 Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive patients with STEMI. All the analyses were age- and sex-matched, considering 4 age classes: <55, 55 to 64, 65 to 74, and ≥75 years. A total of 13 235 patients were classified as having STEMI (72.1% men and 27.9% women). A progressive shift from thrombolysis to primary percutaneous coronary intervention occurred over time, with a concomitant increase in overall reperfusion rates (P for trend <0.0001), which was consistent across sex and age classes. The crude rates of in-hospital death were 3.2% in men and 8.4% in women (P<0.0001), with a significant increase over age classes for both sexes and a significant decrease over time for both sexes (all P for trend <0.01). On multivariable analysis, age (odds ratio 1.09, 95% CI 1.07-1.10, P<0.0001) and female sex (odds ratio 1.44, 95% CI 1.07-1.93, P=0.009) were found to be significantly associated with in-hospital mortality after adjustment for other risk factors, but no significant interaction between these 2 variables was observed (P for interaction=0.61). CONCLUSIONS: Despite a nationwide shift from thrombolytic therapy to primary percutaneous coronary intervention for STEMI affecting both sexes and all ages, women continue to experience higher in-hospital mortality than men, irrespective of age.

Clinical characteristics and outcome of diabetic patients with acute myocardial infarction. Data from the BLITZ-1 study.

BACKGROUND: The determinants of a worse outcome in diabetic patients after an acute myocardial infarction (AMI) are controversial. They include delayed hospital admission, worse clinical presentation and lesser efficacy of accepted therapeutic interventions. Therefore, to improve our knowledge, we aimed to describe the clinical characteristics, treatment options and short-term outcomes of diabetic patients in a survey of consecutive AMI subjects admitted to the Italian coronary care unit (CCU) network in the current era of reperfusion. METHODS: The BLITZ study prospectively enrolled patients with AMI, within 48 hours of symptom onset, admitted to 296 out of the 341 existing Italian CCUs from October 15 to 29, 2001. Diabetic status was recorded by collecting clinical history. In-hospital and post-discharge management and outcomes were collected up to 30 days from admission. RESULTS: Overall, 434 of 1959 enrolled patients (22%) had a clinical diagnosis of diabetes. Diabetic patients were older, more frequently women, had a worse coronary risk profile, and an unfavorable clinical presentation compared to non-diabetics. Among 1275 patients with ST-elevation AMI, diabetics (20%) received a similar proportion of any reperfusion therapy (61 vs 66%, p = 0.10), but significantly less primary percutaneous coronary angioplasty (9 vs 16%, p = 0.003). Diabetic patients were treated less often with oral beta-blockers than non-diabetics both during hospitalization (56 vs 64%, p = 0.003) and at discharge (54 vs 61%, p = 0.01). In contrast, in-hospital use of angiotensin-converting enzyme inhibitors (76 vs 67%, p = 0.0003), digitalis (10 vs 5%, p = 0.0005), and diuretics (54 vs 36%, p < 0.0001) was more frequent among diabetics. During their index admission, subjects with diabetes had higher in-hospital mortality (11 vs 6%, p = 0.0004), as well as higher rates of reinfarction (6 vs 2%, p = 0.0003), new congestive heart failure (28 vs 14%, p < 0.0001), cardiogenic shock (10 vs 5%, p = 0.0005) or recurrent angina (22 vs 16%, p = 0.0034). A similar pattern was observed at 30-day follow-up. At multivariate analysis, diabetic status was not confirmed to be an independent predictor of 30-day mortality. CONCLUSIONS: Although diabetic patients with AMI admitted to the Italian CCU network have a higher in-hospital and 30-day morbidity and mortality rates compared to non-diabetics, a clinical diagnosis of diabetes has no independent predictive value on short-term outcome.

Temporal trends in the epidemiology, management, and outcome of patients with cardiogenic shock complicating acute coronary syndromes.

AIMS: Despite advances in the management of patients with acute coronary syndrome (ACS), cardiogenic shock (CS) remains the leading cause of death in these patients. We describe the evolution of clinical characteristics, in-hospital management, and outcome of patients with CS complicating ACS. METHODS AND RESULTS: We analysed data from five Italian nationwide prospective registries, conducted between 2001 and 2014, including consecutive patients with ACS. Out of 28 217 ACS patients enrolled, 1209 (4.3%) had CS: 526 (44%) at the time of admission and 683 (56%) later on during hospitalization. Over the years, a reduction in the incidence of CS was observed, even though this was not statistically significant (P for trend = 0.17). The proportions of CS patients with a history of heart failure declined, whereas the proportion of those with hypertension, renal dysfunction, previous PCI, and AF significantly increased. The use of PCI considerably increased from 2001 to 2014 [19% to 60%; percentage change 41, 95% confidence interval (CI) 29-51]. In-hospital mortality of CS patients decreased from 68% (95% CI 59-76) in 2001 to 38% (95% CI 29-47) in 2014 (percentage change -30, 95% CI -41 to -18). Compared with 2001, the risk of death was significantly lower in all of the registries, with reductions in adjusted mortality between 45% and 66%. CONCLUSIONS: Over the last 14 years, substantial changes occurred in the clinical characteristics and management of patients with CS complicating ACS, with a greater use of PCI and a significant reduction in adjusted mortality rate.

Contrast echocardiographic evaluation of early changes in myocardial perfusion after recanalization therapy in anterior wall acute myocardial infarction and their relation with early contractile recovery.

Temporal changes in myocardial perfusion after recanalization and their relation with functional recovery in patients with acute myocardial infarction (AMI) using intravenous myocardial contrast echocardiography (MCE) have not yet been clarified. To address this issue, 19 patients with first, uncomplicated anterior wall AMI were studied using intravenous MCE within 24 hours of recanalization and before discharge. MCE was performed using harmonic power Doppler. Each asynergic left ventricular (LV) myocardial segment was scored for myocardial perfusion (1 = complete, 0.7 = patchy but >50%, 0.3 = patchy <50%, and 0 = absent) and a regional perfusion index was calculated within the dysfunctioning myocardium. During the day-1 study (11 +/- 2 hours from recanalization), the regional perfusion index was 0.4 +/- 0.3 and the LV wall motion score index was 1.9 +/- 0.2. During the study before discharge (7 +/- 4 days from admission), all but 2 patients showed an improvement of either perfusion index (0.6 +/- 0.3, p <0.0001) or wall motion score index (1.7 +/- 0.4, p <0.0001). Changes in perfusion score from 24-hours to before discharge showed a significant correlation with LV segment contractile recovery at 2-month of follow-up (R(2) = 0.42, 95% confidence interval 0.33 to 0.50, p <0.0001). Thus, our data show that after recanalized AMI, there is a significant amount of microvascular obstruction that recovers in the days after, and the extent of this perfusion improvement appears to be related with early myocardial contractile recovery. Our data provide clinical evidence for a transient microvascular dysfunction after successfully recanalized AMI.

[The RUTA project (Registro UTIC Triveneto ANMCO). An e-network for the coronary care units for acute myocardial infarction]. / Il progetto RUTA (Registro UTIC Triveneto ANMCO). Un registro informatico delle unità coronariche del Triveneto per l'infarto miocardico acuto.

In the era of evidence-based medicine, the monitoring of the adherence to the guidelines is fundamental, in order to verify the diagnostic and therapeutic processes. Informatic paperless databases allow a higher data quality, lower costs and timely analysis with overall advantages over the traditional surveys. The RUTA project (acronym of Triveneto Registry of ANMCO CCUs) was designed in 1999, aiming at creating an informatic network among the coronary care units of a large Italian region, for a permanent survey of patients admitted for acute myocardial infarction. Information ranges from the pre-hospital phase to discharge, including all relevant clinical and management variables. The database uses DBMS Personal Oracle and Power-Builder as user interface, on Windows platform. Anonymous data are sent to a central server.

[Myocardial infarction redefined based on the consensus document of the ESC/ACC]. / L'infarto miocardico ridefinito a proposito del documento di consenso dell'ESC/ACC.

An expert committee of the European Society of Cardiology and the American College of Cardiology has recently proposed new and more precise criteria for the diagnosis of myocardial infarction, entailing both relevant implications in clinical practice and scientific, epidemiological and organizational aspects. The Board of the Emergency Area of the National Association of Hospital Cardiologists (ANMCO) will review the document and analyze the issues of major concern.

Chronic aspirin and statin therapy in patients with impaired renal function and acute coronary syndromes: results from the IN-ACS Outcome Registry.

BACKGROUND: The cardioprotective role that statin and aspirin has appears to be reduced in patients with chronic kidney disease (CKD). This analysis aims to evaluate the impact of statin and aspirin on the outcome of patients with CKD and acute coronary syndrome (ACS). METHODS: All patients who were enrolled in the IN-ACS Outcome registry, diagnosed with CKD, were included in our analysis. We divided patients into four groups, according to previous chronic therapy: neither aspirin nor statin therapy (Group 1), aspirin only therapy (Group 2), statin only therapy (Group 3) and aspirin plus statin therapy (Group 4). RESULTS: Of the 5483 patients enrolled that had data on glomerular filtration rate available, 1484 had CKD: These segregated into 589 patients in Group 1, 477 in Group 2, 89 in Group 3 and 329 in Group 4. Despite having a higher baseline risk profile, groups 3 and 4, as compared to the other two groups, exhibited a significantly lower in-hospital mortality (1% in Group 3, 2% in Group 4; but 8% in Group 1 and 7% in Group 2, p = 0.0007); while at 30 days it remained so, as it was 1% in Group 3, 4% in Group 4 (and 10% in Group 1 and 10% in Group 2 p = 0.0002); and at 1 year it was 11% in Group 3 and 13% in Group 4 (compared to 20% in Group 1 and 23% in Group 2, p = 0.0012). CONCLUSIONS: In a large cohort of patients with CKD and ACS, chronic treatment with statin or the combination of aspirin and statin is associated with short-term and long-term better outcomes for in-hospital mortality, as compared to those receiving no therapy or aspirin therapy alone.

A decade of changes in clinical characteristics and management of elderly patients with non-ST elevation myocardial infarction admitted in Italian cardiac care units.

OBJECTIVE: To describe the evolution of clinical characteristics, in-hospital management and early outcome of elderly patients with non-ST elevation myocardial infarction (NSTEMI). METHODS: We analysed data from five consecutive Italian nationwide registries, conducted between 2001 and 2010, including patients with acute coronary syndromes admitted to cardiac care units (CCUs). RESULTS: Of 10 983 patients with NSTEMI enrolled in the 5 surveys, 4350 (39.6%) were ≥75 years old (mean age 81±5 years). Some clinical characteristics such as diabetes mellitus, hypertension, renal dysfunction and previous percutaneous coronary intervention increased significantly, whereas a history of stroke, myocardial infarction and heart failure decreased over time. An invasive approach increased from 26.6% in 2001 to 68.4% in 2010 (p<0.0001) and revascularisation rates increased from 9.9% to 51.7% (p<0.0001). Early use and prescription at discharge of ß-blockers, statins and dual antiplatelet treatment increased significantly (p<0.0001). Thirty-day observed mortality decreased from 14.6% (95% CI 9.9 to 20.4) to 9.5% (95% CI 7.7 to 11.6). At the multivariate logistic regression analyses adjusted for baseline characteristics, compared with 2001, the risk of death was significantly lower in all the other studies performed at different times with reductions in adjusted mortality between 66% and 45%. CONCLUSIONS: Over the past decade, substantial changes have occurred in the clinical characteristics and management of elderly patients admitted with NSTEMI in Italian CCUs, with a greater use of revascularisation therapy and recommended medications. These variations have been associated with a reduction in 30-day adjusted mortality rate.

Vitamin K antagonists in patients with nonvalvular atrial fibrillation: appropriateness and quality of treatment in an Italian cohort.

BACKGROUND: Vitamin K antagonists (VKA) are highly recommended in patients with atrial fibrillation for their efficacy in preventing stroke. However, there is a lack of data on oral anticoagulation (OAC) with VKA overall treatment (i.e. from writing the prescription to time spent in therapeutic range) in patients discharged from hospital with a diagnosis of atrial fibrillation. OBJECTIVE: The aim of this study was to assess the adherence to stroke prevention guidelines in a cohort of patients discharged with atrial fibrillation from the two hospitals of the Agency for Health Services no. 3 'Upper Friuli'. METHODS: All patients discharged from the hospitals with a diagnosis of nonvalvular atrial fibrillation during the year 2009 were enrolled in this study. Record linkage for the previous 5 years and pharmaceutical data were used to assess comorbid conditions (ICD9-CM) and to calculate congestive heart failure, hypertension, age at least 75 years, diabetes and stroke (CHADS2) scores. Prescription orders were obtained from discharge letters. Patients' adherence to VKA prescription was assessed through pharmacy records, and prothrombin/international normalized ratios (INR) for a period of 180 days after discharge from the whole 'Upper Friuli' laboratories. A patient was considered to have purchased VKA if at least one drug purchase was found in the pharmacy records. Time in therapeutic range (TTR) was calculated in patients who had at least two INR measurements. RESULTS: In 2009, 509 patients (mean age 80 ±â€Š8 years) were discharged with atrial fibrillation from 'Upper Friuli' hospitals (90% from internal medicine); of these, 284 patients (55.8%) had a CHADS2 score greater than 1 and no contraindications to VKA therapy at discharge. Within this subgroup, 112 patients (39.4%) received VKA prescription at discharge; of these, 84 (29.6%) purchased VKA and 58 patients had a TTR of at least 65% (20.4%). CONCLUSION: VKA prescription for atrial fibrillation patients is low and not explained by present or past comorbid condition. A second failure is represented by patients' low compliance. Overall, adherence to VKA guidelines in atrial fibrillation is scarce.