Polypill Strategy in Secondary Cardiovascular Prevention.

BACKGROUND: A polypill that includes key medications associated with improved outcomes (aspirin, angiotensin-converting-enzyme [ACE] inhibitor, and statin) has been proposed as a simple approach to the secondary prevention of cardiovascular death and complications after myocardial infarction. METHODS: In this phase 3, randomized, controlled clinical trial, we assigned patients with myocardial infarction within the previous 6 months to a polypill-based strategy or usual care. The polypill treatment consisted of aspirin (100 mg), ramipril (2.5, 5, or 10 mg), and atorvastatin (20 or 40 mg). The primary composite outcome was cardiovascular death, nonfatal type 1 myocardial infarction, nonfatal ischemic stroke, or urgent revascularization. The key secondary end point was a composite of cardiovascular death, nonfatal type 1 myocardial infarction, or nonfatal ischemic stroke. RESULTS: A total of 2499 patients underwent randomization and were followed for a median of 36 months. A primary-outcome event occurred in 118 of 1237 patients (9.5%) in the polypill group and in 156 of 1229 (12.7%) in the usual-care group (hazard ratio, 0.76; 95% confidence interval [CI], 0.60 to 0.96; P = 0.02). A key secondary-outcome event occurred in 101 patients (8.2%) in the polypill group and in 144 (11.7%) in the usual-care group (hazard ratio, 0.70; 95% CI, 0.54 to 0.90; P = 0.005). The results were consistent across prespecified subgroups. Medication adherence as reported by the patients was higher in the polypill group than in the usual-care group. Adverse events were similar between groups. CONCLUSIONS: Treatment with a polypill containing aspirin, ramipril, and atorvastatin within 6 months after myocardial infarction resulted in a significantly lower risk of major adverse cardiovascular events than usual care. (Funded by the European Union Horizon 2020; SECURE ClinicalTrials.gov number, NCT02596126; EudraCT number, 2015-002868-17.).

Emerging clinical setting of direct oral anticoagulants: atherothrombotic events prevention.

: Despite substantial progress in the treatment of atherosclerotic disease a non-negligible rate of acute atherothrombotic events persists. Evidence suggesting a safer profile of direct oral anticoagulants (DOACs) compared with vitamin K antagonists and the involvement of coagulation in the atherosclerotic process has led to exploration of the role of DOACs in the prevention of atherothrombotic events. In this review, we discuss the findings of recent studies on DOACs, particularly rivaroxaban, in atherothrombotic disease which represents a new clinical setting for oral anticoagulants.

Update on cardiac implantable electronic devices: from the injectable loop recorder to the leadless pacemaker, to the subcutaneous defibrillator.

A very fast-paced improvement of technology in the field of cardiac implantable devices has been observed in the last ten years. The aim of this review is to highlight the most important innovations which have been recently introduced in this field, such as the leadless pacemaker (a heart stimulator without intracardiac leads), the subcutaneous defibrillator (a completely extracardiac defibrillator device), the injectable loop recorder (a miniaturized subcutaneous continuous echocardiographic monitor provided by alarms and telephonic transmission) and many other new devices which will completely change the clinical practice in this field over the next decade.

A handbook for the clinical cardiologist about CRT/ICD. A practical guide about how to survive during an on call shift.

Cardiac resynchronization therapies (CRTs) have been demonstrated to improve the clinical management and prognosis of selected patients with heart failure. CRT devices include both CRT pacemakers (CRT-P) and CRT defibrillators (CRT-D), with the latter being used to treat life-threatening ventricular arrhythmias. A significant advantage of CRTs is the ability to monitor several vital parameters which, thanks to advanced technology, may be remotely assessed. Personalized programming options allow patients to receive the maximum benefit from these treatments. In this review we report the main diagnostic and therapeutic algorithms used in clinical practice.

Cardiac imaging in patients with cardiac syncope.

Syncope is a common symptom with a possibly unfavorable prognosis, especially when the cause is a cardiac disease. Often diagnostic workup requires multiple and challenging investigations to determine whether the patient has a structural heart disease. Cardiac imaging tests should be used when baseline clinical findings raise the suspicion of a cardiac syncope. Transthoracic echocardiography is the first line imaging examination as it helps establish the cause of syncope and supplies useful information for prognostic stratification by evaluating systolic ventricle function. Advanced imaging techniques such as multidetector computed tomography and cardiac magnetic resonance imaging should be reserved for selected cases when echocardiography is inconclusive. With this review we aim to report the main information obtainable with cardiac imaging tests in patients with suspected or known cardiac syncope. We summarize the most common as well as rarer heart structural diseases which may cause syncope and briefly state the possible physio-pathologic mechanism. For each heart disease we describe the role of the various imaging techniques and the possible diagnostic and prognostic information provided by these techniques.

Natriuretic peptides in acute chest pain and acute coronary syndrome: from pathophysiology to clinical and prognostic applications.

BACKGROUND: Plasma levels of natriuretic peptides (NPs) appear to have an important prognostic value in many clinical settings including coronary artery disease and provide additional information about cardiovascular risk. CONTENT: The aim of this study was to review the literature on the role of NPs in the prognosis and management of patients with acute chest pain and acute coronary syndrome (ACS). Several trials have assessed the prognostic value of NPs as biomarkers of myocardial injury for risk stratification in patients with acute chest pain and ACS. The additional prognostic information on measurement of NP levels is independent of that provided by cardiac troponin and the various clinical and ECG features and traditional risk markers available at hospital admission. CONCLUSION: Although measurement of the level of NPs is not recommended as a diagnostic tool in ACS management, their concentrations seem to distinguish patients at a higher risk not only for heart failure but also for ACS. NPs are a good risk marker for ACS, in addition to troponins, but have not yet been proved suitable for guiding therapy.