[Clinical risk management: a new frontier for Italian Cardiology]. / La gestione del rischio clinico: una nuova frontiera per la Cardiologia italiana.

Patient safety is the moral and ethical responsibility of healthcare professionals, representing a constantly evolving field in industrialized countries whose key factors are sustainability, training and prevention. Clinical risk management is primarily concerned with systems issues, but people are of paramount importance to effective teamwork and leadership. Hospitals have recently been urged to adopt the methods of high-fidelity organizations to identify and change ineffective practice patterns: recognizing that little things that go wrong are early warning signs of trouble, near miss and errors become information about the health of systems and learn from them. Italian Cardiology will have to assume clinical risk as a common practice, through a rigorous examination of the causes of adverse events, staff training, sharing of validated adverse event analysis tools, identification of corrective actions and definition of shared procedures, the systematic control of the adoption of the planned interventions, the evaluation of the results of the measures implemented by applying stringency and scientific method in this area. The text tries to explain, in a pragmatic way, the main problems that hinder the diffusion of the culture of safety in Italian hospitals and in cardiology by proposing solutions.

[ANMCO Position paper: Cardiovascular disease in women - prevention, diagnosis, treatment and organization of care]. / Position paper ANMCO: Malattie cardiovascolari nella donna ­ prevenzione, diagnosi, terapia e organizzazione delle cure.

Cardiovascular diseases are still the main cause of death among women despite the improvements in treatment and prognosis achieved in the last 30 years of research. The determinant factors and causes have not been completely identified but the role of "gender" is now recognized. It is well known that women tend to develop cardiovascular disease at an older age than men, and have a high probability of manifesting atypical symptoms not often recognized. Other factors may also co-exist in women, which may favor the onset of specific cardiac diseases such as those with a sex-specific etiology (differential effects of estrogens, pregnancy pathologies, etc.) and those with a different gender expression of specific and prevalent risk factors, inflammatory and autoimmune diseases and cancer. Whether the gender differences observed in cardiovascular outcomes are influenced by real biological differences remains a matter of debate.This ANMCO position paper aims at providing the state of the research on this topic, with particular attention to the diagnostic aspects and to care organization.

[ANMCO Position paper: Care pathway for advanced heart failure patients candidate for heart transplantation/ventricular assist device]. / Position paper ANMCO: Percorso assistenziale del paziente con insufficienza cardiaca avanzata candidabile a trapianto/assistenza ventricolare meccanica.

Heart failure is a complex clinical syndrome with a severe prognosis, despite therapeutic progress. The management of the advanced stages of the syndrome is particularly complex in patients who are referred to palliative care as well as in those who are candidates for cardiac replacement therapy. For the latter group, a prompt recognition of the transition to the advanced stage as well as an early referral to the centers for cardiac replacement therapy are essential elements to ensure that patients follow the most appropriate diagnostic-therapeutic pathway. The aim of this document is to focus on the main diagnostic and therapeutic aspects related to the advanced stages of heart failure and, in particular, on the management of patients who are candidates for cardiac replacement therapy.

[Delirium in cardiology: an old problem, a new emergency]. / Il delirium in cardiologia: un vecchio problema, una nuova emergenza.

Delirium is a common cognitive behavioral disorder, with acute onset, frequent in elderly hospitalized patients. This condition has long been the subject of research in the critical area, with the development of targeted prevention and management protocols. In the cardiology field, however, awareness of delirium is poor. The problem of delirium has recently begun to involve practitioners since the publication of first studies showing the increase of adverse events in patients with this condition. The pathophysiology of delirium is unclear and the risk factors are based on clinical conditions and factors related to patient's care itself that need to be readily identified. Thus, delirium is a clinical manifestation that can easily be confused with other conditions. Notwithstanding, delirium can be prevented and treated when clinically evident, with a number of non-pharmacological interventions based on a multidisciplinary approach. Pharmacological therapy, due to its unclear effectiveness, should be reserved to patients with severe agitation or at risk of injuring themselves and others. The purpose of this review is to increase the awareness in healthcare professionals about the recent data on etiology, prevention, treatment and prognosis of delirium and to put the basis for a protocol that could be used in Cardiology departments.

Fast cardiologist-administered midazolam for electrical cardioversion of atrial fibrillation.

AIM: To evaluate the safety and the feasibility of sedation administered by cardiologists with rapid intravenous bolus of midazolam followed by flumazenil infusion during transthoracic biphasic electrical cardioversion (TEC) for atrial fibrillation (AF). METHODS: Two hundred and sixty-five consecutive patients (119 females, mean age 67.4 +/- 8.5 years) with either acute (24 patients) or persistent AF (mean arrhythmia duration 3.7 +/- 3.0 months) underwent TEC. Midazolam (0.05 mg/kg) was administered as rapid intravenous bolus by the cardiologist, whereas the anaesthesiologist was simply alerted. At the end of the procedure, intravenous flumazenil 0.25 mg was given, followed by 0.25 mg over 1 h. Patients received continuous electrocardiographic and pulse-oxymetric monitoring. RESULTS: Adequate sedation was obtained in 262 patients (98.9%), with a mean midazolam dose of 4.4 +/- 0.9 mg. After drug administration, the mean time to patient's sedation and reawakening were 3.1 +/- 1.9 and 6.1 +/- 2.7 min, respectively. The mean reduction in oxygen saturation was 5.4 +/- 3.7%. Sinus rhythm was restored in 254 patients (95.8%). All but 41 patients (15.5%) were completely amnesic. None reported pain. No adverse events were registered. No urgent call for the anaesthesiologist was made. CONCLUSIONS: Conscious sedation with fast-administered midazolam followed by flumazenil for cardioversion of atrial fibrillation is safe, effective and well tolerated, easing the procedure and shortening its duration.