International Society for Extracellular Vesicles Workshop. QuantitatEVs: multiscale analyses, from bulk to single extracellular vesicle.

The 'QuantitatEVs: multiscale analyses, from bulk to single vesicle' workshop aimed to discuss quantitative strategies and harmonized wet and computational approaches toward the comprehensive analysis of extracellular vesicles (EVs) from bulk to single vesicle analyses with a special focus on emerging technologies. The workshop covered the key issues in the quantitative analysis of different EV-associated molecular components and EV biophysical features, which are considered the core of EV-associated biomarker discovery and validation for their clinical translation. The in-person-only workshop was held in Trento, Italy, from January 31st to February 2nd, 2023, and continued in Milan on February 3rd with "Next Generation EVs", a satellite event dedicated to early career researchers (ECR). This report summarizes the main topics and outcomes of the workshop.

The Italian MacNew heart disease health-related quality of life questionnaire: a validation study.

Patient-centered treatment outcomes such as health-related quality of life are recommended in clinical care and research studies. Health-related quality of life questionnaires need to be validated in the language of the target population. The reliability and validity of the Italian version of the MacNew Questionnaire was determined in patients with angina, myocardial infarction, or ischemic heart failure. Sociodemographic and clinical data were collected on 298 patients [angina, n = 88; MI, n = 106; heart failure, n = 104; mean age, 64.8 (±10.6) years] at three centers in Italy. MacNew mean scores were higher (p < 0.001) in patients with myocardial infarction than in patients with either angina or heart failure with no floor and minimal ceiling effects. The three-factor structure of the original MacNew form was largely confirmed explaining 54.6% of the total variance. The Italian MacNew version demonstrates high internal consistency reliability (Cronbach's α ≥ 0.86), confirms the convergent validity hypotheses with strong correlations on six of eight comparisons (r ≥ 0.86), partially confirms discriminative validity with the SF-36 health transition item, and fully confirms discriminative validity with the Hospital Anxiety and Depression Scale. The Italian version of the MacNew Questionnaire demonstrates satisfactory psychometric properties, and is reliable and valid in Italian-speaking patients with angina, MI, or heart failure. Responsiveness could not be tested due to the cross-sectional design of the parent study, and needs to be investigated in an intervention study.

Predictive value of cardiac troponin-I compared to creatine kinase-myocardial band for the assessment of infarct size as measured by cardiac magnetic resonance.

BACKGROUND: The estimation of infarct size by biochemical myocardial necrosis markers is used in current clinical practice, rather than the more expensive and not always available imaging techniques. However, for this purpose, the peak value of serum biomarkers can overestimate the necrotic area, especially after reperfusion. OBJECTIVE: We investigated whether late release cardiac troponin I (cTnI) values could predict more precisely infarct volume measured by delayed-enhancement cardiac magnetic resonance (DE-CMR) in patients with acute myocardial infarction [ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI)] independently of reperfusion (spontaneous and provoked). METHODS: Sixty patients with a first acute myocardial infarction (55 STEMI and five NSTEMI) and normal function were enrolled. Among STEMI patients, 52 underwent reperfusion. cTnI and creatine kinase-myocardial band were assessed at admission and at 6, 12, 24, 48, 72 and 96 h (+/-1 h) from symptom onset. DE-CMR (Siemens Avanto 1.5T) was performed before discharge (4 +/- 2 days). Infarct size was determined by manual delineation of the areas of delayed enhancement. Infarct volume was calculated as the sum of each slice of infarct size area multiplied by thickness. RESULTS: Peak cTnI was 55 +/- 59 ng/ml (range 0.3-347). The area under the curve of cTnI was 1916 +/- 2224 ng/ml. The volume of infarcted myocardium assessed by DE-CMR was 27 +/- 25 ml (range 0-134). The single value of cTnI at 72 h after symptom onset provided the most accurate estimation of predischarge infarct volume (r = 0.84, 95% confidence interval 0.75-0.91) and was significantly more accurate than creatine kinase-myocardial band value assessed at any time during the same period (r = 0.42, 95% confidence interval 0.19-0.62; P < 0.002). CONCLUSION: In patients with a first acute myocardial infarction, cTnI value assessed at 72 h from symptom onset shows the best correlation with predischarge infarct volume as assessed by DE-CMR and is superior to cTnI and creatine kinase-myocardial band peak and total values.

Clinical characteristics, management, and prognosis of octogenarians with acute heart failure admitted to cardiology wards: results from the Italian Survey on Acute Heart Failure.

BACKGROUND: Heart failure is the leading cause of hospitalization among the elderly. This study compares clinical characteristics, management, and prognosis of octogenarians (OLD) with younger (YOUNG) patients in the Italian Survey on Acute Heart Failure (AHF). METHODS: A nationwide, prospective, observational study on AHF was done. Two hundred six Italian departments with intensive cardiac care units enrolled 2,807 patients in 3 months. RESULTS: Octogenarians (mean age 84 +/- 4 years) represented 28% of enrollees. Females were 50% in the OLD group versus 36% in the YOUNG group (P < .0001). Risk factors such as obesity, diabetes, and smoking were more frequent in the YOUNG group. Comorbidities such as anemia and renal dysfunction were more common in the OLD group (64% vs 53%, P < .0001, and 56% vs 43%, P < .0001). More octogenarians were admitted with cardiogenic shock and pulmonary edema, whereas younger patients presented more frequently in New York Heart Association class III to IV (P = .002). Left ventricular ejection fraction was measured in 90% of octogenarians versus 93% of the younger ones and was preserved in 41% of the OLD group versus 31% of the YOUNG group (P < .0001). Coronary angiography was performed in 20% of the YOUNG group and 10% of the OLD group. In-hospital mortality was twice as high in the OLD group (11.8% vs 5.6%, P < .001). In multivariable analysis, the strongest predictors of this event were use of inotropic agents, advanced age (> or =80 years), and elevated troponin at admission. CONCLUSIONS: Octogenarians represent more than one fourth of the admissions for AHF and have a more severe clinical presentation. Their management is less aggressive, and treatments recommended by guidelines are underused. In-hospital mortality is high in the OLD group independently of left ventricular ejection fraction.

Improved workflow, sonographer productivity, and cost-effectiveness of echocardiographic service for inpatients by using miniaturized systems.

AIMS: The aim of this study was to assess the cost-effectiveness of using certified sonographers and miniaturized echocardiography systems to perform echocardiograms at bedside in comparison to moving inpatients from the admission department to the echocardiography laboratory (echo-lab). METHODS AND RESULTS: From 26 September 2005 to 27 October 2005, 112 patients admitted in six hospital wards connected through a 100 Mbit LAN to the echo-lab were scanned within the admission ward by sonographers using a miniaturized echo system. Logistical data were collected and results were compared with those obtained from 194 consecutive patients coming from the same wards and studied in the echo-lab with high-end machines between 8 March 2005 and 15 April 2005. Performing echocardiograms in the admission department avoided long waiting time of the inpatients in the echo-lab before and after the study, increased the percentage of patients studied within 3 and 5 days from request (88 vs. 77% and 100 vs. 95%, respectively; P = 0.03), increased both sonographer (by 33.9%; P < 0.001) and echo-lab productivity (by 41%; P < 0.001), and reduced costs of echocardiograms by 29%. CONCLUSION: Implementation of digital echocardiography, certified sonographers, and a miniaturized echo system allowed improvement of the cost-effectiveness of the service provided by the echo-lab for inpatients, and avoided patients' discomfort derived from prolonged waiting time before and after the exam.

Effect on quality of life of different accelerated diagnostic protocols for management of patients presenting to the emergency department with acute chest pain.

This study assessed the effects on quality of life (QoL) of dobutamine-atropine stress echocardiography (DASE) and electrocardiogram exercise testing (EET) accelerated diagnostic protocols for early stratification of low-risk patients with acute chest pain (ACP). A total of 290 patients with ACP, a nondiagnostic electrocardiogram, and negative biomarkers were randomly assigned to an accelerated diagnostic protocol (DASE, n = 110, or EET, n = 89) or usual care (n = 91) and followed up for 2 months. QoL was assessed at discharge and 2-month follow-up using the Nottingham Health Profile questionnaire. Baseline and 2-month follow-up answers to the Nottingham Health Profile questionnaire were available for 207 patients (71%; 55 in the usual-care, 77 in the DASE, and 75 in the ETT arm). At predischarge, patients in the usual-care arm reported higher impairment in the physical mobility and pain dimensions compared with the DASE and EET arms (p = 0.019 and p = 0.023, respectively). At 2-month follow-up, QoL improved in all groups; however, patients in the usual-care arm had significantly worse scores than patients managed using accelerated diagnostic protocols in the physical mobility, pain, social isolation, emotional reactions, and energy level dimensions (p = 0.014, p = 0.002, p = 0.04, p = 0.01, and p = 0.003, respectively). In conclusion, low-risk patients with ACP had non-negligible impairment of QoL in the acute phase. Emergency department ADPs with early DASE and EET reduced QoL impairment at both baseline and 2-month follow-up.

Impact of the main implantable cardioverter-defibrillator trials in clinical practice: data from the Italian ICD Registry for the years 2005-07.

AIMS: Several studies have demonstrated the life-saving role of implantable cardioverter-defibrillator (ICD) therapy. In order to evaluate the effects of major trials in clinical practice, we report the clinical data of patients enrolled in the Italian ICD Registry for the years 2005-07. METHODS AND RESULTS: The Registry collects prospectively national ICD implantation activity on the basis of EURID Card. The number of ICDs per million of inhabitants was 180.6 in the year 2005, 192.5 in the year 2006, and 220.6 in the year 2007 (P = 0.02). The median age was 69 years for all 3 years considered. Implantable cardioverter-defibrillator implantation for primary prevention concerned 4692 patients in 2005 (44.2%), 5938 patients in 2006 (52.2%), 7324 patients in 2007 (55.7%) and for secondary prevention 5921 patients in 2005 (55.8%), 5447 patients in 2006 (47.8%), and 5828 patients in 2007 (44.3%). Single-chamber ICDs were implanted in 30.9, 31.0, and 28.5% of patients, dual chamber ICDs in 31.9, 31.5, and 31.7%, and biventricular ICDs in 37.2, 37.5, and 39.8%, respectively. CONCLUSION: The ICD implantation rate in Italy increased significantly in the period 2005-07. The registry showed a significant increase in prophylactic and biventricular ICD use, reflecting a favourable adherence to trials and guidelines in the clinical practice.

Fast data acquisition and analysis with real time triplane echocardiography for the assessment of left ventricular size and function: a validation study.

AIMS: To assess accuracy and reproducibility of real time simultaneous triplane echocardiography (RT3PE) for the assessment of left ventricular (LV) volumes and ejection fraction (EF) using cardiac magnetic resonance (CMR) as a reference method. METHODS AND RESULTS: A total of 24 patients with various degrees of LV dysfunction (EF from 36 to 57%) in sinus rhythm with good image quality were enrolled in the study. Digital loops of apical views were recorded with standard two-dimensional imaging and with RT3PE. Echocardiography and CMR were performed within 1 hour. RT3PE measurements of LV end-diastolic volume, end-systolic volume, and EF resulted closely correlated to CMR (r = 0.95, 0.97, and 0.95, respectively) with small biases (-4 ml, -6 ml, and 1%, respectively) and narrow limits of agreement (SD = 15 ml, 12 ml, and 6%, respectively). Two-dimensional echocardiography (2DE) showed a weaker correlation with CMR (r = 0.85, 0.91, and 0.83, respectively; P < 0.06) with similar biases (-4 ml, -10 ml, 5%, respectively), but wider limits of agreement (SD = 28 ml, 21 ml, 10%, respectively, P < 0.007). RT3PE showed lower interobserver variability for the assessment of EF (SD = 2% vs. 5%, P = 0.03) and lower measurement time of LV EF (175 +/- 54 sec vs. 241 +/- 49 sec, respectively; P < 0.0001), as compared to 2DE. CONCLUSION: RT3PE allows simple and fast image acquisition and volume calculation. In addition, it allows more accurate and reproducible EF measurements than conventional 2DE.

Radiofrequency ablation of drug-refractory atrial fibrillation: an observational study comparing 'ablate and pace' with pulmonary vein isolation.

AIMS: To compare clinical characteristics, procedure complexity, acute and long-term outcome of 'ablate and pace' (A&P) with pulmonary vein isolation (PVI) in patients with drug-refractory atrial fibrillation (AF). So far, only few small studies have compared the two procedures. METHODS AND RESULTS: We analysed retrospectively a cohort of symptomatic consecutive patients with drug-refractory AF. Group 1 included 100 patients treated with A&P and Group 2 included 144 patients treated with PVI. Group 1 patients were older (74 +/- 8 vs. 56 +/- 9 years; P < 0.0001), had lower left ventricular ejection fraction (50 +/- 13% vs. 59 +/- 7%; P < 0.05), and a lower prevalence of paroxysmal AF (46% vs. 65%; P < 0.05). Acute success was not statistically different (98% vs. 92.3%, P = ns). Group 1 patients had shorter procedure time and lower radiation exposure with respect to Group 2 patients (70 +/- 15 vs. 204 +/- 58 min, and 8 +/- 4 vs. 57 +/- 22 min; P < 0.0001, respectively). After a median follow-up of 29 months (I, III quartile; 15, 40 months) vs. 25 months (I, III quartile; 8, 36 months) (P = ns), all the patients in Group 1 were free of symptomatic AF, while 113 patients (79%) of Group 2 were in stable sinus rhythm (P < 0.0001). Persistent or permanent AF has been documented in 58 patients (58%) of Group 1 vs. 11 (8%) of Group 2 (P < 0.0001). CONCLUSION: In this series (i) patients treated with A&P and PVI for drug-refractory AF showed significant differences in clinical profile; (ii) A&P is a shorter and less complex procedure, but is associated with a higher rate of persistent AF; (iii) symptomatic recurrences of paroxysmal AF were more frequent in PVI group. Randomized studies appear necessary to identify the best strategy in selected cases.

Transient left ventricular apical ballooning syndrome: a 4-year experience.

BACKGROUND: Transient left ventricular apical ballooning syndrome, primarily described in Japanese patients, has been recently recognized outside Japan also. Aim of this study is to elucidate incidence and clinical features of left ventricular apical ballooning syndrome in a tertiary-care hospital in northeastern Italy. METHODS AND RESULTS: From January 2002 to August 2006, 29 patients admitted for suspected acute coronary syndrome (25 women, mean age 64+/-12 years) fulfilled the Mayo Clinic Criteria of left ventricular apical ballooning syndrome. Twenty patients (69%) had an episode of emotional or physiologic stress preceding left ventricular apical ballooning syndrome. Fourteen patients (48%) had at least one risk factor for coronary artery disease. Chest pain was present at admission in 24 patients (83%). Twenty-five patients (86%) had ST-T segment abnormalities at ECG on admission. Four patients were treated with fibrinolytic therapy and one with glycoprotein IIb/IIIa inhibitors. At coronary angiography, 23 patients (79%) had no coronary lesions, 2 (7%) had small vessel occlusion and 4 (14%) had nonsignificant coronary stenosis. ECG changes and echocardiographic wall motion abnormalities completely regressed in all patients within 10 weeks. Neither death nor major complications occurred during in-hospital stay and after discharge. Two patients (7%) experienced a recurrence during follow-up. CONCLUSION: Left ventricular apical ballooning syndrome is a novel syndrome with a nonnegligible incidence, a clinical presentation mimicking acute myocardial infarction and a favorable outcome. The present data confirm a higher prevalence in women and the frequent association with emotional stress. The differential diagnosis with acute myocardial infarction at presentation is still puzzling, and only ECG findings in conjunction with echocardiography and coronary angiography are so far diagnostics.

How many patients would be misclassified using M-mode and two-dimensional estimates of left atrial size instead of left atrial volume? A three-dimensional echocardiographic study.

OBJECTIVES: Left atrial size has shown prognostic importance in a variety of cardiac conditions. Diameters, area, and volume derived from M-mode and two-dimensional (2D) echocardiography are commonly used to estimate left atrial size. However, M-mode and 2D measures of left atrial size rely on various geometrical assumptions and their accuracy remains to be determined. To address this issue, we compared M-mode and 2D parameters routinely used to estimate left atrial size with three-dimensional (3D) echo measured left atrial volume (LAV) as a reference standard. METHODS: We studied 104 patients (55% males, 62 +/- 15 years, range 10-87 years), presenting for a routine echocardiographic evaluation. RESULTS: The mean 3D LAV for the study population was 90 +/- 68 ml (range 24-458 ml). We found highly significant (P < 0.0001) correlations between 3D LAV and left atrial anterior-posterior (r = 0.78, 95% CI = 0.69-0.85), superior-inferior (r = 0.74, 95% CI = 0.63-0.81) and medial-lateral (r = 0.91, 95% CI = 0.86-0.93) diameters. A highly significant correlation was also found between 3D LAV and left atrial area (r = 0.94, 95% CI = 0.91-0.96). However, using M-mode anterior-posterior diameter or left atrial area would have misclassified 57% and 70% of our study patients, respectively, regarding the degree of left atrial dilatation. Closer correlations and narrower confidence intervals were found between 3D LAV and single-plane (r = 0.98; 95% CI = 0.94-0.97) and biplane (r = 0.97; 95% CI = 0.96-0.98) 2D LAVs. CONCLUSION: Left atrial diameters and area measurements were poor predictors of 3D LAV, especially in the enlarged left atria. Therefore, these parameters can be misleading in assessing the severity of left atrial dilatation. Two-dimensional LAVs are accurate in estimating 3D LAV. The small additional accuracy obtained by using the biplane instead of the single-plane area-length method, and the fact that the biplane method is more technically demanding and time consuming, may allow the use of the area-length for routine clinical use.

Congenital quadricuspid aortic valve associated with obstructive hypertrophic cardiomyopathy.

Quadricuspid aortic valve is a rare congenital abnormality; it is usually an isolated lesion, but several concomitant congenital abnormalities have been described. We report a case of congenital quadricuspid aortic valve associated with obstructive hypertrophic cardiomyopathy. Two-dimensional (2D) transthoracic and transesophageal echocardiography and real-time three-dimensional (3D) echocardiography clarified the morphological and functional status of the aortic valve. To our knowledge, the association between quadricuspid aortic valve and obstructive hypertrophic cardiomyopathy has never been described before.

American College of Cardiology/American Heart Association perioperative assessment guidelines for noncardiac surgery reduces cardiologic resource utilization preserving a favourable clinical outcome.

OBJECTIVES: The American College of Cardiology (ACC) and the American Heart Association (AHA) provided perioperative evaluation and management guidelines for assessing cardiac risk in noncardiac surgery. Even if previously validated as safe and effective in risk stratification, there is often a gap between clinical practice and the recommendations of the ACC/AHA guidelines. We evaluated the impact of strict application of ACC/AHA guidelines for cardiac risk assessment of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic. METHODS: One hundred and sixty-four consecutive patients who underwent elective vascular surgery after ACC/AHA guidelines implementation (from September 2004 to May 2005) were enrolled in the study and compared with a historical group of 166 patients operated from April 2002 to September 2002. Preoperative resources utilization (cardiologic consultations, non-invasive diagnostic tests, coronary angiograms, coronary revascularizations) and clinical events [all-cause death, acute myocardial infarction (AMI) and acute myocardial ischaemia] occurring within 30 days after surgical procedure were compared. RESULTS: Guidelines implementation reduced preoperative cardiologic consultations by 21% (P < 0.001) and preoperative non-invasive diagnostic testing by 11% (P = 0.01), and increased utilization of preoperative beta-blockers by 13% (P = 0.01). Preoperative coronary angiograms (2% versus 4%) and coronary revascularizations (3% versus 2%) and all-cause death (1% versus 2%), AMI (2% versus 1%) and acute myocardial ischaemia (4% versus 2%) during follow-up were similar in both groups. CONCLUSIONS: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic reduced preoperative resources utilization, improved medical treatment and preserved a low rate of perioperative cardiac complications.

Comparison of early dobutamine stress echocardiography and exercise electrocardiographic testing for management of patients presenting to the emergency department with chest pain.

This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.

Pulmonary embolism and fever: an indication for urgent echocardiography not reported in clinical guidelines?

We report the case of a 39-year-old woman who developed worsening dyspnea and abdominal pain 4 days after subtotal gastroresection. She underwent thoracic computed tomography scan and lung scintigraphy and was diagnosed with pulmonary embolism. Despite the fact that she was feverish, she was treated by the insertion of a vena cava filter and transferred to our Emergency Department. Twelve hours later, a beta-haemolytic Streptococcus agalactiae was reported to be growing in both bottles of blood cultures that had been taken. The patient underwent transthoracic two- and three-dimensional echocardiography, which showed a large pulmonary valve vegetation prolapsing into the main and right pulmonary artery during systole.

In-hospital outcome of patients with acute coronary syndrome: relationship with inflammation and remodeling markers.

OBJECTIVES AND METHODS: The present study was designed to evaluate the role of some inflammation [interleukin (IL)-1beta, soluble IL-1 receptor, IL-1 receptor antagonist (IL-1RA), high-sensitivity C-reactive protein (hsCRP) and fibrinogen], and remodeling markers [matrix metalloproteinase (MMP)-9, tissue inhibitor of metalloproteinase (TIMP)-1 and TIMP-2] in patients with acute coronary syndrome (ACS; 40 patients), or chronic stable angina (CSA; 40 patients) compared to age- and sex-matched healthy controls (20 subjects). RESULTS: IL-1RA, hsCRP, fibrinogen, MMP-9, and TIMP-1 plasma levels were significantly higher in patients than in controls, whereas soluble IL-1 receptor had an opposite pattern. Among patients with ACS, hsCRP plasma levels were higher in patients with non-ST segment elevation myocardial infarction (NSTEMI) than in those with unstable angina (UA). TIMP-1 plasma levels were higher in those patients with ACS who did not respond to medical therapy (non-responsive unstable angina; NR-UA). A CRP plasma level higher than 0.86 mg/dl had a 91% positive predictive value (PPV) and 63% negative predictive value for NSTEMI (odds ratio = 6.4, 95% confidence interval = 1.5-27.4). TIMP-1 plasma level higher than 21.5 ng/ml had a 100% PPV for patients with NR-UA or NSTEMI. Binary logistic analysis confirmed TIMP-1 levels as being able to predict responsiveness to therapy. CONCLUSIONS: In conclusion, a different biochemical pattern characterizes ACS patients: those with NR-UA show only an increase of remodeling markers, whereas ACS patients with NSTEMI have an increase of both remodeling and inflammation markers.

Unusual extension of an intracardiac primary lymphoma to the right jugular vein.

We report an unusual case of a 61-year-old woman with right atrial primary cardiac lymphoma extending into the right jugular vein through the superior vena cava. A transoesophageal echocardiographic study revealed the presence of a large mass occupying four fifths of the right atrial cavity and invading the superior vena cava, which appeared almost completely occluded. These findings were confirmed by computed tomography scan and magnetic resonance imaging. At autopsy, a large (7 x 3 cm) whitish ovoid mass with multiple nodules was found in the right atrium and superior vena cava. Histopathological examination revealed a monotonous population of lymphoid B-cells.

Infective endocarditis in chronic haemodialysis patients: an increasing clinical challenge.

Infective endocarditis (IE) in chronic haemodialysis (HD) is significantly more common and causes greater morbidity and mortality than in the general population, being second only to cardiovascular disease as the leading cause of death in this group of patients. Because of the peculiarity of this group of patients, it has been recently proposed to add a fifth category (health-care associated and HD-associated IE) in the actually four categories classification of IE (namely, native valve IE, prosthetic valve IE, IE in e.v. drug users, and nosocomial IE). Given that rates of acceptance into HD are increasing (including a higher proportion of older patients in whom valvular calcification is virtually ubiquitous), and along with improved survival in HD patients, the incidence of IE in this subset of patients will probably increase with significant diagnostic and therapeutic implications. In particular cardiac, diagnostic, echocardiographic, and surgical expertises are required to correctly identify patients at higher risk and who may benefit from surgical treatment. The aim of this review is to clarify the peculiar features of chronic HD patients with regard to pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE.

Are hospitalizations for percutaneous coronary procedures missed opportunities for teaching rules of secondary prevention?

BACKGROUND AND AIMS: Percutaneous coronary intervention (PCI) is the most frequently used revascularization approach, often repeatedly applied. The quest for the ultimate revascularization procedure however may capture cardiologist's attention and lead them to minimize the issue of secondary prevention in their patients. Aims of this study were to assess: 1. The individual risk factor profile, 2. The relation between the risk factors correction and the number of hospital admissions for elective procedures, 3. The appropriateness of medical treatment in patients admitted for elective coronary invasive procedures (diagnostic and interventional). 4. The patients knowledge of threshold values for cardiovascular risk factors. PATIENTS AND METHODS: 100 patients (71% males, mean age 68 years) consecutively admitted for elective coronary angiography or PCI. They underwent a classical risk factors assessment and were divided in three groups according to the number of admissions for coronary angiography and in two groups according to the number of PCIs. RESULTS: Fifty-seven% of patients had been previously admitted for invasive examination at least three times and 58% had already been treated with at least one PCI. Seventy-one% were treated with beta-blockers but only 25% of them received a dosage found effective in RCTs (randomized clinical trials). Sixty% were treated with ACE-inhibitors and 83% received the dosage found effective in RCTs. Fifty-two% were treated with statins and 95% received a dosage found effective in RCTs. Nine% were still active smokers. Fourty-nine% had a LDL cholesterol level above 100 mg/dL. The percentage of patients not on target was unrelated to the number of hospital admissions for invasive procedures. CONCLUSIONS: Modern cardiology is quickly embracing high tech procedures and trials results but often fails to spend enough time teaching how to control risk factors according to the recommendations of the evidence-based guidelines, even independently of the number of hospitalizations for invasive cardiovascular procedures.