Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'.

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

[Gender discrepancy: time to implement gender-based clinical management]. / Position paper ANMCO: Differenze di genere nell'approccio farmacologico cardiovascolare.

It is well established that gender strongly influences cardiovascular risk factors, playing a crucial role in cardiovascular prevention, clinical pathways, diagnostic approach and treatment. Beyond the sex, which is a biological factor, gender entails a socio-cultural condition that impacts access and quality of care due to structural and institutional barriers. However, despite its great importance, this issue has not been adequately covered. Indeed sex and gender differences scarcely impact the clinical approach, creating a lot of disparities in care and outcomes of patients. Therefore, it becomes essential to increase the awareness of the importance of sex and gender influences on cardiovascular diseases. Moreover, new strategies for reducing disparities should be developed. Importantly, these differences should be taken into account in guideline recommendations. In this regard, it is crucial to include a greater number of women in clinical trials, since they are currently underrepresented. Furthermore, more women should be involved as member of international boards in order to develop recommendations and guidelines with more attention to this important topic.The aim of this ANMCO position paper is to shed light on gender differences concerning many cardiovascular drugs in order to encourage a more personalized therapeutic approach.

[ANMCO Position paper: Ionizing radiation exposure and radioprotection in the cath-lab]. / Position paper ANMCO: Radioesposizione e radioprotezione nei laboratori di cardiologia interventistica.

In the last decades, because of the improvements in the percutaneous treatment of coronary heart disease, valvular heart disease, congenital heart defects, and the increasing number of cardiac resynchronization therapy and cardioverter-defibrillator implantations, the interventional cardiologists' radio-exposure has importantly risen, causing concerns for ionizing radiation-associated diseases such as cancer and neurodegenerative disorders. Consequently, the radiation exposure issue importantly affects operators' safety. However, our knowledge of this field is poor and most operators are unaware to be at risk, especially because of the absence of effective preventive measures. The aim of this ANMCO position paper is to improve the awareness of operators and identify new ways of reducing operator ionizing radiation dose and minimizing the risk.

[ANMCO Position paper: Choosing Wisely - ANMCO proposals for 2023]. / Position paper ANMCO: Choosing Wisely ­ le proposte dell'ANMCO nel 2023.

Nowadays, a progressive and exponential increase in the use of invasive and non-invasive instrumental diagnostics and therapeutic services has been shown. Although unnecessary, instrumental examinations are often largely prescribed, replacing clinical evaluation. Their correct use, on the contrary, would address precise epidemiological and clinical contexts. Therefore identifying whether a test or procedure is appropriate or not plays a crucial role in clinical practice. Several documents from scientific societies and expert groups indicate the most appropriate cardiovascular diagnostic and therapeutic procedures. The international Choosing Wisely campaign invited the main scientific societies to identify five techniques or treatments used in their field that are often unnecessary and may potentially damage patients. The Italian Association of Hospital Cardiologists (ANMCO) joined the project identifying the five cardiological practices in our country at greater risk of inappropriateness in 2014. This list has recently been updated. Moreover, possible solutions to this problem have been proposed.

[Appropriateness of the request for preoperative cardiological evaluation in non-cardiac surgery: 8-year experience in a high-volume cardiological center]. / Appropriatezza della richiesta di consulenza cardiologica preoperatoria nella chirurgia non cardiaca: esperienza di 8 anni di un centro cardiologico ad alto volume di attività.

BACKGROUND: In the last decades the population undergoing non-cardiac surgery has become more numerous and complex. Cardiovascular perioperative complications represent at least one third of the perioperative deaths. Despite the pivotal role of the cardiologist in the perioperative management, current guidelines are often hardly useful in different settings of clinical practice. Local clinical protocols contribute to fill these gaps, to define the role of each specialist in the perioperative context and to achieve the best medical outcome. METHODS: This single-center retrospective study analyzes the background of 33 463 preoperatory cardiologic visits, the adherence to scientific evidence in our institute and the impact of the implementation of a shared clinical protocol (CP) in terms of reduction of inappropriate requests of cardiological evaluations. RESULTS: Among all the patients, the mean age was 59 ± 18 years, 52.8% were male. Hypertension was the most prevalent disease followed by diabetes, chronic coronary syndrome and atrial fibrillation. The "low-risk surgery" category was the most represented (56.2%) and the vast majority of patients (70.1%) was totally free from predictors of perioperative cardiovascular events. After the introduction of the CP, the number of inappropriate evaluations decreased by 32%, mainly in the low-risk category. However, despite the overall reduction, almost two thirds of the evaluations were still deemed inappropriate according to the CP, mostly (82.9%) in the low-risk category and to a lesser degree (55%) in the moderate/high-risk category. CONCLUSIONS: The inappropriate use of the resources resulted in disappointing organizational performance, poor assistance quality and a huge number of inappropriate preoperatory evaluations. The implementation of a CP, developed on the basis of the local needs, is a useful tool to enhance the organizational standards for the cardiological evaluation of patients undergoing non-cardiac surgery. Regular verifications, a widespread knowledge of the guidelines and a more efficient system of management and surveillance may improve the appropriateness of these evaluations.

Preoperative assessment of cardiovascular risk in patients undergoing noncardiac surgery: the Orion study.

In patients undergoing noncardiac surgery risk indices can estimate patients' perioperative risk of major cardiovascular complications. The indexes currently in use were derived from observational studies that are now outdated with respect to the current clinical context. We undertook a prospective, observational, cohort study to derive, validate, and compare a new risk index with established risk indices. We evaluated 7335 patients (mean age 63±13 years) who underwent noncardiac surgery. Based on prospective data analysis of 4600 patients (derivation cohort) we developed an Updated Cardiac Risk Score (UCRS), and validated the risk score on 2735 patients (validation cohort). Four variables (i.e. the UCRS) were significantly associated with the risk of a major perioperative cardiovascular events: high-risk surgery, preoperative estimate glomerular filtration rate <30 ml/min/1.73 m2, age ≥75 years, and history of heart failure. Based on the UCRS we created risk classes 1,2,3 and 4 and their corresponding 30-day risk of a major cardiovascular complication was 0.8% [95% confidence interval (CI) 0.5-1.7], 2.5 (95% CI 1.6-5.6), 8.7 (95% CI 5.2-18.9) and 27.2 (95% CI 11.8-50.3), respectively. No significant differences were found between the derivation and validation cohorts. Receiver operating characteristic (ROC) curves demonstrate a high predictive performance of the new index, with greater power to discriminate between the various classes of risk than the indexes currently used. The high predictive performance and simplicity of the UCRS make it suitable for wide-scale use in preoperative cardiac risk assessment of patients undergoing noncardiac surgery.

[Evaluation of cardiovascular risk and perioperative management of patients undergoing noncardiac surgery. Results of an ANMCO web survey]. / Valutazione del rischio cardiovascolare e della gestione perioperatoria del paziente candidato a chirurgia non cardiaca. I risultati della web survey ANMCO.

BACKGROUND: Cardiovascular risk stratification and perioperative management of subjects undergoing non-cardiac surgery have recently been updated in the 2014 European Society of Cardiology guidelines. Nevertheless, and notwithstanding the epidemiological relevance of this condition, an underevaluation of the importance of perioperative risk stratification is a common feeling. METHODS: The ANMCO Cardiovascular Prevention Area organized, last year, a web-based survey with 15 questions to investigate perioperative management and care pathways in non-cardiac surgery and to evaluate guideline adherence of Italian cardiologists. Participation in the survey was anonymous. RESULTS: Respondents had a homogeneous geographical, as well as working (coronary care unit, post-intensive care unit, ambulatory service) distribution. Among respondents, 38% evaluated more than 20 patients each month, and 25% more than 20 patients aged >75 years. Local diagnostic guidelines were available according to 60% of respondents. Despite guideline recommendations, cardiological evaluation preceded the anesthesiologic one according to 36% of respondents, and 42% reported that it was performed independent of baseline risk. In addition, perioperative use of risk scores was low (1%), and functional capacity was reported from only 56% of respondents. Half of them used bridge therapy with heparin after stopping direct oral anticoagulants. CONCLUSIONS: The results of the ANMCO web-based survey confirm the need to promote educational programs on risk stratification and to raise awareness of Italian cardiologists on this matter in order to improve guideline adherence.

Treatment of heart failure in the elderly: Which drugs are essential and which should be avoided.

With improved health care and with population aging, heart failure (HF) has become a common disease among the elderly and is one of the principal causes of mortality in elderly age. But the pharmacological management of HF in the elderly has still not yet been defined, as the clinical context is complicated by comorbidities, and differs from that of younger adults. In general, elderly patients with HF should be treated according to current guideline recommendations, for which ACE-I, beta-blockers and anti-aldosterones constitute the cornerstone of therapy. Interesting prospects are opening up with the use of new drugs such as neprilysin inhibitors, which appear to reproduce in the elderly the positive effects observed in the young adult population, and ivabradine, which may substitute the traditional use (now probably obsolete) of digitalis. Currently, however, treatment of HF in elderly patients is characterized by insufficient drug titration and by a habitual underuse of the recommended therapies - this is partly due to prescription inertia and in part to the negative effect of polypharmacotherapy on patient adherence. Even if HF therapy is similar in older and younger patients, the presence in older patients of more comorbidities, and frailty, functional status, and socio-environmental factors related to aging require a multidisciplinary approach to care and, above all, an additional assessment aimed at personalizing the treatment.

New assessment for advanced age: Italian study protocol on the assessment of surgical risk in the over-75-year age-group.

The role of age in the risk stratification of patients candidate for non-cardiac surgery is still today an unresolved issue. European guidelines, in contrast to American guidelines, do not attribute to age an independent role in increasing the risk, and the indices for assessment of perioperative cardiovascular risk are based on studies that were carried out on middle-aged subgroups of the population without specific attention to the elderly patient. While the indices of geriatric assessment have still not yet gained a standardized role in the risk stratification of patients candidate to non-cardiac surgery, their need is becoming increasingly urgent considering the epidemiological impact of elderly patients with multi-comorbidities who more and more in the future will undergo such interventions. The European guidelines themselves identify an "evidence gap" concerning frailty which requires a deeper evaluation. The aim of the multicenter observational study VALUTA-75 is to verify if the indices of risk stratification routinely used by the cardiologist integrated with those of physical and cognitive performance of specific geriatric pertinence can improve the ability to predict perioperative cardiovascular and non cardiovascular events, with the scope of improving the therapeutic process.

Antiplatelet therapy and outcome in patients undergoing surgery following coronary stenting: Results of the surgery after stenting registry.

OBJECTIVES: The aim of the present study was to define the feasibility and clinical impact of complying with national consensus recommendations on perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and noncardiac surgery. BACKGROUND: There are limited evidence-based recommendations on the perioperative management of antiplatelet therapy in stented patients undergoing surgery. METHODS: The recommendations provided by the national consensus document were applied in a multicenter, prospective registry of consecutive patients with prior coronary stenting undergoing any type of surgery at 19 hospitals in Italy. The primary end-point was in-hospital net adverse clinical events (NACE) represented by the composite of all-cause death, myocardial infarction, probable/definite stent thrombosis and Bleeding Academic Research Consortium (BARC) grade ≥3 bleeding. Patients were followed for 30 days. RESULTS: A total of 1,082 patients were enrolled. Adherence to consensus recommendations occurred in 85% of the cases. Perioperative aspirin and dual antiplatelet therapy were maintained in 69.7 and 10.5% of the cases, respectively. In-hospital NACE rate was 12.7%, being significantly higher in patients undergoing cardiac surgery (36.3% vs. 7.3%, P < 0.01), mainly due to BARC 3 bleeding events (32.3%). At 30 days, MACE rates were similar (3.5% vs. 3.5%, P = NS) in patients undergoing cardiac and noncardiac surgery, whereas BARC ≥3 bleeding events were significantly higher with cardiac surgery (36.3% vs. 5.6%, P < 0.01). CONCLUSIONS: The results of this registry demonstrate the safety and feasibility of applying a national consensus document on the perioperative management of antiplatelet therapy in stented patients undergoing surgery. © 2016 Wiley Periodicals, Inc.

Invasive strategy in non-ST-segment elevation acute coronary syndrome: What should be the benchmark target in the real world patients? Insights from BLITZ-4 Quality Campaign.

AIMS: To define a benchmark target for an invasive strategy (IS) rate appropriate for performance assessment in intermediate-to-high risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS). METHODS AND RESULTS: During the BLITZ-4 campaign, which aimed at improving the quality of care in 163 Italian coronary care units, 4923/5786 (85.1%) of consecutive patients admitted with NSTE-ACS with troponin elevation and/or dynamic ST-T changes on the electrocardiogram were managed with IS. The reasons driving the choice (RDC) for a conservative strategy (CS) in the remaining 863 patients were prospectively recorded. In 33.8%, CS was mandatory because of patients refusal, known coronary anatomy or death before coronary angiography; in 52.8% it was clinically justified because of active stroke, bleeding, advanced frailty, severe comorbidities, contraindication to antiplatelet therapy or because they were considered to be at low risk; only in 13.4% the reasons, such as renal failure, advanced age or other, were less stringent. As compared to patients undergoing IS, those in the CS were 12years older and had significantly more severe comorbidities. The in-hospital and 6-month all-cause mortality were 9.0% vs 0.9% and 22.0% vs 3.9% in CS and IS groups respectively (p<0.0001 for both). CONCLUSION: As the RDC for CS were clinically correct in vast majority of cases the observed 85% invasive strategy rate may be considered as the desirable benchmark target in patients with NSTE-ACS. For the same reason, it remains questionable if the higher rate of IS could have improved the prognosis in CS patients, despite their highly unfavorable prognosis.

[The network for acute coronary syndromes in the metropolitan area of Cagliari (Italy): management of ST-elevation myocardial infarction, reperfusion time, and adherence to guidelines]. / La rete per l'emergenza coronarica nell'Area Vasta di Cagliari: gestione dell'infarto miocardico acuto con sopraslivellamento del tratto ST, analisi dei tempi di riperfusione e aderenza alle linee guida.

BACKGROUND: An integrated network for the management of acute ST-elevation myocardial infarction (STEMI) allows a pre-hospital diagnosis and facilitates the best strategy to provide the most effective reperfusion therapy. This study aims to assess the network impact on timing and mode of reperfusion in the metropolitan area of Cagliari. METHODS: From January 1, 2008 to December 31, 2010 all patients affected by STEMI with symptom onset <12h were enrolled. We evaluated modality of hospital access, reperfusion therapies, and time for avoidable delay. The first medical contact-to-balloon time (FMC-to-balloon) was compared between patients without ECG transmission (No-ECG group) and those with ECG transmission and direct transport to the cath-lab (Cath-Lab-ECG group) or the emergency room/intensive cardiac care unit (ER/ICCU-ECG group). RESULTS: Out of 622 patients enrolled, 324 (52.1%) arrived to hospital by emergency medical systems. In this group a pre-hospital diagnosis was made in 79.3% of cases (n = 257); among them, 138 patients (53.7%) had a direct access to cath-lab, 99 to ICCU (38.5%), and 20 (7.8%) to ER. In the whole study population an urgent coronary angiography was performed in 612 patients (98.4%) and a primary percutaneous coronary intervention (p-PCI) in 589 (96.2%). In the Cath-Lab-ECG group the FMC-to-balloon was 89 ± 29 min (median 87 min, interquartile range 72-100), significantly lower than in the ER/ICCU-ECG group [122 ± 39 min (115 min)] and the No-ECG group [150 ± 54 min (139 min)] (p<0.01). A FMC-to-balloon ≤90 min was achieved in 66.4% of Cath-Lab-ECG patients, 22.1% of ER/ICCU-ECG patients, and 8.3% of No-ECG patients (Cath-Lab-ECG vs ER/ICCU-ECG, p<0.01). CONCLUSIONS: Our results show that an integrated network provides a pre-hospital diagnosis in the majority of STEMI. However, only a direct transport to the cath-lab allows to achieve a FMC-to-balloon ≤90 min in a large proportion of patients. Out of this condition, adherence to guideline-recommended time of ≤90 min is significantly lower.