Concomitant screening of coronary artery disease and lung cancer with a new ultrafast-low-dose Computed Tomography protocol: A pilot randomised trial.

We performed a pilot randomised study to assess the feasibility and radiation exposure of a new computed tomography (CT) protocol that allows screening of both coronary artery disease (CAD) and lung cancer. Current or former heavy smokers at high lung cancer risk with indication to cardiac CT for suspected or known CAD were randomised to undergo concomitant CT evaluation of either cardiac or thoracic area or cardiac CT only. Out of 129 subjects deemed eligible for the study, 110 agreed to participate and were randomised to simultaneous cardiac and lung CT (Gr.A; n = 55) or cardiac CT only (Gr.B; n = 55). The feasibility (i.e. adequate visualization of coronary artery segments) was noninferior with simultaneous cardiac and lung CT compared with the standard cardiac CT (870 of 889 segments [97%] in Gr.A vs 878/890 segments [99%] in Gr.B; mean difference 2.0% [90% confidence interval: -0.3% to 4.1%]). The safety (i.e. effective radiation dose) of the concomitant cardiac and lung CT protocol was noninferior to the standard cardiac CT (1.5 [95% confidence intervals: 1.2-1.7] vs. 1.4 [95% confidence intervals: 1.1-1.6] mSv; mean difference 0.1 mSv [90% confidence interval: -0.2 to 0.3 mSv]). In the two groups, a total of 25 significant (>70%) coronary stenoses were found at cardiac CT (9/55 cases of Gr.A vs 11/55 cases of Gr.B). Pulmonary nodules >2 mm were detected in 7 of the 55 Gr.A subjects. This pilot randomised study shows that concomitant CAD and lung cancer screening by means of a new CT protocol is both feasible and safe, thus allowing a comprehensive evaluation of both cardiac and thoracic regions during one CT scanning only. (ClinicalTrials.gov Identifier: NCT03727958).

Risk Factors for Ischemic Heart Disease.

BACKGROUND: Several risk factors have been empirically linked to an increased risk of cardiovascular disease. Some of them are therapeutically amenable to modification; while others are not. Modifiable risk factors include physical inactivity, tobacco use, diet, "bad fats" in the blood, hypertension, and being overweight; while non-modifiable risk factors include the patient's family history, the presence versus absence of diabetes mellitus, and demographic characteristics like age, gender, ethnicity, and socio-economic status. METHODS: In this article, we review those risk factors that are both clinically important and amenable to change. CONCLUSION: To prevent cardiovascular disease, it is important to minimize modifiable risk factors, like LDL cholesterol.

Clinical effects of routine postdilatation of drug-eluting stents.

OBJECTIVES: To assess the clinical effects of postdilatation of drug-eluting stents (DES). BACKGROUND: Subotpimal stent expansion occurs after DES deployment. Postidlatation may improve DES expansion, but it is unclear whether postdilatation may also improve clinical outcomes. METHODS: Since July 2009, we adopted a strategy of routine postdilatation with noncompliant balloons of all DES, while previously postdilatation was performed only for suboptimal results. The first 279 consecutive patients (age 62 ± 9 years, 231 men) who underwent routine postilatation were compared with 262 patients (age 61 ± 9 years, 220 men) who received DES in the previous 6 months (standard treatment). RESULTS: The two groups were similar for age, sex, clinical presentation, and main risk factors, including incidence of diabetes. Routine postdilatation resulted in an improved minimal lumen diameter at the end of the procedure (2.60 ± 0.34 vs. 2.51 ± 0.37 mm, P = 0.003). At 12-month follow-up incidence of MACE (including periprocedural myocardial infarction) was 19.5% in the standard treatment group and 12.5% in routine postdilatation group (P = 0.04), with a significant difference in target vessel revascularization (10.7% vs. 5.4%, P = 0.03), while incidence of myocardial infarction was not significantly different between the two groups (10.7% vs. 9.3%, P = 0.70). Stent thrombosis (definite or probable) occurred in 3 patients in standard treatment group, while no case of stent thrombosis occurred among patients treated with routine postdilatation (1.1% vs. 0%, P = 0.11). CONCLUSIONS: Our results suggest that a strategy of routine postdilatation with non compliant balloons may improve clinical outcomes of DES.

Optimization of the atrioventricular delay in sequential and biventricular pacing: physiological bases, critical review, and new purposes.

Atrioventricular (AV) delay optimization in sequential and biventricular (BiV) pacing, although widely recommended, is often poorly performed in clinical practice as an improper setting can reduce the success of the stimulation. Despite the several methods proposed, the AV delay is frequently programmed in an empirical way or left to a predefined value (usually the manufacturer's setting), without considering the different variables involved in this context, concerning the intra- and interindividual variability of the electromechanical events, the peculiarities of the several cardiopathies, the spontaneous interatrial and AV conduction, the pharmacological therapy, and the pacing mode. The manuscript illustrates the physiological bases of the optimization, describes why and how to programme the best AV delay at rest and during daily activities and discusses critically all methods proposed, divided into three groups: predefined formulas, iterative attempts, and automatic settings. The manuscript is not only a review because it tries to clarify this complex topic, stating the fundamental concept in BiV pacing; the optimal AV delay should be short enough to have always a pre-exitated stimulation and contemporary an optimal left ventricular filling. The paper suggests new purposes and new solutions for this goal, it shows the limits of the actual guidelines and the disappointing results obtained in several studies by automatic methods, goading to find new algorithms.

Safety of drug eluting stents in patients on chronic anticoagulation using long-term single antiplatelet treatment with clopidogrel.

BACKGROUND: Use of triple therapy with aspirin, clopidogrel, and anticoagulants significantly increases bleeding, thus drug eluting stents (DES) are usually avoided in patients requiring anticoagulation. We tested use of DES vs. BMS using a long-term therapy with clopidogrel only and anticoagulants in this group of patients. METHODS: We enrolled 165 consecutive patients, 79 receiving DES (age 67 +/- 9 years, 84% with atrial fibrillation) and 86 receiving bare metal stents (BMS) (age 70 +/- 11 years, 71% with atrial fibrillation). All patients received aspirin + clopidogrel + oral anticoagulants for 4 weeks, then aspirin was stopped and clopidogrel was continued during the 12-month follow-up. Primary end point was the combined incidence of major adverse coronary events and major bleedings. RESULTS: Incidence of the primary endpoint was 10.1% in patients with DES and 26.7% in patients with BMS (P = 0.01). There was a large difference in incidence of target vessel revascularization (8.1% for DES, 23.3% for BMS, P = 0.01), whereas incidence of myocardial infarction (3.8% in DES vs. 8.1% in BMS) and major bleeding (1.3% vs. 2.3%, respectively) were not significantly different. There were no cases of stent thrombosis. On multivariate Cox regression analysis, the only factor associated with a reduced risk of the primary endpoint was use of DES (hazard ratio 0.35 with 95% confidence interval 0.14-0.85, P = 0.02). CONCLUSIONS: Results of our cohort study suggest that use of DES associated with a treatment with clopidogrel only may be safe and significantly reduce the need for new revascularization in patients requiring chronic anticoagulation.

A prognostic index relating 24-hour ambulatory blood pressure to cardiac events in ischemic cardiomyopathy following defibrillator implantation.

BACKGROUND: We assessed the role of left ventricular ejection fraction and of ambulatory blood pressure monitoring (ABPM) to predict cardiac death and heart failure in patients with defibrillator fulfilling MADIT II criteria. ABPM variables assessed included: mean 24 hours diastolic and systolic blood pressure, mean 24 hours heart rate, and pulse pressure. METHODS: We studied 105 consecutive patients (age 67 +/- 11), all with a defibrillator and ejection fraction or= 220 n = 71) had clinical events at 12-month follow-up, compared with 61% of patients with low PI (< 220 n = 34) (P < 0.0001). CONCLUSION: The PI built by mean 24 hours diastolic and systolic blood pressure and age could be a simple method to stratify risk of cardiac death and acute heart failure in MADIT II patients, in whom ejection fraction, uniformly depressed, is not predictive.