Cardio-oncology rehabilitation: are we ready?

Cardio-oncology rehabilitation (CORE) is not only an essential component of cancer rehabilitation but also a pillar of preventive cardio-oncology. Cardio-oncology rehabilitation is a comprehensive model based on a multitargeted approach and its efficacy has been widely documented; when compared with an 'exercise only' programme, comprehensive CORE demonstrates a better outcome. It involves nutritional counselling, psychological support, and cardiovascular (CV) risk assessment, and it is directed to a very demanding population with a heavy burden of CV diseases driven by physical inactivity, cancer therapy-induced metabolic derangements, and cancer therapy-related CV toxicities. Despite its usefulness, CORE is still underused in cancer patients and we are still at the dawning of remote models of rehabilitation (tele-rehabilitation). Not all CORE is created equally: a careful screening procedure to identify patients who will benefit the most from CORE and a multidisciplinary customized approach are mandatory to achieve a better outcome for cancer survivors throughout their cancer journey. The aim of this paper is to provide an updated review of CORE not only for cardiologists dealing with this peculiar population of patients but also for oncologists, primary care providers, patients, and caregivers. This multidisciplinary team should help cancer patients to maintain a healthy and active life before, during, and after cancer treatment, in order to improve quality of life and to fight health inequities.

The Key Role of a Psychoactive Substance Use History in Comprehensive Cardiovascular Risk Assessment, Diagnosis, Treatment, and Prevention.

BACKGROUND: Psychoactive substances have toxic effects resulting different cardiovascular and non-cardiovascular organ damage. Through a variety of mechanisms, they can trigger the onset of various forms of cardiovascular disease: acute or chronic, transient or permanent, subclinical or symptomatic. Hence, a thorough knowledge of the patient's drug habits is essential for a more complete clinical-etiopathogenetic diagnosis and consequent therapeutic, preventive, and rehabilitative management. SUMMARY: The prime reason for taking a psychoactive substance use history in the cardiovascular context is to identify those people who use substances (whether habitual or occasional users, symptomatic or not) and adequately assess their overall cardiovascular risk profile in terms of "user status" and type of substance(s) used. A psychoactive substance history could also alert the physician to suspect, and eventually diagnose, cardiovascular disease related to the intake of psychoactive substances, so optimizing the medical management of users. This anamnesis could finally assess the likelihood of patients persisting in the habit as a user or relapse, while maintaining high their cardiovascular risk profile. Taking such a history should be mandatory when a causal connection is suspected between intake of psychoactive substances and the observed symptoms or pathology, regardless of whether the individual is a declared user or not. KEY MESSAGES: The purpose of this article was to provide practical information on when, how, and why to perform a psychoactive substance use history.

Age- and sex-based reference ranges for non-invasive ventricular repolarisation parameters.

BACKGROUND: Some electrocardiographic parameters are able to assess indirectly ventricular repolarisation homogeneity. It is consequently essential to discriminate between normal and abnormal values in clinical decision-making. Considering there is still not a consensus about normal cut-off values, the aim of this study was to document reference intervals in all age groups of a healthy population, providing for age- and sex-percentile tables, which can be used easily and quickly in clinical practice. METHODS: We evaluated repolarisation markers in 606 sex-matched participants aged 1 day-94 years. Each subject underwent a 12-lead electrocardiogram at rest, and the following parameters were measured: QT, corrected QT, QTpeak, Tpeak-Tend, Tpeak-Tend dispersion, Tpeak-Tend/QT and QTpeak/QT ratio. RESULTS: A relationship was demonstrated between age and QTpeak, Tpeak-Tend, QT and QTc. In children, QTpeak, Tpeak-Tend and QT intervals increased linearly with age. In adolescents, all the three parameters remained stable. In adults, QTpeak and QT showed a further significant increase. On the contrary, Tpeak-Tend interval was longer in adults aged between 20 and 64 years than in participants aged 65 years or over, but the difference was not statistically significant. Male vs female participants showed longer Tpeak-Tend intervals; this sex difference was not statistically significant at birth and during childhood, whereas it was in adolescents and in adults. CONCLUSIONS: Repolarisation parameters showed age- and sex-based variations, which are important to know to differentiate normal from pathological values.

The Year 2022 in Cardiovascular Diseases-Clinics and Practice.

This journal has recently achieved significant milestones, receiving its first impact factor of 2 [...].

Erythrocyte Indices in Patients With Takotsubo Syndrome.

BACKGROUND: Although the prognosis of patients with Takotsubo syndrome (TTS) is relatively favorable, serious complications may occur. This study aimed to investigate the relationship between blood parameters and the occurrence of in-hospital complications. METHODS: Clinical charts of 51 patients with TTS were retrospectively evaluated, and data regarding blood parameters assessed during the first 24 hours of hospitalization were studied. RESULTS: Levels of hemoglobin less than 13 g/dL in men and 12 g/dL in women (P < 0.01), levels of mean corpuscular hemoglobin concentration (MCHC) less than 33 g/dL (P = 0.01), and levels of red blood cell distribution width-coefficient of variation higher than 14.5% (P = 0.01) were significantly associated to the occurrence of major adverse cardiovascular events (MACE). Markers, such as, platelets to lymphocytes ratio, lymphocytes to monocytes ratio, neutrophils to lymphocytes ratio, and white blood cell count to mean platelet volume, were unable to differentiate patients with and without complications (P > 0.05). MCHC and estimated glomerular filtration rate were independent predictors of MACE. CONCLUSIONS: Blood parameters may have a role in the stratification risk of patients with TTS. Patients showing low levels of MCHC and decreased estimated glomerular filtration rate were more likely to have in-hospital MACE. This should encourage physicians to closely monitor blood parameters in patients with TTS.

[Substances of abuse and cardiovascular risk: cannabinoids]. / Sostanze d'abuso e rischio cardiovascolare: i cannabinoidi.

Progressive legalization for medical conditions or recreational use has led to an increased use of cannabis and synthetic cannabinoids over the past years. Most consumers are young and healthy, without cardiovascular risk factors; however, this population is expected to include older individuals. Thus, concerns have arisen about safety and short- and long-term potential adverse effects, with special emphasis on vulnerable groups. Studies show that cannabis might be linked with thrombosis, inflammation, and atherosclerosis, and many reports have associated cannabis and synthetic cannabinoids use with serious adverse cardiovascular complications, including myocardial infarction, cardiomyopathy, arrhythmias, stroke, and cardiac arrest. A clearly defined causal role cannot be demonstrated, because of confounding variables. Physicians need to become aware of the possible spectrum of clinical presentations, not only for timely diagnosis and treatment, but also for effective counseling and prevention.In this review, we aim to provide a basic understanding of the physiological effects of cannabis, the role of the endocannabinoid system in cardiovascular disease, and the cardiovascular consequences of cannabis and synthetic cannabinoid use, including a comprehensive review of the studies and case reports that provide supportive evidence for cannabis as a trigger of adverse cardiovascular events according to the current literature.

Behavior of repolarization variables during exercise test in the athlete's heart.

BACKGROUND: T peak-T end, QT peak/QT ratio and T peak-T end/QT ratio are markers able to test myocardial repolarization homogeneity, their increase has been related to a higher risk of ventricular tachyarrhythmias. These parameters have not yet been studied in left ventricular hypertrophy due to training. Aim of the research was to test the behavior of these variables in the athlete's heart during exercise. METHODS: We examined 70 athletes, all males, divided into two groups according to the absence or the presence of a left ventricular mass index over 49 g/m(2.7) and a control group composed of 35 healthy, untrained males. All study participants underwent electrocardiogram at rest, transthoracic echocardiogram, and ergometric test. Repolarization markers (QT, corrected QT, QT dispersion, T peak-T end, QT peak/QT, T peak-T end/QT) were calculated at rest, at peak exercise and during recovery. RESULTS: There was no statistically significant difference among the groups regarding all the parameters studied, except for corrected QT at rest between athletes with left ventricular hypertrophy and control group. The behavior of repolarization markers during exercise was not dissimilar in the three groups. CONCLUSIONS: Athlete's heart is not associated to any alteration in ventricular repolarization homogeneity, neither at rest nor during physical activity nor during recovery. Training-induced left ventricular hypertrophy does not affect relationship QT parameters/RR interval.

[Long COVID: nosographic aspects and clinical epidemiology]. / Long COVID: aspetti nosografici ed epidemiologia clinica.

Recent evidence shows that a range of persistent or new symptoms can manifest after 4-12 weeks in a subset of patients who have recovered from acute SARS-CoV-2 infection, and this condition has been coined long COVID by COVID-19 survivors among social support groups. Long COVID can affect the whole spectrum of people with COVID-19, from those with very mild acute disease to the most severe forms. Like the acute form, long COVID has multisystemic aspects. Patients can manifest with a very heterogeneous multitude of symptoms, including fatigue, post-exertional malaise, dyspnea, cognitive impairment, sleep disturbances, anxiety and depression, muscle pain, brain fog, anosmia/dysgeusia, headache, and limitation of functional capacity, which impact their quality of life. Because of the extreme clinical heterogeneity, and also due to the lack of a shared, specific definition, it is very difficult to know the real prevalence and incidence of this condition. Risk factors for developing long COVID would be female sex, initial severity, and comorbidities. Globally, with the re-emergence of new waves, the population of people infected with SARS-CoV-2 continues to expand rapidly, necessitating a more thorough understanding of potential sequelae of COVID-19. This review summarizes up to date definitions and epidemiological aspects of long COVID.

COVID-19, Vaccines, and Thrombotic Events: A Narrative Review.

The coronavirus disease 2019 (COVID-19), a deadly pandemic that has affected millions of people worldwide, is associated with cardiovascular complications, including venous and arterial thromboembolic events. Viral spike proteins, in fact, may promote the release of prothrombotic and inflammatory mediators. Vaccines, coding for the spike protein, are the primary means for preventing COVID-19. However, some unexpected thrombotic events at unusual sites, most frequently located in the cerebral venous sinus but also splanchnic, with associated thrombocytopenia, have emerged in subjects who received adenovirus-based vaccines, especially in fertile women. This clinical entity was soon recognized as a new syndrome, named vaccine-induced immune thrombotic thrombocytopenia, probably caused by cross-reacting anti-platelet factor-4 antibodies activating platelets. For this reason, the regulatory agencies of various countries restricted the use of adenovirus-based vaccines to some age groups. The prevailing opinion of most experts, however, is that the risk of developing COVID-19, including thrombotic complications, clearly outweighs this potential risk. This point-of-view aims at providing a narrative review of epidemiological issues, clinical data, and pathogenetic hypotheses of thrombosis linked to both COVID-19 and its vaccines, helping medical practitioners to offer up-to-date and evidence-based counseling to their often-alarmed patients with acute or chronic cardiovascular thrombotic events.

Association between Tpeak-Tend/QT and major adverse cardiovascular events in patients with Takotsubo syndrome.

BACKGROUND: Conflicting results have been described in the scientific literature regarding the relationship between electrocardiographic parameters and complications in patients with Takotsubo syndrome (TTS). Aim of the present study was to investigate whether there is an association between markers of ventricular repolarization and major adverse cardiovascular events (MACE) during hospitalisation. METHODS: A retrospective chart review was conducted on a sample of patients with diagnosis of TTS, based on the fulfilment of the revised Mayo Clinic criteria. MACE included acute heart failure, cardiogenic shock, sustained ventricular tachycardia, ventricular fibrillation, and death. The following parameters, assessed on the admission electrocardiogram, were analysed: ST-segment elevation, ST-segment depression, T wave inversion, presence of Q waves, QT interval, QT interval corrected for heart rate, QT-dispersion, Tpeak-Tend (Tpe) interval, Tpe dispersion, Tpe/QT ratio, and QTpeak/QT ratio. RESULTS: Patients with MACE, compared to patients without MACE, showed more commonly anterior ST-segment elevation and had significantly higher values of Tpe/QT ratio. Low ejection fraction and Tpe/QT ratio > 0.27 identified a sub-population of patients more likely to have MACE during hospitalisation. CONCLUSIONS: Tpe/QT ratio represents a useful electrocardiographic parameter in the acute phase of TTS.

Prevalence Of familial hypercholeSTerolaemia (FH) in Italian Patients with coronary artERy disease: The POSTER study.

BACKGROUND AND AIMS: Familial hypercholesterolaemia (FH) is a powerful risk factor for cardiovascular (CV) events. High levels of low-density lipoprotein cholesterol (LDL-C) since birth are linked to the early onset of atherosclerotic disease. A genetic mutation determining FH is present in about one subject out of 250; FH should be more represented among subjects with a documented diagnosis of coronary artery disease (CAD). The POSTER Study evaluated the prevalence of FH in Italian patients with a recent CAD event. METHODS: Eighty-two cardiology centres enrolled patients with a documented CAD event; CV risk profile, drug therapy and biochemical parameters were collected. Dutch Lipid Clinic Network (DLCN) criteria were used to define patients with a potential FH diagnosis (score ≥6); these patients underwent molecular testing for genetic diagnosis of FH. RESULTS: Overall, 5415 patients were enrolled and the main index events were myocardial infarction with ST-elevation, non ST-elevation acute coronary syndrome (ACS), or a recent coronary revascularization (34.8%, 37.2%, and 28% respectively). Mean age was 66 ± 11 years, men were 78%; about 40% were already treated with statins, proportion that increased after the acute event (96.5%). Based on the DLCN score, the prevalence of potential FH was 5.1%, 0.9% of them had a diagnosis of definite FH (score >8). These patients were younger than patients with a score <6 (56 ± 10 vs 66 ± 11, p < 0.001), and LDL-C levels were in most of them (~87%) >190 mg/dL. FH was genetically confirmed in 42 subjects (15.9%); genetic diagnosis was defined as not conclusive for FH in 63 patients (23.9%). Finally, in 159 subjects (60.2%) no pathogenic mutations in the tested genes were identified, defining them as negative for monogenic familial hypercholesterolemia. CONCLUSIONS: Results underscore a relatively high prevalence of potential FH in patients with a recent CAD event. Therefore, an early identification of these subjects may help improve the management of their high CV risk and, by cascade screening, identify possible FH relatives.

[Lifestyle, risk factors and prevention of cancer: role of the cardiologist]. / Stili di vita, fattori di rischio e prevenzione delle malattie oncologiche: il ruolo del cardiologo.

Although commonly thought of as two separate disease entities, cardiovascular diseases and cancer, the leading causes of death, possess various possible interactions, including a number of similar risk factors (e.g. obesity, diabetes, chronic inflammation). Each cardiologist should provide counseling for a correct lifestyle (diet, physical exercise, avoiding smoking and alcohol abuse); doing so, not only cardiovascular diseases, but also cancer could be prevented. Besides, intervention on diet, physical activity and smoking has been shown to be effective even in patients with known cancers. Many drugs used in cardiovascular prevention (i.e. aspirin, metformin, statins, and beta-blockers) have shown in vivo and in vitro promising pleiotropic properties, and, in observational studies, they were also effective in the prevention of some cancers, although this matter is controversial, emphasizing the need for interventional studies in the field of primary and secondary cancer prevention. Considerable interest has emerged regarding the potential adjuvant chemotherapeutic use of these drugs, but real-world epidemiological data remain inconclusive. In this review, we explore the risk factors common to both cardiovascular diseases and cancer, as well as the role of preventive cardiology treatments, highlighting the related major epidemiologic studies and potential biological mechanisms.

Sex differences in the management of acute coronary syndromes in Italy: data from the MANTRA registry.

AIMS: Several studies have shown sex differences in acute coronary syndromes (ACS), but their understanding is far from complete. Thus, the study aims to evaluate sex differences in management and outcomes of unselected patients with ACS. METHODS AND RESULTS: From 22 April 2009 to 29 December 2010, 6394 consecutive patients with ACS (44.7% ST-elevation myocardial infarction) were prospectively enrolled and followed for 6 months. Women (N = 1894, 29.6%) were older, had more comorbidities, and worse clinical presentation than men. Fewer women underwent reperfusion [68.0% women vs. 84.1% men, P < 0.0001, adjusted odds ratio (OR): 0.53, 95% confidence interval (CI): 0.43-0.66] in ST-elevation myocardial infarction, and coronary angiography during hospitalization (72.2% women vs. 81.1% men, P < 0.0001, adjusted OR: 0.70, 95% CI: 0.57-0.85) in no-ST-elevation ACS. Women had worse outcomes than men during hospitalization, and at 6-month follow-up. At multivariable analysis, female sex was significantly associated with a higher risk of in-hospital Thrombolysis in Myocardial Infarction major bleedings (OR: 1.80, 95% CI: 1.09-2.96, P = 0.02), but not of 6-month death. CONCLUSION: Women with ACS in clinical practice present a clustering of high-risk features that may contribute to their worse outcomes as compared with men, although female sex is not an independent predictor of death at 6-month follow-up.

Effects of nebivolol versus carvedilol on left ventricular function in patients with chronic heart failure and reduced left ventricular systolic function.

BACKGROUND: Beta-adrenoceptor antagonist (beta-blocker) therapy results in a significant improvement in left ventricular (LV) systolic function and prognosis in patients with chronic heart failure. Both carvedilol and nebivolol produce hemodynamic and clinical benefits in chronic heart failure, but it is unknown whether their peculiar pharmacologic properties produce different effects on LV function. OBJECTIVE: To assess the effects on LV function of nebivolol compared with carvedilol in patients with chronic heart failure and reduced LV systolic function. METHODS: Seventy patients with a LV ejection fraction

[From risk charts to guidelines: tools for evaluation and management of cardiovascular risk]. / Dalle carte del rischio alle linee guida: gli strumenti per la valutazione e la gestione del rischio cardiovascolare.

Despite the wide improvement of diagnostic techniques and the introduction of effective pharmacological and instrumental therapeutic strategies aimed to the treatment of cardiovascular diseases, their incidence and lethality are still elevated, with economic implications increasingly less sustainable by the public medical systems. The modern practice of cardiovascular prevention requires, thus, that diagnostic and therapeutic interventions, both at population level and on the single patient, should be more and more precise, effective, and appropriate. From this point of view, a correct global cardiovascular risk stratification assumes a preponderant relevance, in order to allow an adequate therapeutical response. For this purpose several work instruments, as risk charts and guidelines, namely dedicated to arterial hypertension and dyslipidemias, were developed and offered to clinicians interested in cardiovascular prevention. The aim of this review is to illustrate, in synthesis, those instruments, aiming to facilitate their implementation, thus reducing the actual gap between theoretical indications and the real world.

In-hospital complications of acute myocardial infarction in hypertensive subjects.

BACKGROUND: Recent studies have shown a worse in-hospital outcome in hypertensive than in normotensive patients with acute myocardial infarction (AMI), which has been attributed to more frequent complications. The aim of this study was to investigate clinical patterns, risk factors, and in-hospital complications in hypertensive and normotensive patients with AMI. METHODS: Of 4994 consecutive patients with AMI admitted to the intensive care unit, hypertensive patients with first infarction (n = 915; mean age 68.8 +/- 11.4 years) and 915 gender- and age-matched normotensive subjects were retrospectively studied. RESULTS: In the univariate analysis, hypertensive subjects presented more frequently non-Q-wave infarction and ST segment depression than did normotensive subjects, even if hypertensive subjects more frequently had diabetes, dyslipidemia, renal failure, peripheral artery disease, cerebrovascular disease, and chronic obstructive pulmonary disease (P < .01 for all). Hypertensive subjects less frequently presented with cardiogenic shock (4.0% v 11.6%; P < .01), atrioventricular block (4.9% v 7.4%; P = .02), ventricular fibrillation (2.2% v 3.7%; P = .04), cardiac rupture (0.1% v 0.9%; P = .02), and ventricular thrombosis (0.5% v 1.5%; P < .03), and a higher frequency of paroxysmal atrial fibrillation (9.2 v 5.6%; P < .01). Mortality was significantly higher in patients with anterior versus inferior infarction, for all normotensive and hypertensive subjects (13.7% v 7.1%; P < .001), but mortality was remarkably higher in normotensive than in hypertensive subjects (17.8% v 6.2%; P < .001), regardless of infarction site (anterior, 11.2% v 4.1%; P < .001; inferior, 4.4% v 1.9%; P < .001). CONCLUSIONS: Hypertensive subjects with first AMI have a better in-hospital outcome than age- and gender-matched normotensive subjects, perhaps due to a less severe extension of the infarction area or to a different pathophysiologic mechanism.

Fibrinogen as a predictor of mortality after acute myocardial infarction: a forty-two-month follow-up study.

BACKGROUND: Several studies suggest that fibrinogen may be considered an independent risk factor for coronary artery disease, but it is still on debate if we need its evaluation during an acute myocardial infarction (AMI) to prevent future fatal or non-fatal cardiovascular events. Therefore, we decided to investigate this field. METHODS: We studied 92 male patients with AMI, evaluating at admission age, body mass index, systolic blood pressure, cigarette smoking, ejection fraction, plasma levels of total cholesterol, triglycerides, fibrinogen, glycemia, and white blood cell count. All patients were followed up for 42 months to evaluate total mortality and cardiovascular morbidity. RESULTS: During the follow-up 5 patients died and 64 had one or more non-fatal cardiovascular events: angina (n = 78), heart failure (n = 17), re-AMI (n = 3), stroke (n = 3), or revascularization procedure (n = 16). A multivariate analysis revealed that fibrinogen plasma levels at admission (r = +0.213, p < 0.05) were independently associated with mortality, while systemic thrombolysis was negatively associated (r = -0.447, p < 0.0001). CONCLUSIONS: Plasma fibrinogen levels were the only independent predictor of mortality in a 42-month follow-up post-AMI. This finding, together with other observations from recent studies, suggest that fibrinogen evaluation during AMI may be useful in identifying patients at higher risk of acute event recurrence.

Contemporary antithrombotic strategies in patients with acute coronary syndrome admitted to cardiac care units in Italy: The EYESHOT Study.

BACKGROUND: Several new antithrombotic therapies have emerged for the treatment of acute coronary syndrome (ACS). We sought to assess contemporary patterns of antithrombotic therapies use in patients with ACS. METHODS AND RESULTS: EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units) was a nationwide, prospective registry aimed to evaluate antithrombotic strategies employed in patients admitted to intensive cardiac care units (CCUs) for an ACS in Italy. Over a three-week period, 203 CCUs enrolled 2585 consecutive patients: 41.2% with ST-elevation myocardial infarction (STEMI) and 58.8% with non-ST elevation ACS (NSTE-ACS). During hospitalisation, low-molecular-weight heparins, aspirin, and clopidogrel were the most commonly used antithrombotic therapies. Among patients treated with percutaneous coronary intervention (PCI, n=1755), any crossover of heparin therapy occurred in 30.8% of cases, while switching from one P2Y12 inhibitor to another occurred in 3.6% of cases in the CathLab and in 14.2% before discharge. Of the 790 patients who did not receive revascularisation, switching of a P2Y12 inhibitor occurred in 5.7% of cases. At discharge, a new P2Y12 inhibitor (ticagrelor or prasugrel) in association with aspirin was prescribed in 59.5% of STEMI and 33.9% of NSTE-ACS patients: the most powerful predictor for prescription was PCI (odds ratio (OR) 6.18; 95% confidence interval (CI) 4.76-8.01; p<0.0001), whereas age ≥ 75 years was strongly associated with clopidogrel use (OR 0.28; 95% CI 0.22-0.36; p<0.0001). CONCLUSIONS: The EYESHOT registry shows the current pattern of antithrombotic treatments for ACS patients admitted to Italian CCUs and provides insights which may help to improve the clinical care of such patients.

[Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)]. / "Fare di più non significa fare meglio". Le proposte dell'ANMCO.

In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA's Less Is More and BMJ's Too Much Medicine series, and the American College of Physicians' High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody's proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation's Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.