[Body mass index and cardiovascular events: the "obesity paradox"]. / Recenti acquisizioni sui rapporti tra indice di massa corporea e danno cardiovascolare: il "paradosso dell'obesità".

Excessive body mass among healthy subjects carries an increased risk of subsequent cardiovascular events. Excess weight implies the presence of white, viscero-abdominal fat, that promotes insulin-resistance, is infiltrated by macrophages, and is less differentiated compared to subcutaneous or brown fat. Conversely, among patients with cardiovascular disease, slim patients have a greater risk of recurrent atherothrombotic events than fatter patients ("obesity paradox"). Lean patients with cardiovascular disease, on average, have more comorbidities and haemorrhagic complications than their heavier counteparts, and probably they conceal predisposing factors that are still unknown and therefore difficult to treat.

A Rare Case of Left Subacute Atrial Dissection: Multimodality Imaging Approach.

Today, left atrial dissection is described as a rare complication of cardiac surgery, particularly after a mitral valve replacement. We report a rare case of left subacute atrial dissection occurred as a result of a domestic accidental fall. Transesophageal echocardiogram, angio-computed tomography, and magnetic resonance imaging showed an intramural formation with clear margins and a seamless cleavage with the posterolateral wall of the left atrium, which determined an obstacle to the ventricular filling. The patient was then operated in order to empty the hematoma and reattach the atrial wall.

A handbook for the clinical cardiologist about CRT/ICD. A practical guide about how to survive during an on call shift.

Cardiac resynchronization therapies (CRTs) have been demonstrated to improve the clinical management and prognosis of selected patients with heart failure. CRT devices include both CRT pacemakers (CRT-P) and CRT defibrillators (CRT-D), with the latter being used to treat life-threatening ventricular arrhythmias. A significant advantage of CRTs is the ability to monitor several vital parameters which, thanks to advanced technology, may be remotely assessed. Personalized programming options allow patients to receive the maximum benefit from these treatments. In this review we report the main diagnostic and therapeutic algorithms used in clinical practice.

[Cardiogenic shock: from early diagnosis to multiparameter monitoring]. / Shock cardiogeno: dalla diagnosi precoce al monitoraggio multiparametrico.

Cardiogenic shock (CS) is a life-threatening condition that occurs in response to reduced cardiac output, in the presence of adequate intravascular volume, and results in tissue hypoxia. CS can occur as a result of several etiologies but the most common is acute myocardial infarction. Despite the introduction of emergency revascularization for CS complicating acute myocardial infarction, mortality still remains exceptionally high, particularly in patients with refractory CS. The diagnosis of CS is sometimes challenging and it is based on clinical, hemodynamic, and biochemical signs. A multidisciplinary technical platform as well as specialized and experienced medical teams are crucial to treat this group of patients.We briefly summarize the main aspects of diagnosis, etiology and pathophysiology with a particular focus on macro- and microhemodynamic parameters that are essential for the diagnosis and treatment of this patient population.

[Cardiogenic shock: from pharmacological treatment to mechanical circulatory support]. / Shock cardiogeno: dal trattamento farmacologico all'assistenza meccanica al circolo.

Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to reduced cardiac output, despite adequate filling status. The development of multiorgan dysfunction is believed to be the major contributor to the high early mortality. Little evidence exists as to which vasopressor or inotrope should best be used for early treatment; however, customized pharmacological therapy, tailored on hemodynamic monitoring, is essential to achieve normal peripheral perfusion. Moreover, an increasing number of mechanical circulatory support devices are available for hemodynamic support in patients with CS but, at present, data derived from randomized clinical trials on the effectiveness, safety, differential indications for mechanical support devices, and optimal implant timing are limited.The aim of this review is to offer an overview of the pharmacological and device options, providing a practical approach to the treatment of patients with CS.

[Noninvasive ventilation: general characteristics, indications, and review of the literature]. / Ventilazione non invasiva: caratteri generali, indicazioni e revisione della letteratura.

Noninvasive ventilation (NIV), including both continuous and bilevel positive airway pressure, plays a pivotal role in the treatment of acute respiratory failure secondary to acute heart failure. For an appropriate use of NIV, it is essential to consider the underlying pathophysiological principles, the differences between the different modes of ventilation, the main indications, contraindications and complications. The aim of this review is also to give practical guidance on how and when to start NIV at the bedside, how to monitor the response and how to choose the most appropriate interface. A review of the literature supports the use of NIV in terms of efficacy (reduction in intubation and mortality) and safety (in particular, the risk of myocardial infarction associated with its use, suggested by a previous study, has been definitely confuted). Nevertheless, NIV is still largely underused in contemporary clinical practice, as reported by data from real-world registries. This may be due to several factors, including lack of knowledge/confidence, reluctance of application in particular settings (acute coronary syndromes) and the risk of adverse effects (hypotension), which need to be reappraised.

[Noninvasive ventilation and sedation: evidence and practical tools for its utilization]. / Ventilazione non invasiva e sedazione: evidenze a supporto e consigli pratici.

Noninvasive ventilation (NIV) has gained increased acceptance inside the critical area, since it has been shown to be effective in reducing or avoiding the need for oro-tracheal intubation. NIV efficacy is dependent on the selection of the appropriate patients and on their compliance to therapy. Actually, full collaboration is not easily reached especially in agitated patients.Sedation during NIV is useful to reduce the rate of treatment failure, but robust data to guide the development of best practice are limited and sometimes local customs appear to exert a strong influence on patterns of care. Different sedative drugs are ready for use but none of currently available agents fulfill the criteria for the ideal drug. Knowledge of the pharmacological and hemodynamic characteristics of every single sedative agent is crucial to choose the right drug for every clinical scenario. Close monitoring is mandatory to avoid adverse effects. The aim of this article is to review the currently available literature, to recognize the contraindications for sedation use and to provide practical guidance.

[Hemodynamic effects of positive end-expiratory pressure]. / Gli effetti emodinamici della pressione positiva di fine espirazione.

The application of a positive end-expiratory pressure (PEEP), the cornerstone of noninvasive ventilation (NIV), causes hemodynamic changes in the cardiovascular system. To understand the benefits of NIV it is necessary to resume concepts of cardiovascular physiology and pathophysiology about cardiac function determinants, venous return, ventricular interdependence and heart-lung interaction, and to understand how PEEP interacts with them. The hemodynamic effects of PEEP are mediated by the increase in transpulmonary pressure, which results in increased pulmonary vascular resistance and in an attending small reduction of venous return in conditions of euvolemia, in a substantial reduction of left ventricular afterload and a potential positive effect on left ventricular stroke volume.The aim of this review is to describe how the application of PEEP does not necessarily induce detrimental hemodynamic effects, but may decrease oxygen consumption and improve cardiac performance. These effects can justify the use of NIV in hemodynamically unstable patients.

[Recent advances in atherothrombotic diseases]. / Recenti progressi in tema di aterotrombosi.

New concepts in the field of atherothrombosis include the human potential to repair and regenerate areas of vascular damage through endogenous growth factors, and the identification of uncommon arterial thrombophilias that promote atherothrombosis. The endogenous factors erythropoietin and insulin-like growth factor-1 are emerging as robust opponents of the vascular and hemostatic alterations that occur in atherothrombosis. Both factors activate the intracellular Akt pathway and the biosynthesis of constitutive nitric oxide, with anti-apoptotic, insulin-sensitizing, vasodilator, anti-inflammatory, antioxidant and antiplatelet effects, all of which oppose arterial degeneration and occlusion. Additionally, erythropoietin and insulin-like growth factor-1 induce the mobilization of stem cells that can differentiate and repair areas of vascular damage thereby halting the progression towards established disease. In selected patients with an arterial thrombotic event, we believe it is justified to search for an uncommon acquired or inherited thrombophilic condition in the presence of at least one of the following: young age, recurrent events, lack of traditional metabolic or acquired vascular risk factors, and no significant artery stenoses at angiography. In these groups of patients, and in those with a marked family history of thrombosis, the prevalence of several functional polymorphisms of genes involved in the hemostatic system is significantly higher compared with controls. Acquired thrombophilias that should be searched for include the antiphospholipid syndrome, systemic lupus erythematosus, and myeloproliferative disorders.

Erythropoietin in heart and vessels: focus on transcription and signalling pathways.

Erythropoietin (Epo) is synthesized mainly under hypoxic conditions by renal and extrarenal tissues, including liver, spleen, brain, lung, bone marrow, and reproductive organs. Hypoxia abrogates the degradation of hypoxia-inducible factors (HIF)-1 and -2, that can then bind to the hypoxia response element within the Epo gene, activating its transcription. Receptors for Epo are expressed on cells known to synthesize Epo, but also on cardiomyocytes, cardiac fibroblasts, and endothelial, retinal, gastric, prostate and vascular smooth muscle cells. Epo-receptor binding triggers at least three intracellular signalling cascades: (1) janus tyrosine kinase 2 (JAK2)/signal transducer and activator of transcription 5 (STAT5); (2) phosphatidylinositol-3 kinase (PI3K)/Akt, and (3) RAS/mitogen-activated protein kinase (MAPK). Epo also enhances nitric oxide (NO) bioavailability through endothelial NO synthase transcription and activation, and exerts antiapoptotic actions through Bcl-2 and Bcl-XL. NO is a powerful vasodilator, insulin-sensitizer, inhibitor of atherothrombosis and apoptosis, and essential for progenitor mobilization. This article is a concise review of recent advances regarding the molecular and cardiovascular effects of Epo.

Lost and found: an unusual late complication of the Angio-Seal closure device.

We report an unusual case of breakage and embolisation of a femoral access closure device (Angio-Seal), which caused acute leg ischemia after percutaneous coronary intervention in a diabetic patient with documented peripheral vascular disease. Embolectomy from the superficial femoral artery revealed the polymer anchor split in two parts and embedded within a large (25x5 mm) thrombus.