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Although direct oral anticoagulants (DOACs) have been in use for more than 10 years, their use in clinical practice does not always comply with established indications, especially in terms of dosage. With the National APPRO– FA EVO Audit Initiatives, data were collected on the use of DOACs in Italian hospital heart centres. In the present study, we analyse DOAC use based on the indications reported in the summary of product characteristics.

A young man of 29 years presented to the Emergency Room reporting worsening dyspnea for about 2 weeks. He had never had previous cardiovascular disease nor had risk factors for them. Hemodynamics were stable, but arterial blood gases showed hypocapnic hypoxia. The ECG revealed a S1Q3T3 pattern, incomplete right bundle branch block and signs of right ventricular overload. D–dimer was 4493 ng/ml. CT pulmonary angiogram (CTPA) showed massive bilateral embolism with thrombotic material in the right ventricle (RV) and almost complete obliteration of pulmonary trunk and main pulmonary arteries; moreover, there were subpleural nodularities in upper pulmonary lobes. Echocardiogram showed a dilated and hypokinetic RV, moderate tricuspid regurgitation with a sPAP of 80 mmHg, thrombotic pulmonary trunk obliteration and floating thrombi adhered to the tricuspid valve. UFH therapy was started. After ten days, there was no improvement in clinical status, echocardiography and CTPA. So, we decided to perform mechanical thrombectomy. In addition to thrombotic material, fibrous tissue was extracted and histologically analyzed. At the end of the procedure, the patient became hemodynamically unstable (BP 80/40 mmHg and HR 130 bpm) with dyspnea and tachypnea. ABG showed mixed acidosis. Right ventricular function worsened due to high afterload for the persistence of thrombotic material in the pulmonary trunk, defining a picture of obstructive shock. We started fibrinolysis (with rtPA), enoximone and norepinephrine, but asystole occurred and the patient eventually died. The histological examination revealed that the mass was a pleomorphic rhabdomyosarcoma of the pulmonary artery. Primary pulmonary artery sarcoma is an extremely rare and histologically heterogeneous disease. It develops mainly from great pulmonary arteries and then it grows up in the lumen of vessels. It may involve pulmonary valve and RV and invade pulmonary parenchyma and loco–regional lymph nodes. Diagnosis is challenging, because it simulates pulmonary embolism in clinical, echocardiographic and radiological presentation. Suspicion may arise from lack of benefit from anticoagulant therapy. Nodular pulmonary infiltrates are typical. There are two surgical approaches: pneumectomy or endarterectomy (as palliation). Prognosis is poor: mean survival of 1,5 month without therapy and 10 months with pneumectomy. In addition to the progression of the disease, death can occur for obstructive shock, as in our patient.

A 72–year–old overweight man, with known hypertension and dyslipidaemia, had an episode of high intensity chest pain, which appeared at rest and lasted for several hours. A few days later, he underwent a cardiological examination and the electrocardiogram showed normofrequent sinus rhythm, ST elevation of 3 mm and Q waves formed in the anterior and lateral wall leads. The patient was diagnosed with late ST elevation myocardial infarction and was transported to our emergency department. On blood test, troponin levels were significantly elevated. He was treated with dual antiplatelet therapy (DAPT, aspirin and ticagrelor) and then underwent percutaneous coronary intervention (PCI). The mid segment of the LAD was suboccluded and two drug eluting stent (DES) were implanted. The right coronary artery also had a critical stenosis at the second segment treated with implantation of a DES. Final angiographic result was good (TIMI 3). The patient was admitted to our coronary unit where he continued to receive DAPT. During hospitalization a routine transthoracic echocardiogram (TTE) was performed which showed dilated left ventricle with a–dyskinesis of the apex and middle segment of the septum and the anterior wall and reduced ejection fraction (FE 35%). Within the apical segment of the septum and inferior wall, was noted an area of 40x14 mm with different echogenicity, probably referable to intramyocardial haematoma (IH) of the ventricular wall or a stratified thrombus. Both Colour Doppler and echo–contrast, using Sonovue, did not show a continuity between the suspected IH and one of the ventricular cavities. On cardiac MRI, this finding was considered of uncertain interpretation (whether IH or non–protundant mural thrombus). Late transmural enhancement was also observed at the same echocardiographic sites with subendocardial hypointensity bands consistent with areas of no–reflow. As the patient was clinically stable and TTE monitoring showed no progression of IH, a joint decision was made by cardiologists and cardiac surgeon to continue conservative management with DAPT without initiating anticoagulant therapy. At 1 month follow–up, TTE showed a reduction of the IH and an improvement of the EF to 45%. IH is a rare complication of myocardial infarction and revascularization treatments. The incidence is not well documented and the finding is usually occasional by TTE. Appropriate management is still controversial and a personalised approach is recommended.

In A.O. San Camillo–Forlanini, dedicated “Holding Areas” (HA) are active. They enable a rapid allocation of patients (pts), avoiding their long stay in the Emergency Department (ER) and therefore reducing the overcrowding. Moreover they allow the optimization of diagnosis and care, thanks to the direct management of specialists and reduce improper hospitalizations. Our HA is committed to receive (except on weekends) 3 pts/day destined to hospitalization in Cardiology. Here the patients are re–examined and quickly undergo to further specific tests, aiming at identifying those who can be addressed to alternative paths (Day Hospital/Day Service) and those who need to be hospitalized. For the latter, the HA allows to select the most appropriate diagnostic/therapeutic path according to the model of the intensity of care: critical area (ICU); ordinary hospitalization; short stay (SHS). In 2020 (with a total of 206 of Cardiology HA opening days, net of the lockdown and summer closure periods) 402 patients from the ER were admitted to cardiology HA. Among those, 20% (81 pts) was assigned to the SHS (availability of 2 beds/day, except for weekends) while another 4.3% (17 pts) was allocated to outpatient care. 52% of SHS pts had ischemic pathology (NSTE–ACS at low risk, CCS – Chronic Coronary Syndrome – with positive stress test, doubtful chest pain with multiple risk factors), 33% arrhythmic pathology (66% tachyarrhythmias, 34% bradyarrhythmias) and 12.6% heart failure (Killip class I–III). The HA reduced the average hospital stay (AHS): for SCA–NSTE, for example, from 5.1 days to 3.6 and the waiting time for diagnostic procedures (for example, for coronary angiography from 1.8 to 0.3 days). The opening of the SHS has further reduced the duration of the AHS: 1.5 nights for the CCS (the need for revascularization was not indicated in 68% of cases); 1 night for tachyarrhythmias (electrical cardioversion in 89% of cases); 3.75 nights for bradyarrhythmias (PMK implantation in 55% of patients). The overall average stay in SHS was very brief (2.5 nights) allowing a rapid turnover even with more difficult procedures. While criticalities persist (limited availability of SHS beds, “short” week opening), the results obtained confirm the need for dedicated and specialized HA in order to reduce improper hospitalizations, trim hospitalization times and broaden the appropriateness of care.

The entropy of an ergodic finite-alphabet process can be computed from a single typical sample path using the entropy of the k-block empirical probability and letting kgrow with nroughly like log n. We further assume that the distribution of the process is a g-measure. We prove large deviation principles for conditional, non-conditional and relative k(n)-block empirical entropies.

The large deviation properties of equilibrium (reversible) lattice gases are mathematically reasonably well understood. Much less is known in nonequilibrium, namely for nonreversible systems. In this paper we consider a simple example of a nonequilibrium situation, the symmetric simple exclusion process in which we let the system exchange particles with the boundaries at two different rates. We prove a dynamical large deviation principle for the empirical density which describes the probability of fluctuations from the solutions of the hydrodynamic equation. The so-called quasi potential, which measures the cost of a fluctuation from the stationary state, is then defined by a variational problem for the dynamical large deviation rate function. By characterizing the optimal path, we prove that the quasi potential can also be obtained from a static variational problem introduced by Derrida, Lebowitz, and Speer.

We formulate a dynamical fluctuation theory for stationary non-equilibrium states (SNS) which is tested explicitly in stochastic models of interacting particles. In our theory a crucial role is played by the time reversed dynamics. Within this theory we derive the following results: the modification of the Onsager–Machlup theory in the SNS; a general Hamilton–Jacobi equation for the macroscopic entropy; a non-equilibrium, nonlinear fluctuation dissipation relation valid for a wide class of systems; an H theorem for the entropy. We discuss in detail two models of stochastic boundary driven lattice gases: the zero range and the simple exclusion processes. In the first model the invariant measure is explicitly known and we verify the predictions of the general theory. For the one dimensional simple exclusion process, as recently shown by Derrida, Lebowitz, and Speer, it is possible to express the macroscopic entropy in terms of the solution of a nonlinear ordinary differential equation; by using the Hamilton–Jacobi equation, we obtain a logically independent derivation of this result.

We prove for a class of conservative interacting particle systems the validity of Onsager reciprocity relations for the transport coefficients if the microscopic dynamics is invariant under the combined action of time reversal and parity. The situation is reminiscent of TCPinvariance in quantum field theory. Our systems include multicomponent zero-range and exchange dynamics.