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Technological innovation provides easily accessible tools capable of simplifying healthcare processes. Notably, digital technology application in the cardiology field can improve prognosis, reduce costs, and lead to an overall improvement in healthcare. The digitization of health data, with the use of electronic health records and of electronic health files in Italy, represents one of the fields of application of digital technologies in medicine. The 2023 States General of the Italian Association of Hospital Cardiologists (ANMCO) provided an opportunity to focus attention on the potential benefits and critical issues associated with the implementation of the aforementioned digital tools, artificial intelligence, and telecardiology. This document summarizes key aspects that emerged during the event. more...

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. more...

Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, either symptomatic or incidental, is a common complication in the history of cancer disease. The risk of VTE is 4-7-fold higher in oncology patients, and it represents the second leading cause of death, after cancer itself. In cancer patients, compared with the general population, VTE therapy is associated with higher rates of recurrent thrombosis and/or major bleeding. The need for treatment of VTE in patients with cancer is a challenge for the clinician because of the multiplicity of types of cancer, the disease stage and the imbricated cancer treatment. Historically, in cancer patients, low molecular weight heparins have been preferred for treatment of VTE. More recently, in large randomized clinical trials, direct oral anticoagulants (DOACs) demonstrated to reduce the risk of VTE. However, in the "real life", uncertainties remain on the use of DOACs, especially for the bleeding risk in patients with gastrointestinal cancers and the potential drug-to-drug interactions with specific anticancer therapies.In cancer patients, atrial fibrillation can arise as a perioperative complication or for the side effect of some chemotherapy agents, as well as a consequence of some associated risk factors, including cancer itself. The current clinical scores for predicting thrombotic events (CHA2DS2-VASc) or for predicting bleeding (HAS-BLED), used to guide antithrombotic therapy in the general population, have not yet been validated in cancer patients. Encouraging data for DOAC prescription in patients with atrial fibrillation and cancer are emerging: recent post-hoc analysis showed safety and efficacy of DOACs for the prevention of embolic events compared to warfarin in cancer patients. Currently, anticoagulant therapy of cancer patients should be individualized with multidisciplinary follow-up and frequent reassessment. This consensus document represents an advanced state of the art on the subject and provides useful notes on clinical practice. more...

Retrospective data from Chinese cohorts published in the last few days have placed a strong emphasis on the possibility that acute myocardial injury represents a critical component in the development of serious complications in patients hospitalized with COVID-19. These analyses showed that 19-27% of hospitalized patients with moderate/severe COVID-19 developed acute myocardial injury, defined as an increase in troponin levels. Fifty-sixty percent of these patients died. The highest mortality rate was detected among patients with both progressively incremental troponin levels and a history of cardiovascular disease. Some pathophysiological reasons have been hypothesized regarding the frequently observed increase in troponin levels in patients hospitalized with COVID-19, but, at the moment, these data could already suggest some clinical management implications, also with the aim of prospectively collecting research data: a troponin dosage should be considered, as a prognostic indicator, in all patients with moderate/severe COVID-19 at hospital admission, periodically during hospitalization, and in the case of clinical deterioration. In those patients with increased troponin levels, serial determinations should be carried out to define the enzymatic trajectory and therefore also the degree of clinical attention that must necessarily be closer in those who turn out to have persistently high or increasing troponin levels. In order to reduce the overdiagnosis risk of acute myocardial injury in critically ill patients, detection of increased troponin levels should always be contextualized into a multi-parametric evaluation. more...

Decisional support systems based on machine learning (ML) in medicine are gaining a growing interest as some recent articles have highlighted the high diagnostic accuracy exhibited by these systems in specific medical contexts. However, it is implausible that any potential advantage can be obtained without some potential drawbacks. In light of the current gaps in medical research about the side effects of the application of these new AI systems in medical practice, in this article we summarize the main unexpected consequences that may result from the widespread application of "oracular" systems, that is highly accurate systems that cannot give reasonable explanations of their advice as those endowed with predictive models developed with ML techniques usually are. These consequences range from the intrinsic uncertainty in the data that are used to train and feed these systems, to the inadequate explainability of their output; through the risk of overreliance, deskilling and context desensitization of their end-users. Although some of these issues may be currently hard to evaluate due to the still scarce adoption of these decisional systems in medical practice, we advocate the study of these potential consequences also for a more informed policy of approval beyond hype and disenchantment. more...

Fractional flow reserve (FFR) is considered the gold standard for functional assessment of coronary stenosis in stable coronary artery disease. The use of FFR enables an ischemia-guided revascularization with improvement of clinical outcomes in a cost-effective fashion. Both clinical and interventional cardiologists should be aware of the advantages and potential pitfalls of this technique. We focus on FFR with the aim to provide the clinical cardiologist with information on indications and technical aspects to confirm a correct execution of FFR in different coronary anatomical settings. more...

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyze the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education and legal aspects. more...

The ECG signal can be derived from different sources. These include systems for surface ECG, Holter monitoring, ergometric stress tests and systems for telemetry and bedside monitoring of vital parameters, useful to rhythm and ST-segment analysis and ECG screening of cardiac electrical sudden death predictors. A precise ECG diagnosis is based upon a correct recording, elaboration and presentation of the signal. Several sources of artifacts and potential external causes may influence the quality of the original ECG waveforms. Other factors that may affect the quality of the information presented depends upon the technical solutions employed to improve the signal. The choice of the instrumentations and solutions used to offer a high quality ECG signal are therefore of paramount importance. Some requirements are reported in detail in scientific statements and recommendations. The aim of this consensus document is to offer a scientific reference for the choice of systems able to offer a high quality ECG signal acquisition, processing and presentation suitable for clinical use. more...

Telemedicine applied to heart failure patients is a tool for recording, remote transmission, storage and interpretation of cardiocirculatory parameters and/or diagnostic images, useful, as emphasized by the latest guidelines, to allow for intensive home monitoring in patients with advanced heart failure or during the vulnerable post-acute phase to improve the prognosis and quality of life for patients.Recently, several meta-analyses have shown that the patterns of care supported by telemedicine are not only effective, but also economically advantageous. The benefit is unquestionable with a 30-35% reduction in mortality and a 15-20% reduction in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management as all modern devices can transmit technical and diagnostic data. However, telemedicine can bring benefits to the patient with heart failure only if it is part of a shared and integrated, multidisciplinary and multiprofessional "Chronic Care Model". Moreover, the future development of remote telemonitoring programs in our country goes through the primary use of products certified as medical device, field validation of organizational solutions proposed, a legislative and administrative adaptation to new care methods and the widespread growth of competence in clinical care to remotely manage the complexity of chronicity.With this consensus document the Italian Cardiology reaffirms its willingness to contribute to the government of the tumultuous and fragmented technological development, proposing a new phase of qualitative assessment, standardization of processes and testing the application of telemedicine to heart failure. more...

Rivaroxaban is a new oral direct factor Xa inhibitor recently approved for the treatment of venous thromboembolism (VTE) and for the prevention of stroke in nonvalvular atrial fibrillation (AF). Using a modified Delphi method, a group of Italian multidisciplinary specialists (internists, hematologists, angiologists, cardiologists, neurologists) guided by an expert panel reviewed the practical management of these clinical conditions in different healthcare settings and debated the limitations and gaps in clinical studies, national guidelines and the role of rivaroxaban in VTE and nonvalvular AF. This survey, named "EXTRA project", was divided into two arms (EXTRA-VTE, EXTRA-AF) and took place in two phases: the first was based on a questionnaire filled out on-line, and the second was a meeting attended by all the specialists to address the most controversial topics. Almost all of the participants expressed agreement in considering rivaroxaban a new cornerstone of stroke prevention and treatment of VTE. They appreciated its predictable pharmacokinetics and pharmacodynamics, the wide therapeutic window, the lack of relevant interactions with many commonly prescribed co-medications, no requirement for routine coagulation monitoring or dose adjustment, and the good tolerability in a broad spectrum of patients at high risk of complications. The results are here reported and discussed together with the therapeutic contextualization and the future clinical perspectives of rivaroxaban. more...

Background: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, particularly in the elderly. AF is considered an independent predictor of mortality and risk factor for stroke. AF-related stroke is usually severe and associated with a high rate of mortality and disability. Despite its prevalence, AF is a poorly known disease and it is underestimated by the general population. The aim of the Censis survey was to analyze the levels of AF knowledge and information in the Italian population and the level of AF risk awareness by general practitioners and AF patients., Methods: The survey included structured interviews with a sample of 1000 Italian citizens aged ≥18 years, 300 general practitioners, and 1200 AF patients., Results: The analysis confirmed low levels of knowledge of AF. In particular, the results showed that only one third of Italians know AF that is however perceived as a severe disease. In this subgroup, the risk of stroke associated with AF is known by 65%, but it is also widespread the wrong concept that AF is associated with an increased risk of myocardial infarction. The lack of knowledge of AF and its complications by the Italian population is due to educational gaps of general practitioners. In particular, only 50% of the Italian general practitioners perceive the thromboembolic risk of paroxysmal AF as comparable to that of permanent AF. In addition, there is an underuse of the scores for thromboembolic and hemorrhagic risk stratification recommended by current guidelines and a frequent use of antiplatelet therapy rather than oral anticoagulant therapy. There is also a low level of knowledge and awareness of the disease among AF patients. However, the majority of AF patients are aware of the importance of antithrombotic prophylaxis for stroke prevention., Conclusions: This study demonstrates limited knowledge and awareness of AF in the general population and also among general practitioners and affected patients. more...

The Italian National Outcome Programme has assessed the performance of Italian hospitals regarding several clinical performance indicators, including 30-daymortality after admission for acute myocardial infarction. Risk adjustment was obtained using demographic and comorbidity data based on the hospital discharge databases in the index admission, as well as in those of the previous two years. Noticeably, the ICD-9-CM 410.7* classification coding for NSTEMI (Non-ST elevation myocardial infarction)myocardial infarction, i.e. the less severe form, was not used, due to known variability in its use. We found that hospital-specific adjusted relative risk of death versus the national mean, as computed by the programme, is negatively associated with the proportion of NSTEMI infarctions at each Tuscan and Florentine hospital, coherently with the hypothesis of a selection by the emergency network, which addresses STEMI (ST elevation myocardial infarction) patients to hospitals offering haemodynamic laboratory with reperfusive services. Individual level clinical data of 3,200 patients in the AMI-Florence study in the period April 2008-March 2010 found that ICD-9-CM410.7* is underused. The analysis based on hospital discharge diagnoses (410.7* vs. other 410* codes) cannot explain differences in mortality among Florentine hospitals, as opposed to the use of a classification of myocardial infarction type (STEMI vs. NSTEMI) based on clinical data collected in AMI-Florence. more...

Heart failure and myocardial infarction result in considerable consumption of healthcare resources. Therefore, there is interest in the availability of drug therapies that can favorably modify their prognosis in the post-acute phase, reducing mortality and rehospitalization rates. Aldosterone antagonists represent a class of drugs which offer advantages in these settings, in addition to those obtained with beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, even though attention should be drawn to their potential adverse effects. In particular, eplerenone exhibits a better safety profile than spironolactone. Since it has very little affinity for glucocorticoid, androgen and progesterone receptors, eplerenone has less antiandrogenic and progestagenic effects, resulting in a lower incidence of gynecomastia. The EPHESUS study showed that eplerenone can reduce mortality in the short and long term and the rate of new hospitalizations after a myocardial infarction complicated by heart failure. In addition, in the EMPHASIS-HF study eplerenone reduced cardiovascular mortality and hospitalizations after mild heart failure (NYHA class IIa). Despite these important results, which confirmed those obtained with spironolactone in severe heart failure in the RALES study, aldosterone antagonists are still underutilized. In particular, eplerenone is not yet available in Italy, although it is recommended by the latest European Society of Cardiology guidelines. more...

Background: Heart failure (HF) is one of the leading causes of hospitalization and medical expenditure, especially in elderly patients. Cooperation between specialists and general practitioners may improve outcomes. A 1-year hospital-territory disease management program was designed in collaboration with the Tuscany Region and the Ministry of Health involving specialists, general practitioners and nurses to investigate the impact of our model on healthcare organization and hospitalization rates in patients with HF., Methods: The program used a web-based clinical report form, and monitoring of patients from specialists and nurses was coordinated by the general practitioners. We enrolled 106 patients (78.3% male, mean age 74.6 years), with a mean left ventricular ejection fraction 49% and mean Charlson index 2.2., Results: A statistically significant reduction was observed in the number of hospitalizations and emergency calls compared with the previous year. HF severity did not substantially changed in 69.8% of patients, whereas it improved in 17.0% and worsened in 13.2% (NYHA class)., Conclusions: Our preliminary data suggest that cooperation between hospitals and medical systems in the territory by means of a web-based clinical report may result in better management of healthcare interventions in the territory with subsequent reduction of hospitalizations. An extension of this model is now ongoing for collecting data from different areas, both within and outside Tuscany. more...

Since the mid '90s, the concept of evidence-based medicine has grown exponentially, contributing to the advancement of personalized medicine, which considers the "female gender" as an extremely important area of customization, but orphan of targeted research. Strong evidence do exists demonstrating gender differences in bleeding risk associated with antithrombotic treatment, mostly related to lower values of body mass, organ size and renal function in women than men. Across clinical studies, the search for the specific risk of bleeding in the female vs male gender has gained attention only recently; therefore, data from different studies and relatively limited meta-analyses should be assessed carefully. As for antiplatelet therapy for primary prevention, the risk of major bleeding events, such as cerebral hemorrhage, is lower for women than for men. Conversely, in acute situations in which antithrombotic drugs are given in association, the risk of bleeding is greater for women, in particular for combination therapies with heparin or low molecular weight heparin or thrombolytic agents. Numerous studies in the literature evaluated the incidence of minor and major bleeding during oral anticoagulant therapy in relation to gender, but the results are not entirely consistent and appear to vary over the years. In summary, there are some aspects of guidance in the complex spectrum of the bleeding risk related to antithrombotic treatment, with indications of a lower bleeding risk in women than men related to long-term preventive single antithrombotic drug treatments. In addition, hormonal effects and use of outprescribed drugs may also play a significant role in modulating hemostasis. more...

Over the last years, numerous evidence on the existing relationship between nutrition and chronic degenerative diseases have led investigators to search for the optimal dietary pattern to maintain a good health status. It's well known, in fact, that nutrition is capable of substantially modifying the risk profile ofa subject in primary and/or secondary prevention. Several models of diet have been imposed on public attention, but the one that got the most interest is certainly the Mediterranean diet. Recently, several studies have shown that a strict adherence to a Mediterranean dietary pattern is associated with a lower incidence of mortality and incidence of chronic degenerative diseases such as cardiovascular disease and cancer. Meta-analyses conducted by our group have revealed, in a population of over than 2 million of people, that adherence to Mediterranean diet determines a significant reduction on the risk of cardiovascular and cerebrovascular accidents. To the best of the knowledge the most effective indications for an optimal therapeutic strategy in nutrition include: increase the consumption of fruits and vegetables up to the recommended 5 servings a day, prefer whole grains, replace saturated and trans fats with unsaturated fats, reduce the consumption of sugar and sweetened beverages, and limit salt intake. With these simple indications, together with recommendations of following the principles of the traditional Mediterranean diet, a substantial reduction of the risk of incidence and/or mortality from cardiovascular disease can be easily obtained. more...

Background: Tako-tsubo (stress) cardiomyopathy (TTC) is a recently described acute cardiac syndrome that mimics ST-segment elevation myocardial infarction. The TTC Tuscany Registry is an observational prospective multicenter registry established to define the prevalence, epidemiology and prognosis of TTC in the Tuscany area., Methods: From January 1 to December 31, 2009, 105 consecutive patients hospitalized in the 14 Cardiology Units of the Tuscany Region with a diagnosis of TTC, were enrolled in the registry. TTC diagnosis was made using the Mayo Clinic modified criteria. Clinical, instrumental, laboratory and 6-month follow-up data were collected. Results. TTC represented 1.2% of all myocardial infarctions in the Tuscany Region during 2009, and it was diagnosed in 0.6% of the angiographic exams performed during the same year. The data collected showed that TTC affects mainly the female gender (91%) in the post-menopausal period (70 ± 11 years), though 5% of patients were ≤50 years old. An antecedent stressful event was frequently detected (74%). The main clinical presentation was chest pain (86%), associated with ST-segment elevation (59%). Mean left ventricular ejection fraction on admission was 40 ± 9%, and was associated with apical (37%), midapical (49%) or midventricular (5%) wall motion abnormalities. Left ventricular ejection fraction recovered to 51 ± 9% in 7 ± 9 days. Heart failure was the most common complication in the acute phase (14%), and 4 patients presented with cardiogenic shock. No patient died during the index hospitalization. At 6-month follow-up, no patient had TTC recurrence, 9 patients were rehospitalized (7 for noncardiac disease) and 2 patients died of noncardiac causes., Conclusions: Our data, which represent the largest prospective series of patients with a diagnosis of TTC, show that the prevalence of TTC in Tuscany is similar that described in other national and international studies. Moreover, the data highlight that TTC may occur also in male patients and in patients aged <50 years. The mid-term prognosis is good, but the risk of acute complications related to heart failure cannot be neglected. more...

About 50% of patients with sepsis show myocardial involvement characterized by biventricular enlargement, reduced contractility and diastolic dysfunction. This increases the risk of death and leads to an extremely poor prognosis in the case of severe sepsis or septic shock, with full recovery of cardiac function seen in survivors at 7-10 days. The pathogenesis of myocardial dysfunction has long been investigated and, although it is still not fully understood, seems not to be due to reduced coronary flow, but to circulating substances released by pathogens (e.g. endotoxins) and host immuno-inflammatory responses (e.g. cytokines and mechanisms related to nitric oxide). First-line therapy is causal and consists of antibiotics plus the surgical excision of the infectious focus; in the presence of severe sepsis or septic shock, it is also necessary to promptly start circulatory and multiorgan support treatment. This review describes current knowledge concerning the instrumental and clinical characteristics, pathophysiology, prognosis and therapy of myocardial dysfunction during sepsis, and briefly considers possible future therapeutic perspectives. more...

The intima-media thickness (IMT) is defined as the distance between the hyperechogenic inner (blood-intima interface) and outer line (media-adventitia interface) of the arterial wall. It is a surrogate marker of atherosclerotic damage. No consensus guidelines are available on which site and how carotid IMT sampling should be performed, and comparison among data from different studies is difficult. IMT is the "phenotype" of the early phases of atherosclerotic disease and is related to the main traditional risk factors. Moreover, IMT is a marker of organ damage either in the heart or in other vascular districts. Although threshold IMT values for the prediction of cardiovascular events have not been identified, high IMT values are associated with an increased occurrence of cardiovascular events. Indeed, an IMT > or = 0.9 mm was demonstrated to be associated with an increased cardiovascular risk even after age adjustment. The value of IMT as an independent risk factor is still under debate, especially in young patients at intermediate risk. Moreover, the IMT regression reported in therapeutic trials with statins and antihypertensive drugs was only weakly or not at all associated with a decrease in cardiovascular events. In comparison to carotid IMT, femoral IMT is more strictly correlated with the severity of coronary artery disease and the need for revascularization in effort angina. The simultaneous measurement of carotid and femoral IMT may improve risk stratification in patients with coronary heart disease. The challenge for the future is to establish an IMT cut-off value for a better definition of the individual cardiovascular risk. Such cut-off value may be derived from the combined measurement of carotid and femoral IMT. more...

Isolated ventricular premature beats are the most common arrhythmia in clinical practice. Not all ventricular premature beats are equal, as they may evolve into worsening of the arrhythmia and even severe left ventricular dysfunction in some subsets of patients, particularly those with frequent ventricular premature beats originating from the left ventricle. The resulting systolic dysfunction is reversible following arrhythmia termination. Radiofrequency ablation allows us to achieve effective and safe results and should be considered the treatment of choice. We report a case of left ventricular dysfunction without signs of structural heart disease, secondary to left ventricular premature beats evolved into runs of non-sustained ventricular tachycardia, successfully treated with radiofrequency ablation of the arrhythmic focus. more...

The prevalence of non-alcoholic fatty liver disease (NAFLD) ranges from 17% to 33% in the general population. It is frequently associated with obesity (60-90%), dyslipidemia (27-92%), diabetes (28-55%) and arterial hypertension (22%); in the presence of the metabolic syndrome, its incidence is 2-fold higher. NAFLD can be considered as an early mediator of the atherosclerotic process with which it shares some pathogenetic mechanisms (insulin resistance, oxidative stress, endothelial dysfunction, inflammatory activation). Patients with NAFLD are usually asymptomatic, high values of liver enzyme tests being the most common finding. Although liver biopsy is the current gold standard for diagnosis of NAFLD, it is not a practical screening tool given the cost, time-consuming nature and potential morbidity of this procedure. Ultrasound is a relatively inexpensive technique of liver imaging. Patients with NAFLD exhibit a higher mortality rate than the general population. The most frequent causes of death are represented by liver-related diseases, malignant neoplasms and cardiovascular disease, the latter being as frequent as malignant neoplasms. Data on cardiac abnormalities in patients with NAFLD are scarce. Abnormalities in left ventricular geometry and diastolic function have been described in patients with NAFLD as well as a more severe coronary artery disease characterized by vulnerable plaques, though observed in small cohort studies. According to the available evidence, NAFLD should be taken into consideration by cardiologists because its identification allows a better risk stratification in both primary and secondary prevention. Its correlation with coronary artery disease strongly suggests that NAFLD plays a proatherogenic role per se, in addition to the well known atherosclerotic risk factors. The finding of increased fatty liver content should prompt to assess the coexistence of other risk factors as well as to tailor the appropriate therapeutic regimen in order to reduce fatty liver content. more...

The "Continuity of Care Hospital", which is now realized in the Santa Verdiana Hospital, Castelfiorentino (Italy), is aimed at solving the existing gap between hospitalists and primary care physicians. This new model of care could represent an effective tool for solving the emerging medical and teaching needs of a population characterized by advanced age and comorbidities. more...

A commonly used definition describes an error as a harmful or potentially harmful occurrence for the patient. Although over the last years the evolution of medicine has been characterized by remarkable technological advances, the percentage of errors in clinical practice has not changed since the '40s. In this setting, the aim of our review is to assess how errors develop in real life in modern cardiology and how they can be identified early, corrected, and possibly prevented. In our opinion, the more a healthcare system (i.e., a cardiology ward or a hospital) is capable of facing its error, the safer it is. In our daily practice, errors can be distinguished in "clinical errors" (mainly related to knowledge) and "system errors" (mainly referring to healthcare organization; i.e., the integrated cardiac network). Bearing in mind the high frequency and consequences, cardiologists should consider errors as among the main determinants of quality of care, which the whole team has to deal with. Time and resources should be spent to identify the best approaches to cope with errors, tailored for each cardiology team. Ultimately, the care of a patient with heart disease should be viewed holistically and not as the afinalistic sum of procedures, no matter how technically developed. more...

Clopidogrel in combination with aspirin is the recommended standard of care for reducing the occurrence of cardiovascular events in patients presenting with acute coronary syndromes; these protective effects of clopidogrel have been shown both in patients undergoing percutaneous coronary intervention (PCI) and in those treated with medical therapy alone. However, significant shortcomings still exist, including a delayed onset of action in platelet inhibition, individual response variability (with some patients being frankly hyporesponsive), and a prolonged time to recovery of platelet function following cessation of treatment. Among these, clopidogrel hyporesponsiveness seems to be particularly important, as a growing body of evidence suggests that residual platelet reactivity on clopidogrel is associated with a significant increase in the risk of developing adverse clinical events. Prasugrel is a novel, third-generation oral thienopyridine that is a specific, irreversible antagonist of the platelet adenosine 5'-diphosphate P2Y12 receptor. Prasugrel has more potent antiplatelet activity, faster onset of action, and less interpatient variability as compared to clopidogrel. These pharmacodynamic properties led prasugrel to be more effective in preventing ischemic events in patients with acute coronary syndromes undergoing PCI in the setting of the recent TRITON-TIMI 38 study. However, the greater protective effects toward ischemic events were partially counterbalanced by an increased risk of bleeding, particularly in patients with history of transient ischemic attack/stroke, in those with body weight <60 kg and in those older than 74 years. A favorable net clinical benefit of prasugrel compared with clopidogrel has been shown. more...

"End stage" heart failure is unresponsive to conventional pharmacological and non pharmacological treatments and has a bad prognosis either regarding survival or quality-of-life; besides cardiac transplantation is limited by organ shortage. Therefore mechanical devices have been developed, initially as "bridge to transplantation" and, more recently, as "destination therapy": definitive treatment for non-transplantable patients. In these patients instrumental evaluation, treatment and rehabilitation are not yet defined and standardized. This paper reports the initial experience realized, as a part of a regional cooperation project within Florence and Siena University Hospitals activities, with the first three male patients, aged 45 to 70 years, affected by end-stage heart failure (NYHA class IV), non-eligible to transplantation, and implanted with Jarvik Flowmaker 2000, an intraventricular axial-flow VAD generating a continuous blood flow. After clinical stabilization, patients underwent a specific evaluation and treatment purposely designed for these subjects during ICU and post-ICU stay and, subsequently, a formal cardiac rehabilitation program. Hemodynamic, bioumoral and functional parameters were recorded at the beginning, during and at the end of intensive rehabilitation program. All patients completed the program, achieving a remarkable and meaningful functional recovery, such to allow them going home, continuing with a self-activity with weekly follow-up in the Rehabilitation Center. The experience acquired by following these patients longitudinally--from the VAD implantation to hospital discharge--allowed us to develop a flow-chart divided in five phases, identifying the main clinical problems, the rehabilitative treatment goals and the useful indicators to define criteria for shift from every phase to the following one. more...

Mediterranean diet (MD) is an eating pattern that has been worldwide promoted as a model for healthy eating and has been reported to contribute to a favourable health status and to a better quality of life. Over the last years, despite evidences on the beneficial effects of the single components of MD have been reported, research interest has been focused on the whole dietary pattern rather than on a single nutrient, since individual analyses of nutrients and food can ignore important interactions between components of a diet and, more importantly, because people do not eat isolated nutrients. Therefore, dietary scores estimating the adherence to the MD have been operationalised and have been found to be associated with a reduction of overall mortality, cardiovascular diseases, hypertension and obesity. Furthermore, a high degree of adherence to MD has been found related to lower concentrations of inflammation, endothelial dysfunction and coagulation markers. In a recent meta-analysis on over than 1,5 million of persons we were able to demonstrate that a higher adherence to Mediterranean diet is associated with a significant reduced risk of incidence and mortality from all causes and from cardiovascular, neoplastic and neurodegenerative diseases. more...

British and US surveys document that the time dedicated weekly by physicians to the critical evaluation of biomedical journals is limited and should be expanded. This in the light of the fact that clinicians increasingly need controlled and updated medical information. The critical interest and competence in the evaluation of medical literature may be taught at the University. Universities, and in particular Medical Schools, include, among their tasks, education, research and health care. A modern and effective education in the critical analysis of biomedical journals should represent an important methodological feature of Medical Schools, given that it can constitute an instrument for the reasoned analysis of the profile of biomedical research and for the synthesis and incorporation of research results into daily clinical practice. more...

A historical analysis of Western medicine clearly indicates high attention to the body dimension and to corporeal functions. Even if what today may be defined "the science of physical exercise in medicine" goes back only to the last fifty years, the great Mediterranean cultures have always dedicated great care to the harmonic development of the human body. The importance of the role of physical exercise in maintaining an appropriate health status is mentioned in the Hippocratic Corpus (V-IV century before Christ). In the contemporaneous Hippocratic Oath one may read that the physicians of the Hippocratic School are called upon to "regulate the lifestyle of sick people in the light of their well being". At that time the prescriptions regarding patients' lifestyle, taking into account the limited effectiveness of therapeutic measures, were primarily concentrated on an appropriate diet and motor activity. This historical review describes the evolution of physical activity in medicine with regard to the current awareness of its relevance at every stage of life; the presentation of the historical roots of the concepts of motor activity and of physical exercise and of their progress through time aims at defining their current preventive, therapeutic and rehabilitative roles. more...

During the 17th century, new drinks entered the European market: wine and beer, which were largely widespread among the different European countries, were joined by coffee and tea; their consumption at was first limited to the higher classes, but they soon became popular at all levels of society. Even if their therapeutic effects were strongly stressed from different points of view, at first they encountered a certain resistance. Tea, in particular, represented a sort of compromise between a pleasant habit, bound to economic and social reasons, and a therapeutic scope. Green tea is unfermented tea. In Japan the most frequently used method of production is steaming, that deactivates the oxidase in tea leaves, determining the retention of a brilliant green colour. Its use has been proposed in a number of clinical conditions and pathologies, even if its putative therapeutic properties must be further assessed in rigorously designed and conducted clinical trials. Aim of this paper is to call needed attention to the potential role of green tea extracts in prevention and in therapy in relation to the scientific methodology of clinical research. more...

This paper presents an analysis of some innovative educational perspectives regarding the figure of the physician, on the basis of the awareness that the cultural formation of the medical class represents a major strategy in achieving a high quality medical standard and an effective evidence-based health care. Quality education, both during the graduate curriculum and in the post-graduate phase (today including Decision Making, Knowledge Management, Health Economics, General Practice Medicine, Evidence Based Medicine and Evidence Based History of Medicine, as in the Florence Medical School), is essential for the training of updated health professionals, as well as being geared to life-long learning. The classical medical education paradigm involved knowing, knowing how to do and knowing how to be; today this model should be enriched by other key competences for practicing medicine, among them knowing how to make other people do things and knowing how to continue with self-education. With specific reference to making others carry out tasks, the current need for team work renders it necessary for physicians to reconstruct their competences continuously in the light of the essential integration with the competence of non-medical colleagues with whom they work in an inter-disciplinary pattern. With regard to knowing how to continue with self-education, this is possibly the most relevant current and future challenge, not only for health systems but also for physicians. more...

Over the last decades, an increasing body of evidence has been accumulated on the beneficial effect of polyunsaturated fatty acids both in primary and secondary prevention of cardiovascular diseases. However, the vast majority of the studies has been performed on long-chain polyunsaturated fatty acids, such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) and not on their biochemical precursor, alpha-linolenic acid (ALA). Actually, ALA has some other beneficial effects apart from the known antiarrhythmic effect. In fact, ALA has a strong inhibitory effect on omega-6 metabolic pathway. An adequate daily intake of ALA shifts metabolic pathway to EPA, so favoring the formation of products with a predominant antiaggregating and vasorelaxing action, with respect to eicosanoids with a predominant thrombotic effect. Some important evidences have been raised on the association between ALA and cardiovascular mortality. Indeed, dietary ALA has been associated with a lower rate of fatal and nonfatal coronary events. Hence, major scientific associations published nutritional guidelines including a specific recommendation for ALA. more...

The growing number of research on quality of life is stimulated by the need to compare therapeutic treatments that have a similar efficacy to reduce mid- and long-term mortality, but that can warrant different levels of quality of life. The aim of this review was to describe theories and applications of different questionnaires (generic vs specific), methodology to construct a new questionnaire, and the methods of translation and cross-cultural adaptation in another language. Finally, the characteristics of the Coronary Revascularization Outcome Questionnaire, a validated instrument that measures symptoms, physical, psychosocial and cognitive function, adverse effects and satisfaction with treatment for bypass surgery and coronary angioplasty are described. The Italian version is actually used in a multicenter trial in several heart surgery and interventional departments. more...

The antiphospholipid syndrome is associated with complications of pregnancy or venous or arterial thrombosis in the presence of antiphospholipid antibodies. Venous thromboembolism is the most common clinical feature. Pathogenetic mechanisms underlying the syndrome are not completely understood and several hypotheses have been raised. Secondary prophylaxis after venous thromboembolism episodes requires oral anticoagulants (prothrombin time-international normalized ratio 2-3) for 6 to 12 months. More intensive anticoagulant regimens are indicated in case of recurrence. A longer or life-long course of treatment is indicated in patients with recurrent or life-threatening events or in the presence of high titers of antiphospholipid antibodies. Among risk factors for venous thromboembolism, inherited thrombophilia is recently described, such as defects of the physiological coagulation inhibitors, genetic mutations of factor V and factor II of the coagulation cascade and hyperhomocysteinemia. High levels of factor VIII, factor IX and lipoprotein(a) have recently been proposed as new risk factors for venous thromboembolism. The coexistence of inherited thrombophilia seems to enhance the thrombogenic risk, in particular in the venous vascular bed. The new insights into the diagnosis of inherited thrombophilia could allow a better evaluation of the thrombotic risk, leading to tailor the prophylactic strategy. more...