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With the growing knowledge about the role of inflammatory processes in the pathogenesis of atherosclerotic lesions, inflammation has been identified as a cardiovascular risk factor and therapeutic target to reduce the residual risk in patients with atherosclerotic disease. Several therapeutic agents with anti-inflammatory action have been tested to evaluate their efficacy and safety in the context of atherosclerotic cardiovascular diseases. Among these, colchicine, a drug with multiple therapeutic effects including anti-inflammatory action, in randomized clinical trials conducted in the setting of atherosclerotic cardiovascular disease secondary prevention, significantly reduced the risk of adverse cardiovascular events.This position paper of the Italian Association of Hospital Cardiologists (ANMCO) summarizes the main biological mechanisms through which colchicine contributes to the inhibition of inflammatory processes that increase the atherosclerotic cardiovascular risk. Furthermore, the document reports the available evidence on clinical impact of colchicine treatment in the reduction of residual cardiovascular risk in chronic and acute coronary syndromes. Finally, practical information is provided regarding the use of this drug in this specific clinical setting, emphasizing precautions and possible side effects.

The perspective on amyloidosis has changed deeply over the last 10 years following major advances in diagnosis and treatment options, especially in cardiac amyloidosis. This intrinsically heterogeneous disease exposes to the risk of fragmentation of knowledge and requires the interaction among experts of different specialties and subspecialties. Suspicion of disease, timely recognition and confirmation of final diagnosis, prognostic stratification, clinical management and therapeutic strategies represent essential steps to be taken. Missing or delaying the diagnosis may have dramatic impact on patient outcome, as in the case of chemotherapy in unrecognized light-chain amyloidosis. Therefore, there is an urgent need for the foundation of an Italian Amyloidosis Network to deal with the challenges of this condition and orient clinical management at national and local levels. The present consensus document aims to provide the rationale and scopes of the Italian Amyloidosis Network, which has been conceived as an organizational framework for professionals managing patients with amyloidosis.

Inflammation plays an important role in cardiovascular disease. Growing evidence suggests a profound involvement of the inflammatory response in the development and progression of atherosclerosis and its complications. In patients with atherosclerotic cardiovascular disease (ASCVD), residual cardiovascular risk often remains high despite optimal medical therapy and the achievement of the therapeutic targets recommended by current guidelines. Among the multiple components of residual risk, residual inflammatory risk, assessed by plasma levels of high-sensitivity C-reactive protein, has shown a strong association with the incidence of cardiovascular events. Recent studies suggest that therapeutic modulation of inflammation, particularly the interleukin (IL)-1/IL-6 pathway, is a promising strategy for the prevention and treatment of cardiovascular and kidney diseases. This review aims to discuss pragmatically the interaction between inflammation and ASCVD, describe current evidence on anti-inflammatory therapies in patients with cardiovascular and renal diseases, and outline the potential implications of these new therapeutic approaches in contemporary and future practice.

Vaccine-associated myocarditis and pericarditis usually develop within 14 days of COVID-19 vaccination, are exceptionally rare, manifest with mild clinical pictures and are commonly characterized by a favorable evolution. Young men inoculated with two doses of an mRNA vaccine are the subgroup at higher risk. Recent epidemiological studies evaluated the incidence and risk of vaccine-associated myocarditis and pericarditis among men and women, in different ranges of age and specific types of vaccines. Long-term population analyses demonstrated that the cardiovascular risk conferred by COVID-19 extends beyond the acute phase, representing the rationale for implementing prevention strategies for SARS-CoV-2 infection, monitoring specific populations at higher risk and pursuing the completion of the vaccination campaign. This document provides an update on the most recent scientific evidence and critical interpretation of available data in constant evolution towards personalized strategies of immunization.

Although traditionally considered a rare and incurable condition, the perspective on cardiac amyloidosis (CA) has changed deeply over the last 10 years following major advances in diagnosis and treatment options. First, the development of non-invasive diagnostic methods, predominantly cardiac scintigraphy with bone tracers, has dramatically changed the epidemiology of the disease, revealing the real prevalence of the transthyretin-related form (ATTR), and has consistently reduced the need for histological amyloid confirmation by endomyocardial biopsy. Second, the availability of new specific therapies, such as tafamidis, has made CA early recognition a clinical need with major impact on patients' management and natural history. Since the demonstration of the essential role of bone tracer scintigraphy to non-invasively differentiate ATTR from immunoglobulin light-chain amyloidosis (AL), this imaging technique has become part of the vocabulary and clinical practice of physicians of many specialties, including cardiologists managing patients with cardiomyopathies.In this paper, we address the main questions regarding cardiac scintigraphy with bone tracers and CA, providing cardiologists with the knowledge to guide clinical indications, evaluation and clinical interpretation of images.

Heart failure is a complex clinical syndrome with a severe prognosis, despite therapeutic progress. The management of the advanced stages of the syndrome is particularly complex in patients who are referred to palliative care as well as in those who are candidates for cardiac replacement therapy. For the latter group, a prompt recognition of the transition to the advanced stage as well as an early referral to the centers for cardiac replacement therapy are essential elements to ensure that patients follow the most appropriate diagnostic-therapeutic pathway. The aim of this document is to focus on the main diagnostic and therapeutic aspects related to the advanced stages of heart failure and, in particular, on the management of patients who are candidates for cardiac replacement therapy.

Eosinophilic myocarditis is a rare form of myocardial inflammation characterized by interstitial infiltration by eosinophils. Clinical presentation may vary from complete absence of symptoms to fulminant myocarditis with cardiogenic shock, to chronic heart failure due to progression to restrictive cardiomyopathy. The main causes of eosinophilic myocarditis are hypersensitivity reactions secondary to drug exposure, eosinophilic granulomatosis with polyangiitis, hypereosinophilic syndrome and infections. Antibiotics and agents acting on the central nervous system are the most frequently reported drugs capable of causing hypersensitivity myocarditis. Infections are usually due to intestinal parasites. Imaging techniques together with clinical and laboratory data help rising the suspicion of eosinophilic myocarditis. However, the definite diagnosis is made by endomyocardial biopsy. The evidence of eosinophilic infiltrate among myocytes allows to start an immunosuppressive treatment, usually based on corticosteroids, that are the cardinal therapy for eosinophilic myocarditis. Anticoagulation should be undertaken in case of endoventricular thrombosis, which frequently complicates eosinophilic myocarditis, mainly those cases associated with hypereosinophilic syndrome and eosinophilic granulomatosis with polyangiitis. In this focused review, we will try to provide answers to the most common questions on the causes, presentation, diagnosis, treatment, and outcomes of eosinophilic myocarditis.

Anti-interleukin (IL)-1 agents have been developed for the treatment of autoinflammatory diseases characterized by overproduction of IL-1. Idiopathic recurrent pericarditis with inflammatory phenotype (fever, leukocytosis, and elevation of C-reactive protein) has similar features and responds well to this treatment. At present, in Italy, prescription of anakinra is possible for idiopathic recurrent pericarditis with corticosteroid dependence and colchicine resistance. Anakinra is a recombinant antagonist of IL-1 receptor and blocks either IL-1α (released from pericardial cells) or IL-1β (derived for inflammatory cells, during pericarditis). Anakinra is prescribed at the dose of 2 mg/kg/day subcutaneously up to 100 mg/day subcutaneously for at least 3 to 6 months with subsequent tapering. Anakinra allows a quick control of symptoms after 1-2 doses and a fast and safe tapering and withdrawal of corticosteroids. Colchicine can be used together with anakinra. The most common side effect is represented by local skin injection site reactions after 1-2 weeks of therapy. These reactions are usually transient and can be treated by anti-histamines and topical corticosteroids. Less common side effects include elevation of transaminases (4-5%), cutaneous or respiratory infections (2-3%), and leukopenia (1-3%). Side effects are rarely responsible for permanent discontinuation of therapy. The aim of the present review is to provide a practical guide on the use of these drugs for cardiologists, who are often not familial with this new therapy for pericarditis.

The triple therapy (angiotensin-converting enzyme [ACE] inhibitors or angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists) certificated by the 2012 guidelines for symptomatic patients with heart failure and reduced ejection fraction, reaffirmed in the following document of 2016 with the introduction of angiotensin receptor-neprilysin inhibitors (ARNI), has not yet reached an adequate implementation in clinical practice (where the majority of patients is only treated with the double treatment of ACE-inhibitors or angiotensin receptor blockers and beta-blockers). Among the reasons for this general failure, we should consider the enrollment of unselected cases from the real world, without exclusion criteria for age, comorbidity and stage of the disease, the therapeutic inertia of many cardiologists and not least the clinical and organizational complexity of the conventional scheme of implementation of therapy indicated by the guidelines. Not only the prescription of triple therapy is inadequate, but also the "target doses" defined by the large randomized controlled trials should be considered unrealistic in the majority of patients, who often achieve a therapeutic effect at lower doses, generally better tolerated ("target effect"). The new guidelines forthcoming will certify a further step forward with the quadruple therapy (sodium-glucose co-transporter 2 inhibitors, ARNI, beta-blockers and mineralocorticoid receptor antagonists), underlining how a fourfold intervention with different pharmacological mechanisms is able to determine the greatest benefits in patients with systolic heart failure. The discussion is open on the possibility of simplifying and speeding up the conventional implementation scheme of treatment, exploiting the ability of all these pharmacological principles to exert a significant and rapid favorable effect on prognosis already at a low dose in the first 4-8 weeks of treatment.

The COVID-19 pandemic represents an unprecedented event that has brought deep changes in hospital facilities with reshaping of the health system organization, revealing inadequacies of current hospital and local health systems. When the COVID-19 emergency will end, further evaluation of the national health system, new organization of acute wards, and a further evolution of the entire health system will be needed to improve care during the chronic phase of disease. Therefore, new standards for healthcare personnel, more efficient organization of hospital facilities for patients with acute illnesses, improvement of technological approaches, and better integration between hospital and territorial services should be pursued. With experience derived from the COVID-19 pandemic, new models, paradigms, interventional approaches, values and priorities should be suggested and implemented.

The European Society of Cardiology guidelines on non-ST-elevation acute coronary syndromes suggest different temporal strategies for the angiographic study depending on the risk profile. The scientific evidence underlying the guideline recommendations and the critical issues currently existing in Italy that often do not allow either an extended strategy of revascularization within 24 h or the application of the principle of the same day transfer from a spoke to a hub center are analyzed. The position paper focuses, in particular, on the subgroup of patients with a defined diagnosis of non-ST-elevation myocardial infarction by proposing a timing of coronary angiography/revascularization that takes into account the available scientific evidence and the organizational possibilities of a considerable part of national cardiology services.

Colchicine is one of the more ancient drugs of vegetal origin still in use in clinical practice. It has been used for centuries as drug to treat gout, but its anti-inflammatory effects made it efficacious also in different cardiovascular indications (e.g. pericarditis, acute and chronic coronary syndromes, atrial fibrillation), that are well beyond its original indication. The treatment and prevention of pericarditis is the only registered cardiovascular indication in Italy (allowing prescription in class A by the National Healthcare System), while other indications are off-label. When used at low doses (0.5 mg/day), the drug is safe and efficacious with limited side effects, mainly gastrointestinal. Gastrointestinal absorption is fast since the drug is a small lipophilic molecule that is eliminated by cells through P-glycoprotein. Colchicine is metabolized by cytochrome P450 in the liver and mainly excreted into the biliary tract. It is also excreted, essentially unmodified, by the kidneys. It is concentrated in white blood cells, especially neutrophils, that are without P-glycoprotein. In these cells, blocking tubulin polymerization, colchicine reduces their function, also interfering with endothelial adhesion and platelet interactions. Moreover, it is responsible for a non-specific inhibition of the inflammasome, thus reducing the generation of pro-inflammatory cytokines, such as interleukin-1. The aim of this paper is to provide concise replies to the most common clinical questions on the use of colchicine for cardiovascular indications.

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists (ANMCO), reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure. Data deriving from a national survey in Italian hospitals about IABP use are also provided.

Myocarditis is an inflammatory heart disease that can occur acutely, as in acute myocarditis, or persistently, as in chronic myocarditis or chronic inflammatory cardiomyopathy. Different agents can induce myocarditis, with viruses being the most common triggers. Generally, acute myocarditis affects relatively young people and men more than women. Myocarditis has a broad spectrum of clinical presentations and evolution trajectories, although most cases resolve spontaneously. Patients with reduced left ventricular ejection fraction, heart failure symptoms, advanced atrioventricular block, sustained ventricular arrhythmias or cardiogenic shock (the latter known as fulminant myocarditis) are at increased risk for death and heart transplantation. The presentation of chronic inflammatory cardiomyopathy may be more subtle, with progressive symptoms of heart failure or appearance of rhythm disturbance, not rarely preceded by an infective episode. Autoimmune disorder or systemic inflammatory conditions can be another significant predisposing substrate of myocarditis, especially in women. Emerging causes of myocarditis are drug-related like the new anticancer therapies, the immune checkpoint inhibitors. In this Italian Association of Hospital Cardiologists (ANMCO) and Italian Society of Cardiology (SIC) expert consensus document on myocarditis, we propose diagnostic strategies for identifying possible causes of the disease and factors associated with increased risk. Finally, we propose potential treatments and when referring patients to tertiary centers, especially for high-risk patients. Even if endomyocardial biopsy is the invasive diagnostic tool for making definitive diagnosis and differentiation of histological subtypes (i.e., lymphocytic vs eosinophilic vs giant cell myocarditis), it is not always readily available in all centers. Thus, we propose when this exam is mandatory or when it can be postponed or substituted by cardiac magnetic resonance imaging. This document reflects the Italian perspective on managing patients with myocarditis and their follow-up, considering also current US and European scientific position statements.

Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The Food and Drug Administration and the European Medicines Agency sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like traditional anticoagulants, novel oral anticoagulants may cause gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of gastrointestinal bleeding as compared with warfarin. However, the usefulness of PPIs in patients receiving these anticoagulants deserves to be further demonstrated. Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.

The complexity of cardiovascular diseases has led to an extensive use of technological instruments and the development of multimodality imaging. This extensive use of different cardiovascular imaging tests in the same patient has increased costs and waiting times.The concept of appropriateness has changed over time. Appropriateness criteria address the need for specific cardiovascular imaging tests in well-defined clinical scenarios, and define the kind of cardiovascular imaging that is appropriated for each clinical scenario in different stages of the disease. The concept of appropriateness criteria has replaced the old idea of appropriate use criteria and reflects the increasing effort of the international Scientific Societies to create and review in a critical way the management of diagnostic tests used by clinicians.The aim of this Italian consensus document is to address the use of multimodality imaging in the diagnosis and management of the major cardiovascular clinical scenarios, taking into consideration not only the international guidelines and scientific documents already published, but also the reality of Italian laws as well as the various professional profiles involved in patient management and availability of technological diagnostic instruments.

Managing a patient suffering from a chronic disease requires a multidisciplinary team that can take care of them beyond the simple coordination of various specialties. In this context, a central role in the treatment of chronic heart disease is the continuity of care that should promote organic integration among different hospital departments, hospital and community. This position paper of the Italian Association of Hospital Cardiologists (ANMCO) aims at defining the general principles to inspire care for complex cardiac patients at different phases of the disease. A multidisciplinary integrated holistic approach uses analytical tools able to understand the elements that characterize complexity and therefore suggest appropriate management strategies: (i) care pathways aimed at optimizing treatments; (ii) care pathways in intensive care and ward in a multidisciplinary perspective; (iii) integration of social and health needs; (iv) nursing role in the context of continuity of outpatient, community and home care; (v) promotion of educational interventions.

Cardiac magnetic resonance is an accurate and versatile tool for multiparametric morphologic and functional evaluation of the heart and great vessels, with a wide range of clinical applications: from acute and chronic ischemic heart disease to the assessment of the substrate of complex ventricular arrhythmias and the follow-up of patients with valvular and congenital heart disease. The accuracy in cardiac volume and ejection fraction quantification, tissue characterization, valvular regurgitant fraction and cardiac shunt assessment, pharmachologic stress myocardial perfusion and three-dimensional reconstruction of great vessels are the points of strength that have made Cardiac magnetic resonance an invaluable tool for diagnostic, classification and follow-up of patients with various cardiac diseases.

Cardiac magnetic resonance (CMR) has proved to be a powerful tool in the assessment of several cardiac diseases, thanks to its capability to offer multiparametric morphologic and functional evaluation of the heart and great vessels, using neither ionizing radiations nor nephrotoxic contrast medium. The accuracy in quantification of cardiac volumes and ejection fraction (gold standard) together with native and post-contrast myocardial tissue characterization have made CMR an invaluable tool for the diagnosis, prognosis and therapeutic planning in patients with heart failure and cardiomyopathy.

Cardiac tamponade is a pericardial syndrome characterized by diastolic impairment due to the accumulation of pericardial fluid under pressure. It may be an acute life-threatening condition if not recognized and treated (e.g. cardiac tamponade by hemopericardium), or may present as a subacute condition allowing in some cases a delayed treatment.The causes of cardiac tamponade are the same as for pericardial effusion, primarily cancer in one third of cases (being lung cancer the most common type of cancer), bacterial infections (25% of cases), iatrogenic factors (15% of cases), and acute aortic disease with aortic dissection. Cardiac tamponade is reported in <1% of cases of myocardial infarction and is mainly due to heart rupture, or more rarely to hemorrhagic evolution of post-myocardial infarction pericarditis.Cardiac tamponade is a clinical diagnosis that is confirmed by echocardiography. The risk of recurrent cardiac tamponade is around 10% at 10-year follow-up and is mainly determined by the underlying etiology, with cancer patients showing the highest mortality.In this focused review, we will try to provide answers to the most common questions on the causes, presentation, diagnosis, treatment, and outcomes of cardiac tamponade.

Constrictive pericarditis is one of the most feared complications of patients with pericarditis, especially if recurrent. The common perception is that the higher the number of recurrences, the higher the risk of constriction. However, the risk of constriction is related to the etiology and not to the number of recurrences. Constriction has never been reported as a complication of idiopathic recurrent pericarditis, while the risk is low (<1%) after a first attack of idiopathic or viral pericarditis, intermediate for immune-mediated etiologies (2-5%, e.g. systemic inflammatory diseases, post-pericardiotomy syndromes) and cancer, and high especially for bacterial etiologies (20.30%, e.g. tuberculosis, purulent pericarditis). Constriction may be reversible in the setting of pericarditis and about 7-10% of patients with acute pericarditis may have transient constriction during the acute phase of inflammation, due to increased pericardial stiffness. Empiric anti-inflammatory therapy may prevent pericardiectomy in one half of cases.The clinical diagnosis is not easy but feasible with prompt recognition of the clinical symptoms and signs that may mimic heart failure and chronic hepatic disease (e.g. jugular vein distention, peripheral edema, ascites), the echocardiographic signs (e.g. septal bounce, respiratory variations of transmitral and tricuspid flows, annulus reversus, inferior vena cava plethora), and other imaging features (e.g. pericardial thickening in about 80% of cases, pericardial calcifications).In this paper, we will try to give an answer to common clinical doubts for assessing the risk of constriction, making the diagnosis, and addressing the therapy of these patients also underlying the possible outcomes.

Although a new or worsening pericardial effusion is a diagnostic criterion for pericarditis, in clinical practice the presence of pericardial effusion does not necessarily imply the evidence of pericarditis. Up to 40-50% of cases of pericarditis do not show the presence of pericardial effusion (dry pericarditis). The clinician should first evaluate any related symptoms and signs (symptomatic vs asymptomatic), its size and hemodynamic impact, then rule out pericarditis and the presence of an underlying disease (e.g. cancer, systemic inflammatory diseases, renal failure, hypothyroidism). If no cause is apparent ("idiopathic effusion"), the decision to tap should be individualized and based on symptoms. A large, chronic pericardial effusion may have a good long-term prognosis even without routine drainage.In this paper, we will try to clarify common doubts and outline evidence-based approaches to diagnosis, therapy and follow-up of these patients, also addressing the possible complications and outcomes.

Acute pericarditis is not uncommon in clinical practice and may occur either as isolated disease or as a manifestation of another disease (known or still unknown). The etiology is varied and complex and a clinically-oriented approach to management is possible by identifying initial presentation features of high risk (risk of complications or specific disease: fever >38°C, subacute course without acute chest pain, large pericardial effusion, cardiac tamponade, and lack of response to empiric anti-inflammatory therapy), that suggest admission and additional diagnostic evaluation. In any case, a prompt anti-inflammatory therapy at full doses till remission is warranted to prevent complicated and prolonged courses. In this paper, we will try to clarify common doubts and outline evidence-based approaches to the diagnosis, therapy and follow-up of these patients.

Colchicine has been recently demonstrated to be efficacious and safe for the prevention of several postoperative complications including the postpericardiotomy syndrome (PPS), postoperative pericardial and pleural effusions, and postoperative atrial fibrillation according to the results of the COPPS trial. The aim of the present paper is to critically review the premise, results and implications of this trial for current clinical practice and future research. The COPPS study is a multicenter, double-blind, randomized trial. On the third postoperative day, 360 patients (mean age 65.7 ± 12.3 years, 66% males) were randomized to receive placebo or colchicine (1.0 mg twice daily for the first day followed by 0.5 mg twice daily for 1 month in patients ≥70 kg, and halved doses for patients <70 kg or intolerant to the highest dose). Colchicine significantly reduced the incidence of the PPS at 12 months [relative risk reduction (RRR) 58%; number needed to treat (NNT) 8], postoperative pericardial (RRR 43.9%; NNT 10) and pleural effusions (RRR 52.3%; NNT 8) as well as the incidence of postoperative atrial fibrillation (RRR, 45%; NNT 11) with similar side effects in the study groups. Colchicine is a promising drug for the prevention of several postoperative complications (PPS, postoperative effusions and postoperative atrial fibrillation) based on its anti-inflammatory effects and good tolerability at the study doses. Although further studies are needed before routine recommendation of the drug will be possible for patients undergoing cardiac surgery, colchicine seems to have the potentiality of becoming a new therapeutic standard in the perioperative period.

Pericarditis is a common clinical problem, above all in its incessant and recurrent forms. Treatment should be targeted according to etiology, but this is often unfeasible with a conventional approach, because most cases are labeled as "idiopathic" in the majority of immunocompetent patients from developed countries. Clinical risk stratification of acute pericarditis may be useful to select patients who should be admitted to hospital, and in whom a complete evaluation should be performed to identify causes that require specific therapy. In idiopathic and viral pericarditis the mainstay of treatment is the use of aspirin or a nonsteroidal anti-inflammatory drug with the possible adjunct of colchicine to prevent recurrences, above all in recurrent pericarditis. Corticosteroids are too often considered and should be limited to rare, specific indications (definite rheumatologic disease, presumed autoimmune etiology, intolerance or contraindications to aspirin or non-steroidal anti-inflammatory drugs, pregnancy) being a clear risk factor for a prolonged and chronic course of the disease in idiopathic or viral forms. Despite the common fear of a possible evolution towards constrictive pericarditis, such complication is not recorded in acute and recurrent pericarditis of viral and idiopathic etiology. The prognosis is good in these cases and the risk of constriction is related to the presence of a specific etiology and not to the number of recurrences.

Recurrent pericarditis is the most troublesome problem to tackle in the management of pericardial diseases. Therapeutic modalities usually assume the etiology is autoimmunity, but several cases may be related to infectious etiology or previous inadequate treatments. Therapeutic choices are non-specific and varied. Several small prospective studies have successfully used colchicine to treat and prevent recurrencies after failure of conventional treatment. Although clinical trials were lacking, colchicine has been proposed by expert consensus as first choice drug for recurrent pericarditis in the 2004 guidelines of the European Society of Cardiology. A stronger evidence base for this indication comes from the CORE trial, a prospective, randomized, open label trial, where colchicine as adjunct to conventional treatment significantly decreased symptoms persistence at 72 hours, and halved recurrence rate at 18 months (24.0% vs 50.6%, p=0.022; NNT= 4.0). No serious adverse effects were observed, while corticosteroids were an independent risk factor for further recurrences (OR 2.89).

Background: Only 30% of survivors from out-of-hospital cardiac arrest receive basic life support (BLS) before the arrival of emergency personnel. This is also due to reluctance to perform BLS, especially mouth-to-mouth ventilation without barrier devices in victims who are unknown to the rescuer (either layperson or healthcare provider)., Methods: To evaluate the incidence of reluctance to perform mouth-to-mouth ventilation without barrier devices and its consequences in a simulated BLS scenario proposed by a questionnaire to healthcare providers of critical area in a public general hospital., Results: Answers were collected from 128 of 165 (77.5%) interviewed healthcare providers. Physicians were 46 of 128 (35.9%), professional nurses were 78 of 128 (60.9%) and 4 of 128 (3.2%) were other health workers devoted to patient assistance. Seventy-five of 128 (58.6 %) were reluctant to perform mouth-to-mouth ventilation without barrier devices; 68 of 75 (90.6%) would perform BLS only by chest compression. Compared with non-reluctant providers, they would have been available to perform assisted ventilation by non-validated alternative methods (54.2 vs 18.8% respectively, p < 0.001). Seven of 75 (9.6%, no physician among them) would perform no BLS at all. The most significant predictors of reluctance were age < 40 years (p = 0.07) and previous attendance of BLS-BLSD courses (p = 0.07)., Conclusions: Reluctance to perform mouth-to-mouth ventilation without barrier devices is frequent and may reduce the number of potential BLS providers. Because of the concern about disease transmission between victim and rescuer, rescuers with a duty to respond such as healthcare providers should follow precautions including the use of barrier device also outside their workplace. When barrier devices are unavailable first responders should consider chest compression alone instead of not performing any BLS maneuvers. BLS training should help give a greater emphasis on this topics.