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Dilated Cardiomyopathy (DCM)is associated with an increased risk of developing ventricular arrhythmias and sudden cardiac death (SCD), although to a lesser extent than ischemic heart disease (IHD).It is now well established that defibrillator implantation (ICD) reduces mortality in patients with reduced systolic function after a myocardial infarction, conversely, this effect is less evident in patients with DCM. The aim of this work is to report the experience of a dedicated outpatient clinic for heart failure patients and to underline the importance of a multiparametric assessment for a patient who is a candidate for ICD implantation. From December 2019 to December 2023, 38 patients (34 males and 4 females) (mean age 62.6 years) were referred to our hospital with a diagnosis of hypokinetic dilated heart disease of first detection, in 4 cases due to declared alcohol and/or substance abuse.Three patients had already undergone defibrillator implantation in primary prevention but did not have on board the 4 classes of drugs recommended by the latest guidelines, so they were subjected to the maximum tolerated dose and re–evaluated remotely with clinical improvement and echocardiographic values. The other 35 patients, whose disease began with de novo reduced ejection fraction heart failure (HFrEF), admitted to our ICU, all underwent coronary angiography with finding of a coronary tree free of critical alterations; 28 had performed a magnetic resonance imaging (MRI) that showed no edema, necrosis and/or fibrosis; only in two patients have been documented fibrosis with a low percentage of distribution, which does not account for low EF values. Of the other 7 patients, 4 did not undergo MRI 2 for claustrophobia and 3 for atrial fibrillation. Maximal drug therapy with the 4 pillars recommended by the guidelines was set up for all patients;the introduction of glyphozines in diabetic patients has been shared with diabetologist. All patients underwent echocardiographic check–ups at 3–6 months and one year, which over time documented a recovery associated with improvement in symptoms and quality of life. All patients also underwent ECG according to Holter for arrhythmic risk stratification: none of them required ICD implantation procedures. This preliminary analysis shows that a correct application of the guidelines allows to improve the prognosis of patients with dilated cardiomyopathy; of course, further larger studies are needed to substantiate these findings.

A 53–year–old woman presented herself at our center for the appearance of oppressive chest pain radiating to the upper limbs associated with cold sweat, which arose in resting conditions. The patient had as cardiovascular risk factors tobacco habits and an important family history of cardiovascular diseases (father died of AMI at a young age) and had entered menopause for some months. The ECG showed signs of anterior transmural ischemia (Figure 1a) with corresponding echocardiographic kinetic abnormalities of the cardiac apex (EF 40%). The patient underwent an emergency coronary angiography documenting an intramyocardial bridge with evident systolic squeezing of the vessel in the proximal–middle section of the anterior descending artery and normal appearance of the remaining coronary tree (Figure 2). She was subjected to infusion of intracoronary nitrates with improvement of the instrumental picture and on that occasion it was opted for medical therapy alone with double antiplatelet therapy and low–dose calcium antagonist. On the second day after the diagnostic procedure, there was a recurrence of anginal symptoms with evidence on the ECG of anterolaterally reversed T waves (figure 1b). The patient underwent a new coronary angiography, IVUS–guided, with documentation of probable intramural hematoma in the absence of non–flow–limiting dissection image with an area of 7 mm² (Figure 3). During the subsequent hospitalization, the patient remained asymptomatic with stable ECG tracing, but telemetry revealed ventricular tachyarrhythmias for which beta–blocker therapy was optimized with improvement of the arrhythmic burden. The pre–discharge echocardiogram showed improvement of cardiac kinesis with resumption of systolic function (EF 48%). The patient was discharged stable and asymptomatic with follow–up at our dedicated ischemic heart disease clinic. This case report is an example of an infrequent cause of acute coronary syndrome, of non–atherosclerotic origin, to be considered in clinical practice.