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The term "extreme sports" includes a range of sporting activities, predominantly individual, practised outdoors in a wild and non-competitive environment, which have in common the critical role of environmental variables, the importance of qualitative parameters in evaluating performance, the centrality of technological elements and the high perceived risk which, together with the spectacularity, attracts the attention of the media, favoring its popularity. Despite their diversity, these disciplines share specific risks and physiological and pathophysiological aspects. The average age of participants is generally higher than that of traditional and competitive sports, and the prevalence of male subjects implies a higher likelihood of cardiological evaluation whose path has yet to be codified like that of traditional sports. The risk of severe injuries in these sports is not higher than that of traditional sports and non-sporting activities. In contrast, the risk of cardiovascular events is documented only for some sports practised in the mountains, such as mountaineering, skiing and mountain biking, and it does not appear to be higher than that of equivalent physical activities performed at low altitudes. The diagnostic and prognostic criteria for cardiological counseling of enthusiasts are not defined. Environmental exposure to extremes of temperature, altitude, wind and humidity, and dehydration are typical characteristics of these activities, which should be addressed with adequate experience, preparation and equipment to minimize the potential impact on health. Finally, many of these activities are often conducted in "remote areas" compared to the possibility of emergency response, which should be considered in the risk assessment of an acute cardiovascular event. The definition of cardiovascular risk constitutes an open area of research to allow the practice of these sports to an increasing number of participants.

The exposure to high altitude, with its inherent hypobaric hypoxia, elicits transient compensatory physiological responses of the cardiovascular and respiratory system which, however, do not preclude a safe sojourn at least up to 3500 m to the vast majority of well compensated patients with heart disease on stable drug therapy. Existing scientific statements of the European and American Societies of Cardiovascular and High-Mountain Medicine have released specific and helpful recommendations, though mostly based on expert consensus rather than solid evidence. The risk of cardiac events has been recorded only during sports activities, does not seem to depend on altitude and is similar to what is observed during intense exercise at sea level. Besides altitude itself, other aspects of the mountain environment should be considered, such as lower temperature, wind and dehydration which all require careful planning and equipment typical of the alpine sports. The distance of most mountain areas from medical centers able to provide effective care in time-dependent emergencies, and the lack in most cases of dedicated protocols, should also be considered as an important, most likely the most important limiting factor in high-risk patients.

Electronic cigarettes (e-cigarettes) are battery-powered devices containing a liquid based on propylene glycol or vegetable glycerin. These compounds, when vaporized, act as a vehicle for nicotine, flavors, and other chemical components. These devices have been marketed without clear evidence of risks, long-term safety, and efficacy. Toxicological data show lower plasma concentrations of carbon monoxide and other cancer-inducing substances as compared to traditional smoking. However, several studies have highlighted an increase in sympathetic tone, vascular stiffness, and endothelial dysfunction, all factors associated with cardiovascular risk that, however, is largely inferior to the cardiovascular risk related to traditional smoking. Recent clinical studies have shown how the use of e-cigarettes, combined with adequate psychological support, can be effective in reducing traditional smoking but not nicotine addiction. New policy directives are focusing on the possibility to ban some deleterious products in favor of the use of low-nicotine devices able to promote smoking cessation and reducing the risk of addiction, especially in young people. The use of e-cigarettes among smokers might be promoted with the specific aim of facilitating smoke cessation, but non-smokers and adolescents should be warned against using such devices. Finally, particular attention should be paid to smokers so that the combined use of electronic and traditional cigarettes can be limited as much as possible.

The aim of this review is to explore the available evidence concerning the relationship between the different parameters of the complete blood count, its pathophysiological changes and cardiovascular disease, specifically focusing on the acute ischemic setting. Erythrocytes, leukocytes and platelets undergo significant and more or less durable changes over time in response to conditions of systemic inflammatory, infectious and neoplastic disease. This is the reason why blood cell count parameters can (and should) be implemented in the global assessment of the patient with acute coronary syndrome.From the literature review it emerges that anemia and thrombocytopenia have an independent negative prognostic role in the medium and long term, being markers of the overall frailty of patients with ischemic heart disease. On the other hand, essential thrombocythemia and polycythemia vera, two chronic myeloproliferative neoplasms, are characterized by an important increase in thrombotic risk. Both conditions are given a brief description for the particular importance of the close collaboration between cardiologists and hematologists in the diagnosis and treatment of these diseases in the context of ischemic heart disease.

Early interruption of a clinical trial is not a rare case, and it may be due to several reasons that are summarized in the present article. It is important for the clinician, the primary user of the information derived from clinical trials, to be able to assess whether the eventual interruption of the trial had been planned in the study protocol, whether the study organization was such as to correctly monitor the accrual of efficacy and safety data, who took the decision to interrupt the trial, whether the study patients have been exposed to excessive risks and, finally, whether the conclusions of the study report are valid. In most cases, these issues are carefully assessed during the review process of the study publication (and, of course, by the regulatory authorities) but, particularly for the studies interrupted for "overwhelming evidence of benefit", wisdom and prudence are mandatory, and the results must be considered within the context of all available evidence.

In patients with acute coronary syndrome, total chronic occlusion of a non-culprit vessel is a frequent angiographic finding (10-30%) and it is associated with increased mortality. The effective treatment of these lesions results in better outcomes, and procedural success depends partly on the anatomical features of the lesion. As indicated by current guidelines, the treatment of non-infarct-related artery lesions is not recommended in the acute setting, even in case of hemodynamic instability. We here report the case of a 57-year-old patient suffering from an acute coronary syndrome with double occlusion, acute and chronic, of the left anterior descending artery, both treated in the acute setting with good angiographic and clinical results.

Because of the aging of the population, the proportion of elderly patients admitted to the coronary care unit for an acute coronary syndrome (ACS) is increasing. Until a decade ago, treatment of elderly patients was based on poor scientific evidence, as older patients were commonly excluded from randomized controlled trials. In the last years, real-world registries and randomized controlled trials specifically addressing the older population have been published and provided clear evidence. Primary percutaneous angioplasty has become the standard of care for the treatment of ST-elevation myocardial infarction also in the elderly population, whereas the Italian Elderly ACS and the After Eighty randomized trials have demonstrated the superiority of an invasive strategy over an initial conservative strategy also in elderly patients affected by non-ST-elevation myocardial infarction. Moreover, real-world registries have shown that an increased use of early revascularization was associated with a progressive reduction in mortality after ACS: these findings have been confirmed also in a clinical context characterized by high mortality rates such as that of cardiogenic shock. As 80% of deaths after an ACS have been shown to be due to cardiovascular causes also in the elderly, the focus has been shifted to secondary prevention. Data regarding the use of both ticagrelor or low-dose prasugrel, as compared to clopidogrel, showed that a reduction of ischemic events was counterbalanced by an increase in bleeding events. In perspective, it might be interesting to explore the superiority of a strategy that limits the duration of dual antiplatelet therapy to a short period after an ACS (when the ischemic event rate is higher) in elderly patients, and to explore other endpoints such as mid-term quality of life outcome after ACS in elderly patients.

The principle of patient information, awareness and documented consent for the participation in clinical trials is a cornerstone in the modern ethics of clinical research. However, this procedure is seldom applicable in the critically ill patient who becomes suddenly incapable of fully evaluating the risk vs benefit of the alternative therapeutic options. This issue becomes particularly problematic in those conditions where the benefit of any intervention is highly time-dependent, such as acute myocardial infarction, stroke, cardiac arrest, polytrauma and other similar conditions. The new directive 536/2014/EC defines the concept that in these cases the expert clinician and the Ethics Committees, based upon a rigorous study protocol, are in better conditions, as compared to patients' proxies and any legal representative, to take an appropriate decision. This decision should be later confirmed (deferred consent) by the patient, in case he returns competent, or by his proxies or legal tutor, in order to use experimental data. The new directive ends a long period of disparity among the Member States, some of which had taken unilateral decisions allowing the participation of incapable patients, whereas others, among which Italy, had a more conservative approach. Unfortunately, owing to technical and bureaucratic issues, the new regulation is unlikely to become active before the beginning of 2018.

The increasing life expectancy in older adults and the better survival of patients with multiple pathologies require the capability to treat complex clinical conditions with an increased risk of iatrogenic complications. Nevertheless, recent improvements in the pharmacological and interventional treatment of acute coronary syndrome (ACS) have promoted a shift from therapeutic nihilism to a more active management of complex ACS cases. Despite the paucity of specific randomized clinical trials, observational studies seem to show benefit of an early invasive treatment in these patients. This approach requires close cooperation of clinical intensivists, interventional cardiologists and cardiovascular surgeons either in a specialized heart center or in a network of hospitals.

Elderly patients account for one third of those admitted to cardiac care units with non-ST-elevation acute coronary syndromes, but are largely underrepresented in randomized clinical trials which form the basis of practice guidelines. Conducting trials in this patient population is especially difficult due to coexisting pathologies, informed consent issues, a perceived higher risk of interventional procedures, and complexity of follow-up. The Italian Elderly ACS Study has been a positive experience in terms of accepting this challenge, carrying it on with limited resources and delineating convincing results, although not statistically conclusive due to its final limited sample size. The indications from the study are straightforward in patients with elevated troponin levels on admission and other high-risk characteristics: in these patients, an early invasive approach has reduced by 40% to 60% the risk of fatal and nonfatal ischemic complications at 1-year follow-up. This result has been achieved with an incidence of bleeding complications which was by far lower than previously reported in the literature, probably due to a systematic radial approach to vascular interventions and a cautious use of antithrombotic treatments in the acute phase.

The management of antiplatelet therapy in patients with coronary stents undergoing surgery is a growing clinical problem and often represents a matter of debate between cardiologists and surgeons. It has been estimated that about 4-8% of patients undergoing coronary stenting need to undergo surgery within the next year. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. In addition, surgery confers an additional risk of perioperative cardiac ischemic events, being high in these patients because of the pro-inflammatory and pro-thrombotic effects of surgery. Current international guidelines recommend to postpone non-urgent surgery for at least 6 weeks after bare metal stent implantation and for 6-12 months after drug-eluting stent implantation. However, these recommendations provide little support with regard to managing antiplatelet therapy in the perioperative phase in case of urgent operations and/or high hemorrhagic risk. Furthermore, ischemic and hemorrhagic risk is not defined in detail on the basis of clinical and procedural characteristics. Finally, guidelines shared with cardiologists and surgeons are lacking. The present consensus document provides practical recommendations on the management of antiplatelet therapy in the perioperative period in patients with coronary stents undergoing surgery. Cardiologists and surgeons contributed equally to its creation. An ischemic risk stratification has been provided on the basis of clinical and procedural data. All surgical interventions have been defined on the basis of the hemorrhagic risk. A consensus on the most appropriate antiplatelet regimen in the perioperative phase has been reached on the basis of the ischemic and hemorrhagic risk. Dual antiplatelet therapy should not be withdrawn for surgery at low bleeding risk, whereas aspirin should be continued perioperatively in the majority of surgical operations. In the event of interventions at high risk for both bleeding and ischemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be considered.

The 2011 edition of the ESC guidelines on non-ST-segment elevation acute coronary syndromes (NSTE-ACS) maintains the approach strongly based upon risk stratification, following the concept that "the higher the risk of ischemic events, the larger will be the benefit of an aggressive pharmaco-interventional approach". This concept applies both to the indication and timing of angiography/revascularization and to the choice of concomitant pharmacological therapies. The proofs of efficacy of the most recent drug treatments are solid, but the choice among the several available options and the evaluation of the efficacy/safety ratios in patient subsets require clinical wisdom, especially for the management of the most complex and frail patients. The indication for performing coronary angiography within 24h in high-risk patients would imply extending to NSTE-ACS patients the networks already in place for primary percutaneous coronary intervention in ST-elevation myocardial infarction.

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.

Despite the striking advances in the treatment of cardiovascular disease during the last 30 years, the cardiovascular disease burden has continued to increase. The goal of future therapy should not be restricted to more effective, and costly, treatments, but will have to include strategies to impact on the atherogenic lifestyle of the welfare civilization. Future sanitary plans should facilitate physical activity and an healthier use of food. In this context, physicians should recall to themselves the important cultural role of educating patients and putting pressure on political decision makers. Also, a more aggressive drug therapy towards reducing the burden of traditional risk factors should be facilitated by specific resource allocation, possibly by reducing the present unwarranted and nonselective diagnostic excess. A more aggressive treatment of the acute phase of ischemic cardiovascular disease will have to be pursued by more extensive and timely use of treatments of proven efficacy, at present still adopted in a minority of cases. Since the damage caused by acute ischemic cardiovascular disease often results in invalidity, a more effective therapy of the acute phase has the potential for reducing secondary sanitary costs, particularly after acute myocardial infarction and stroke. Practice Guidelines, made available and continuously updated by the Scientific Societies, should be considered as the key referral sources for sanitary planning.

Patients older than 75 years represent about one third of those admitted to the Italian coronary care units due to an acute coronary syndrome, with a greater prevalence of the form without ST-segment elevation. Compared to younger patients, the elderly have higher risk characteristics and more adverse outcomes, particularly mortality and heart failure. Despite this, they receive less effective treatments, and especially less coronary reperfusion therapy. This attitude is only partially motivated by the fear of the potential adverse effects of antithrombotic and invasive treatments in the elderly, on the basis of misleading meta-analyses and observational studies. A more objective approach is taking fuel by recent randomized studies showing that the treatment effect is even greater in the elderly (particularly when evaluated in terms of "number of lives saved"), whereas the benefit is often hardly seen in the younger population. Also, the idea that the elderly may have little room for percutaneous coronary intervention has been progressively wiped away by the experience of those Centers that have started systematic coronary angiography regardless of the patients' age. The presence of severe copathologies has been often considered to limit intervention in the elderly. This real difficulty (although more typical of the seventh and eighth decade than at older age) should be rather considered specifically and not as a mere consequence of age. The elderly patient is at higher risk of iatrogenic bleeding: therapeutic regimens should be adjusted specifically in order to reduce this untoward effect of effective treatments.

Background: Specific guidelines for interventional cardiology in elderly patients are not available, and it appears that aged patients are treated more conservatively. Nevertheless data on the real clinical practice are lacking. The aim of the study was to describe different therapeutic strategies in elderly patients enrolled in the Italian Drug Evaluation in Angioplasty (IDEA) study., Methods: The IDEA study is a registry of consecutive percutaneous coronary interventions (PCI) performed from September 15 to 29, 2003, at 79 Italian cath-labs., Results: Out of 1517 consecutive PCI patients, 491 (32%) were aged > or = 70 years. Compared to younger patients, those > or = 70 years old showed more frequently (p < 0.001) renal insufficiency (10.4 vs 4.4%), peripheral vasculopathy (18 vs 6.9%), history of stroke (7.3 vs 3.3%) or previous surgical coronary revascularization (15 vs 7.5%) and multivessel disease (61 vs 49%). In patients aged > or = 70 years, acute coronary syndrome was the more frequent clinical indication for PCI (54 vs 49% in patients < 70 years, p = 0.05). Globally, stent use was 89% with no differences related to the patients' age. Drug-eluting stents were used in 21% of the procedures in elderly patients and in 22% in younger patients. Use of glycoprotein IIb/IIIa receptor antagonists in acute coronary syndrome was not correlated with the patients' age; nevertheless in elderly patients with acute myocardial infarction these drugs were less used during primary angioplasty compared to younger patients (48 vs 72%, p = 0.001). In-hospital mortality was higher in patients aged > or = 70 years (2.9 vs 0.9%, p = 0.004), particularly in patients treated for acute coronary syndromes (5.5 vs 1.4%, p = 0.002). In these patients, more bleeding complications (7.1 vs 3.9%, p < 0.001) and heart failure (5.5 vs 1.6%, p = 0.004) were observed., Conclusions: Compared to younger patients, elderly patients enrolled in the IDEA study had a higher risk profile and higher in-hospital morbidity and mortality. Except for a lower use of glycoprotein IIb/IIIa receptor antagonists for acute myocardial infarction, no discriminations were observed in elderly patients in terms of clinical indications, antiplatelet therapy and drug-eluting stent use.