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Variant angina is a condition triggered by the transient vasospasm of epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. Among patients with coronary artery vasospasm, a non-negligible subset experiences silent myocardial ischemia, defined as the objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. This condition is associated with the increased cardiac mortality and incidence of acute cardiac events. Herein, we described the case of a 65-year-old man who was admitted to our Emergency Department (ED) for syncope. He reported palpitations before the event but did not complain of chest pain. Baseline electrocardiogram (ECG) showed that troponin values of biphasic T waves in V2-V6 were normal. The patient was admitted to our coronary care unit (CCU) for monitoring. Immediately after hospital admission, he developed dynamic ST segment elevation and non-sustained polymorphic ventricular tachycardia, being symptomatic only for palpitations. Both ECG abnormalities and symptoms quickly resolved after the administration of intravenous nitrates and oral calcium channel blockers. Coronary angiography showed a critical non-occlusive fixed stenosis at the proximal right coronary artery (RCA). The lesion was treated by angioplasty and stenting, and the patient was discharged on dual antiplatelet therapy, statins and oral high-dose calcium-channel antagonist.

Hospitalization for congestive heart failure represents a growing burden for health care systems. Heart failure is characterized by extracellular fluid overload and loop diuretics have been for decades the cornerstone of therapy in these patients. However, extensive use of intra-venous diuretics is characterised by several limitations: risk of worsening renal function and electrolyte imbalance, symptomatic hypotension and development of diuretic resistance. Extracorporealveno-venous ultrafiltration (UF) represents an interesting adjunctive therapy to target congestion in patients with heart failure and fluid overload. UF consists of the mechanical removal of iso-tonic plasma water from the blood through a semipermeable membrane using a pressure gradient generated by a pump. Fluid removal through UF presents several advantages such as removal of higher amount of sodium, predictable effect, limited neuro-hormonal activation, and enhanced spontaneous diuresis and diuretic response. After twenty years of “early” studies, since 2000 some pilot studies and randomized clinical trials with modern devices have been carried out with somehow conflicting results, as discussed in this review. In addition, some practical aspects of UF are addressed.

Aims Lipid management plays a key role in secondary prevention after acute coronary syndrome. Current European Society of Cardiology guidelines recommend a dual goal: to achieve LDL cholesterol (LDL-C) Methods and results We conducted a retrospective analysis of a monocentric observational registry prospectively enrolling patients admitted to our hospital for ST segment elevation myocardial infarction (STEMI) and followed-up in our dedicated PMI ambulatory. The analysis considered the patients enrolled between 2013 and 2017. Demographical and clinical data were extracted from a dedicated digital database, and the clinical events occurred during follow-up were obtained by telephone interviews or clinical records. We considered a combined endpoint of major adverse cardiovascular events (MACE) of all-cause death, non-fatal MI, non-fatal stroke and unplanned revascularization. LDL-C was collected at baseline and at 1, 6 and 12 months after the event. The lower value collected at follow-up was used to define the achievement of the target goals. We conducted a Kaplan-Meier analysis and log-rank test comparing patients who achieved LDL-C Conclusion Our data from a real-world cohort of PMI patients emphasize the importance of achieving both the guideline-recommended secondary prevention goals of LDL-C

Background. Cardiogenic shock (CS) is the leading cause of in-hospital mortality in ST-segment elevation myocardial infarction (STEMI). Only limited data are available on the long-term outcome of STEMI patients with CS undergoing contemporary treatment. We aimed to investigate long-term mortality and its predictors in STEMI patients with CS and to develop a risk score for long-term mortality prediction. Methods and Results. We retrospectively included 465 patients with STEMI complicated by CS and treated with primary angioplasty and intra-aortic balloon pump between 2005 and 2018. Long-term mortality, including both in-hospital mortality and all-cause mortality following discharge from the index hospitalization, was the primary endpoint. The long-term mortality (median follow-up 4 (2.0–5.2) years) was 60%, including in-hospital mortality (34%). At multivariate analysis, independent predictors of long-term mortality were age (HR 1.41, each 10-year increase), admission left ventricular ejection fraction (HR 1.51, each 10%-unit decrease) and creatinine (HR 1.28, each mg/dl increase), and acute kidney injury (HR 1.81). When these predictors were pooled together, the area under the curve (AUC) for long-term mortality was 0.80 (95% CI 0.75–0.84). Using the four variables, we developed a risk score with a mean (cross-validation analysis) AUC of 0.79. When the score was applied to in-hospital mortality, its AUC was 0.79, and 0.76 when the score was applied to all-cause mortality following discharge. Conclusions. In STEMI patients with CS, the risk of death is still substantial in the years following the index event. A simple clinical score at the time of the index event accurately predicts long-term mortality risk.

A 70-year-old man was referred to the emergency department for an episode of ongoing chest pain during physical activity. Urgent coronary angiogram revealed a 75% stenosis in the left anterior descending coronary artery and a total occlusion of a large diagonal branch. Both stenoses were treated successfully with percutaneous coronary intervention. After reperfusion, the ECG showed a "De Winter" pattern, which was the ECG expression of a culprit lesion located in a large diagonal branch rather than in the left anterior descending.

Background When implantable cardioverter defibrillator (ICD) battery is depleted most patients undergo generator replacement (GR) even in the absence of persistent ICD indication. The aim of this study was to assess the incidence of ventricular arrhythmias and the overall prognosis of patients with and without persistent ICD indication undergoing GR. Predictors of 1‐year mortality were also analyzed. Methods and Results Patients with structural heart disease implanted with primary prevention ICD undergoing GR were included. Patients were stratified based on the presence/absence of persistent ICD indication (left ventricular ejection fraction ≤35% at the time of GR and/or history of appropriate ICD therapies during the first generator's life). The study included 371 patients (82% male, 40% with ischemic heart disease). One third of patients (n=121) no longer met ICD indication at the time of GR. During a median follow‐up of 34 months after GR patients without persistent ICD indication showed a significantly lower incidence of appropriate ICD shocks (1.9% versus 16.2%, P P =0.009). At multivariable analysis permanent atrial fibrillation, chronic advanced renal impairment, age >80, and persistent ICD indication were found to be significant predictors of 1‐year mortality. Conclusions Patients without persistent ICD indication at the time of GR show a low incidence of appropriate ICD therapies after GR. Persistent ICD indication, atrial fibrillation, advanced chronic renal disease, and age >80 are significant predictors of 1‐year mortality. Our findings enlighten the need of performing a comprehensive clinical reevaluation of ICD patients at the time of GR.

Background Atrial fibrillation (AF) is a common finding in patients with ST elevation myocardial infarction (STEMI). However, its prognostic influence in MI remains controversial. Almost all previous studies were performed before the era of primary percutaneous coronary intervention (pPCI), and there is a lack of data in patients with STEMI complicated by cardiogenic shock (CS). The aim of our study was to evaluate the prognostic impact of AF in a large real-world population of STEMI undergoing pPCI stratified by the presence of CS. Methods Our registry included 3017 consecutive patients with STEMI undergoing pPCI in our department in 2005-2017. The presence of a persistent (>30 min) systolic blood pressure < 90 mmHg associated with signs of pulmonary congestion/impaired end organ perfusion needing catecholamine infusion or mechanical support devices qualified for CS. Firstly we performed mortality analysis in all patients with AF during hospitalization; secondly, we compared patients with the first episode of AF and patients with AF during hospitalization but known AF in anamnesis. The analysis was stratified for the presence of CS. Univariate (cross-tables and Kaplan-Meier curves with log-rank test) and multivariate mortality analysis (Cox regressions) were performed. In STEMI patients without CS we also performed a propensity-matched analysis including all variables known before STEMI that could influence the occurrence of a first episode of AF. Results AF was present in 337 (11.3%) patients during hospitalization; in 193 (57.3%) of them was the first episode. CS occurred in 250 patients (8.4%), 27.2% of whom were affected by an AF episode (86.5% as the first episode). Among patients without CS, AF occurred in 269 patients (9.7%) and for the 77.5% was the first episode. In CS patients, AF was not associated with increased mortality, neither at 30 days (43.5% vs 43.7%, p = 0.867) nor at 1 year (47.5% vs 53.1%, p = 0.633). In the population without CS, AF was an independent predictor of mortality both at 30 days (HR 2.25 (1.05; 4.82), p = 0.037) and at 1 year (HR 1.87 (1.094; 3.18), p = 0.022); only new-onset AF was an independent predictor of mortality. We successfully matched 175 pairs of patients with similar propension to experience the first episode of AF. Among them the first episode of AF was confirmed to be an indipendent predictor of mortality (figure). Conclusion In the present large real-world cohort of unselected patients with STEMI, the presence of an episode of AF during hospitalization was an independent predictor of mortality in patients not complicated by cardiogenic shock. Conversely, AF did not show a significant prognostic impact in patients with STEMI complicated by CS. Furthermore, the presence of a first episode of AF was confirmed to be an independent predictor of mortality, while an AF episode in patients with known AF was not found to have prognostic impact. Abstract Figure

Background Pulmonary vein isolation (PVI) performed with radio-frequency catheter ablation (CA) is an effective therapy for atrial fibrillation (AF). However previous data have suggested that PVI is less effective in persistent (PER) vs. paroxysmal (PAR) AF. Atrial fibrosis and scar, indeed, are an important substrate involved in persistent AF, and some author correlate them to an increased rate of recurrences after CA. For this reason several adjunctive ablation strategies have been suggested for invasive treatment in PER AF pts. However, there is a lack of evidence on their effectivness in current literature. Objective the aim of our study was to assess the rate of AF recurrences in PAR and PER AF patients after a first pulmonary vein isolation (IVP) procedure, and their relationship with low voltage areas of the left atrium assessed by means of high density mapping performed before CA. Methods we analyzed 214 patients of the SMOP-AF study (Substrate Mapping as Outcome Predictor in Atrial Fibrillation Ablation), a prospective multi-centric registry enrolling patients with both PAR and PER AF undergoing a first radio-frequency CA procedure aimed to obtain permanent PVI . High-density mapping was performed in sinus rhythm using the CARTO system before PVI. Areas with less than 0,5 mV on mapping were defined as low voltage zone (LVZ); LVZ was indexed on the atrial area. Comparisons were made by cross-tables and Chi-square test or Student T test. Results Patients with PER AF (n = 44, 21%) were older (63 ± 9 vs 58 ± 10 yrs, p = 0.01), but notably with no difference in LVEF and atrial dimensions as compared to pts with PAR AF. In addition no statistical difference was observed in procedural variables, except for a greater LVZ area on atrial mapping (8 ± 18 % vs. 5 ± 15 %, p = 0.04) and a longer p wave duration (115 ± 21 msec vs. 103 ± 18 msec, p = 0.01) in pts with PER AF. The incidence of recurrence in the overall population was 15.3% at 3 months and 13.7% from 3 to 12 months: there was no statistical difference in success-rate between PER and PAR pts (respectively 79,5% vs 86% p value = 0.315 in blanking period and 85,3% vs 86,5% p value = 0.8 at 3-12 months follow-up). No statistical difference was observed for ablation variables (number of lesion, contact force, force time integral) in pts with vs. without recurrences. Conclusion Our study showed that pulmonary vein isolation alone seems to be as effective in paroxismal and persistent AF patients with low degree of left atrial fibrosis. Our data call into question the idea that PVI alone is not effective in PER AF. High density mapping of the LA could help to identify a subset of PER AF patients with a limited extension of low voltage areas (i.e around 10% of the overall LA surface) that could benefit from PVI without adjunctive ablation strategies. Our data needs to be confirmed in a longer follow-up.

BACKGROUND ICD implantation with or without resynchronization is an established therapy for the prevention of sudden cardiac death in patients with LV dysfunction. However, when elective replacement interval (ERI) approaches most patients undergo generator replacement (GR) even in the absence of persistent indication to ICD therapy- Moreover, at the time of GR patients are usually older and with more comorbidities as compared to the time of first implantation. AIM The aim of our work was to evaluate the rate and predictors of mortality and to analyze.the incidence of appropriate ICD therapies after GR. METHODS Our registry includes 323 patients with structural heart disease (SHD) implanted with ICD in primary prevention who underwent GR. Our population was stratified based on the presence or absence of persistent indication to ICD at the time of GR, which was defined as: LVEF ≤ 35% and/o history of appropriate ICD therapies during the first generator"s life. In each group the incidence of appropriate ICD therapies after GR, 1 and 2 years mortality after GR and multivariate predictors of 1 year mortality. Were analyzed. Comparisons between categorical variables were made using χ2 or Fisher Exact test when required and continuous variables were compared using Mann Whitney test. Kaplan-Meier curves with Log Rank test were used to investigate 1 and 2 years mortality. RESULTS In our population, 81% were male, 41% had ischemic heart disease, 60% had CRT-D. Median LVEF at the time of first implantation was 30% (25-35), whereas at the time of GR was 35% (25-45); median age at GR was 64 (56-73) years. Notably 33.6% of our population no longer met ICD indication at the time of GR; this subgroup showed a significantly lower mortality at one and two years as compared to patients with persistent ICD indication: 1% vs 9% and 2.1% vs 13.5% respectively (figure 1 and 2). At multivariable analysis permanent AF (HR: 3.6; 95% CI 1.9-8.6) chronic renal disease (HR 4; 2.3-8.9), and persistent ICD indication were independent predictors of 1-year mortality. When survival analysis was limited to patients implanted with single-chamber and dual-chamber devices only AF an renal insufficiency remained significantly predictors of mortality. Nevertheless, in this subgroup, the absence of persistent indication was associated with a significantly lower rate of appropriate ICD therapies after GR (0% vs 14.8%, p = 0.02). CONCLUSION The absence of persistent indication at the time of generator replacement was associated with a significantly better prognosis and a lower incidence of appropriate therapies after GR. Atrial fibrillation, renal insufficiency and persistent ICD indication significantly predicted 1 year mortality in our population. Our data suggest the importance of an arrhythmic vs. non-arrhythmic risk evaluation in the individual patient at the time of ICD generator replacement Abstract Figure.

Kounis and Zavras (1) first described Kounis syndrome (KS) or “syndrome of allergic angina” in 1991, an acute coronary syndrome (ACS) triggered by an anaphylactic or anaphylactoid insult. There are three reported typologies of the disease: coronary vasospasm with no pre-existing coronary artery disease (type I); coronary vasospasm on a pre-existing quiescent plaque, causing its direct erosion or rupture (type II); and stent thrombosis with occluding thrombus (type III). We reported a case of a patient with anaphylactoid type II KS, presenting with acute myocardial infarction because of a distal embolization of a thrombus.

Background Pulmonary veins isolation (PVI)is an effective therapy for atrial fibrillation (AF), recommended by current guidelines. However, recurrences after first radio-frequency (RF) catheter ablation (CA) are still high. PV reconnection could be due to ineffective transmural lesions; automated ablation lesion tags (the VisiTag algorithm) based on predefined parameters of catheter stability and contact force (CF) have been developed to allow the detection of ineffective ablation lesion, nevertheless there is a lack of multicenter studies exploring this technology. Objective the aim of our study was to assess the rate of recurrence after a first PVI procedure in a large, multicentric Italian population and to explore the efficacy of Visitag algorithm (CARTO 3) used to guide RF ablation of AF. Methods we analyzed 214 patients of the SMOP-AF study (Substrate Mapping as Outcome Predictor in Atrial Fibrillation Ablation), a prospective multi-centric study enrolling patients with paroxysmal and persistent AF undergoing a first PVI procedure after an high-density mapping during sinus rhythm. During the procedure, ablation was guided by an automated annotation system in which tag based on predefined parameters were displayed real-time in each lesion site on the electroanatomical map. Visitag settings for the catheter position stability were a 2,5 mm distance limit for at least 7 sec and a minimum CF of 5 g over 30% of the ablation and a FTI>400 g*s. Where available (n=106, 49.5%), Ablation Index (AI), which also incorporates information on delivered RF power, was used instead of FTI to guide RF ablation with a threshold range of 400–550 for anterior/roof and 330–420 for posterior/inferior segments. Minimum and mean contact force, time and power values for each RF-lesion were recorded while both FTI and AI values were calculated automatically by the CARTO system. Comparison between groups were made by cross-tables, Mann-Whitney or Student T test as appropriated. Results the mean age of the enrolled population was 59±9 years, left ventricular ejection fraction was 59±9%. AF was paroxysmal in 89.7%, persistent in 10.3% of the patients and refractory to at least one anti-arrhythmic drug in 86.4% of the population. At 3 months follow-up 85% of the patients were free from AF recurrences and the success rate increased to 90.8% at 3–6 months, and 86.3% at 3–12 months follow-up. The mean ablation time was shorter in AI-guided vs. FTI-guided procedures (31±9 vs 46±29 min; p Conclusion PVI isolation using dedicated algorithms developed to guide the effectiveness of RFCA leads to a very high success-rate after a single procedure. The use of AI, which integrates contact force information with delivered power, reduces the procedural time and increases the overall success-rate

Background radio frequency catheter ablation (CA) is an effective therapy for atrial fibrillation (AF). Some authors have described a potential relationship between the presence of areas of fibrosis in the left atrium (LA) and the success of CA, nevertheless there is a lack of multicenter studies in this field. Objective the aim of our study was to assess the relationship between the of presence of low voltage areas of the LA detected during subtrate mapping at the time of the procedure and recurrences of AF after CA. Methods we analyzed 214 patients of the SMOP-AF (Substrate Mapping as Outcome Predictor in Atrial Fibrillation Ablation), a prospective multi-centric study enrolling patients with both paroxysmal and persistent AF undergoing a first radio-frequency CA procedure. High-density mapping was performed in sinus rhythm using the CARTO system before performing pulmonary vein isolation. Areas with less than 0,5 mV on mapping were defined as low voltage zone (LVZ), while between 0,5 mV and 1,5 mV intermediate voltage zone (IVZ). IVZ and LVZ were expressed as a percentage of the LA surface. Comparisons were made by Pearson correlation, cross-tables and Chi-square test or Student T test. Results the mean age of the enrolled population was 59±9 years, left ventricular ejection fraction was 59±9%, 86.4% of the pts had tested at least one anti-arrhythmic drug. Persistent atrial fibrillation was present in 10.3% of patients. The rate of documented AF recurrence at 3 months was 15,3% (n=29). There was a statistical significant correlation between the presence of IVZ and the rate of recurrences at 3 months (r=0.16, p value 0.03). Patients with IVZ greater than 4% of the left atrium surface showed a higher risk of recurrences (19.5% vs. 8,7%, p value 0.04). No statistical difference was observed in other procedural variables (number of lesions, contact force, force-time integral) among patients with or without recurrences. Conclusion Our study showed a relationship between CA short-term success rate and the presence of areas of intermediate voltage zone detected with high-density substrate mapping at the time of the procedure. The presence of areas of intermediate voltage zone greater than 4% of the LA determines a 2.5 folds increased risk of short-term recurrence. Our data needs to be confirmed in a longer follow-up.

Introduction Elevated serum uric acid (eSUA) has been identified as independent risk factors for cardiovascular diseases, including coronary artery disease, and it has been associated with increased mortality in the general population. However, whether eSUA is associated with adverse outcomes in the setting of ST-segment elevation myocardial infarction (STEMI) is still controversial. Although the mechanisms of this possible relationship is similarly unsettled it has been suggested that eSUA could trigger oxidative stress and inflammatory response. Aim This study sought to investigate the association between eSUA with short- and long-term mortality and with inflammatory response in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). Methods We prospectively enrolled all STEMI patients undergoing pPCI in our hospital between 2005 and 2017. Blood samples were collected on admission and at 24 and 48 hours after pPCI: SUA and the inflammatory biomarkers C-reactive protein (CRP), neutrophil count and neutrophil to lymphocytes ratio (NLR) were parameter of interest. NLR was obtained by dividing the total count of neutrophil by the total count of lymphocyte. eSUA was defined as >6.8 mg/dl. Cumulative 30-days and 1-year mortalities were estimated using the Kaplan-Meyer analysis and compared with the long-rank test. Landmark analysis was set at 365 days. Multivariable analyses were performed by Cox proportional hazard models. Results Out of the dataset of 2959 STEMI patients treated with pPCI, we analyzed 2369 patients who had SUA data. Overall age was 63 (p25-p75: 54–73) years, men were 2295 (75.5%), anterior MI 1390 (45.8%). eSUA was present in 563 patients (23.8%). 30-day mortality was 5.8% (n=31) among patients with eSUA and 2% (n=34) among patient with normal SUA level (p2 (30-day mortality HR 1.196, 95% CI 1.006–1.321, p=0.042; 1-year mortality HR 1.178, 95% CI 1.052–1.320, p=0.005). On admission CRP was higher in the group with eSUA as compared with the group with normal SUA levels (respectively, 1.27 [0.57–3.37] mg/dl vs 0.72 [0.30–1.8] mg/dl, p Figure 1 Conclusions Elevated serum uric acid is associated with higher short- and long-term mortality and with a greater inflammatory response after reperfusion in patients with STEMI treated with primary PCI.

Incomplete ST segment resolution (iSTR) is a well-known marker of poor outcome in patients undergoing primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI). The use of glycoprotein IIbIIIa inhibitors (GPIs) was suggested to be associated with a survival benefit in high-risk patients. A simple score to predict the risk for developing iSTR could help early identification of these patients and could allow a tailored use of pharmacological tools, such as GPIs. The aim of this study was to create and validate a numerical score to predict iSTR occurrence in STEMI patients undergoing pPCI and to assess its association with the potential benefit of GPIs use. We prospectively enrolled all STEMI patients undergoing pPCI in our University Hospital (2005–2017). iSTR was defined as a Out of a total of 2959 patients, 1774 were included in the derivation: 480 (27%) of them presented iSTR. All-cause mortality at 30 days was significantly higher in patients with iSTR (OR 3.2, 95% CI 2.1–4.9, p198 mg/dl at admission (OR 1.77, 95% CI 1.29–2.49, p75 years (OR 1.54, 95% CI 1.15–2.10, p=0.004, score 1.5), female sex (OR 1.41, 95% CI 1.06–1.88, p=0.02, score 1.5) and Killip class >2 (OR 1.44, 95% CI 1.05–1.98, p=0.024, score 1.5) were identified as independent predictors of iSTR, creating a ISTR-score that ranged from 0 to 11. The validation cohort consisted in 1185 patients, with 31% showing iSTR. The c-statistic was 0.67 and 0.66 in the derivation and validation cohorts. Patients with score ≥4 versus A simple pre-procedural risk score may predict iSTR following pPPCI, allowing a rapid risk stratification and the identification of patients who show a favorable risk/benefit ratio for the use of more aggressive strategies such as GPIs. These findings deserve a prospective, randomized evaluation.

Background Evidence from a large randomized clinical trial has led international guidelines to downgrade to Class III the recommendation level for the routine use of intra-aortic balloon pump (IABP) in patients with STEMI complicated by cardiogenic shock (CS). Despite this, its use in clinical practice remains high. Purpose The aim of our study was to evaluate whether IABP use could provide a prognostic benefit in a large real-world population of STEMI patients undergoing primary PCI (pPCI). Methods Our registry included 2958 consecutive patients undergoing primary pPCI for STEMI in our department from 2005 to 2017. The presence of a persistent (>30 min) systolic blood pressure Results CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. Mortality at 30 days was 3.7 in inferior vs 7.1% in anterior STEMI (p3 mg/dL) during hospital stay. In the subgroup of patients with anterior STEMI, there was a marked survival benefit at univariate analysis (30-day mortality 41% vs 61%, p=0.013 – see figure panel B), confirmed at multivariable analysis (HR 0.40, 95% CI 0.19–0.88, p=0.023) after adjusting for the same variables of the previous model. In the subgroup of patients with inferior STEMI, IABP use was not significantly associated with a lower 30-day mortality (32% vs 41%, p=0.380). Figure 1 Conclusion In the present large real-world cohort of unselected patients with STEMI, the use of IABP in case of CS was found to improve survival. This finding suggests that IABP could still play a role in patient with STEMI complicated by CS, especially when additional risk features are present, such as anterior MI. We suggest that additional careful prospective studies are needed before abandoning or markedly limiting the use of IABP in this clinical setting.

Background Redundant clinical and non-invasive examinations after percutaneous coronary intervention (PCI) increase the cost of medical care with no outcome improve. A multidisciplinary consensus document (MCD) providing a follow-up (FU) strategy based on 3 clinical and angiographic risk profile (A high, B intermediate, and C low) has been recently proposed. Aim To evaluate the potential reduction of cardiologic consults (CC), stress tests (ST), and echocardiograms (EC) with the application of the MCD after PCI. Methods The Post-PCI registry is a multicenter, observational, prospective data collection carried out during a four-week period that included consecutive patients undergoing PCI at 31 Italian Hospitals both for acute coronary syndromes (ACS) or stable coronary artery disease (SCAD). FU strategies were left at investigator's discretion. A comparison between the CC, ST and EC performed in the first 12-months with the potential suggested by the MCD was evaluated. Results A total of 1113 patients were included; 12-months follow up was available in 90% of the cases (mean age 68±11 years old, 58% ACS). Based on MCD risk profile 17% were in A, 74% in B and 9% in C strategy. On average observed CC and ST were significantly lower compared to the expected based on MCD (respectively 1.63±1.07 vs 1.91±0.28, and 0.41±0.59 vs 0.61±0.84; on the contrary EC were significantly higher (0.64±0.73 vs 0.34±0.75, all: p75 years old) patients [OR 0.59 (CI 95% 0.43–0.80)]. Conclusion Our data suggest that in a real word population of patients undergoing PCI, a follow-up strategy based on clinical and anatomical risk profile would allow to a reduction of cardiac tests and consultations, particularly in patients at intermediated and low risk leading to an increase of appropriateness of prescription and to a cost reduction of medical care. Acknowledgement/Funding The Post-PCI registry was supported by the Italian Society of Interventional Cardiology (SICI-GISE) receiving an unrestricted grant from Astra Zeneca

Background The implantation of an implantable cardioverter defibrillator (ICD) in secondary prevention is a class I indication for patients with an estimated survival more than 1 year with a good functional status. However, in the elderly population, it is often difficult to estimate the expected survival, especially after an acute event such as an out-of-hospital cardiac arrest (OHCA). Purpose To evaluate 1-year survival after OHCA of patients older than 80 compared to those younger than 80. Methods We considered all the patients who suffered an OHCA in our Province (55ehz748.1135 inhabitants in northern Italy) from October 1st 2014 to November 30th 2017 stratified in two groups accordingly to their age at the moment of OHCA: elderly group (≥80 years old) and non-elderly group ( Results In the period analysis resuscitation was attempted in 1464 OHCA patients: 632 of the elderly group (mean age of 86.4±4.4 years) and 832 of the non-elderly group (mean age of 63.4±13.8 years). The two groups were different at baseline. In the non-elderly group there were more males (74.5% vs 42.4%, p Conclusions Elderly patients have a worst prognosis in the acute phase after an OHCA. However, after hospital discharge, older and younger patients showed a similar 1-year survival. This result highlights how age should not be considered alone to decide whether an ICD in secondary prevention could be indicated or not in older OHCA survivors.

Background According to the European Society of Cardiology guidelines secondary prevention ICD implantation is a class I indication only for those patients with an estimated survival >1 year with a good functional status. However, it is not specified how to assess the functional status and its evaluation could be quite difficult in the case of Out-of-Hospital Cardiac Arrest (OHCA) survivors. Cerebral Performance Category (CPC) scale is the most widespread scale to define the neurological and functional outcome, but it is not known if it can be used to guide ICD implantation. Purpose To evaluate whether the presence of a bad neurological outcome (CPC >2) in OHCA survivors at discharged could be used as a prognostic index in order to evaluate the implantation of an ICD. Methods We considered all the patients enrolled in the Cardiac Arrest Registry of our Province (55ehz746.0583 inhabitants in northern Italy) from the 1 October 2014 to the 31 January 2018 presenting a CPC >2 at discharge. We evaluated the survival and the neurological status variation at 1-year. Results In the study period CPR was attempted in 1565 confirmed OHCA (60.2% males, 73.4±15.8 years). Of these, 119 (7.6%) were discharged and 26 of them (21.8%) showed a CPC more than 2 (13 CPC = 3, 11 CPC = 4 and 2 CPC A). 1-year survival of CPC>2 patients was significantly lower than those with a CPC≤2 (46.1% vs 92.5% p2 survived at 1 year; a good cerebral performance (CPC 1) was recovered in 2 of them, whilst a moderate cerebral disability (CPC 2) was present in 1 of them. A severe cerebral disability (CPC 3 or 4) persisted in the other 9 patients. The neurological prognosis of patients based on CPC at hospital discharge is presented in Figure 1. Figure 1 Conclusions Our results highlight that 1-year survival is quite low in patients with a CPC >2 at discharge and an improvement in cerebral performance occur in a minority of them. The prognosis of the patients was very variable and unpredictable for all the CPC scale values at hospital discharge. This evidence suggest that an ICD implantation should carefully evaluated in this kind of patients and a clinical and neurological re-evaluation can be reasonable some time after the event to decide if implant an ICD.

OBJECTIVE ST-segment elevation myocardial infarction (STEMI) patients with type 2 diabetes mellitus (DM) have higher in-hospital mortality than those without. Since cardiac and renal functions are the main variables associated with outcome in STEMI, we hypothesized that this prognostic disparity may depend on a higher rate of cardiac and renal dysfunction in DM patients. RESEARCH DESIGN AND METHODS We retrospectively analyzed 5,152 STEMI patients treated with primary angioplasty. Left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate (eGFR) were evaluated at hospital admission. The primary end point was in-hospital mortality. A composite of in-hospital mortality, cardiogenic shock, and acute kidney injury was the secondary end point. RESULTS There were 879 patients (17%) with DM. The incidence of LVEF ≤40% (30% vs. 22%), eGFR ≤60 mL/min/1.73 m2 (27% vs. 18%), or both (12% vs. 6%) was higher (P < 0.001 for all comparisons) in DM patients. In-hospital mortality was higher in DM patients than in non-DM patients (6.1% vs. 3.5%; P = 0.002), with an unadjusted odds ratio (OR) of 1.81 (95% CI 1.31–2.49; P < 0.001). However, DM was no longer associated with an increased mortality risk after adjustment for cardiac and renal function (OR 1.03, 95% CI 0.68–1.56; P = 0.89). A similar behavior was observed for the secondary end point, with an unadjusted OR for DM of 1.52 (95% CI 1.25–1.85; P < 0.001) and an OR after adjustment for cardiac and renal function of 1.07 (95% CI 0.85–1.36; P = 0.53). CONCLUSIONS The study indicates that the increased in-hospital mortality and morbidity of DM patients with STEMI is mainly driven by their underlying cardio-renal dysfunction.

Transcatheter mitral valve repair with MitraClip has emerged as a possible therapeutic option for patients with severe mitral regurgitation (MR) with high risk for surgical valve repair. MitraClip intervention has demonstrated to improve haemodynamics and clinical outcomes in selected patients in observational and randomized studies. Preoperative pulmonary hypertension (PH) is known to affect prognosis in patients undergoing surgical mitral valve intervention. The aim of the present review is to discuss the available literature focused on the haemodynamic and clinical effects of MitraClip in patients with severe MR and PH.