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A 45-year-old woman, without cardiovascular risk factors and affected by chronic migraine, presented to the emergency department due to the onset of a typical chest pain. After performing an electrocardiogram she was promptly transported to the Cath lab, with the diagnosis of ST segment elevation myocardial infarction (STEMI), for urgent coronarography. A spontaneous dissection of the first obtuse marginal branch was detected which was treated with two drug eluting stents implantation. A day after the procedure, during a migraine crisis, at the continuous electrocardiographic monitoring it was registered a brief episode of complete atrioventricular block, which regressed spontaneously after a few minutes. For this reason, she underwent atropine test which resulted negative for AV conductance defects. No more episodes were recorded during the hospital stay, however it was decided to implant a loop recorder (Biotronik BIOMONITOR III) before the discharge. The patient received a remote monitoring device in order to allow a closer follow-up in course of the COVID-19-related lockdown, that caused a relevant reduction in the outpatients’ services. A few months later a sinusal pause of about 9 s was recorded with the emergence of an idioventricular rhythm at 25 b.p.m. When contacted by telephone the patient reported being hospitalized because of pulmonary complications of SARS-CoV-2 infection. She referred of being bedridden, without any cardiac monitor and of being asymptomatic for syncope. Thus, she was transferred to a Cardiology Unit dedicated to patients affected by SARS-CoV-2 disease, for further diagnostic investigations. This represents a case in which the remote monitoring technology resulted fundamental in the management of patients with implantable devices, in particular during COVID-19-related lockdown. However, it is at least as much important to encourage the patient to carry the transmitter with him, even in the case of unexpected events or hospitalizations, in order to gain access to all the information store in the CIED which might be useful to the diagnosis of the underlying disease. Biotronik has developed the smallest remote transmitter in commerce (CardioMessenger Smart) which is functional to this kind of use. Moreover, it has an automatic interrogation function which can send the alerts about the arrhythmic events quicker than the other brands and so it’s more practical in situations where the patient is hospitalized in non-cardiological units.

Background and aims Despite the relation between autoimmune diseases and increased atherosclerotic risk is established, the influence of autoimmune disorders on in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) is only partly known. ISR is an aberrant reparative process mainly characterized by an increased number of vascular smooth muscle cells and excessive deposition of extracellular proteoglycans and type III collagen. Chronic inflammation, always present in autoimmune diseases, modulates the endothelial response to PCI. Aim of this review is to resume the current evidence on the association between ISR and autoimmune diseases, focusing on pathogenic mechanisms and therapeutic targets. Methods We conducted a comprehensive review of the literature on the relationship between ISR and insulin-dependent diabetes mellitus (IDDM), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), antiphospholipid-antibodies syndrome (APS), inflammatory bowel diseases (IBD), and Hashimoto's thyroiditis (HT). Results Patients affected with IDDM, RA, SLE, APS, IBD and HT proved to face higher rates of ISR compared to the general population. The endothelial dysfunction seems the principal common pathogenic pathway for ISR and is attributed to both the immune system disorder and the systemic inflammation. Some evidence suggested that methotrexate and anti-tumor necrosis factor treatments can be effective in reducing ISR, while antibodies against vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 showed to reduce neointimal hyperplasia in animal models. Conclusions Autoimmune diseases are a risk factor for ISR. The study of the potential cardiovascular benefits of the current therapies, mainly anti-inflammatory drugs, and the pursuit of innovative treatments appear of paramount interest.

Background The optional periprocedural antithrombotic management for carotid artery stenting (CAS) is still debated. Methods We aimed to compare the procedural and 1-month outlook of patients undergoing CAS with tirofiban as parenteral antiplatelet therapy. We retrospectively compared patients receiving tirofiban during CAS versus those undergoing CAS without tirofiban, using propensity score matching. Ancillary antithrombotic therapy included in all patients aspirin, clopidogrel, and unfractioned heparin. The primary outcome was the change in serum troponin from baseline to postprocedural peak levels. A total of 30 patients undergoing CAS were included, 15 receiving tirofiban on top of heparin and dual oral antiplatelet therapy (DAPT) and 15 receiving only heparin and DAPT. Bail-out use of tirofiban was an exclusion criterion. Results Baseline troponin was 3.00 (0.06; 5.20) ng/mL in the tirofiban group vs. 4.6 (0.02; 13.10) ng/mL in the no-tirofiban group (P = 0.229), and postprocedural peak 3.5 (0.06; 5.50) ng/mL vs. 6.30 (0.09; 28.40) ng/mL (P = 0.191). Peak-baseline difference in troponin was lower in the tirofiban group than in the no-tirofiban group: 0.3 (0.00; 1.7) ng/mL vs. 1.3 (0.01; 10.00) ng/mL (P = 0.044); the relative peak-baseline change in troponin was analogously different: 24.3% (0%; 44.7%) vs. 50% (21.3%; 80.0%) (P = 0.039). No case of death, myocardial infarction, stroke, or transient ischemic attack occurred during in-hospital stay or at 1-month follow-up. Conclusions Tirofiban during CAS might provide periprocedural myocardial protection and reduce myocardial injury as determined by serial troponin measurements.