Search

BACKGROUND Patients with delayed presentation of acute myocardial infarction with ST-segment elevation (STEMI) frequently have a poor prognosis but literature about acute complications in intensive cardiac care unit (ICCU) and in-hospital outcome are still limited. METHODS All STEMI patients admitted to our institution between June 2007 and December 2013 were divided into patients presenting more than 12 h after symptom onset (lateSTEMI) and within 12 h (STEMI). Baselines clinical features including details about treatment of choice were collected. Major acute complications in ICCU and in-hospital mortality were the main end-points. RESULTS A total of 1372 patients were included, 147 (10.8%) were lateSTEMI. In ICCU lateSTEMI patients compared with STEMI patients experienced more frequently heart failure (75, 51.2% vs. 298, 24.3%; P

Coronary care units, initially developed to treat acute myocardial infarction, have moved to the care of a broader population of acute cardiac patients and are currently defined as Intensive Cardiac Care Units (ICCUs). However, very limited data are available on such evolution. Since 2008, in Italy, several surveys have been designed to assess ICCUs’ activities. The largest and most comprehensive of these, the BLITZ-3 Registry, observed that patients admitted are mainly elderly males and suffer from several comorbidities. Direct admission to ICCUs through the Emergency Medical System was rather rare. Acute coronary syndromes (ACS) account for more than half of the discharge diagnoses. However, numbers of acute heart failure (AHF) admissions are substantial. Interestingly, age, resources availability, and networking have a strong influence on ICCUs’ epidemiology and activities. In fact, while patients with ACS concentrate in ICCUs with interventional capabilities, older patients with AHF or non-ACS, non-AHF cardiac diseases prevail in peripheral ICCUs. In conclusion, although ACS is still the core business of ICCUs, aging, comorbidities, increasing numbers of non-ACS, technological improvements, and resources availability have had substantial effects on epidemiology and activities of ICCUs. The Italian surveys confirm these changes and call for a substantial update of ICCUs’ organization and competences.

Aims To define a benchmark target for an invasive strategy (IS) rate appropriate for performance assessment in intermediate-to-high risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Methods and results During the BLITZ-4 campaign, which aimed at improving the quality of care in 163 Italian coronary care units, 4923/5786 (85.1%) of consecutive patients admitted with NSTE-ACS with troponin elevation and/or dynamic ST-T changes on the electrocardiogram were managed with IS. The reasons driving the choice (RDC) for a conservative strategy (CS) in the remaining 863 patients were prospectively recorded. In 33.8%, CS was mandatory because of patients refusal, known coronary anatomy or death before coronary angiography; in 52.8% it was clinically justified because of active stroke, bleeding, advanced frailty, severe comorbidities, contraindication to antiplatelet therapy or because they were considered to be at low risk; only in 13.4% the reasons, such as renal failure, advanced age or other, were less stringent. As compared to patients undergoing IS, those in the CS were 12years older and had significantly more severe comorbidities. The in-hospital and 6-month all-cause mortality were 9.0% vs 0.9% and 22.0% vs 3.9% in CS and IS groups respectively (p Conclusion As the RDC for CS were clinically correct in vast majority of cases the observed 85% invasive strategy rate may be considered as the desirable benchmark target in patients with NSTE-ACS. For the same reason, it remains questionable if the higher rate of IS could have improved the prognosis in CS patients, despite their highly unfavorable prognosis.

Introduction: The efficacy and safety of switching P2Y12 receptor antagonists in patients admitted for acute coronary syndrome (ACS) remain unclear. We assessed the short-term clinical outcomes (in-hospital and within 30 days) of switching P2Y12 inhibitor (P2Y12I) drugs versus maintaining the same regimen by performing a comprehensive review and meta-analysis of available data. Methods: MEDLINE/PubMed/SCOPUS/Cochrane databases were screened for studies regarding switching of P2Y12I in patients with ACS that reported 30 days follow-up. Major cardiac events (MACE) and bleeding were compared between patients who were switched/not switched. Results: 22,500 patients from 14 studies were included. Unstable angina/non-ST elevation myocardial infarction (62.0%, interquartile range, 52.8%–68.0%) was the most common clinical presentation. The total number switched was 4294 (19.1%); escalation in 3416 (79.5%) patients (from clopidogrel to prasugrel, 62.9%) and de-escalation in 18.5%. Pooled analysis revealed no significant differences in MACE for any comparison; risk of bleeding was significantly increased among switched patients overall (odds ratio [OR], 1.60; 95% confidence interval [CI] 1.22–2.10) and increased in the escalation group (OR, 1.51; 95% CI, 1.06–2.16). Conclusions: Among patients presenting with ACS, switching from one P2Y12I agent to another in the acute phase seems associated with a short-term increased risk of bleeding. Accurate upfront selection and prescription of a P2Y12I based on ischemic and bleeding risks is paramount to avoid adverse events switching-related during hospitalization and in the first 30 days. Keywords: Novel P2Y12 inhibitors, Switching, Clopidogrel, Ticagrelor, Prasugrel, Acute coronary syndrome

ObjectivesTo retrospectively evaluate the impact on daily activities of transcatheter closure of patent foramen ovale (PFO) versus medical therapy in patients with migraine and to analyze the role of the residual shunt after PFO closure.BackgroundWhile non-controlled observational studies reported an improvement of migraine after PFO closure, a randomized trial has shown no benefit of such an intervention. The role of residual shunt after PFO closure is also poorly known.MethodsOut of 217 patients with migraine and echocardiographic evidence of PFO, 89 were managed with percutaneous PFO closure (Group A) while 128 were medically treated (Group B). All MIDAS questionnaires were obtained at the first evaluation and repeated at least 6 months after the index evaluation or after the PFO closure. All the patients were also asked to give a subjective estimate of their migraine status. A postprocedural transcranial Doppler study was available in 70 patients in Group A.ResultsThe mean basal MIDAS score did not differ between the two groups (p=0.859). After a mean follow-up (FU) of 1399±982 days the MIDAS score decreased significantly in both groups (Group A baseline vs FU, p

Aims: Given the different pathogenesis, use of drug eluting stent (DES) in patients with Spontaneous Coronary Artery Dissection SCAD may delay the healing of the dissected vessel. Aim of our studywas to compare the safety and the efficacy of DES vs. bare metal stent (BMS) in a cohort of patients who underwent stenting for SCAD. Methods and results: Consecutive patients with SCAD between January 1995 and August 2014 were retrospectively identified in 12 centers and included. Major Adverse Cardiac Events (MACE) was the primary end point. A total of 238 SCAD patients were identified: of them 108 patients underwent PCI with DES or BMS. Overall 24 patients (22.2%) suffered an intra-procedural complication without any differences between the 2 groups. At median follow-up of 1201 days (Inter Quartile Range 541-2760), incidence of the primary endpoint showed a trend towards less events in the DES-treated patients (38.7% vs. 25.9% p = 0.14) mainly driven by the benefit of DES in terms of TVR (17.6% vs. 4%, p = 0.08), mortality (16.8% vs. 9.3%, p = 0.4), and MI rate (16% vs. 8.4%, p = 0.33). STEMI at presentation (HR 6.4, CI 95% 1.29-31.9, p = 0.02) but not kind of stent (HR 0.97, CI 95% 0.2-4.7, p = 0.9) emerged as independently related to prognosis at multivariable analysis. Conclusions: In SCAD patients use of DES seems to be as safe as BMS with trend of better efficacy in the long term. (C) 2017 Elsevier B. V. All rights reserved

Background Chronic renal dysfunction (RD) frequently coexists with heart failure (HF) and influences outcome. Patients with acute HF (AHF) and severe RD are frequently excluded in the trials. We characterized these subjects and assessed incidence and predictors of in-hospital and one-year mortalities. Methods We selected the 455 patients included in the "IN-HF Outcome" Italian registry belonging to the lowest quartile of estimated glomerular filtration rate (eGFR < 40 ml/min/1.73 m2). Results Mean eGFR at entry in severe RD patients was 28 ± 9 ml/min/1.73 m2. Compared to 1368 patients with more preserved eGFR, they were older, with more co-morbidities and more frequently ischemic etiology of HF. In-hospital and one-year all-cause mortality rates were 14% and 44% respectively, twice higher than the entire population. Predictors of in-hospital mortality were an abnormal status of consciousness, older age, hyponatremia, lower systolic blood pressure and eGFR. The same conditions (except eGFR) predicted one-year mortality together with the absence of diabetes and no treatment with beta-blockers or diuretics. Conclusions In patients with AHF and severe RD, in-hospital and one-year all-cause mortality rates are very high. Independent predictors such as older age, and signs of hypoperfusion and hyponatremia may be identified but preventing and reversing RD remain the key targets for the clinical management of these patients.

Background— Clinical observational studies on heart failure (HF) deal mostly with hospitalized patients, few with chronic outpatients, all with no or limited longitudinal observation. Methods and Results— This is a multicenter, nationwide, prospective observational trial on a population of 5610 patients, 1855 hospitalized for acute HF (AHF) and 3755 outpatients with chronic HF (CHF), followed up for 1 year. The cumulative total mortality rate at 1 year was 24% in AHF (19.2% in 797 patients with de novo HF and 27.7% in 1058 with worsening HF) and 5.9% in CHF. Cardiovascular deaths accounted for 73.1% and 65.3% and HF deaths for 42.4% and 40.5% of total deaths in AHF and CHF patients, respectively. One-year hospitalization rates were 30.7% in AHF and 22.7% in CHF patients. Among the independent predictors of 1-year all-cause death, age, low systolic blood pressure, anemia, and renal dysfunction were identified in both acute and chronic patients. A few additional variables were significant only in AHF (signs of cerebral hypoperfusion, low serum sodium, chronic obstructive pulmonary disease, and acute pulmonary edema), whereas others were observed only in CHF patients (lower body mass index, higher heart rate, New York Heart Association class, large QRS, and severe mitral regurgitation). Conclusions— In this contemporary data set, patients with CHF had a relatively low mortality rate compared with those with AHF. Rates of adverse outcomes in patients admitted for AHF remain very high either in-hospital or after discharge. Most deaths were cardiovascular in origin and ≈40% of deaths were directly related to HF.

Summary Aims: To review currently available knowledge on presentation, clinical features and management of heart failure (HF) in elderly people. Methods: To review currently available evidence, we performed a thorough search of several evidence-based sources of information, including Cochrane Database of Systematic Reviews, Clinical Evidence, Evidence-based guidelines from National Guidelines Clearinghouse and a comprehensive MEDLINE search with the MeSH terms: ‘heart failure’, ‘elderly’ and ‘management’. Results: A number of features of ageing may predispose elderly people to HF, and may impair the ability to respond to injuries. Another hallmark of elderly patients is the increasing prevalence of multiple coexisting chronic conditions and geriatric syndromes that may complicate the clinical presentation and evolution of HF. Although diagnosis may be challenging, because atypical symptoms and presentations are common, and comorbid conditions may mimic or complicate the clinical picture, diagnostic criteria do not change in elderly people. Drug treatment is not significantly different from that recommended in younger patients, and largely remains empiric, because clinical trials have generally excluded elderly people and patients with comorbid conditions. Disease management programmes may have the potential to reduce morbidity and mortality for patients with HF. Conclusions: Heart failure is the commonest reason for hospitalisation and readmission among older adults. HF shows peculiar features in elderly people, and is usually complicated by comorbidities, presenting a significant financial burden worldwide, nevertheless elderly people have been generally excluded from clinical trials, and thus management largely remains empiric and based on evidence from younger age groups.

A 66-year-old healthy man admitted for an acute renal colic suddenly experienced a brief episode of loss of consciousness followed by persistent superior left arm hyposthenia during i.v. infusions of a non-steroidal anti-inflammatory drug using a standard antecubital right vein access (ARVA). A magnetic resonance imaging (MRI) scan showed a stroke with an embolic pattern. Carotid …

We thank Drs Mewton and Bresson for their interest in our article.1 The issues raised by the authors are essentially 3: the diagnosis being based on subjective criteria, the exclusion of patients with systemic inflammatory diseases, and the rationale for the definition of perimyocarditis and myopericarditis not being based on solid pathophysiological evidence. First, in clinical practice, a spectrum of myopericardial syndromes can be encountered, ranging from pure pericarditis to increasing degrees of inflammatory myocardial involvement (myopericarditis and perimyocarditis) to pure myocarditis.2,3 Diagnostic criteria for acute pericarditis are well recognized and established.3–5 Although not supported by guidelines and consensus documents, myopericarditis and perimyocarditis definitions also have been proposed on the basis of clinical criteria.3 Myopericarditis is a primarily pericardial inflammatory syndrome occurring when clinical diagnostic criteria …

Objective The purpose of this study was to determine the sensitivity and specificity of new criteria proposed by Duke University for case definition of infective endocarditis as compared to the previously accepted Von Reyn criteria. Patients A total of 143 consecutive suspected cases of infective endocarditis in 137 febrile patients were included. Of these, 69 had infective endocarditis, pathologically proven in 28, but with only a clinical diagnosis in 41. In the remaining 74 cases, the diagnosis of-infective endocarditis was rejected after a follow-up of at least 3 months. Results The sensitivity of Duke's criteria was significantly higher, both when patients with possible infective endocarditis were considered as true-positive (definition 1; 100% vs 69%, P

The natural history of myopericarditis/perimyocarditis is poorly known and recently published data have presented contrasting results on their outcomes. The aim of the present article is to assess their prognosis in a multicenter, prospective cohort study. A total of 486 patients (median age 39

Background— The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study. Methods and Results— A total of 486 patients (median age, 39 years; range, 18–83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P Conclusions— The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting.

To assess and promote compliance of Italian cardiological intensive care units (CCUs) with evidence-based guidelines for the management of acute myocardial infarction (MI).The process of diagnosis and treatment of MI was prospectively evaluated in 163 CCUs by use of 30 indicators during two enrolment phases, each followed by a feedback of both local and general performance. Overall, 5854 patients with ST-segment elevation MI (STEMI) and 5852 with non-ST-segment elevation MI (NSTEMI) were consecutively enrolled. The target for each indicator was defined as compliance with the relevant recommendations in ≥90% of suitable patients and it was met for nine (30%) and 10 (33.3%) indicators in the first and second phases, respectively. Regardless of target, a significant improvement in compliance was observed in the second phase in 10 out of 30 indicators (33.3%). Use of pre-hospital ECG, expedite delivery of reperfusion therapy, dosage of antithrombotic drugs, and non-pharmacological implementation of secondary prevention were often off target. Similar in-hospital mortality was observed in phases I and II, both in patients with STEMI (4.0 vs. 4.2%, p=0.79) and NSTEMI (1.8 vs. 2.4%, p=0.11). Overall, 30-day mortality were 5.7% for patients with STEMI and 3.4% with NSTEMI.Performance indicators can accurately weigh the whole process of diagnosis and treatment of patients with MI and monitor the improvements in the quality of care. In our large population of consecutive patients, satisfactory 30-day outcomes were observed despite suboptimal adherence to guidelines for some indicators of recognised prognostic relevance.

Aims Registries and surveys improve knowledge of the ‘real world’. This paper aims to describe baseline clinical profiles, management strategies, and the in-hospital outcome of patients admitted to hospital for an acute heart failure (AHF) episode. Methods and results IN-HF Outcome is a nationwide, prospective, multicentre, observational study conducted in 61 Cardiology Centres in Italy. Up to December 2009, 5610 patients had been enrolled, 1855 (33%) with AHF and 3755 (67%) with chronic heart failure (CHF). Baseline and in-hospital outcome data of AHF patients are presented. Mean age was 72 ± 12 years, and 39.8% were female. Hospital admission was due to new-onset heart failure (HF) in 43% of cases. Co-morbid conditions were observed more frequently in the worsening HF group, while those with de novo HF showed a higher heart rate, blood pressure, and more preserved left ventricular ejection fraction (LVEF). Electrical devices were previously implanted in 13.3% of the entire group. Inotropes were administered in 19.4% of the patients. The median duration of hospital stay was 10 days (interquartile range 7–15). All-cause in-hospital death was 6.4%, similar in worsening and de novo HF. Older age, hypotension, cardiogenic shock, pulmonary oedema, symptoms of hypoperfusion, hyponatraemia, and elevated creatinine were independent predictors of all-cause death. Conclusion Our registry confirms that in-hospital mortality in AHF is still high, with a long length of stay. Pharmacological treatment seems to be practically unchanged in the last decades, and the adherence to HF guidelines concerning implantable cardioverter defibrillators/cardiac resynchronization therapy is still very low. Some AHF phenotypes are characterized by worst prognosis and need specific research projects.

Background Intensive cardiac care units (ICCUs) have shifted from the observation of patients with myocardial infarction to the care of different acute cardiac diseases. However, few data on such an evolution are available. Methods and results From 7 to 20 April 2008, 6986 consecutive patients admitted to 81% of Italian ICCUs were prospectively enrolled. Patients observed were mainly elderly men (median age 72 years) with several co-morbidities. Most of them were triaged to ICCU from the emergency room, but 15% of admissions were transfer-in from other hospitals. Several diagnostic and therapeutic procedures were applied (78% had echocardiography and 35% coronary angiography) during the ICCU stay [median length 4 days, interquartile range (IQR) 2-5]. The discharge diagnosis was ST-elevation acute coronary syndrome (ACS) in 21%, non-ST-elevation ACS in 31%, acute heart failure (AHF) in 14% and other acute non-ACS, non-AHF cardiac diseases in 34%. Of those with ST-elevation ACS, 60% received reperfusion (15% fibrinolysis and 45% primary percutaneous coronary intervention). The overall in-ICCU crude mortality was 3.3%. Conclusion The BLITZ-3 survey provides a unique snapshot of current epidemiology and patterns of care of patients admitted to ICCUs. Although ACS still remains the most frequent admission diagnosis, the number of non-ACS patients is substantial. However, the correct standard of care for these non-ACS patients has to be defined.

In Piedmont (north-western Italy) a network for emergency treatment of acute ST-elevation myocardial infarction is being implemented. To provide a baseline for care assessment and quality improvement, a regionwide survey was conducted. We describe the clinical characteristics, treatment and outcomes of patients admitted to the coronary care units (CCUs) of the Regional Health System.All patients with acute ST-elevation myocardial infarction12 h of symptom onset, admitted to any of the 31 CCUs (13 with full-time interventional facilities) between February and May 2005, were enrolled in the study.Of 818 patients (28.1% female, mean age 66 +/- 12 years), 14.3% had diabetes mellitus and 39.7% anterior myocardial infarction; 77% had their first medical contact within 3 h of symptom onset, and 53% reached full-time interventional CCUs. The 118 emergency medical system was used by 50% of patients. Median door-to-electrocardiogram time was 9 min (10 min in 60%). Reperfusion treatment was attempted in 682 patients (83.4%) as follows: lysis in 254 (31.1%), lysis-angioplasty in 95 (11.6%), and primary angioplasty in 333 (40.7%); 136 patients (16.6%) received no reperfusion treatment. Median door-to-needle time was 35 min (30 min in 43%). Emergency angioplasty was performed on site in 356 patients, with a median door-to-balloon time of 84 min (90 min and60 min in 50% and 23%, respectively). Emergency transfer to a full-time interventional centre was required in 93 patients (24% of candidates), regardless of their risk profile, with median decision-to-door out and travel times of 45 min and 52 min, respectively. In-hospital death, reinfarction and stroke occurred in 62 (7.6%), 13 (1.6%) and 10 patients (1.2%), respectively. Mortality was 5.9% and 16.7% in patients with and without reperfusion treatment, respectively. At multivariate analysis, the type of reperfusion treatment was not a predictor of mortality, whereas this was the case for the absence of reperfusion treatment (odds ratio 2.16; 95% confidence interval 1.17-4.02), TIMI risk index33 (odds ratio 6.78; 95% confidence interval 3.70-12.40), and chronic renal failure (odds ratio 4.96; 95% confidence interval 1.82-13.55).In Piedmont, candidates for myocardial reperfusion treatment admitted to the CCUs of the Regional Health System are about 600 per million inhabitants/year. The 118 emergency medical system is used by about half of them, and medical contact occurs within 3 h of symptom onset in most cases. Use of reperfusion treatment is frequent, the choice is related to on-site availability rather than to risk profile, and door-to-treatment times can be improved. Use of emergency transfer is limited, poorly selected, and slow.

To investigate the relative incidence, clinical presentation and prognosis of myopericarditis among patients with idiopathic or viral acute pericarditis.Prospective observational clinical cohort study.Two general hospitals from an urban area of 220 000 inhabitants.274 consecutive cases of idiopathic or viral acute pericarditis between January 2001 and June 2005.Relative prevalence of myopericarditis. Clinical features at presentation including echocardiographic data (ejection fraction (EF), wall motion score index (WMSI)) and follow-up data at 12 months including complications, results of echocardiography, electrocardiography and treadmill testing.Myopericarditis was recorded in 40/274 (14.6%) consecutive patients. At presentation, the following clinical features were independently associated with myopericarditis: arrhythmias (odds ratio (OR) = 17.6, 95% confidence interval (CI) 5.7 to 54.1; p0.001), male gender (OR = 6.4, 95% CI 2.3 to 18.4; p = 0.01), age40 years (OR = 6.1, 95% CI 2.2 to 16.9; p = 0.01), ST elevation (OR = 5.4, 95% CI 1.4 to 20.5; p = 0.013) and a recent febrile syndrome (OR = 2.8, 95% CI 1.1 to 7.7; p = 0.044). After 12 months' follow-up an increase of EF (basal EF 49.6 (5.1)% vs 12-month EF 59.1 (4.6)%; p0.001) and decrease of WMSI (basal WMSI 1.19 (0.27) vs 12-month WMSI 1.02 (0.09); p0.001) were recorded in patients with myopericarditis, with a normalisation of echocardiography, electrocardiography and treadmill testing in 98% of cases. Use of heparin or other anticoagulants (OR = 1.1, 95% CI 0.3 to 3.5; p = 0.918) and myopericarditis (OR = 2.3, 95% CI 0.7 to 7.6; p = 0.187) was not associated with an increased risk of cardiac tamponade or recurrences.Myopericarditis is relatively common and shows a benign evolution also in spontaneous cases not related to vaccination.

A 28-year-old man was admitted to the Emergency Department for syncope after several hours of violent vomiting and diarrhea. A few minutes after arrival, he complained of palpitations followed by a sudden loss of consciousness. An ECG showed a polymorphic ventricular tachycardia degenerating into ventricular fibrillation (Figure 1⇓). Because of recurrent major ventricular arrhythmias, resuscitation was necessary for 1 hour. The patient was eventually admitted to the Coronary Care Unit. Physical examination, ECG (Figure 2⇓), chest x-ray, …

Aims: HIV patients are at high risk of subsequent cardiac events after an ACS, while remain unclear if this vulnerability depends from enhanced thrombosis or progression of plaque. Methods and results: All consecutive patients with HIV infection receiving standard (highly active antiretroviral therapy) HAART therapy presenting with ACS in our centers from January 2001 to September 2012 were studied, recording clinical data regarding the cardiac history and HIV treatment, as well details about the coronary intervention procedures. Cardiac death, new myocardial infarction or revascularizations and in-stent thrombosis were recorded as co-primary end points. We enrolled 201 patients, 179 (89%) male with a median age of 53 (47-62) years, 96 (48%) presenting STEMI. After a median of 701 (284-1237) days, 30 (15%) of patients died, 12 (6%) for cardiac reason, 20 (10%) suffered a myocardial infarction, 29 (15%) a subsequent revascularization and 7 (3.8%) a stent thrombosis with an overall incidence of 44 (21.6%) MACE (major adverse cardiac events). Patients that experience MACE did not differ for cardiovascular risk factor or treatment of choice while showed a higher rate of chronic renal failure (9, 20.5% vs 8, 5.4% p=0.002) and multivessel/left main disease at presentation (30, 68.2% vs 70, 47.6% p=0.017). At the multivariable adjustement, the only independent predictor of MACE was the multivessel/left main disease (HR 1.16-5.58; p=0.02) whereas CD4 count