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The oncological patient presents many pathophysiological particularities, including a hypercoagulable state, which causes frequent thromboembolic complications. Furthermore, the side effects of chemotherapy, laborious surgical interventions and the poor performance status favor the occurrence of deep vein thrombosis (DVT). The aim of this retrospective study is to identify the prevalence of paraneoplastic DVT in patients admitted in the Cardiology Department of the “Sf. Spiridon” County Clinical Emergency Hospital from Iași and to establish the correlations between the DVT, type of neoplasia and certain particularities of the patients. Material and methods: The current retrospective study was conducted over a two-year period and enrolled 100 patients divided into two groups based on the presence or absence of a neoplasia (25 patients having a tumoral pathology and 75 patients without such a comorbidity). All study participants underwent a complete clinical examination and were assessed through biochemical and echocardiographic parameters. Results: Various tumor locations were identified in the 25 patients with a malignancy, the most prevalent being the colorectal cancer (6 cases, 24% of total), followed by the lung cancer (4 cases, 16%) and, with a similar occurrence, the brain, ovarian and breast cancer (2 cases each, 8%). Among the patients with neoplasia, 13 had a history of cancer (52% of cases from the neoplasia group), while for the remaining 12 patients it was a de novo diagnosis. Conclusions: Patients with DVT showed a significant cancer prevalence, either previously diagnosed or incidentally discovered. The increased risk of DVT in cancer patients is multifactorial and represents a diagnosis and therapeutic challenge. In our study, we recorded a slightly increased prevalence of cancer in women (56% vs. 44%), who had cervical cancer as the most common etiology (35.7%). On the other hand, male sex was associated with an increased frequency of colorectal cancer (36.4% of all cancers diagnosed in men), followed by lung cancer (27.3%).

Venous thromboembolism (VTE) can be the first symptom of an occult malignancy in apparently healthy individual. Inferior vena cava (IVC) tumors are rare conditions but with negative prognosis. We present the case of a 57 year-old male patient, with complete situs inversus, diagnosed with hepatic cirrhotic disease and frequent decompensations, that was hospitalized for deep venous thrombosis (DVT) and ascites. Further imagistic investigations revealed a 22 cm tumor inside the IVC with consequent Budd-Chiari syndrome that was actually causing the liver and kidney disease, extending from the infrarenal level to the right atrium. After compensation, the patient was referred to a multidisciplinary surgical team. However, the management of such patients is very difficult, and the prognosis is altered. Possible IVC leiomyosarcoma are very rare and such vascular extension has been rarely reported.

Intermediate-high-risk pulmonary embolism (PE) is characterized by right ventricular (RV) dysfunction and elevated circulating cardiac troponin levels despite apparent hemodynamic stability at presentation. In these patients, full-dose systemic thrombolysis reduced the risk of hemodynamic decompensation or death but increased the risk of life-threatening bleeding. Reduced-dose thrombolysis may be capable of improving safety while maintaining reperfusion efficacy. The Pulmonary Embolism International THrOmbolysis (PEITHO)-3 study (ClinicalTrials.gov Identifier: NCT04430569) is a randomized, placebo-controlled, double-blind, multicenter, multinational trial with long-term follow-up. We will compare the efficacy and safety of a reduced-dose alteplase regimen with standard heparin anticoagulation. Patients with intermediate-high-risk PE will also fulfill at least one clinical criterion of severity: systolic blood pressure ≤110 mm Hg, respiratory rate >20 breaths/min, or history of heart failure. The primary efficacy outcome is the composite of all-cause death, hemodynamic decompensation, or PE recurrence within 30 days of randomization. Key secondary outcomes, to be included in hierarchical analysis, are fatal or GUSTO severe or life-threatening bleeding; net clinical benefit (primary efficacy outcome plus severe or life-threatening bleeding); and all-cause death, all within 30 days. All outcomes will be adjudicated by an independent committee. Further outcomes include PE-related death, hemodynamic decompensation, or stroke within 30 days; dyspnea, functional limitation, or RV dysfunction at 6 months and 2 years; and utilization of health care resources within 30 days and 2 years. The study is planned to enroll 650 patients. The results are expected to have a major impact on risk-adjusted treatment of acute PE and inform guideline recommendations. ispartof: THROMBOSIS AND HAEMOSTASIS vol:122 issue:05 pages:857-866 ispartof: location:Germany status: published

Treatment of patients with immune thrombocytopenic purpura (ITP) associated with recurrent venous and arterial thrombosis can represent a major challenge. We present the rare case of a 56-year-old female who was first diagnosed with severe ITP at the age of 36. She required corticosteroid therapy and splenectomy in evolution. However, in the last three years she had several episodes of recurrent venous thromboembolism for which she required different anticoagulant therapies despite severe thrombocythemia. The patient also developed acute myocardial infarction treated by primary percutaneous coronary intervention that was complicated with acute intrastent thrombosis. Thus, maximal antiplatelet therapy was mandatory. For ITP, the patient received intravenous steroids, platelet transfusion as well as eltrombopag. Moreover, the patient also suffered from a haemorrhagic uterine fibroma that required surgery. Thus, a close multidisciplinary approach was needed for the successful treatment of this patient.

Assessing the biochemical parameters in patients with pulmonary embolism (PE), deep vein thrombosis (DVT) or both brings complimentary information for the cardiovascular (CV) and death risk stratification. The purpose of the study was to evaluate the association between biochemical parameters and PE, DVT or both. The study was prospective, conducted over a 12-month period and included 151 patients diagnosed with PE, DVT or both pathologies. These patients were extensively analysed taking into account biochemical parameters associated with the above-mentioned pathologies. Mean age was 59.23 � 18.22 years and 55% were women. 38.40% patients had PE, 48.30% had DVT and 13.20% had both pathologies. GFR upon admission was strongly negatively associated with age, r(148)= -0.75, p[0.01, intra-hospital death r(148)= -0.18, p=0.02 and with AST levels r(144)= -0.21, p=0.01 and positively statistically significant with the number of days of hospitalization r(8)= +0.79, p=0.0. Moreover, for one unit decrease in GFR the number of days of hospitalization decreased with 0.231. Moreover, AST correlated with intra-hospital death r(146)= 0.25, p[0.01, creatinine upon admission r(144)= 0.24, p[0.01, urea upon admission r(143)= 0.16, p=0.04 and glucose levels r(139)= 0.19, p=0.02, but negatively associated with GFR upon admission with r(144)= -0.21, p=0.01; for each one unit decrease of GFR there was an increase in AST levels by 0.21. Also there was a significant correlation between the thrombolysis therapy and the number of days of hospitalization r(151)= 0.21, p[0.01 and between positive inotropic support and intra-hospital death with r(151)= 0.27, p[0.01. In patients with PE, DVT or both, renal function, AST levels and the number of days of hospitalization were associated with an increased risk of death, especially in patients with PE � DVT.

Current Guidelines for the diagnosis and management of acute pulmonary embolism (PE), as well as all other Guidelines, summarize and evaluate the already available evidence and consensus “with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition”. In this review we present the most important new recommendations of the latest ESC Guidelines on the diagnosis and management of acute pulmonary embolism.

Background: Acute heart failure (HF) represents an increasingly common and challenging presentation in the emergency room, also inducing a great socio-economic burden. Extensive research was conducted toward finding an ideal biomarker of acute HF, both in terms of sensitivity and specificity, but today practicians’ interest has shifted towards a more realistic multimarker approach. Natriuretic peptides (NPs) currently represent the gold standard for diagnosing HF in routine clinical practice, but novel molecules, such as sST2, emerge as potentially useful biomarkers, providing additional diagnostic and prognostic value. Methods: We conducted a prospective, single-center study that included 120 patients with acute HF and 53 controls with chronic HF. Of these, 13 patients (eight with acute HF, five from the control group) associated the coronavirus-19 disease (COVID-19). The diagnosis of HF was confirmed by a complete clinical, biological and echocardiographic approach. Results: The serum levels of all studied biomarkers (sST2, NT-proBNP, cardiac troponin) were significantly higher in the group with acute HF. By area under the curve (AUC) analysis, we noticed that NT-proBNP (AUC: 0.976) still had the best diagnostic performance, closely followed by sST2 (AUC: 0.889). However, sST2 was a significantly better predictor of fatal events, showing positive correlations for both in-hospital and at 1-month mortality rates. Moreover, sST2 was also associated with other markers of poor prognosis, such as the use of inotropes or high lactate levels, but not with left ventricle ejection fraction, age, body mass index or mean arterial pressure. sST2 levels were higher in patients with a positive history of COVID-19 as compared with non-COVID-19 patients, but the differences were statistically significant only within the control group. Bivariate regression showed a positive and linear relationship between NT-proBNP and sST2 (r(120) = 0.20, p &lt, 0.002). Conclusions: we consider that sST2 has certain qualities worth integrating in a future multimarker test kit alongside traditional biomarkers, as it provides similar diagnostic value as NT-proBNP, but is emerging as a more valuable prognostic factor, with a better predictive value of fatal events in patients with acute HF.

(1) Background: In patients suffering from heart failure, the main causes of death are either hemodynamic failure, or ventricular arrhythmias. The only tool to significantly reduce arrhythmic sudden death is the implantable cardioverter defibrillator (ICD), but not all patients benefit to the same extent from these devices. (2) Methods: The primary outcome of this single-center study was defined as cardiovascular death in patients with ischemic and non-ischemic heart failure who have benefited from ICD therapy. The secondary outcomes were death from any cause, sudden cardiac death, ICD-related therapies (appropriate antitachycardia pacing or shock therapy for ventricular tachycardia or fibrillation) and recurrences of ventricular tachyarrhythmias. (3) Results: A total of 403 consecutive ICD recipients—symptomatic heart failure patients with ICD for the primary prevention of sudden cardiac death—were included retrospectively: 59% ischemic cardiomyopathy (ICMP) and 41% non-ischemic cardiomyopathy (NICMP) patients. Within a median follow-up period of 36 months, the incidence of cardiovascular mortality was not significantly different in patients with NICMP and ICMP: the primary outcome had occurred in 9 patients (5.4%) in the NICMP group and in 14 patients (5.9%) in the ICMP group (hazard ratio 1, 95% confidence interval (CI) 0.45 to 2.28, p = 0.97). All-cause mortality occurred in 14 of 166 patients (8.4%) in the NICMP group and 18 of 237 patients (7.6%) in the ICMP group. Sudden cardiac death occurred in two patients (1.2%) in the NICMP group and in four patients (1.7%) in the ICMP group (hazard ratio 0.71, 95% CI, 0.13 to 3.88, p = 0.69). The rate of appropriate device therapies was comparable in both groups. (4) Conclusions: In this study, ICD implantation for primary prevention of sudden cardiac death in patients with symptomatic systolic heart failure was associated with similar rates of cardiovascular and all-cause mortality in patients with ischemic heart disease, and in patients with heart failure from other causes. NICMP and ICMP showed comparable rates of recurrent ventricular tachyarrhythmias and appropriate ICD therapies.

If atrial fibrillation (AF) and acute coronary syndrome (ACS) coexist, they should be treated with combined antithrombotic therapy. To reduce the risk of bleeding while maintaining the desired antithrombotic effect, choices should be made for each patient according to the balance between the bleeding and the thrombotic risk. There are many ways to select the type and dose of the oral anticoagulant (OAC) and P2Y12 inhibitors. As a rule of thumb, aspirin and P2Y12 inhibitors should be recommended to all patients. The duration of this combination therapy is a matter of debate; available data promote an initial period of one to four weeks of triple antithrombotic association with aspirin and P2Y12 inhibitors (clopidogrel in the absence of high ischaemic risk) and preferable direct oral anticoagulants (DOACs). On discontinuing aspirin, double therapy with P2Y12 inhibitors and a DOAC provides similar efficacy and superior safety for many patients on ACS medical or interventional treatment, especially if the risk of bleeding is high and that of thrombosis is low. Further studies are needed to clarify the concerns for a slight augmentation in the number of ischaemic cases (myocardial infarction and stent thrombosis) with double antithrombotic regimen in patients at high ischaemic risk.

Background Syncope represents a common condition among the general population. It is also a frequent complaint of patients in the emergency department (ED). Pulmonary embolism (PE) considers a differential diagnosis, particularly in a case of syncope without chest pain. Study question What is the prevalence of PE among patients who presented an episode of syncope to the ED and among those hospitalized for syncope in a tertiary care hospital? Study design From January 2012 to December 2017, we conducted a prospective observational study among adult patients presenting themselves to the ED consecutively or admitted for syncope. Measures and outcomes Syncope and PE were defined by professional guidelines. PE was ruled out in patients who had a low pretest clinical probability, as per Wells score and a negative D-dimer assay. In other patients, computed tomography pulmonary angiography was performed. Results Seventeen thousand eight-two patients (mean age 71.3 ± 13.24 years) visited the ED for syncope. PE was detected in 45 patients (mean age 65.75 ± 9.45 years): 4 with low risk, 26 with intermediate risk, and 15 with high risk. The prevalence of PE in those hospitalized with syncope was 11.47%, which is 45 of 392 (confidence interval 95% 8.48-15.04), and was 2.52%, 45 of 1782 (confidence interval 95% 1.8-3.3), in patients presenting with syncope to the ED. The location of the embolus was bilateral in 24 patients (53.33%), in a main pulmonary artery in 10 (22.22%), in a lobar artery in 10 (22.22%), and in a segmental artery in 1 (2.22%). Conclusions The occurrence of syncope, if not explained otherwise, should alert one to consider PE as a differential diagnosis. PE rate, presenting as syncope, is the highest in patients with large thrombi, which is responsible for bilateral or proximal obstruction in a main or lobar pulmonary artery.

Background In patients with acute coronary syndrome (ACS), a persistent hypercoagulable state has been demonstrated and antithrombin therapy in addition to platelet inhibition has been proposed. Areas of uncertainty Vitamin K antagonists (VKAs) were used as oral anticoagulant (OAC) therapy and produced mixed results whereas trials are still ongoing with non-vitamin K OACs (NOACs). Data sources A literature search regarding benefits and risks of different OAC therapies in ACS was conducted through MEDLINE and EMBASE (last 20 years until September 2018). Therapeutic advances Patients receiving dual antiplatelet therapy (DAPT) in combination with NOAC are to be considered at high bleeding risk. Rivaroxaban 2.5 mg BID in triple therapy with DAPT, rivaroxaban 15 mg, or dabigatran 110/150 mg BID in dual therapy with P2Y12 inhibitor (mainly clopidogrel) is safer in terms of bleeding risk than triple therapy with VKA plus DAPT. The reduction in ischemic events by NOACs was most promising when added to single antiplatelet therapy. Ongoing trials with apixaban and edoxaban could clarify whether dual therapy NOACs with P2Y12 inhibitor sufficiently protect against stent thrombosis or myocardial infarction and are safer in terms of bleeding risk than a dual therapy with a VKA and clopidogrel. In the absence of randomized trials, it is unknown whether dual therapy with NOAC and aspirin could be an alternative to NOAC and a P2Y12 inhibitor. Thus, the overall benefit of adding NOAC to antiplatelet treatment after ACS in patients without clear indication for long-term OAC is still unknown. Conclusions Different OACs have been tested as antithrombotic therapy after ACS in combination with single or DAPT and led to a modest reduction in ischemic events. Further studies evaluating NOACs in combination with single antiplatelet therapy or shorter duration of triple antithrombotic therapy are warranted.

Objective: This study aimed to identify possible differences between blood culture-negative and blood culture-positive groups of infective endocarditis (IE), and explore the associations between biological parameters and in-hospital mortality. Methods: This was a retrospective study of patients hospitalized for IE between 2007 and 2017. Epidemiological, clinical and paraclinical characteristics, by blood culture-negative and positive groups, were collected. The best predictors of in-hospital mortality based on the receiver-operating characteristic (ROC) analysis and AUC (area under the curve) results were identified. Results: A total of 126 IE patients were included, 54% with negative blood cultures at admission. Overall, the in-hospital mortality was 28.6%, higher in the blood culture-negative than positive group (17.5% vs. 11.1%, p = 0.207). A significant increase in the Model for End-Stage Liver Disease Excluding International Normalized Ratio (MELD-XI) score was observed in the blood culture-negative group (p = 0.004), but no baseline characteristics differed between the groups. The best laboratory predictors of in-hospital death in the total study group were the neutrophil count (AUC = 0.824), white blood cell count (AUC = 0.724) and MELD-XI score (AUC = 0.700). Conclusion: Classic laboratory parameters, such as the white blood cell count and neutrophil count, were associated with in-hospital mortality in infective endocarditis. In addition, MELD-XI was a good predictor of in-hospital death.

Holt-Oram syndrome (HOS) is a rare monogenic disorder characterized by upper limb abnormalities, congenital heart defects and/or conduction abnormalities. It is determined by mutations of TBX5 gene and is inherited in an autosomal dominant manner. Penetrance is complete, but variable expressivity is present, which gives sometimes diagnostic difficulties. Our case is a young adult with a personal history of preaxial polydactyly operated in infancy, multiple cardiac malformations (atrial septal defect, bicuspid aortic valve, left ventricular non-compaction) and radiologic findings consistent with HOS. Family history is negative for HOS. In conclusion, we present a case of HOS diagnosed in the adult period to highlight the diagnostic problems for the proband and the family and the importance of an early diagnostic.

Repetitive or recurrent hospitalizations are a general major health issue in patients with chronic disease. Congestive heart failure, is associated with a high incidence and presence of early rehospitalization, but variables in order to identify patients at increased risk and also an analysis of potentially remediable factors contributing to readmission have not been previously reported and it remains still a difficult problem. We retrospectively assessed 100 patients aged between 48-85 years old, of which 75% were men, who had been hospitalized with documentation of congestive heart failure in St. Spiridon County Emergency Hospital. They were hospitalized between 2010-2017. Even if recurrent heart failure was the most common cause for readmission or rehospitalization, other cardiac disorders and noncardiac illnesses were also accounted for readmission. Predictive factors of an increased probability of readmission included prior patient�s medical heart failure history, heart failure decompensation precipitated or accelerated by an ischaemic episode, atrial fibrillation or uncontrolled hypertension. Factors contributing to preventable readmissions included noncompliance with medications or diet, inadequate discharge planning or follow-up, failure of both social support system and the seek of a promp medical attention when symptoms reappeared. We also identified an inappropriate colaboration with family doctors especially for the patients from rural areas. Patients were more likely to cite side effects of prescribed medications rather than nonadherence as a precipitating factor for readmission. Thus, we can appreciate that early rehospitalization in patients with congestive heart failure may be avoidable in up to 50% of cases. Identification of high risk patients is possible and also necessary shortly after admission in order to identify nonpharmacological interventions designed to decrease readmission frequency.

Nonalcoholic fatty liver disease (NAFLD) is defined as the presence of hepatic fat accumulation after ruling out other causes of hepatic steatosis. The aim of the study is to identify the role of statin therapy in dyslipidemic patients with very high cardiovascular risk and NAFLD in achieving low density lipoprotein (LDL) cholesterol targets while also evaluating the changes in liver enzymes levels. This prospective study included 140 patients with NAFLD, hyperlipidemia and elevated cardiovascular risk. Serum lipids were assessed and liver function tests were performed at baseline and at 6 months follow up in 10 mg/ 20 mg daily atorvastatin treatment schedule. The results showed that total cholesterol, LDL cholesterol and triglycerides were significantly reduced at 6 months follow-up, while high density lipoprotein (HDL) cholesterol has not undergone important changes. Statin treatment significantly improved alanine aminotransferase serum levels, whereas aspartate aminotransferase levels were not significantly reduced between baseline and follow-up. Although statin therapy appears to be safe and effective for use in patients with NAFLD, an insufficient treatment is commonly observed in clinical practice, in order to avoid liver damage . NAFLD is not only a major cause of liver related morbidity and mortality, but also an independent cardiovascular risk factor, with cardiovascular mortality being the most important cause of death. Therefore, detecting and modifying risk factors without impairing liver function is desirable.

Coronary artery disease (CAD) is one of the major predictors of future cardiovascular events (CVEs). In addition, biomarkers such as high-sensitivity C-Reactive Protein (hsCRP), fibrinogen, homocysteine, and free fatty acid (FFA) correlate well with a future CVE. The Framingham Risk Score is a gender-specific algorithm used to estimate the 10-year cardiovascular risk of an individual. Cardiac rehabilitation is an instrument of medical management in cardiovascular diseases; beyond prevention, it can improve heart and muscle functioning in patients that were undergoing CABG, and cardiac and vascular adaptation. Over a 2-year period, 120 subjects were randomized and comprehensively evaluated. The mean age of the patients under study was 65.70 � 9.91 years old. For the Framingham cardiovascular risk score, the mean value in the Phase I was 16.5, while the mean value in Phase III was 10.6. The difference registered after cardiac surgery and the value in 6 months after the onset of cardiac rehabilitation program was important and statistically significant, as p [ 0.05. Fibrinogen showed significant phase-to-phase reductions of plasmatic values. Lipid profile values showed a statistically significant decrease. The renal filtration function evaluated by plasma creatinine showed statistically significant improvement and, in terms of absolute values, creatinine level was reduced in a range between 0.2-0.4 mg/dL. Also, it was recorded a significantly lower level of blood urea. By comparing the Phase I and Phase III results, we observed that the median 10-year Framingham cardiovascular risk score was approximately 6% lower (p [0.05), reflecting the survival benefit gained by patients under the intensive cardiovascular recovery program.

The aim of the study was to evaluate if the incidence of LASC and LAT in patients with atrial fibrillation (AF) having implantable devices and which undergone an elective EC is higher than in the c...

The aim of this study is to evaluate the relationship and the accuracy of SCORE (Systematic Coronary Risk Evaluation Project) risk correlated to multiple methods for determining subclinical cardiovascular disease (CVD) in a healthy population.This cross-sectional study included 120 completely asymptomatic subjects, with an age range 35-75 years, and randomly selected from the general population. The individuals were evaluated clinically and biochemical, and the SCORE risk was computed. Subclinical atherosclerosis was assessed by various methods: carotid ultrasound for intima-media thickness (cIMT) and plaque detection; aortic pulse wave velocity (aPWV); echocardiography - left ventricular mass index (LVMI) and aortic atheromatosis (AA); ankle-brachial index (ABI).SCORE mean value was 2.95±2.71, with 76% of subjects having SCORE5. Sixty-four percent of all subjects have had increased subclinical CVD changes, and SCORE risk score was correlated positively with all markers, except for ABI. In the multivariate analysis, increased cIMT and aPWV were significantly associated with high value of SCORE risk (OR 4.14, 95% CI: 1.42-12.15, p=0.009; respectively OR 1.41, 95% CI: 1.01-1.96, p=0.039). A positive linear relationship was observed between 3 territories of subclinical CVD (cIMT, LVMI, aPWV) and SCORE risk (p0.0001). There was evidence of subclinical CVD in 60% of subjects with a SCORE value5.As most subjects with a SCORE value5 have subclinical CVD abnormalities, a more tailored subclinical CVD primary prevention program should be encouraged.

Background Ischemic heart disease represents the most important cause of mortality worldwide, and the management of patients with ST-elevation myocardial infarction (STEMI) still remains a great challenge. For a great number of patients who do not have immediate access to primary percutaneous coronary intervention (PCI), facilitated angioplasty may be a reasonable therapeutic option. Areas of uncertainty The goal of reperfusion therapy is achieving repermeabilization of the infarct-related artery. However, the restoration of normal epicardial flow is not always followed by microvascular tissue perfusion and the presence of myocardial blush. Early studies assessing the benefits of facilitated angioplasty over primary PCI encountered disappointing results, with an increased number of bleeding complications. The invasive strategy following fibrinolysis mainly consists in angiography and PCI of the infarct-related artery between 2 and 24 hours after successful fibrinolysis or rescue PCI in failed fibrinolysis, hemodynamic, electrical instability, or worsening ischemia. Currently, a strategy of routine early angiography after fibrinolysis is recommended, taking into account studies that have demonstrated a reduced rate of reinfarction and recurrent ischemia, without an increased risk of stroke or major bleeding complications. Therapeutic advances After evaluating 1892 patients with STEMI within 3 hours after the onset of symptoms and revealing, beyond clear benefit of fibrinolysis, an increased risk of bleeding complications, the STREAM trial was the one that led to halving the tenecteplase dose for patients aged >75 years. A safety profile of adjusted-dose fibrinolytic therapy in elderly patients with STEMI will be further investigated by the ongoing STREAM-2 trial. Conclusions With the current increased burden of acute coronary syndromes and the lack of immediate primary PCI facilities for all patients with STEMI, facilitated angioplasty seems a feasible therapeutic option. Another benefit of facilitated angioplasty may be represented by a major contribution of thrombolytic therapy in re-establishing microvascular myocardial blood flow.

Background Acute pulmonary embolism (PE) requires rapid diagnosis and early and appropriate treatment, often under conditions of hemodynamic instability. The therapeutic strategy should optimally integrate the therapeutic arsenal in a multidisciplinary but unitary approach. Areas of uncertainty The short list of the major uncertainties associated with acute PE should include limited general public awareness on venous thromboembolism, acute hemodynamic support not based on evidence from randomized clinical trials, with few updates lately, mainly linked to extracorporeal membrane oxygenation, thrombolytic therapy having firm indications only in high-risk PE, without clear strategies for particular clinical situations (ie, stroke, tumors, thrombi in transit, and cardiac arrest), using old therapeutic agents with old administration regimens, lack of evidence from large-volume trials on the optimal interventional approach, and relatively imprecise indications for surgical treatment. Data sources We reviewed current data on the diagnosis and therapeutic approach of acute PE. Therapeutic advances A collaborative idea has been reached: apply the multidisciplinary expertise of a rapid response heart team to patients with PE in Pulmonary Embolism Response Teams. Optimization of acute hemodynamic support involves the cautious use of volume expansion; diuretic treatment may provide early improvement in normotensive patients with acute PE and RV failure, and during massive PE, we may use the venoarterial extracorporeal membrane. Until new data accumulate, rescue reperfusion should be performed only if hemodynamic decompensation develops despite adequate anticoagulation. Only EkoSonic catheter is approved by the FDA in the interventional treatment of acute PE, without the routine use of retrievable inferior vena cava filters. Outcomes of pulmonary embolectomy after an early triage of patients with hemodynamically unstable PE are acceptable. In selected low-risk patients, an ambulatory treatment of PE with DOAC is effective and safe. Conclusions Nowadays, evidence and ideas have been gathered that can significantly improve the outcome of patients with PE with varying degrees of severity, remaining to demonstrate the cost-effectiveness of this advanced therapeutic approach.

A fatal disease until Mid-Twentieth Century, nowadays infective endocarditis is curable due to advances in diagnostic techniques, especially in echocardiography, the possibility of cardiac surgery during the active infectious process and new antibiotics. We present a 62 years-old man, with no significant past medical illness, referred for persistent cough, fatigue, shortness of breath, loss of weight and paleness, with recent history of persistent fever and positive blood cultures with Streptococcus gallolyticus. Echocardiographic examination revealed aortic and mitral valve vegetations and anterior mitral valve leaflet abscess. During surgery, the presence of a “kissing abscess” on the atrial side of the anterior mitral leaflet, arising from a vegetation on the non-coronary cusp of the aortic valve, was confirmed, together with an intervalvular fibrosa abscess. Special reinforcement with an oversewn bovine pericardial patch and reconstruction of the intervalvular fibrous body was necessary during aortic and mitral valve replacement. Despite delayed diagnosis, the case had a favorable outcome, the patient being discharged presenting a good clinical state. Numerous complications, including abscesses and early infective endocarditis on prosthetic aortic valve, would have been probably avoided with prompt recognition and early treatment of endocarditis.

Mitral valve prolapse (MVP), described for the first time by JB Barlow in 1966 as the displacement of abnormally thickened mitral valve leaflets into the left atrium during systole, is the most frequently valvulopathy in clinical practice. Usually asymptomatic and predominantly in woman, MVP could associate atypical chest pain. Electrocardiogram (ECG) is normal in majority of cases but sometimes ST segment depression and negative T waves in inferior leads could occur. Previous ECG and the absence of coronary risk factors are the key of differential diagnosis for acute coronary syndrome. We present the case of a 48 year-old female known with MVP, hospitalized for persistent atypical anterior chest pain, ST-T segment depression and T-wave inversion in inferior and lateral leads suggesting an acute coronary syndrome. Patient’s symptoms and ECG changes have disappeared 12 hours after admission under specific treatment. MDCT coronary angiography done after 1 month showed normal coronary arteries and the treatment was stopped. This case confirms that MVP diagnosis, a rare cause of ST segment depression, must be differentiated from an acute coronary syndrome.

Electrical storm (ES) defined as the occurrence of three or more distinct episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) in 24 hours, requiring the intervention of the ICD, are not rare events. Identification of the risk predictors of ES occurrence appear to be important, since these events are associated with increased morbidity and mortality. The aim of the study was to assess the prevalence, features, and predictors of ES in patients with ICD and in patients in whom ICD was implanted for primary prophylaxis vs. secondary prophylaxis. A retrospective analysis of 250 patients with ICD and mean age 62.76 ± 11.20 years, with a mean follow-up of 52.4 ± 33.2 months was made based on initial files at implantation and on subsequently results from the devices interrogation. The ICD was implanted for primary prevention of sudden cardiac death in 198 patients (79,2%) and for secondary prevention in 52 patients (20.8%). ES was present in 22 (8.8%) of patients, 17 (8.5%) patients ...

For the old old patients (pts) with congestive heart failure the use of combinations of drugs can easily lead to a sort of “evidence-based” polypragmasie. We analyzed a lot of 125 pts with congestive heart failure older than 85 years (mean 87.43 +/− 2.54 years), 53.6% male, enrolled consecutively between January 2011 – December 2012. We have compared some features of two subgroups: survivors' (S = 112 pts) vs deceased (D = 13 pts). The old old patients group included patients with length of hospitalization of 8.10+/−3.98 days and the rate of rehospitalization 6.4% and the death rate 10.4%. Number of drugs taken was 5.53+/−1.86 in S group vs 5.85+/−1.86 in D group (p = 0.560) and the length-of-stay was 8.18+/−3.79 in S group vs 7.38+/−5.53 in D group (p = 0.494). There were significant differences between group S vs D in: NYHA class, atrial fibrillation, hemoglobin level, blood urea nitrogen, and serum sodium. The number of drugs given to old old patients has not proven to reduce the length of stay...

Aim The objective of this study was to evaluate the clinical presentation, inpatient management, and in-hospital outcome of patients hospitalized for acute heart failure syndromes (AHFS) and classified as pulmonary edema (PE). Methods The Romanian Acute Heart Failure Syndromes (RO-AHFS) study was a prospective, national, multicenter registry of all consecutive patients admitted with AHFS over a 12-month period. Patients were classified at initial presentation by clinician-investigators into the following clinical profiles: acute decompensated HF, cardiogenic shock, PE, right HF, or hypertensive HF. Results RO-AHFS enrolled 3224 patients and 28.7% (n = 924) were classified as PE. PE patients were more likely to present with pulmonary congestion, tachypnea, tachycardia, and elevated systolic blood pressure and less likely to have peripheral congestion and body weight increases. Mechanical ventilation was required in 8.8% of PE patients. PE patients received higher doses (i.e. 101.4 ± 27.1 mg) of IV furosemide for a shorter duration (i.e. 69.3 ± 22.3 hours). Vasodilators were given to 73.6% of PE patients. In-hospital all-cause mortality (ACM) in PE patients was 7.4%, and 57% of deaths occurred on day one. Increasing age, concurrent acute coronary syndromes, life-threatening ventricular arrhythmias, elevated BUN, left bundle branch block, inotrope therapy, and requirement for invasive mechanical ventilation were independent risk factors for ACM. Conclusions In this national registry, the PE profile was found to be a high-acuity clinical presentation with distinctive treatment patterns and a poor short-term prognosis. Advances in the management of PE may necessitate both the development of novel targeted therapies as well as systems-based strategies to identify high-risk patients early in their course.

Our aim was the assessment of the prognostic significance of right heart thrombi (RiHT) and their characteristics in pulmonary embolism in relation to established prognostic factors.138 patients (69 females) aged (mean±sd) 62±19 years with RiHT were included into a multicenter registry. A control group of 276 patients without RiHT was created by propensity scoring from a cohort of 963 contemporary patients. The primary end-point was 30-day pulmonary embolism-related mortality; the secondary end-point included 30-day all-cause mortality. In RiHT patients, pulmonary embolism mortality was higher in 31 patients with systolic blood pressure versus 12%, p=0.0002) and was higher in the 83 normotensives with right ventricular dysfunction (RVD) than in the 24 normotensives without RVD (16% versus 0%, p=0.038). In multivariable analysis the simplified Pulmonary Embolism Severity Index predicted mortality (hazard ratio 2.43, 95% CI 1.58–3.73; pversus 8%, p=0.003), especially normotensive patients with RVD (16% versus 7%, p=0.02).30-day mortality in patients with RiHT is related to haemodynamic consequences of pulmonary embolism and not to RiHT characteristics. However, patients with RiHT and pulmonary embolism resulting in RVD seem to have worse prognosis than propensity score-matched controls.

Peripheral arterial disease (PAD) is a common manifestation of generalized atherosclerosis, which affects more than 200 million patients worldwide. Currently, there is no ideal biomarker for PAD risk stratification and diagnosis. The goal of this research was to investigate the levels of inflammation biomarkers and cystatin C and to explore their utility for the diagnosis of PAD. The study included 296 participants, distributed in two groups: 216 patients diagnosed with PAD and 80 patients without PAD as controls. All studied biomarker levels (C-reactive protein, CRP, fibrinogen, erythrocyte sedimentation rate, ESR, neopterin, beta 2-microglobulin, B2-MG, and cystatin C) were significantly higher in the PAD group and indirectly correlated with the ankle&ndash, brachial index (ABI). The final logistic regression model included an association of neopterin, fibrinogen, and cystatin C as the most efficient markers for the prediction of PAD diagnosis. When comparing the area under the curve (AUC) for all biomarkers, the value for neopterin was significantly higher than those of all the other analyzed biomarkers. In agreement with previous studies, this research shows that markers such as fibrinogen, CRP, ESR, B2-MG, and cystatin C have significant value for the diagnosis of PAD, and also clearly underlines the accuracy of neopterin as a leading biomarker in PAD prediction.

Patients with intermediate-risk pulmonary embolism (PE) may, depending on the method and cut-off values used for definition, account for up to 60% of all patients with PE and have an 8% or higher risk of short-term adverse outcome. Although four non-vitamin K-dependent direct oral anticoagulants (NOACs) have been approved for the treatment of venous thromboembolism, their safety and efficacy as well as the optimal anticoagulation regimen using these drugs have not been systematically investigated in intermediate-risk PE. Moreover, it remains unknown how many patients with intermediate-high-risk and intermediate-low-risk PE were included in most of the phase III NOAC trials. The ongoing Pulmonary Embolism International Thrombolysis 2 (PEITHO-2) study is a prospective, multicentre, multinational, single-arm trial investigating whether treatment of acute intermediate-risk PE with parenteral heparin anticoagulation over the first 72 hours, followed by the direct oral thrombin inhibitor dabigatran over 6 months, is effective and safe. The primary efficacy outcome is recurrent symptomatic venous thromboembolism or death related to PE within the first 6 months. The primary safety outcome is major bleeding as defined by the International Society on Thrombosis and Haemostasis. Secondary outcomes include all-cause mortality, the overall duration of hospital stay (index event and repeated hospitalizations) and the temporal pattern of recovery of right ventricular function over the 6-month follow-up period. By applying and evaluating a contemporary risk-tailored treatment strategy for acute PE, PEITHO-2 will implement the recommendations of current guidelines and contribute to their further evolution.

The aim of the study was to evaluate the correlation between electrocardiographic parameters and heart rate variability with cardiovascular events and mortality among chronic hemodialysis patients. In this prospective study, we enrolled 116 asymptomatic patients in whom we performed ambulatory 24-h electrocardiographic Holter monitoring and before and after hemodialysis electrocardiographs. We measured the interval (PR, QRS, QTc, QTc dispersion) differences on the surface electrocardiographs and obtained frequency-domain measures from Holter monitoring (VLF, LF, HF and the LF/HF ratio). During the follow-up period, 13 participants died (11.2 %) and 16 (13.8 %) patients experienced a cardiovascular event. The pre–post-dialysis difference in QTc interval was the best predictor for cardiovascular events (95 % CI 0.453–0.786), while pre-dialysis QRS interval was the predictor for all-cause mortality (95 % CI 1.134–3.136). Also, both outcomes were predicted by pre–post-dialysis difference in PR interval and VLF. Interval changes during hemodialysis are predictive for cardiovascular events and mortality. Autonomic dysfunction and changes in PR should be monitored routinely, particularly in patients with suspected coronary artery disease.

We report three cases of chronic atrial fibrillation without anticoagulation admitted for acute lower limb ischemia in which embolic source was left atrial appendage (LAA) thrombus revealed only by transesophageal echocardiography (TEE). Transthoracic echography (TTE) revealed left atrial dilatation (LA) with no contrast or intracavitary mass. TEE revealed LA with spontaneous echographic contrast, low ostial emptying velocities and congenital morphology of LAA with older and organized thrombus or with echolucent centre (” beard-beark sign of recent and growing thrombus”) and thoracic aorta atheroma plaques. They were discharged on acenocumarol/ novel oral anticoagulant therapy. Two-dimensional echocardiography should be recommended in all patients with periprocedural acute peripheral embolism and TEE only in selected cases. Very high incidence of acute embolic ischemia is probably due to lack of preoperative anticoagulation more than to nontherapeutical anticoagulation (international normalized ratio INR

Neurofibromatosis type 1 (also known as von Recklinghausen’s disease) is a genetic disorder characterized by neurofibromas, skin pigmentation, eye and bone abnormalities. It is associated with pheochromocytoma in 1 to 5% of cases which determines symptoms related to catecholamine excessive secretion. We present the case of a 54-year-old man that was admitted to the cardiology clinic due to acute onset of tachyarrhythmia (atrial flutter) and high blood pressure. Neurofibromatosis type 1 was diagnosed by clinical examination while laboratory exams, 24-hour continuous blood pressure monitoring and imaging exams raised the probability of pheochromocytoma. After proper pharmacological stabilization, the patient underwent surgery and the 110/110 mm left adrenal mass was removed via abdominal laparotomy. The patient evolution was favorable and regular follow-up is scheduled. In conclusion, even though asymptomatic screening for pheochromocytoma is not recommended, this pathology should be suspected in all patients with neurofibromatosis especially if they present acute onset of cardiovascular signs.

Background and Aims: Prediabetes, a category of incipient hyperglycemia that includes impaired fasting glycemia (IFG) and impaired glucose tolerance (IGT), has an increasing incidence in the modern world. We searched for differences in anthropometric and metabolic characteristics between subjects with isolated IFG and IFG+IGT. Material and Methods: In our cross-sectional study, 154 subjects with IFG and IFG+IGT, without any other major pathologies, were analyzed. Anthropometric data, lipid profile, uric acid, insulin resistance indexes, adiponectin, leptin and leptin-to-adiponectin ratio were compared. Results: Only 122 subjects (64 with isolated IFG and 58 with IFG+IGT), without any other identifiable major disease, were included in the final analysis. Most characteristics of the two groups were similar, only minor differences in anthropometric data, biochemical profile and insulin resistance indexes being noted. Insulin resistance indexes were stronger associated with adiponectin in the group with isolated IFG and with leptin and leptin-to-adiponectin ratio in the IFG+IGT group. Conclusions: Our data suggest a similar anthropometric and metabolic profile in subjects with isolated IFG and with IFG+IGT. In isolated IFG, insulin resistance seems to correlate better with adiponectin, while in IFG+IGT it seems to associate mostly with leptin and derived parameters

Drawings made by training children into cardiopulmonary resuscitation (CPR) during the special education week called "School otherwise" can be used as non-verbal means of expression and communication to assess the impact of such training. We analyzed the questionnaires and drawings completed by 327 schoolchildren in different stages of education. After a brief overview of the basic life support (BLS) steps and after watching a video presenting the dynamic performance of the BLS sequence, subjects were asked to complete a questionnaire and make a drawing to express main CPR messages. Questionnaires were filled completely in 97.6 % and drawings were done in 90.2 % cases. Half of the subjects had already witnessed a kind of medical emergency and 96.94 % knew the correct "112" emergency phone number. The drawings were single images (83.81 %) and less cartoon strips (16.18 %). Main themes of the slogans were "Save a life!", "Help!", "Call 112!", "Do not be indifferent/insensible/apathic!" through the use of drawings interpretation, CPR trainers can use art as a way to build a better relation with schoolchildren, to connect to their thoughts and feelings and obtain the highest quality education.