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Aims: Using the principles of clinical governance, a patient-centred approach intended to promote holistic quality improvement, we designed a prospective, multicentre study in patients with acute coronary syndrome (ACS). We aimed to verify and quantify consecutive inclusion and describe relative and absolute effects of indicators of quality for diagnosis and therapy., Methods and Results: Administrative codes for invasive coronary angiography and acute myocardial infarction were used to estimate the ACS universe. The ratio between the number of patients included and the estimated ACS universe was the consecutive index. Co-primary quality indicators were timely reperfusion in patients admitted with ST-elevation ACS and optimal medical therapy at discharge. Cox-proportional hazard models for 1-year death with admission and discharge-specific covariates quantified relative risk reductions and adjusted number needed to treat (NNT) absolute risk reductions. Hospital codes tested had a 99.5% sensitivity to identify ACS universe. We estimated that 7344 (95% CI: 6852-7867) ACS patients were admitted and 5107 were enrolled-i.e. a consecutive index of 69.6% (95% CI 64.9-74.5%), which varied from 30.7 to 79.2% across sites. Timely reperfusion was achieved in 22.4% (95% CI: 20.7-24.1%) of patients, was associated with an adjusted hazard ratio (HR) for 1-year death of 0.60 (95% CI: 0.40-0.89) and an adjusted NNT of 65 (95% CI: 44-250). Corresponding values for optimal medical therapy were 70.1% (95% CI: 68.7-71.4%), HR of 0.50 (95% CI: 0.38-0.66), and NNT of 98 (95% CI: 79-145)., Conclusion: A comprehensive approach to quality for patients with ACS may promote equitable access of care and inform implementation of health care delivery., Registration: ClinicalTrials.Gov ID NCT04255537., Competing Interests: Conflicts of interest: S.L. reports grants and personal fees from Astra Zeneca, personal fees from Daiichi Sankyo, personal fees from Bayer, personal fees from Pfizer/BMS, personal fees from ICON, personal fees from Chiesi, personal fees from Novonordisk, all outside the submitted work. C.M. has nothing to disclose. G.Carrara reports personal fee from Advice Pharma during the conduct of the study. G.Casella has nothing to disclose. D.G. reports he has participated in advisory boards for Amgen and for Sanofi, outside the submitted work. M.G., A.R., L.T., M.P., F.O., M.G., L.G., L.S.C., Dr. S.D.S., and A.A. have nothing to disclose. G.M.D.F. serves as member of the steering committee for Amgen and consultant for UCB. L.O.V. reports personal fees from Eli Lilly; personal fees from Daiichi Sankyo, personal fees from AstraZeneca; personal fees from Menarini; personal fees from Bayer; personal fees from Pfizer; personal fees from BMS; personal fees from Boehringer Ingelheim, all outside the submitted work. Prof. Campo reports grants from SMT; grants from Siemens; Grants from MEDIS; grants from Boston Scientific, grants from GE Healthcare, all outside the submitted work., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Cocaine abuse is widely increasing, especially in younger individuals. Cocaine is a major cause of chest pain and acute coronary syndrome and is the leading cause for drug abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Cocaine use, especially long-term, is associated with an increased risk of all-cause mortality, and with several significant, life-threatening cardiovascular diseases although the multifactorial underlying cellular and molecular pathophysiological mechanisms of acute and chronic cocaine cardiotoxicity are not well established due to limited studies. Current findings have important public health implications, reinforcing recommendations for substance use screening among young adults with heart diseases, and highlighting the need for education on its deleterious effects. Cocaine should be considered a cardiovascular risk factor, requiring attention to early detection of vascular disease in cocaine users.

Atherosclerosis often affects the coronary arterial tree. Very often the disease does not translate in significant narrowing of the vessels, thus determining only a non-obstructive disease. This condition that is described as non-obstructive coronary artery disease (NobsCAD) should be distinguished from the absence of disease (i.e. smooth coronary arteries) as it carries a specific prognostic value. The detection and reporting of NobsCAD should prompt preventive measures that can be individualized upon the degree of the underlying burden of disease. The accompanying clinical condition, the other cardiovascular risk factors present, and the description of the severity and extent of NobsCAD should provide the framework for an individualized treatment that should also consider the best available evidences and scientific guidelines. The description of NobsCAD represents an important information to be collected whenever a coronary angiogram (both invasive and non-invasive) is performed. Treating the patient according to the presence and extent of NobsCAD offers prognostic benefits well beyond those offered by considering only the traditional cardiovascular risk factors. In order to reach this goal, NobsCAD should not be confused with the absence of coronary atherosclerosis or even ignored when detected as if it was a trivial information.

Cardiomyopathies are a heterogeneous group of cardiac diseases for which diagnosis and treatment are not always simple. The diagnosis of cardiomyopathy, in particular the etiology, comes from an integration between symptoms and results collected by several instrumental exams. The brain storming for the diagnosis includes also the identification of the "red flags", i.e. the pathognomonic features for each etiology that can drive the choice of appropriate diagnostic tests and therapy. In this review, we provide a step by step approach in order to help cardiologists, not specifically dedicated to cardiomyopathies, to draw the diagnosis, therapy and follow-up. This approach will be accompanied by the consultation of other specialists to discuss together the results of the exams performed and to deepen extracardiac signs and symptoms.

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the most important long-chain polyunsaturated fatty acids of the n-3 series (n-3 PUFA). Recent studies have clarified that EPA and DHA have different tissue distribution and influence target organs in a distinct way. In addition to the main effect of reducing triglycerides (TG), they exert antithrombotic, antiarrhythmic, anti-inflammatory, anti-atherogenic, and hemodynamic effects. The different action of PUFA n-3 depends on the dosage and duration of treatment: the effect on TG requires high doses and a few weeks/months of treatment.Several epidemiological studies have shown a relationship between hypertriglyceridemia and cardiovascular risk, confirmed by post-hoc analysis of statin trials and by recent genetic linkage studies. Moreover in secondary prevention, the evidence of a significant "residual risk", even in the presence of an adequate control of LDL-cholesterol, has led the scientific community to consider further intervention objectives in the context of the individual lipid profile, the most promising of which is certainly hypertriglyceridemia.The recent landmark REDUCE-IT study is the first major lipid intervention study to demonstrate a benefit deriving from an approach not based on the LDL target, focusing on a determinant factor of residual risk such as hypertriglyceridemia and treating it with high doses of n-3 PUFA (4 g/day).Overall, the "lipid residual risk" approach involves two integrated actions: (i) the achievement of the LDL-cholesterol target (<70 mg/dl) by using statins, ezetimibe, PCSK9 inhibitors; (ii) checking TG levels in order to start n-3 PUFA in case of TG values >150 mg/dl, at an initial dosage of 2-3 g/day (up to 4 g/day after 10-12 weeks).

Although commonly thought of as two separate disease entities, cardiovascular diseases and cancer, the leading causes of death, possess various possible interactions, including a number of similar risk factors (e.g. obesity, diabetes, chronic inflammation). Each cardiologist should provide counseling for a correct lifestyle (diet, physical exercise, avoiding smoking and alcohol abuse); doing so, not only cardiovascular diseases, but also cancer could be prevented. Besides, intervention on diet, physical activity and smoking has been shown to be effective even in patients with known cancers. Many drugs used in cardiovascular prevention (i.e. aspirin, metformin, statins, and beta-blockers) have shown in vivo and in vitro promising pleiotropic properties, and, in observational studies, they were also effective in the prevention of some cancers, although this matter is controversial, emphasizing the need for interventional studies in the field of primary and secondary cancer prevention. Considerable interest has emerged regarding the potential adjuvant chemotherapeutic use of these drugs, but real-world epidemiological data remain inconclusive. In this review, we explore the risk factors common to both cardiovascular diseases and cancer, as well as the role of preventive cardiology treatments, highlighting the related major epidemiologic studies and potential biological mechanisms.

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

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyze the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education and legal aspects.