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Introduction Dilated cardiomyopathy (DCM) is a condition whose etiologies may be various. DCM with ventricular disfunction is a frequent complication of chemotherapy. Peripartum cardiomyopathy is characterized by a reduced ejection fraction (EF), presenting toward the end of pregnancy or in the first months after delivery. Lipodystrophy may be associated to dilated and hypertrophic cardiomyopathy. Material and Methods A 28-years-old pregnant woman in her late 33rd week was admitted with acute heart failure complicated by pulmonary edema. The patient had history of acute lymphoblastic leukemia during childhood treated with chemo and radiotherapy, followed by hematopoietic stem cell transplantation (HSCT). Afterwards she developed partial acquired lipodystrophy, causing diabetes mellitus, insulin resistance, dyslipidemia, leptin deficiency and steatohepatitis. A mild left ventricular disfunction had been reported before HSCT, with complete recovery at follow up. After admission, the scenary rapidly deteriorated towards cardiogenic shock, so a caesarean section was performed. Transthoracic echocardiography revealed diffuse hypokinesia conditioning severe left ventricular (LV) dysfunction (EF 24%), moderate mitral and tricuspidal valve regurgitation and left to right shunt in possible atrial septal defect. A cycle of levosimendan was administrated, with subsequent improvement in LV function (EF 32%). Cardiac magnetic resonance (CMRI) showed hypokinetic DCM with no pathological findings in T1, T2, STIR sequences nor LGE. In parallel, empty sella in possible Sheehan Syndrome was hypothesized. A diagnosis of peripartum cardiomyopathy on the basis of a chemotherapy-induced cardiomyopathy in a good compensation status was made, with no evidence of lipodystrophy-related cardiac involvement. After recovery the patient was discharged with optimal cardiological therapy and a wearable cardioverter defibrillator. During follow up, the patient improved ventricular function (EF 40%) without any registered arrhythmia. She will be evaluated for heart transplantation. Conclusions Pregnancy in patients with cardiac disease can be life-threatening for mother and fetus, a multidisciplinary approach and a correct timing are crucial to achieve the best possible result. Left ventricular disfunction can be related to many etiologies, and instrumental tests such as echocardiogram and CMRI are crucial to evaluate the cause of the disfunction. Close follow up in patients who underwent chemo/radiotherapy or are affected by metabolic diseases may avoid long-term cardiac complications.

Background. Adjuvant endocrine therapy (AET) significantly reduces breast cancer recurrence and mortality in women with hormone receptor positive tumors, but poor adherence to treatment remains a significant problem. The aim of this study is to analyze AET side effects, their impact on adherence to treatment and possible support strategies. Methods. The study included 373 breast cancer patients treated with AET, who were asked to fill out a specific questionnaire during their follow up visits at the Breast Unit of "Mauriziano Umberto I” Hospital. Results. Side effects were reported by 82% of patients, 81% of those taking tamoxifen and 67.5% of those taking aromatase inhibitors (AI). The most common side effect in tamoxifen group were hot flashes (52%), while it was arthralgia in AI group (60%). The addition of GnRH agonist to both tamoxifen and AI significantly worsened menopausal symptoms and premenopausal women were significantly more likely to report side effects than those who were menopausal at diagnosis. Globally, 21% of patients considered to discontinue therapy due to side effects, 8.2% reported an irregular assumption and 12% definitively discontinued the treatment. The discontinuation rate was 6.4% during the first 5 years of treatment and 24% during extended therapy. Arthralgia was the main side effect which led patients to discontinue AET. Most patients felt well supported during follow up visits, but only 9% used the dedicated menopause service and 15% received psychological support. Conclusions. AET side effects significantly affect the quality of life of breast cancer survivors leading to irregular assumption and discontinuation of therapy, but our study showed that adherence to AET may be improved by proper patient-physician communication and a good quality care network. The challenge is to be more aware of treatment-related side effects and to offer therapies to improve their tolerance and adequate medical and psychological support.

Aims Left ventricular (LV) aneurysms and pseudoaneurysms are two complications of myocardial infarction, either symptomatic or silent, leading to death or serious morbidity in several cases and often precluding non-cardiac surgery. Here the differential diagnosis is challenging and multimodality imaging is often needed to assess the risk of heart rupture. Methods and results A 71 years-old woman was referred to our Cardiology Department for a preoperative evaluation before lung lobectomy. Her past medical history included multiple cardiovascular risk factors and abdominal aorta aneurysm. She also had severe peripheral arterial disease treated with femoral popliteal bypass surgery in June 2021. In August 2021 she suffered from vascular graft thrombosis requiring a redo surgery. During hospitalization, she was found to have a lung adenocarcinoma. The patient had an unremarkable cardiological history and was asymptomatic. EKG was unremarkable. Transthoracic echocardiography revealed a mildly impaired LV systolic function (EF = 40%), an inferolateral basal wall akinesia and a huge aneurysm with intracavitary thrombus and a wide neck arising right below the posterior mitral annulus. The annular distortion caused by the expanding aneurysm contributed to the development of mitral regurgitation (MR) by displacing the annulus and subvalvular apparatus, resulting in restriction of the posterior mitral valve leaflet, coaptation failure, and moderate MR. Coronary angiography demonstrated a severe 3-vessel coronary artery disease. To further characterize the aneurysm, a cardiac magnetic resonance was carried out. T1 weighted inversion recovery LGE 2-chamber and short axis views showed transmural LGE of the inferior wall and confirmed the presence of a saccular dilatation with thin wall, wide neck (5 × 6 cm) and large intracavitary thrombus at high risk of rupture. Since the presence of metastatic lesions was excluded, the patient underwent cardiac surgery followed by elective lobectomy. Intraoperative findings were consistent with LV aneurysm with a thin myocardial wall. Aneurysm and related thrombus were removed and the orifice was closed with a Dacron patch. In the same setting a myocardial revascularization with two coronary artery bypass grafts was also performed. Surgery was successfully performed without any complication. Intraoperative transesophageal echocardiography clearly revealed the aneurysm and witnessed the reduction of MR after the restoration of LV inferolateral wall geometry. Conclusions Our case highlights the importance of thorough evaluation prior to non-cardiac surgery using multimodality imaging, especially when incidental echocardiographic findings in asymptomatic patients occur. A careful pre-operative assessment of patients planned for non-cardiac surgery is the key to favourable postoperative outcome.

Out-of-hospital cardiac arrest (OHCA) remains one of the principle challenges in the setting of critical care medicine and emergency cardiology. Areas covered: Long-term survival rates even after successful resuscitation are variable but increasing in the recent years; due to the improvement of base and advanced cardiac life support techniques an increasing number of resuscitated patients are admitted to the hospital. Recent data suggested that patients surviving to hospital discharge after OHCA presented long-term outcome similar to patients with ST-elevation myocardial infarction. However, limited and incompletely clear data are available in the literature about the selection and risk stratification of patients to be subjected to coronary angiography, particularly in patients who have unfavorable clinical features in whom procedures may be futile and may affect public reporting of morality. Recently the ESC and AHA addressed appropriate treatments for ST-elevation myocardial infarction (STEMI) patients with out-of-hospital cardiac arrest. Expert commentary: Immediate coronary intervention in the setting of OHCA appears to be associated with better survival to discharge; the documentation of an occluded coronary artery in medium 25% of patients without signs of STEMI at ECG helps to explain why early angiography can improve outcomes. In the treatment of OHCA we can find some ethical issues; for example a combination of comorbidities with advanced age and prolonged ischemia indicated by severe lactic acidosis may signify a high enough chance of multiorgan failure or anoxic brain injury and where the benefit of coronary reperfusion therapy appears minimal.

Recent studies demonstrated the possibility to avoid axillary dissection (ALND) in selected patients with one or two metastatic nodes. Otherwise, patients with positive nodal ultrasound-guided fine-needle aspiration cytology (US-FNAC) currently undergo ALDN. The aim of this study is to quantify the nodal burden in patients with positive US-FNAC treated with ALND and to evaluate if clinical or pathological characteristics associated with low nodal involvement can be identified. This is a multicentric retrospective study involving 297 patients who underwent ALND because of a positive preoperative US-FNAC. A total of 157 patients showed bulky axillary lymph nodes at diagnosis, and 70% of them had three or more metastatic nodes. One hundred and forty patients had a clinically negative axilla and in 50% of them, 4 or more metastatic nodes were found with axillary dissection. Overall, the median number of metastatic nodes was 5. Favorable pathological characteristics of tumors were found in patients with only one or two metastatic nodes: smaller primary tumor, a lower proportion of grade 3, invasive lobular carcinomas and a higher proportion of low-Ki67 tumors. In the group of patients with clinically negative axilla and potentially meeting ACOSOG Z0011 criteria, 22 (31%) showed less than three metastatic axillary nodes. A preoperative positive axillary FNAC is associated with a metastatic nodal burden significantly higher than in patients with positive sentinel lymph node biopsy (SLNB). Nevertheless, about 30% of patients with cN0 axilla, positive axillary FNAC performed because of suspicious nodes on imaging, T1-2 primary tumor and breast-conserving surgery showed less than three metastatic axillary nodes, thus meeting ACOSOG Z0011 trial's criteria and therefore would be eligible for skipping ALND according to current guidelines.

Introduction: Atherothrombosis and coronary artery disease affect more than 13 million individuals only in the United States, about 8 millions in Europe and are the major causes of death worldwide. In particular chronic stable angina impairs patient quality of life, is associated with an important health spending and increased patient mortality; it is a prominent symptom of coronary artery disease (CAD), the latter being prevalent worldwide in patients. A key role in pathophysiology of cardiovascular acute events is played by activated platelets. Aspirin and adenosine diphosphate antagonist in addition to it is recommended for 1 year for reduction of cardiovascular events in patients with prior myocardial infarction with a weak recommendation to continue thereafter. P2Y12 receptor antagonists, in addition to aspirin, have been shown in the last years, to reduce ischemic events in patients with acute coronary syndrome but their role in secondary prevention is still new and unclear. The aim of our paper is to review the long-term effect of therapy with ticagrelor on the basis of recent evidence based data. Methods: We performed an online search on the major search engines. All the randomized controlled trials were summarized in the table. Results: We included in our paper six randomized controlled trials and we mentioned about ten post – hoc analysis, sub studies and registries. All studies included the type the therapy and a mid or long term clinical follow up. Conclusions: The studies reported in our paper and in particular PEGASUS – TIMI 54 study showed the merit to placing attention of prevention secondary ischemic events after acute coronary syndrome in the context of treatment with dual anti – platelet therapy; it proved a clinical benefit in patients treated with ticagrelor (60 mg x 2) for 3 years. Nevertheless, the effectiveness of these results cannot be generalized to patients with higher bleeding risk or low ischemic risk. In fact prolonged therapy with ticagrelor 60 mg in combination with aspirin could be considered valuable in patients with repeated acute ischemic events or with several coronary revascularizations over time (especially in patients with lower bleeding risk).

Background The aim of this study was to assess clinical and echographic markers of cardiovascular dysfunction in infants born small for gestational age (SGA) compared to a control group of subjects born adequate for gestational age (AGA). Methods This was a single-center cross-sectional case-control study. We recruited 20 SGA and 20 gestational age–matched AGA subjects at 24 months of age. The study population underwent anthropometric and Doppler 2-dimensional echocardiographic assessments, and carotid artery intima-media thickness (cIMT) and endothelium-dependent vasodilation evaluation (FMD). The pressure-volume curve during diastole was calculated using the algorithm for the elastance calculation on 1 single beat. Results SGA children showed lower stroke volume, lower left ventricle (LV) dimensions and volume, and greater LV thickness. Diastolic function was impaired in SGA with lower capacitance and higher elastance. Birth weight standard deviation score was positively associated with capacitance and negatively associated with E/E’ ratio and elastance, and in SGA infants, the end-diastolic pressure-related volume curve was shifted to the left compared to AGA. cIMT and systemic vascular resistance were significantly higher, while FMD was lower, in SGA compared to AGA; birth weight standard deviation score was directly correlated with FMD and inversely correlated with cIMT. Finally, a longer breastfeeding duration was associated to a lower cIMT even after correction for confounding factors. Conclusions This study shows that infants born SGA present an early and subtle cardiovascular dysfunction compared to AGA controls. These alterations are strongly related to weight at birth. Finally, breastfeeding exerts an important protective and beneficial cardiovascular effect.

Background: correlation between pulmonary function tests (PFTs) and CT-histogram derived indexes is poorly known in Idiopathic Pulmonary Fibrosis (IPF). Objective: To investigate correlation between PFTs (FVC and DLCO) and CT-histogram derived indexes in a cohort of patients (pts) with IPF. Methods: 42 IPF pts having at least two HRCT (baseline and follow-up) and two PFTs available collected no more than 1 month from HRCT evaluation were analyzed. The extent of fibrotic disease was quantified on HRCT examinations calculating Kurtosis, High Attenuation Area (HAA) and Fibrotic Area (FA) indexes. Pearson’s correlation coefficient was performed to assess the strength of association between pulmonary function tests and HRCT indexes. Results: Considering baseline HRCT and PFTs, Pearson correlation analysis revealed moderate correlations between Kurtosis and FVC (r=0.58 with p=0.0001), Kurtosis and DLCO (r=0.52 with p=0.0005), HAA and FVC (r=-0.56 with p=0.0001), HAA and DLCO (r=-0.48 with p=0.0017), FA and FVC (r=-0.56 with p=0.0002), and FA and DLCO (r=-0.49 with p=0.0013). On follow-up, analyzing HRCT and PFTs, Kurtosis and FVC showed a positive strong correlation (r=0.62 with p Conclusions: HRCT quantification indexes showed a moderate or good strength of association with pulmonary function tests; therefore, they may be useful for radiologists in the monitoring of IPF disease.

Introduction: The term Interstitial Pneumonia with Autoimmune Features (IPAF) has been proposed to classify patients with Interstitial Lung Disease (ILD) associated with autoimmune signs not classifiable for a specific Connective Tissue Disease (CTD). Currently, no prospective IPAF cohort are reported. Aims and Objectives: To describe a prospective cohort of IPAF patients. Methods: The study was conducted according to the declaration of Helsinki. A total of 170 consecutive ILD patients with at least one IPAF criteria were considered in the last year (Fischer A, Eur Respir J 2015; 46 (4): 976-987). From these, 58 patients were able to satisfy classification criteria for CTDs, while 33 patients were classified as IPAF. Results: IPAF patients (69.7% females) referred a history of smoke in 51.5% of cases and reported a restrictive pattern in Pulmonary Function Tests in 66.7% of cases. A clinical domain was present in 72.7% of patients, whereas serological and morphological domains respectively in 72.7% and 87.9% of cases. The most frequent item from each domain were arthritis (42.4%), Antinuclear Antibodies (ANA) (30.3%) and Nonspecific Interstitial Pneumonia (75.8%) as HRCT pattern. No cases of ulcers, telangiectasia and mechanic’s hand were reported. Only ANA, Rheumatoid Factor, anti-SSA, anti DsDNA and Anti Citrullinated Protein Antibodies were found as serological domain. Conclusions: This study suggests that most of IPAF patients have a clinically relevant ILD without serological and clinical items highly specific for CTDs. When these items were present, patients were generally able to satisfy specific CTD criteria. Probably, some of IPAF patients can have an early form of CTDs.

Background: the predictive role of CT-histogram indexes in assessing survival was poorly studied in IPF. Objective: To investigate the accuracy of CT-histogram derived indexes in the assessment of survival in IPF patients (pts). Methods: 42 IPF pts with a follow-up time of 3 years were retrospectively collected; HRCT and pulmonary function tests (FVC and DLCO) performed at diagnosis were analyzed; the extension of fibrosis was quantified on HRCT using Kurtosis, Skewness, Mean Lung Density (MLD), High Attenuation Areas (HAA%) and Fibrotic Areas (FA%). Univariate Cox-regression analysis assessed Hazard ratios for each variable. A Multivariate model including Skewness, FVC, DLCO and age tested their prognostic value in assessing survival. Through ROC analysis, threshold values demonstrating the best sensitivity and specificity in predicting mortality were identified and used as cut-off points to graph Kaplan-Meier curves specific for the CT-indexes. Results: Kurtosis, Skewness, MLD, HAA% and FA% were good predictors of mortality (HR 0.44, 0.74, 1.01, 1.12, 1.06; p=0.03, p=0.01, p=0.02, p=0.02 and p=0.017 respectively). Skewness, which demonstrated the lowest AIC value (55.52), was considered the best analyzed CT-index in predicting mortality. Significant survival differences considering proposed cut-off points were also demonstrated according to Kurtosis (p=0.02), Skewness (p=0.005), MLD (p=0.003), HAA% (p=0.009) and FA% (p=0.02) – obtained from quantitative HRCT analysis at the diagnosis time. Conclusions: CT-histogram derived indexes may provide an accurate estimation of survival in a population of IPF patients since the time of diagnosis.

The term interstitial pneumonia with autoimmune features (IPAF) has been proposed to define patients with interstitial lung disease (ILD) associated with autoimmune signs not classifiable for connective tissue diseases (CTDs). This new definition overcomes previous nomenclatures and provides a uniform structure for prospective studies through specific classification criteria.This work evaluates the characteristics of IPAF patients reported in the literature, to highlight potential limits through a comparative analysis and to suggest better performing classification criteria.Four retrospective studies on the IPAF population have been considered. The study subjects differed in age, sex, smoking habit, ILD pattern and outcomes. Another important difference lies in the diverse items considered in the classification criteria. The retrospective design of the studies and the absence from some of them of a rheumatologist clearly involved in the diagnosis may have influenced the data, but current IPAF criteria seem to include a rather heterogeneous population. To overcome these discrepancies, this review suggests a limitation in the use of single items and the exclusion of extremely specific CTD criteria. This should avoid the definition of IPAF for those diseases at different stages or at early onset. The investigation of a functional or morphological cut-off of pulmonary involvement would be useful.

Heart rate is a fundamental determinant of cardiac oxygen consumption and plays a pivotal role in the pathophysiology of chronic stable angina (CSA). Ivabradine selectively and specifically inhibits the sino-atrial If current, slowing selectively heart rate without other significant haemodynamic effects. The consequent clinical effects are a sinus rate reduction similar to that obtained with beta-blockers, but without the related haemodynamic side effects. Ivabradine clinical benefits have been demonstrated both in patients with stable coronary artery disease (CAD) with associated systolic left ventricular dysfunction or in patients with congestive heart failure (HF). In this review we focused on the pharmacology and clinical research about ivabradine in the context of anti-ischemic therapy for CAD patients. Actually most guidelines suggest ivabradine therapy as last resort antianginal drugs in patients with uncontrolled symptoms or excessive heart rate despite maximum tolerated beta-blockade. However, the peculiar pharmacologic effects of the drug suggest that most patients with CAD might benefit from adding ivabradine to their therapeutic schemata. In fact, even if the recently released main analysis of the SIGNIFY study seems not to support an employ of ivabradine in primary prevention, it is easy to imagine a future wider use of this drug in elderly patients with incomplete myocardial revascularization and in patients with total chronic coronary occlusions and failure or unacceptable risk for percutaneous or surgical coronary revascularization.

Cardiovascular diseases and in particular coronary atherosclerotic disease are the leading cause of mortality and morbidity in the industrialized countries. Coronary atherosclerosis has been recognized for over a century and it was the subject of various studies. Pathophysiological studies have unravelled the interactions of molecular and cellular elements involved in atherogenesis; during the last decades the basic research has focused on the study of the instability of atherosclerotic plaque. Plaque rupture and resulting intracoronary thrombosis are thought to account for most acute coronary syndromes including ST - segment elevation myocardial infarction and non ST - segment elevation myocardial infarction. This is a brief review of the pathophysiology of atherosclerotic plaque development.

Intracoronary bolus administration may provide high local bivalirudin concentration without changing the global dose, potentially offering a more favorable antithrombotic effect in the infarct related artery (IRA).The purpose of this study was to investigate the feasibility and safety of intracoronary bolus administration of bivalirudin followed by the standard intravenous infusion in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).In 245 consecutive patients treated with primary PCI, bivalirudin bolus was given directly in the IRA, followed by a standard intravenous infusion. Clinical reperfusion markers, postprocedural coronary flow indexes, and bleeding events of the intracoronary group were compared with a propensity score-matched cohort of primary PCI patients (n=245) treated with the standard bivalirudin protocol of intravenous bolus and infusion.Higher rates of ⩾70% ST-segment resolution (72.7% vs 60.0%, p=0.004), lower postprocedural peak CK-MB levels (188.3±148.7 vs 242.1±208.1 IU/dl, p=0.025) and better Thrombolysis in Myocardial Infarction (TIMI) frame count values (14.7 vs 17.9, p=0.001) were observed in the IC bolus group compared with the standard intravenous bolus group. Rates of bleeding were similar between groups. Only three cases of acute stent thrombosis were observed, all in the intravenous bolus group (p=0.25).Intracoronary bivalirudin bolus administration during primary PCI is safe and improves ST-segment resolution, postprocedural coronary flow and enzymatic infarct size compared with the standard intravenous route.

Background: Two therapeutic options are currently available for patients with mild-to-moderate idiopathic pulmonary fibrosis (IPF): pirfenidone and nintedanib. To date, there is still insufficient data on the efficacy of these 2 agents in patients with more severe disease. Objectives: This national, multicenter, retrospective real-life study was intended to determine the impact of nintedanib on the treatment of patients with severe IPF. Methods: All patients included had severe IPF and had to have at least 6 months of follow-up before and at least 6 months of follow-up after starting nintedanib. The aim of the study was to compare the decline in lung function before and after treatment. Patient survival after 6 months of therapy with nintedanib was assessed. Results: Forty-one patients with a forced vital capacity (FVC) ≤50% and/or a diffusing capacity of the lung for carbon monoxide (DLCO) ≤35% predicted at the start of nintedanib treatment were enrolled. At the 6-month follow-up, the decline of DLCO (both absolute and % predicted) was significantly reduced compared to the pretreatment period (absolute DLCO at the –6-month, T0, and +6-month time points (5.48, 4.50, and 5.03 mmol/min/kPa, respectively, p = 0.03; DLCO% predicted was 32.73, 26.54, and 29.23%, respectively, p = 0.04). No significant beneficial effect was observed in the other functional parameters analyzed. The 1-year survival in this population was 79%, calculated from month 6 of therapy with nintedanib. Conclusions: This nationwide multicenter experience in patients with severe IPF shows that nintedanib slows down the rate of decline of absolute and % predicted DLCO but does not have significant impact on FVC or other lung parameters.

Introduction: Gender, age, physiology (GAP) system have proven to be an easy tool for predicting disease stages and survival in idiopathic pulmonary fibrosis (IPF) patients. Objective: To validate mortality risk as determined by the GAP system in a real-life multicentre IPF population treated with pirfenidone. Methods: The study included patients who received pirfenidone for at least 6 months. The GAP calculator and the GAP index were determined. The primary outcome was all-cause mortality. The prognostic accuracy of the GAP system was evaluated with respect to calibration and discrimination. Results and Conclusion: Sixty-eight IPF patients were enrolled in the study. The median follow-up was 2.4 years (range 0.1-7.4 years). A total of 22 deaths as first event (32%) and of 10 lung transplantation (15%) were recorded. The cumulative incidence of mortality at 1, 2 and 3 years was 10.4%, 22.4% and 38.4%, respectively. The differences between the predicted and observed mortality were not significant for the GAP index while the observed mortality become comparable to that predicted by the GAP calculator only in the third year of follow-up. The C-index for the GAP index was 0.74 (95% CI 0.57-0.93) while the C-statistic value for the GAP calculator was 0.77 (95% CI 0.59-0.95).

Background: pirfenidone and nintedanib are two drugs approved for the treatment of mild to moderate of IPF, however data about the efficacy of these drugs on more severe patients (pts) are scarce. Method: We conducted a retrospective multicenter national real life study in Italy to evaluate the efficacy of nintedanib for the treatment of pts with severe IPF. We considered 41 pts consecutive with at least 6 months pre and post nintedanib therapy and with FVC ≤ 50% and/or DlCO ≤ 35% and compared pulmonary functional trends pre and post therapy. Survival was also calculated starting from month 6 of therapy with nintedanib. Results: At time zero (start nintedanib therapy), pts had a FVC % of 60.63 (SD 14.57) and a DlCO of 26.54 (SD 5.70). Therapy with nintedanib slowed the fall of DlCO (p= 0.004) e and TlCO (p=0.03) compared to pre treatment period but no other significant changes in pulmonary function data, including FVC, was registered. One year survival starting from month 6 of therapy with nintedanib was 79%. Conclusions: In this national multicenter experience, nintedanib reduced in patients with severe IPF the rate of decline of DlCO and of TlCO without significant impact on FVC and on other PFT data. Our results suggest that the drug might also be effective in patients with more advanced disease.

AIMS Increased right atrial size is related to adverse prognosis in pulmonary hypertension. The potential incremental value of right atrial function assessment is still unclear. We tested the relationship between right atrial two-dimensional speckle-tracking echocardiography impairment and hemodynamic, functional and clinical deterioration in patients with pulmonary hypertension. METHODS We prospectively evaluated 36 patients (27 female, 9 male; mean age 68 ± 13 years) with suspected pulmonary hypertension undergoing right heart catheterization and 16 matched controls. All patients underwent baseline evaluation by New York Heart Association functional class, 6-min walking test, brain natriuretic peptide (BNP), and standard two-dimensional echocardiography in less than 48 h of right heart catheterization. Right atrial two-dimensional speckle-tracking echocardiography was assessed by averaging all segments in standard four-chamber apical view. RESULTS Right atrial global integral strain was significantly lower in patients compared with controls (11.40 ± 5.22% vs. 25.72 ± 5.95 P

Drug eluting balloons (DEB) have been developed to overcome the limitations of drug eluting stents (DES), but clinic results of various DEB studies are still not consistent. Thus, we performed a meta-analysis to compare outcomes of DEB and DES for the treatment of coronary artery disease (CAD).Medline/Web databases were searched for studies comparing DEB and DES for obstructive CAD, reporting late lumen loss (LLL) and rates for overall mortality, myocardial infarction (MI), stent thrombosis (ST) and target lesion revascularization (TLR).8 studies (1462 patients) were included in the meta-analysis. Compared with DES, DEB treated patients showed non-significantly higher LLL (weighted mean difference [WMD] 0.32, 95% confidence interval [CI] -0.15 to 0.78, P=0.18) and non-significantly higher rate of binary restenosis (odds ratio [OR] 1.40 [0.68-2.48], P=0.36). Mortality (OR 1.13[0.54-2.37], P=0.74), MI (OR 0.95, [0.50-1.80], P=0.87), ST (OR 1.12, [0.34-4.19], P=0.77) and TLR rates (OR 1.19[0.60-2.38], P=0.61) were similar between the 2 treatments. A pre-specified meta-regression analysis showed that LLL WMD and TLR OR were inversely correlated to the prevalence of diabetes (P0.0001) and directly correlated to reference coronary diameters (P0.001).The present meta-analysis showed that compared to DES, DEB use resulted in similar clinical efficacy and safety. Thus DEB could be considered a reasonable alternative to DES for the treatment of CAD in selected clinical settings (Clinicaltrials.gov identifier: NCT01760200).

The aim of this retrospective study was to map the specific ischemic lesion patterns of distribution in patent foramen ovale-related stroke (PFO-stroke) and atrial fibrillation-related stroke (AF-stroke) in patients with idiopatic ischemic stroke. 750 ischaemic strokes were screened on basis of diagnostic imaging and tests: patients with known causes were excluded. 171 patients with unknown cause were selected and divided in two groups: AF-stroke (43 patients) and PFO-stroke (128 patients). Vascular territories of ischemic involvement were divided into four classes in each group: the anterior cerebral artery, the middle cerebral artery, the vertebro-cerebral artery (including the posterior cerebral artery) and multisite (MS) involvement. Infarcts in vertebro-basilar territory and multisite represented each one about 32% of infarcts in PFO-stroke group and their involvement are more frequent than AF-stroke group (p = 0.03). Ischemic lesions in PFO-group were predominantly cortical (34.3%), and in AF-group cortical-subcortical (60.4%). Multisite pattern of ischemic lesion was more frequent in patients with severe degree of right to left shunts (37.5%). In clinical practice, PFO may be considered a cause of cortical stroke on the basis of radiological findings, when VB vascular territory or MS brain involvement is present in younger patients (

Cardiovascular disease, in particular acute coronary syndromes (ACS), is still one of the leading causes of death in industrialized countries. ACS including ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UA) are associated with lower mortality if diagnosed early. The diagnosis is based on clinical symptoms, ECG and circulating biomarker-level changes. Recent studies have shown that there are alternatives to the known biomarkers such as ultrasensitive troponin I or T and creatine kinase Mb; there are, in fact, novel biomarkers such as miRNAs. These are 22-nucleotide-long non-coding RNAs that regulate gene expression at post-transcriptional level. Several recent studies have shown that miRNAs play a physiological role in cardiovascular homeostasis and in the pathogenesis of cardiovascular disease. Expression-pattern studies of myocardial tissue reveal that several miRNAs are up- or down-regulated during myocardial infarction. The purpose of the present review is to highlight the state of the art and future views on this topic.

Intra-aortic balloon counterpulsation is the most widely used form of mechanical hemodynamic support in the setting of cardiogenic shock due to ST-segment elevation myocardial infarction (STEMI). Intra-aortic balloon pump (IABP) is also strongly recommended (class 1b) in the current European guidelines for treatment of STEMI. The evidence of a possible benefit of IABP in this setting is based mainly on registry data and a few randomized trials. Cardiogenic shock and subsequent death due to STEMI result from three factors: hemodynamic deterioration, occurrence of multiorgan dysfunction and systemic inflammatory response. IABP does not cause an immediate improvement in blood pressure, but the recent SHOCK II trial shows positive effects on multiorgan dysfunction. Some experimental and clinical studies have indicated that IABP results in hemodynamic benefits as a result of afterload reduction and diastolic augmentation with improvement of coronary perfusion. However, the effect on cardiac output is modest and may not be sufficient to reduce mortality. Furthermore we can say that the use of IABP before coronary revascularization in the setting of STEMI complicated with cardiogenic shock may make the interventional procedure safer by improving left ventricular unloading. The purpose of the present review is to clarify the state of the art on this topic.

Acute coronary syndromes and, in paticular, ST – segment elevation myocardial infarction are the principle causes or mortality and morbidity in the industrialized countries. The manadgement of acute myocadial infarction is much debated in the literature; primary percutaneous coronary intervention is the treatment of choice. In the recent years there has been an increasing interest in the concept of adjunctive pharmacological therapy to improve outcomes in primary percutaneous coronary intervention. In the literature randomized trials of intravenous or more recently intracoronary injection of glycoprotein IIb/IIIa inhibitors have provided conflicting results with no definitive evidence for efficacy. The aim of the report is to review the evidence to our date on the role of intracoronary injection of abciximab during primary percutaneous intervention in the setting of acute myocardial infarction.

In a variant proportion of patients presenting with chest pain and electrocardiographic changes characteristic for ST – elevation myocardial infarction, percutaneous coronary intervention achieves epicardial coronary artery reperfusion but not the myocardial reperfusion (ranging from 5p to 50p). Furthermore, prolonged myocardial ischemia often breaks down the coronary microvasculature and the flow to the infarct myocardium may seem to be markedly reduced. This condition is known as no reflow – phenomenon. The no reflow - phenomenon is associated with an increased incidence of malignant ventricular arrhythmias, heart failure and 30-days mortality. In the recent years in literature, several articles (subsequently discussed in the present review) have been published and made relevant to the study of the pathophysiology regarding no reflow – phenomenon. This knowledge has assisted in the development of new treatment strategies, such as prophylactic use of vasodilators, mechanical devices and drugs inhibiting platelet. The review has focused on the current literature about intra – coronary injection of drugs to treat no – reflow and microvascular dysfunction.

Cardiovascular disease and in particular, acute coronary syndromes are one of the principle causes of death in the industrialized countries. In the setting of acute coronary syndromes (both ST – segment or non ST - segment elevation myocardial infarction), platelets aggregation plays a key and central role in their development. Platelets are the mediators of hemostasis at sites of vascular injury, but they also mediate pathologic thrombosis; activated platelets stimulate thrombus formation in response to rupture of an atherosclerotic plaque or endothelial cell erosion promoting atherothrombotic disease. Recent patent relates to the methods and devices for treating atherosclerosis and to prevent in-stent restenosis or thrombosis. Because of the importance of platelets involvement in the initiation and propagation of thrombosis, antiplatelet drugs have a source of research; in the recent past, new antiplatelet drugs (such as ticagrelor) have been studied and placed in the routine therapy. The aim of this paper is to summarize the pharmacological properties and the clinical characteristics of ticagrelor.