Thromboembolic and hemorrhagic risk stratification in patients with atrial fibrillation. Part II: hemorrhagic risk and guidelines recommendations

Robust evidence exists on the efficacy of traditional anticoagulant oral therapy in the prevention of thrombo-embolic risk in patients with non valvular atrial fibrillation, but fears and concerns of hemorrhagic events for the physicians and logistic difficulties related to the periodic International Normalized Ratio evaluation for the patients are at the basis of a noticeable under-utilization of the therapy with vitamin K antagonists in the real world. Stratification of the hemorrhagic risk has, thus, particular importance; for this objective we may use now several score system, among whom the more suggested is the HASBLED, with the principal aim to select and trait modifiable risk factors for bleeding. These score systems have been evaluated in some recent clinical trials. During the last years, a number of national and international guidelines on the prevention of the thrombo-embolic risk in patients with non valvular atrial fibrillation have been updated. These guidelines, generally, recommend the use of the CHA2DS2VaSC score for the evaluation of the thrombo-embolick risk, and of the HAS-BLED score for the evaluation of the hemorrhagic one. The consequent risk stratification is fundamental as a clinical guide for the use of oral anticoagulant therapy

Age- and sex-based reference ranges for non-invasive ventricular repolarisation parameters.

SummaryBackground Some electrocardiographic parameters are able to assess indirectly ventricular repolarisation homogeneity. It is consequently essential to discriminate between normal and abnormal values in clinical decision-making. Considering there is still not a consensus about normal cut-off values, the aim of this study was to document reference intervals in all age groups of a healthy population, providing for age- and sex-percentile tables, which can be used easily and quickly in clinical practice. Methods We evaluated repolarisation markers in 606 sex-matched participants aged 1 day–94 years. Each subject underwent a 12-lead electrocardiogram at rest, and the following parameters were measured: QT, corrected QT, QTpeak, Tpeak-Tend, Tpeak-Tend dispersion, Tpeak-Tend/QT and QTpeak/QT ratio. Results A relationship was demonstrated between age and QTpeak, Tpeak-Tend, QT and QTc. In children, QTpeak, Tpeak-Tend and QT intervals increased linearly with age. In adolescents, all the three parameters remained stable. In adults, QTpeak and QT showed a further significant increase. On the contrary, Tpeak-Tend interval was longer in adults aged between 20 and 64 years than in participants aged 65 years or over, but the difference was not statistically significant. Male vs female participants showed longer Tpeak-Tend intervals; this sex difference was not statistically significant at birth and during childhood, whereas it was in adolescents and in adults. Conclusions Repolarisation parameters showed age- and sex-based variations, which are important to know to differentiate normal from pathological values

Thromboembolic and hemorrhagic risk stratification in patients with atrial fibrillation. Part I: the thromboembolic risk

Atrial fibrillation, whose prevalence is in constant increase, is associated to a noticeably greater thrombo-embolic risk. Various associated factors, such as older age, arterial hypertension, heart failure, previous cerebrovascular events (stroke and transient ischemic attacks), diabetes mellitus, female sex and vascular diseases determine a further increase of the risk of stroke in patients with atrial fibrillation. Robust evidence exists on the efficacy of traditional anticoagulant oral therapy in the prevention of thrombo-embolic risk in these patients, but fears and concerns of hemorrhagic events for the physicians and the logistic difficulties related to the periodic International Normalized Ratio evaluation for the patients are at the basis of a noticeable under-utilization of the therapy with vitamin K antagonists in the real world. Stratification of the thrombo-embolic risk has thus particular importance; for this scope we may use now score systems as CHA2DS2 and, above all, CHA2DS2-Vasc, that allows the identification of truly low risk patients, which do not require an antithrombotic treatment. Novel oral anticoagulants, lastly, will help physicians in order to obtain a better management of trombo-embolic risk in atrial fibrillation

Usefulness of QT dispersion in clinical practice

The measurement of QT dispersion in the surface electrocardiogram has been proposed as a non invasive method for assessing inhomogeneity of myocardial repolarization and has been linked to an increased risk of arrhythmic cardiac death. Several studies have evaluated the use of QTd in a wide variety of cardiac diseases and have reached conflicting conclusions regarding its clinical significance

The Health Department of Sicily “Regional recommendations for hospital discharge and communication with patients after admission due to a cardiologic event” Decree

Mortality and rehospitalizations still remain high after discharge for an acute cardiologic event. In this context, hospital discharge represents a potential pitfall for heart disease patients. In the setting of care transitions, the discharge letter is the main instrument of communication between hospital and primary care. Communication, besides, is an integral part of high-quality, patient-centered interventions aimed at improving the discharge process. Inadequate information at discharge significantly affects the quality of treatment compliance and the adoption of lifestyle modifications for an effective secondary prevention. The Health Department of Sicily, in 2013, established a task force with the aim to elaborate “Regional recommendations for hospital discharge and communication with patients after admission due to a cardiologic event”, inviting to participate GICR-IACPR and many other scientific societies of cardiology and primary care, as discharge letter and communication are fundamental junctions of care transitions in cardiology. These recommendations have been published as a specific decree and contain: – a structured model of discharge letter, which includes all of the parameters characterizing patients at high clinical risk, high thrombotic risk and low risk according to the Consensus document ANMCO/GICR-IACPR/GISE; is thus possible to identify these patients, choosing consequently the most appropriate follow-up pathways. A particular attention has been given to the “Medication Reconciliation” and to the identification of therapeutic targets; – an educational Kit, with different forms on cardiac diseases, risk factors, drugs and lifestyle; – a check-list about information given to the patient and caregivers. The “Recommendations” represent, in conclusion, the practical realization of the fruitful cooperation between scientific societies and political-administrative institutions that has been realized in Sicily in the last years

Physical exercise and Sport activities in patients with and without coronary heart disease

Background: The quantity and intensity of physical activity required for the primary prevention of coronary heart disease remain unclear. Therefore, we examined the association between physical activity and coronary risk. Methods: We studied 100 patients with chest pain, 78 men and 22 women, not older than 65 years, admitted to a coronary care unit. Patients were subdivided in 3 groups: the first group included patients with acute myocardial infarction, the second group included patients with chronic heart disease, the third included patients with non-ischemic chest-pain. A questionnaire on daily physical activity was filled by each patient. Results: A significantly higher percentage of patients with myocardial infarction and coronary heart disease had a sedentary life style compared to patients of the third group. Compared with subjects without heart disease, a significantly higher percentage of patients of the first and second group covered a daily average distance shorter than 500 meters, while a significantly inferior percentage covered a distance longer than 1 Km every day. A significantly lower percentage of patients with coronary heart disease practised sport compared with the third group. At the time of hospitalization a very small percentage of coronary heart disease patients still practised sport. Conclusions: The association between physical activity and reduced coronary risk is clear; in order to obtain benefits it is sufficient just walking every day. Regarding physical activity, continuity is important: patients, who practised sport only in juvenile age, breaking off when older, may lose the obtained advantages

From risk charts to guidelines: tools for evaluation and management of cardiovascular risk

Despite the wide improvement of diagnostic techniques and the introduction of effective pharmacological and instrumental therapeutic strategies aimed to the treatment of cardiovascular diseases, their incidence and lethality are still elevated, with economic implications increasingly less sustainable by the public medical systems. The modern practice of cardiovascular prevention requires, thus, that diagnostic and therapeutic interventions, both at population level and on the single patient, should be more and more precise, effective, and appropriate. From this point of view, a correct global cardiovascular risk stratification assumes a preponderant relevance, in order to allow an adequate therapeutical response. For this purpose several work instruments, as risk charts and guidelines, namely dedicated to arterial hypertension and dyslipidemias, were developed and offered to clinicians interested in cardiovascular prevention. The aim of this review is to illustrate, in synthesis, those instruments, aiming to facilitate their implementation, thus reducing the actual gap between theoretical indications and the real world

After ACC/AHA and ESC Guidelines Pre-operative cardiological evaluation in non-cardiac surgery: certainties, controversial areas and opportunities for a team approach

A standardized and evidence-based approach to the cardiological management of patients undergoing noncardiac surgery has been recently defined by Task Forces of the American Heart Association (AHA), American College of Cardiology (ACC) and the European Society of Cardiology (ESC) that published their guidelines in 2007 and 2009, respectively. Both the recommendations moved from risk indices to a practical, stepwise approach of the patient, which integrates clinical risk factors and test results with the estimated stress of the planned surgical procedure. In the present paper the main topics of the guidelines are discussed, and moreover, emphasis is placed on four controversial issues such as the use of prophylactic coronary revascularization in patients with myocardial ischemia, the perioperative management of patients with congestive heart failure, the routine use of betablockers and statins, and, finally, the management of antiplatelet therapies in patients with coronary stents. In addition to promoting an improvement of immediate perioperative care, the preoperative cardiological evaluation should be a challenge for identifying subjects with enhanced risk of cardiovascular events, who should be treated and monitored during a long-term follow-up