Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

: The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended

Blocking the RAAS at different levels: an update on the use of the direct renin inhibitors alone and in combination

Francesca Cagnoni1, Christian Achiri Ngu Njwe1, Augusto Zaninelli4, Alessandra Rossi Ricci1, Diletta Daffra2, Antonio D’Ospina1, Paola Preti3, Maurizio Destro11Internal Medicine, Ospedale Unificato Broni-Stradella, Stradella (PV), Italy; 2Internal Medicine, S.S. Annunziata Hospital, Varzi (PV), Italy; 3Internal Medicine, University of Pavia, Pavia, Italy; 4School of Medicine, University of Florence, Florence, ItalyAbstract: The renin–angiotensin–aldosterone system (RAAS), an important regulator of blood pressure and mediator of hypertension-related complications, is a prime target for cardiovascular drug therapy. Angiotensin-converting enzyme inhibitors (ACEIs) were the first drugs to be used to block the RAAS. Angiotensin II receptor blockers (ARBs) have also been shown to be equally effective for treatment. Although these drugs are highly effective and are widely used in the management of hypertension, current treatment regimens with ACEIs and ARBs are unable to completely suppress the RAAS. Combinations of ACEIs and ARBs have been shown to be superior than to either agent alone for some, but certainly not all, composite cardiovascular and kidney outcomes, but dual RAAS blockade with the combination of an ACEI and an ARB is sometimes associated with an increase in the risk for adverse events, primarily hyperkalemia and worsening renal function. The recent introduction of the direct renin inhibitor, aliskiren, has made available new combination strategies to obtain a more complete blockade of the RAAS with fewer adverse events. Renin system blockade with aliskiren and another RAAS agent has been, and still is, the subject of many large-scale clinical trials and furthermore, is already available in some countries as a fixed combination. Keywords: angiotensin II receptor blockers, renin–angiotensin–aldosterone system, hypertension, angiotensin-converting enzyme inhibitor

Atherothrombotic Burden and Medium-Term Prognosis in Patients with Acute Ischemic Stroke: Findings of the SIRIO Study

Background: Short-and medium-term mortality after acute stroke is related to the severity of the index event and the patient's age. However, recent studies have reassessed the prognostic value of the systemic atherothrombotic burden in these patients, not only in the long term. This post hoc analysis of the findings of the SIRIO trial (Stroke in Italy and Related Impact on Outcome) examined the prognostic impact of systemic atherothrombosis. Methods: SIRIO was a multicenter observational study enrolling patients during the acute phase of stroke of both ischemic and hemorrhagic origin. The present analysis, however, only covered patients with ischemic stroke. At baseline, the main personal and clinical details were recorded and patients were classified as having either polyvascular disease or single arterial disease on the basis of whether they had symptomatic atherothrombotic disease in other sites besides the cerebrovascular location. For all patients we calculated the Essen Stroke Risk Score (ESRS), dividing them into groups with scores of less than 3 or 3 and more. We recorded total mortality and non-fatal vascular events 12 months after enrolment. Multivariate logistic regression analysis was used to select predictors of medium-term mortality and nonfatal cardiovascular events. There were 2,561 patients with ischemic stroke, 823 of them classified as having polyvascular disease; 940 (out of 2,485) had an ESRS of less than 3 and 1,545 had a score of 3 or more. Results: The combined endpoint 'death (all causes) and nonfatal cardiovascular events within 12 months of hospital discharge' was significantly dependent on the following factors: ESRS, Rankin scale and National Institutes of Health Stroke Scale scores, and polyvascular disease. Polyvascular disease status significantly affected mortality and nonfatal cardio- and cerebrovascular events after discharge (OR = 1.44, 95% CI = 1.10-1.88). Age was also confirmed as a significant predictor of the combined endpoint. Conclusions: Besides age and the clinical severity of the index event, symptomatic involvement of several vascular districts was also an important predictor of mortality and nonfatal cardiovascular events in the medium term in patients with ischemic stroke. Copyright (C) 2012 S. Karger AG, Base

Ezetimibe/simvastatin vs simvastatin in coronary heart disease patients with or without diabetes

Abstract Background Treatment guidelines recommend LDL-C as the primary target of therapy in patients with hypercholesterolemia. Moreover, combination therapies with lipid-lowering drugs that have different mechanisms of action are recommended when it is not possible to attain LDL-C targets with statin monotherapy. Understanding which treatment or patient-related factors are associated with attaining a target may be clinically relevant. Methods Data were pooled from two multicenter, randomized, double-blind studies. After stabilization on simvastatin 20 mg, patients with coronary heart disease (CHD) alone and/or type 2 diabetes mellitus (T2DM) were randomized to ezetimibe 10 mg/simvastatin 20 mg (EZ/Simva) or simvastatin 40 mg. The change from baseline in low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), TC/HDL-C ratio, triglycerides, and the proportion of patients achieving LDL-C Results EZ/Simva treatment (N = 93) resulted in significantly greater reductions in LDL-C, TC, and TC/HDL-C ratio and higher attainment of LDL-C Conclusion EZ/Simva is an effective therapeutic option for patients who have not achieved recommended LDL-C treatment targets with simvastatin 20 mg monotherapy. Trial Registration Clinical trial registration numbers: NCT00423488 and NCT00423579</p

Effect of prior medical treatments on ischemic stroke severity and outcome

Antiplatelets, antihypertensives, and statins might reduce the severity of the event or improve outcome in patients who, despite prior medical treatment, have a stroke. We evaluated, in patients who had an ischemic stroke, the effect, on stroke severity and outcome, of prior treatment with antiplatelets, antihypertensives, and statins, used either alone or in a three-drug combination. Stroke in Italy and Related Impact on Outcome (SIRIO) was a prospective, nationwide, multicenter, hospitalbased, observational study that included patients aged ≥18 years with acute ischemic stroke. We studied 2,529 acute ischemic stroke patients from the SIRIO population: 887 were antiplatelet users, 1,497 antihypertensive users, 231 statin users, and 138 threedrug combination users prior to the index event. The adjusted logistic regression analysis showed an association between prior treatment with statins and good functional outcome at discharge, while prior treatment with antiplatelets, antihypertensives or the three-drug combination did not influence severity or outcome. The absolute probability of a good functional outcome was 46.3% (95% CI: 40.3%-53.2%) in statin users and 36.7% (95% CI: 34.7%-38.7%) in non-users of statins; the absolute risk difference was 9.6% (95% CI: 2.9%-16.4%; p=0.004). Prior treatment with antiplatelets, antihypertensives, or the three-drug combination did not influence stroke severity or outcome, while prior treatment with statins did not influence stroke severity but was associated with a better functional outcome

II coure delle donne

Heart diseases in women have a very different incidence and prognosis from that of men. However, the selected diagnostic tools are very different in relation to gender. In a gender-related approach to atherosclerotic disease, one of the most important topic is the evaluation of risk to develop cardiovascular events in women. This review represents the opinion of a task force of the Italian Society of Cardiology, on all debated issues regarding the relationship between women and heart diseases. This working group has analyzed the literature published in the last years, integrating the concepts emerged from the experience of physicians accustomed to the study and treatment of women with heart diseases. First of all, we analyzed the epidemiology of coronary heart disease in women, emphasizing the differences in the risk of developing cardiovascular events between European and American women. Then, we illustrated the new risk factors for ischemic heart disease that have specifically been studied in large female populations. These new risk factors could be used for a better evaluation of the cardiovascular risk, and for analyzing gender differences in diagnosis, response to therapy and prognosis of atherosclerotic disease. Some considerations about postmenopausal hormone replacement therapy were done, by providing suggestions for a corrected diagnosis and therapeutic approach in women with known cardiovascular disease. Atherosclerosis represents a really different disease in females with respect to males. The analysis of the literature supports the hypothesis that the pathophysiological mechanisms of this disease may be different or peculiar according to gender. We therefore suggest a tailored approach to this disease, in order to better quantify global cardiovascular risk, treat and prevent cardiovascular diseases, with the aim to reduce cardiovascular mortality and morbidity