Renin-Angiotensin-Aldosterone System Inhibitors, Statins, and Beta-Blockers in Diabetic Patients With Critical Limb Ischemia and Foot Lesions

Medical therapy for secondary prevention is known to be under-used in patients with peripheral artery disease (PAD). Few data are available on the subgroup with critical limb ischemia (CLI). Prescription of cardiovascular preventive therapies was recorded at discharge in a large, prospective cohort of patients admitted for treatment of CLI and foot lesions, stratified for coronary artery disease (CAD) diagnosis. All patients were followed up for at least 1 year. The primary endpoint was major adverse cardiovascular events (MACE). 618 patients were observed for a median follow-up of 981 days. Renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, beta-blockers, and antithrombotic drugs were prescribed in 52%, 80%, 51%, and 99% of patients, respectively. However, only 43% of patients received optimal medical therapy (OMT), defined as the combination of RAAS inhibitor plus statin plus at least one antithrombotic drug. It was observed that the prescription of OMT was not affected by the presence of a CAD diagnosis. On the other hand, it was noticed that the renal function affected the prescription of OMT. OMT was independently associated with MACE (HR 0.688, 95%CI 0.475-0.995, P = .047) and, after propensity matching, also with all-cause mortality (HR 0.626, 95%CI 0.409-0.958, P = .031). Beta-blockers prescription was not associated with any outcome. In conclusion, patients with critical limb ischemia are under-treated with cardiovascular preventive therapies, irrespective of a CAD diagnosis. This has consequences on their prognosis

Profilassi in chirurgia

Si definisce profilassi (dal greco: difendere o prevenire in anticipo) una qualsiasi procedura medica o di sanit\ue0 pubblica attuata con lo scopo di prevenire, e quindi evitare, l\u2019insorgenza di malattie, piuttosto che curarle. In chirurgia generale, ed a maggior ragione nel paziente geriatrico, la profilassi si effettua essenzialmente come: \u2022 Profilassi antibiotica \u2022 Profilassi antitrombotic

Approccio chirurgico nel paziente anziano

Nell\u2019approccio chirurgico al paziente anziano \ue8 fondamentale che il medico sappia stabilire un buon rapporto interpersonale, fattore gi\ue0 importante in generale, ma che nel paziente geriatrico assume una netta rilevanza ai fini del corretto inquadramento della patologia o delle patologie associate

Approccio chirurgico al paziente geriatrico

Nell\u2019approccio chirurgico al paziente anziano \ue8 fondamentale che il medico sappia stabilire un buon rapporto interpersonale, fattore gi\ue0 importante in generale, ma che nel paziente geriatrico assume una netta rilevanza ai fini del corretto inquadramento della patologia o delle patologie associate. L\u2019obiettivo di un\u2019accurata valutazione preoperatoria nel paziente anziano \ue8: 1) definire l\u2019entit\ue0 del declino fisiologico; 2) identificare e valutare la eventuale presenza di patologie concomitanti

Pharmacological protection of reperfusion injury in ST-segment elevation myocardial infarction. Gone with the wind?

Primary percutaneous coronary intervention (PCI) represents the greatest progress in the treatment of ST-elevation myocardial infarction (STEMI) over the last 30 years. It reduces infarct size with an early restoration of blood flow within an ischemic myocardium. However, it is associated with a still partly mysterious paradox: reperfusion injury [1]. It is characterized by reversible mechanical dysfunction called “myocardial stunning” and microvascular obstruction or the “no reflow phenomenon” which corresponds to the presence of capillary damage, endothelial cell swelling, intraluminal thrombosis and injured cardiomyocytes. Several mediators are involved in ischemia/reperfusion injury; on one hand prolonged ischemia causes pH alterations, activation of anaerobic metabolism, dysfunction of ATPase-dependent ion transport mechanisms, intracellular calcium overload, cell swelling and finally cell death. On the other hand, after reperfusion, there is an increase of reactive oxygen species and tissue infiltration of neutrophils and pro-inflammatory cytokines with paradoxical exacerbation of the ischemic injury. Consequently, at the clinical level, reperfusion injury is associated with residual large infarct size, impaired left ventricular ejection fraction, ventricular arrhythmias and poor prognosis

Fisiopatologia dell\u2019invecchiamento

L\u2019invecchiamento \ue8 un processo universale, fisiologico, geneticamente determinato ed irreversibile, caratterizzato dalla progressiva perdita delle riserve funzionali e dei meccanismi che consentono la capacit\ue0 di adattamento all\u2019ambiente con crescente probabilit\ue0 di malattie e di morte. Conoscere come, con l\u2019invecchiamento, si modifica l\u2019organismo umano \ue8 per il medico elemento dal quale non si pu\uf2 prescindere, poich\ue9 mentre \ue8 doveroso trattare la malattia, \ue8 imperdonabile curare la vecchiaia

Infezioni in chirurgia

Le infezioni del sito chirurgico (ISC) sono uno dei problemi che maggiormente affliggono la chirurgia. Sono associate a morbilit\ue0 o a prolungamento della degenza e possono necessitare anche di cure intensive, portando, nei casi pi\uf9 estremi, al decesso del paziente. Per tutti questi motivi, vanno ben conosciute e trattate

BRS implantation in long lesions requiring device overlapping: Myth or reality?

Dealing with bioresorbable vascular scaffolds (BVS) implantation in long lesions requiring device overlapping in this particular moment might seem a little provocative for several reasons. First, most studies testing BVS have focused on their safety and efficacy profile in simple patients with simple lesions. Second, ABSORB II did not meet its primary endpoint, while ABSORB III showed a higher rate of target vesselmyocardial infarction (TV-MI) at 2 years. Third, data on porcine model showed that overlapping zone has delayed but greater neointimal proliferation with consequent higher risk for scaffold thrombosis in the shortterm and of in-scaffold restenosis in the long-term. Fourth, recently published data showed higher risk of TVF in patients treated with â\u89¥60 mm BVS. Given all these premises, it may seem right to put aside this technology, while it may seem inappropriate to hypothesize the use of BVS in long lesions. The aim of the present review is precisely to critically review the available evidences regarding BVS with particular regard to overlapping BVS in order to understand whether this technology has a future per se and especially in long coronary lesions requiring overlap

Ticagrelor improves endothelial function by decreasing circulating Epidermal Growth Factor (EGF)

Ticagrelor is one of the most powerful P2Y12inhibitor. We have recently reported that, in patients with concomitant Stable Coronary Artery Disease (SCAD) and Chronic Obstructive Pulmonary Disease (COPD) undergoing percutaneous coronary intervention (PCI), treatment with ticagrelor, as compared to clopidogrel, is associated with an improvement of the endothelial function (Clinical Trial NCT02519608). In the present study, we showed that, in the same population, after 1 month treatment with ticagrelor, but not with clopidogrel, there is a decrease of the circulating levels of epidermal growth factor (EGF) and that these changes in circulating levels of EGF correlate with on-treatment platelet reactivity. Furthermore, in human umbilical vein endothelial cells (HUVEC) incubated with sera of the patients treated with ticagrelor, but not with clopidogrel there is an increase of p-eNOS levels. Finally, analyzing the changes in EGF and p-eNOS levels after treatment, we observed an inverse correlation between p-eNOS and EGF changes only in the ticagrelor group. Causality between EGF and eNOS activation was assessed in vitro in HUVEC where we showed that EGF decreases eNOS activity in a dose dependent manner. Taken together our data indicate that ticagrelor improves endothelial function by lowering circulating EGF that results in the activation of eNOS in the vascular endothelium

Limb salvage in diabetic patients with no-option critical limb ischemia: outcomes of a specialized center experience

Objective: To describe the characteristics, the management and the outcome of a consecutive series of patients with diabetic foot lesions (DF) and no-option critical limb ischemia (CLI) treated with a multidimensional, interdisciplinary approach in a dedicated center. Research Design and Methods: The prospective database of the Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) collects medical history, risk factors, chemistry values, angiographic data, characteristic of foot lesions, medical and surgical therapies of all patients admitted with a diagnosis of DF and CLI. All patients were followed-up for at least 1 year and/or total recovery. The primary endpoint was 1-year amputation-free survival (AFS), secondary endpoints were limb salvage and survival. Results: Between October 2014 and October 2017, 1024 patients with DF and CLI were admitted to the center. Eighty-four of them (8.2%) fulfilled the criteria for no-option CLI. At 1 year, AFS, limb salvage, and survival rates were 34%, 34%, and 83%, respectively. Lesions located proximal to the Lisfranc joint were associated with major amputation (HR 2.1 [1.2–3.6]). One-year survival of patients treated with minor procedures was significantly higher compared to patients treated with major amputation (96% vs 76%, log-rank p = 0.019). Major amputation was independently associated with mortality (HR 7.83 [1.02–59.89]). Conclusions: The application of dedicated and standardized strategies permitted limb salvage in one-third of patients with no-option CLI. Patients with stable lesions limited to the forefoot and without ischaemic pain had a greater probability to successfully receive conservative treatments. Limb salvage was associated with subsequent higher one-year survival