Critical issues in megatrials on new oral anticoagulants. Rocket AF: applying results to low risk patients

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Full-dose atorvastatin versus conventional medical therapy after non-ST-elevation acute myocardial infarction in patients with advanced non-revascularisable coronary artery disease

Aims: This study tested the hypothesis that the addition of full-dose atorvastatin (80 mg/day) to conventional medical treatment could reduce ischaemic recurrences after non-ST-elevation acute myocardial infarction (NSTE-AMI) in patients with severe and diffuse coronary artery disease (CAD) not amenable to any form of mechanical revascularisation. Methods and results: The study was an open-label, randomised, controlled, blinded end-point classification trial, employing the PROBE (Prospective Open Treatment and Blinded End Point Evaluation) design. A total of 290 patients (mean age 74.6 +/- 9.6 years) with NSTE-AMI and angiographic evidence of severe and diffuse CAD, not amenable to revascularisation by either coronary surgery or angioplasty, were randomised to atorvastatin 80 mg/day (n = 144) or conventional medical treatment (n = 146). A primary end point event (combination of cardiovascular death, non-fatal acute myocardial reinfarction and disabling stroke within 12 months of randomisation) occurred in 16.0% of patients treated with atorvastatin 80 mg/day and in 26.7% of patients receiving conventional treatment (HR 0.56; 95% CI 0.33-0.93, p = 0.027). The study was not blinded. Consequently, a bias in the assessment of clinical outcome cannot be completely excluded. Conclusions: In conclusion, when compared with a conventional treatment strategy, full-dose therapy with atorvastatin 80 mg/day provides greater protection against ischaemic recurrences after NSTE-AMI in patients with severe, diffuse, non-revascularisable CAD

Smoking cessation interventions after acute coronary syndromes. Results of a cross-sectional survey in the Lazio Region of Italy.

Given the limited research on Italian hospital smoking care practices, a cross-sectional survey was undertaken in April-May 2011 to describe the current status of smoking cessation interventions for ACS patients in cardiovascular institutions of the Lazio Region of Italy. Lazio is a region of central Italy with a resident population of about 5,600,000. According to the data of the Regional Health Authority, about 10.000 patients are admitted for ACS every year in this region of Italy. Acute cardiac care in the region is currently provided by 33 Cardiology Divisions. All of these units were considered as eligible for the survey. The eligible respondent for each unit was the director. A self-report questionnaire was developed based on previous studies that examined the specific features of smoking cessation care provided to hospitalised patients. Questionnaires were forwarded by the Lazio Regional Section of the Italian National Association of Hospital Cardiologists (ANMCO). Completed questionnaires were received from 22 of the 33 eligible Divisions (66%). These 22 responding units currently provide acute care to about 70% of all ACS patients of the region. Responding units were more likely to represent public non-teaching hospitals (p=0.002), while non-responders were mostly from private non-teaching institutions (p=0.04). Response rates were not influenced by the presence of either interventional catheterization laboratory (Cathlab)or cardiac surgery within the hospitals. The survey suggest that most of cardiology units fail to provide recommended smoking care interventions to ACS patients. In particular, brief smoking cessation advice before discharge represents the only systematically implemented approach in clinical practice (22 units; 100%). Smoking cessation counselling is provided only in 9 units (40%). Specific pharmacotherapy is prescribed in selected case only in about one third of units (7 units; 32%), with varenicline being the preferred drug. Structural variables and organizational complexity have no influence on smoking care, as hospitals with Cathlab and cardiac surgery do not implement more effective strategies. Overall, this survey shows that the majority of smoking ACS inpatients may receive inadequate smoking care and that hospitals have considerable opportunity for improvement

Management strategies and choice of antithrombotic treatment in patients admitted with acute coronary syndrome - Executive summary for clinical practice

Consensus Document of the Regional Chapters of the Italian National Association of Hospital Cardiologists (ANMCO) and of the Italian Society of Emergency Medicine (SIMEU) This document has been developed by the Lazio regional chapters of two scientific associations, the Italian National Association of Hospital Cardiologists (ANMCO) and the Italian Society of Emergency Medicine (SIMEU), whose members are actively involved in the everyday management of Acute Coronary Syndromes (ACS). The document is aimed at providing a specific, practical, evidence-based guideline for the effective management of antithrombotic treatment (antiplatelet and anticoagulant) in the complex and ever changing scenario of ACS. The document employs a synthetic approach which considers two main issues: the actual operative context of treatment delivery and the general management strategy

Cardiovascular risk profile and lifestyle habits in a cohort of Italian cardiologists. Results of the SOCRATES survey

Objectives. To offer a snapshot of the personal health habits of Italian cardiologists, the Survey on Cardiac Risk Profile and Lifestyle Habits in a Cohort of Italian Cardiologists (SOCRATES) study was undertaken. Background. Cardiologists' cardiovascular profile and lifestyle habits are poorly known worldwide. Methods. A Web-based electronic self-reported survey, accessible through a dedicated website, was used for data entry, and data were transferred via the web to a central database. The survey was divided in 4 sections: baseline characteristics, medical illnesses and traditional cardiovascular risk factors, lifestyle habits and selected medication use. The e-mail databases of three national scientific societies were used to survey a large and representative sample of Italian cardiologists. Results. During the 3-month period of the survey, 1770 out of the 5240 cardiologists contacted (33.7%) completed and returned one or more sections of the questionnaire. More than 49% of the participants had 1 out of 5 classical risk factors (e.g. hypertension, hypercholesterolemia, active smoking, diabetes and previous vascular events). More than 28% of respondents had 2 to 5 risk factors and only 22.1% had none and therefore, according to age and sex, could be considered at low-intermediate risk. Despite the reported risk factors, more than 90% of cardiologists had a self-reported risk perception quantified as mild, such as low or intermediate. Furthermore, overweight/obesity, physical inactivity and stress at work or at home were commonly reported, as well as a limited use of cardiovascular drugs, such as statins or aspirin. Conclusions. The average cardiovascular profile of Italian cardiologist is unlikely to be considered ideal or even favorable according to recent statements and guidelines regarding cardiovascular risk. Thus, there is a large room for improvement and a need for education and intervention

Cardiac rehabilitation is safe and effective also in the elderly, but don't forget about drugs!

In the setting of heart failure (HF) pharmacotherapy demonstrates a quantifiable improvement in exercise tolerance also in HF with preserved ejection fraction (HFpEF). For patients with HFpEF, often older, with higher prevalence of hypertension, diabetes mellitus, atrial fibrillation and other comorbidities, endpoints such as quality of life and functional capacity may be more clinically relevant. However several study show as the use of ACE-I and B-blocker were lesser than expected. Beta-blocker therapy is the keystone of pharmacotherapy of HF patients and exercise training is the essential core of rehabilitation programs, it is important to elucidate the relationship between these therapies. Exercise training improves the clinical status of HF, improving left ventricular ejection fraction and improving quality of life, but it is possible that b-blocker may attenuate exercise training adaptations. Despite this, possible adverse b-blocker effects are just presumed and not confirmed by published randomized clinical trials. Metanalysis suggests that b-blocker compared with placebo enhances improvements in cardiorespiratory performance in exercise training intervention. Despite these evidences, prescription of gold standard therapy and adherence are still suboptimal and should be a priority goal for all CR program.  Riassunto Nell’ambito dei pazienti con scompenso cardiaco (SC) la terapia farmacologica permette di ottenere un miglioramento della tolleranza all’esercizio fisico anche nei pazienti con frazione di eiezione conservata. Questi pazienti spesso più anziani, con una più elevata incidenza di ipertensione, diabete mellito, fibrillazione atriale e comorbidità, endpoints quali qualità della vita e capacità funzionale dovrebbero risultare più clinicamente rilevanti. Tuttavia molti studi mostrano come l’utilizzo di ACE-I e Beta-bloccanti sia minore di quanto ci si aspetterebbe. Va evidenziato comunque come la terapia beta-bloccante costituisca il cardine della terapia farmacologica dello SC e come l’esercizio fisico sia il cuore dei programmi di riabilitazione, pertanto è importante valutarne le possibili interazioni. L’esercizio fisico migliora lo stato clinico dei pazienti con SC, ma è possibile che la terapia con Beta-bloccanti possa attenuare questi vantaggi. Tale assunto tuttavia rimane solo presunto e non confermato dai risultati dei trial pubblicati. Infatti una metanalisi suggerisce che la terapia Beta-bloccante, confrontata con il placebo, migliori la performance cardiorespiratoria nel gruppo sottoposto ad esercizio fisico. Malgrado tali evidenze, la prescrizione di una terapia medica ottimale e l’aderenza alla stessa rimangono ancora non ottimali e dovrebbe rappresentare un obiettivo primario per tutti i programmi di riabilitazione.

Barriers to cardiac rehabilitation access of older heart failure patients and strategies for better implementation

In heart failure (HF), cardiac rehabilitation (CR) may reduce decompensations, hospitalization, and ultimately mortality in long term. Many studies over the past decade have demonstrated that aerobic exercise training is effective and safe in stable patients with HF. Exercise CR resulted in a clinically important improvement in the QOL. Several clinical and psychosocial factors are associated with decreased participation in CR programs of elderly HF patients, such as perception of exercise as tiring or painful, comorbidities, lack of physician encouragement, and opinion that CR will not improve their health status. Besides low functional capacity, and chronic deconditioning may also deter patients from participating in CR programs.  Recent data suggest that current smoking, a BMI ≥30 kg/m2, diabetes mellitus, and cognitive dysfunction are associated with failure to enroll in outpatient CR in older age group. Moreover the lack of availability of CR facilities or the absence of financial refunds for enrolment of CHF patients in cardiac rehabilitation programs can play a crucial role. Many of this factors are modifiable through patient education and self care strategy instruction, health providers sensibilization, and implementing economic measures in order to make CR affordable.  Riassunto Numerosi studi hanno dimostrato come la riabilitazione cardiovascolare (RC) con esercizio aerobico sia risultato efficace e sicuro nei pazienti con scompenso cardiaco (SC), nel ridurre ospedalizzazioni, mortalità ed indurre un miglioramento della qualità di vita. Tuttavia numerosi fattori clinici e psicosociali, come la bassa capacità funzionale, le comorbidità, la percezione dell’esercizio fisico come noioso o doloroso, sono associati a ridotta partecipazione a RC da parte di pazienti anziani con SC.  Inoltre dati recenti mostrano come l’abitudine tabagica, un BMI ≥30 kg/m2, il diabete mellito ed il deterioramento cognitivo siano associati con il mancato arruolamento di pazienti anziani in programmi di RC.  In aggiunta la mancanza di disponibilità di strutture per la RC o l'assenza di rimborsi finanziari per l'iscrizione dei pazienti con SC in programmi di riabilitazione cardiaca possono svolgere un ruolo cruciale. Molti di questi fattori risultano modificabili attraverso programmi di educazione sanitaria del paziente, sensibilizzazione del personale sanitario ed attraverso un’implementazione delle misure economiche al fine di rendere accessibile la RC

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