Direct oral anticoagulants use in elderly patients with non valvular atrial fibrillation. state of evidence

Non-valvular atrial fibrillation (NVAF) increases the risk of stroke by three-to five-fold, especially in elderly patients, creating a huge burden on medical system as well as a negative impact on patients' lives. Balancing efficacy and bleeding risk is a challenge when considering anticoagulation therapy in elderly patients, because of their frequent high risk of both stroke and bleeding. Real world data reveal the underuse of anticoagulation in the elderly, especially due to physicians' fear of bleeding, often neglecting the thromboembolic risk. Care of elderly patients with NVAF is often complicated by factors including adherence, cognitive impairment, health literacy, risk of falling, adverse effects, involvement of caregivers, and patient-physician relationship. Therefore, shared decision making and conversations between clinicians and patients are crucial. In addition, elderly patients often suffer from multiple comorbidities, requiring multiple concomitant medications, with an increased risk of drug interactions. Four non-Vitamin K antagonist oral anticoagulants, the so-called direct oral anticoagulants (DOACs) - dabigatran, rivaroxaban, apixaban and edoxaban - have been approved for reducing the risk of stroke and systemic embolism in patients with NVAF. Clinical trials and real-world data show the advantages of this class of drugs compared to conventional anticoagulation in the treatment of elderly patients with NVAF and identify subgroups of older patients who may be more suitable candidates for particular agents. However, there are conflicting opinions on the absolute benefit of DOACs use in elderly patients. A key factor to consider is that elderly patients frequently suffer from renal impairment and therefore dose adjustments according to creatinine clearance are mandatory for DOACs. As each DOAC comes with its own unique advantages and safety profile, a personalized case by case approach should be adopted to decide on the appropriate anticoagulation regimen for elderly patients after weighing the overall risks and benefits of therapy

Cardiac and Vascular Remodeling After 6 Months of Therapy With Sacubitril/Valsartan: Mechanistic Insights From Advanced Echocardiographic Analysis

14Background: Effects of Sacubitril/Valsartan (S/V) on left ventricular (LV) mechanics and ventricular-arterial coupling in patients with heart failure with reduced ejection fraction (HFrEF) are not completely understood. The aim of this study was to evaluate both cardiac and vascular remodeling in a group of HFrEF patients undergoing S/V therapy. Methods: Fifty HFrEF patients eligible to start a therapy with S/V were enrolled. Echocardiographic evaluation was performed at baseline and after 6 months of followup (FU). Beside standard evaluation, including global longitudinal strain (GLS), estimated hemodynamic forces (HDFs) and non-invasive pressure-volume curves (PV loop) were assessed using dedicated softwares. HDFs were evaluated over the entire cardiac cycle, in systole and diastole, both in apex to base (A-B) and latero-septal (L-S) directions. The distribution of LV HDFs was evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio). Parameters derived from estimated PV loop curves were left ventricular end-systolic elastance (Ees), arterial elastance (Ea), and ventricular-arterial coupling (VAC). Results: At 6 months of FU indexed left ventricular end-diastolic and end-systolic volumes decreased (EDVi: 101 ± 28mL vs. 86 ± 30mL, p < 0.001; ESVi: 72 ± 23mL vs. 55 ± 24mL, p < 0.001), ejection fraction and GLS significantly improved (EF: 29 ± 6% vs. 37 ± 7%, p < 0.001; GLS: −9 ± 3% vs. −13 ± 4%, p < 0.001). A reduction of Ea (2.11 ± 0.91 mmHg/mL vs. 1.72 ± 0.44 mmHg/mL, p = 0.008) and an improvement of Ees (1.01 ± 0.37 mmHg/mL vs. 1.35 ± 0.6 mmHg/mL, p < 0.001) and VAC (2.3 ± 1.1 vs. 1.5 ± 0.7, p < 0.001) were observed. Re-alignment of HDFs occurred, with a reduction of diastolic L-S/A-B HDFs ratio [23 (20–35)% vs. 20 (11–28) %, p < 0.001]. Conclusion: S/V therapy leads to a complex phenomenon of reverse remodeling involving increased myocardial contractility, HDFs distribution improvement, and afterload reduction.openopenMonosilio, Sara; Filomena, Domenico; Luongo, Federico; Sannino, Michele; Cimino, Sara; Neccia, Matteo; Mariani, Marco Valerio; Birtolo, Lucia Ilaria; Benedetti, Giulia; Tonti, Giovanni; Pedrizzetti, Gianni; Vizza, Carmine Dario; Maestrini, Viviana; Agati, LucianoMonosilio, Sara; Filomena, Domenico; Luongo, Federico; Sannino, Michele; Cimino, Sara; Neccia, Matteo; Mariani, Marco Valerio; Birtolo, Lucia Ilaria; Benedetti, Giulia; Tonti, Giovanni; Pedrizzetti, Gianni; Vizza, Carmine Dario; Maestrini, Viviana; Agati, Lucian

A step forward towards increasing the mobility and participation of people with disabilities utilizing Satellite Navigation Technology Applications

Large groups of the population in Europe encounter significant difficulties in taking part in everyday life due to their functional limitations. The NADIA (NAvigation for DIsability Applications) Project, funded and promoted by the Italian Space Agency (ASI) and implemented by Thales Alenia Space Italia with the collaboration of a mixed team of companies, university and user associations, has made concrete steps forward in demonstrating that satellite navigation applications can have an important role in facilitating the mobility of people with disabilities. This paper describes not only some basic features of the system, but looks at how they are related to the process of defining user needs and requirements, highlighting the role of end users and of professional users of Assistive Technology (AT)

Prognostic role of pre- and post-interventional myocardial injury in patients undergoing transcatheter aortic valve implantation

Chronic pre-procedural and acute post-procedural myocardial injury are frequently observed in patients with aortic stenosis undergoing trans-catheter aortic valve implantation (TAVI). The aim of our study was to investigate the prognostic role of high sensitivity cardiac troponins (hs-cTns) elevation before and after TAVI