Aspirin use for primary prevention in elderly patients

The net clinical benefit of aspirin in primary prevention is uncertain as the reduction in occlusive events needs to be balanced against the increase in gastro-intestinal and cerebral bleedings. The meta-analysis of ATT (Anti Thrombotic Trialists) Collaboration in 2009 showed that aspirin therapy in primary prevention was associated with 12% reduction in cardio-vascular events, due mainly to a reduction in non-fatal myocardial infarction (0.18% vs 0.23% per year, p<0.0001). However, the benefit in term of coronary events was almost balanced by the increase in major bleedings. The balance between potential benefit and harm of aspirin differs in each person and appears to be favorable in subjects at higher cardio-vascular risk. Older people have increased risk of hemorrhage as well as increased risk of heart attack and stroke. As a consequence, it is important consider both likelihoods of benefits as well as harm within the lifespan and functioning of the person. The older people who most likely benefit from aspirin in primary prevention are those at higher cardio-vascular risk, with preserved functional abilities, low comorbidity, low risk of bleeding and a prolonged life expectancy.   Riassunto Il beneficio clinico netto dell’aspirina in prevenzione primaria è poco chiaro, a causa del bilancio critico tra riduzione delle occlusioni vascolari e aumento dei sanguinamenti gastro-intestinali e cerebrali. La metanalisi del 2009 del ATT (Anti Thrombotic Trialists) Collaboration mostra che l’aspirina in prevenzione primaria determina una riduzione del 12% degli eventi cardiovascolari, principalmente dovuta ad una riduzione dell’infarto miocardico non-fatale (0.18% vs 0.23% per anno, p<0.0001). Tuttavia il beneficio in termini di eventi coronarici è controbilanciato dall’incremento dei sanguinamenti maggiori. Ne deriva che il bilancio tra vantaggi ed effetti avversi differisce nel singolo soggetto ed appare potenzialmente favorevole nei casi a più elevato rischio cardiovascolare. Nella popolazione anziana è aumentato sia il rischio trombotico che quello emorragico. Di conseguenza, è importante considerare il rapporto rischio/beneficio in relazione alla aspettativa di vita e alla capacità funzionale. In sostanza gli anziani che possono trarre vantaggio dall’aspirina in prevenzione primaria sono quelli a più alto rischio cardiovascolare, con mobilità conservata, scarsa comorbidità, basso rischio emorragico e lunga aspettativa di vita

Primary Angioplasty with Manual Thrombectomy Alone as a Therapeutic Strategy in a Patient with Acute Myocardial Infarction and Severe Anemia

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Pheochromocytoma presenting as an acute coronary syndrome complicated by acute heart failure: The challenge of a great mimic

Pheochromocytoma is a rare neuroendocrine tumor with a highly variable clinical presentation. The serious and potentially lethal cardiovascular complications of these tumors are related to the effects of secreted catecholamines. We describe a case of a 50-year-old woman urgently admitted to our hospital because of symptoms and clinical and instrumental findings consistent with an acute coronary syndrome complicated by acute heart failure. Urgent coronary angiography showed normal coronary arteries. During her hospital stay, the recurrence of episodes characterized by a sudden increase in blood pressure, cold sweating, and nausea allowed us to hypothesize a pheochromocytoma. The diagnosis was confirmed by elevated levels of urinary catecholamines and by the finding of a left adrenal mass on magnetic resonance imaging. The patient underwent left adrenalectomy. Therefore, the initial diagnosis was critically reappraised and reviewed as a cardiac manifestation of a pheochromocytoma during catecholaminergic crisis

Simultaneous analysis of kynurenine and tryptophan in human plasma by capillary electrophoresis with UV detection

Plasma kynurenine (Kyn)/tryptophan ratio has been proposed as a useful marker for the monitoring activation of the cellular immune system. Here, we describe an easy capillary electrophoresis method with UV detection for the separation and detection of Kyn and tryptophan in human plasma using methltryptophan as internal standard. The plasma samples were simply treated with acentonitrile for the elimination of proteins, the supernatant was evaporated, and the dried sample was resuspended with water and directly injected on the capillary without sample derivatization procedures. The use of a run buffer composed by 100 mmol/L Bis-Tris propane at pH 2.15 allowed to baseline resolve the analytes within 9 min. Precision tests indicated a good repeatability of our method both for times (CV &lt; 0.53%) and areas (CV &lt; 2.8%). Moreover, a good reproducibility of intra-assay and interassay tests was obtained (CV &lt; 3.9% and CV &lt; 7.6%, respectively). The obtained limit of detections for Kyn and tryptophane, evaluated at 226 nm, were 0.15 and 0.40 mol/L, respectively. The method suitability was tested by measuring analyte levels both in healthy volunteers, acute myocardial infarction and chronic kidney disease patients

Helicobacter pylori active infection in patients with acute coronary heart disease

Objectives. To evaluate the possible role of the active Helicobacter pylori infection as a trigger factor in acute coronary heart disease (CHD). Methods. Forty patients with acute coronary syndromes, 40 patients with infections other than H. pylori (control group A) and 40 healthy subjects (control group B), pair matched for age, sex and CHD risk factors were studied. In each patient and control subject the presence of H. pylori stool antigen (HpsA) and serum anti-CagA were tested. Results. Twenty-eight of patients with CHD resulted positive for HpSA compared to 14 patients of control group A and 16 subjects of group B (p = 0.00095). No significant difference was found in the anti-CagA positivity among patients with CHD and control groups. Concomitant positivity for anti-CagA and HpSA was found in 13 patients with CHD, four controls of group A and five controls of group B (p = 0.017). Conclusions. Our findings revealed a higher rate of HpSA positivity and a significantly higher association between HpSA and anti-CagA positivity in patients with acute CHD compared to control groups. These data suggest that active H. pylori infection may play a role as a trigger factor in acute cardiovascular events. (C) 2004 The British Infection Society. Published by Elsevier Ltd. All rights reserved

Hypertension in the elderly. why one size does not fit all

Over recent years, managing hypertension in older people has gained increasing attention, with reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data. Although limited, available evidence suggests that the association between blood pressure and adverse outcomes significantly varies at advanced age according to frailty status. In particular, the negative prognostic impact of hypertension seems to attenuate or even revert in individuals with older biological age, e.g., patients with disability, cognitive impairment, and poor physical performance. Consequently, "one size does not fit all" and personalized treatment strategies are needed, customized to individuals' frailty and functional status. Similar to other cardiovascular diseases, hypertension management in older people should be characterized by a geriatric approach based on biological rather than chronological age and a geriatric comprehensive evaluation including frailty assessment is required to provide the most appropriate treatment, tailored to patients' prognosis and health care goals. The aim of this review was to illustrate the importance of a patient-centered geriatric approach to hypertension management in older people with the final purpose to promote a wider implementation of frailty assessment in routine practice

A subgroup analysis of the ODYSSEY APPRISE study: safety and efficacy of alirocumab in the Italian cohort

Background and Aims ODYSSEY APPRISE trial evaluated efficacy and safety of alirocumab in 994 patients with hypercholesterolemia and high CV risk in a real-life setting. The aim of the present report is to detail on the Italian cohort enrolled and treated in the trial. Methods and Results The methodology of the of the multinational, single-arm, Phase 3b open-label ODYSSEY APPRISE (Clinicaltrials.gov: NCT02476006) has been previously reported. 255 Italian patients were enrolled and treated according to the trial protocol. Overall mean exposure to alirocumab was 83.3 ± 27.7 weeks. At week 12, LDL-C decreased by 51.3 ± 23.1 % and this reduction was overall maintained for the duration of the study. A similar reduction was observed in patients with and without heterozygous familial hypercholesterolemia (HeFH 50.7% ± 23.9 vs. non-FH, 53.6% ± 19.6). LDL-C was reduced below 1.8 mmol/L and/or by ≥ 50% reduction from baseline in 62 % of patients overall (61 % in HeFH and 67 % in non-FH). Alirocumab was similarly well tolerated in the Italian cohort as in the entire study population and the more common treatment emergent adverse events (TEAEs) were influenza, myalgia and nasopharyngitis. The incidence LDL-C levels &lt; 25 mg/dl and &lt; 15 mg/dl, was 8.2% and 2.9% respectively. Conclusion The efficacy and safety of alirocumab in a real-life setting, in the Italian subgroup of patients are consistent with findings in the entire study population and confirm that alirocumab is a beneficial approach to further reduce LDL-C levels in patients at high CV risk on maximally tolerated conventional lipid lowering treatmen

Closed loop stimulation in prevention of vasovagal syncope. Inotropy controlled pacing in vasovagal syncope (INVASY): A multicentre randomized, single blind, controlled study

Objectives: To determine whether dual-chamber rate-adaptive Closed Loop Stimulation (CLS) could prevent recurrence of Vasovagal Syncope (VVS). Background: During VVS, an increase in myocardial contractility associated with a reduction of ventricular filling produces an increase in baroreceptor afferent flow and a consequent decrease in the heart rate. The CLS algorithm is a form of rate-adaptive pacing, which responds to myocardial contraction dynamics, by measuring variations in right ventricular intracardiac impedance: during an incipient VVS it could increase paced heart rate and avoid bradycardia, arterial hypotension and syncope. Methods: Fifty patients (27 males, mean age 59 ± 18 year) with severe and recurrent vasovagal syncope and positive Head Up Tilt Test (HUTT) with cardioinhibition, received a CLS pacemaker (INOS2, Biotronik GmbH Co., Germany). The primary end point was recurrence of two VVSs during a minimum of 1 year of follow-up. Randomization between DDD-CLS and DDI mode (40 bpm) pacing was performed only during the first stage of the study (first year): 9/26 randomized to DDI mode (control group) and 17/26 in DDD-CLS mode. All the 24 patients recruited in the second stage of the study (second year) were programmed in DDD-CLS mode. Results: Of the nine patients randomized to the DDI mode, seven had recurrences of syncope during the first year. At the end of the first year the nine patients were reprogrammed to the CLS mode and no syncope occurred after reprogramming. The 41 patients programmed to CLS had a mean follow-up of 19 ± 4 months: none reported VVS, only four (10%) reported occasional presyncope and their quality of life greatly improved. Positive HUTT at the end of the first year failed to predict the clinical response to CLS pacing. Conclusions: The study demonstrates the effectiveness of CLS pacing in preventing cardioinhibitory VVS. A possible placebo effect of pacemaker implantation occurred in 22% of patients. © 2004 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved