Strategies for cardiovascular prevention by evidence based medicine

Cardiovascular prevention aims to early identify patients at higher risk of developing a cardiovascular event, Prompt identification and treatment of those can potentially reduce the risk of events to occur.The purpose of this study was to assess the efficacy of drug therapy in primary and secondary cardiovascular prevention using the evidence based medicine approach.In the first part of this thesis, the focus is on the role of two main surrogate end points for cardiovascular events, for which the prognostic role is still unclear (serial measurement of carotid intimamedia thickness (IMT) and left ventricular hypertrophy (LVH)).In the second part, the efficacy of drug therapy strategies for cardiovascular events prevention is assessed for three topics lacking of clear evidence:1) Calcium Channel Blockers (CCBs) and clinical outcomes2) The role of Ace Inhibitors (ACE-Is) vs Angiotensin Receptor Blockers (ARBs) in patients without left ventricular systolic dysfunction3) The efficacy of statin therapy in primary prevention according to the gender.Literature review was performed by collecting all the articles relevant to the objectives of the study. A meta-regression analysis was performed to test the relationship between serial IMT or LVH changes and clinical outcomes. A meta-analysis was performed to calculate the overall estimates of effect of ACE-Is vs ARBs in patients without heart failure, of CCBs in hypertension or coronary artery disease and of statins in primary prevention according to gender. A publication bias test and sensitivity analysis were also performed.The results showed that neither carotid IMT or LVH change predict the risk of cardiovascular events.Furthermore, CCBs reduced the risk of myocardial infarction and were more effective than ACE-Is in preventing stroke, however they are possibly less effective than other medications in preventing heart failure.In patients without heart failure, ARBs were not as effective as ACE-is in reducing cardiovascular outcomes.Finally, statins in primary prevention of coronary heart disease appeared more effective in men than in women.Publications portfolio:Journal of the American College of Cardiology; 2010; 56:2006-20: http://www.sciencedirect.com/science/article/pii/S0735109710040507International journal of cardiology; 2013; 167:2757-64: http://www.sciencedirect.com/science/article/pii/S0167527312008753Journal of hypertension; 2009; 27:1136-51: http://ovidsp.tx.ovid.com/sp-3.24.1b/ovidweb.cgi?&S=JKLOFPEJGODDJDOENCHKMFGCNABLAA00&Link+Set=S.sh.22.23.27.31%7c8%7csl_10Journal of the American College of Cardiology; 2013;61:131-42: http://www.sciencedirect.com/science/article/pii/S0735109712053016International journal of cardiology; 2010; 138:25-31: http://www.sciencedirect.com/science/article/pii/S016752730800943

Transcatheter Aortic Valve Implantation for Severe Pure Aortic Regurgitation with Dedicated Devices

Aortic regurgitation (AR) is not the most common valvular disease; however, its prevalence increases with age, with more than 2% of those aged >70 years having at least moderate AR. Once symptoms related to AR develop, the prognosis becomes poor. Transcatheter aortic valve implantation for patients with pure severe AR and at prohibitive surgical risk is occasionally performed, but remains a clinical challenge due to absence of valvular calcium, large aortic root and increased stroke volume. These issues make the positioning and deployment of transcatheter aortic valve implantation devices unpredictable, with a tendency to prosthesis embolisation or malposition. To date, the only two dedicated transcatheter valves for AR are the J-Valve (JC Medical) and the JenaValve (JenaValve Technology). Both devices have been used successfully via the transapical approach. The transfemoral experience is limited to first-in-human publications and to a clinical trial dedicated to AR, for which the completion date is still pending

intravenous versus intracoronary bolus of glycoprotein iib iiia inhibitor administration during primary percutaneous coronary intervention on long term left ventricular systolic and diastolic function

Background: In primary percutaneous coronary intervention (PCI), glycoprotein (GP) IIb/IIIa inhibitors are often given in order to attain and maintain better myocardial perfusion. Wetested the hypothesis that intracoronary (IC) bolus of GP IIb/IIIa inhibitors might producea greater improvement in left ventricular (LV) systolic and diastolic function than an intravenous(IV) bolus. Methods and results: Seventy seven patients undergoing primary PCI for their firstST elevation myocardial infarction (STEMI) were randomly assigned to either an IC or IVbolus of GP IIb/IIIa inhibitor, followed by IV infusion. Compared with the echocardiographic findings within 3 days after PCI, LV ejection fraction was higher at 1 year, with no significant differences between the IV and IC groups (IV: 44% vs. 49%, p = 0.001; IC: 43% vs. 48%,p < 0.001). LV diastolic function (E/E') did not significantly change at 1 year by either approach. Conclusions: LV systolic function improved by a similar magnitude following primary PCI, with either IC or IV bolus administration of GP IIb/IIIa inhibitor therapy. However, no significant changes were observed in LV diastolic function

Intravenous versus intracoronary bolus of glycoprotein IIb/IIIa inhibitor administration during primary percutaneous coronary intervention on long-term left ventricular systolic and diastolic function

Background: In primary percutaneous coronary intervention (PCI), glycoprotein (GP) IIb/IIIa inhibitors are often given in order to attain and maintain better myocardial perfusion. Wetested the hypothesis that intracoronary (IC) bolus of GP IIb/IIIa inhibitors might producea greater improvement in left ventricular (LV) systolic and diastolic function than an intravenous(IV) bolus.Methods and results: Seventy seven patients undergoing primary PCI for their firstST elevation myocardial infarction (STEMI) were randomly assigned to either an IC or IVbolus of GP IIb/IIIa inhibitor, followed by IV infusion. Compared with the echocardiographic findings within 3 days after PCI, LV ejection fraction was higher at 1 year, with no significant differences between the IV and IC groups (IV: 44% vs. 49%, p = 0.001; IC: 43% vs. 48%,p &lt; 0.001). LV diastolic function (E/E’) did not significantly change at 1 year by either approach.Conclusions: LV systolic function improved by a similar magnitude following primary PCI, with either IC or IV bolus administration of GP IIb/IIIa inhibitor therapy. However, no significant changes were observed in LV diastolic function

The role of myocardial scintigraphy in the assessment of coronary artery disease

Single photon emission computed tomography (SPECT) for the assessment of myocardial perfusion was introduced in the early 1970s, following pioneer studies of Gould et al. It has rapidly become one of the most used noninvasive technique for the assessment of myocardial ischemia. Thanks to the current technetium based tracers that allow electrocardiogram gated synchronization, it is possible to assess the regional ventricular systolic function and the evaluation of myocardial perfusion as well. In the last twenty years, beyond its diagnostic role, myocardial SPECT has become also a prognostic technique. Indeed, it has acquired a role for the short-term prediction of major coronary events in a large cohort with known or suspected coronary artery disease (CAD). The aim of this review is to give an update of the correct use and interpretation of myocardial SPECT in patients with known or suspected CAD and without left ventricular dysfunction

Consensus based recommendations for diagnosis and medical management of Poland syndrome (sequence)

Background Poland syndrome (OMIM: 173800) is a disorder in which affected individuals are born with missing or underdeveloped muscles on one side of the body, resulting in abnormalities that can affect the chest, breast, shoulder, arm, and hand. The extent and severity of the abnormalities vary among affected individuals. Main body The aim of this work is to provide recommendations for the diagnosis and management of people affected by Poland syndrome based on evidence from literature and experience of health professionals from different medical backgrounds who have followed for several years affected subjects. The literature search was performed in the second half of 2019. Original papers, meta-analyses, reviews, books and guidelines were reviewed and final recommendations were reached by consensus. Conclusion Being Poland syndrome a rare syndrome most recommendations here presented are good clinical practice based on the consensus of the participant experts

Serum Albumin Is Inversely Associated With Portal Vein Thrombosis in Cirrhosis

We analyzed whether serum albumin is independently associated with portal vein thrombosis (PVT) in liver cirrhosis (LC) and if a biologic plausibility exists. This study was divided into three parts. In part 1 (retrospective analysis), 753 consecutive patients with LC with ultrasound-detected PVT were retrospectively analyzed. In part 2, 112 patients with LC and 56 matched controls were entered in the cross-sectional study. In part 3, 5 patients with cirrhosis were entered in the in vivo study and 4 healthy subjects (HSs) were entered in the in vitro study to explore if albumin may affect platelet activation by modulating oxidative stress. In the 753 patients with LC, the prevalence of PVT was 16.7%; logistic analysis showed that only age (odds ratio [OR], 1.024; P = 0.012) and serum albumin (OR, -0.422; P = 0.0001) significantly predicted patients with PVT. Analyzing the 112 patients with LC and controls, soluble clusters of differentiation (CD)40-ligand (P = 0.0238), soluble Nox2-derived peptide (sNox2-dp; P &lt; 0.0001), and urinary excretion of isoprostanes (P = 0.0078) were higher in patients with LC. In LC, albumin was correlated with sCD4OL (Spearman's rank correlation coefficient [r(s)], -0.33; P &lt; 0.001), sNox2-dp (r(s), -0.57; P &lt; 0.0001), and urinary excretion of isoprostanes (r(s), -0.48; P &lt; 0.0001) levels. The in vivo study showed a progressive decrease in platelet aggregation, sNox2-dp, and urinary 8-iso prostaglandin F2 alpha-III formation 2 hours and 3 days after albumin infusion. Finally, platelet aggregation, sNox2-dp, and isoprostane formation significantly decreased in platelets from HSs incubated with scalar concentrations of albumin. Conclusion: Low serum albumin in LC is associated with PVT, suggesting that albumin could be a modulator of the hemostatic system through interference with mechanisms regulating platelet activation

Betabloccanti in pazienti con scompenso cardiaco e fibrillazione atriale = [Betablockers in patients with heart failure and atrial fibrillation]

A recent individual patient data meta-analysis has shown that beta-blockers reduce mortality in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) who are in sinus rhythm but not in those who are in atrial fibrillation. Similar results applied also to cardiovascular death or first hospitalization for heart failure. The European Society of Cardiology guidelines recommend beta-blockers in patients with HFrEF regardless of baseline rhythm. However, despite improving symptoms, the prognostic benefits of beta-blockers have now been questioned by these authors in patients with HFrEF and atrial fibrillation. In this review we comment the findings of this study