Preoperative risk evaluation in patients over 75 years candidates to non-cardiac and cardiac surgery

In the 24th and 25thof June 2016, 80 national experts were invited to Rome from The Italian Society of Geriatric Cardiology and the Italian Association of Cardiovascular Prevention and Rehabilitation to revise the current knowledge on the perioperative risk in the elderly. Cardiologists, geriatricians, heart and general surgeons and anesthesiologists discussed the topic with the objective of reaching a consensus and to launch observational research and registries in the field of perioperative risk evaluation in the elderly. The introduction of objective measures of frailty on top of traditional cardiac evaluation in the different surgical contexts could allow for a more precise definition of "surgical risk", appropriate perioperative management and postoperative outcome.</p

Cardiovascular risk prediction in the real world. The discouraging evidences coming from literature

Risk prediction plays a leading role in cardiovascular (CV) prevention. Thus, several risk charts have been developed in different Countries in the attempt to identify subjects at high risk who might benefit from more aggressive and early interventions. However despite the availability of several risk charts, they are underutilized in clinical practice. Indeed risk charts show main limitations: they estimate absolute, but not individual risk; their performance is affected by changes on the incidence of CV diseases; they do not take into account the duration of risk exposure, which is related to the progression of atherosclerosis. Moreover, risk estimate might be less accurate in younger, in women, and in the elderly. Addition of novel risk markers have substantially failed to improve risk charts' discrimination power. Imaging has recently gained relevance in CV risk stratification for its ability to detect subclinical atherosclerosis. Among imaging techniques coronary artery calcium score(CACS) emerged as the most powerful and independent predictor of CV events. Hence, a CACSbased screening strategy have been proposed in all asymptomatic middle-aged people. However since CACS it is still quite expensive and not-radiation free, it is not recommended by most scientific guidelines. Conversely, detecting subclinical organ damage (SOD) like LV hypertrophy, carotid plaque, renal failure, microalbuminuria or the metabolic syndrome in subjects at intermediate risk is pretty cost-effective yielding to reclassification of subjects into higher-risk strata. Thus, merging information coming from different tools (risk scores, biomarkers, and non-invasive imaging) individual risk might be better stratified saving costs. In the next future, an integrated, semi-automated, high-reproducible and inexpensive ultrasound approach could represent a key point to approach the individual risk

COVID-19 pandemic: what consequences for cardiac rehabilitation?

The ongoing COVID-19 pandemic spreading all around the world has stressed over its capabilities and determined profound changes in the health systems in all countries and has caused hundreds of thousand deaths. Health professionals have been called to a tremendous effort to deal with this emergency, often contaminating or succumbing themselves to the disease

The GICR polls: a new instrument for Cardiovascular Prevention and Rehabilitation in Italy

During the year 2015 GICR-IACPR, a scientific society for Cardiovascular Prevention and Rehabilitation (CRP) in Italy, carried out several "Polls" based on its website, in order to know current attitudes of health operators involved in the management and care of cardiac patients. The Poll #1 focused on post revascularization residual myocardial ischemia, familial dyslipidemia, erectile dysfunction, sleep apnoea, and hyperuricaemia, all conditions being paradigmatic of well known situations of high cardiovascular risk and disability in the CRP setting. In the present report feasibility and results of the GICR Poll #1 are discussed

Cardio-oncology: the new frontier of clinical and preventive cardiology

Even if cancer and cardiovascular diseases are considered two distinct diseases, an intricate interconnection between these conditions has been established. Increased risk of malignancy has been identified in patients with cardiovascular disease, as well as a greater propensity to the development of cardiovascular diseases has been observed in patients with cancer. The development of cardiotoxicity following exposure to certain anticancer drugs only partially explains this relationship. Shared risk factors and common pathogenic mechanisms suggest the existence of a common biology and a complex interplay between these two conditions. Due to improving longevity and therapeutic advances, the number of patients affected or potentially at risk of developing these two diseases is constantly increasing and currently, several drugs against cancer from anthracyclines to checkpoint inhibitors, can also cause a wide range of unexpected cardiovascular side effects. Management of these issues in clinical practice is an emerging challenge for cardiologists and oncologists, and led to the development of a new dedicated discipline called cardio-oncology. Surveillance and prevention strategies as well as interventions to reduce cardiovascular risk and prevent cardiotoxicities are the primary objectives of cardio-oncology. In this review, we explore the etiopathogenesis common to cardiovascular disease and cancer and the complex interplay between them. We also report the main characteristics of the drugs responsible for cardiotoxicity, highlighting the available strategies for optimal patient management based on a multidisciplinary approach in the cardio-oncology setting

Primary Cardiovascular Disease Prevention: Risk Factors Control vs. Imaging Subclinical Atherosclerosis

The burden of cardiovascular disease in developed countries has shown dramatic improvements over the last 50 years, largely due the identification and control of major risk factors including, smoking hypertension and high cholesterol. However, due to the significant increase in obesity and diabetes CVD incidence rates will not reduce as far over over the next years. Risk prediction in asymptomatic individuals remains a major challenge. Primary preventive treatment is currently based on the assessment of individual's global risk mainly through screening of conventional risk factors and their treatment with lifestyle intervention and pharmacotherapy, often based on multivariate risk equations, and yet a large proportion of CVD still occurs in individuals who are classified as carrying low- or intermediate-risk according to the risk scores. Atherosclerosis is the most common pathophysiologic process underlying CVD, often after a prolonged asymptomatic phase during which it may be possible to modify the course of the disease. Unlike conventional probabilistic risk scores, non-invasive imaging techniques such as carotid intima-media thickness (CIMT) along with plaque assessment (Figure 2), measured by B-mode ultrasound, and coronary calcium scoring (CAC) detected by CT scan have the advantage of direct visualization of the consequences of atherosclerosis on the arterial system. We consider the proposal that imaging of subclinical atherosclerosis is superior to risk equations as it directly identifies the disease and can effectively predict the risk of future CV events in low- and intermediate-risk individuals. In addition, imaging can improve the adherence to guidelines based treatment in patients and their physicians

preoperative evaluation before non cardiac surgery in subjects older than 65 years

Non cardiac surgery is becoming increasingly common in elderly patients; they are usually affected by overt cardiac disease or show multiple risk factors, responsible for a higher incidence of perioperative fatal or nonfatal cardiac events. Of interest, acute myocardial infarction occurring in the perioperative period shows a high mortality rate in people over 65 years old. The cardiovascular risk stratification and perioperative management of subjects undergoing noncardiac surgery have been recently updated in the 2014 European Society of Cardiology Guidelines. However, several critical points still lack of strong evidence and are based on expert opinions only. For example, the use of drugs, such as betablockers, before, during and after the surgery, presents many uncertainties regarding the selection of patients more likely to benefit, dosage and duration of therapy, and effects on outcome. Data on elderly patients undergoing non cardiac surgery are scarce. Accordingly, a prospective registry enrolling a large number of aged subjects undergoing non cardiac surgery (particularly at high or intermediate risk) should be able to give us adequate insights on the management strategies currently used, on the incidence of death or cardiovascular events in the postoperative period and on the areas of potential improvement in care. Furthermore, the effects on outcome of structured programs of Guidelines implementation in the clinical practice of cardiologists, anesthesiologists and other health personnel involved in perioperative care, could be positive and should be evaluated

Left ventricular systolic dysfunction in chronic kidney disease: from asymptomatic changes in geometry and function to overt heart failure.

A bidirectional relationship between kidney and heart function is present in all stages of cardiac and renal disease, from the asymptomatic phase of left ventricular systolic dysfunction to overt heart failure, as well as from the initial reduction of glomerular filtration rate to end-stage kidney disease, respectively. The simultaneous presence of both diseases has a significant impact on prognosis and requires specific therapeutic strategies. The early recognition of abnormalities of renal and myocardial function may have a relevant influence on management of combination of these conditions

Choosing wisely in cardiology: Five proposals from the Italian Association for Cardiovascular Prevention and Rehabilitation

We do not always accomplish what is best for our patients. Is "more procedures, more drugs" a real synonym of good and always useful medicine? Probably not. Indeed, it has been highlighted that many tests and treatments, widely used in medical practice, do not bring benefits to patients, but they can be harmful. So, why do we keep performing them? Many reasons, surely one of the main is the constant fear of malpractice legal-medical consequences; this led to the development of a defensive medicine, no longer focused on the health of the patient. For this reason, the Italian Association of Cardiac Prevention and Rehabilitation (GICR-IACPR) joined an international project "Choosing Wisely", supported by the Slow Medicine Initiative, a network which states that "Less is more”. The purpose of "Choosing Wisely " project is to improve the quality and safety of health services through the reduction of practices that, according to available scientific knowledge, do not bring significant benefits to the patients, but can, on the contrary, expose them to risks. This GICR-IACPR paper proposes to avoid five widespread practices in cardiology, at risk for inappropriateness and lacking of clinical evidence of benefit: • Do not perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery • Do not perform Computed Tomography for coronary calcium score in patients at high cardiovascular risk • Do not perform Holter electrocardiographic monitoring in patients suffering from syncope, near syncope or dizziness, in whom a non-arrhythmic origin has been documented • Do not routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding prophylaxis in patient with single drug antiplatelet therapy in absence of additional risk factors. • Avoid routine use of infective endocarditis prophylaxis in mild to moderate native valve diseas

Erectile dysfunction and cardiovascular disease: Focus on

Erectile dysfunction (ED) is a common clinical problem and its prevalence increases in frequency with age. ED is a risk marker for major cardiovascular events independently of other more common risk factors in men with and without known cardiovascular disease. On the basis of the “artery-size hypothesis” patients with cardiovascular disease often report ED before disease detection, in average 3 years. Thus, by an early identification of ED, the cardiologist is given a unique opportunity to better assess the cardiovascular risk of each patient. Although there is a general impression that ED has an important predictive role, its diagnosis in clinical practice is widely suboptimal owing to misconceptions from the side of the patient and a suboptimal management of the personal relationship from the side of the physician. This paper explores the critical connection between ED and cardiovascular disease and evaluates how this association may influence clinical practice