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

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

Management of functional pancreatic neuroendocrine neoplasms

: Functional pancreatic neuroendocrine neoplasms (pNENs) are rare and heterogeneous diseases in terms of both clinical and pathological aspects. These tumors secrete hormones or peptides, which may cause a wide variety of symptoms related to a clinical syndrome. The management of functional pNENs is still challenging for clinicians due to the need to control both tumor growth and specific symptoms. Surgery remains the cornerstone in the management of local disease because it can definitively cure the patient. However, when the disease is not resectable, a broad spectrum of therapeutic options, including locoregional therapy, somatostatin analogs (SSAs), targeted therapies, peptide-receptor radionuclide therapy (PRRT), and chemotherapy, are available. The present review summarizes the main key issues regarding the clinical management of these tumors, providing a specific highlight on their therapeutic approach

Utility and limitations of ejection fraction and of diastolic dysfunction in heart failure patients

The echocardiographic evaluation of left ventricular (LV) systolic function, and especially of ejection fraction (EF) plays a central role in the diagnosis of heart failure (HF) due to its undisputed prognostic value. Limitations of EF are substantially: i) the variability and reproducibility of measurements, and ii) the load-dependence. Measurement of stroke volume, longitudinal function and myocardial strain can overcome the limitations of EF in assessing the contractile reserve of patients with HF and may help to define both the phenotype and prognosis of the disease. The recognition of diastolic dysfunction (mainly by echocardiography) is the pathophysiological basis to make diagnosis of HF with preserved ejection fraction (HFpEF). The limitations are essentially related to its feasibility, since performing a multi-parametric quantitative echocardiographic evaluation, as indicated by the guidelines, may be difficult in clinical practice. Difficulties in method standardization, the poor attitude of cardiologists to test their reproducibility (test-retest, variability) favor the evaluation “at-a-glance” of LV structural and functional LV abnormalities

Il rischio tecnologico in sanità

An overall risk management process in healthcare should involve the evaluating of potential risk related to medical devices and technology. The importance of this analysis is undelined by many legislative measures of both the Italian Country and the European Community. This article describes the importance of a medical devices vigilance system and the analysis that can be conducted to establish the baseline hazards associated with a device, evaluating its potential hazards. To improve patients safety, the risk analysis should include any risks associated with the manufacture and delivery of the device

The study of left ventricular diastolic function by Doppler echocardiography: the essential for the clinician

An abnormal diastolic function of left ventricle represents the main pathophysiological mechanism responsible for different clinical states such as restrictive cardiomyopathy, infiltrative myocardial disease and, specially, diastolic heart failure (also called heart failure with preserved systolic function), which is present in a large number of patients with a clinical picture of pulmonary congestion

Reliability analysis of GEM® Premier™ technology: a multicenter study

This paper describes how specific blood gas analyzer characteristics can support the emerging clinical and organizational user's needs while ensuring patient safety. A oneyear data set from two Italian hospitals was analyzed from 10 different blood gas analyzers. Performance measurements in terms of mean down time (MDT) were calculated to show how technical characteristics declared by the manufacturer compare to the analyzer availability in real clinical settings. Results show a high level of reliability for the analyzed technology, associated with very low MDT of each sensor integrated in the cartridge. Moreover, results show a high level of efficiency in cartridge usage. Such results are consistent with the specification of the GEM® Premier™ maintenance- free technology and are particularly relevant in the point-of-care testing setting.</p

Understanding care relationships in diabetes practice. A psychodynamic interview-based exploratory study

ObjectiveTo explore the subjective experience of physicians working in diabetic settings about their care relationships in order to find some unique clues contributing to physician professional health and capacity to manage patients' adherence.Research design and methodsAn interview-based exploratory study has been carried out involving 18 physicians (77.8% female) with at least 3 years of clinical practice in diabetes care. In-depth interviews about the emotional experience with patients with diabetes were conducted and audio recorded. Interviews transcripts were analyzed through a computer-based text analysis which allowed the identification of thematic domains (Cluster Analysis) and latent factors (Correspondence Analysis) viewed through a psychodynamic and constructivist lens.ResultsSix thematic domains emerged respectively referring to: Concern (8.43%), Control (14.42%), Ambivalence (22.08%), Devotion (22.49%), Guilt (19.29%) and Strive for Achievement (13.30%). Moreover, three latent dimensions were taken into account, which explained 69.20% of data variance: Affect Repression (28.50%), Tendency to Repair (22.70%) and Anxiety Pattern (18.00%).ConclusionsOverall, the results of the present study confirm the challenging nature of diabetes care. In particular, physicians ongoing effort to restore patients' psychological integrity in chronic condition constitute the most novel finding above all. In this regard, the need for emotional labor in physicians' education and training is suggested in order to both prevent burnout symptoms (e.g. depersonalization) and promote shared decision making in care relationships. However, findings should be treated as preliminary given the convenience nature of the sample and its reduced size