Publications by authors named "Domenico Gabrielli"

81 Publications

Post-discharge antithrombotic management and clinical outcomes of patients with new-onset or pre-existing atrial fibrillation and acute coronary syndromes undergoing coronary stenting: Follow-up data of the MATADOR-PCI study.

Eur J Intern Med 2021 Apr 7. Epub 2021 Apr 7.

Division of Cardiology, Garibaldi-Nesima Hospital, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy.

Background: . Patients with concomitant atrial fibrillation (AF) and acute coronary syndromes (ACS) do not seem to receive proper antithrombotic therapies and present high rates of adverse clinical events.

Methods: . We analyzed the follow-up data of the prospective, nationwide MATADOR-PCI registry. We assessed the use of antithrombotic strategies and the incidence of major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) at 6 months, in patients with new-onset or pre-existing AF admitted for ACS and treated with percutaneous coronary intervention (PCI).

Results: . Out of the 588 patients enrolled in the registry and discharged alive (287 with pre-existing and 301 with new-onset AF), data at 6 months were obtained for 579 (98.5%) patients. Compared to hospital discharge, the rate of triple antithrombotic therapy was significantly reduced (from 76.4% to 23.6% and from 53.8% to 23.6%; both p<0.0001) while dual antithrombotic therapy (DAT) increased (from 11.8% to 56.3% and from 5.8% to 30.9%; both p<0.0001) at follow-up, in patients with pre-existing and new-onset AF, respectively. Among patients with a class IA indication to receive oral anticoagulation therapy (OAT), it was prescribed in 91% and 88% of patients with pre-existing and 64% and 62% of new-onset AF, at discharge and follow-up, respectively. At 6 months from discharge the overall rate of MACE was 8.4% and 7.6% (p=0.75), while NACE occurred in 10.8% vs 10.0% (p=0.74) of patients with pre-existing or new-onset AF, respectively.

Conclusions: . At follow-up, DAT was the most used antithrombotic strategy for both patients with pre-existing and new-onset AF with concomitant ACS. These two groups of patients presented comparable rates of MACE and NACE at 6 months.
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http://dx.doi.org/10.1016/j.ejim.2021.03.029DOI Listing
April 2021

[Bempedoic acid: a new therapeutic opportunity for the treatment of hypercholesterolemia].

G Ital Cardiol (Rome) 2021 Apr;22(4):301-310

U.O.C. Cardiologia, Ospedale Civile "Augusto Murri", Fermo.

In the last decades, scientific evidence regarding the key role of cholesterol in atherosclerosis pathogenesis has led to the development of lipid-lowering treatments that can be used in addition to statins or in place of them in case of intolerance. Bempedoic acid represents an effective and safe new therapeutic option in hypercholesterolemia management. Clinical studies have demonstrated that bempedoic acid can significantly reduce low-density lipoprotein cholesterol in several clinical settings. Furthermore, bempedoic acid has also been associated with the improvement of other biomarkers, including reduced apolipoprotein B and high-sensitivity C-reactive protein, effects that can increase the clinical benefits of this treatment.
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http://dx.doi.org/10.1714/3574.35576DOI Listing
April 2021

[Sodium-glucose co-transporter 2 inhibitors: mechanisms of renal action. Implications for diabetes and heart failure].

G Ital Cardiol (Rome) 2021 Apr;22(4):284-291

U.O.C. Cardiologia-UTIC, Ospedale Civile "A. Murri", Fermo.

The liver is not the exclusive site of glucose production in humans in the post-absorption state. Experimental data showed that the kidney is able of carrying out gluconeogenesis. Renal glucose production accounts for 20% of systemic glucose production. Evidence indicates that the kidney is able to reabsorb glucose from the glomerular filtrate through the sodium-glucose co-transporters (SGLT) 1 and 2 placed under the Bowman's capsule, in the thick portion of the proximal convoluted tubule, preserving this essential energy substrate for the organism. The maximal renal glucose reabsorption capacity (TmG), as well as the threshold for the spillover of glucose in the urine, are higher in diabetics than normal subjects and contribute to the hyperglycemic state in the absence of glycosuria. The administration of SGLT2 inhibitors in diabetics improves the excretion of sodium and glucose, reducing the threshold of glycosuria and TmG. This also restores the sodium concentration in the filtrate that reaches the macula densa (juxtaglomerular apparatus), which signals the appropriate perfusion of the kidney, defusing the secretion of renin and the activation of the neurohormonal axis that leads to the production of angiotensin II.Large clinical trials conducted with SGLT2 inhibitors in subjects with type 2 diabetes mellitus have demonstrated the great ability of this new class of drugs to achieve cardiac and renal benefits. All studies have shown SGLT2 inhibitors reduce the risk of hospitalizations for heart failure and the progression of kidney damage. A part of the favorable mechanisms is mediated by the natriuretic effect that is associated with the glycosuric effect, which reduces the activation of the renin-angiotensin-aldosterone system together with glomerular hyperfiltration.The aim of this review is to expand the knowledge among general cardiologists on the role of SGLT2 and SGLT1 in renal glucose homeostasis in healthy and diabetic subjects in the light of a potent class of drugs counteracting heart failure.
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http://dx.doi.org/10.1714/3574.35574DOI Listing
April 2021

[Cardiology units and organizational models of heart transplantation centers in Italy: a survey by the Italian Association of Hospital Cardiologists-Italian Society of Organ Transplantation (ANMCO-SITO)].

G Ital Cardiol (Rome) 2021 Mar;22(3):239-243

U.O. Cardiologia, ASUR Marche, Area Vasta 4, Ospedale Civile "Augusto Murri", Fermo.

Background: The extent and quality of the involvement of cardiology units in health programs delivered by Italian centers for heart transplantation (HTx) have not been investigated previously.

Methods: The Italian Association of Hospital Cardiologists (ANMCO) and the Italian Society for Organ Transplantation (SITO) developed and delivered a nationwide survey to the Directors of the Italian centers for HTx to investigate the extent to which cardiology units contribute to HTx programs. The survey investigated: (i) the organization of the centers and institutional frame under which cardiology units contributed to HTx programs; (ii) the volumes of procedures and clinical services delivered by cardiology units to HTx centers for listing patients, following those waiting for HTx, managing acute heart failure, selecting and allocating organs to recipients, following and managing organ rejection after HTx.

Results: Of the 14 Italian centers involved, 13 provided full responses to the survey. Between 2017-2019, on average, 46% of the respondents performed up to 15 HTx/year, and additional 46% performed between 16 and 30 HTx/year. Of the respondents, 62% were included in a department of cardiac Surgery which did not include a cardiology unit; furthermore, 54% declared not to be included in a formal network for heart failure management. Cardiology units were the source for referrals of candidates to HTx in 85% cases. Of the respondents, 15% declared to be able to provide cardiological services thorough intra-center multidisciplinary team including cardiologists, whereas cardiological services were outsourced in 61% of the respondents. The clinical follow-up of patients waiting for HTx was performed directly by surgeons in 38% of the respondents. Worsening heart failure was managed directly by the HTx center in 33% of the cases using dedicated beds. Post-HTx follow-up, including endomyocardial biopsy, involved external cardiology units in less than 25% of the centers.

Conclusions: The ANMCO-SITO survey shows that in Italy a very wide variability exists in terms of organization of HTx centers and their relationships with cardiology units for delivering specific cardiological services and procedures. In large majority, patient referral to HTx centers is mediated by cardiology units, whereas HTx was rarely included in a structured cardiological network for heart failure management.
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http://dx.doi.org/10.1714/3557.35344DOI Listing
March 2021

Non-high-density lipoprotein cholesterol versus low-density lipoprotein cholesterol in clinical practice: ANMCO position paper.

J Cardiovasc Med (Hagerstown) 2021 Mar 1. Epub 2021 Mar 1.

Clinical and Rehabilitative Cardiology Unit, San Filippo Neri Hospital ASL Roma 1, Rome Department of Translational and Precision Medicine, Sapienza University of Roma, Rome U.O.C. Cardiologia-UTIC, San Paolo Hospital, Bari Cardilogy-Intensive Care Unit, Ospedali di Città di Castello e Gubbio - Gualdo Tadino, Azienda USL Umbria 1, Perugia Cardiology Department, Le Scotte University Hospital, Siena Cardiology Unit, Bellaria Hospital, AUSL of Bologna, Bologna Cardiology Unit, Ospedale Santa Maria della Misericordia, Rovigo Cardilogy-Intensive Care Unit, Santa Maria degli Ungheresi Hospital, Polistena, Reggio Calabria Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome Cardiology Unit 2, ASST Grande Ospedale Metropolitano Niguarda Cà Granda, Milan Cardiology Unit, ASL 3, Ospedale Padre A. Micone, Genova Cardiology Division, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione 'Garibaldi' Catania, Catania Cardilogy Unit, Presidio Molinette, A.O.U. Città della Salute e della Scienza di Torino, Torino Cardiologia-UTIC-Emodinamica, Ospedale del Mare, Napoli Cardiovascular Center, University Hospital and Health Services of Trieste, Trieste Presidente Fondazione per il Tuo cuore, Heart Care Foundation, Florence Division of Cardiology, Augusto Murri Hospital, Fermo, Italy.

Bloodstream cholesterol is a central contributor to atherosclerotic cardiovascular diseases. For several decades, low-density lipoprotein cholesterol (LDL-C) has been the main biomarker for the prediction of cardiovascular events and therapeutic target of lipid-lowering treatments. More recently, several findings have supported the greater reliability of non-high-density lipoprotein cholesterol (non-HDL-C) as a predictive factor and possible therapeutic target in refining antiatherogenic treatments, especially among patients with lower LDL-C and higher triglyceride values. This article discusses the limits of current standard methods for assessing LDL-C levels and emphasizes the persistent residual cardiovascular risk in patients treated with lipid-lowering agents on the basis of recommended LDL-C targets. It highlights that patients with controlled LDL-C and non-targeted non-HDL-C have a higher cardiovascular risk. The article focuses on the role of non-HDL-C as a better predictor of atherosclerotic disease as compared with LDL-C and as a therapeutic target. Finally, this article includes an executive summary aimed at refining preventive approaches in atherosclerotic cardiovascular disease.
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http://dx.doi.org/10.2459/JCM.0000000000001175DOI Listing
March 2021

Spontaneous coronary artery dissection: Overview of pathophysiology.

Trends Cardiovasc Med 2021 Jan 14. Epub 2021 Jan 14.

U.O.C. Cardiologia Clinica e Riabilitativa, San Filippo Neri Hospital, ASL Roma 1, via Martinotti 20, 00135 Rome, Italy.

The growing use of imaging examinations has led to increased detection of spontaneous coronary artery dissection (SCAD) as a non-atherosclerotic cause of acute coronary syndrome (ACS). Since a greater awareness of pathophysiologic mechanisms has relevant implications in clinical practice, we aim to provide an update to current knowledge of SCAD pathophysiology. We discuss the most common conditions associated with SCAD, including predisposing factors and triggers, and focus on potential mechanisms leading to SCAD development. Furthermore, we report the main genetic research findings that have shed further light on SCAD pathophysiology. Finally, we summarize practical considerations in SCAD management based on pathophysiologic insights.
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http://dx.doi.org/10.1016/j.tcm.2021.01.002DOI Listing
January 2021

Impact of history of depression on 1-year outcomes in patients with chronic coronary syndromes: An analysis of a contemporary, prospective, nationwide registry.

Int J Cardiol 2021 May 8;331:273-280. Epub 2021 Jan 8.

Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy; Heart Care Foundation, Firenze, Italy.

Background: Depression is common in patients with acute cardiovascular conditions and it is associated with adverse clinical events.

Methods: Using the data from a nationwide, prospective registry on patients with chronic coronary syndromes (CCS), we assessed the impact of depression on major adverse cardiovascular events (MACE), a composite of all-cause death and hospitalization for myocardial infarction, revascularization, heart failure or stroke, and quality of life (QoL) at 1-year follow-up.

Results: From the 5070 consecutive CCS patients enrolled in the registry, 531 (10.5%) presented a history of depression and the remaining 4539 (89.5%) did not. At 1 year (median 369; IQR 362-378 days) from enrolment, the incidence of the primary composite outcome was 9.8% for patients with a history of depression and 7.2% for non-depressed patients (p = 0.03). Patients with history of depression had a significantly higher rate of all-cause mortality (3.0% vs 1.4%; p = 0.004) and hospital admission for heart failure (3.4% vs 1.3%; p = 0.0002) compared to the group without depression. However, history of depression did not result as an independent predictor of MACE at multivariable analysis [hazard ratio 1.17, 95% confidence interval (0.87-1.58), p = 0.31]. Depressed patients had worse QoL according to all domains of the EQ. 5D-5L questionnaire as compared to non-depressed patients (all p < 0.001), at both enrolment and follow-up.

Conclusions: In this contemporary, large cohort of consecutive patients with CCS, patients with a history of depression experienced a two-fold rate of mortality, a higher incidence of MACE and a worse QoL at 1-year follow-up, compared to non-depressed patients.
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http://dx.doi.org/10.1016/j.ijcard.2020.12.086DOI Listing
May 2021

Antithrombotic management of patients with acute coronary syndrome and atrial fibrillation undergoing coronary stenting: a prospective, observational, nationwide study.

BMJ Open 2020 12 22;10(12):e041044. Epub 2020 Dec 22.

Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy.

Objective: The aim of the study was to assess current management of patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) undergoing coronary stenting.

Design: Non-interventional, prospective, nationwide study.

Setting: 76 private or public cardiology centres in Italy.

Participants: Patients with ACS with concomitant AF undergoing percutaneous coronary intervention (PCI).

Primary And Secondary Outcome Measures: To obtain accurate and up-to-date information on pharmacological management of patients with AF admitted for an ACS and undergoing PCI with stent implantation.

Results: Over a 12-month period, 598 consecutive patients were enrolled: 48.8% with AF at hospital admission and 51.2% developing AF during hospitalisation. At discharge, a triple antithrombotic therapy (TAT) was prescribed in 64.8%, dual antiplatelet therapy (DAPT) in 25.7% and dual antithrombotic therapy (DAT) in 8.8% of patients. Among patients with AF at admission, TAT and DAT were more frequently prescribed compared with patients with new-onset AF (76.3% vs 53.8% and 12.5% vs 5.3%, respectively; both p<0.0001), while a DAPT was less often used (11.2% vs 39.5%; p<0.0001). At multivariable analysis, a major bleeding event (OR: 5.40; 95% CI: 2.42 to 12.05; p<0.0001) and malignancy (OR: 5.11; 95% CI: 1.77 to 14.78; p=0.003) resulted the most important independent predictors of DAT prescription.

Conclusions: In this contemporary registry of patients with ACS with AF treated with coronary stents, TAT still resulted as the antithrombotic strategy of choice, DAT was reserved for high bleeding risk and DAPT was mainly prescribed in those developing AF during hospitalisation.

Trial Registration Number: NCT03656523.
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http://dx.doi.org/10.1136/bmjopen-2020-041044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757435PMC
December 2020

Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO).

Eur J Intern Med 2021 Mar 2;85:1-13. Epub 2020 Dec 2.

Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste, Italy.

Aspirin and P2Y receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.
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http://dx.doi.org/10.1016/j.ejim.2020.11.014DOI Listing
March 2021

[ANMCO/SIC Consensus document on the management of myocarditis].

G Ital Cardiol (Rome) 2020 Dec;21(12):969-989

S.C. Cardiologia, Dipartimento Cardiotoracovascolare, Azienda Sanitaria Universitaria Giuliano Isontina-ASUGI, Università di Trieste.

Myocarditis is an inflammatory heart disease that can occur acutely, as in acute myocarditis, or persistently, as in chronic myocarditis or chronic inflammatory cardiomyopathy. Different agents can induce myocarditis, with viruses being the most common triggers. Generally, acute myocarditis affects relatively young people and men more than women. Myocarditis has a broad spectrum of clinical presentations and evolution trajectories, although most cases resolve spontaneously. Patients with reduced left ventricular ejection fraction, heart failure symptoms, advanced atrioventricular block, sustained ventricular arrhythmias or cardiogenic shock (the latter known as fulminant myocarditis) are at increased risk for death and heart transplantation. The presentation of chronic inflammatory cardiomyopathy may be more subtle, with progressive symptoms of heart failure or appearance of rhythm disturbance, not rarely preceded by an infective episode. Autoimmune disorder or systemic inflammatory conditions can be another significant predisposing substrate of myocarditis, especially in women. Emerging causes of myocarditis are drug-related like the new anticancer therapies, the immune checkpoint inhibitors. In this Italian Association of Hospital Cardiologists (ANMCO) and Italian Society of Cardiology (SIC) expert consensus document on myocarditis, we propose diagnostic strategies for identifying possible causes of the disease and factors associated with increased risk. Finally, we propose potential treatments and when referring patients to tertiary centers, especially for high-risk patients. Even if endomyocardial biopsy is the invasive diagnostic tool for making definitive diagnosis and differentiation of histological subtypes (i.e., lymphocytic vs eosinophilic vs giant cell myocarditis), it is not always readily available in all centers. Thus, we propose when this exam is mandatory or when it can be postponed or substituted by cardiac magnetic resonance imaging. This document reflects the Italian perspective on managing patients with myocarditis and their follow-up, considering also current US and European scientific position statements.
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http://dx.doi.org/10.1714/3472.34551DOI Listing
December 2020

Risk stratification and secondary prevention post-myocardial infarction: insights from the EYESHOT Post-MI study.

J Cardiovasc Med (Hagerstown) 2020 Oct 29. Epub 2020 Oct 29.

Division of Cardiology, Augusto Murri Hospital, Fermo, Italy.

Background: Clinical management of patients more than 1 year after acute myocardial infarction (MI) is challenging. Patient risk stratification may help to establish therapeutic priorities. We aimed to describe the comprehensive risk profile and management of patients with prior MI.

Methods: We analyzed data from the EYESHOT Post-MI study, which evaluated the management of patients 1-3 years after MI. The risk profile of participants was defined according to the qualifying high-risk features of the PEGASUS-TIMI 54 trial (history of diabetes, history of recurrent MI, angiographic evidence of multivessel coronary disease, chronic kidney disease with estimated glomerular filtration rate <60 ml/min, age ≥65 years). Patients were classified into five subgroups according to the presence of zero, one, two, three, or more than three features.

Results: Of the 1633 patients in the EYESHOT Post-MI study, 1008 could be stratified according to PEGASUS-TIMI 54 high-risk features. About 22% of patients had no high-risk features, whereas 25% showed at least three features. The prevalence of patients with specific clinical severity indicators was progressively higher with the increasing number of high-risk features. Dual antiplatelet therapy and oral anticoagulation were more frequently used in patients with an increasing number of high-risk features (P for trend <0.0001). Lipid-lowering therapies were less frequently prescribed in patients with a higher number of features (P for trend 0.006 for statins; P for trend 0.007 for ezetimibe).

Conclusion: Higher-risk post-MI patients, identified by PEGASUS-TIMI 54 high-risk features, showed an increased prevalence of major clinical severity indicators. Secondary prevention therapies were not adequately implemented in higher-risk patients.
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http://dx.doi.org/10.2459/JCM.0000000000001132DOI Listing
October 2020

The Italian National Association of Hospital Cardiologists and ESC look ahead to young cardiologists.

Eur Heart J 2021 Jan;42(1):12-13

ANMCO President, Division of Cardiology, Augusto Murri Hospital, Fermo, Ancona, Italy.

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http://dx.doi.org/10.1093/eurheartj/ehaa917DOI Listing
January 2021

Temporal Trends in Invasive Management and In-Hospital Mortality of Patients With Non-ST Elevation Acute Coronary Syndromes and Chronic Kidney Disease.

Angiology 2021 03 6;72(3):236-243. Epub 2020 Oct 6.

Division of Cardiology, Ospedale A. Manzoni, Lecco, Italy.

We analyzed data from 4 nationwide prospective registries of consecutive patients with acute coronary syndromes (ACS) admitted to the Italian Intensive Cardiac Care Unit network between 2005 and 2014. Out of 26 315 patients with ACS enrolled, 13 073 (49.7%) presented a diagnosis of non-ST elevation (NSTE)-ACS and had creatinine levels available at hospital admission: 1207 (9.2%) had severe chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <30), 3803 (29.1%) mild to moderate CKD (eGFR 31-59), and 8063 (61.7%) no CKD (eGFR > 60 mL/min/1.73 m). Patients with severe CKD had worse clinical characteristics compared with those with mild-moderate or no kidney dysfunction, including all the key predictors of mortality ( < .0001) which became worse over time (all < .0001). Over the decade of observation, a significant increase in percutaneous coronary intervention rates was observed in patients without CKD ( for trend = .0001), but not in those with any level of CKD. After corrections for significant mortality predictors, severe CKD (odds ratio, OR: 5.49; 95% CI: 3.24-9.29; < .0001) and mild-moderate CKD (OR: 2.33; 95% CI: 1.52-3.59; < .0001) remained strongly associated with higher in-hospital mortality. The clinical characteristics of patients with NSTE-ACS and CKD remain challenging and their mortality rate is still higher compared with patients without CKD.
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http://dx.doi.org/10.1177/0003319720962676DOI Listing
March 2021

Pathophysiology and management of recreational drug-related acute coronary syndrome: ANMCO position statement.

J Cardiovasc Med (Hagerstown) 2021 Feb;22(2):79-89

U.O.C. Cardiologia Clinica e Riabilitativa, P.O San Filippo Neri - ASL Roma1, Rome.

Recreational drug use may cause coronary artery disease through several mechanisms. An increasing number of young patients with drug-related acute coronary syndrome have been reported over recent years. The present position statement reports the most recent epidemiological data on acute coronary syndrome in the setting of drug abuse, describes the main pathophysiological mechanisms underlying coronary artery disease and acute events in these patients, and provides practical recommendations on management and an overview of prognosis.
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http://dx.doi.org/10.2459/JCM.0000000000001091DOI Listing
February 2021

Updated clinical evidence and place in therapy of bempedoic acid for hypercholesterolemia: ANMCO position paper.

J Cardiovasc Med (Hagerstown) 2021 Mar;22(3):162-171

Division of Cardiology, Augusto Murri Hospital, Fermo, Ancona, Italy.

The central role of high low-density lipoprotein cholesterol levels in atherosclerotic cardiovascular disease has led to research focused on lipid-lowering agents for cardiovascular risk reduction. Bempedoic acid is an emerging treatment for hypercholesterolemia that has recently been approved for marketing in the United States and Europe. This review focuses on its mechanism of action and summarizes the main preclinical study findings. Furthermore, we report the clinical evidence supporting and guiding its use in hypercholesterolemia management.
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http://dx.doi.org/10.2459/JCM.0000000000001108DOI Listing
March 2021

External applicability of the ISCHEMIA trial: an analysis of a prospective, nationwide registry of patients with stable coronary artery disease.

EuroIntervention 2020 Dec 18;16(12):e966-e973. Epub 2020 Dec 18.

Division of Cardiology, A. O. San Camillo-Forlanini, Roma, Italy.

Aims: We sought to assess the proportion of patients eligible for the ISCHEMIA trial and to compare the characteristics and outcomes of these patients with those without ISCHEMIA inclusion or with ISCHEMIA exclusion criteria in a contemporary, nationwide cohort of patients with stable coronary artery disease (CAD).

Methods And Results: Among the 5,070 consecutive patients enrolled in the START registry, 4,295 (84.7%) did not fulfil the inclusion criteria (ISCHEMIA-Not Included or ISCHEMIA-Unclassifiable), 582 (11.5%) had exclusion criteria (ISCHEMIA-Excluded), and the remaining 193 (3.8%) were classified as ISCHEMIA-Like. At one year, the incidence of the primary outcome, a composite of death from cardiovascular (CV) causes, myocardial infarction (MI), or hospitalisation for unstable angina and heart failure, was 0.5% in the ISCHEMIA-Like versus 3.3% in other patients (p=0.03). The composite secondary outcome of CV mortality and MI occurred in 0.5% of the ISCHEMIA-Like patients and in 1.4% of the remaining patients (p=0.1).

Conclusions: In a contemporary real-world cohort of stable CAD patients, only 4% resulted in being eligible for the ISCHEMIA trial. These patients presented an extremely low annual risk of adverse events, especially when compared with other groups of stable CAD patients. Visual summary. Proportion of patients with stable CAD enrolled in the START registry with or without ISCHEMIA criteria and their rate of MACE at 1 year.
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http://dx.doi.org/10.4244/EIJ-D-20-00610DOI Listing
December 2020

Prevalence and Predictors of Out-of-Target LDL Cholesterol 1 to 3 Years After Myocardial Infarction. A Subanalysis From the EYESHOT Post-MI Registry.

J Cardiovasc Pharmacol Ther 2021 Mar 6;26(2):149-157. Epub 2020 Aug 6.

Division of Cardiology, A.O. San Camillo-Forlanini, Roma, Italy.

Background: There is an incomplete understanding of the prevalence and predictors of attainment of low-density lipoprotein cholesterol (LDL-C) goal after myocardial infarction (MI).

Aim: To evaluate the prevalence of achievement of LDL-C goal of 70 mg/dL, to identify the baseline features associated with suboptimal lipid control, and to assess the use of LDL-C-lowering drug therapies (LLT) beyond the first year after MI.

Methods: The EYESHOT Post-MI was a prospective, cross-sectional, Italian registry, which enrolled patients presenting to cardiologist 1 to 3 years after MI. In this retrospective post-hoc analysis, patients were categorized in 2 groups according to the achievement or not of the LDL-C goal of 70 mg/dL. Univariable and multivariable logistic regression analyses were performed to identify the baseline features associate with LDL-C≥70 mg/dL.

Results: The study population included 903 patients (mean age 65.5 ± 11.5 years). Among them, LDL-C was ≥70 mg/dL in 474 (52.5%). Male sex ( = 0.031), hypertension ( = 0.024), prior percutaneous coronary intervention ( = 0.016) and high education level ( = 0.008) were higher in the LDL-C <70 group. At multivariable analysis, low education level was an independent predictor of LDL-C≥70 mg/dL (OR:1.582; 95%CI, 1.156-2.165; = 0.004). Conversely, hypertension increased the probability to achieve the LDL-C goal (OR:0.650; 95%CI, 0.443-0.954; = 0.028). Among off-target patients, LLT was not modified in the majority of cases (67.3%), intensified in 85 (18.6%), and actually reduced in 63 patients (13.8%).

Conclusions: In patients presenting to cardiologists 1 to 3 years from the last MI event, LDL-C is not under control in a large proportion of patients, particularly in those with a low education level or without hypertension. LLT is underused in this very-high-risk setting.
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http://dx.doi.org/10.1177/1074248420947633DOI Listing
March 2021

Evidence on clinical relevance of cardiovascular risk evaluation in the general population using cardio-specific biomarkers.

Clin Chem Lab Med 2020 Jul 21;59(1):79-90. Epub 2020 Jul 21.

Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, Padova, Italy.

In recent years, the formulation of some immunoassays with high-sensitivity analytical performance allowed the accurate measurement of cardiac troponin I (cTnI) and T (cTnT) levels in reference subjects. Several studies have demonstrated the association between the risk of major cardiovascular events and cardiac troponin concentrations even for biomarker values within the reference intervals. High-sensitivity cTnI and cTnT methods (hs-cTn) enable to monitor myocardial renewal and remodelling, and to promptly identify patients at highest risk ofheart failure. An early and effective treatment of individuals at higher cardiovascular risk may revert the initial myocardial remodelling and slow down heart failure progression. Specific clinical trials should be carried out to demonstrate the efficacy and efficiency of the general population screening by means of cost-benefit analysis, in order to better identify individuals at higher risk for heart failure (HF) progression with hs-cTn methods.
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http://dx.doi.org/10.1515/cclm-2020-0310DOI Listing
July 2020

[Proposal for a standardized discharge letter after hospital stay for acute pulmonary embolism].

G Ital Cardiol (Rome) 2020 Aug;21(8):607-618

U.O. Cardiologia, Ospedale Civile "Augusto Murri", Fermo.

Pulmonary embolism represents the third leading cause of cardiovascular mortality in developed countries. It requires, in most cases, hospital treatment and always a structured follow-up program. Therefore, at the time of discharge, the communication and the transfer of information from the specialist to the general practitioner, through the discharge letter, represents a crucial opportunity. The aim is to improve the quality of the transmitted content, including information regarding initial assessment, procedures during hospitalization, residual risks, discharge treatments, therapeutic goals and follow-up plan in accordance with the latest guidelines. The discharge letter after hospitalization for pulmonary embolism must include personalized information, especially regarding the anticoagulant regimen in the specific onset setting. Finally, the follow-up program should be accurately described. A standardized discharge letter template, accompanied by some final notes addressed to the general practitioner and patient, could represent a useful tool to improve the quality and time of transmission of information between health professionals after pulmonary embolism.
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http://dx.doi.org/10.1714/3405.33895DOI Listing
August 2020

[ANMCO Position paper: Pulmonary circulation diseases and COVID-19].

G Ital Cardiol (Rome) 2020 Aug;21(8):575-583

U.O. Cardiologia, Ospedale Civile "Augusto Murri", Fermo.

The new coronavirus disease 2019 (COVID-19), which is causing hundreds of thousands of deaths worldwide, is complex and can present with a multi-organ localization. One of its worst complications is an interstitial pneumonia with acute respiratory failure also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which requires non-invasive or invasive ventilation. A severe coagulopathy with poor prognosis is found in 5-10% of cases. SARS-CoV-2 is manifesting as a multi-dimensional disease and, recently, unique co-existing pathophysiological and clinical aspects are being defined: (i) an increased immune and inflammatory response with the activation of a cytokine storm and consequent coagulopathy, which promote both venous thromboembolic events and in situ thrombosis localized in small arterioles and pulmonary alveolar capillaries; (ii) a high intrapulmonary shunt, which often accounts for the severity of respiratory failure, due to reduced hypoxic pulmonary vasoconstriction with pulmonary neo-angiogenetic phenomena. Furthermore, the high incidence of venous thromboembolism in COVID-19 patients admitted to the intensive care unit and the autoptic findings of in situ micro-thrombosis at the pulmonary vascular level, suggest that in this disease coagulopathy, unlike septic disseminated intravascular coagulation, is driven towards a hyper-thrombogenic state, giving rise to a debate (with ongoing studies) about the preventive use of anticoagulant doses of heparin to reduce mortality. The aim of this position paper from the Italian Association of Hospital Cardiologists (ANMCO) is to highlight the main implications that COVID-19 infection has on the pulmonary circulation from a pathophysiological, clinical and management point of view.
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http://dx.doi.org/10.1714/3405.33888DOI Listing
August 2020

[Being cardiologist at the time of SARS-CoV-2: what do not forget during the post-pandemic phase?]

G Ital Cardiol (Rome) 2020 Aug;21(8):565-569

U.O. Cardiologia, Ospedale Civile Augusto Murri, Fermo.

In Italy, the epidemic explosion stage of COVID-19 seems to have been overcome; however, the virus has not been eradicated and the re-emergence of some outbreaks of infection substantiates the danger that the disease may persist. It is therefore necessary to keep the level of surveillance high, to maintain social distancing measures and to act in the control of disease risk factors of a serious or complicated course. Among the risk factors of severe COVID-19 in addition to age, male gender, hypertension and cardiovascular diseases, a major role seems to be played by other cardiovascular risk factors conditioned by an unhealthy lifestyle such as obesity, metabolic syndrome, diabetes and smoking. The new phase requires the maintenance of measures that avoid crowding and close interpersonal contact especially during exercise, in addition to controlled access to hospitals. This will require the reorganization of the traditional methods of cardiovascular prevention and rehabilitation activities, such as gyms and collective educational sessions, and the dilution of outpatient checks. The risk that this scenario may worsen the already suboptimal control of cardiovascular risk factors is therefore real. We do not currently know how long this new phase will last, therefore it is necessary to give impetus to new tele-health initiatives to stimulate the adoption of a healthy lifestyle in primary prevention and tele-monitoring and tele-rehabilitation programs in secondary prevention.
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http://dx.doi.org/10.1714/3405.33886DOI Listing
August 2020

Association of high-risk coronary atherosclerosis at CCTA with clinical and circulating biomarkers: Insight from CAPIRE study.

J Cardiovasc Comput Tomogr 2021 Jan-Feb;15(1):73-80. Epub 2020 Jun 11.

Heart Care Foundation Onlus, Florence, Italy.

Background: High-risk coronary atherosclerosis features evaluated coronary CT angiography (CCTA) were suggested to have a prognostic role. The present study aimed to evaluate the association of circulating biomarkers with high-risk plaque features assessed by CCTA.

Methods: A consecutive cohort of subjects who underwent CCTA because of suspected CAD was screened for inclusion in the CAPIRE study. Based on risk factors (RF) burden patients were defined as having a low clinical risk (0-1 RF with the exclusion of patients with diabetes mellitus as single RF) or an high clinical risk (≥3 RFs). In all patients, measurement of inflammatory biomarkers and CCTA analysis focused on high-risk plaque features were performed. Univariate and multivariate logistic regression analysis were used to evaluate the relationship between clinical and biological variables with CCTA advanced plaque features.

Results: 528 patients were enrolled in CAPIRE study. Older age and male sex appeared to be predictors of qualitative high-risk plaque features and associated with the presence of elevated total, non-calcified and low-attenuation plaque volume. Among circulating biomarkers only hs-CRP was found to be associated with qualitative high-risk plaque features (OR 2.02, p = 0.004 and 2.02, p = 0.012 for LAP and RI > 1.1, respectively) with borderline association with LAP-Vol (OR 1.52, p = 0.076); HbA1c and PTX-3 resulted to be significantly associated with quantitative high-risk plaque features (OR 1.71, p = 0.003 and 1.04, p = 0.002 for LAP-Vol, respectively).

Conclusions: Our results support the association between inflammatory biomarkers (hs-CRP, PTX- 3), HbA1c and high-risk atherosclerotic features detected by CCTA. Male sex and older age are significant predictors of high-risk atherosclerosis.
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http://dx.doi.org/10.1016/j.jcct.2020.03.005DOI Listing
April 2021

COMPASS criteria applied to a contemporary cohort of unselected patients with stable coronary artery diseases: insights from the START registry.

Eur Heart J Qual Care Clin Outcomes 2020 Jun 19. Epub 2020 Jun 19.

Division of Cardiology, Azienda Ospedaliera G. Rummo, Benevento.

Background: Recently, the COMPASS trial demonstrated that dual therapy reduced cardiovascular outcomes compared with aspirin alone in patients with stable atherosclerotic disease.

Methods And Results: We sought to assess the proportion of patients eligible for the COMPASS trial and to compare the epidemiology and outcome of these patients with those without COMPASS inclusion or with any exclusion criteria in a contemporary, nationwide cohort of patients with stable coronary artery disease (CAD).Among the 4068 patients with detailed information allowing evaluation of eligibility, 1416 (34.8%) did not fulfill the inclusion criteria (COMPASS-Not-Included), 841 (20.7%) had exclusion criteria (COMPASS-Excluded) and the remaining 1811 (44.5%) were classified as COMPASS-Like. At 1 year, the incidence of major adverse cardiovascular event (MACE), a composite of cardiovascular death, myocardial infarction and stroke, was 0.9% in the COMPASS-Not-Included and 2.0% in the COMPASS-Like (p = 0.01), and 5.0% in the COMPASS-Excluded group (p < 0.0001 for all comparisons). Among the COMPASS-Like population, patients with multiple COMPASS enrichment criteria presented a significant increase in the risk of MACE (from 1.0% to 3.3% in those with 1 and ≥3 criteria, respectively; p = 0.012), and a modest absolute increase in major bleeding risk (from 0.2% to 0.4%, respectively; p = 0.46).

Conclusions: In a contemporary real-world cohort registry of stable CAD, most patients resulted as eligible for the COMPASS. These patients presented a considerable annual risk of MACE that consistently increases in the presence of multiple risk factors.
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http://dx.doi.org/10.1093/ehjqcco/qcaa054DOI Listing
June 2020

Acute coronary syndromes in cancer patients.

J Cardiovasc Med (Hagerstown) 2020 Dec;21(12):944-952

Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

: Cardiovascular disease and cancer are responsible for the majority of deaths in the Western world. These two entities share common risk factors and their intersection will be more and more frequent in future due to general population aging and long-term cancer control. Clinical presentation, management and outcome of acute coronary syndromes (ACS) in cancer patients could differ from noncancer ones. Cancer patients were frequently excluded from clinical trials and so the paucity of data further complicates the scenario. The management of ACS in cancer patients represents a unique setting in which the risk/benefit ratio of invasive treatment should be carefully evaluated. This review focused on the available evidence of all aspects of ACS in cancer patients providing a guide to a multidisciplinary approach.
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http://dx.doi.org/10.2459/JCM.0000000000000993DOI Listing
December 2020

Current lipid lowering treatment and attainment of LDL targets recommended by ESC/EAS guidelines in very high-risk patients with established atherosclerotic cardiovascular disease: Insights from the START registry.

Int J Cardiol 2020 10 26;316:229-235. Epub 2020 May 26.

Division of Cardiology, S. Filippo Neri Hospital, Roma, Italy.

Background: Current European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidemias have further reduced low density lipoprotein-cholesterol (LDL-C) targets, as compared to the guidelines released in 2016. These targets are particularly restraining for patients at very high risk (VHR).

Methods: Using the data from a nationwide, prospective registry on patients with established atherosclerotic cardiovascular disease (ASCVD), we sought to assess: 1) the contemporary use of conventional cholesterol-lowering therapies and the achievement of LDL-C goals according to previous and current ESC guidelines in subjects at VHR; 2) the proportion of VHR patients potentially eligible for proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) treatment.

Results: Among the 5053 patients with data available, 4751 (94.0%) were deemed as VHR. Among these patients, the mean LDL-C levels were 62.4 ± 47.7 mg/dl at enrollment. A high dose of statin was used in 54.9%, while the association of high dose statin and ezetimibe was prescribed in 4.8% of VHR patients. A target level of LDL-C < 70 mg/dl recommended by 2016 ESC guidelines was reached by 58.1%, while a target of <55 mg/dl and LDL-C reduction ≥50% recommended by 2019 ESC guidelines, would be reached by 3.2% of patients at VHR. Accordingly, 9.4% and 1.4% of VHR patients would be eligible for PCSK9i according to ESC guidelines and Italian regulations, respectively.

Conclusions: In VHR patients enrolled in this large cohort of established ASCVD managed by cardiologists, the lipid management and LDL-C targets attainment is largely suboptimal.
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http://dx.doi.org/10.1016/j.ijcard.2020.05.055DOI Listing
October 2020

High-sensitivity cardiac troponin I and T methods for the early detection of myocardial injury in patients on chemotherapy.

Clin Chem Lab Med 2021 Feb 22;59(3):513-521. Epub 2020 May 22.

Dipartimento di Medicina di Laboratorio, Azienda Ospedaliera Universitaria di Padova, and Dipartimento di Medicina - Università di Padova, Padova, Italy.

Important advances achieved in pharmacological cancer treatment have led progressively to a reduction in mortality from many forms of cancer, and increasing numbers of previously incurable patients can now hope to become cancer-free. Yet, to achieve these improved outcomes a high price has been paid in terms of untoward side effects associated with treatment, cardio-toxicity in particular. Several recent studies have reported that cardiac troponin assay using high-sensitivity methods (hs-cTn) can enable the early detection of myocardial injury related to chemotherapy or abuse of drugs that are potentially cardiotoxic. Several authors have recently suggested that changes in hs-cTn values enable the early diagnosis of cardiac injury from chemotherapy, thus potentially benefitting cancer patients with increased troponin values by initiating early cardioprotective therapy. However, large randomised clinical trials are needed in order to evaluate the cost/benefit ratio of standardised protocols for the early detection of cardiotoxicity using the hs-cTn assay in patients treated with chemotherapy.
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http://dx.doi.org/10.1515/cclm-2020-0362DOI Listing
February 2021

The Combination of Oral Anticoagulant and Antiplatelet Therapies: Stay One Step Ahead.

J Cardiovasc Pharmacol Ther 2020 09 11;25(5):391-398. Epub 2020 May 11.

Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy.

Antithrombotic drugs, which include antiplatelets and anticoagulants, are effective in prevention and treatment of many cardiovascular disorders such as acute coronary syndromes, stroke, and venous thromboembolism and are among the drugs most commonly prescribed worldwide. The advent of direct oral anticoagulants, which are safer alternatives to vitamin K antagonists and do not require laboratory monitoring, has revolutionized the treatment of nonvalvular atrial fibrillation and venous thromboembolism. The combination of oral anticoagulant and antiplatelet therapy is required in many conditions of great clinical impact such as the coexistence of atrial fibrillation and coronary artery disease, with indication to percutaneous coronary intervention. However, strategies that combine anticoagulant and antiplatelet therapies lead to a significant increase in bleeding rates and it is crucial to find the right combination in the single patient in order to optimize the ischemic and bleeding risk. The aim of this review is to explore the evidence and controversies regarding the optimal combination of anticoagulant and antiplatelet therapy through the consideration of past dogmas and new perspectives from recent clinical trials and to propose a tailored therapeutic approach, according to specific clinical scenarios and individual patient characteristics. In particular, we separately explored the clinical settings of stable and acute coronary syndromes and percutaneous revascularization in patients with atrial fibrillation.
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http://dx.doi.org/10.1177/1074248420923528DOI Listing
September 2020