Publications by authors named "Giuseppe Boriani"

555 Publications

Echocardiographic Left Ventricular Mass Assessment: Correlation between 2D-Derived Linear Dimensions and 3-Dimensional Automated, Machine Learning-Based Methods in Unselected Patients.

J Clin Med 2021 Mar 19;10(6). Epub 2021 Mar 19.

Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, 41121 Modena, Italy.

A recently developed algorithm for 3D analysis based on machine learning (ML) principles detects left ventricular (LV) mass without any human interaction. We retrospectively studied the correlation between 2D-derived linear dimensions using the ASE/EACVI-recommended formula and 3D automated, ML-based methods (Philips HeartModel) regarding LV mass quantification in unselected patients undergoing echocardiography. We included 130 patients (mean age 60 ± 18 years; 45% women). There was only discrete agreement between 2D and 3D measurements of LV mass (r = 0.662, r = 0.348, < 0.001). The automated algorithm yielded an overestimation of LV mass compared to the linear method (Bland-Altman positive bias of 13.1 g with 95% limits of the agreement at 4.5 to 21.6 g, = 0.003, ICC 0.78 (95%CI 0.68-8.4). There was a significant proportional bias (Beta -0.22, t = -2.9) = 0.005, the variance of the difference varied across the range of LV mass. When the published cut-offs for LV mass abnormality were used, the observed proportion of overall agreement was 77% (kappa = 0.32, < 0.001). In consecutive patients undergoing echocardiography for any indications, LV mass assessment by 3D analysis using a novel ML-based algorithm showed systematic differences and wide limits of agreements compared with quantification by ASE/EACVI- recommended formula when the current cut-offs and partition values were applied.
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http://dx.doi.org/10.3390/jcm10061279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8003438PMC
March 2021

Red blood cell distribution width in patients undergoing transcatheter aortic valve implantation: Implications for outcomes.

Int J Clin Pract 2021 Mar 18:e14153. Epub 2021 Mar 18.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

Background: Red cell distribution width (RDW) is recently emerging as a prognostic indicator in many cardiovascular diseases. However, less is known about its predictive role in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods: We retrospectively included very high-risk patients with severe aortic valve stenosis undergoing TAVI between February 2012 and December 2019. Patients were classified according to RDW tertiles. Our primary endpoint was long-term all-cause mortality. The secondary endpoint was a composite of in-hospital major adverse events as defined by the Valve Academic Research Consortium 2 criteria and/or long-term all-cause mortality.

Results: A total of 424 patients [median age 83.5 years, 52.6% females] were analysed. After a median follow-up of 1.55 years, all-cause mortality was 25.5%. At the multivariate-adjusted Cox regression analysis, patients in the highest RDW tertile were associated with a higher risk for all-cause mortality [hazard ratio [HR] 1.73, 95%confidence interval [CI] 1.02-2.95] compared with the lowest tertile. When considering RDW as a continuous variable, we found an 11% increased risk in overall mortality [HR 1.11, 95% CI 1.00-1.24] for each increased point in RDW. The highest RDW tertile was also independently associated with the occurrence of the composite endpoint [odds ratio [OR] 2.10, 95% CI 1.17-3.76] compared with lower tertiles.

Conclusions: In our cohort, elevated basal RDW values were independent predictors of increased long-term mortality and higher rate of in-hospital adverse events. The inclusion of a routinely available biomarker as RDW, may help the pre-operative risk assessment in potential TAVI candidates and optimise their management.
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http://dx.doi.org/10.1111/ijcp.14153DOI Listing
March 2021

The challenge to improve knowledge on the interplay between subclinical atrial fibrillation, atrial cardiomyopathy, and atrial remodeling.

J Cardiovasc Electrophysiol 2021 Mar 11. Epub 2021 Mar 11.

Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

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http://dx.doi.org/10.1111/jce.14992DOI Listing
March 2021

Clinical Factors Associated with Atrial Fibrillation Detection on Single-Time Point Screening Using a Hand-Held Single-Lead ECG Device.

J Clin Med 2021 Feb 12;10(4). Epub 2021 Feb 12.

Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Sydney 2006, Australia.

Our aim was to assess the prevalence of unknown atrial fibrillation (AF) among adults during single-time point rhythm screening performed during meetings or social recreational activities organized by patient groups or volunteers. A total of 2814 subjects (median age 68 years) underwent AF screening by a handheld single-lead ECG device (MyDiagnostick). Overall, 56 subjects (2.0%) were diagnosed with AF, as a result of 12-lead ECG following a positive/suspected recording. Screening identified AF in 2.9% of the subjects ≥ 65 years. None of the 265 subjects aged below 50 years was found positive at AF screening. Risk stratification for unknown AF based on a CHADSVASc > 0 in males and >1 in females (or CHADSVA > 0) had a high sensitivity (98.2%) and a high negative predictive value (99.8%) for AF detection. A slightly lower sensitivity (96.4%) was achieved by using age ≥ 65 years as a risk stratifier. Conversely, raising the threshold at ≥75 years showed a low sensitivity. Within the subset of subjects aged ≥ 65 a CHADSVASc > 1 in males and >2 in females, or a CHADSVA > 1 had a high sensitivity (94.4%) and negative predictive value (99.3%), while age ≥ 75 was associated with a marked drop in sensitivity for AF detection.
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http://dx.doi.org/10.3390/jcm10040729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917757PMC
February 2021

Sinergy between drugs and devices in the fight against sudden cardiac death and heart failure.

Eur J Prev Cardiol 2021 Mar;28(1):110-123

Centro CardioAritmologico, via Alessandro Poerio 91, 00152, Roma, Italy.

The impact of sudden cardiac death (SCD) in heart failure (HF) patients is important and prevention of SCD is a reasonable and clinically justified endpoint if associated with a reduction in all-cause mortality. According to literature, in HF with reduced ejection fraction, only three classes of agents were found effective in reducing SCD and all-cause mortality: beta-blockers, mineralcorticoid receptor antagonists and, more recently, angiotensin-receptor neprilysin-inhibitors. In the PARADIGM trial that tested sacubitril/valsartan vs. enalapril, the 20% relative risk reduction in cardiovascular deaths obtained with sacubitril/valsartan was attributable to reductions in the incidence of both SCD and death due to HF worsening and this effect can be added to the known positive effect of implantable cardioverter-defibrillators in appropriately selected patients. In order to maximize the implementation of all the available treatments, patients with HF should be included in virtuous networks with a dialogue between all the physician involved, with commitment by all these physicians for appropriate decision-making on application of pharmacological and device treatments according to available evidence, as well as commitment for drug titration before and after device implant, taking advantage from remote monitoring, and with the safety of back up device therapy when indicated. There are potential synergistic effects of drug therapy, with all the therapies acting on neuro-hormonal and sympathetic activation, but specifically with sacubitril/valsartan, and device therapy, in particular cardiac resynchronization therapy, with added incremental benefits on positive cardiac remodelling, prevention of HF progression, and prevention of ventricular tachyarrhythmias.
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http://dx.doi.org/10.1093/eurjpc/zwaa015DOI Listing
March 2021

Anticoagulation in patients with atrial fibrillation and active cancer: an international survey on patient management.

Eur J Prev Cardiol 2020 Sep 3. Epub 2020 Sep 3.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy.

Background: In patients with active cancer and atrial fibrillation (AF) anticoagulation, thrombotic and bleeding risk still entail uncertainty.

Aim: We explored the results of an international survey examining the knowledge and behaviours of a large group of physicians.

Methods And Results: A web-based survey was completed by 960 physicians (82.4% cardiologists, 75.5% from Europe). Among the currently available anticoagulants for stroke prevention in patients with active cancer, direct oral anticoagulants (DOACs) were preferred by 62.6%, with lower values for low molecular weight heparin (LMWH) (24.1%) and for warfarin (only 7.3%). About 46% of respondents considered that DOACs should be used in all types of cancers except in non-operable gastrointestinal cancers. The lack of controlled studies on bleeding risk (33.5% of respondents) and the risk of drug interactions (31.5%) were perceived as problematic issues associated with use of anticoagulants in cancer. The decision on anticoagulation involved a cardiologist in 27.8% of cases, a cardiologist and an oncologist in 41.1%, and a team approach in 21.6%. The patient also was involved in decision-making, according to ∼60% of the respondents. For risk stratification, use of CHA2DS2-VASc and HAS-BLED scores was considered appropriate, although not specifically validated in cancer patients, by 66.7% and 56.4%, respectively.

Conclusion: This survey highlights that management of anticoagulation in patients with AF and active cancer is challenging, with substantial heterogeneity in therapeutic choices. Direct oral anticoagulants seems having an emerging role but still the use of LMWH remains substantial, despite the absence of long-term data on thromboprophylaxis in AF.
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http://dx.doi.org/10.1093/eurjpc/zwaa054DOI Listing
September 2020

Percutaneous pericardiocentesis for pericardial effusion: predictors of mortality and outcomes.

Intern Emerg Med 2021 Feb 22. Epub 2021 Feb 22.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124, Modena, Italy.

Pericardial effusion can dangerously precipitate patient's hemodynamic stability and requires prompt intervention in case of tamponade. We investigated potential predictors of in-hospital mortality, a composite outcome of in-hospital mortality, pericardiocentesis-related complications, and the need for emergency cardiac surgery and all-cause mortality in patients undergoing percutaneous pericardiocentesis. This is an observational, retrospective, single-center study on patients undergoing percutaneous pericardiocentesis (2010-2019). We enrolled 81 consecutive patients. Median age was 71.4 years (interquartile range [IQR] 58.1-78.1 years) and 51 (63%) were male. Most of the pericardiocentesis were performed in an urgency setting (76.5%) for cardiac tamponade (77.8%). The most common etiology was idiopathic (33.3%) followed by neoplastic (22.2%). In-hospital mortality was 14.8% while mortality during follow-up (mean 17.1 months) was 44.4%. Only hemodynamic instability (i.e., cardiogenic shock, hypotension refractory to fluid challenge therapy and inotropes) was associated with in-hospital mortality at the univariate analysis (odds ratio [OR] 7.2; 95% confidence interval [CI] 1.76-29.4). Non-neoplastic/non-idiopathic etiology and hemodynamic instability were associated with the composite outcome of in-hospital mortality, need for emergency cardiac surgery, or pericardiocentesis-related complications (OR 5.75, 95% CI 1.65-20.01, and OR 5.81, 95% CI 2.11-15.97, respectively). Multivariate Cox regression analysis adjusted for possible confounding variables (age, coronary artery disease, and hemodynamic instability) showed that neoplastic etiology was independently associated with medium-term mortality (hazard ratio [HR] 4.05, 95% CI 1.45-11.36). In a real-world population treated with pericardiocentesis for pericardial effusion, in-hospital adverse outcomes and medium-term mortality are consistent, in particular for patients presenting with hemodynamic instability or neoplastic pericardial effusion.
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http://dx.doi.org/10.1007/s11739-021-02642-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898017PMC
February 2021

[Clinical management of older, frail patients with atrial fibrillation. Operative strategies from a multidisciplinary expert group].

G Ital Cardiol (Rome) 2021 Feb;22(2):3-27

Direzione Sanitaria, Azienda USL di Bologna.

Atrial fibrillation (AF) is the most common arrhythmia in elderly people. Older patients with AF have several comorbidities and should be treated with complex therapeutic schemes. Arrhythmia complications are also common at an advanced age. Accordingly, AF can be considered a marker of frailty. Few indications can be found concerning the management of frail older subjects in current guidelines. The Frailty in Atrial Fibrillation Survey Study (FAST) was designed to overcome the gap of knowledge about this extremely vulnerable subset of patients. A multidisciplinary team composed by cardiologists, geriatricians and internists participated in the project. In a first phase, a survey was conducted aiming at clarifying specialty-related differences in definition and oral anticoagulant therapy (OAT) management of frail individuals. In the second phase, specific chapters were prepared about AF and frailty epidemiology, the network for the management of the arrhythmia, the diagnostic strategies for AF (including a minimum data set of tools derived from the geriatric multidimensional assessment), OAT and the choice between a rate or a rhythm control strategy. For each chapter, up-to-date evidence and current guideline recommendations were presented and discussed among the 47 Italian centers participating in the project. In the last phase of FAST, the results of the survey and the final draft of the chapters were merged into the present document. A lack of homogeneity in frailty definition existed. The integration among cardiologists, geriatricians and internists can represent the most effective tool to get through these differences improving the management of frail older patients.
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http://dx.doi.org/10.1714/3547.35222DOI Listing
February 2021

Red cell distribution width: a routinely available biomarker with important clinical implications in patients with atrial fibrillation.

Curr Pharm Des 2021 Feb 11. Epub 2021 Feb 11.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena. Italy.

Red blood cell distribution width (RDW) is an inexpensive marker of anisocytosis, simply available in the standard complete blood cell count. Besides its traditional use in the differential diagnosis of anemias, RDW values reflect abnormalities in erythropoiesis and red blood cell metabolism-related to aging, sex, ethnicity, systemic inflammatory state, and oxidative stress. Thus, higher RDW values are common findings in several acute clinical conditions and chronic diseases. Increasing evidence suggests a prognostic role of higher RDW levels in many cardiovascular diseases. Among them, we aimed to review current literature focusing on the possible relation between RDW and atrial fibrillation (AF). Since aging, inflammation, and atrial substrate remodeling have a well-established role in AF pathogenesis, AF burden and patient prognosis, we analyzed available data exploring the possible use of RDW in identifying patients at higher risk of AF and as a biomarker of worse outcomes for AF patients.
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http://dx.doi.org/10.2174/1381612827666210211125847DOI Listing
February 2021

Worldwide Survey of COVID-19-Associated Arrhythmias.

Circ Arrhythm Electrophysiol 2021 03 7;14(3):e009458. Epub 2021 Feb 7.

Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons (E.J.C., S. Kochav, I.G., A.B., H.G., E.Y.W.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCEP.120.009458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982128PMC
March 2021

Optimized Implementation of cardiac resynchronization therapy - a call for action for referral and optimization of care.

Europace 2021 Feb 5. Epub 2021 Feb 5.

Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heartfailure hospitalization rates and reduces all-cause mortality. Nevertheless, up to two-thirds ofeligible patients are not referred for CRT. Furthermore, post implantation follow-up is oftenfragmented and suboptimal, hampering the potential maximal treatment effect. This jointposition statement from three ESC Associations, HFA, EHRA and EACVI focuses onoptimized implementation of CRT. We offer theoretical and practical strategies to achievemore comprehensive CRT referral and post-procedural care by focusing on four actionabledomains; (I) overcoming CRT under-utilization, (II) better understanding of pre-implantcharacteristics, (III) abandoning the term 'non-response' and replacing this by the concept ofdisease modification, and (IV) implementing a dedicated post-implant CRT care pathway.
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http://dx.doi.org/10.1093/europace/euab035DOI Listing
February 2021

Beyond the 2020 guidelines on atrial fibrillation of the European society of cardiology.

Eur J Intern Med 2021 Jan 28. Epub 2021 Jan 28.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; School of Medicine, University of Belgrade, Belgrade, Serbia.

The most recent atrial fibrillation (AF) guidelines delivered by European Society of Cardiology (ESC) offer an updated approach to AF management, with the perspective of improved characterization of the arrhythmia, the cardiac substrate and the patients profile in terms of associated risk factors and comorbidities. Recommendations were based on careful scrutiny and assessment of all available evidence with the final aim to offer to practitioners a lower level of uncertainty in the complex process of decision making for patients with AF. The 2020 ESC guidelines on AF propose a paradigm shift in the clinical approach to AF patients, moving from a single-domain AF classification to comprehensive characterization of AF patients. Given the complex nature of AF, an integrated holistic management of AF patients is suggested by the guidelines for improving patients outcomes through the formal introduction of the CC (Confirm AF and Characterize AF) to ABC (Atrial fibrillation Better Care) pathway. In line with this concept, these new guidelines underline the importance of a more comprehensive management of AF patients which should not be limited to simply prescribe oral anticoagulation or decide between a rhythm or rate control strategy. Indeed, each step of the ABC pathway represents one of the pivotal pillars in the management of AF and only a holistic approach has the potential to improve patients' outcomes. In this review we will discuss the background that supports some of the new recommendations of 2020 ESC guidelines, with important implications for daily management of AF patients.
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http://dx.doi.org/10.1016/j.ejim.2021.01.006DOI Listing
January 2021

Infective endocarditis with perivalvular abscess complicated by septic embolization with acute ST-segment elevation myocardial infarction and peripheral ischemia.

Int J Cardiol Heart Vasc 2021 Feb 12;32:100711. Epub 2021 Jan 12.

Cardiology Division, Policlinico di Modena, Azienda Ospedaliero-Universitaria di Modena, Largo del Pozzo, 71, 41125 Modena, Italy.

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http://dx.doi.org/10.1016/j.ijcha.2020.100711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811112PMC
February 2021

Inhibition of lysyl oxidase stimulates TGF-β signaling and metalloproteinases-2 and -9 expression and contributes to the disruption of ascending aorta in rats: protection by propylthiouracil.

Heart Vessels 2021 May 19;36(5):738-747. Epub 2021 Jan 19.

Phase I Clinical Trials Unit and Experimental Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Mutations in lysyl oxidase (LOX) genes cause severe vascular anomalies in mice and humans. LOX activity can be irreversibly inhibited by the administration of β-aminoproprionitrile (BAPN). We investigated the mechanisms underlying the damage to the ascending thoracic aorta induced by LOX deficiency and evaluated whether 6-propylthiouracil (PTU) can afford protection in rats. BAPN administration caused disruption of the ascending aortic wall, increased the number of apoptotic cells, stimulated TGF-β signaling (increase of nuclear p-SMAD2 staining), and up-regulated the expression of metalloproteinases-2 and -9. In BAPN-treated animals, PTU reduced apoptosis, p-SMAD2 staining, MMP-2, and -9 expression, and markedly decreased the damage to the aortic wall. Our results suggest that, as in some heritable vascular diseases, enhanced TGF-β signaling and upregulation of MMP-2 and -9 can contribute to the pathogenesis of ascending aorta damage caused by LOX deficiency. We have also shown that PTU, a drug already in clinical use, protects against the effects of LOX inhibition. MMP-2 and -9 might be potential targets of new therapeutic strategies for the treatment of vascular diseases caused by LOX deficiency.
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http://dx.doi.org/10.1007/s00380-020-01750-6DOI Listing
May 2021

Long-term outcomes of postoperative atrial fibrillation following non cardiac surgery: A systematic review and metanalysis.

Eur J Intern Med 2021 Mar 2;85:27-33. Epub 2021 Jan 2.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy. Electronic address:

Background: New-onset atrial fibrillation (AF) in non-cardiac postoperative setting is common and is associated with a high risk of in-hospital mortality and morbidity. The long-term risks of stroke, mortality and AF recurrence rate in patients with postoperative AF (POAF) are unclear.

Methods: We performed a systematic literature review in electronic databases from inception to March 5th, 2020 of studies reporting the incidence of stroke, mortality and AF recurrence in patients with POAF. We confined our analysis to studies with a cohort of at least 150 patients with POAF and with a median follow-up of 12 months as a minimum. Odds Ratios (OR) were pooled using a random-effects model.

Results: Qualitative analysis included 8 studies (7 observational cohort studies and 1 randomized controlled trial) enrolling 3,718,587 patients. Six studies underwent metanalysis comprising 17,684 postoperative patients with POAF and 2,169,248 postoperative patients without POAF. The development of POAF conferred a four-fold increased risk of stroke in the long-term [OR 4.05; 95% confidence interval (CI) 2.91-5.62]. Mortality in the two studies reporting long-term data was higher in patients with POAF compared to those without POAF (OR 3.59; CI 95% 2.84-4.53). Data about recurrence were too heterogeneous to undergo metanalysis.

Conclusions: POAF is associated with a greater risk of stroke and mortality over the long-term period. Studies focusing on AF recurrence are needed to address the perception of POAF as a benign transient entity. The increased mortality risk following POAF should encourage systematic detection and prevention of this arrhythmia.
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http://dx.doi.org/10.1016/j.ejim.2020.12.018DOI Listing
March 2021

Clinical and electrocardiographic characteristics at admission of COVID-19/SARS-CoV2 pneumonia infection.

Intern Emerg Med 2021 Jan 4. Epub 2021 Jan 4.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Di Modena, Largo del Pozzo, 71, 41125, Modena, Italy.

Background: The aim of the present study was to compare clinical and electrocardiographic characteristics of patients with COVID-19 pneumonia in Modena, Emilia Romagna, Italy.

Methods: Patients admitted to the emergency department for suspected COVID-19 pneumonia from March the 16th to April the 15th were enrolled in the study. COVID-19 pneumonia was confirmed by positive nasopharyngeal swab. Primary endpoint was 30-day mortality.

Results: 201 patients were diagnosed with COVID-19 pneumonia. Compared to survivors, patients who died were older (79.7 ± 10.8 vs 65.6 ± 14.1, p < 0.001), with a more complex cardiovascular history, including coronary artery disease (CAD, 33.3% vs 13.3%, p = 0.004), atrial fibrillation (23.8 vs 8.8, p = 0.011) and chronic kidney disease (CKD 35.7% vs 7.0%, p < 0.001). 30-day mortality was 20,9% in these patients; atrial fibrillation (OR 12.74, 95% CI 3.65-44.48, p < 0.001), ST-segment depression (OR 5.30, 95% CI 1.50-18.81, p = 0.010) and QTc-interval prolongation (OR 3.17, 95% CI 1.24-8.10, p = 0.016) at ECG admission were associated to an increased mortality risk. On the contrary, sinus rhythm (OR 0.08, 95% CI 0.02-0.27, p < 0.001) and low-molecular weight heparin (LMWH) administration (OR 0.08, 95% CI 0.02-0.29, p < 0.001) were related to reduced mortality. At multivariate analysis, after adjustment for age, sex, diabetes, CAD, and MCA admission, sinus rhythm (HR 2.7, CI 95% 1.1-7.0, p = 0.038) and LMWH (HR 8.5, 95% CI 2.0-36.6, p = 0.004) were confirmed to be independent predictors of increased survival.

Conclusion: Sinus rhythm at ECG admission in COVID-19 pneumonia patients was associated with greater survival as well as LMWH administration, which conferred an overall better outcome.
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http://dx.doi.org/10.1007/s11739-020-02578-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781180PMC
January 2021

What do we do about atrial high rate episodes?

Eur Heart J Suppl 2020 Dec 22;22(Suppl O):O42-O52. Epub 2020 Dec 22.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.

Atrial high rate episodes (AHREs) are defined as asymptomatic atrial tachyarrhythmias detected by cardiac implantable electronic devices with atrial sensing, providing automated continuous monitoring and tracings storage, occurring in subjects with no previous clinical atrial fibrillation (AF) and with no AF detected at conventional electrocardiogram recordings. AHREs are associated with an increased thrombo-embolic risk, which is not negligible, although lower than that of clinical AF. The thrombo-embolic risk increases with increasing burden of AHREs, and moreover, AHREs burden shows a dynamic pattern, with tendency to progression along with time, with potential transition to clinical AF. The clinical management of AHREs, in particular with regard to prophylactic treatment with oral anticoagulants (OACs), remains uncertain and heterogeneous. At present, in patients with confirmed AHREs, as a result of device tracing analysis, an integrated, individual and clinically-guided assessment should be applied, taking into account the patients' risk of stroke (to be reassessed regularly) and the AHREs burden. The use of OACs, preferentially non-vitamin K antagonists OACs, may be justified in selected patients, such as those with longer AHREs durations (in the range of several hours or ≥24 h), with no doubts on AF diagnosis after device tracing analysis and with an estimated high/very high individual risk of stroke, accounting for the anticipated net clinical benefit, and informed patient's preferences. Two randomized clinical trials on this topic are currently ongoing and are likely to better define the role of anticoagulant therapy in patients with AHREs.
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http://dx.doi.org/10.1093/eurheartj/suaa179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753882PMC
December 2020

COVID-19 pandemic: complex interactions with the arrhythmic profile and the clinical course of patients with cardiovascular disease.

Eur Heart J 2021 02;42(5):529-532

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

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http://dx.doi.org/10.1093/eurheartj/ehaa958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799155PMC
February 2021

Permanent Atrial Fibrillation as the Terminal Stage of a Chronic Disease: Palliative Care Needs to be Considered in Selected Patients with Markedly Impaired Quality of Life.

Cardiology 2020 Dec 15:1-3. Epub 2020 Dec 15.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

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http://dx.doi.org/10.1159/000512436DOI Listing
December 2020

Grey zones in the practice of permanent cardiac pacing: The case of preventive pacing for improving rhythm control in atrial fibrillation.

Int J Clin Pract 2021 01;75(1):e13728

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

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http://dx.doi.org/10.1111/ijcp.13728DOI Listing
January 2021

Prognostic value of implantable defibrillator-computed respiratory disturbance index: The DASAP-HF study.

Heart Rhythm 2021 Mar 24;18(3):374-381. Epub 2020 Oct 24.

Ospedale Monaldi, Naples, Italy.

Background: Sleep apnea, as measured by polysomnography, is associated with adverse outcomes in heart failure. The DASAP-HF (Diagnosis and Treatment of Sleep Apnea in Patient With Heart Failure) study previously demonstrated that the respiratory disturbance index (RDI) computed by the ApneaScan algorithm (Boston Scientific) accurately identifies severe sleep apnea in implantable cardioverter-defibrillator (ICD) patients.

Objective: The purpose of the long-term study phase was to assess the incidence of clinical events after 24 months and investigate the association with RDI values.

Methods: Patients with left ventricular ejection fraction ≤35% implanted with an ICD were enrolled and followed-up for 24 months. The RDI calculated at 1 month after implantation was used to stratify patients (below or above 30 episodes/h). The endpoints were all-cause death and a combination of all-cause death or cardiovascular hospitalization.

Results: Of the 265 enrolled patients, 224 had usable RDI values. Severe sleep apnea (RDI ≥30 episodes/h) was diagnosed in 115 patients (51%). These patients were more frequently male (84% vs 72%; P = .030) and had higher creatinine levels. During median follow-up of 25 months, 19 patients (8%) died. Cardiovascular hospitalizations were reported in 19 patients (8%). The risk of all-cause death was higher in patients with RDI ≥30 episodes/h (hazard ratio [HR] 3.33; 95% confidence interval [CI] 1.35-8.21; P = .023), as well as the risk of all-cause death or cardiovascular hospitalization (HR 1.94; 95% CI 1.01-3.76; P = .048). At multivariate analysis, independent predictors of death were RDI ≥30 episodes/h (HR 4.02; 95% CI 1.16-13.97; P = .029) and creatinine levels (HR 2.36; 95% CI 1.26-4.42; P = .008).

Conclusion: In heart failure patients implanted with an ICD, higher RDI values are associated with death and cardiovascular hospitalizations. Device-detected severe sleep apnea independently predicts death.
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http://dx.doi.org/10.1016/j.hrthm.2020.10.019DOI Listing
March 2021

Continuous monitoring of sleep-disordered breathing with pacemakers: Indexes for risk stratification of atrial fibrillation and risk of stroke.

Clin Cardiol 2020 Dec 12;43(12):1609-1615. Epub 2020 Nov 12.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.

Background: Sleep apnea (SA) is a risk factor for atrial fibrillation (AF). Advanced pacemakers are now able to calculate indexes of SA severity.

Hypothesis: We investigated the changes in pacemaker-measured indexes of SA, we assessed their predictive value for AF occurrence and the associated risk of stroke and death at long-term.

Methods: We enrolled 439 recipients of a pacemaker endowed with an algorithm for the calculation of a Respiratory Disturbance Index (RDI). The RDI variability was measured over the first 12 months after implantation, as well as its potential association with the occurrence of AF, defined as device-detected cumulative AF burden ≥6 hoursours in a day.

Results: The individual RDI mean was 30 ± 18 episodes/h, and the RDI maximum was 59 ± 21 episodes/h. RDI ≥30 episodes/h was detected in 351 (80%) patients during at least one night. The proportion of nights with RDI ≥30 episodes/h was 14% (2%-36%). AF ≥6 hours was detected in 129 (29%) patients during the first 12 months. The risk of AF was higher in patients with RDI maximum ≥63 episodes/h (HR:1.74; 95%CI: 1.22-2.48; P = .001) and with RDI mean ≥ 46 episodes/h (HR:1.63; 95%CI: 1.03-2.57; P = .014). The risk of all-cause death or stroke was higher in patients with AF burden ≥6 hours (HR:1.75; 95%CI: 1.06-2.86; P = .016). Moreover, among patients with no previous history of AF the risk was higher in those with RDI maximum ≥63 episodes/h (HR:1.96; 95%CI: 1.06-3.63; P = .031).

Conclusions: Pacemaker-detected SA showed a considerable variability during follow-up. We confirmed the association between RDI and higher risk of AF, and we observed an association between higher RDI maximum and all-cause death or stroke among patients with no previous history of AF.
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http://dx.doi.org/10.1002/clc.23489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724201PMC
December 2020

Prevention of long-lasting atrial fibrillation through antitachycardia pacing in DDDR pacemakers.

Int J Clin Pract 2020 Nov 9:e13820. Epub 2020 Nov 9.

Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola University Hospital, Bologna, Italy.

Objective: The MINERVA trial showed that in pacemaker patients with atrial fibrillation (AF) history, DDDRP pacing combining three algorithms - (a) atrial antitachycardia pacing with Reactive ATP enabled, (b) atrial preventive pacing and (c) managed ventricular pacing (MVP)-may effectively delay progression to persistent/permanent AF compared with standard DDDR pacing. We performed a comparative non-randomised evaluation to evaluate if Reactive ATP can be the main driver of persistent/permanent AF reduction independently on preventive pacing.

Methods: Thirty-one centres included consecutive dual-chamber pacemaker patients with AF history. Reactive ATP was programmed in all patients while preventive atrial pacing was not enabled. These patients were compared with the three groups of MINERVA randomised trial (Control DDDR, MVP, and DDDRP). The main endpoint was the incidence of AF longer than 7 consecutive days.

Results: A total of 146 patients (73 years old, 54% male) were included and followed for a median observation period of 31 months. The 2-year incidence of AF > 7 days was 12% in the Reactive ATP group, very similar to that found in the DDDRP arm of the MINERVA trial (13.8%, P = .732) and significantly lower than AF incidence found in the MINERVA Control DDDR arm (25.8%, P = .012) and in the MINERVA MVP arm (25.9%, P = .025).

Conclusions: In a real-world population of dual-chamber pacemaker patients with AF history, the use of Reactive ATP is associated with a low incidence of persistent AF, highlighting that the positive results of the MINERVA trial were related to the effectiveness of Reactive ATP rather than to preventive pacing.
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http://dx.doi.org/10.1111/ijcp.13820DOI Listing
November 2020

Atrial fibrillation pattern and factors affecting the progression to permanent atrial fibrillation.

Intern Emerg Med 2020 Nov 7. Epub 2020 Nov 7.

Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy.

Atrial fibrillation (AF) may progress from a non-permanent to a permanent form, and improvement in prediction may help in decision-making. In- and outpatients with non-permanent AF were enrolled in a prospective study and followed every 6 months. At baseline, 314 out of 523 patients (60%) had non-permanent AF (25.5% paroxysmal AF, 52.5% persistent, 2% first diagnosed AF). They were mostly males (188, 59.9%), median age 71 years [interquartile range (IQ) 62-77], median CHADSVASc 3 (IQ 1-4), median HATCH score 1 (IQ 1-2). During a follow-up of 701 (IQ 437-902) days, 66 patients (21%) developed permanent AF. CHADSVASc and HATCH scores were incrementally associated with AF progression (p for trend CHADSVASc < 0.001, HATCH p = 0.001). Cox multivariable proportional hazard regression analysis showed that age [hazard ratio (HR) 1.042; 95%CI 1.005-1.080; p = 0.025], moderate-severe left atrial (LA) enlargement at echo (HR 2.072, 95%CI, 1.121-3.831; p = 0.020), antiarrhythmics drugs (HR 0.087, 95%CI 0.011-0.659, p = 0.018), EHRA score > 2 (HR 0.358, 95%CI 0.162-0.791, p = 0.011) and valvular disease (HR 2.196, 95%CI 1.072-4.499, p = 0.032) were significantly associated with AF progression. Adding "moderate-severe LA dilation" to clinical scores, eg. HATCH score (HATCH-LA) with 2 points (Cox multivariable regression analysis) improved prediction of AF progression vs. HATCH score (p = 0.0225). In patients without permanent AF, progression of AF was independently associated with age, LA dilation, AF symptoms severity, antiarrhythmic drugs and valvular disease. Adding LA dilation (moderate-severe volume increase) to clinical scores improved prediction of progression to permanent AF.
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http://dx.doi.org/10.1007/s11739-020-02551-5DOI Listing
November 2020

Role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia.

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

Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan.

: Ventricular tachycardia is a major health issue in patients with structural heart disease (SHD). Implantable cardioverter defibrillator (ICD) therapy has significantly reduced the risk of sudden cardiac death (SCD) in such patients, but on the other hand, it has led to frequent ICD shocks as an emerging problem, being associated with poor quality of life, frequent hospitalizations and increased mortality. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias, as the coexistence of surviving myocardial fibres within fibrotic tissue leads to the formation of slow conduction pathways and to a dispersion of activation and refractoriness that constitutes the milieu for ventricular tachycardia circuits. Catheter ablation has repeatedly proven to be well tolerated and highly effective in treating VT and in the last two decades has benefited from continuous efforts to determine ventricular tachycardia mechanisms by integration with a wide range of invasive and noninvasive imaging techniques such as intracardiac echocardiography, cardiac magnetic resonance, multidetector computed tomography and nuclear imaging. Cardiovascular imaging has become a fundamental aid in planning and guiding catheter ablation procedures by integrating structural and electrophysiological information, enabling the ventricular tachycardia arrhythmogenic substrate to be characterized and effective ablation targets to be identified with increasing precision, and allowing the development of new ablation strategies with improved outcomes. In this review, we provide an overview of the role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia.
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http://dx.doi.org/10.2459/JCM.0000000000001121DOI Listing
October 2020

Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology.

Eur J Heart Fail 2020 12;22(12):2349-2369

Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France.

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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http://dx.doi.org/10.1002/ejhf.2046DOI Listing
December 2020

COVID-19 pandemic: usefulness of telemedicine in management of arrhythmias in elderly people.

J Geriatr Cardiol 2020 Sep;17(9):593-596

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

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http://dx.doi.org/10.11909/j.issn.1671-5411.2020.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568046PMC
September 2020

Cardiac Electronic Devices: Future Directions and Challenges.

Med Devices (Auckl) 2020 25;13:325-338. Epub 2020 Sep 25.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.

Cardiovascular implantable electronic devices (CIEDs) are essential management options for patients with brady- and tachyarrhythmias or heart failure with concomitant optimal pharmacotherapy. Despite increasing technological advances, there are still gaps in the management of CIED patients, eg, the growing number of lead- and pocket-related long-term complications, including cardiac device-related infective endocarditis, requires the greatest care. Likewise, patients with CIEDs should be monitored remotely as a part of a comprehensive, holistic management approach. In addition, novel technologies used in smartwatches may be a convenient tool for long-term atrial fibrillation (AF) screening, especially in high-risk populations. Early detection of AF may reduce the risk of stroke and other AF-related complications. The objective of this review article was to provide an overview of novel technologies in cardiac rhythm-management devices and future challenges related to CIEDs.
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http://dx.doi.org/10.2147/MDER.S245625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526741PMC
September 2020

Cardioversion of recent-onset atrial fibrillation: current evidence, practical considerations, and controversies in a complex clinical scenario.

Kardiol Pol 2020 11 6;78(11):1088-1098. Epub 2020 Oct 6.

Atrial fibrillation (AF) represents the most common arrhythmia and is associated with increased morbidity and mortality generating high social costs. Due to its high prevalence, AF is usually managed not only by cardiologists but also by general practitioners or clinicians in emergency departments. The conventional classification of AF includes "recent‑onset AF" defined as an arrhythmia episode shorter than 48 hours. In patients with a definite duration of AF of less than 24 hours and a very low-risk profile (CHA2DS2VASc of 0 in men and 1 in women), the thromboembolic risk seems to be low, and the standard 4‑week anticoagulation therapy is now regarded as optional treatment. Cardioversion (electrical or pharmacological) in recent‑onset AF represents a valid rhythm control strategy. Electrical cardioversion is usually reserved for hemodynamically unstable patients and performed with biphasic waveform shocks. On the other hand, pharmacological cardioversion is preferred in hemodynamically stable patients. Several antiarrhythmic drugs have been studied so far, but some questions still remain unresolved mainly due to lack of randomized clinical trials and prospective studies. The current guidelines do not uniformly agree on which drug to use for pharmacological cardioversion, and drug preference varies widely in clinical practice. The aim of this narrative review is to sum up and critically evaluate novel evidence regarding recent‑onset AF as well as to provide some practical considerations particularly focused on rhythm control with pharmacological cardioversion.
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http://dx.doi.org/10.33963/KP.15638DOI Listing
November 2020