[Optimal therapeutic management in the clinical journey of patients with heart failure]. / L'ottimizzazione terapeutica nel percorso del paziente con scompenso cardiaco.

Heart failure (HF) is still characterized by high mortality rates, despite the progress achieved in terms of treatment options. With regard to the treatment of HF with reduced ejection fraction (HFrEF), the 2016 European Society of Cardiology guidelines included in the therapeutic algorithm the angiotensin receptor-neprilysin inhibitor class, whose efficacy in modifying patient prognosis has been extensively proven in many clinical studies. Sacubitril/valsartan, the only representative of this drug class, can effectively affect the natural history of HF, thus reducing cardiovascular mortality (sudden death and death due to worsening cardiac function), total mortality, as well as first and recurrent hospitalization events, by improving renal function, cardiac remodeling, functional capacity and the patient's health-related quality of life.The purpose of this article is to analyze the different phases of the journey of patients with HFrEF (first general practitioner consultation; admission to the emergency department and subsequent hospitalization; referral to a specialist HF clinic) and promotion of a networking approach involving the general practitioner, the hospital and the HF specialist based on common pre-defined diagnostic and therapeutic protocols, that meets patient needs at all stages of the disease (case-specific dosing assessment, drug titration before follow-up and prevention of adverse events).

[Hyperthyroidism and hypopituitarism: two incompatible diagnoses?] / Ipertiroidismo e ipopituitarismo: due diagnosi fra loro inconciliabili?

We report the case of a 67-year-old man, with a past medical history of radiotherapy for nasopharyngeal carcinoma, who presented with the classical features of a hyperthyroidism (H), due to Graves' disease, with a high TSH receptor antibodies (TRAb) titre. Thyrostatic therapy was started, with gradual improvement of the symptoms and of the thyroid function tests. Two years later, TRAb became negative and the therapy was stopped. In the following months a previously unknown anterior pituitary insufficiency became evident. Therapy with cortisone acetate, L-thyroxine and testosterone was started, resulting in prolonged normalization of the clinical picture. Six years later a short relapse of H was observed, simultaneously to a new increase of TRAb titre, requiring the transitory interruption of the L-thyroxine therapy. In a few months span H disappeared and central hypothyroidism manifested again, so that the patient is still taking replacement therapy. This case illustrates how H and hypopituitarism are not mutually exclusive diagnoses and how, even if rarely, central hypothyroidism and H could alternate in the clinical history of the same patient.

[Greater saphenous vein thrombosis and testosterone replacement therapy: an occasional association?] / Trombosi della grande safena e terapia sostitutiva con testosterone: un'associazione casuale?

We describe a case of greater saphenous vein thrombosis in a 50-year-old previously healthy man, occurred only 3 weeks after starting testosterone (T) replacement therapy (20 mg/day, gel) for hypergonadotropic hypogonadism. There were no clinical known risk factors for thrombosis. Laboratory assessment of thrombophilia, performed later, revealed only methylenetetrahydrofolate reductase (MTHFR) A1298C polymorphism. On the basis of other recently reported cases, we suppose a relationship between androgenic therapy and venous thrombosis. We suggest the same caution before starting T replacement therapy in male as in female administration of estrogens.

Zofenopril or irbesartan plus hydrochlorothiazide in elderly patients with isolated systolic hypertension untreated or uncontrolled by previous treatment: a double-blind, randomized study.

OBJECTIVE: To compare zofenopril + hydrochlorothiazide (Z + H) vs. irbesartan + hydrochlorothiazide (I + H) efficacy on daytime SBP in elderly (>65 years) patients with isolated systolic hypertension (ISH), untreated or uncontrolled by a previous monotherapy. METHODS: After a 1-week run-in, 230 ISH patients (office SBP ≥ 140  mmHg and DBP < 90  mmHg + daytime SBP ≥ 135  mmHg and daytime DBP < 85  mmHg) were randomized double-blind to 18-week treatment with Z + H (30 + 12.5  mg) or I + H (150 + 12.5  mg) once daily, in an international, multicenter study. Z and I doses could be doubled after 6 and 12 weeks, and nitrendipine 20  mg added at 12 weeks in nonnormalized patients. RESULTS: In the full analysis set (n = 216) baseline-adjusted average (95% confidence interval) daytime SBP reductions after 6 weeks (primary study end point) were similar (P = 0.888) with Z + H [7.7 (10.7, 4.6)  mmHg, n = 107] and I + H [7.9 (10.7, 5.0)  mmHg, n = 109]. Daytime SBP reductions were sustained during the study, and larger (P = 0.028) with low-dose Z + H at study end [16.2 (20.0, 12.5)  mmHg vs. 11.2 (14.4, 7.9)  mmHg I + H]. Daytime SBP normalization (<135 mmHg) rate was similar under Z + H and I + H at 6 and 12 weeks, but more common under Z + H at 18 weeks (68.2 vs. 56.0%, P = 0.031). Both drugs equally reduced SBP in the last 6 h of the dosing interval and homogeneously reduced SBP throughout the 24 h. The proportion of patients reporting drug-related adverse events was low (Z + H: 4.4% vs. I + H: 6.0%; P = 0.574). CONCLUSION: Elderly patients with ISH respond well to both low and high-dose Z or I combined with H.

[Di George syndrome: not always a pediatric diagnosis]. / Sindrome di Di George: una diagnosi non sempre pediatrica.

We describe a delayed diagnosis of Di George syndrome, in a 51 yr-old woman, with past medical history of epilepsy, mental retardation, chronic psychosis, nephrocalcinosis. She presented facial dysmorphism, multiple encephalic calcifications, hypocalcemia and lymphopenia. A microdeletion of 22q 11.2 was detected by fluorescence in situ hybridization (FISH), confirming the clinical suspicion .