[Preoperative dental screening in patients waiting for elective cardiovascular procedures: presentation of the SIC-ANMCO-SICCH-AIE-SIE-SidP intersociety consensus document]. / Lo screening dentale preoperatorio nei pazienti in attesa di interventi chirurgici cardiovascolari elettivi: presentazione del documento di consenso intersocietario SIC-ANMCO-SICCH-AIE-SIE-SidP.

The Italian scientific societies of cardiology (SIC and ANMCO), cardiothoracic surgery, endodontics, and periodontology realized that a specific protocol addressing preoperative dental/peri-dental screening in patients undergoing elective cardiothoracic surgery was lacking in the literature. As a consequence, they projected and then realized in 2019 a consensus document to establish the modalities for such a diagnostic and therapeutic screening, whose related options and timing depend on the patient's physical conditions as well as the time available before surgery. A high level of agreement was reached by the experts involved in the release of the consensus document and each clinical issue was addressed adequately. Three tables were released, with the aim of sharing a standardized protocol for the perioperative dental/peri-dental screening of patients who are waiting for elective cardiothoracic procedures. The authors of the consensus document, which has been widely diffused by all the involved scientific societies, hope that it can be largely accepted and applied, during the multidisciplinary phase preceding cardiovascular surgery the most.

Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Association of Interventional Cardiology (SICI-GISE) and Italian Society of Cardiac Surgery (SICCH): clinical approach to pharmacologic pre-treatment for patients undergoing myocardial revascularization procedures.

The wide availability of effective drugs in reducing cardiovascular events together with the use of myocardial revascularization has greatly improved the prognosis of patients with coronary artery disease. The combination of antithrombotic drugs to be administered before the knowledge of the coronary anatomy and before the consequent therapeutic strategies, can allow to anticipate optimal treatment, but can also expose the patients at risk of bleeding that, especially in acute coronary syndromes, can significantly weigh on their prognosis, even more than the expected theoretical benefit. In non ST-elevation acute coronary syndromes patients in particular, we propose a 'selective pre-treatment' with P2Y12 inhibitors, based on the ischaemic risk, on the bleeding risk and on the time scheduled for the execution of coronary angiography. Much of the problems concerning this issue would be resolved by an early access to coronary angiography, particularly for patients at higher ischaemic and bleeding risk.

Recurrent Angioedema: Occurrence, Features, and Concomitant Diseases in an Italian Single-Center Study.

BACKGROUND: Angioedema (AE) is a potentially life-threatening condition with hereditary (HAE), acquired (AAE), or iatrogenic causes. A careful workup allows for the identification of the etiology of attacks and the appropriate management. In this cohort study, based on a clinical practice setting, we aimed at investigating clinical and laboratory findings concerning different features of patients with recurrent AE who were referred to a single, tertiary-level center for HAE. METHODS: Clinical and laboratory data of patients fulfilling the criteria for C1-inhibitor-deficient HAE (C1-INH-HAE), C1-INH-AAE, angiotensin-converting enzyme inhibitor-related AE (ACEI-RA), and idiopathic AAE (I-AAE) were evaluated. Descriptive statistics were analyzed by means of the Mann-Whitney U test. The Fisher exact test was used for group comparisons. RESULTS: Patients were diagnosed with type 1 HAE (n = 14), type 2 HAE (n = 1), C1-INH-AAE (n = 8), ACEI-RA (n = 16), or I-AAE (n = 26). We included only patients with concomitant autoimmune diseases from the I-AAE group (n = 8, aut-I-AAE). Age at disease onset and at diagnosis was younger in type 1 HAE than in all the other groups. The diagnostic delay was longer in type 1 HAE than in ACEI-RA. C4 and C1q levels were lower in C1-INH-AAE than in type 1 HAE, ACEI-RA, and aut-I-AAE. Both HAE and C1-INH-AAE showed lower C1-INH antigen and function compared to the other groups. Peripheral attacks were more frequent in type 1 HAE, while airway, abdominal, and oral attacks were prevalent in C1-INH-AAE. CONCLUSION: Investigating the clinical and laboratory features of recurrent AE without wheals represents a major topic for facilitating early diagnosis and improving treatment strategies for this heterogeneous and misdiagnosed condition.

Optimal duration of dual anti-platelet therapy after percutaneous coronary intervention: 2016 consensus position of the Italian Society of Cardiology.

Definition of the optimal duration of dual anti-platelet therapy (DAPT) is an important clinical issue, given the large number of patients having percutaneous coronary intervention (PCI), the costs and risks of pharmacologic therapy, the consequences of stent thrombosis, and the potential benefits of DAPT in preventing ischaemic outcomes beyond stent thrombosis. Nowadays, the rationale for a prolonged duration of DAPT should be not only the prevention of stent thrombosis, but also the prevention of ischaemic events unrelated to the coronary stenosis treated with index PCI. A higher predisposition to athero-thrombosis may persist for years after an acute myocardial infarction, and even stable patients with a history of prior myocardial infarction are at high risk for major adverse cardiovascular events. Recently, results of pre-specified post-hoc analyses of randomized clinical trials, including the PEGASUS-TIMI 54 trial, have shed light on strategies of DAPT in various clinical situations, and should impact the next rounds of international guidelines, and also routine practice. Accordingly, the 2015 to 2016 the Board of the Italian Society of Cardiology addressed newer recommendations on duration of DAPT based on most recent scientific information. The document states that physicians should decide duration of DAPT on an individual basis, taking into account ischaemic and bleeding risks of any given patient. Indeed, current controversy surrounding optimal duration of DAPT clearly reflects the fact that, nowadays, a one size fits all strategy cannot be reliably applied to patients treated with PCI. Indeed, patients usually have factors for both increased ischaemic and bleeding risks that must be carefully evaluated to assess the benefit/risk ratio of prolonged DAPT. Personalized management of DAPT must be seen as a dynamic prescription with regular re-evaluations of the risk/benefit to the patient according to changes in his/her clinical profile. Also, in order to derive more benefit than harm from new treatments, a multi-parametric approach using several risk scores of the ischaemic and bleeding risks might improve the process of risk factor characterization. In patients with high ischaemic risk, particularly those with a history of myocardial infarction, the benefits of extended DAPT (particularly with ticagrelor up to 3 years) are likely to outweigh the risks.

[ANMCO/SIC/SICI-GISE/SICCH Consensus document: Clinical approach to pharmacological pretreatment for patients undergoing myocardial revascularization]. / Documento di consenso ANMCO/SIC/SICI-GISE/SICCH: Approccio clinico al pretrattamento farmacologico in pazienti candidati a procedure di rivascolarizzazione miocardica.

The wide availability of drugs effective in reducing cardiovascular events and the use of myocardial revascularization have greatly improved the prognosis of patients with coronary artery disease. However, the combination of antithrombotic drugs to be administered before the exact knowledge of the coronary anatomy and before the consequent therapeutic strategy can, on one hand, allow to anticipate an optimal treatment but, on the other hand, may expose the patient to a bleeding risk not always necessary. In patients with ST-elevation acute coronary syndrome with an indication to primary angioplasty, the administration of unfractionated heparin and aspirin is considered the pre-procedural standard treatment. The upstream administration of an oral P2Y12 inhibitor, even if not supported by randomized controlled trials, appears reasonable in view of the very high likelihood of treatment with angioplasty. In patients with non-ST elevation acute coronary syndrome, in which it is not always chosen an invasive strategy, the occurrence of bleeding can significantly weigh on prognosis, even more than the theoretical benefit of pretreatment. Fondaparinux is the anticoagulant with the most favorable efficacy/safety profile. Antiplatelet pretreatment must be selective, guided by the ischemic risk conditions, the risk of bleeding and the time schedule for coronary angiography.In patients with stable coronary artery disease, generally treated with aspirin, pretreatment with clopidogrel is advisable in case of already scheduled angioplasty, and it appears reasonable in case of high likelihood, at least in patients at low bleeding risk. In patients candidate to surgical revascularization, aspirin is typically maintained and the oral P2Y12-inhibitor discontinued, with i.v. antiplatelet drug bridging in selected cases.Anti-ischemic drugs are useful in controlling symptoms, but they have no specific indications with regard to revascularization procedures. Statins showed protective effects on periprocedural damage and late clinical events, when administered early. Although randomized data are lacking, it seems reasonable their pre-procedural administration, due to potential advantages without significant adverse effects.

An increased endothelial-independent vasodilation is the hallmark of the neurally mediated syncope.

BACKGROUND: The neurally mediated syncope (NMS) is sustained by complex cardiac and vascular reflexes, acting on and amplified by central autonomic loops, resulting in bradycardia and hypotension. HYPOTHESIS: Our aim was to assess whether the pathophysiology of NMS is also related to an abnormal peripheral vasoreactivity. METHODS: We evaluated by ultrasound the flow-mediated vasodilation (FMD) and the nitrate-mediated dilation (NMD) in 17 patients with NMS, induced by drug-free tilt test in 6 subjects and by nitrate-potentiated tilt test in the other 11 cases; the syncope was classified as vasodepressive (VD) in 8 cases, cardioinhibitory (CI) in 7, and mixed in 2. RESULTS: The FMD was not different from controls (10.2 ± 4.5 vs 11.4 ± 3.9, P = ns), with normal recovery times; the NMD was greater in fainting subjects than in controls (26.7 ± 7.3 vs 19.0 ± 3.6, P < 0.05), with higher values in VD than in CI syncope (31.1 ± 7.0 vs 23.1 ± 5.0, P = ns); compared to controls, subjects with NMS showed normal recovery times after FMD but longer recovery times after nitrate administration (13.0 ± 5.6 vs 6.3 ± 0.7 minutes, P < 0.05). CONCLUSIONS: The evaluation of endothelial function supports evidence that NMS is characterized by a marked and sustained endothelial-independent vasodilation, in the presence of a normal FMD; vascular hyperreactivity in response to nitrate administration is particularly overt in vasodepressive syncope and can explain the high rate of responses to nitrate administration during tilt test.

Cryptogenic cerebral ischemia: clinical usefulness of a flexible ultrasound diagnostic algorithm for detection of patent foramen ovale.

OBJECTIVES: Paradoxical thromboembolism across a patent foramen ovale (PFO) may be involved in the pathogenesis of cryptogenic strokes. We tested the feasibility and the clinical usefulness of an early screening for PFO combining different ultrasound techniques in patients with acute cerebral ischemia of undetermined cause. METHODS: Consecutive patients with acute ischemic stroke or transient ischemic attack with undetermined cause were selected. Contrast-enhanced transcranial Doppler ultrasound (c-TCD) for detection of right-to-left shunt was performed on admission. Patients with right-to-left shunt on c-TCD underwent contrast-enhanced transesophageal echocardiography (c-TEE) and/or contrast-enhanced transthoracic echocardiography (c-TTE) for PFO confirmation. We tested the feasibility of this ultrasound algorithm in patients with acute cerebral ischemia, as well as its impact on further treatment decision. RESULTS: Over 30 months, we admitted 154 of 674 (23%) patients with undetermined stroke cause. Right-to-left shunt was detected by c-TCD in 76 of 148 (51%) patients. Of them, five of 76 (7%) patients dropped out of the study, whereas 10 of 76 (13%) could not perform a c-TEE due to lack of compliance. In the remaining 61 patients, a PFO was detected by c-TEE in 49 (80%) patients. Additional c-TTE study extended the examination for PFO detection to 66 patients, with a total of 57 PFO diagnosis (86%). An alternative stroke cause (i.e. an ulcerated aortic plaque) was detected in four patients. CONCLUSION: A combined ultrasound approach based on a flexible diagnostic algorithm improved our ability to detect a PFO or alternative stroke cause in patients with acute cerebral ischemia of undetermined cause and to optimize secondary stroke prevention.

Short-Term and Two-Year Rate of Recurrent Cerebrovascular Events in Patients with Acute Cerebral Ischemia of Undetermined Aetiology, with and without a Patent Foramen Ovale.

Purpose. We investigated stroke recurrence in patients with acute ischemic stroke of undetermined aetiology, with or without a patent foramen ovale (PFO). Methods. Consecutive stroke patients underwent to Transcranial Doppler and Transesophageal Echocardiography for PFO detection. Secondary stroke prevention was based on current guidelines. Results. PFO was detected in 57/129 (44%) patients. The rate of recurrent stroke did not significantly differ between patients with and without a PFO: 0.0% versus 1.4% (1 week), 1.7% versus 2.7% (1 month), and 3.5% versus 4.2% (3 months), respectively. The 2-year rates were 10.4% (5/48) in medically treated PFO and 8.3% (6/72) in PFO-negative patients (P = 0.65), with a relative risk of 1.25. No recurrent events occurred in 9 patients treated with percutaneous closure of PFO. Conclusion. PFO was not associated with increased rate of recurrent stroke. Age-related factors associated with stroke recurrence in cryptogenic stroke should be taken into account when patients older than 55 years are included in PFO studies.

Outpatient oesophageal-precordial electrical cardioversion of atrial fibrillation: an effective and safe technique to restore sinus rhythm.

OBJECTIVE: External electrical cardioversion is commonly used in the management of atrial fibrillation (AF), but usually involves general anaesthesia. We tested the efficacy, safety and tolerability of a minimally invasive cardioversion technique, not requiring general anaesthesia, performed on an outpatient basis. METHODS: We performed outpatient oesophageal cardioversion in 87 consecutive patients (mean age: 67.5 +/- 9.6 years; weight: 77.47 +/- 12.34 kg; left atrium diameter: 46.25 +/- 6.85 mm; LVEF: 55.5 +/- 16%) with persistent AF (mean duration: 6.99 +/- 11.55 months). A biphasic shock was delivered via an oesophageal decapolar lead (cathode) and two precordial patches (anode) under a mild sedation (midazolam 2.5-5 mg). In the first 25 patients, a step-up protocol (from 10 to 100 J) was performed whereas, in the other 62, a first shock at 50 J and a second one at 100 J, were delivered. RESULTS: Patients described the level of discomfort caused by the procedure according a five-grade scale. Cardioversion was achieved in 97.7% of patients using a mean effective energy of 51.2 +/- 15.7 J. In 88.5% of patients, sinus rhythm was restored by using 50 J or less. No complications occurred and no patient required hospital admission. Mean discomfort score was 1.56 +/- 0.74 out of 5. Sinus rhythm persisted in 62.6% of patients at the 1-month follow-up. CONCLUSIONS: Outpatient oesophageal cardioversion is a safe, acceptable and effective way to cardiovert patients with AF. It may be a useful alternative to external cardioversion. A relatively high starting energy (50 J) was demonstrated to be superior to a low-energy step-up technique.

Multislice computed tomography in an asymptomatic high-risk population.

Approximately 50% of all acute coronary syndromes occur in previously asymptomatic patients. This study evaluated the value of multislice computed tomography for early detection of significant coronary artery disease (CAD) in high-risk asymptomatic subjects. One hundred sixty-eight asymptomatic subjects with >or=1 major risk factor (hypertension, diabetes, hypercholesterolemia, family history, or smoking) and an inconclusive or unfeasible noninvasive stress test result (stress electrocardiography, echocardiography, or nuclear scintigraphy) were evaluated in an outpatient setting. After clinical examination and laboratory risk analysis, all patients underwent multislice computed tomographic (MSCT) coronary angiography within 1 week. In all subjects, conventional coronary angiography was also carried out. Multislice computed tomography displayed single-vessel CAD in 16% of patients, 2-vessel CAD in 7%, and 3-vessel CAD in 4%. Selective coronary angiography confirmed the results of multislice computed tomography in 99% of all patients. Sensitivity and specificity of MSCT coronary angiography were 100% and 98%, respectively, with a positive predictive value of 95% and a negative predictive value of 100%. In conclusion, MSCT coronary angiography is an excellent noninvasive technique for early identification of significant CAD in high-risk asymptomatic patients with inconclusive or unfeasible noninvasive stress test results.

Distribution and prognostic significance of QT intervals in the lowest half centile in 12,012 apparently healthy persons.

The presence of an abnormally short QT interval has been noted among survivors of idiopathic ventricular fibrillation and among close relatives of victims of unexplained sudden death. Most reported cases have had rate-corrected QT (QTc) intervals of <300 ms. The prevalence of such values in the community has not been documented. We reviewed the electrocardiograms (ECGs) of 12,012 subjects who underwent routine medical examinations for occupational reasons. The QT interval was measured by 2 physicians in all cases, and QTc interval was calculated. All ECGs with QTc values in the lowest 5% were reviewed by 2 cardiologists expert in QT analysis, and the QT measurement was corrected if necessary. Information about subsequent survival was obtained from the case file or from public records. In the lowest 1/2 centile, the distribution of QTc values continued to follow a normal pattern without evidence of a distinct subpopulation of low values. The shortest QTc encountered was 335 ms. Information about subsequent survival was available for 36 of the 60 subjects with the lowest 1/2 centile of QTc values. None of these subjects died during the 7.9 +/- 4.5 years subsequent to the ECG that demonstrated the short QT interval. In conclusion, a QTc interval of

Functional assessment of the collateral-dependent circulation in chronic total coronary occlusion using transthoracic Doppler ultrasound and venous adenosine infusion.

The measurement of collateral flow reserve (CFR; the hyperemic/baseline collateral flow velocity ratio) in patients with chronic total coronary occlusion requires invasive and expensive techniques. Noninvasive transthoracic coronary Doppler echocardiography may be an alternative option. Fifty-one patients with chronic total coronary occlusion were evaluated by transthoracic coronary Doppler echocardiography and venous adenosine infusion to measure CFR in occluded coronary arteries (the left anterior descending artery in 44 patients and the artery supplying the posterior descending artery in 7 patients). CFR data were plotted against 3 angiographic parameters: (1) grade of the epicardial filling of the occluded artery (1=absent, 2=partial, 3=complete), (2) stenosis of the donor artery, and (3) the extent of coronary artery disease (vessels with >or=70% stenosis). Collateral flow was maintained at stress in 34 patients (CFR>or=1, range 1.0 to 2.2) but was withdrawn in 17 patients (CFR<1, range 0.25 to 0.90). CFR increased with the degree of angiographic collateral flow (grade 1: 0.73+/-0.29; grade 2: 1.16+/-0.31; grade 3: 1.34+/-0.49; F=5.31, p=0.008). A multivariate model of CFR prediction showed a direct relation with angiographic collateral grade and the number of diseased vessels and an inverse relation with stenosis of the donor artery. In conclusion, CFR measurement is feasible by transthoracic coronary Doppler echocardiography. One third of the patients with chronic total coronary occlusion had collateral flow withdrawal at stress, which occurs when collateral circulation is poor and when the donor artery is stenotic. CFR correlates with angiographic collateral grade and with the extent of coronary artery disease.

Non-invasive diagnostic and functional evaluation of cardiac and pulmonary involvement in systemic sclerosis.

BACKGROUND: The aim of the present study was to evaluate the role of non-invasive methods in the early detection of pulmonary and cardiac involvement in Systemic sclerosis (SSc) and to identify clinical and/or instrumental patterns of prognostic value. PATIENTS AND METHODS: Twenty female patients affected by SSc (8 with diffuse cutaneous SSc and 12 with limited cutaneous SSc) were enrolled in our study. Cardiac and pulmonary involvement (respiratory function tests and carbon monoxide lung diffusion [DLCO], chest radiography, high resolution computed tomography [HRCT] and lung perfusion magnetic resonance) were evaluated. RESULTS: All 18 patients studied with respiratory function tests showed a significant reduction of DLCO. HRCT was considerably more sensitive than traditional chest radiography (59% versus 28%; p<0.05). Lung perfusion MRI revealed normal findings in 15 patients. Abnormal lung perfusion MRI results were found only in 3 patients. Angina pectoris with electrocardiographic and scintigraphic ischemic changes, severe regional wall motion abnormalities and complex arrhythmias seemed to be associated with poor prognosis. CONCLUSION: Taken together these results indicate that a pulmonary involvement occurs both in limited and in diffuse cutaneous SSc patients and develops, in 83% of the cases, without any regional lung perfusion abnormality. Furthermore, cardiac involvement is detected in 65% of the cases as a consequence of a range of noxious events including myocardial ischemia, fibrosis and pressure overload which may result in ventricular dysfunction and arrhythmias. Lung perfusion MRI should be considered as a complementary diagnostic method for the functional evaluation of these symptoms in systemic sclerosis.