[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).

PCI versus CABG for multivessel coronary disease in diabetics.

OBJECTIVES: To explore the clinical performance of a strategy of revascularization by percutaneous coronary intervention (PCI) with drug-eluting stent (DES) in diabetic patients with multivessel disease (MVD) compared with coronary artery bypass graft (CABG), when it is based on clinical judgment. BACKGROUND: Diabetes mellitus (DM) is a major risk factor for poor outcome after PCI. However, PCI may result in better outcome if the choice of revascularization (PCI versus CABG) is based on the physician decision, rather than randomization. Limited experiences have compared revascularization by DES-PCI versus CABG in DM patients with MVD. METHODS: From August 2004 to August 2005, 220 consecutive DM patients with MVD underwent DES-PCI (93) or CABG (127) at our Institution. The type of revascularization was dependent on patient and/or physician choice. Major adverse cardiac and cerebrovascular events (MACCE) included death, myocardial infarction, repeat coronary revascularization, and stroke. RESULTS: Compared with PCI patients, CABG patients had higher prevalence of 3-vessel disease (P < 0.001), significant LAD involvement (P < 0.001), presence of total occlusions (P = 0.04), collateral circulation (P < 0.001). At 2-year follow-up, MACCE were not different between CABG group and DES-PCI group (OR 1.2; P = 0.6) and, only when the clinical judgment on the revascularization choice was excluded at propensity analysis, DES-PCI increased the risk of 24-month MACCE in total population (OR 1.8; P = 0.04). CONCLUSIONS: For patients with DM and MVD, a clinical judgment-based revascularization by DES-PCI is not associated with worse 2-year outcome compared with CABG.

Drug-eluting stents for the treatment of coronary lesions in cardiac transplant vasculopathy: acute and mid-term clinical and angiographic outcomes.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the major cause of graft failure and death in cardiac transplant recipients after transplantation. We aimed to evaluate the clinical and angiographic outcomes of patients with evidence of CAV who were treated percutaneously with drug-eluting stents (DES-PCI). METHODS: Between December 2002 and September 2005, we reviewed the baseline procedural characteristics and the clinical outcome of consecutive cardiac transplanted recipients with evidence of CAV treated with DES-PCI, eligible for at least 9 months of follow-up. RESULTS: Fifteen consecutive patients received a total of 18 coronary DESs. Total treated lesions were 20; 12 (60%) involved the left anterior descending artery. CAV was focal in nine patients, diffuse in five patients, and mixed in only one patient. Mean time interval from transplantation to DES implantation was 126 +/- 44 months. Angiographic and procedural success was 100%. There were no adverse in-hospital events. During follow-up (17.9 +/- 8.4 months), two patients died of noncardiac cause. Six patients required a new percutaneous intervention for a repeat revascularization rate of 40%: one patient underwent target lesion revascularization because of in-DES restenosis, one patient had target vessel revascularization because of a new coronary lesion proximal to the stent. Finally, four more patients underwent repeat DES-PCI in a coronary vessel other than the treated one. CONCLUSIONS: Although DES implantation seems to be associated with a high procedural success rate and a low restenosis rate, the repeat revascularization rate due to CAV progression remains in nearly half of our study patients.