[The slow acceptance of new oral anticoagulants in Italy: a critical analysis of a problem]. / La lenta accettazione dei nuovi anticoagulanti orali in Italia: analisi critica di un problema.

The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) into clinical practice has revolutionized the prevention and the therapeutic approaches to thromboembolic events in patients with nonvalvular atrial fibrillation and represents with no doubts one of the most remarkable advances in the history of cardiovascular medicine over the last years. NOACs beyond a comparable efficacy with vitamin K antagonists allow to overcome the limitations of this last category of drugs owing to their less drug to drug interactions and a predictable anticoagulant effect that allows a fixed dose administration without the need for continuous monitoring. However, the penetration of NOACs into the Italian market is still lower than predicted with respect to their use in other European countries.The aim of this review is to critically analyze the reasons behind this attitude through the adoption of the nominal group technique, a methodology that permits to reach an official consensus.

[The Italian Survey on Cardiac Rehabilitation - 2013 (ISYDE.13-Directory): national availability and organization of cardiac rehabilitation facilities]. / Italian Survey on Cardiac Rehabilitation (ISYDE.13-Directory): report su strutture, organizzazione e programmi di cardiologia riabilitativa in Italia.

BACKGROUND: The Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (GICR-IACPR) and the Italian Society of Cardiologists of Accredited Hospitals (SICOA) developed the ISYDE.13 survey with the purpose to take a detailed snapshot of number, distribution, facilities, staffing levels, organization, and program details of cardiac rehabilitation (CR) units in Italy. METHODS: The study was carried out using a web-based questionnaire running on the GICR-IACPR website for 4 weeks from September 2 to 29, 2013. RESULTS: Out of 221 CR centers existing in Italy (+14% vs 2008), 191 (86%) participated in the survey. On a national basis, there is a CR unit every 268 852 inhabitants. The majority of CR units are located in public hospitals (57.1%), the remaining 42.9% in private hospitals; 130 CR centers (68%) provide inpatients care and account for 3527 beds (5.9 per 100 000 inhabitants): of these 374 are day-hospital beds and 408 are sub-intensive beds. Forty-one of the Italian in-hospital CR centers offer also outpatient programs and 61 centers (32%) offer only outpatient CR programs; 131 of the CR units (68.6%) are linked to dedicated cardiology divisions and in 77% of cases the head is a cardiologist. Home-based programs are offered by 9 centers (4.7%) and CR programs with telecare supervision by 16 (8.4%). Long-term secondary prevention follow-up programs are provided by 94 of CR services (49.2%). During one week of activity, the 191 centers completed 1335 inpatient CR programs and 971 outpatient CR programs. According to these data, it may be assumed that in Italy approximately 100 000 patients are referred annually to CR programs. CONCLUSIONS: ISYDE.13 showed an incremental trend of CR provision in Italy, particularly in outpatient programs. However, at present, the national network of CR units covers only one third of the potential requirements defined by current secondary prevention recommendations.

Incidence and clinical presentation of myocardial ischemia in patients with chronic CAD in Italy: the ISPICA survey study.

AIM: This survey study was performed to provide an overall picture on the incidence of symptoms, with or without typical angina, in the real-life clinical practice and to identify clinical factors associated with atypical presentations in an unselected population of consecutive outpatients with chronic coronary artery disease (CAD). METHODS: Thirty-six cardiology units located in different geographic areas of Italy enrolled a total of 1475 outpatients (73.6% men and 26.3% women; mean age 71 ±â€Š10 and 67 ±â€Š9 years in men and women, respectively) with a documented diagnosis of chronic CAD. Each patient underwent a medical history, with a detailed investigation as to the presence of typical angina or ischemic equivalents defined as sensation of chest pressure, or arm, neck, or jaw pain. RESULTS: At admission, symptoms suggesting ischemic episodes were reported by 24.4% of patients. After an in-depth medical history collection by the specialist, the prevalence of combined typical or atypical myocardial ischemic episodes was ascertained in 39.3% of the overall population.Typical angina was reported by 13.6% of men and 22.7% of women (P < 0.0001), whereas ischemic equivalents were present in 7.3 and 12.9% of male and female patients, respectively (P < 0.001). Previous coronary artery bypass grafting (CABG; P < 0.001) and fewer medical visits by cardiologists (P = 0.02) were independent predictors of atypical presentations. CONCLUSION: The ISPICA study shows that in an Italian population of real-world patients with chronic CAD, ischemic episodes, with both typical and atypical presentation, are still present in nearly 50% of patients, despite optimal medical therapy, and that atypical presentations of angina are linked to fewer visits by specialists and previous CABG. These findings would suggest to encourage patients with chronic CAD and general practitioners to consider more frequent cardiology specialist visits and to take into account the possibility of atypical presentations, particularly in patients with previous CABG.

ISMAR-study presentation: in-hospital epidemiology and clinical management of respiratory and cardiac comorbidities in cardiac and respiratory disease units.

BACKGROUND: Cardiovascular and respiratory diseases are leading causes of morbidity and their co-occurrence has important implications in mortality and other outcomes. Even the most recent guidelines do not reliably address clinical, prognostic, and therapeutic concerns due to the overlap of respiratory and cardiac diseases. STUDY OBJECTIVES AND DESIGN: In order to evaluate in the reality of clinical practice the epidemiology and the reciprocal impact of cardio-pulmonary comorbidity on the clinical management, diagnostic workup and treatment, 1,500 cardiac and 1,500 respiratory inpatients, admitted in acute and rehabilitation units, will be enrolled in a multicenter, nationwide, prospective observational study. For this purpose, each center will enroll at least 50 consecutive patients. At discharge, data analysis will be aimed at the definition of cardiac and pulmonary inpatient comorbidity prevalence, demographic characteristics, length of hospital stay, and risk factors, taking into account also procedures, pharmacological and non-pharmacological treatment, and follow up in patients with cardio-respiratory comorbidity. CONCLUSIONS: The purely observational design of the study aims to give new relevant information on the assessment and management of overlapping patients in real life clinical practice, and new insight for improvement and implementation of current guidelines on the management of individual diseases.

Anticoagulation in "real world" patients with atrial fibrillation in Italy: results from the ISPAF (Indagine Sicoa Paziente Con Fibrillazione Atriale) survey study.

BACKGROUND: Atrial fibrillation (AF) is associated with a high risk of stroke and other thrombo-embolic events and their prevention relies on antithrombotic therapy, at present mainly with vitamin K antagonists (VKA). The aim of this study was to provide an overall picture on the extent to which current recommendations on oral anticoagulation (OAC) therapy with VKA in AF correspond to actually prescribed OAC in an unselected, real world, population of consecutive patients with AF in Italy. Secondary objective was to assess the rate of "optimal" anticoagulation. METHODS: Sixty-three cardiology units located in different geographic areas of Italy enrolled a total of 2046 outpatients with nonvalvular AF (54% males and 46% females, age 73.3±10.2 years). RESULTS: OAC with VKAs was prescribed in 1394 (68%) of patients and was progressively more frequent on going from paroxysmal (46%) to persistent (71%) and permanent AF (78%)(P<0.001). A high prescription rate (88%) occurred in patients with CHA2DS2-VASc >2. In patients with CHA2DS2-VASc=0 and HAS-BLED<3, still 59% were on OAC, whereas in 33% of patients with CHA2DS2-VASc ≥2 and HAS-BLED<3, OAC therapy was not prescribed. In patients with CHA2DS2-VASc ≥2 and HAS-BLED>3, the preference was towards OAC prescription. 66% of patients were at target for INR. CONCLUSIONS: The ISPAF study shows that in an Italian population of real world patients with AF adherence to current guidelines on OAC therapy based on stroke-risk scoring system is rather high, although rate of prescription should be increased. However, contrary to recommendations, in a high proportion of low-risk patients OAC therapy is still prescribed, and this might expose patients to unjustified risks.

[Atrial fibrillation and new oral anticoagulants: a therapeutic revolution?]. / Fibrillazione atriale e nuovi anticoagulanti: rivoluzione terapeutica?

Oral anticoagulant therapy (OAT) with vitamin K antagonists significantly reduces thromboembolic risk in patients with atrial fibrillation (AF), but is associated with increased hemorrhagic risk. In older patients, despite a higher hemorrhagic risk, the net clinical benefit is in favor of OAT. In clinical practice, however, underuse of OAT and suboptimal quality control, with unsatisfactory INR time in therapeutic range, are frequently reported. This is particularly true in older patients with AF, despite the fact that they are at higher risk of thromboembolic events. New oral anticoagulants (NOAs) are represented by direct thrombin inhibitors (dabigatran) or direct Xa factor inhibitors (rivaroxaban, apixaban). In phase III studies, NOAs have shown at least a non-inferiority to warfarin in thromboembolic risk reduction in AF patients and are also associated with a reduction in life-threatening bleedings, in particular intracranial bleedings. In addition, NOAs are administered in daily fixed doses and do not require regular INR monitoring. For all these reasons, NOAs will likely replace warfarin in the elderly in the next future.