[Optimizing the care management pathway of patients with ischemia and non-obstructive coronary arteries]. / Ottimizzazione del percorso clinico-gestionale del paziente con ischemia in assenza di malattia coronarica ostruttiva.

Ischemia with non-obstructive coronary arteries (INOCA) is defined by the coexistence of anginal symptoms and demonstrable ischemia, with no evidence of obstructive coronary arteries. The underlying mechanism of INOCA is coronary microvascular dysfunction with or without associated vasospasm. INOCA patients have recurrent symptoms, functional limitations, repeated access to the emergency department, impaired quality of life and a higher incidence of cardiovascular events than the general population. Although well described in chronic coronary syndrome guidelines, INOCA remains underdiagnosed in clinical practice because of insufficient awareness, lack of accurate diagnostic tools, and poorly standardized and consistent definitions to diagnose, both invasively and non-invasively, coronary microvascular dysfunction.To disseminate current scientific evidence on INOCA as a distinct clinical entity, during 2022 we conducted at 30 cardiology units all over the country a clinical practice improvement initiative, with the aim of developing uniform and shared management pathways for INOCA patients across different operational settings. The present document highlights the outcomes of this multidisciplinary initiative.

Sex-Related Differences in Long-Term Outcomes After Early-Onset Myocardial Infarction.

Importance: There is growing awareness of sex-related differences in cardiovascular risk profiles, but less is known about whether these extend to pre-menopausal females experiencing an early-onset myocardial infarction (MI), who may benefit from the protective effects of estrogen exposure. Methods: A nationwide study involving 125 Italian Coronary Care Units recruited 2,000 patients between 1998 and 2002 hospitalized for a type I myocardial infarction before the age of 45 years (male, n = 1,778 (88.9%). Patients were followed up for a median of 19.9 years (IQR 18.1-22.6). The primary composite endpoint was the occurrence of cardiovascular death, non-fatal myocardial re-infarction or non-fatal stroke, and the secondary endpoint of hospitalization for revascularisation by means of a percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). Results: ST-elevation MI was the most frequent presentation among both men and women (85.1 vs. 87.4%, p = ns), but the men had a greater baseline coronary atherosclerotic burden (median Duke Coronary Artery Disease Index: 48 vs. 23; median Syntax score 9 vs. 7; both p < 0.001). The primary composite endpoint occurred less frequently among women (25.7% vs. 37.0%; adjusted hazard ratio: 0.69, 95% CI 0.52-0.91; p = 0.01) despite being less likely to receive treatment with most secondary prevention medications during follow up. Conclusions: There are significant sex-related differences in baseline risk factors and outcomes among patients with early-onset MI: women present with a lower atherosclerotic disease burden and, although they are less frequently prescribed secondary prevention measures, experience better long-term outcomes. Trial Registration: 4272/98 Ospedale Niguarda, Ca' Granda 03/09/1998.

Long-term outcomes of early-onset myocardial infarction with non-obstructive coronary artery disease (MINOCA).

BACKGROUND: Acute myocardial infarction with non-obstructive coronary artery disease (MINOCA) is frequent in patients experiencing an early-onset MI, but data concerning its long-term prognosis are limited and conflicting. METHODS: The Italian Genetic Study on Early-onset MI enrolled 2000 patients experiencing a first MI before the age of 45 years, and had a median follow-up of 19.9 years. The composite primary endpoint was cardiovascular (CV) death, non-fatal MI, and non-fatal stroke (MACE); the secondary endpoint was rehospitalisation for coronary revascularisation. RESULTS: MINOCA occurred in 317 patients (15.9%) and, during the follow-up, there was no significant difference in MACE rates between them and the patients with obstructive coronary artery disease (MICAD: 27.8% vs 37.5%; adjusted hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.57-1.09;p = 0.15). The CV death rate was lower in the MINOCA group (4.2% vs 8.4%, HR 0.26, 95%CI 0.08-0.86;p = 0.03), whereas the rates of non-fatal reinfarction (17.3% vs 25.4%; HR 0.76, 95%CI 0.52-1.13;p = 0.18), non-fatal ischemic stroke (9.5% vs 3.7%; HR 1.79, 95%CI 0.87-3.70;p = 0.12), and all-cause mortality (14.1% vs 20.7%, HR 0.73, 95%CI 0.43-1.25;p = 0.26) were not significantly different in the two groups. The rate of rehospitalisation for coronary revascularisation was lower among the MINOCA patients (6.7% vs 27.7%; HR 0.27, 95% CI 0.15-0.47;p < 0.001). CONCLUSIONS: MINOCA is frequent and not benign in patients with early-onset MI. Although there is a lower likelihood of CV death,the long-term risk of MACE and overall mortality is not significantly different from that of MICAD patients.

[An unusual case of ischemic mitral valve]. / Un insolito caso di valvola mitrale ischemica.

Mechanisms leading to mitral regurgitation can be multiple and have different etiologies. We present the case of severe mitral insufficiency due to posterior papillary muscle rupture in a young man, with exertional dyspnea, but permanently asymptomatic for chest pain and without clinical and laboratory signs of myocardial ischemia at the time of our evaluation.

The Cardiac Rehabilitation Psychodynamic Group Intervention (CR-PGI): An Explorative Study.

Objective: An explorative study focusing on the process of a Cardiac Rehabilitation Psychodynamic Group Intervention (CR-PGI) addressed to myocardial infarction (MI) patients is discussed. The study aimed at analyzing whether the treatment based on CR-PGI serves as a communicational context within which MI patients are enabled to explore new interpretations of their post-infarction condition. Methods: The intervention, divided into 12 weekly one-hour group sessions, was addressed to MI patients recruited within a Public Hospital of southern Italy. Each session was audio-recorded and lexical correspondence analysis (LCA) was applied to the verbatim transcripts, in order to provide a map of the evolution of the communication exchange occurring over the 12 sessions. Results: The findings showed that the discourses associated to the first eight sessions differed from the discourses of the last four sessions. Two main transitions occurred. The first concerns the response to the infarction, first interpreted as a process of affective elaboration and afterwards as practical management of the functional aspects associated with the condition of MI patients. The second concerns the nature of the change and contrasts a lifestyle-oriented model with a social role approach, which refers to social, legal, and medical practices related to the acknowledgment of being an MI patient. Conclusion: The findings offer preliminary support to the capacity of CR-PGI to work as a context where new meanings for the biographical rupture of the MI can be explored. Consistently with the rationale of the model, the intervention seems to have promoted the emergence of new ways of feeling and understanding one's condition.

[The APULIA HF multicenter study: efficacy of a management protocol shared between hospital and territorial health services for acute decompensated heart failure patients]. / Studio multicentrico APULIA HF: efficacia di un protocollo di gestione condiviso fra ospedale e territorio dei pazienti ospedalizzati per scompenso cardiaco acuto.

BACKGROUND: The aim of this study was to demonstrate the efficacy of a management model to reduce hospitalizations in patients recently admitted for acute decompensated heart failure. METHODS: The management model was based on a close integration between hospital and territory health services. Clinical evaluation, ECG, echocardiographic findings, total body bioimpedance and brain natriuretic peptide serum levels were used to assess clinical stability of patients at discharge and during follow-up. A dedicated nurse (care manager) was involved in patient empowerment, telephone follow-up, check of adherence to therapy and clinical conditions, and management of scheduled evaluations. All hospitalizations occurring prior to or after enrolment in the municipalities involved in the study were considered, as well as the hospitalizations occurring among enrolled patients. RESULTS: A total of 301 patients were enrolled, 226 of them from the Centers of the Puglia Region, Italy. An overall reduction of 6% in total hospitalizations with DRG 127 was observed; the reduction was most evident in the two centers with the smaller reference population (-16% and -26%, respectively). In the group of patients enrolled, an overall reduction in hospital admissions was observed after comparing the period before and after enrolment. A significant increase in the prescription rate of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, beta-blockers and aldosterone antagonists was also observed. Finally, an overall reduction in the costs for patient management was demonstrated. Similar results were obtained in the two additional Centers of the Basilicata and Lazio Regions. CONCLUSIONS: An integrated management between hospital and territory allows optimization of the management of heart failure patients, with improvement of therapy and reduction in hospitalizations and management costs.

[Metabolic syndrome: a true syndrome or only a cluster of risk factors?]. / Sindrome metabolica o solo un "cluster" di fattori di rischio?

Although the classical cardiovascular risk factors (such as smoking, hypertension and hypercholesterolemia) are becoming gradually more effectively controlled, a continuous increase of the so-called "cardiometabolic risk" linked to obesity and impaired glycemic control is observed. Starting from the beginning of this century, the definition of the "metabolic syndrome" has become very popular to identify a combination of different factors concurring to increase cardiovascular risk. In the medical literature a controversy does exist concerning this question: is the metabolic syndrome a real syndrome or should it be considered a simple cluster of risk factors? In this synthetic review the analysis of the most recent studies suggests that a) the metabolic syndrome causes an increased cardiovascular risk; b) this risk varies in accordance with the number and characteristics of the diagnostic criteria used; and c) the adjustment for the traditional risk factors lowers but does not eliminate entirely the incremental relative risk attributable to the metabolic syndrome. Whether the risk of metabolic syndrome is greater than the risk attributable to the sum of each component remains to be elucidated. However, the most reliable evidence supports the opinion that the risk prediction associated with this syndrome is not greater than the sum of its parts.