[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.

Side Branch is the Main Determinant Factor of Bifurcation Lesion Complexity: Critical Review with a Proposal Based on Single-centre Experience.

Although bifurcation stenting can be often managed with a simple provisional approach, in some settings, more complex techniques are appropriate. Based on our clinical experience and on data from literature, we propose a simple algorithm that may assist in selecting cases for elective double stenting. We found that, when the side branch is of adequate dimensions and affected by significant disease (longer than 10 mm and/or with presence of ostial calcifications), double stenting is associated with a lower incidence of adverse events, compared with provisional stenting.

Polymicrobial intensive care unit-acquired pneumonia: prevalence, microbiology and outcome.

BACKGROUND: Microbial aetiology of intensive care unit (ICU)-acquired pneumonia (ICUAP) determines antibiotic treatment and outcomes. The impact of polymicrobial ICUAP is not extensively known. We therefore investigated the characteristics and outcomes of polymicrobial aetiology of ICUAP. METHOD: Patients with ICUAP confirmed microbiologically were prospectively compared according to identification of 1 (monomicrobial) or more (polymicrobial) potentially-pathogenic microorganisms. Microbes usually considered as non-pathogenic were not considered for the etiologic diagnosis. We assessed clinical characteristics, microbiology, inflammatory biomarkers and outcome variables. RESULTS: Among 441 consecutive patients with ICUAP, 256 (58%) had microbiologic confirmation, and 41 (16%) of them polymicrobial pneumonia. Methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, and several Enterobacteriaceae were more frequent in polymicrobial pneumonia. Multi-drug and extensive-drug resistance was similarly frequent in both groups. Compared with monomicrobial, patients with polymicrobial pneumonia had less frequently chronic heart disease (6, 15% vs. 71, 33%, p = 0.019), and more frequently pleural effusion (18, 50%, vs. 54, 25%, p = 0.008), without any other significant difference. Appropriate empiric antimicrobial treatment was similarly frequent in the monomicrobial (185, 86%) and the polymicrobial group (39, 95%), as were the initial response to the empiric treatment, length of stay and mortality. Systemic inflammatory response was similar comparing monomicrobial with polymicrobial ICUAP. CONCLUSION: The aetiology of ICUAP confirmed microbiologically was polymicrobial in 16% cases. Pleural effusion and absence of chronic heart disease are associated with polymicrobial pneumonia. When empiric treatment is frequently appropriate, polymicrobial aetiology does not influence the outcome of ICUAP.

Immediate and medium-term outcomes following the treatment of very long (> or =50 mm) chronic total coronary artery occlusions.

OBJECTIVE: The follow-up patency rates and associated clinical and angiographic variables following stenting of very long (> or =50 mm) and chronic (>6 months) total coronary artery occlusive lesions are not well documented. The aim of the present study was to evaluate the early results and mid-term outcomes following angioplasty of such lesions. METHODS: Between January 2000 and June 2002, we treated 278 chronic coronary occlusions. Of these, eighty-nine occlusions (89 patients) were with lesions > or =50 mm long; these patients constituted the study population. RESULTS: Mean duration of occlusion was 7 +/- 2 months (range, 6-13 months). Procedural success was obtained in 81 patients. A total of 211 coronary stents (2.6 +/- 1.1 stents/patient) were implanted, and mean stent length was 59 +/- 9 mm. In 3 patients, TIMI flow 1-2 was observed after stent implantation. Thus, the angiographic success was considered to be 78/89 patients (87.6%). Periprocedural major adverse cardiac events occurred in 6 patients (6.7%). Clinical success was obtained in 74 patients (83%). During a 9.6 +/- 2 month follow-up, forty-three patients (55.1%) remained angina free, thirty-two (41%) had recurrence of angina, three patients (3.9%) had a new myocardial infarction and no deaths were reported. Target vessel revascularization was required in 34 patients (43.6%). Angiographic follow-up was obtained in 70 patients (90%) at a mean of 7.4 +/- 2 months. Restenosis was observed in 36 patients (51%), six of whom had reocclusion. A significant correlation was observed between the need for reintervention and stent length (R 0.52), residual stenosis (R 0.73) and diabetes mellitus (0.68). CONCLUSION: Although coronary artery stenting for very long (> or =50 mm) chronically occlusive lesions is feasible, safe and associated with a low incidence of periprocedural adverse clinical events, these complex and expensive procedures still have a high 6-month restenosis rate. These results might be significantly improved with the advent of drug-eluting stents.

In patients with coronary artery disease endothelial function is associated with plasma levels of C-reactive protein and is improved by optimal medical therapy.

BACKGROUND: Endothelial function is impaired in patients with coronary artery disease (CAD); in these patients plasma levels of C-reactive protein (CRP) and impaired endothelial function are related to future cardiac events. The aim of the present study was to evaluate the effects of medical therapy on endothelial function and CRP in patients with CAD. METHODS: Seventy-three patients (52 men, 21 women, mean age 66 +/- 9 years) with CAD and 32 control subjects (25 men, 7 women, mean age 65 +/- 11 years) were enrolled in the study. The endothelial function was evaluated by means of flow-mediated dilation (FMD) of the brachial artery following ischemia and CRP by means of a high-sensitivity assay. After baseline evaluation of CRP and FMD all patients received full medical therapy for 3 months and were then again tested for endothelial function and CRP. RESULTS: Compared to healthy controls, patients had significantly more impaired endothelial function (FMD 3.6 +/- 3.2 vs 8 +/- 2.4%, p < 0.01) and higher CRP plasma levels (1.6 +/- 0.9 vs 0.9 +/- 0.56 mg/dl, p < 0.05). At baseline a significant negative correlation was found between CRP plasma levels and FMD in patients with CAD (r = -0.56, p < 0.05) while no correlation was found in controls. Medical therapy resulted in a significant improvement in endothelial function (3.64 +/- 3 vs 7.2 +/- 3.5%, p < 0.01), and a decrease of CRP (-0.26 +/- 0.19, p < 0.01); the changes in CRP and FMD were independent of the drug used. A positive correlation was found between the improvement in FMD and the degree of CRP reduction (r = 0.57, p < 0.01). CONCLUSIONS: In patients with CAD plasma levels of CRP are associated with an impaired endothelial function suggesting a correlation between inflammation and the integrity of the endothelium. Full medical therapy reduces CRP with a parallel improvement in endothelial function.

Increased levels of C-reactive protein after oral hormone replacement therapy may not be related to an increased inflammatory response.

BACKGROUND: It has been suggested that hormone replacement therapy (HRT) in postmenopausal women is associated with an increased inflammatory response that may trigger acute cardiovascular events. This suggestion is mainly based on the finding of elevated C-reactive protein (CRP) levels after HRT. The aim of the present study was to evaluate a broad spectrum of vascular inflammation markers in 389 postmenopausal women with increased cardiovascular risk at baseline and after either 6 months of HRT (126 women) or no HRT (263 women). METHODS AND RESULTS: Compared with baseline, CRP levels significantly increased after HRT (0.9+/-0.2 versus 1.6+/-0.4 mg/L, P<0.01); on the contrary, soluble intracellular adhesion molecule-1 decreased from 208+/-57 to 168+/-37 ng/mL (P<0.01) after HRT. Similarly, vascular cell adhesion molecule-1 decreased from 298+/-73 to 258+/-47 ng/mL (P<0.01), plasma E-selectin levels were reduced from 17.8+/-5.6 to 14.8+/-3.9 ng/mL (P<0.01), interleukin-6 levels decreased from 1.51+/-0.22 to 1.29+/-0.28 pg/mL, and s-thrombomodulin plasma levels decreased from 4.8+/-0.7 to 4.3+/-0.9 ng/mL (P<0.01). No significant changes in either CRP or vascular inflammatory marker were detected in women not taking HRT. CONCLUSIONS: The discrepancy between increased plasma levels of CRP and reduced plasma levels of all other markers of inflammation suggests that the increased CRP levels after oral HRT may be related to metabolic hepatic activation and not to an acute-phase response. HRT seems to be associated with an overall decrease in vascular inflammation.

Lipid profiles and endothelial function with low-dose hormone replacement therapy in postmenopausal women at risk for coronary artery disease: a randomized trial.

AIMS: To compare the effect of low (0.3 mg) and commonly prescribed (0.625 mg) doses of conjugated equine estrogens (CEE) on brachial artery flow-mediated dilation and lipid profiles. METHODS AND RESULTS: Twenty-five postmenopausal women (mean age, 65+/-6 years) at risk for coronary artery disease (CAD) (> or =2 established risk factors) entered a double-blind crossover study. Brachial artery endothelial function was evaluated by means of high-resolution vascular echography. Both CEE doses significantly decreased total cholesterol (-13%, 0.3 mg; -15%, 0.625 mg), low-density lipoprotein-cholesterol (LDL-C) (-15%, 0.3 mg; -16%, 0.625 mg), and lipoprotein(a) (-28%, 0.3 mg; -39%, 0.625 mg) values from baseline levels. Both treatments increased high-density lipoprotein-cholesterol (HDL-C) (5%, 0.3 mg; 7%, 0.625 mg) and triglycerides (3%, 0.3 mg; 8%, 0.625 mg). There was no dose effect for changes in the LDL-C/HDL-C ratio (-21%, 0.3 mg; -23%, 0.625 mg). Both doses improved brachial artery dilation during reactive hyperemia by 63% over baseline. CONCLUSION: In women at risk for CAD, low-dose hormone replacement treatment (HRT) improves lipid profiles and brachial artery endothelial function comparably to the most commonly prescribed dose. The benefit:risk ratio of low-dose HRT provides an attractive option for postmenopausal women at risk for CAD.

Subclavian artery stenting: Immediate and mid term clinical follow-up results.

BACKGROUND: Intravascular stents are increasingly being used to treat subclavian artery obstructive disease. This study aimed to assess the immediate and mid-term clinical outcome of subclavian artery stenting. METHODS AND RESULTS: Total occlusion of the subclavian artery was seen in 7 (28%) out of the 25 consecutive patients treated for subclavican artery stenosis. Mean lesion length was 14 +/- 4.3 mm. The mean preprocedure diameter stenosis was reduced from 83.2 +/- 14.9% to 9.6 +/- 5.4% postprocedure. Procedural success was achieved in all patients. Clinical follow-up was obtained in all patients. The initial success was maintained at follow-up (mean = 12 +/- 4 months) in 24 (96%) patients. Recurrence of symptoms occurred in 1 (4%) patient who had an angiographically documented restenosis four months after the procedure. It was successfully redilated. CONCLUSION: Stenting for subclavian artery obstructive disease is safe, technically feasible and has favorable clinical outcomes. It may be considered as the therapy of choice for subclavian artery obstructive disease.

Recanalization of chronic total coronary occlusions: the impact of a new specific guidewire on primary success rate.

BACKGROUND: Although chronic total occlusions are encountered frequently in patients with coronary artery disease, an effective strategy to deal with them has yet to be devised. Various new guidewires have been designed in an attempt to negotiate chronic occlusions successfully. The authors have analysed the impact of the Athlete guidewire on procedural success in this lesion subset. METHODS: Sixty-two consecutive patients undergoing percutaneous intervention for chronic total occlusions over a two-year period were retrospectively studied. For the initial attempt, conventional guidewires were used. In case of failure, further attempts were made using the Athlete guidewire. Procedural success rates with the use of conventional and Athlete guidewires were assessed. RESULTS: Failure of the first attempt with the conventional guidewire occurred in 32 (51.6%) patients and success was achieved in 30 (48.4%) patients. In the former patients, a second attempt was made using the Athlete guidewire to cross the occlusion. The second attempt was successful in 20 patients (60%) in whom the first attempt was unsuccessful, while in the remaining 12 (40%) patients the occlusion could not be crossed even during the second attempt and the procedure was then terminated. Following the use of the Athlete guidewire, the success rate increased to 62% (p < 0.001). No complication occurred during the first attempt, while one patient had a coronary perforation using the Athlete guidewire, which was managed successfully without the need for bypass surgery. CONCLUSION: The use of the Athlete guidewire is feasible and safe, and enhances the chances of successfully treating chronic total occlusions during percutaneous coronary revascularization procedures.