Francesca Giovannelli

Management of hypertension and stroke prevention: results of the Italian cardiologist survey

Objective: To provide an overview of current habits, priorities, perceptions and knowledge of cardiologists with regard to hypertension and stroke prevention in outpatient practice.

Blood Pressure Levels at the Time of Percutaneous Coronary Revascularization and Risk of Coronary In-Stent Restenosis

BACKGROUND High blood pressure (BP) levels expose patients treated with percutaneous coronary interventions (PCI) to very high risk of 10-year cardiovascular morbidity and mortality. OBJECTIVE To investigate the role of BP levels at the time of PCI on the risk of in-stent restenosis (ISR). METHODS We retrospectively included 796 patients previously treated with PCI, who underwent repeated angiography for recurrent angina or reversible myocardial ischemia. Patients were stratified into either case (n = 354) and control (n = 442) groups in the presence or absence of ISR (defined as in-stent diameter stenosis ≥50%). BP levels were measured at the time of first and second procedures. Normal BP levels were defined for <140/90 mm Hg. RESULTS Patients with normal BP showed significantly higher ISR-free survival (Log-rank: 5.937; P = 0.015). Both systolic (HR (95% CI): 0.731 (0.590-0.906)) and systolic/diastolic BP (HR (95% CI): 0.757 (0.611-0.939)) were significantly and independently associated with lower risk of ISR at Cox-regression analysis, adjusted for potential confounding factors, including stent type and concomitant medications. Patients with ISR showed lower rates of normal systolic/diastolic BP values (166 (47%) vs. 254 (57%); P = 0.003) compared to controls. They also received higher stent number (1.40±0.74 vs. 1.24±0.51; P < 0.001) with higher stent length (24.3±15.6 vs. 21.7±13.9 mm; P = 0.012), and lower rate of drug-eluting stents (DESs) (210 (48%) vs. 139 (40%); P = 0.025) compared to controls. CONCLUSIONS Normal BP at the time of PCI is associated with nearly 24% risk reduction of ISR as evaluated in a new angiography in patients with coronary artery disease.

Transfemoral approach with systematic use of FemoSeal™ closure device compared to transradial approach in primary angioplasty

To compare the incidence of major adverse cardiac and cerebrovascular events (MACCE) and thrombolysis in myocardial infarction (TIMI) bleedings in primary percutaneous coronary intervention (pPCI) performed through transradial approach (TRA) or transfemoral approach (TFA) with systematic closure by FemoSeal™.

The Role of Cardiac Rehabilitation in the Treatment and Secondary Prevention of Cardiovascular Disease

One of the most striking developments in recent medical thinking has been the evolution of the philosophy of rehabilitation, or the ‘third phase of medical care’. The impact of this discipline on medical practice stems from the widespread intensification in contemporary medical teaching of the concept that delineates the patient’s relationship with himself, his family and work and also with the total community. Several observations have progressively led to cardiac rehabilitation being considered an important part of cardiovascular prevention and to the development of various educational programmes and clinical interventions to identify and modify major coronary risk factors and consequently to reduce morbidity and mortality in patients with established heart diseases.In this article, the most recent studies on cardiac rehabilitation programmes are reviewed. We also highlight the need for additional studies in order to evaluate the risk of exercise for patients with diagnosed or occult cardiovascular disease and, especially, to evaluate the role of physical activity relative to other interventions on healthcare costs.

Angiotensin II Receptor Antagonists

Stroke is a devastating disease that heavily affects overall cardiovascular mortality and quality of life in surviving patients, and has a relevant burden on healthcare systems. Recent data derived both from large epidemiological surveys and from the analysis of events occurring in the clinical trials on hypertension, performed over the last 10 years, indicate that the incidence of stroke remains very high. These observations highlight the need for a more effective strategy to prevent stroke, especially in the hypertensive population.Hypertension is one of the major, modifiable cardiovascular risk factors contributing to stroke development, and therapeutic control of elevated blood pressure is associated with a relevant benefit in terms of reduced stroke incidence. On the other hand, even when sufficient control of hypertension is achieved, the risk of stroke remains significantly higher in hypertensive patients than that observed in normotensive patients. For these reasons, it is important to explore whether additional benefits in terms of stroke prevention can be obtained with specific treatment beyond blood pressure control.Head-to-head comparisons between older, traditional (diuretics and β-blockers) and newer (calcium channel antagonists, ACE inhibitors and angiotensin II receptor blockers) antihypertensive drugs provided evidence on stroke prevention across a number of large, randomised studies. This evidence convincingly supports the hypothesis that those agents blocking the renin-angiotensin system may confer protection towards stroke beyond its blood pressure-lowering properties, and indicates that this may be important to how hypertension is treated. In view of the persisting low perception of the impact of treatment on stroke, as well as of the insufficient control of blood pressure and stroke in many Western countries, these novel observations may generate remarkable educational and therapeutic outcomes.

The Role of Cardiac Rehabilitation in Heart Failure Patients

Several observations have progressively led to cardiac rehabilitation (CR) being considered an important part of cardiovascular prevention. This in turn has led to various intervention programmes being developed to identify and modify risk factors and consequently reduce morbidity and mortality in patients with established heart diseases. Therefore, as a result of this, CR programmes have been developed for patients after myocardial infarction, coronary artery bypass graft surgery and percutaneous intervention. However, limited information is available on the usefulness of rehabilitation programmes in the clinical management of patients with chronic heart failure, and studies have been developed recently to evaluate the outcome of supervised physical training on patients with chronic heart failure.In this article we review the most recent studies on CR in patients with heart failure. We also highlight the need for additional studies in order to evaluate the risk of exercise for patients with diagnosed or occult cardiovascular disease and, especially, to evaluate the role of physical activity relative to other interventions, and also the impact on healthcare costs.

Natriuretic Peptides Focus on Atrial Natriuretic Peptide as a New Marker of Target Organ Damage

Natriuretic peptides (NPs) are a family of polypeptides characterised by vasorelaxing activity and potent natriuretic effects. They were first identified in 1981 by the pivotal work of de Bold and colleagues. In the 25 years elapsed since the initial discovery, an impressive amount of research has been carried out to identify the structure of the active peptide and its receptors, to characterise the biological functions of these molecules and their involvement in the pathophysiology of diseases and, finally, to identify their direct contributory role in the pathogenesis of some cardiovascular disorders.NPs include different biologically active fragments: the atrial natriuretic peptide (ANP), the brain natriuretic peptide (BNP) and C-type natriuretic peptide (CNP). Extensive research has identified some interesting features of ANP and BNP. In particular, it has been demonstrated that the ANP plays a role in the regulation of salt and water balance, as well as that of blood pressure homeostasis. In addition, ANP is involved in the pathophysiology of hypertension and heart failure, and it exerts a cellular antiproliferative effect in the cardiovascular system. More recently, a direct contributory role of ANP in the development of hypertension and cerebrovascular disorders has been demonstrated. On the other hand, BNP has a key role in congestive heart failure, particularly because of its distinct enhancement in terms of myocardial expression and production. These observations have progressively led researchers to consider ANP as a potential determinant of cardiovascular diseases and qualified BNP as a sensitive and specific marker of cardiac dysfunction.In this article, the most recently pathophysiological properties of NPs are reviewed, with particular regard to the most intriguing new hypothesis on their pathological and clinical significance in different cardiovascular settings.