Giuseppe Favretto

Clinical features and short term outcomes of patients with acute pulmonary embolism. The Italian Pulmonary Embolism Registry (IPER)

BACKGROUND Registries are essential to obtain information on the whole spectrum of patients with pulmonary embolism (PE). The aim of the Italian Pulmonary Embolism Registry (IPER) is to report on demographics, clinical features, management, and outcomes of patients diagnosed with PE in everyday clinical practice. METHODS Patients with confirmed acute PE were enrolled in a web-based registry, in Cardiology, Emergency or Internal Medicine Departments in 47 hospitals in Italy. RESULTS Overall, 1716 patients were included, mean age 70 ± 15 years, (14% of the patients were <50 and 43% >75 year old); 57% of female gender and 11.7% hemodynamically unstable at presentation/diagnosis. D-dimer was performed in 1358 patients (80%). Computerized tomographic pulmonary angiogram (CT) was used for diagnosis in the majority of the patients (82.1%), followed by perfusion lung scan (8.6%). Thrombolytic agents were used in 185 (10.8%) patients, percutaneous thrombectomy in 14 (0.8%) and surgery in 2 (0.1%). One hundred sixteen patients died while in-hospital (6.7%), 68 (3.9%) due to PE. Death or clinical deterioration occurred in 138 patients (8.0%). All-cause mortality was 31.8% in hemodynamically unstable patients and 3.4% in hemodynamically stable patients; the corresponding PE-related deaths were 23.3% and 1.4% respectively. Age >75 (HR 1.50, 95% CI 1.01-2.25), immobilization > 3 days before diagnosis of PE (HR 2.54, 95% CI 1.72-3.77) and hemodynamic impairment (HR 6.38, 95% CI 4.26-9.57) were independent predictors for in-hospital death. CONCLUSIONS Patients with PE have a considerable risk of death during the hospital stay, PE being the most common cause of early mortality.

Prevalence and management of familial hypercholesterolemia in patients with coronary artery disease: The heredity survey

BACKGROUND AND AIMS Familial hypercholesterolemia (FH) is a genetic disorder characterized by high levels of low density lipoprotein cholesterol (LDL-C) predisposing to premature cardiovascular disease. Its prevalence varies and has been estimated around 1 in 200-500. The Heredity survey evaluated the prevalence of potential FH and the therapeutic approaches among patients with established coronary artery disease (CAD) or peripheral artery disease (PAD) in which it is less well documented. METHODS Data were collected in patients admitted to programs of rehabilitation and secondary prevention in Italy. Potential FH was estimated using Dutch Lipid Clinic Network (DLCN) criteria. Potential FH was defined as having a total score≥6. RESULTS Among the 1438 consecutive patients evaluated, the prevalence of potential FH was 3.7%. The prevalence was inversely related to age, with a putative prevalence of 1:10 in those with <55yrs of age (male) and <60yrs (female). Definite FH (DLCN score>8) had the highest percentages of patients after an ACS (75% vs 52.5% in the whole study population). At discharge, most patients were on high intensity statin therapy, but despite this, potential FH group still had a higher percentage of patients with LDL-C levels not at target and having a distance from the target higher than 50%. CONCLUSIONS Among patients with established coronary heart disease, the prevalence of potential FH is higher than in the general population; the results suggest that a correct identification of potential FH, especially in younger patients, may help to better manage their high cardiovascular risk.

ANMCO Position Paper: Long-term follow-up of patients with pulmonary thromboembolism

Abstract Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, is the third most common cause of cardiovascular death. The management of the acute phase of VTE has already been described in several guidelines. However, the management of the follow-up (FU) of these patients has been poorly defined. This consensus document, created by the Italian cardiologists, wants to clarify this issue using the currently available evidence in VTE. Clinical and instrumental data acquired during the acute phase of the disease are the cornerstone for planning the FU. Acquired or congenital thrombophilic disorders could be identified in apparently unprovoked VTE during the FU. In other cases, an occult cancer could be discovered after a VTE. The main targets of the post-acute management are to prevent recurrence of VTE and to identify the patients who can develop a chronic thromboembolic pulmonary hypertension. Knowledge of pathophysiology and therapeutic approaches is fundamental to decide the most appropriate long-term treatment. Moreover, prognostic stratification during the FU should be constantly updated on the basis of the new evidence acquired. Currently, the cornerstone of VTE treatment is represented by both the oral and the parenteral anticoagulation. Novel oral anticoagulants should be an interesting alternative in the long-term treatment.

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.

Position paper ANMCO: Raccomandazioni per il follow-up del paziente con tromboembolia polmonare

: Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is the third most common cause of cardiovascular death. The management of the acute phase of VTE is well described in several papers and guidelines, whereas the management of the follow-up of the patients affected from VTE is less defined. This position paper of the Italian Association of Hospital Cardiologists (ANMCO) tries to fill the gap using currently available evidence and the opinion of the experts to suggest the most useful way to manage patients in the chronic phase.The clinical and laboratory tests acquired during the acute phase of the disease drives the decision of the following period. Acquired or congenital thrombophilic factors may be identified to explain an apparently not provoked VTE. In some patients, a not yet clinically evident cancer could be the trigger of VTE and this could lead to a different strategy. The main target of the post-acute management is to prevent relapse of the disease and to identify those patients who could worsen or develop chronic thromboembolic pulmonary hypertension. The knowledge of the etiopathogenetic ground is important to address the therapeutic approach, choosing the best antithrombotic strategy and deciding how long therapy should last. During the follow-up period, prognostic stratification should be updated on the basis of new evidences eventually acquired.Treatment of VTE is mainly based on oral or parenteral anticoagulation. Oral direct inhibitors of coagulation represent an interesting new therapy for the acute and extended period of treatment.

Diagnosi e terapia dell'ipertensione arteriosa polmonare nelle Cardiologie italiane: risultati dell'indagine conoscitiva INCIPIT2

BACKGROUND: Pulmonary arterial hypertension (PAH) is a rare clinical condition characterized by increased pulmonary vascular resistance and premature death. It is necessary to activate a pathway from the screening of pulmonary hypertension to the diagnosis of PAH, so as to use the drugs able to improve the outcome. Nowadays, in Italy, there are no data about the management of PAH in peripheral centers and about the integration of peripheral centers with those of excellence. METHODS: In order to have a map of the actual Italian pathway for diagnosis and therapy of PAH, on behalf of the ANMCO Pulmonary Circulation Area, 923 Italian cardiology departments were asked to reply, on a special electronic file, to a few simple questions about their organization, from December 2012 to May 2013. RESULTS: 101/923 centers (48 in the North, 18 in the Middle, 35 in the South) answered correctly. 32% has no organization for PAH, 68% has a pathway for PAH diagnosis and management, and two thirds of them collaborate with excellence centers. 36 centers perform right heart catheterization with vascular reactivity (21 with nitric oxide, 8 with adenosine, 5 with epoprostenol, 2 with nitric oxide or epoprostenol). 61/101 are prescriber centers: 33 perform right heart catheterization with vascular reactivity test, 23 send their patients to the reference center for right heart catheterization, 5 perform no right heart catheterization before the prescription of specific drugs for PAH, and only 14 prescribe intravenous prostanoids. In 2011, the participating centers followed 561 patients with PAH, of whom 126 (23%) were in independent centers. With regard to the network organization of the groups, the participating centers are partly independent of the diagnostic pathway, partly refer to outside regions; in others there is a structured regional network and there are 3 Italian regions with Hub & Spoke networks that receive patients coming from other regions. CONCLUSIONS: Our results show the interest of Italian Cardiology to find a pathway for the diagnosis of PAH and a heterogeneity suggesting the need for a shareable pathway, thus improving the collaboration between peripheral cardiology departments and the excellence centers for PAH in a functional Hub & Spoke network.