Salvatore Evola

Troponin I/ejection fraction ratio: a new index to differentiate Takotsubo cardiomyopathy from myocardial infarction.

– Transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid-segments with or without apical involvement; the regional wall motion abnormalities extend beyond a single epicardial vascular distribution; a stressful trigger is often, but not always, present; – Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; – New ECG abnormalities (either ST-segment elevation and/or T wave inversion) or modest elevation in cardiac troponin; and – Absence of pheochromocytoma or myocarditis.

Angiographic Evaluation of Coronary Microvascular Dysfunction in Patients with Heart Failure and Preserved Ejection Fraction.

The aim of this study was to evaluate myocardial perfusion and coronary blood flow through validated angiography indices to assess whether there is greater MVD in patients with microvascular angina and HFPEF compared to those who do not have.

G-protein-coupled receptor kinase 5 polymorphism and Takotsubo cardiomyopathy.

Background Takotsubo cardiomyopathy (TTC) is an increasingly reported clinical syndrome that mimics acute myocardial infarction without obstructive coronary artery disease and is characterized by transient systolic dysfunction of the apical and/or mid-segments of the left ventricle. The syndrome mainly occurs in postmenopausal women with high adrenergic state conditions. Nowadays, the pathophysiology of TTC is not yet known and the possibility of a genetic predisposition is controversial. Aims The purpose of this study was to assess the genetic susceptibility to TTC through analysis of the L41Q polymorphism of the G-protein-coupled receptor kinase 5 (GRK5). Methods and results In a cohort of 20 patients enrolled in two tertiary Italian centers with diagnosis of TTC, accordingly to the commonly accepted Mayo Clinic criteria and in 22 healthy individuals (control) we have evaluated the polymorphism in GRK5 gene. The TTC patients had a mean age of 65 ± 9 years and 19 of 20 were women. The presence of one or two L41 alleles of GRK5 was significantly more frequent in TTC group than in the control group (40 vs. 8%, P = 0.0372). Conclusion In our study, we have found a significant difference in the frequency of GRK5 polymorphism between TTC patients and controls, supporting a genetic predisposition to this cardiac syndrome.

Risk factors for contrast induced nephropathy: A study among Italian patients

This study aimed to make a profile of patients at highest risk of developing contrast induced nephropathy (CIN) in order to take appropriate prevention measures. 591 patients undergoing coronary procedures were divided into two groups: patients with (CIN-group) and without (no-CIN) an increase in creatinine level equal or more than 25% from baseline values within 24-48 h after the coronary procedure. All patients underwent an accurate anamnesis, objective exam, hematochemical measurements, and diagnostic exams. The results of this study while confirming that, average age (p = 0.01), diabetes mellitus (p < 0.0001), base line renal insufficiency (p = 0.0001), diuretic therapy (p = 0.002), higher contrast doses (p = 0.01), are associated with a higher risk of contrast-induced nephropathy, also demonstrated that both clinical (p = 0.01) and subclinical (p < 0.0001) atherosclerosis, and higher preprocedural high sensitive C-reactive protein levels (hs- CRP) (p = 0.02) are risk factors for CIN.

The percutaneous closure of patent foramen ovale (PFO): impact on the quality of life.

Patent foramen ovale (PFO) is an abnormal communication between the right and the left atriumdue to an incomplete fusion between septum primum and septum secundum [1]. It involves 25–30% of the general population [2]. PFO is often associated to cryptogenic cerebral vascular accident (CVA) [3,4] and migraine with aura [5]. PFO can be also associated with other anatomical abnormalities (Chiari network, septal aneurysm, eustachian valve) which can increase the shunt [1]. As the prevailing increase of PFO percutaneous interventions, we found interesting to assess the “Quality of Life” after percutaneous closure, intending to describe the state of physical, psychological and social well-being. In our center between July 2009 and July 2012, the percutaneous closure of PFO was performed in 34 patients: 20 women (58.8%) and 14 men (41.2%); mean age 46±9.67. The diagnosis of right to left shunt was achieved by the bubble test (9 ml of saline and 1 ml of air) with the transcranial Doppler (TCDc). Then a trans-thoracic echocardiography (TTE) confirmed the right to left shunt of micro-bubbles and allowed to find out the presence of atrial septal aneurysm (ASA) and other anatomical anomalies such as the Chiari network and the eustachian valve. The anatomical and functional characteristics of PFO were then better studied with transesophageal echocardiography (TEE)-(Fig. 1). The indications employed for percutaneous treatment, after careful echocardiographic studies and neurological consults, consist in the occurrence of ischemic events TIA/STROKE, classified as cryptogenic nature (65% of our treated patients), often recurrent, or the presence of multiple cerebral ischemic lesions detected with MRI, even if asymptomatic, for which no valid etiopathogenetic cause could be identified. Moreover 56% complained frequent and debilitating episodes of migraine with aura before treatment. Percutaneous PFO closure was performed under local anesthesia with intracardiac ultrasound guidance (9 MHz Ultra ICE, Boston Scientific Corporation, San Jose, California) to optimize the positioning of the devices. The PFO devices used up to now are: Amplatzer® (4 patients 11.8%), Cardia® (4 patients 11.8%), and Figulla® Flex PFO Occluder (26 patients 76.4%). All patients were then treated with acetylsalicylic acid 100–325 mg/die and Ticlopidine 500 mg/die or Clopidogrel 75 mg/die for the first six months and then only acetylsalicylic acid for another 6 months. The follow-up includes a Holter-ECG (7 days after closure) and then programmed controls: TTE at 1 and 3 months, TTE+TCDc at 6 months and at 1 year. After informed consent, our treated patients were subjected to a validated questionnaire, “Quality of Life” (QoL) SF 36 V1 standard [6], administered before PFO closure and then after 6 months. The questionnaire is a self-compile generic test on quality of life studying multiple aspects of the psycho-physical well-being of the subject through 36 questions. The result obtained from the responses is represented by 8 scales, which is a quantification of a specific aspect of health status. Among our 34 treated patients, 4 were excluded from the study for recent closure; 29 patients were subjected to QoL questionnaire while n=1 was unavailable. The mean values obtained on different fields, from the analysis of the questionnaires, before and after treatment administration, were compared using the Student t-test for paired samples, in order to assess the statistical significance of improvements on quality of life. The obtained values are expressed as mean±1 SD. A p value of b0.05 was considered statistically significant. The procedure was successfully performed in 34 treated patients. No complicationswere recorded during the procedure. The presence of newonset atrial fibrillation (AF) was excluded. A closure rate of 86.6% was obtained and no cerebrovascular symptomatic events occurred in treated patients, until now. The QoL SF-36 questionnaire reported a positive impact of the procedure on the quality of life by re-appropriation of normal daily activities; also from the psychological point of view. The comparison of the mean values obtained from the analysis on different fields of the questionnaire, before and after treatment, has suggested a statistically significant improvement in quality of life (Table 1). This result is reasonably related to the improvement of migraine patients which were confined below all aspects. Among our 19 patients which were affected from severe migraine with aura, 94.7% had in fact a significant benefit in health, due to an important reduction of the migraine frequency and severity or even their interruption (p=0.0001). In patients with cryptogenic stroke and PFO, the percutaneous closure treatment represents a possible and effective procedure and a possible alternative to the only antiplatelet or anticoagulant medical therapy conducted for a lifetime [7,8], even if the first randomized controlled trial, CLOSURE I,has not demonstrated the superiority of the percutaneous treatment against themedical therapy [9]. In our center the percutaneous technique was initiated relatively recently, however our results are encouraging. We considered only the presence of CVA as the main

Diagnosi di disfunzione del microcircolo coronarico in pazienti diabetici con sindrome X cardiaca: confronto tra le metodiche attualmente in uso

: The study population included 208 patients with chest pain and uninjured coronary arteries that we split into two populations: diabetics (72 patients) and non-diabetics (136 patients). We split patients with chest pain and uninjured coronary arteries that had a myocardial scintigraphy into two populations: patients with positive scintigraphy and negative. We calculated, on angiographic images of each patient, stored on suitable digital supports, Timi Frame Count (TFC), Myocardial Blush Grade (MBG) and Total Myocardial Blush Score (TMBS) using the protocol described by Gibson and Yusuf. On the basis of Yusufs experience we imagined a new index: the Total Timi Frame Count as the sum of the three coronary Timi Frame Count. From our results we found a worse coronary microcirculation in diabetic patients with lower values of TFC, MBG and TMBS (p=0.02),compared with non- diabetics. New index TTFC is usually higher in diabetics than non-diabetic patients. Patients with positive scintigraphy had a worse TMBS than patients with a negative one, with a high statistical significance (p=0.003).We focused on the correlation between scintigraphy defect and angiography data in the arteries of ischemia relieved by nuclear imaging. The analysis showed that healthy vessels had a lower TFC than diseased vessels and therefore a better microcirculation with a high statistical significance (p=0.0001). According to the literature, diabetic population has a major microcirculation disease; moreover the study of microcirculation by coronary angiography and myocardial scintigraphy shows a good correlation between two methods.The study population included 208 patients with chest pain and uninjured coronary arteries that we split into two populations: diabetics (72 patients) and non-diabetics (136 patients). We split patients with chest pain and uninjured coronary arteries that had a myocardial scintigraphy into two populations: patients with positive scintigraphy and negative. We calculated, on angiographic images of each patient, stored on suitable digital supports, Timi Frame Count (TFC), Myocardial Blush Grade (MBG) and Total Myocardial Blush Score (TMBS) using the protocol described by Gibson and Yusuf. On the basis of Yusufs experience we imagined a new index: the Total Timi Frame Count as the sum of the three coronary Timi Frame Count. From our results we found a worse coronary microcirculation in diabetic patients with lower values of TFC, MBG and TMBS (p=0.02),compared with non- diabetics. New index TTFC is usually higher in diabetics than non-diabetic patients. Patients with positive scintigraphy had a worse TMBS than patients with a negative one, with a high statistical significance (p=0.003).We focused on the correlation between scintigraphy defect and angiography data in the arteries of ischemia relieved by nuclear imaging. The analysis showed that healthy vessels had a lower TFC than diseased vessels and therefore a better microcirculation with a high statistical significance (p=0.0001). According to the literature, diabetic population has a major microcirculation disease; moreover the study of microcirculation by coronary angiography and myocardial scintigraphy shows a good correlation between two methods.

Impact of Dual Antiplatelet Therapy with Proton Pump Inhibitors on the Outcome of Patients with Acute Coronary Syndrome Undergoing Drug-Eluting Stent Implantation

This study aimed to assess if proton pump inhibitors (PPIs) may reduce the effectiveness of clopidogrel, than H2 antagonist (anti-H2) in order to determine rehospitalization for acute coronary syndrome (re-ACS), target vessel revascularization (TVR) and cardiac death. This case-control study included 176 patients with ACS undergoing angioplasty (PCI) with drug-eluting stent implantation. The population was divided into two groups: PPI group (n = 121) consisting of patients receiving at discharge dual antiplatelet therapy (DAT) plus PPI and anti-H2 group (n = 55), consisting of patients receiving at discharge DAT + H2 receptor antagonist (H2RA). In a followup of 36 months the prevalence of ACS event (P = 0.014), TVR (P = 0.031) was higher in the PPI group than in the anti-H2 group; instead there was no statistically significant difference between groups for death. The variables independently associated with ACS were the diabetes, omeprazole, and esomeprazole; instead the variables independently associated with TVR were only omeprazole. Our data shows that the use of omeprazole and esomeprazole, with clopidogrel, is associated with increased risk of adverse outcomes after PCI with drug-eluting stent implantation.

The association between coronary microvascular dysfunction and carotid intima media thickness in patients with cardiac syndrome X

OBJECTIVE The aim of this study was to evaluate in patients with cardiac syndrome X (CSX), using validated angiography indices, coronary blood flow and myocardial perfusion of the microcirculation to assess whether there is greater microvascular dysfunction in patients with increase of carotid intima media thickness (C-IMT), compared to those who do not have. METHODS Our study was performed on a population 124 patients with CSX that underwent coronary angiography and carotid ultrasound. We divided the sample into two categories: patients with increase of C-IMT and those without increase. We calculated Gibson and Yusuf indices for each patient based on angiographic images, including TIMI Frame Count (TFC), Myocardial Blush Grade (MBG) and Total Myocardial Blush Score (TMBS). RESULTS Our sample compared two groups: patients with increase of C-IMT (n-63) and patients without increase of C-IMT (n-61). We showed that patients with increase C-IMT had a longest TFC of three major coronary arteries (TFC LAD 44.7±12.5; TFC RCA 26.2±6.9; TFC CX 27±5.9), than control group. We found lower MBG on three coronary arteries (MBG LAD 2.5±0.3; MBG RCA 2.3±0.3; MBG CX 2.1±0.32) in patients with increase of C-IMT than control group, with good statistical significance. CONCLUSION Analysis of microcirculation trough angiography indexes in patients with CSX with increase of C-IMT and without has led to asses that patients with increase of C-IMT population has a greater involvement of microcirculation than patients without.

Real-world use of ticagrelor and prasugrel in patients with NSTEMI undergoing percutaneous coronary intervention

Background and Methods Dual antiplatelet therapy is mandatory for all the patients with acute coronary syndrome, who underwent PCI. Our study includes 111 patients with NSTEMI, who underwent PCI, in a maximum time of 72 h after their ischemic event. The efficacy endpoint was represented by post-PCI TIMI grade flow, in-hospital mortality, angina and reAMI during hospitalization, whereas at 12-month follow-up the efficacy end point was represented by reAMI, ischemic stroke, and cardiac death. As safety endpoint, we analyzed the incidence of bleeding according to TIMI and GUSTO classifications. A comparison was made between the short-term outcomes of patients who switched from clopidogrel to prasugrel or ticagrelor, and the short-term outcomes of patients who received prasugrel or ticagrelor as starting treatment.

Microvascular angina in diabetic patients with uninjured coronary arteries

AimsThe study aims at the evaluation, of patients with chest pain and uninjured coronary arteries, and the impact of diabetes mellitus on coronary microcirculation. Moreover we want to verify whether a correlation between myocardial scintigraphy results and coronary angiography or not.MethodsThe study population included 316 patients (173 males,143 females) with uninjured coronary arteries. Patients with chest pain (208) were divided into two populations: diabetics (72) and non-diabetics (136).We compared 66 patients with a myocardial scintigraphy with results of angiographic indexes. On angiographic images we evaluated, on the three major epicardial, Gibson’s indexes (TFC, MBG), the Yusuf’s index(TMBS) and a new index: Total Timi Frame Count (TTFC).ResultsPatients with positive scintigraphy had a worse TMBS than patients with negative scintigraphy (p=0.003) and a lower TFC of healthy vessels than diseased vessels (p=0.0001). We found a worse coronary microcirculation in diabetic patients with lower values of MBG and TMBS (p=0.02),compared with non- diabetics. New index TTFC is usually higher in diabetics than non-diabetic patients.ConclusionThe study of microcirculation by coronary angiography and myocardial scintigraphy shows a good correlation between two methods. The analysis of diabetic patients and non-diabetic with chest pain and uninjured coronary arteries has led to assess that diabetic population has a major microcirculation disease.