bluuebunny/crossref_metadata_2025 huggingface dataset:
P35 A RARE CASE OF VENTRICULAR ARRHYTHMIA STORM AND COMPLETE ATRIOVENTRICULAR BLOCK IN A PATIENT WITH BECKER MUSCULAR DYSTROPHY
Authors: Zannoni J , Del Torto A , Tundo F , Assanelli E
Published: May 2022

A 68 year–old male presented to the Emergency Department of our Institute with palpitations for the last 20 minutes. The patient suffered from Becker’s muscular dystrophy (BMD) with hypotonic tetraparesis and dilated cardiomyopathy with moderate left ventricular dysfunction. The patient had also arterial hypertension and a previous ischemic stroke treated with thrombolysis and subsequently with warfarin. On the admission, the patient was alert, blood pressure was 90/60 mmHg and heart rate 180 bpm. An ECG (Fig. 1) showed regular, wide–complex tachycardia (QRS duration of 240 msec) with right branch block morphology with left axial deviation. A bolus of amiodarone 200 mg ev was administered without efficacy followed by a bolus of lidocaine 50 mg. The patient developed symptomatic hypotension, so external electrical cardioversion was performed with a single DC shock at 200J, effective in restoring sinus rhythm. Amiodarone and beta blocker therapy was started. On laboratory tests, the main values were normal, including the ultrasensitive troponin hs–cTnI. Echocardiography showed a mildly dilated left ventricle with diffuse hypokinesia conditioning severe reduction of systolic function (FE 35%) (Fig. 2). On subsequent telemetric ECG monitoring, no recurrences of sustained ventricular tachycardia (VT) were recorded, but it was observed an episode of complete atrioventricular (AV) block conditioning a symptomatic 9.5–second asystole, treated with atropine. Then the patient underwent CRT–D implantation in secondary prevention. The day after the procedure, an arrhythmic storm occurred and was effectively treated with multiple attempts of antitachycardia pacing and device shock. In the following days, the patient continued to present with episodes of VT despite antiarrhythmic drugs. Hence, an endo–epicardial ablation of the arrhythmic substrate was evaluated in Heart team. In view of an intubation and the high anesthesiological risk, it was indicated to continue the optimized medical therapy. Mexiletine 200 mg tid was added to metoprolol 100 mg bid and amiodarone 200 mg od. In the following days, no arrhythmic recurrences were recorded on continuous ECG monitoring. The patient was discharged from the hospital asymptomatic and with no sign of heart failure. At 2 years of follow–up, the patient remained asymptomatic, with no arrhythmic events recorded by the device and in the absence of any adverse effects caused by mexiletine.
P78 AN ANTEGRADE RECANALIZATION OF LEFT ANTERIOR DESCENDING CHRONIC TOTAL OCCLUSION WITH ORBITAL ATHERECTOMY IN PATIENT WITH SEVER LEFT VENTRICULAR DISFUNCTION
Authors: Fulgenzi F , Forlani D , Di Marco M , D‘Alleva A , Magnano R , Pezzi L , Verrengia E , Vitulli P , Corazzini A , Paloscia L
Published: May 2022

We share the case of a 71–year old man, affected by hypertension, presented in Emergency Room (ER) with chest pain. No clinical evidence of heart failure. EKG showed fast atrial fibrillation with QS complex and ST elevation in precordial leads. Echocardiogram confirmed sept and apex akinesia. Troponin I peak was 72pg/ml. In ER electrical cardioversion was efficacy performed. He was referred for invasive coronary angiography, that showed a left anterior descending (LAD) chronic total occlusion (CTO), with Rentrop grade 2 collaterals providing retrograde flow from the right coronary artery (RCA), a severe stenosis of ramus intermedius (RI) and a moderate stenosis of circumflex. A stress–echocardiogram demonstrated vitality of medio–basal anterior wall. Subsequent, recanalization procedure of LAD CTO was planned. J–CTO score was 1 (tapered calcific, lesion, <20mm). double radial access and ante grade approach was chosen. An EBU3.5 guiding catheter was engaged in the left coronary artery, and 8000 units of heparin administered. The iFR of Cx was 0.99, indicative of non significant myocardial ischemia. During hemodynamic evaluation of RI, a ventricular fibrillation occurred, treated by DC–SHOCK and PCI with stenting with no polymer, eluted with Biolimus A9 (3.0x24mm) with good result. The occlusion was crossed via an antegrade approach with an Asahi Gaia II wire and with microcatheter support. Gaia II was changed in favor of Asai Sion blu, and the IVUS catheter was enable of cross the lesion. Efficacy orbital atherectomy with Diamondback 260 was performed (5 ante and retro grade run at 80Krpm and a retro grade run at 120 Krpm. Ivus was able to cross the lesion. Efficacy pre–dilatation with semi and non compliant balloon (2.5–3.5mm) was performed and then stented with a 3.0 × 36 mm Bioloimu A9–eluting stent. Finally, IVUS confirmed correct stent expansion, achieving an excellent angiographic result. Patient was discharged with triple anti–thrombotic therapy, with indication to “life jacket” till the assessment at 1 month.
P83 PERCUTANEOUS INTERVENTION FOR AORTIC COARCTATION IN YOUNG ADULTS: A CASE SERIES
Authors: Virgili G , Muraca I , Carrabba N , Bruscoli F , Migliorini A , Pennesi M , Pontecorboli G , Marchionni N , Bovenzi F , Stefàno P , Valenti R
Published: May 2022

Introduction

Aortic coarctation is one of the most frequent misdiagnosed congenital heart diseases and the most commonly missed foetal congenital heart disease. In adulthood the treatment of this pathology is primarily percutaneous.

Case Presentation

We present a case series of two young patients. The formers was a 37–years–old male with recent onset of heart failure symptoms due to misdiagnosed congenital aortic coarctation. The latter was a 39–years–old woman with exertional dyspnoea and a previous operated bicuspid aortic valve; in this case the intervention for the aortic defect was made in a second time, in order to avoid a huge demolishing surgical procedure. The execution of a diagnostic multimodality imaging allowed to detect the aortic coarctation, which received indication to percutaneous correction of the aortic defect after the multidisciplinary “Heart Team” discussion (image 2 and 3). In the cath–lab, the use of novel digital techniques, integrating the angiographic images with previously acquired angio–CT, allowed a safe stent delivery with minimum amount of contrast injection (image 1).

Conclusion

Percutaneous treatment of aortic coarctation in young adult is safe and effective. Fusion imaging tools could be very useful to optimize procedural results and sparing contrast dye, suggesting their possible implementation in different percutaneous procedures.
P99 LONG TERM DUAL ANTIPLATELET THERAPY AFTER MYOCARDIAL INFARCTION IN CLINICAL PRACTICE: IMPACT OF NUISANCE BLEEDING ON MEDICATION ADHERENCE
Authors: Ratti G , Monda C , Di Tommaso C , Ratti F , Fulgione L , Fulgione C , Mallardo M , Tammaro P
Published: May 2022

Background

Long term dual antiplatelet therapy (LTDAPT) with ticagrelor 60 mg and low–dose aspirin are indicated after acute coronary syndrome (ACS) for the secondary prevention of atherothrombotic events in high–risk patients with a history of ACS of at least 1 year. LTDAPT had a well tolerability and safety profile, but the risk of TIMI major bleeding was increased. However even non significant bleeding may be important because have an effect on quality of life and therefore may lead to treatment discontinuation. Objective To understand the experiences of patients with LTDAPT and nuisance bleeding, and their impact on medication adherence.

Methods

We retrospectively reviewed 225 patients in follow up after ACS with at least one high risk condition (Fig. 1), treated with ticagrelor 60 mg twice daily (after 90 mg twice daily for 12 months). The outpatient follow–up program after hospitalization provides a visits at day 30 after discharge and subsequently after 3 months, then continuing with six–monthly checks. The intensity of bleeding was assessed according to the TIMI score. Any overt bleeding event that did not meet the criteria of major and minor was defined “minimal”.

Results

they are shown in Fig. 2. Minmal bleedings were present in 49 patients (21%), but were not a cause for discontinuation of therapy. However 39 (79%) subjects had asked opinion on stop the therapy at the telephone consultation. We found that: (1) participants adhered to treatment when they believed long term DAPT was important to health outcomes; (2) those who experienced nuisance bleeding reported symptoms to be mild and manageable; (3) participants’ and their family’s understanding of LTDAPT risks and benefits, and their ability to manage symptoms, influenced medication adherence. Factors influencing long term DAPT knowledge included access to medication counselling, engaging with information communicated during medication counselling, and access to timely, relevant and expert information and advice after discharge from hospital.

Conclusions

All adverse events judged to be “not serious” in trials may have an effect on quality of life and therefore may lead to treatment discontinuation. The need to educate the patient in order to improve adherence should therefore be emphasized. The authors underline the importance of careful outpatient follow–up and constant counselling in order to check out compliance and possible adverse effect of long term DAPT risks treatment.
P101 ARRHYTHMIC MITRAL VALVE PROLAPSE: COULD ELECTROANATOMICAL MAPPING AND CARDIAC MAGNETIC RESONANCE BE GOOD FRIENDS?
Authors: Piscitelli L , Pedone C , Perugini E , Coutsoumbas G , Riva L , Dattolo G , Carinci V , Barbato G , Cardelli L , Casella G
Published: May 2022

Background

There is an increasing awareness of the association between mitral valve prolapse (MVP) and sudden cardiac death (SCD), but risk stratification is still challenging. Mitral annular disjunction (MAD) is a recognized risk factor for arrhythmic complications. A multimodality imaging strategy, including advanced echocardiography, magnetic resonance (CMR) and electromechanical mapping, could improve risk stratification and management by combining anatomical and functional information.

Case Review

We report a case of a 50–year–old woman without cardiovascular risk factors, complaining for worsening palpitations in the last months. Echocardiogram documented bileaflet MVP with moderate regurgitation, MAD (12 mm in inferolateral wall) and normal ventricular systolic function. 24–hour Holter monitoring revealed a high (13%) premature ventricular complexes burden with ventricular bigeminy and non–sustained ventricular tachycardia. Stress test showed a reduction of the arrhythmias during exercise. CMR confirmed MAD but no late gadolinium enhancement areas were detected. The patient underwent electrophysiological study with electroanatomic mapping (CARTO). The latter revealed multifocal fragmented and delayed low voltage potentials close to the posterior papillary muscle and the posterior anular mitral area, respectively. Both locations were the targets of endoventricular radiofrequency ablation. However, due to her high arrhythmic risk profile the patient implanted a cardioverter defibrillator.

Discussion

In arrhythmic risk stratification of MVP with MAD, CMR could have technical limitations due to diffuse fibrosis patterns or irregular cardiac rhythm that could undermine a detailed and complete evaluation. Thus, electroanatomical mapping during electrophysiological testing could offer additional and complementary information that could improve risk stratification and further management.
P103 LIBMAN–SACKS ENDOCARDITIS AND FIBROELASTOMA IN ANTYPHOSPHOLIPIDIC SYNDROME: A RARE COEXISTANCE
Authors: Piscitelli L , Pedone C , Perugini E , Coutsoumbas G , Corbo P , Martin S , Dal Passo B , Dattolo G , Casella G
Published: May 2022

Background

Libman–Sacks endocarditis (LSE) is the most common cardiac manifestation of the antiphospholipid antibody syndrome (APS), a systemic autoimmune disease characterized by the presence of arterial and venous thrombosis associated with the persistent presence of antiphospholipid antibodies (Sydney criteria). Cardioembolic events, mainly stroke, are important prognostic determinants of APS. Echocardiography, mostly transesophageal, is the main diagnostic tool to early identification and timely management of LSE.

Case Summary

we report a case of 33–year–old man, with no cardiovascular risk factors. In the last few months, he had a myocardial infarction without obstructive coronary artery disease, a femoral venous thrombosis and a cryptogenic stroke. After clinical and laboratory workout he received diagnosis of primary APS and started an anticoagulation therapy with warfarin. 2D and 3D transesophageal echocardiogram performed after stroke showed two vegetations of the mitral valve. The first one appeared as granular mass, attached to ventricular and atrial surface of the posterior leaflet, measuring 16 x 5 mm. The second one was a smaller, mobile, pedunculated and more hyperechogenic mass apposed on the anterior leaflet. Mitral valve had mild to moderate regurgitation. The patient underwent surgical vegetation excision due to the high embolic risk. Resected specimens revealed sterile fibrinous and verrucous vegetations referable to LSE and a papillary fibroelastoma.

Discussion

In this case we demonstrated a very rare coexistence of abacterial endocarditis and papillary fibroelastoma. We can assume a predisposing role of fibroelastoma by altering the morphology and structure of the mitral leaflets in LSE development.
P107 MULTIMODALITY IMAGING IN ASCENDING AORTA PSEUDO–ANEURYSM COMPLICATED BY MOBILE TROMBUS SYMPTOMATIC FOR RECURRENT ISCHEMIC STROKE
Authors: Monari D , Mei D , Mantovani F , Guiducci V , Navazio A
Published: May 2022

A 80–year–old male patient was admitted to hospital with a clinical picture of Broca‘s aphasia. The patient had arterial hypertension, diabetes, chronic kidney disease and peripheral vasculopathy. In remote cardiological history he presents long standing persistent atrial fibrillation on OAC and he had a biological aortic valve prosthesis (Medtronic 23). Overall time in the therapeutic range (INR 2.0–2.5) was adequate considering the presence of atrial fibrillation. A CT scan was performed on suspicion of stroke, showing a recent ischemic lesion in the left middle temporal region complicated by same–site subarachnoid blood suffusion. During the hospital stay there was a recurrence of the aforementioned symptoms: at the CT check a new acute ischemic same–site lesion and a new ischaemic lesion at the left temporal site was highlighted. In the suspicion of a cardio–embolic origin of cerebro–vascular events, it was decided to carry out imaging for the study of the aorta and heart cavities to exclude embolic sources. Given the patient‘s comorbidities and the reported allergies (contrast medium with angioedema–like reaction at a previous CT) it was decided to perform transesophageal echocardiography (TEE) first. TEE documented the presence of a saccular aneurysm of probable pseudo–aneurysmatic nature, which extends from 20 mm from the valvular plane, characterized by pedunculated, mobile thrombotic apposition, adhered to the internal collar, projecting into the psueudo–aneurysmatic cavity (image 1). This finding was confirmed and better characterized with the help of the real time three–dimensional echocardiographic method (image 2). To confirm and better characterize the extension of the pseudo–aneurysm and plan any strategy, a CT scan with contrast medium was required. Performing contrast–enhanced CT, after careful preparation with premedication with antihistamine and cortisone, confirmed the finding of pseudo–aneurysm of the ascending aorta, but the pedunculated thrombotic apposition was less clearly evidenced compared with TEE (giving the superior temporal resolution of TEE) (image 3). The case was therefore assessed in Heart Team and the patient was scheduled for surgically exclusion of the pseudo–aneurysm.

Conclusion

In our case a multimodality imaging approach was used to diagnose and confirm the presence of ascending aorta pseudo–aneurysm complicated by pedunculated thrombotic apposition inside it, symptomatic for recurrent ischaemic stroke.
P122 EXTENDED PULMONARY ADENOCARCINOMA INFILTRATING THE LEFT ATRIUM
Authors: Dell‘Uomo M , Bier N , Irene D , Nicolì L , Sordi M , Patella M , De Paolis M , Dominici M
Published: May 2022

Cardiac tumors can be primary (benign or malignant) or metastatic (malignant) and can arise in any part of the heart tissue, causing obstruction in the inflow or outflow tract of the valves, thromboembolism, arrhythmias and pericardial disorders. Diagnosis is made by echocardiography and, frequently, by cardiac MRI. The treatment of metastatic malignancies depends on the type and origin of the tumor; however, the prognosis is generally poor.73–year–old patient, he reaches echocardiographic control after having started, 5 months earlier, chemotherapy with weekly carboplatin–paclitaxel scheme for the diagnosis of primary left hilar pulmonary heteroplasia. In medical history: systemic arterial hypertension, iron deficiency anemia and thrombocytopenia in a patient with a history of alcohol–related liver cirrhosis and esophageal varices.On transthoracic echocardiogram (Figures 1 and 2): normal size and bi–ventricular systolic function; mild aortic and mitral insufficiency. Presence of non–mobile isoechoic oval mass adhering to the left atrium, 43 x 27 mm in size, at the outlet of the left pulmonary veins, which does not cause obstruction to the atrio–ventricular blood supply.On CT of chest without and with contrast (Figure 3): primary heteroplastic left hilar pulmonary lesion that infiltrates the left atrium and obliterates the left main bronchus before the bifurcation and the bronchus for the left upper lobe; the corresponding pulmonary vessels also appear infiltrated. The diagnosis was therefore of intracardiac tumor secondary to primary lung lesion.Secondary cardiac tumors are about 20 times more frequent than primary ones. The ability of the tumor to spread to the heart depends on the relationship between the specific biological potential of the primary tumor, the location of the latter and the contractile and draining force of the myocardium.Cardiac metastases can involve, also in combination, pericardium, epicardium, myocardium, endocardium, heart chambers or create endocavitary neoplastic thrombus. Tumors spread to the heart through four possible routes: direct extension, the blood route, the lymphatic route, intracavitary diffusion from the inferior vena cava or pulmonary veins, as in our case.The haemodynamic alterations they cause depend on the engagement of the atrioventricular orifice by the tumor mass.
P177 A SHOT TO THE HEART
Authors: Fais L , Orrù F , Garau V , Carboni G , Mascia D , Cirio E , Delogu G
Published: May 2022

We report the case of a 50–year–old man who, during a wild bird hunt, was accidentally fired with a shotgun loaded with pellets which hit the chest, the neck and the face of the hunter. The patient was taken to the emergency room, tachypnoic and suffering from chest pain, systolic blood pressure was 150/70 mmHg, SpO2 88%, analgesic therapy, liquids administration and O2 therapy were performed with moderate response. On physical examination there was a reduced vesicular murmur in middle field on the right, no heart murmurs; noticeable edema of face and neck soft tissues and absence of evident jugular turgor. The ECG showed sinus rhythm, HR 100/min, morphology at the limit for ST slightly rigid in the inferior site. He underwent a total body CT in which a shotgun pellet was found located at the heart base near the right atrium, with associated pericardial fluid, with a maximum thickness of about 10 mm, with blood density. A shotgun pellet was also found in the apical segment of the right upper lung lobe with associated parenchymal ground glass (the pellet site of passage) without pneumothorax and pleural effusion. CT also showed multiple hunting pellets in the soft tissues of the face and of the neck without significant lesions. The echocardiogram confirmed the presence of circumferential pericardial effusion of mild degree, but progressively worsening, mainly represented along the cardiac apex and the inferolateral wall, but without signs of cardiac tamponade (right atrium within limits, absence of significant Doppler variation in blood flow across cardiac valves). The hospital where the patient arrived was at a distance of 30 minutes from the cardiac surgery, therefore the patient was urgently transferred to the cardiac surgery room of the hub (distance of 30 minutes). Fortunately, the patient maintained hemodynamic stability and arrived in the operating room with good blood pressure, but with a pre–tamponade effusion. The man quickly underwentcardiac surgery, the pericardial effusion was drained and the responsible breach was found in at the atrio–caval junction and successfully sutured. The patient was discharged in the 6th day and currently is in good clinical condition.
P205 PROGNOSTIC VALUE OF AMYLOID–Β (1–40) IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION
Authors: Janjusevic M , Gagno G , Fluca A , Beltrami A , Sinagra G , Aleksova A
Published: May 2022

Background

Survivors of acute myocardial infarction (AMI) have an increased risk of various cardiovascular complications during follow–up; therefore, adequate risk stratification remains the main challenge in the clinical setting. Amyloid β 1–40 (Aβ (1–40)) has already emerged as a negative prognostic marker for cardiovascular mortality, both in patients with stable chronic coronary artery disease and in patients with NSTEMI–type infarction. This is probably due to the pro–inflammatory and pro–atherosclerotic role of this peptide.

Methods

Plasma Aβ (1–40) values were tested acutely in a large prospective cohort of patients hospitalized for AMI (both NSTEMI and STEMI). The primary end–point was defined as all–cause mortality during the period of follow–up.

Results

894 individuals were enrolled in the study (607 with STEMI and 287 with NSTEMI). The median plasma concentration of Aβ (1–40) at the time of admission was 96.59 (60.94–134.5) pg/ml. During a median follow–up of 43 months, 123 patients died (primary endpoint). Higher Aβ (1–40) concentrations were associated with an increased risk of mortality, both on univariate analysis and after correction for other confounding variables. Furthermore, we found a strong positive correlation between plasma Aβ (1–40) values and age. The prognostic value of Aβ (1–40) was maintained only in the subgroup of patients with greater than the median age of 67 years.

Conclusions

This is currently the largest single–centre study evaluating the role of plasma Aβ (1–40) concentrations in predicting outcome in a population of patients admitted for AMI, both STEMI and NSTEMI. Our data represent a strong correlation between plasma (1–40) values and the increased risk of all–cause mortality during follow–up.
P208 THE TREATMENT WITH BETA–BLOCKERS AFTER MYOCARDIAL INFARCTION WITHOUT REDUCED EJECTION FRACTION (REBOOT) TRIAL. CURRENT STATUS
Authors: Vetrano A , Vetrano D , Pariggiano I
Published: May 2022

Background

There is a lack of evidence regarding the benefits of maintenance β–blocker (BB) treatment in post–acute AMI patients (pts) without reduced LVEF in the era of invasive management.

Design and Trial Status

REBOOT is an independent multinational pragmatic, controlled, randomized, open–label, with blinded endpoint adjudication clinical trial testing the benefits of BB maintenance therapy in post–AMI pts (either with or without ST segment elevation) discharged with LVEF >40%. Patients ≥18 years (yr) old undergoing invasive management during admission and without history of heart failure (HF) are eligible to participate. At discharge, pts are 1:1 randomized to either receive BB (agent and dose chosen by the treating physician) or no BB therapy. The primary endpoint is a composite of “all–cause death, nonfatal reAMI, or HF hospitalization” over a minimum follow–up period of 2 yr. Key secondary endpoints are: a) the incidence rate of each individual component of the composite endpoint; b) cardiovascular death; c) admission for sustained ventricular tachycardia/ventricular fibrillation; and d) admission for atrial fibrillation. Events will be adjudicated by a blinded committee. A sample size of 8468 pts (728 events) was estimated to provide a power of 85% to detect a relative risk reduction of 20% (incidence of primary endpoint in control 10%) and assuming 5% withdrawals. Statistical analyses will be conducted according to the intention–to–treat principle, although a pre–specified per–protocol analysis will also be performed. The Spanish National Center for Cardiovascular Research (CNIC) is the sponsor of the trial, which has no external funding. CNIC coordinates ≥75 Spanish centers, while Istituto di Ricerche Farmacologiche Mario Negri IRCCS coordinate 33 Cardiology Centers distributed in 10 Italian regions. The first pt was included in Spain in October 2018, in Italy in January 2019. The end of enrollment is anticipated in December 2022. At 09 December 2021, 5669 pts had been enrolled from which 1263 in Italy (Figure). Pts baseline characteristics are described in the Table. Hospital admission data for COVID–19 pre and post randomization were also recorded since June 2020.

Conclusions

The REBOOT trial (NCT03596385) will fill the existing scientific gap on the efficacy of β–BB after AMI in pts with LVEF > 40% and no HF who are treated according to current standard–of–care. REBOOT trial results might have an impact on clinical practice guidelines.
P212 PROGNOSTIC ROLE OF ACUTE MYOCARDIAL INFARCTION DIAGNOSTIC CRITERIA IN NON–ST SEGMENT ELEVATION MYOCARDIAL INFARCTION
Authors: Sansonetti A , Armillotta M , Amicone S , Impellizzeri A , Angeli F , Fabrizio M , Stefanizzi A , Bergamaschi L , Magnani I , Rinaldi A , Foà A , Galiè N , Pizzi C
Published: May 2022

Background

Although the majority of patients with NSTEMI share similar risk factors and similar pathophysiology, their outcomes differ considerably. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined acute myocardial infarction (AMI) by an acute myocardial injury together with clinical evidence of acute myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored.

Purpose

To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in NSTEMI patients.

Methods

We enrolled all consecutive patients with AMI undergoing coronary angiogram at our Centre. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high–sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST–T changes or new LBBB); development of pathological Q waves in the ECG; echocardiographic evidence of new loss of viable myocardium or new regional wall motion abnormality. Patients with STEMI and very high risk NSTEMI were excluded. A composite endpoint of all–cause mortality, re–hospitalization for heart failure, and myocardial reinfarction was collected. The predictive value of diagnostic criteria alone and their association were evaluated using Kaplan–Meier survival curves and subsequent Cox–regression analysis to find independent predictors of adverse events.

Results

2791 patients with NSTEMI were evaluate. At admission 196 had clinical criteria alone, 187 had clinic + ECG and 829 had clinic + ECG + echo. The total number of events was 689. The median follow–up was 23.3±14.5 months. We found that patients with clinical criteria alone had a better prognosis at 2 years follow–up (p < 0.001). No other significant prognostic correlation was found. Multivariable Cox–regression model demonstrated that clinical criteria was the only independent predictor of better prognosis in patients with NSTEMI (HR = 0.48; CI 95% 0.31–0.74; p < 0.001).

Conclusions

Our data suggest that in NSTEMI the prognosis is considerably better if clinical criteria alone is present at admission. We hypothesize that the absence of electrocardiographic and echocardiographic alterations in NSTEMI could indirectly indicate smaller infarct sizes or other causes of acute myocardial injury.
P222 BENEFITS OF IVRABRADINE IN HEART FAILURE: FROM TRIALS TO CLINICAL PRACTICE
Authors: Lamaida N , Casillo C , Micera F , Cerciello A
Published: May 2022

The incidence and prevalence of heart failure (HF) are constantly increasing and represent a fundamental problem for patient hospitalizations and the resulting healthcare costs. In the latest European guidelines the importance of therapeutic optimization in patients suffering from (SCC) has been emphasized to improve prognosis. This was confirmed by the results of the SHIFT trial, aimed at establishing the efficacy of Ivabradine in addition to therapy for the SC. The SHIFT study was performed in symptomatic HF patients with left ventricular systolic dysfunction. Patients were in NYHA class between II and IV and with at least one HF exacerbation hospitalization in the previous year, were randomized to receive Ivabradine at an initial dose of 5 mg twice a day. All patients were treated at the optimal dose of therapy, with ACE–I or Sartani (90%), BB (90%) and MRA (60%). The average follow–up was 24 months. Patients who received ivabradine showed a significant 20% reduction in hospitalization for heart failure exacerbation. These results were also confirmed by the improvement of the clinical picture based on the NYHA classification and the ejection fraction. Also in our clinical practice we found the same result: 6 patients of average age (70–75 years), suffering from HF with severe left ventricular systolic dysfunction (NHYA III), and arterial hypertension in standard therapy optimal for HF according to LG, reach outpatient evaluation for clinical and instrumental follow–up. On check–up, they have dilated heart disease with severe left ventricular systolic dysfunction (FE 35–38%) on the echocardiogram. Therapy with Ivabradine 5 mg x 2 / day was introduced. Upon clinical re–evaluation, after 6 months of therapy, an improvement in the functional class of SC (from NYHA III to NYHA II) and in the ejection fraction (from 38% to 45%) was noted.

Conclusions

Ivabradine, together with optimal medical therapy for HF, reduced hospitalizations for HF, increased survival and improved patient symptoms, reducing left ventricular remodeling, as confirmed by our clinical practice. Therefore, therapy with Ivabradine, in combination with Beta–Blockers or alone, constitutes a rational and synergistic therapeutic choice for improving the prognosis and quality of life in patients with SCC.
P223 THYROTOXIC DILATED CARDIOMYOPATHY
Authors: Follesa F , Cherubini S , Castelli F , De Luca L , Gioffrè L , Ciolli A
Published: May 2022

Hyperthyroidism can strongly impact cardiac function. Thyrotoxicosis enhances myocardiocytes metabolism and it can be responsible for hyperdynamic circulation state leading to heart failure with preserved ejection fraction, but also left ventricle dilatation and severe contractile function impairment. It can furthermore provoke arrhythmias, mostly atrial fibrillation, but, as we are going to discuss in this case, even ventricular arrhythmias. A 40–year–old woman came to our emergency department for chest pain. ECG showed reduced R waves voltage in precordial leads and troponin I values were normal. The echocardiogram showed severe left ventricle disfunction with global hypokinesia (EF 35%) and enlarged left ventricle (LVEDD 65 mm). Blood tests revealed severe hyperthyroidism with extremely low level of TSH, FT3 13,45 pg/ml, FT4 3,4 ng/ml and thyroid echography documented multiple solid nodular formations with hypo–isoechogenic signal. She underwent a coronary angiography that showed patent coronary arteries, and a cardiac magnetic resonance confirming severe contractile impairment and hypertrabeculation of the apex and lateral wall. On the assumption of a dilated cardiomyopathy secondary to hyperthyroidism, we started treatment with methimazole, ACE inhibitors and propranolol. During hospitalization, continuous ECG monitoring recorded several episodes of non–sustained ventricular tachycardia, the longest lasting 22 seconds, so the patient was discharged with a wearable cardioverter–defibrillator. It did not record any arrhythmias and it was dismissed a month later. After almost two months of therapy, the echocardiogram showed mild left ventricular contractility improvement (EF 45%), and blood tests documented partial reduction of hyperthyroidism. A 24–hour ECG Holter did not record any arrhythmias and the patient remained asymptomatic during all the period after discharge. Even if rare, scientific literature confirms that dilated cardiomyopathy with reduced ejection fraction can occur as a complication of hyperthyroidism. After the exclusion of an ischemic cause, we underline the need for adequate initiation of treatments for thyrotoxicosis and heart failure, in order to improve chance of left ventricular function recovery. In the case discussed, after two months of therapy, EF was still not completely restored but improved from 35% to 45%, and concurrently arrhythmic risk did clearly decrease.
P247 ARTERIAL STIFFNESS, SUBENDOCARDIAL PERFUSION AND 30–DAYS READMISSION IN ELDERLY INDIVIDUALS WITH HEART FAILURE
Authors: Giani A , Franconi A , Nicolussi Paolaz S , Zampieri A , Falceri A , Gasparini L , Mattachini E , Santuz B , Zamboni M , Fantin F
Published: May 2022

Arterial stiffness and subendocardial perfusion impairment significantly affect cardiovascular morbidity and mortality, playing a relevant role in heart failure. The aim of the present study was to describe the trend of hemodynamical parameters, arterial stiffness indexes and subendocardial viability ratio (SEVR) in geriatric patients, hospitalized with hearth failure, and to define the main predictors of 30–days readmission. A cohort of 41 patients, admitted to the Geriatric ward of Verona University Hospital, affected by heart failure, was included in the study. Each subject underwent clinical evaluation, geriatric comprehensive assessment, routine laboratory testing, and cardiac ultrasound. At the time of admission, after achievement of clinical stability (defined as switching from intravenous to oral diuretic therapy) and at the time of discharge, blood pressure measurement and applanation arterial tonometry (with evaluation of carotid–femoral pulse wave velocity –PWVcf– and SEVR) were also performed. SEVR was corrected for hemoglobin concentration and oxygen saturation. Through the three evaluations, a progressive decrease in PWVcf was described (17.79±4.49 m/s, 13.54±4.54 m/s, 9.94±3.73 m/s respectively, p < 0.001); the trend remained significant even after adjustment for age, gender, mean arterial pressure (MAP) variation and left ventricular ejection fraction (LVEF) (p < 0.001). A significant improvement was registered for both SEVR (83.48±24.43, 97.94±26.84, 113.29±38.02 respectively) and corrected SEVR (12.74±4.69, 15.71±5.30, 18.55±6.66 respectively) values (p < 0.001 for both), and it was still significant when adjusted for age, gender, MAP variation and LVEF (p < 0.001). After discharge, 26.8% of patients was readmitted within 30 days. In a multivariate binary logistic regression analysis, considering 30–days readmission as dependent variable, PWVcf at discharge was the only predictor of readmission (OR 2.004, CI 1.154–3.481, p = 0.014) In conclusion, medical therapy seems to improve arterial stiffness and subendocardial perfusion in geriatric patients hospitalized with hearth failure. Furthermore, PWVcf is a valid predictor of 30–days readmission. Its feasibility and reproducibility in clinical practice, may provide an instrument to detect heart failure patients at high risk of rehospitalization.
P268 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN THE EMERGENCY ROOM IN ELDERLY: DOES ADHERENCE TO INTERNATIONAL GUIDELINES INCREASE IN THE MOST SERIOUS CASES?
Authors: Savioli G , Ceresa I , Fumoso F , Lapia F , Brattoli M , Maggioni P , Mugellini A , Martignoni A , Manzoni F , Muzzi A , Novelli V , Preda L , Lava M , Bressan M
Published: May 2022

Premises

Pulmonary embolism is a pathology still characterized by high mortality. Some international studies have actually shown that adherence to guidelines is generally quite low in both primary and secondary care and ranges, depending on the studies, between 40 and 60%.

Purpose of the Study

see if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the severity of the acute pulmonary embolism. We understood this severity as the presence of organ damage or massive pulmonary embolism.

Methods

Single–center retrospective observational study, on all geriatric patients (>75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We therefore analyzed adherence to the guidelines in three decisional turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 62%). Of these, 81 (32.7%) have organ damage and 86 (34.7%) have massive pulmonary embolism. Patients with organ damage received treatment with a higher adherence to the guidelines (68%) than those who did not have organ damage (51%) in a statistically significant way (p < 0.01). Patients with massive pulmonary embolism received treatment with a higher adherence to the guidelines (69 %) than those with peripheral pulmonary embolism (50%) in a statistically significant way (p < 0.005).

Conclusions

The study suggests that patients with organ damage or massive pulmonary embolism are more likely to receive treatment in the emergency room with greater compliance with international guidelines.
P274 GUESS WHO‘S COMING TO REANIMATION? ANALYSIS OF THE ELDERLY PATIENT WITH EMBOLISM IN NEED OF HOSPITALIZATION IN INTENSIVE CARE: REAL LIFE IN THE EMERGENCY ROOM
Authors: Savioli G , Ceresa I , Muzzi A , Manzoni F , Fumoso F , Lapia F , Brattoli M , Bressan M
Published: May 2022

Premise

Pulmonary embolism is a disease still characterized by high mortality and which may require hospitalization in intensive care.

Purpose

Evaluate which parameters, in the real life of an Emergency Department, correlate with the need and the duration of hospitalization in intensive care.

Methods

Single–center retrospective observational study, on all geriatric patients (> 75) who refer to our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results

We enrolled 247 patients, with a mean age of 83 years and female prevalence (F = 63%). Of these 12 (14 %) required hospitalization in intensive care from the emergency room. Regarding the need for hospitalization in resuscitation, age and vital parameters (arterial pressure, respiratory rate, heart rate), as well as derived shock indices are not correlated (p > 0.05). Only the systolic blood pressure values and it show a trend which however does not reach statistical significance (p = 0.06). Among the blood gas analysis parameters, only low pCO2 has a slight correlation (p < 0.05). The D–Dimer (p < 0.01) and creatinine values (p < 0.05) show correlation between the blood chemistry tests. Regarding the length of stay in resuscitation, age and vital parameters (blood pressure, respiratory rate, heart rate), as well as derived shock indices, do not show any correlation (rho∼0; p > 0.05). A weak correlation is instead present with high values of D–Dimer (rho∼0.25; p < 0.005) and creatinine (rho∼0.33; p < 0.0005). The presence of massive pulmonary embolism shows no correlation (p > 0.5). The presence of organ damage, on the other hand, correlates in a statistically significant manner (p < 0.0005). Excellent correlation is shown by the sPESI index (p < 0.0001). Discrete correlation showed the alteration in pH (rho∼0.61; p < 0.0001). Correlation for the blood gas analysis parameters taken into consideration (pH; pO2; pCO2; lactates).

Conclusions

The study suggests a reduced significance of vital parameters and indices derived from them for the need and duration of hospitalization in resuscitation. Presence of organ damage, low pCO2 values and high D–Dimer and creatinine values are associated with both the need for hospitalization in resuscitation and duration.
P276 BLOOD GAS ANALYSIS AND D–DIMER IN CASES OF ORGAN DAMAGE FROM PULMONARY EMBOLISM IN ELDERLY: POOR CORRELATION IN REAL LIFE IN THE EMERGENCY ROOM
Authors: Savioli G , Ceresa I , Mugellini A , Martignoni A , Fumoso F , Lapia F , Brattoli M , Preda L , Bressan M
Published: May 2022

Premise

Pulmonary embolism is a pathology still characterized by high mortality and severe sequelae, greater in cases of organ damage. Raising suspicion and early recognition of this condition is therefore important to avoid delays in undertaking the right diagnostic and therapeutic process.

Purpose

Evaluate which vital parameters and shock parameters derived from them, in the real life of an Emergency Department, correlate with the presence of organ damage from pulmonary embolism to see which ones may be of help in raising the suspicion of this condition early.

Methods

Single–center retrospective observational study, on all geriatric patients (>75) who were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed all the blood gas analyzes performed upon access to the emergency room. We then had all chest CTs retested by an experienced radiologist. We went to see the correlation of vital parameters and shock indexes from these derivatives with the presence of organ damage from pulmonary embolism. We considered right ventricular dilation, pulmonary artery dilation and the presence of pulmonary infarction organ damage.

Results

We enrolled 247 patients, with a mean age of 83 years and female prevalence (F = 63%). Of these, 79 (32%) have organ damage from pulmonary embolism. The lactate values do not correlate with the presence of organ damage (p > 0.05). The pCO2 values correlate inversely with the presence of organ damage reaching statistical significance (P < 0.05). Instead, the reduction in pO2 values and the increase in pH values do not have any correlation with the presence of organ damage (p > 0.05). The D–Dimer in turn shows a fair association with the values of organ damage from pulmonary embolism (p < 0.01).

Conclusions

The study suggests a reduced significance of blood gas analysis in the early identification of patients with organ damage in the event of pulmonary embolism. A fair correlation is given only by the reduction in pCO2 values and by the increase in D–Dimer values.
P279 MORTALITY RISK DUE TO ACUTE PULMONARY EMBOLISM IN COVID–19 PATIENTS: META–ANALYSIS BASED ON ITALIAN COHORTS
Authors: Zuin M , Rigatelli G , Bilato C , Navaro M , Roncon L
Published: May 2022

Background

Acute pulmonary embolism (PE) has been recognized as a frequent complication of COVID–19 infection influencing the clinical course and outcomes of these patients.

Objectives

We performed a systematic review and meta–analysis to evaluate the mortality risk in COVID–19 Italian patients complicated by acute PE in the short–term period.

Methods

The study was performed in accordance with the Preferred Report Items for Systematic Reviews and Meta–analyses (PRISMA) guidelines. PubMed–MEDLINE and Scopus databases were systematically searched for articles, published in English language and enrolling Italian cohorts of COVID–19 patients from inception through October 20, 2021. Mortality risk data were pooled using the Mantel–Haenszel random effects models with odds ratio (OR) as the effect measure with 95% confidence interval (CI). Heterogeneity among studies was assessed using Higgins and Thomson I2 statistic

Results

Eight investigations enrolling 1.681 patients (mean age 64.9 years, 1.125 males) met the inclusion criteria and were considered for the analysis. A random–effect model showed that acute PE was presents in 3.1% (95% CI: 1.7 to 5.5%, I2: 80.7%) of COVID–19 Italian patients. Moreover, these subjects were at higher mortality risk compared to those without (OR: 1.76, 95% CI: 1.26–2.47, p = 0.001, I2=0%) (Figure 1), Sensitivity analysis confirmed yielded results.

Conclusions

In Italian COVID–19 patients, acute PE was present in one patient out of four and significantly associated with a higher mortality risk in the short–term period. The identification of acute PE in these patients remains critical to promptly identify vulnerable populations who would require prioritization in treatment and prevention and close monitoring.