bluuebunny/crossref_metadata_2025_split huggingface dataset:
USE OF CARDIAC CONTRACTILITY MODULATION: OUR EXPERIENCE
Authors: Lamaida N , Masarone D , Uran C , Cerciello A 
Published: May 2024

Abstract

Introduction
Despite strong advances in diagnostic and treatment, heart failure (HF) remains the single largest cause of mortality in the western world.Cardiac contractility modulation (CCM) is a relatively new electrical device–based technique proposed for enhancing ventricular contractile strength of the failing myocardium independent of the synchrony of myocardial contraction. Two prospective randomized multicenter studies have demonstrated improvements in NYHA functional classification, quality of life. CCM therapy is recommended for patients in sinus rhythm with a left ventricular ejection fraction (LVEF) ≥25–35%, NYHA class III and normal QRS duration, as this subgroup of patients seems to benefit most from the therapy. Our Center has started its experience with CCM therapy in the population of HF patients with averagely reduced EF (HFmEF) to avoid acting late when the patient is already a candidate for ICD implantation.

Methods
Our initial experience with CCM therapy in patients with HFmEF concerns 5 patients (4 M and 1 F) implanted from May 2023 to November 2023 with the following data (expressed in median and interquartile range): mean age 62 (range 57– 67aa); with EF 38% (35–38%), all with primary dilated heart disease, QRS preserved/not widened 100 ms (100–110) in maximal medical therapy and (including sacubitril/valsartan and SLGT2 inhibitors) with evaluation through questionnaires of the quality of life (QoL) MLWHFQ with value 44 (44–50) and KCCQ 40 (39.1–40). For three of them there had been at least one hospitalization for heart failure in the last year.

Results
The follow up (FU) is still short (the first patient implanted reached a FU of 6 months) but in the three patients who reached three months of FU an increase in EF was found with a median value of 41% (43–39,5) and an improvement in QoL assessed on the MLWHFQ questionnaires with a value of 18 (27–15) and KCCQ with a value of 72.7 (70–73). None of the five patients have currently had hospitalizations for heart failure.

Conclusions
In our initial experience, CCM proves to be an effective therapy already in the short term, in terms of improvement in EF, QoL and no hospitalization for heart failure. What is highlighted in the literature is confirmed: that is, by acting early we avoid the worsening of EF with consequent ICD implantation, which can be avoided by using all the other weapons available to slow down the progression of heart disease.
A STRANGE CASE OF PULMONARY HYPERTENSION
Authors: Soriente L , Ardovino P , Scalcione M , Sasso C , Aliberti C 
Published: May 2024

Abstract
PH is a haemodinamic and pathophysiological state that can be found in multiple clinical conditions.Chronic hemolytic anemia as sickle cell disease (SCD) is complicated by PH with 30 % of prevalence and worse prognosis.PH in SCD is multifactorial including vasoconstriction, proliferation, obstructive remodelling of the pulmonary vessel wall; inflammation and thrombosis in situ play a role in the pulmonary vascular disease.We have observed a 44–yr old woman affected by sickle cell who developed dyspnoea (WHO–FC III) without chest pain or fever. Transthoracic ecocardiography revealed moderate–severe tricuspid with a gradient of 70 mmHg with an assumed right atrial pressure di 20 mmHg estimated by inferior vena cava, right atrial and ventricular dilatation, reduced TAPSE 16 mm, Ryan index 0.8 with normal size and ejection fraction of left ventricular.Electrocardiogram provided right axial deviation.Computed angiography was normal and ventilation /perfusion lung scan showed an elevated probability for CTEPH. BNP was 921 pg /ml and lung diffusion capacity for carbon monoxide was slight decreased .Prophylactic transfusion during crisis to decrease the frequency of these and new direct anticoagulants were started. After two weeks the patient was in WHO–FC II and transtoracic echocardiography showed a slight tricuspidal regurgitation with a pressure gradient of 40 mmHg with TAPSE of 20 mm and Ryan index was normal.In the new guidelines SCD is moved into Group 5 and our patient was not subjected to specific therapy for pulmonary hypertension. DOAC has showed a reasonable alternative to VKAs for VTE.
INSOMNIA DUE TO HYPERTRIGLYCERIDEMIA CAN BE TREATED BY ROSUVASTATIN/EZETIMIBE
Authors: Fazio G 
Published: May 2024

Abstract

Background
Metabolic syndrome associated with elevated fasting triglyceridemia (TG) is often associated with insomnia. The new guidelines of ESC for dyslipidemia advice the statin and/or ezetimibe treatment like fist line therapy in patients with hypertriglyceridemia, also before then fibrates or omega 3 We examined the impact of rosuvastatin/ezetimibe treatment in reduction of insomnia in patents with hypertriglyceridemia.

Methods
In this study was enrolled a group of 148 patients with hypertriglyceridemia and insomnia. Patients were screened for severe insomnia, defined by a score of four or more on the three Hamilton Depression Rating Scale (HDRS) sleep items, and for HTG characterized by TG≥200mg/dL. The duration of sleep was evaluated with smartwatch every 7 days Mean age was 61,12 years. All patient was admitted in ambulatory of cardiology and were in wash out treatment for dyslipidaemic syndrome. In all we added 20 mg of rosuvastatin plus 10 mg of ezetimibe daily to therapy and reassessed patients after 30 days.

Results
Rosuvastatin/ezetimibe treatment was effective as add–on therapy in reduction of insomnia . All treated patients reported an improvement in symptoms. After 30 days, insomnia disappeared in 69% of patients and was reduced in 21% of patients. The number of the sleeping hours improved from 5:35 min to 7:25 minutes. Therapy was well tolerated in 99% of patents, and stopped only in 2 cases.

Conclusions
Our initial experience with rosuvastatin/ezetimibe in hypertriglyceridemia treatment suggests that this therapy may play a role in the treatment of insomnia.
ACS: MANAGEMENT IN A FIRST LEVEL ED
Authors: Petrelli G , Lattanzio F , Giorgini P , Iachetti M , Orlandi J , Rubini G , Zotti M , Concetti G , Bizzarri M 
Published: May 2024

Abstract
The DIDO is the time between the patient‘s arrival in a center without haemodynamics and the departure by ambulance towards the center with haemodynamics. It affects the D2B and the patient‘s prognosis and is an indicator of the effectiveness of the performance on STEMI care when it is less than 30 minutes. From 2009, a protocol was developed on the management of PCI in our hospital, whose primary objective was the containment of DIDO within 30 minutes. After the application of this protocol we went to evaluate our performance on patients who arrived consecutively from 1 January 2022 to 31 December 2022 at the San Benedetto del Tronto ED, Spoke centre not equipped with haemodynamics. Inclusion criteria: age over 18 years, chest pain &lt;12 hours, discharge diagnosis of STEMI ACS. Excluded 2 patients with cardiac arrest admitted to the ICU, 2 patients with diagnostic uncertainty centralized subsequently, 2 patients with no indication for PCI in emergency admitted to the Cardiac Intensive Care Unit, there are 35 patients, 10 females (29%) and 25 males (71%), with an average age of 64.57 years. Comorbidities were present in 71% of patients (cardiovascular pathologies, diabetes and obesity), while in 29% of patients no comorbidity was present. No comorbidity was observed in 60% of patients between 18 and 55 years and in 30% of patients between 65 and 75 years. We evaluate our performance by comparing the trend, over the years, of this indicator. A reduction in the average DIDO was achieved from 56 minutes in 2014 to 33 minutes in 2022 reaching the value of 17 minutes in 75% of cases. The percentage of cases outside the cut off is 25.71%. We tried to hypothesize the causes responsible for a DIDO&gt;30 minutes: an inappropriate attribution of the priority color code to Triage, the presence of comorbidities. In reality, as well as data from international literature, cases of DIDO &gt;30 minutes were associated with delay accumulated for necessary specialist consultations for difficult to interpret ECGs and the delay of the transport the patient to the Hub hospital. To conclude is necessary direct centralization of STEMI ACS patients from 118 to haemodynamics and reduce centralization decision–making times by identifying criteria facilitating the transfer decision in cases of difficult–to–interpret ECGs.
TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE
Authors: Falagario A , Basile P , Caragnano V , Totaro Fila G , Scialpi A , Nestola P , Pestrichella V , Iliceto S 
Published: May 2024

Abstract

Case Report
A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF.

Discussion
We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.
A TAKOTSUBO SYNDROME TRIGGERED BY HYPOCALCEMIA: THE IMPORTANCE OF ELECTROLYTE BALANCE IN CANCER PATIENTS
Authors: Dicorato M , Falagario A , Basile P , Carella M , Carulli E , Forleo C , Guaricci A , Santobuono V , Ciccone M 
Published: May 2024

Abstract

Introduction
Takotsubo Syndrome (TTS) is characterized by a transient left ventricle (LV) systolic dysfunction usually occurring in postmenopausal women after intense physical or emotional stress.

Case Report
A 75–year–old female patient without a history of heart disease was admitted to our hospital for sudden onset of painful muscle spasms associated with a burning sensation in hands and feet. She also reported peri–oral numbness, dysphagia and nausea. She received, at the age of 68, a diagnosis of metastatic serous ovarian cancer BRCA wild–type at IV stage, treated with surgery and chemotherapy and actually receiving palliative care. On arrival, physical examination revealed Chvostek’s sign and Trousseau’s sign. Laboratory exams displayed a severe hypocalcemia without any other electrolyte derangement and a normal cardiac troponin. The first ECG showed sinus tachycardia with a reduced R–wave progression from lead V1 to V4 and no QT prolongation. Therefore, a treatment with intravenous magnesium and calcium gluconate was immediately started. Subsequently, a marked increase of cardiac troponin was observed, without evidence of chest pain or dyspnea. The transthoracic echocardiography was highly suggestive for TTS with a severe LV systolic dysfunction and an apical ballooning shape. When transferred to our ward, the ECG revealed diffuse ST–segment elevation with concomitant ST–segment depression in leads aVR and V1, requiring an urgent coronary angiography, which found normal coronary arteries. Thus, a guideline directed medical heart failure (HF) therapy was initiated, going forward to correct the serum calcium. Patient’s conditions improved rapidly, and systolic function completely recovered after the restoration of the calcium levels.

Discussion
Among the potentials TTS–triggers, electrolyte impairment is rarely described. Specifically, hypocalcemia is rare and its occurrence in cancer patients may have several causes, from chemotherapy to malnutrition. Moreover, the chronic inflammatory state associated with malignancies may increase cardiac adrenoceptor sensitivity, predisposing frail patients to TTS. Heart involvement and hospitalization can suddenly worsen prognosis especially in end–stage cancer. Therefore, an accurate monitoring of serum electrolytes should be provided in this setting. Calcium replacement and HF therapy are pivotal in this scenario.
ADVERSE EVENTS ASSOCIATED WITH GLP1–RECEPTOR AGONISTS TREATMENT IN DIABETIC PATIENTS WITH HIGH CARDIOVASCULAR RISK: A META–ANALYSIS
Authors: Pozzi A , Cirelli C , Rea F , Merlo A , Iorio A , Iacovoni A , Corrado G 
Published: May 2024

Abstract

Background
GLP1–receptor agonists (GLP1–RA) have been associated with a reduction of cardiovascular (CV) outcomes in diabetic patients with high cardiovascular risk. However, these drugs have some adverse effects. The aim of this study was to assess the relative risk (RR) of adverse effects in patients with a high risk of developing CV disease treated with GLP1–agonists.

Methods
we considered randomized controlled trials (RCTs) aimed to assess the cardiovascular effects of GLP1–RA in diabetic patients with high CV risk. The following outcomes were explored: pancreatitis, severe hypoglycemia, renal and urinary serious adverse events (SAE), gastrointestinal SAE and AE, pancreatic cancer, and neoplasms.

Results
8 RCTs, enrolling 60008 patients, were included in the analysis. There was no difference between GLP1–RA and placebo in the risk of pancreatitis (RR 0.99; 95% CI 0.73–1.35; p=0.972), severe hypoglycemia (0.93; 95% CI 0.76–1.15; p=0.501), renal and urinary SAE (0.94; 95% CI 0.82–1.07; p=0.339), pancreatic cancer (RR 0.98; 95% CI 0.56–1.70; p=0.936) and neoplasms (RR 1.02; 95% CI 0.95–1.09; p=0.547) (Fig 1 A e B). Conversely, GLP1–agonist treatment was associated with an increased risk of gastrointestinal AE (RR 1.95; 95% CI 1.23–3.06; p=0.004) (Fig 2). However, when gastrointestinal SAE were considered, GLP1–agonists demonstrated similar risk compared to placebo (RR 1.09; 95% CI 0.92–1.28; p= 0.318) (Fig 2).

Conclusion
in diabetic patients with high cardiovascular risk, the treatment with GLP1–RA has been associated with an increased risk of gastrointestinal AE. No difference in severe gastrointestinal AE has been associated with GLP1–RA.
TRANSOESOPHAGEAL ELECTROPHYSIOLOGICAL STUDY IN PEDIATRIC PATIENTS WITH VENTRICULAR PRE–EXCITATION
Authors: Catucci S , Lombardi M , Maiorano A , Massari E , Meliota G , Pirolo T , Vairo U 
Published: May 2024

Abstract

Introduction
The transoesophageal electrophysiological study (SETE) is a simple, semi–invasive and highly reliable test for risk stratification in patients with ventricular pre–excitation. In paediatric subjects, symptoms may be nonspecific or poorly reported; hence the usefulness of the study in guiding the therapeutic strategy. The guidelines also suggest performing it in all asymptomatic patients with ventricular preexcitation above 8 years of age.Purpose of the study: to evaluate the inducibility of re–entry tachycardia at SETE in paediatric patients with ventricular pre–excitation.

Materials and Methods
We observed 21 patients aged between a few days of life and 12 years (average age 11 years); 14 of them had constant and 7 intermittent pre–excitations. The latter were subjected to the study as they reported dubious symptoms either due to sports activities or due to a previous diagnosis of neonatal TPS. The study was performed by carrying out the protocols of continuous atrial stimulation at increasing frequencies, programmed atrial stimulation with single, double, and triple extra stimulus and atrial stimulation with burst.

Results
Of the 21 patients, 8 (38.1%) were inducible. Of the 14 patients with constant ventricular pre–excitation, 5 had tachycardia upon return to the study (35.7%), 4 of which were symptomatic due to previous TPS. Therefore, only one patient with constant and asymptomatic ventricular pre–excitation was inducible. Of the 7 patients with intermittent ventricular preexcitation (documented by Holter or exercise test), 3 developed TPS at SETE (42.8%): all these patients complained of heart palpitations but did not have a documented arrhythmia. On the contrary, all patients with intermittent ventricular preexcitation and asymptomatic were found to be non–inducible. In patients in whom it was possible to calculate the effective antegrade refractory period of the anomalous pathway, shorter refractory period showed greater inducibility. Non–sustained atrial fibrillation was induced in only two patients.

Conclusions
SETE demonstrates a good correlation between symptoms and inducibility especially in patients with intermittent ventricular pre–excitation. In fact, if the manifest pre–excitation disappears with growth in about a third of patients, the retrograde conduction capacity of the pathway often persists. The study also allows us to identify patients with constant pre–excitation but pathway at low risk.
SAFETY OF SGLT2 INHIBITORS IN ACTIVE CANCER PATIENTS: RATIONALE AND STUDY DESIGN OF TOSCA TRIAL
Authors: Canale M , Fabiani J , Delle Donne M , Colombi L , Lupo A , Barletta V , Capati E , Orso F , Arena G , Frediani L , Pasanisi E , De Caterina R , Zucchelli G , Emdin M , Casolo G , Camerini A 
Published: May 2024

Abstract

Background
SGLT2 inhibitors have dramatically improved the outcome of heart failure patients with both preserved (HFpEF), mildly reduced (HFmrEF) and reduced (HFrEF) ejection fraction. Cancer patients have been excluded (or not enrolled) from pivotal trials so data on safety in such population are lacking. We aimed to collect evidence on safety and activity of empagliflozin and dapagliflozin in active cancer patients.

Study Design
TOSCA is a retrospective/prospective multicentre observational trial now enrolling cancer patients receiving SGLT2i for both HFpEF, HFmrEF and HFrEF. Inclusion criteria included active cancer (histologically confirmed current cancer or history of cancer in previous 3 yrs), heart failure (HF) and SGLT2i therapy for HF. Exclusion criteria were age &lt;18yrs, non–melanoma skin cancer and localised cervical cancer undergone radical treatment. Primary objective is assessing the safety of SGLT2i in active cancer patients expressed as percentage of toxicity (in particular hypoglycaemia, genital and urinary infections, acute renal failure, fractures, diabetic ketoacidosis and thromboembolic events) compared to side effects reported in phase III RCTs. Secondary objective is assessing the efficacy (change in EF, NYHA class variation, hospital/ER admissions for HF, need for diuretics) and exploratory objectives are time course variation of cardiac biomarkers, efficacy in the treatment of cardiac toxicity and drug–drug interactions with anticancer or supportive care drugs. A three months minimum follow–up will be required for every enrolled patient. Planned sample size is 80 patients (to be increased to a maximum of 200 cases) equally distributed between the two study cohorts. Relevance of expected results: SGLT2i are one of the pillars of HF treatment; the proof of safety (and activity) in active cancer patients could allow a wider cancer population to benefit of their efficacy in reducing cardiovascular mortality and could provide the rational basis for RCTs testing their role as cardio–protective strategy.
A NEW PROJECT OF A SPECIFIC EXERCISE PROTOCOL FOR AMBULATORY CARDIOVASCULAR REHABILITATION SPECIFIC FOR HEART FAILURE: REPORT OF THE FIRST EXPERIENCE
Authors: Fontana A , Vincenzi A , Rabbiosi P , Maffioli F , Ipsaro S , Merlo A 
Published: May 2024

Abstract
The indication to cardiovascular rehabilitation (CV rehab) was recently upgraded to I A in the European guidelines (GL) for the treatment of heart failure (HF), along with the four pharmacologic pillars. According to this change, we have implemented our CV rehab protocol to include specific exercises for patients (pts) with HF. We present our management of HF pts in CV rehab. According to GL, all pts with HF should receive CV rehab in order to improve their quality of life and reduce readmissions for HF. We can admit up to 18 day–hospital (DH) pts, and starting from October 2023, we implemented a specific excercise protocol for HF pts. They are screened by the physiotherapist on admission day, and all the following activities are tailored based on this initial physical assessment. It includes the 6–minute–walking test (6MWT), the short physical performance battery (SPPB) for the evaluation of lower limbs strenght, and the explanation of the Borg scale. The SPPB evaluates equilibrium, speed and ability to stand up and sit down with a 0–12 score: a score &lt; 6 indicates extreme frailty which contra–indicates training; a score between 7–9 indicates a frail pt, and a score 10–12 indicates a pre–frail pt. Based on this classification, different types of training are proposed: continuous training (CT), exercise training (ExT), interval training (IT) –further distinguished in low intensity (LIT) and high intensity (HIT)–; inspiratory muscle training (IMT) and resistance strength training (RST). At every DH access, pts exercise for 90 minutes alternating RST, IMT and aerobic training on cyclette (HIT). In each case, every 3–4 minutes of effective exercise an absolute pause of up to 90 seconds is observed. Moreover, the "talk test" ensures that at every moment during excercise the pt can talk without dyspnoea. A nurse teaches basic sanitary notions (correct therapy intake, healthy lifestyle, symptoms recognition); a nutrition expert counsels pts about dietary intake; a psycologist supports pts with group and indivisual sessions, whereas the cardiologist optimizes therapy according to laboratory findings, which are modified by the physical training. In this way, the multidisciplinary team–approach to the HF pt allows for a better care of each individual. So far, our pts have appreciated this initiative and are willing to come back again and again. We plan to collect clinical data of all pts treated with this approach and test its efficacy over a two–year period.