bluuebunny/crossref_metadata_2025_split huggingface dataset:
IMPACT OF POLYVASCULAR DISEASE ON LONG–TERM PROGNOSIS IN PATIENTS WITH ACUTE CORONARY SYNDROME. A PROSPECTIVE COHORT STUDY IN ITALY
Authors: D‘Errigo P , Mureddu G , Rosato S , Altamura V , Faggiano P , Ceravolo R , Badoni G , Baglio G 
Published: May 2024

Abstract

Background
Atherothrombosis should be considered a systemic disease that may involve one or more than one vascular beds. Data on the impact of polyvascular disease on long–term prognosis in patients with acute coronary syndrome (ACS) are still scarce.

Aim
To assess the prevalence of symptomatic polyvascular disease in a cohort of patients with ACS and to investigate the impact on long–term outcomes of single versus multiple vascular beds involvement.

Methods
We analyzed a nationwide, comprehensive, and universal administrative database of consecutive patients older than 40 years admitted for a new episode of ACS in 2013–14 in Italy. Patients with ACS were stratified according to the presence of Peripheral Arterial Disease (PAD) only, Cerebrovascular Disease (CeVD) only, PAD and CeVD (PAD+CeVD) or neither (noPAD/noCeVD). A Cox proportional hazard multivariate model was used to evaluate the impact of PAD only, CeVD only and PAD+CeVD on 5–year MACCE.

Results
331320 new episode of ACS were identified. Among them, 24491 (7.4%) were patients with PAD only, 16269 (4.9%) with CeVD only and 4710 (1.4%) with PAD+CeVD. The 5 years MACCE was 42.6%, 64.7%, 66.1 and 72.2 (p&lt;0.001) for noPAD/noCeVD, PAD only, CeVD only and PAD+CeVD, respectivelly. After adjustment for age, sex, and comorbidities, the hazard ratio (HR) for 5–year MACCE was 1.30 (p&lt;0.0001), 1.39 (p&lt;0.0001), and 1.46 (p&lt;0.0001) in patients with PAD only, CeVD only, and PAD+CeVD, respectively, as compared with patients without PAD and CeVD.

Conclusion
Polyvascular disease represents a major risk factor in patients with ACS. The simultaneous involvement of three vascular beds further increases the risk of long–term outcomes. Greater effort should be directed toward identification of subclinical/clinical atherosclerosis of beds different from coronary for a better risk stratification.
HYPERTRIGLYCERIDEMIA IN PATIENTS WITH ACUTE AND CHRONIC CORONARY SYNDROME: PREVALENCE AND THEIR ASSOCIATION WITH EXTREME CARDIOVASCULAR RISK AND LEFT VENTRICULAR FUNCTIONHYPERTRIGLYCERIDEMIA IN PATIENTS WITH ACUTE AND CHRONIC CORONARY SYNDROME: PREVALENCE
Authors: Maloberti A , La Rosa A , Toscani G , Caccia A , Gualini E , Pezzoli S , Morelli M , Busti A , Colombo V , Tognola C , Algeri M , Intravaia R , Pirola R , Giannattasio C 
Published: May 2024

Abstract

Objective
Hypertriglyceridemia prevalence in Acute and Chronic Coronary Syndrome (ACS and CCS respectively) patients in the era of very low LDL target is still unknow. The objective of our study is to evaluate the prevalence of triglyceride levels above 150 or 200 mg/dL despite statin therapy and LDL cholesterol at targets in ACS and CCS subjects enrolled in a Cardiac Rehabiliatitation (CR) program.

Methods
This cross–sectional observational study was conducted at the Niguarda Hospital (Milan, Italy). Patients undergoing CR after ACS/CCS from January 1, 2012, to March 28, 2023, were included. Data on demographic, clinical, laboratory, and instrumental variables were collected.

Results
The study population consisted of 740 patients with a mean age of 64.3±10.7 years, predominantly male (81.7%). Triglyceride levels significantly decrease during the CR period (131.1±63.8 vs 116.9±75.9 mg/dL; p &lt; 0.001) similarly to LDL cholesterol (107.9 ± 38.8 mg/dL vs 69.9 ± 25.9mg/dL, p&lt;0.001). 50.8% of the subjects reach the LDL cholesterol target. The percentage of patients with triglycerides &gt;150 mg/dL at CR ends was 17.8% (15.6% when considering only patients that reach the LDL target of 55 mg/dL) while it is only 6.8% for triglycerides &gt;200 mg/dL (5.9% when considering only patients that reach LDL target). Patients with triglycerides &gt;150 mg/dL had higher baseline BMI, LDL cholesterol and uric acid with lower ejection fraction at CR ends. Hypertriglyceridemia significantly correlates with extreme CV risk (R= 0.08, p= 0.025). At multivariate analysis, FE (dependent variable) was significantly associated with triglycerides (beta= – 0,145, p= 0,026) and systolic BP (beta= 0,137, p= 0,032).

Conclusion
Despite high intensity statin therapy and lower LDL cholesterol targets, a substantial proportion of patients in cardiac rehabilitation still had elevated triglyceride levels. This study highlights the potential role of Icosapent Ethyl in managing hypertriglyceridemia in these patients.
PACING NEEDS IN CLIP‘S ERA: HIS–BUNDLE PACING AFTER TRICUSPID TRANSCATHETER EDGE–TO–EDGE REPAIR (TEER)
Authors: D‘Amore S , Chieffo E , Dossena C , Carrozzi C , Cacucci M , Landolina M 
Published: May 2024

Abstract
An 85 year–old man with permanent atrial fibrillation and previous inferior wall and right ventricle STEMI treated with percutaneous primary angioplasty in 2013, was referred to our attention to extreme low ventricular rate, daytime pauses of 6 seconds symptomatic for dizziness found in a ECG Holter registration. After the myocardial infarction, the patient developed a severe tricuspid regurgitation (TR) owing to annular dilatation from adverse right ventricular remodeling so, in June 2022, owing to high cardiac surgery risk, the patient was successfully treated with percutaneous transcatheter implantation of three TriClip NT devices on posteroseptal, anteroseptal and anteroposterior commissures. The degree of TR improved from severe to moderate with mild tricuspid stenosis. Permanent pacemaker implantation was indicated. We decided to implant a conduction system pacing lead (His–bundle pacing) mainly for 3 reasons: (1) the presence of three tricuspid clips would have made it very difficult to advance a ventricular pacing catheter through the neo–orifices of the valve; (2) the high risk of clip displacement during catheter maneuvering across the valve plane; (3) a physiologic pacing such as His–bundle pacing seemed more appropriate given the need for high rate of ventricular pacing, in order to avoid further worsening of ventricular function. A Medtronic 3830 ventricular lead was inserted via the axillary vein through the His–dedicated Medtronic deflectable sheat (SelectSite C304–HIS) and in right anterior oblique fluoroscopic view the lead was advanced into the right atrium and we looked for a His bundle potential. It was decided to use the deflectable introducer in order to reach the Koch triangle with fine and precise movements without even accidentally interfering with the clips. The lead tip was screwed to the antero–septal edge of Koch’s triangle, showing optimal parameters of sensing, impedance, and pacing thresholds. Paced QRS was narrow as spontaneous QRS and a selective His–bundle paced QRS was seen on 12–leads. The fluoroscopy time was 10.9 minutes and a Total Dose Area Product (DAP) of 1.9 mGy/m2. The patient was then discharged 2 days later, asymptomatic. At the 1–month and 6–months visits all the pacing parameters was in the normal range and optimal His–bundle pacing treshold. Our case report demonstrates that His–bundle pacing in a patient with a complex transcatheter edge–to–edge tricuspid valve repair could be a safe and feasible option.
AN ACUTE MYOCARDIAL INFARCTION IN A VERY YOUNG MAN DUE TO HYPERHOMOCYSTEINEMIA
Authors: Cangemi S , Barone G , Zabbia D , Vinci D , Lombardo A , Inglese F , Caiolo A , Geraci G 
Published: May 2024

Abstract

Introduction
A young 17–year–old boy smoker and obese was admitted to our cardiology unit for continuous oppressive chest pain radiating to the left arm that had arisen three days earlier. In the emergency room, he had performed blood tests with evidence of an increased troponin and an electrocardiogram that showed mild ST–elevation in inferior leads with ST depression in aVL. We performed an urgent transthoracic echocardiography examination that was unremarkable Investigation Once diagnosed with acute ST–segment elevation myocardial infarction, the patient underwent emergency coronary angiography. Coronary angiography highlighted an intermediate stenosis of the first branch diagonal to the proximal tract and a possible occlusion of the periapical branch of the anterior descending artery. It was decided not to perform PTCA as we could not exclude a distal coronary dissection and considering the vessel was of small caliber. We decided to complete the diagnostic process by performing a cardiac MRI showing edema in the apex and distal inferior wall and transmural gadolinium enhancement at the level of the septum and inferior wall of the distal section. In the context of the damaged wall a focal area of hypointensity to be referred to the "no–reflow" phenomenon Management The patient was treated with DAPT, low molecular weight heparin and high dose statin. A few hours after the coronary angiography the patient stopped having chest pain and remained asymptomatic for the rest of the hospital stay. We performed complete blood tests including with evidence of hyperhomocysteinemia. The lipid panel was normal. Hematological consultation recommended folate and Vitamine B12 treatment. After 12 months the patient is asymptomatic, has stopped smoking and continues to take DAPT. He repeated the echocardiogram which showed no alterations. Genetic testing was performed after hospital discharge and was positive for Methylenetetrahydrofolate reductase (MTHFR) homozygous mutation

Conclusion
Our clinical case shows a rare case of acute myocardial infarction in a very young person. Diagnosis and treatment were complicated by the extreme distality of the occlusion and the few modifiable risk factors identified (smoker, obesity and hyperhomocysteinemia). Hyperhomocysteinemia is an often underestimated cardiovascular risk factor associated with a high risk of cardiovascular events and multivessel coronary disease that should be sought in all young patients with AMI.
SHOULD WE BE CONCERNED ABOUT USING INTRAVASCULAR LITHOTRIPSY ON THE LEFT MAIN? INSIGHT FROM ROLLING STONE RETROSPECTIVE REGISTRY
Authors: Zecchino S , Cerrato E , Pavani M , Varbella F 
Published: May 2024

Abstract

Background
The use of rotational atherectomy is currently prevalent in the treatment of left main coronary artery lesions. However, it often necessitates the use of a large burr to achieve adequate debulking, which, in turn, demands highly experienced operators. Intravascular lithotripsy (IVL) is a promising, user–friendly and increasingly employed technique for calcific plaque modification before percutaneous coronary intervention. Although in many cath labs it is now routinely used to treat lesions of the three main coronary arteries, there are still concerns regarding its use in the left main, primarily due to prolonged inflations required for its optimal efficacy.

Methods
We conducted a retrospective analysis using data from the multicenter retrospective Rolling Stone registry. The analysis involved data from 474 patients, with a stratification between IVL procedures involving left main coronary artery (46 patients) and those that did not (428 patients). The primary effectiveness endpoint was procedural success (defined as achieving residual stenosis &lt; 20% with TIMI III flow); secondary endpoints included the rate of procedural related adverse events, in hospital adverse events and MACE rate at 30 days and 6 months.

Results
Between April 2018 and January 2023, a total of 474 underwent IVL procedures. Most patients presented with calcific lesion requiring lithotripsy in non–left main segments, while IVL was performed on the left main artery in 46 patients. No significative differences were found on baseline characteristics between LM and non–LM groups. Treatment of IVL–LM lesion was marked by a high procedural success rate (97.8%) and a low incidence of procedural and peri–procedural complications. However, there was a higher rate of contrast–induced acute kidney injury in patients treated in LM (6.5% vs. 1.6%, p=0.030), although no other differences for in–hospital outcomes were observed. Furthermore, there were no differences in 30–day and 6–month follow–up outcomes between the two groups.

Conclusions
This study suggests that employing intravascular lithotripsy in the left main coronary artery is not only a safe procedure but also produces excellent results comparable to its application in other coronary branches. This provides a substantial level of confidence in the safety and effectiveness of IVL when used in this specific context.
LIMITATIONS IN THE USE OF SUBCUTANEOUS DEFIBRILLATOR IN PATIENTS WITH LOW BODY MASS INDEX
Authors: Floris R , Demontis M , Carboni G , Marini R , Mancosu M , Frau B , Farris F , Racis M , Delogu G 
Published: May 2024

Abstract

Introduction
Subcutaneous defibrillator is an effective and widely used tool in clinical practice but the presence of large fluctuations in the body mass index and the reduction of subcutaneous tissue may limit its application to all patients.

Case Report
In 2014, a 51–year–old woman underwent implantation of a dual–chamber transvenous defibrillator with left subclavian vein approach in secondary prevention for long Qt syndrome (LQT3). About 6 years after implantation she presented a ventricular lead breakage due to subclavian crush syndrome and was subjected to multiple inappropriate shocks due to lead failure. For this reason, the transvenous defibrillator was replaced with a single–chamber pacemaker for atrial stimulation and a subcutaneous defibrillator was implanted (Fig.1). In the following years the patient lost 14 kg and in the first months of 2022 she complained of the onset of stabbing pain in the precordial region near the upper face of the left sixth rib on the midclavicular line (Fig.2). Over the months, this symptomatology has become increasingly limiting and poorly responsive to normal analgesics but only to opiates; furthermore the pain has also occurred after a few weeks at the left parasternal level along the course of the distal portion of the subcutaneous catheter. For this reason, after discussing the case with the patient, we proceeded to implant a new transvenous lead via left subclavian vein and upgrade to a dual–chamber defibrillator. Subsequently, in the same operating session, the subcutaneous defibrillator was removed, finding only a modest traction resistance of the catheter in the parasternal area, resolved with the use of a 10 French introducer used as a sheet to debride the course of the same from the fibrotic adhesions (Fig .3). In the days following the procedure, the patient reported a progressive total disappearance of the pain symptoms. Reassessed after one year, the patient reports subjective well–being with total absence of chest pain and good quality of life.

Conclusions
The subcutaneous defibrillator represents an important resource for the management of the main ventricular arrhythmias, especially in patients with a high risk of infection and with a long life expectancy. The presence of a stable amount of subcutaneous tissue is a necessary condition to guarantee the tolerance of the lead over time and to avoid chronic pain situations that can lead to its removal.
POST–ROSC ECG PREDICTS SURVIVAL AFTER OUT–OF HOSPITAL CARDIAC ARREST. THE PROGRESS SCORE
Authors: Lopiano C , Pontremoli S , Bendotti S , Primi R , Currao A , Sechi G , Marconi G , Ronchi V , Contri E , Panni G , Sgotti D , Zorzi E , Cazzaniga M , Piccolo U , Bussi D , Ruggeri S , Facchin F , Soffiato E , Centineo P , Reali F , Baldi E , Compagnoni S , Quilico F , Vicini Scajola L , Fasolino A , Savastano S 
Published: May 2024

Abstract

Background
Prognostic assessment of patients following out–of–hospital cardiac arrest (OHCA) is critical to guide care after return of spontaneous circulation (ROSC). The ECG acquired after ROSC in patients with OHCA has proven to be crucial not only for its diagnostic role but also for its prognostic purposes. Indeed, certain electrocardiographic features have been shown to be directly correlated with an increased risk of mortality. We developed a score (PROGRESS–SCORE) that can predict 30–day mortality risk in post–OHCA patients, identifying three risk classes: low (0–4), intermediate (5–7) and high (8–26). The current aim is to validate PROGRESS–SCORE in a new cohort of patients.

Materials and Methods
We retrospectively applied the PROGRESS score to prospectively collected data. Post–ROSC ECGs of patients enrolled from 1/1/2015 to 31/12/2022 from the Lombardy Cardiac Arrest Registry (LombardiaCARe) were collected. Predictors considered were: age &gt;62 years, female sex, presence of more than 1 segment with ST elevation, QRS &gt;120 ms, and diagnostic pattern for Brugada Syndrome. Three risk groups were identified according to the previous classification: low (0–4), intermediate (5–7) and high (8–26). Calibration was assessed by plotting the observed proportions of events against the predicted probabilities: the Harrel–c, derived from a univariable Cox regression, was assessed for discrimination, taking into account the risk category as the independent variable.

Results
A total of 792 post–ROSC ECGs were collected: 490 males (61.9%) with a median age of 70 years; median ECG acquisition time from ROSC was 7 minutes (4.2 – 21.0). 348 (43.9%) patients survived to 30 days and 335 (42.3%) died. Mortality was similar between the intermediate–risk and low–risk groups (HR:1.2[95%CI,0.8–1.9]; p:0.35), but higher in the high–risk group than in the low–risk group (HR:1.9[95%CI,1.3–2.8];p:0.001).

Conclusions
Our results show that post–ROSC ECG can discriminate patients at high risk of mortality after OHCA. This provides a possibility for risk stratification in post–ROSC care, which is essential in order to guide resource allocation. Consequently, the application of our score would help personalization of care.
WEARABLE CARDIOVERTER–DEFIBRILLATORS IN CLINICAL PRACTICE IMPLEMENTATION OF THE ANMCO POSITION PAPER FOR APPROPRIATE USE OF THE WEARABLE CARDIOVERTER DEFIBRILLATOR
Authors: Matteucci A , Alonzo A , Castello L , Marino G , Spinelli A , Di Fusco S , Colivicchi F 
Published: May 2024

Abstract

Introduction
Wearable cardioverter–defibrillators (WCD) have emerged as a valuable tool in the management of patients at risk for life–threatening arrhythmias. These devices offer a non–invasive and temporary solution, providing continuous monitoring and the potential for prompt defibrillation when needed. In this study, we explore the indications for WCD and evaluate arrhythmic events through comprehensive monitoring.

Methods
From November 2022 to December 2023, we conducted an outpatient follow–up of 18 patients receiving WCD. Regular check–ups and comprehensive echocardiography were performed to optimize therapy based on specific indications for each patient.

Results
The average age of the patients was 59.3±17.4 years, with 79% being male. Among the cohort, 58% had hypertension, and a similar percentage comprised smokers and individuals with dyslipidemia, while 32% were diabetic. The indications for receiving WCD were: de novo diagnosis of dilated cardiomyopathy with reduced ejection fraction in 9 (50%) patients, recent acute coronary syndrome and ejection fraction &lt; 35% in 5 (28%), cardiac electronic device infections in 3 (17%) patients and myocarditis with electrical instability in 1 (5%) patient. Patients were in optimal medical therapy (OMT) tailored to their specific comorbidities, with 84% on renin–angiotensin–aldosterone system inhibitors, 95% on beta–blockers, 53% on mineralocorticoid receptor antagonists, 53% on sodium–glucose cotransporter–2 inhibitors, and 37% on antiarrhythmics. The average follow–up was 64±45 days according to specific etiology, with a daily wearing time of 22.9±1.1 hours. No device interventions were recorded. At the end of the follow–up period, 6 (33%) patients still required implantable cardioverter–defibrillator (ICD). Among these, 4 patients (22%) underwent to ICD implantation, 3 for secondary prevention, and 1 for primary prevention, while notably, 2 (11%) patients, declined the procedure.

Conclusions
The use of wearable cardioverter–defibrillators in the outpatient setting for patients at risk of life–threatening arrhythmias allowed to optimize therapy and restrict the indications for ICD, in our cohort up to 67%, with a good safety profile due to the low incidence of device interventions.
ARRHYTHMOGENIC MITRAL VALVE PROLAPSE PRESENTED WITH OUT–OF–HOSPITAL CARDIAC ARREST
Authors: Tarantino G , Colonna P , Scardapane A , Troccoli R , Rodio D , D‘Agostino C 
Published: May 2024

Abstract

Abstract
Despite mitral valve prolapse is generally a benign condition, consistent data regarding it as cause of sudden cardiac death have been arisen. Among the poor–prognosis determinants, mitral annular disjunction plays a paramount role. We discuss the case of a young with mitral valve prolapse presented with resuscitated OHCA.

Introduction
Mitral valve prolapse (MVP) is the most common valvulopathy and its prognosis is usually excellent in the absence of relevant mitral regurgitation. However a recent meta–analisys demonstrated a significant link between MVP and sudden cardiac death (SCD). Among the features that raise the risk there is the mitral annular disjunction (MAD). MAD consists of the systolic separation of the mitral annulus from the ventricular myocardium at the level of the posterior leaflet. Independent from the presence of MAD, a recent scientific consensus has identified the elements which constitute the so called arrhythmic mitral valve complex/phenotype: 1) MVP 2) frequent or complex ventricular arrhythmias 3) absence of any other well–defined arrhythmic cause.

Case Presentation
A 32–year–old woman without any relevant medical history was collapsed; immediately her relatives called 118 and CPR was started. When the EMT arrived, the ECG showed ventricular fibrillation, and 6 DC shock were needed to restore spontaneous circulation. Once in the ED, she underwent urgent coronary angiography resulted negative. The ECG showed sinus rhythm at 65 bpm, infero–lateral negative T waves. A transthoracic echocardiogram (TTE) was carried out and it underlined a slightly depressed ventricular function (E.F. 53%), hypokinesia of the mid–apical septum, a mitral valve prolapse with moderate mitral regurgitation and mitral annular disjunction of 10mm, data concordant with the cardiac magnetic resonance (CMR) and transoesophageal echocardiography (TEE) thereafter performed. Viral and autoimmune screenings resulted negative. The patient underwent dual chamber TV–ICD implantation in secondary prevention.

Discussion
AMVP is a challenging entity because of the need of early identification of the patients affected by the arrhythmic phenotype for whom is indicated a lifelong follow up and in selected cases ICD implantation in primary prevention of SCD. Even if globally rare, SCD among patients affected by MVP is not a statistically dismissible event and in the small available post mortem studies it accounts for 4% to 7% of otherwise unexplained deaths.