Italian Society of Interventional Cardiology (GISE) position paper for Cath lab-specific preparedness recommendations for healthcare providers in case of suspected, probable or confirmed cases of COVID-19

COVID‐19 pandemic raised the issue to guarantee the proper level of care to patients with acute cardiovascular diseases and concomitant suspected or confirmed COVID‐19 and, in the meantime safety and protection of healthcare providers. The aim of this position paper is to provide standards to healthcare facilities and healthcare providers on infection prevention and control measures during the management of suspected and confirmed cases of 2019‐nCoV infection accessing in cath‐lab. The document represents the view of the Italian Society of Interventional Cardiology (GISE), and it is based on recommendations from the main World and European Health Organizations (WHO, and ECDC) as well as from the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI).

[Italian certification for interventional cardiologists from the Italian Society of Interventional Cardiology (SICI-GISE)]

Differently from many European and non-European countries, currently in Italy there is not an official, well-defined process for training, evaluation and certification for interventional cardiologists. Interventional Cardiology is an important branch of Cardiology with peculiarities such as to need specific theoretical and practical training. The lack of standardization of training criteria may result in disparities in the quality of care offered to patients in different locations. The Italian Society of Interventional Cardiology (SICI-GISE) has therefore developed an independent certification process for Italian interventional cardiologists. This is a first step towards the implementation of a well-defined training and certification process for both coronary and structural interventions, and for regular re-certification of established operators.The certification will be issued by SICI-GISE and will be based on the recognition of the skills attained by interventional cardiologists in the setting of coronary diagnostic and interventional procedures. This document describes the minimum eligibility criteria for the training centers, which have the task of recording and validating the training activity carried out by each interventional cardiologist, and the minimum competence requirements that should be attained by the operators to obtain the certification.

[Dyslipidemia management for secondary prevention in cardiovascular disease: from guidelines to clinical practice]

Despite improvements in the treatment and prevention of risk factors (i.e. dyslipidemia), cardiovascular disease (CVD) remains one of the leading causes of morbidity and mortality in countries with a high degree of socio-economic development. As a matter of fact, in the last decades, several trials and meta-analysis highlighted the impact of treatments targeted to lowering cholesterol levels (particularly LDL-cholesterol) on outcomes of patients affected by CVD, both in terms of primary and secondary prevention. The main international CVD guidelines recommend lifestyle modifications and optimal lipid-lowering therapy in individuals with established CVD. The aim of the present document is to describe the dimension of the problem and the available therapies, offering a practical pharmacological flow-chart useful for accurate monitoring and intensive treatment of dyslipidemias in this patient population.

Different distribution of antimicrobial resistance genes and virulence profiles of Staphylococcus aureus strains isolated from clinical mastitis in six countries

Staphylococcus aureus is recognized worldwide as one of the main contagious mastitis agents in cattle and can express a set of antimicrobial resistance genes and virulence-associated genes that explain the wide range of outcomes of intramammary infections. Staphylococcus aureus strains are heterogeneous: their different resistance and virulence patterns, associated with host-level factors and treatment factors, are related to the severity of infection. The aim of this study was to determine phenotypic antibiotic susceptibility, occurrence of selected antimicrobial resistance genes and other virulence genes in 93 S. aureus strains isolated from clinical mastitis in 6 countries: Argentina, Brazil, Germany, Italy, the United States (New York State), and South Africa. These isolates were tested against a total of 16 drugs (amoxicillin-clavulanate, ampicillin, cefazolin, cefoperazone, cefquinome, enrofloxacin, erythromycin, gentamicin, kanamycin, lincomycin, oxacillin, penicillin, rifampin, spiramycin, sulfamethoxazole/trimethoprim, tylosin) by minimum inhibitory concentration (MIC) assay, and examined for the presence of 6 antibiotic-resistance genes (blaZ, mecA, mecC, ermA, ermB, ermC) and 6 virulence-associated genes (scn, chp, sak, hla, hlb, sea) via PCR analysis. The phenotypic results of this study revealed the presence of 19.4% penicillin-resistant strains, whereas 22.6% of the strains were classified as having resistance (5.4%) or intermediate resistance (17.2%) to erythromycin. Most (96.8%) of the isolates were inhibited by cephalosporins, and all were susceptible to amoxicillin-clavulanate. Two strains (1 from Germany, 1 from Italy) were resistant to oxacillin and were positive for mecA. Among the other antimicrobial resistance genes, the most frequently detected was blaZ (46.2%), and 32.3% of the isolates were positive for erm genes: ermC (21.5%) and ermB (10.8%). The most prevalent virulence gene was hla (100%), followed by hlb (84.9%) and sea (65.6%). These results show a low prevalence of antibiotic multidrug resistance in S. aureus isolates, even if the detection of selected antimicrobial resistance genes did not always correspond with the occurrence of phenotypic antibiotic resistance; the immune evasion cluster gene prevalence was quite low in the samples analyzed.

[A strategic roadmap of the Italian Society of Interventional Cardiology (SICI-GISE) to ensure patient's access to appropriate treatment]

In comparison with the international scenario, in Italy the penetration of several important scientific and technological innovations in the field of cardiovascular intervention appears to be inadequate both in terms of number of patients treated with respect to the actual need, and inhomogeneity between the different geographical areas of the country. One of the main institutional objectives of the Italian Society of Interventional Cardiology (SICI-GISE) is to develop a roadmap to guarantee homogeneous access throughout the whole national territory to treatments that are recommended by the major international guidelines. The present document focuses on four main areas of cardiovascular intervention: (i) transcatheter treatment of aortic valve stenosis, (ii) percutaneous mitral valve repair, (iii) prevention of cardioembolic stroke through percutaneous left atrial appendage occlusion in patients with non-valvular atrial fibrillation, (iv) optimization of coronary revascularization with the aid of the functional study of coronary lesions. The purpose of this document is to describe the clinical profile and the economic impact of the aforementioned methods, the current clinical, organizational and management barriers to treatment access in the national territory and the possible solutions for overcoming the aforementioned barriers.

P5531A systematic follow-up strategy after percutaneous coronary intervention based on patient risk profile: the prospective POST-PCI registry

Background

Redundant clinical and non-invasive examinations after percutaneous coronary intervention (PCI) increase the cost of medical care with no outcome improve. A multidisciplinary consensus document (MCD) providing a follow-up (FU) strategy based on 3 clinical and angiographic risk profile (A high, B intermediate, and C low) has been recently proposed.

Aim

To evaluate the potential reduction of cardiologic consults (CC), stress tests (ST), and echocardiograms (EC) with the application of the MCD after PCI.

Methods

The Post-PCI registry is a multicenter, observational, prospective data collection carried out during a four-week period that included consecutive patients undergoing PCI at 31 Italian Hospitals both for acute coronary syndromes (ACS) or stable coronary artery disease (SCAD). FU strategies were left at investigator's discretion. A comparison between the CC, ST and EC performed in the first 12-months with the potential suggested by the MCD was evaluated.

Results

A total of 1113 patients were included; 12-months follow up was available in 90% of the cases (mean age 68±11 years old, 58% ACS). Based on MCD risk profile 17% were in A, 74% in B and 9% in C strategy. On average observed CC and ST were significantly lower compared to the expected based on MCD (respectively 1.63±1.07 vs 1.91±0.28, and 0.41±0.59 vs 0.61±0.84; on the contrary EC were significantly higher (0.64±0.73 vs 0.34±0.75, all: p<0.001). The excess rate for CC, ST and EC as compared to MCD was respectively 25%, 14% and 8% for the strategy A, 14%, 25% and 50% for the strategy B and 26%, 54% and 40% for the strategy C. At multivariable logistic analysis the MCD strategy was an independent predictor (in a model with age, sex, consulting physician, public or private hospital) of an increased number of cardiac examination in patients at intermediated and low risk [B group OR 2.56 (95% CI 1.38–4.75), C group 27.00 (95% CI 8.13–89.62)]. The other independent predictor was age, with a reduced number of examination for elderly (>75 years old) patients [OR 0.59 (CI 95% 0.43–0.80)].

Conclusion

Our data suggest that in a real word population of patients undergoing PCI, a follow-up strategy based on clinical and anatomical risk profile would allow to a reduction of cardiac tests and consultations, particularly in patients at intermediated and low risk leading to an increase of appropriateness of prescription and to a cost reduction of medical care.

Acknowledgement/Funding

The Post-PCI registry was supported by the Italian Society of Interventional Cardiology (SICI-GISE) receiving an unrestricted grant from Astra Zeneca

[SICI-GISE Position paper: Enhancing radiation safety in the catheterization laboratory]

The radiation dose received by interventional cardiologists during their activity in the catheterization laboratory is a matter of concern in terms of possible deterministic and stochastic risk. At the same time, very often, the knowledge of the effect and consequences of radiation exposure in the interventional cardiology community is limited. This document endorsed by the Italian Society of Interventional Cardiology (SICI-GISE) provides recommendations for cardiologists' radiation protection. Radiation safety considerations dedicated to women and other staff personnel working in the catheterization laboratory are also discussed.

Staphylococcus aureus intra-mammary infection affects the expression pattern of IL-R8 in goat

IL-1R8 is a member of Interleukin-1 receptor family acting as a negative regulator of inflammation reliant on ILRs and TLRs activation. IL-1R8 role has never been evaluated in acute bacterial mastitis. We first investigated IL-1R8 sequence conservation among different species and its pattern of expression in a wide panel of organs from healthy goats. Then, modulation of IL-1R8 during natural and experimental mammary infection was evaluated and compared in blood, milk and mammary tissues from healthy and Staphylococcus aureus infected goats. IL-1R8 has a highly conserved sequence among vertebrates. Goat IL-1R8 was ubiquitously expressed in epithelial and lymphoid tissues with highest levels in pancreas. IL-1R8 was down-regulated in epithelial mammary cells following S. aureus infection. Interestingly it was up-regulated in leukocytes infiltrating the infected mammary tissues suggesting that it could represent a target of S. aureus immune evasion.

[Spontaneous coronary artery dissections]

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic coronary artery pathology and an important cause of coronary artery disease in young women with an average age of 40 to 50 years with few or no cardiovascular risk factors. There has been a surge in the diagnosis of SCAD due to an increased use of coronary angiography and the clinical availability and application of high-resolution intracoronary imaging. SCAD is due to the separation of coronary wall layers with the formation of intramural hematoma, compression of the true lumen and secondary myocardial ischemia. Coronary angiography is the first-line imaging, also useful are intravascular ultrasound and optical coherence tomography. Therapy is conservative in most cases because of the high percentage of spontaneous healing of the vascular wall. The prognosis is good, although the disease is burdened by a high prevalence of major adverse coronary events, including recurrence of coronary dissection, thus making careful follow-up essential in survivors of the acute event. Given that the presence of SCAD may be associated with aneurysm formation and dissections of other arteries, screening of the arterial tree may be useful, especially of the supra-aortic trunks and splanchnic circulation.

[Updated SICI-GISE position paper on institutional and operator requirements for transcatheter aortic valve implantation]

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of patients with symptomatic severe aortic stenosis and has become the standard of care for inoperable patients and the preferred therapy for those at increased surgical risk with peculiar clinical and anatomic features. Technology advances, growing experience and accumulating data prompted the update of the 2011 Italian Society of Interventional Cardiology (SICI-GISE) position paper on institutional and operator requirements to perform TAVI. The main objective of this document is to provide a guidance to assess the potential of institutions and operators to initiate and maintain an efficient TAVI program.

[Follow-up strategies after percutaneous coronary intervention: prognostic stratification and multidisciplinary management based on patient risk profile]

The number of percutaneous coronary interventions (PCI) is increasing worldwide. Follow-up strategies after PCI are extremely heterogeneous and can greatly affect the cost of medical care. In the present paper, practical advises are provided with respect to a tailored follow-up strategy on the basis of patients' risk profile. Clinical and interventional cardiologists, cardiac rehabilitators, and general practitioners equally contributed to the creation of the present document and defined three follow-up strategies and types and timing of clinical and instrumental evaluations in post-PCI patients.

Genomic and transcriptomic comparison between Staphylococcus aureus strains associated with high and low within herd prevalence of intra-mammary infection

Background

Staphylococcus aureus (Staph. aureus) is one of the major pathogens causing mastitis in dairy ruminants worldwide. The chronic nature of Staph. aureus infection enhances the contagiousness risk and diffusion in herds. In order to identify the factors involved in intra-mammary infection (IMI) and diffusion in dairy cows, we investigated the molecular characteristics of two groups of Staph. aureus strains belonging to ST8 and ST398, differing in clinical properties, through comparison of whole genome and whole transcriptome sequencing.

Results

The two groups of strains, one originated from high IMI prevalence herds and the other from low IMI prevalence herds, present a peculiar set of genes and polymorphisms related to phenotypic features, such as bacterial invasion of mammary epithelial cells and host adaptation. Transcriptomic analysis supports the high propensity of ST8 strain to chronicity of infection and to a higher potential cytotoxicity.

Conclusions

Our data are consistent with the invasiveness and host adaptation feature for the strains GTB/ST8 associated to high within-herd prevalence of mastitis. Variation in genes coding for surface exposed proteins and those associated to virulence and defence could constitute good targets for further research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12866-017-0931-8) contains supplementary material, which is available to authorized users.

Survival Benefits of Invasive Versus Conservative Strategies in Heart Failure in Patients With Reduced Ejection Fraction and Coronary Artery Disease

Background—

Heart failure with reduced ejection fraction caused by ischemic heart disease is associated with increased morbidity and mortality. It remains unclear whether revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) carries benefits or risks in this group of stable patients compared with medical treatment.

Methods and Results—

We performed a meta-analysis of available studies comparing different methods of revascularization (PCI or CABG) against each other or medical treatment in patients with coronary artery disease and left ventricular ejection fraction ≤40%. The primary outcome was all-cause mortality; myocardial infarction, revascularization, and stroke were also analyzed. Twenty-one studies involving a total of 16 191 patients were included. Compared with medical treatment, there was a significant mortality reduction with CABG (hazard ratio, 0.66; 95% confidence interval, 0.61–0.72; P <0.001) and PCI (hazard ratio, 0.73; 95% confidence interval, 0.62–0.85; P <0.001). When compared with PCI, CABG still showed a survival benefit (hazard ratio, 0.82; 95% confidence interval, 0.75–0.90; P <0.001).

Conclusions—

The present meta-analysis indicates that revascularization strategies are superior to medical treatment in improving survival in patients with ischemic heart disease and reduced ejection fraction. Between the 2 revascularization strategies, CABG seems more favorable compared with PCI in this particular clinical setting.

Occurrence of methicillin-resistant Staphylococcus aureus in dairy cattle herds, related swine farms, and humans in contact with herds

In this study we investigated the circulation of methicillin-resistant Staphylococcus aureus (MRSA) in 2 dairy cattle farms (farm A and B), previously identified as MRSA-positive in bulk tank milk samples, and epidemiologically related to swine farms. Collected specimens included quarter milk samples and nasal swabs from dairy cows, pig nasal swabs collected at both the farm and slaughterhouse level, environmental dust samples, and human nasal swabs from the farms' owners and workers. The prevalence of MRSA was estimated at the herd level by testing quarter milk samples. The prevalence of MRSA was 4.8% (3/63; 95% confidence interval=0-10.2%) and 60% (33/55; 95% confidence interval=47.05-72.95) in farm A and B, respectively. In farm A, MRSA was also isolated from humans, pigs sampled at both farm and slaughterhouse level, and from environmental samples collected at the pig facilities. The dairy cattle facilities of farm A tested negative for MRSA. In farm B, MRSA was isolated from environmental dust samples in both the cattle and pig facilities, whereas nasal swabs collected from cows and from humans tested negative. Sixty-three selected MRSA isolates obtained from different sources in farm A and B were genetically characterized by multilocus sequence typing, spa-typing, ribosomal spacer-PCR, and also tested for the presence of specific virulence genes and for their phenotypical antimicrobial susceptibility by broth microdilution method. Different clonal complex (CC) and spa-types were identified, including CC398, CC97, and CC1, CC already reported in livestock animals in Italy. The MRSA isolates from quarter milk of farm A and B mostly belonged to CC97 and CC398, respectively. Both lineages were also identified in humans in farm A. The CC97 and CC398 quarter milk isolates were also identified as genotype GTBE and GTAF by ribosomal spacer-PCR respectively, belonging to distinct clusters with specific virulence and resistance patterns. The GTBE and GTAF clusters also included swine, environmental, and human isolates from both farms. A high heterogeneity in the genetic and phenotypic profiles was observed in environmental isolates, in particular from farm B. These results demonstrate the possibility of a dynamic sharing and exchange of MRSA lineages or genotypes between different species and farm compartments in mixed-species farms. The risk of transmission between swine and related dairy cattle herds should be considered. Our findings also confirm the zoonotic potential of livestock-associated MRSA and underline the importance of applying biosecurity measures and good hygiene practices to prevent MRSA spread at the farm level and throughout the food production chain.

Genomic characteristics of Staphylococcus aureus strains associated with high within-herd prevalence of intramammary infections in dairy cows

Staphylococcus aureus is one of the most important causes of mastitis in dairy cattle. Based on previous research, Staph. aureus genotypes with different pathogenic and contagious properties can cause intramammary infection (IMI) and coexist in the same herd. Our study aimed to compare Staph. aureus strains from herds that differed in IMI prevalence using different molecular approaches such as ribosomal spacer (RS)-PCR, multilocus sequence typing (MLST), spa typing, ribotyping, pulsed-field gel electrophoresis (PFGE), and multiplex PCR. For this purpose, 31 dairy herds with Staph. aureus IMI were selected, and 16 of these were chosen for a comparison study: the 8 high-prevalence (HP) herds had Staph. aureus IMI prevalence >28% and the 8 low-prevalence (LP) herds had an IMI prevalence <4%. A total of 650 isolates of Staph. aureus from mammary quarters of all positive cows were genotyped with RS-PCR, a technique based on amplification of a portion of the intergenic spacer 16S-23S rRNA, and a subset of 54 strains was also analyzed by multiplex PCR, ribotyping, PFGE, MLST, and spa typing. The RS-PCR analysis revealed 12 different profiles. Staphylococcus aureus strains isolated from 5 out of 8 HP herds showed a profile identical to the genotype B (GTB), described in previous studies as being strongly associated with high within-herd prevalence of Staph. aureus mastitis and the presence of the genes coding for enterotoxins sea, sed, and sej, a long x-region of spa gene, and 3 lukE fragments. Moreover, all strains isolated in the HP herds possessed genes coding for staphylococcal enterotoxins. In LP herds, a limited number of strains of 6 genotypes, different from those isolated in HP herds, were identified and GTB was not found. Within these genotypes, 4 strains were positive for the mecA gene. Preliminary results and comparison with other genotyping methods confirmed that genotyping by RS-PCR is an accurate, rapid, and inexpensive tool for future field studies on Staph. aureus mastitis strains and generates clinically relevant results.

Management and Long-Term Prognosis of Spontaneous Coronary Artery Dissection

The optimal management and short- and long-term prognoses of spontaneous coronary artery dissection (SCAD) remain not well defined. The aim of this observational multicenter study was to assess long-term clinical outcomes in patients with SCAD. In-hospital and long-term outcomes were assessed in 134 patients with documented SCAD, as well as the clinical impact and predictors of a conservative rather than a revascularization strategy of treatment. The mean age was 52 ± 11, years and 81% of patients were female. SCAD presented as an acute coronary syndromes in 93% of patients. A conservative strategy was performed in 58% of patients and revascularization in 42%. On multivariate analysis, distal versus proximal or mid location of dissection (odds ratio 9.27) and basal Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 or 3 versus 0 or 1 (odds ratio 0.20) were independent predictors of conservative versus revascularization strategy. A conservative strategy was associated with better in-hospital outcomes compared with revascularization (rates of major adverse cardiac events 3.8% and 16.1%, respectively, p = 0.028); however, no significant differences were observed in the long-term outcomes. In conclusion, in this large observational study of patients with SCAD, angiographic features significantly influenced the treatment strategy, providing an excellent short- and long-term prognosis.