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Vatrano M, Manzi G, Picariello C, D'Alto M, Enea I, Ghio S, Caravita S, Argiento P, Garascia A, Vitulo P, Gabrielli D, Agostoni P, Corda M, Sinagra G, Grimaldi M, Scelsi L, Badagliacca R, D'Agostino C, Perrone Filardi P, Colivicchi F, Indolfi C, Roncon L, Galiè N, Oliva F, Vizza CD. [ANMCO/SIC Consensus statement on pulmonary arterial hypertension]. G Ital Cardiol (Rome) 2024; 25:192-201. [PMID: 38410902 DOI: 10.1714/4209.42007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Pulmonary hypertension (PH) is a frequent pathological condition worldwide, mainly secondary to cardiovascular and respiratory diseases, with a poor prognosis. Pulmonary arterial hypertension (PAH) is a rare form that affects the arterial pulmonary vasculature. PH and PAH are characterized by non-specific symptoms and a progressive increase of pulmonary vascular resistance that results in progressive, sometimes irreversible, right ventricular dysfunction. In recent years, a growing medical and social commitment on this disease allowed more accurate diagnosis in shorter times. However, the gap between guidelines and clinical practice remains a challenge for all medical doctors involved in the disease management. Considering the needs to share and describe diagnostic and therapeutic pathways, to measure the results obtained and to address the economical and organizational problems of this disease, all involved figures should collaborate to improve its prognostic impact and health expenses. In this consensus document, the PH experts of the Italian Association of Hospital Cardiologists (ANMCO) together with those of the Italian Society of Cardiology (SIC), address 1) definition, classification and unmet needs of PH and PAH; 2) classification and characteristics of centers involved in the diagnosis and treatment of the disease; 3) proposal of organization of a diagnostic-therapeutic pathway, based on robust and recent scientific evidence.
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Affiliation(s)
| | - Giovanna Manzi
- Dipartimento di Scienze Cardiovascolari e Respiratorie, Sapienza Università di Roma, Policlinico Umberto I, Roma
| | | | - Michele D'Alto
- Dipartimento di Cardiologia, Ospedale Monaldi - Università degli Studi della Campania "L. Vanvitelli", Napoli
| | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta
| | - Stefano Ghio
- Divisione di Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Sergio Caravita
- U.O.C. Cardiologia, IRCCS Ospedale San Luca, Istituto Auxologico Italiano, Milano - Dipartimento di Ingegneria Gestionale, dell'Informazione e della Produzione, Università degli Studi di Bergamo, Dalmine (BG)
| | - Paola Argiento
- Dipartimento di Cardiologia, Ospedale Monaldi - Università degli Studi della Campania "L. Vanvitelli", Napoli
| | - Andrea Garascia
- Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Patrizio Vitulo
- Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, IRCCS ISMETT, Palermo
| | - Domenico Gabrielli
- U.O.C. Cardiologia, Dipartimento di Scienze Cardio-Toraco-Vascolari, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano - Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi, Milano
| | - Marco Corda
- S.C. Cardiologia, Azienda Ospedaliera "G. Brotzu", Cagliari
| | - Gianfranco Sinagra
- Dipartimento Cardiotoracovascolare, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Università degli Studi, Trieste
| | - Massimo Grimaldi
- U.O.C. Cardiologia e UTIC, Ospedale Miulli, Acquaviva delle Fonti (BA)
| | - Laura Scelsi
- Divisione di Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari e Respiratorie, Sapienza Università di Roma, Policlinico Umberto I, Roma
| | | | - Pasquale Perrone Filardi
- Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli "Federico II", Napoli
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri - ASL Roma 1, Roma
| | - Ciro Indolfi
- Istituto di Cardiologia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi "Magna Graecia", Catanzaro
| | - Loris Roncon
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Rovigo
| | | | - Fabrizio Oliva
- Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
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Becattini C, Cimini LA, Bassanelli G, Maggioni AP, Pomero F, Lobascio I, Enea I, Pomata DP, Ruggieri MP, Zalunardo B, Novelli A, Di Fusco SA, Triggiani M, Marzolo M, Fioravanti C, Agnelli G, Gonzini L, Gulizia MM. Acute pulmonary embolism and cancer: findings from the COPE study. Clin Res Cardiol 2024; 113:288-300. [PMID: 37966670 PMCID: PMC10850192 DOI: 10.1007/s00392-023-02323-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 10/11/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Patients with acute venous thromboembolism associated with cancer have an increased risk of recurrences and bleeding in the long term. RESEARCH QUESTION To describe the clinical features and short-term course of patients with acute pulmonary embolism (PE) and active cancer, previous cancer or no cancer. STUDY DESIGN AND METHODS Patients with acute PE included in COPE-prospective, multicentre study of adult patients with acute, symptomatic, objectively diagnosed PE-were classified as having active cancer, previous cancer, or no cancer. RESULTS Overall, 832 patients had active cancer, 464 with previous cancer and 3660 patients had no cancer at the time of acute PE. The most prevalent primary sites of active cancer were urogenital (23.0%), gastrointestinal (21.0%), and lung (19.8%), with a high prevalence of metastatic disease (57.6%) and ongoing anticancer treatment (16.2%). At discharge, a direct oral anticoagulant was used in 43.1%, 78.8%, and 82.0% of patients with active cancer, previous cancer, and no cancer, respectively. Rates of death in-hospital and at 30 days were higher in patients with active cancer compared to patients with previous cancer and no cancer (7.9% vs. 4.3% vs. 2.2% and 13.8% vs. 5.2% vs. 2.6%, respectively). Rates of major bleeding were 4.8%, 2.6%, and 2.4%, respectively. Among patients with active cancer, lung or metastatic cancer were independent predictors of death; brain, hematological or gastrointestinal cancer had the highest risk of major bleeding. INTERPRETATION Among patients with acute PE, those with active cancer have high risks for death or major bleeding within 30 days. These risks vary based on primary site of cancer. CLINICAL TRIAL REGISTRATION clinicaltrial.gov identifier: NCT03631810.
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Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy.
| | - Ludovica Anna Cimini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy
| | | | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Fulvio Pomero
- Department of Internal Medicine, Ospedale Michele e Pietro Ferrero, Verduno, Italy
| | | | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta, Italy
| | - Daniela P Pomata
- Medicina d'Urgenza e Pronto Soccorso, Ospedale Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Maria Pia Ruggieri
- U.O.C. Medicina d'Urgenza e Pronto Soccorso, AO San Giovanni Addolorata, Rome, Italy
| | - Beniamino Zalunardo
- Angiology Unit, Azienda ULSS 2 Marca Trevigiana, Castelfranco Veneto, Treviso, Italy
| | - Anna Novelli
- Pronto Soccorso e Medicina d'Urgenza, Ospedali Riuniti, Livorno, Italy
| | | | - Marco Triggiani
- U.O. Cardiologia, Ospedale Civile "La Memoria", Gavardo, Brescia, Italy
| | - Marco Marzolo
- U.O.C. Medicina Interna-Angiologia, Ospedale S. Maria Della Misericordia, Rovigo, Italy
| | | | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy
| | - Lucio Gonzini
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Michele M Gulizia
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
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Caravita S, Gori M, Garascia A, Baratto C, Camassa N, Carigi S, De Gennaro L, De Maria R, Enea I, Gentile P, Giordana F, Leonardi G, Lo Giudice F, Orso F, Romaniello A, Roncon L, Tinti MD, Vatrano M, Vedovati MC, Marini M, Picariello C. [Pulmonary hypertension associated with left heart diseases: pathophysiology, diagnosis, treatment]. G Ital Cardiol (Rome) 2024; 25:88-97. [PMID: 38270364 DOI: 10.1714/4187.41757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Pulmonary hypertension (PH) is a common complication of diseases affecting the left heart, mostly found in patients suffering from heart failure. Left atrial hypertension is the initial driver of post-capillary PH. However, several mechanisms may lead in a subset of patients to structural changes in the pulmonary vessels with development of a pre-capillary component. The right ventricle may be frequently affected, leading to right ventricular failure and a worse outcome. The differential diagnosis of PH associated with left heart disease vs pulmonary arterial hypertension (PAH) is challenging in patients with cardiovascular comorbidities, risk factors for PAH and/or a preserved left ventricular ejection fraction. Multidimensional clinical phenotyping is needed to identify patients in whom hemodynamic confirmation is deemed necessary, that may be completed by provocative testing in the cath lab. In contrast with PAH, management of PH associated with left heart disease should focus on the treatment of the underlying condition. There is currently no approved therapy for PH associated with left heart disease: some PAH-specific treatments have led to an increase in adverse events in these patients.
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Affiliation(s)
- Sergio Caravita
- Dipartimento di Cardiologia, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano - Dipartimento di Ingegneria Gestionale, dell'Informazione e della Produzione, Università degli Studi di Bergamo, Dalmine (BG)
| | - Mauro Gori
- Reparto di Cardiologia 1, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo
| | - Andrea Garascia
- Cardiologia 2-Insufficienza Cardiaca e Trapianti, Dipartimento Cardiotoracovascolare, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Claudia Baratto
- Dipartimento di Cardiologia, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano
| | - Nino Camassa
- U.O.C. Cardiologia Ospedaliera, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari
| | | | | | | | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. S. Anna e S. Sebastiano, Caserta
| | - Piero Gentile
- Cardiologia 2-Insufficienza Cardiaca e Trapianti, Dipartimento Cardiotoracovascolare, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Francesca Giordana
- Divisione di Cardiologia, Dipartimento Emergenza e Aree Critiche, ASO S. Croce e Carle, Cuneo
| | - Giuseppe Leonardi
- U.O.S.D. Scompenso Cardiaco, A.O.U. Policlinico Catania, P.O.G. Rodolico, Catania
| | - Francesco Lo Giudice
- National Pulmonary Hypertension Service, Department of Cardiology, Imperial College NHS Trust, Hammersmith Hospital, Londra, UK
| | - Francesco Orso
- Dipartimento di Cardiologia e Geriatria, A.O.U. Careggi, Firenze
| | | | - Loris Roncon
- Cardiologia, Casa di Cura Città di Rovigo, Rovigo
| | | | - Marco Vatrano
- U.O.C. Cardiologia, PO "Pugliese-Ciaccio", AOU "Renato Dulbecco", Catanzaro
| | | | - Marco Marini
- S.O.D. Cardiologia-UTIC, Dipartimento di Scienze Cardiovascolari, AOU delle Marche, Ancona
| | - Claudio Picariello
- U.O.S. UTIC, U.O.C. Cardiologia, Ospedale Santa Maria della Misericordia Rovigo - ULSS 5 Polesana, Rovigo
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Becattini C, Cimini LA, Bassanelli G, Maggioni AP, Pomero F, Lobascio I, Enea I, Pomata DP, Ruggieri MP, Zalunardo B, Novelli A, Di Fusco SA, Triggiani M, Marzolo M, Fioravanti C, Agnelli G, Gonzini L, Gulizia MM. Correction: Acute pulmonary embolism and cancer: findings from the COPE study. Clin Res Cardiol 2024:10.1007/s00392-023-02369-z. [PMID: 38252147 DOI: 10.1007/s00392-023-02369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy.
| | - Ludovica Anna Cimini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy
| | | | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Fulvio Pomero
- Department of Internal Medicine, Ospedale Michele E Pietro Ferrero, Verduno, Italy
| | | | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta, Italy
| | - Daniela P Pomata
- Medicina d'Urgenza E Pronto Soccorso, Ospedale Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Maria Pia Ruggieri
- U.O.C. Medicina d'Urgenza E Pronto Soccorso, AO San Giovanni Addolorata, Rome, Italy
| | - Beniamino Zalunardo
- Angiology Unit, Azienda ULSS 2 Marca Trevigiana, Castelfranco Veneto, Treviso, Italy
| | - Anna Novelli
- Pronto Soccorso E Medicina d'Urgenza, Ospedali Riuniti, Leghorn, Italy
| | | | - Marco Triggiani
- U.O. Cardiologia, Ospedale Civile "La Memoria", Gavardo, Brescia, Italy
| | - Marco Marzolo
- U.O.C. Medicina Interna-Angiologia, Ospedale S. Maria Della Misericordia, Rovigo, Italy
| | | | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy
| | - Lucio Gonzini
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Michele M Gulizia
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
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Becattini C, Agnelli G, Diamanti M, Maggioni AP, Vanni S, Dentali F, Enea I, Bortolotti P, De Vecchi M, Artusi N, Picariello C, Nitti C, Lucci D, Gulizia MM. Contemporary anticoagulant treatment strategies in patients with acute pulmonary embolism at different risk for death. Vascul Pharmacol 2023; 153:107245. [PMID: 38013135 DOI: 10.1016/j.vph.2023.107245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Availability of new treatment strategies for patients with acute pulmonary embolism (PE) have changed clinical practice with potential influence in short-term patients' outcomes. We aimed at assessing contemporary anticoagulation strategies and mortality in patients with acute PE included in the prospective, non-interventional, multicentre, COntemporary management of PE study. MATERIALS AND METHODS Anticoagulant treatment at admission, during hospital-stay, at discharge and at 30-day are described in the overall population and by clinical severity. RESULTS Overall, 5158 patients received anticoagulant treatment (99%); during the hospital-stay, 2298 received completely parenteral, 926 completely oral and 1934 parenteral followed by oral anticoagulation (1670 DOACs, 264 VKAs). Comorbidities and PE severity influenced the choice of in-hospital anticoagulation. The use of completely parenteral and completely oral anticoagulation varied based on PE severity. In patients treated with thrombolysis, DOACs were used in 46.4% and 80.1% during the hospital stay and at discharge, respectively. Death at 30 days occurred in 34.6% of patients not receiving anticoagulant treatment and in 1.5, 1.3, 3.4 and 8.1% of patients receiving completely oral, sequential with DOACs, sequential with VKAs and completely parenteral regimens, respectively. Increased mortality in patients receiving completely parenteral anticoagulation persisted after adjustment for PE severity. Completely oral anticoagulation was effective and safe also in patients at intermediate-high risk of death. CONCLUSIONS Contemporary anticoagulation for acute PE includes parenteral agents in over 90% of patients; DOACs are used in the large majority of PE patients at discharge and their early use seems effective and safe also in selected intermediate-risk patients. TRIAL REGISTRATION NUMBER NCT03631810.
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Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine- Stroke Unit, University of Perugia, Perugia, Italy.
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine- Stroke Unit, University of Perugia, Perugia, Italy
| | - Michele Diamanti
- Pronto soccorso - Medicina d'urgenza, Ospedale Cà Foncello, Treviso, Italy
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Simone Vanni
- Pronto Soccorso - Medicina d'Urgenza, Ospedale San Giuseppe, Empoli, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta, Italy
| | - Paola Bortolotti
- Pronto Soccorso - Medicina d'Urgenza, Ospedale di Pordenone, Italy
| | | | - Nicola Artusi
- Pronto Soccorso - Medicina d'Urgenza, ASUGI - Polo Cardiologico Cattinara, Trieste, Italy
| | - Claudio Picariello
- U.O.C. Cardiologia, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Cinzia Nitti
- SOD Pronto Soccorso e Medicina D'urgenza, Ospedali Riuniti, Ancona, Italy
| | - Donata Lucci
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Michele M Gulizia
- ANMCO Research Center, Heart Care Foundation, Florence, Italy; Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
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Martelli E, Enea I, Zamboni M, Federici M, Bracale UM, Sangiorgi G, Martelli AR, Messina T, Settembrini AM. Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications. Diagnostics (Basel) 2023; 13:2356. [PMID: 37510100 PMCID: PMC10377859 DOI: 10.3390/diagnostics13142356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.
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Affiliation(s)
- Eugenio Martelli
- Department of General and Specialist Surgery, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Sciences, 8 Via di Sant'Alessandro, 00131 Rome, Italy
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Matilde Zamboni
- Division of Vascular Surgery, Saint Martin Hospital, 22 Viale Europa, 32100 Belluno, Italy
| | - Massimo Federici
- Department of Systems Medicine, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Umberto M Bracale
- Division of Vascular Surgery, Federico II Polyclinic, Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, 5 Via S. Pansini, 80131 Naples, Italy
| | - Giuseppe Sangiorgi
- Department of Biomedicine and Prevention, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Allegra R Martelli
- Faculty-Medicine & Surgery, Campus Bio-Medico University of Rome, 21 Via À. del Portillo, 00128 Rome, Italy
| | - Teresa Messina
- Division of Anesthesia and Intensive Care of Organ Transplants, Umberto I Polyclinic University Hospital, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Alberto M Settembrini
- Division of Vascular Surgery, Maggiore Polyclinic Hospital Ca' Granda IRCCS and Foundation, 35 Via Francesco Sforza, 20122 Milan, Italy
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Enea I, Martelli E. Focus on the Prevention of Acute Limb Ischemia: Centrality of the General Practitioner from the Point of View of the Internist. J Clin Med 2023; 12:jcm12113652. [PMID: 37297848 DOI: 10.3390/jcm12113652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/01/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
The thrombotic mechanism, being common to peripheral arterial disease (PAD), acute myocardial infarction (AMI), and stroke, is responsible for the highest number of deaths in the western world. However, while much has been done for the prevention, early diagnosis, therapy of AMI and stroke, the same cannot be said for PAD, which is a negative prognostic indicator for cardiovascular death. Acute limb ischemia (ALI) and chronic limb ischemia (CLI) are the most severe manifestations of PAD. They both are defined by the presence of PAD, rest pain, gangrene, or ulceration and we consider ALI if symptoms last less than 2 weeks and CLI if they last more than 2 weeks. The most frequent causes are certainly atherosclerotic and embolic mechanisms and, to a lesser extent, traumatic or surgical mechanisms. From a pathophysiological point of view, atherosclerotic, thromboembolic, inflammatory mechanisms are implicated. ALI is a medical emergency that puts both limb and the patient's life at risk. In patients over age 80 undergoing surgery, mortality remains high reaching approximately 40% as well as amputation approximately 11%. The purpose of this paper is to summarize the scientific evidence on the possibilities of primary and secondary prevention of ALI and to raise awareness among doctors involved in the management of ALI, in particular by describing the central role of the general practitioner.
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Affiliation(s)
- Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, 81100 Caserta, Italy
| | - Eugenio Martelli
- Division of Vascular Surgery, Department of Cardiovascular Science, S. Anna and S. Sebastiano Hospital, Campania, 81100 Caserta, Italy
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Science, 00131 Rome, Italy
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Picariello C, Garascia A, Giordana F, Lo Giudice F, Romaniello A, Vedovati MC, Enea I, Caravita S, Camassa N, Vatrano M, Bongarzoni A, Roncon L, Gabrielli D, Colivicchi F. [Anticoagulation therapy during pulmonary embolism follow-up in clinical practice]. G Ital Cardiol (Rome) 2023; 24:275-284. [PMID: 36971171 DOI: 10.1714/4004.39818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Patients with pulmonary embolism are a heterogeneous population and, after the acute phase and the first 3-6 months, the main issue is whether to continue, and hence how long and at what dose, or to stop anticoagulation therapy. In patients with venous thromboembolism (VTE), direct oral anticoagulants (DOACs) are the recommended treatment (class I, level of evidence B in the latest European guidelines), and in most cases, an "extended" or "long-term" low-dose therapy is warranted. This paper aims to provide a practical management tool to the clinician dealing with pulmonary embolism follow-up: from the evidence behind the most used exams (D-dimer, ultrasound Doppler of the lower limbs, imaging tests, recurrence and bleeding risk scores), and the use of DOACs in the extended phase, to six real clinical scenarios with the relative management in the acute phase and at follow-up. Lastly, a practical algorithm is shown to deal with anticoagulation therapy in the follow-up of VTE patients in a simple, schematic, and pragmatic way.
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Affiliation(s)
- Claudio Picariello
- U.O.C. Cardiologia, Azienda Ospedaliera S. Maria della Misericordia, Rovigo
| | - Andrea Garascia
- Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
| | | | - Francesco Lo Giudice
- Dipartimento di Cardiologia, Hammersmith Hospital, Imperial College NHS Trust, Londra, UK
| | | | | | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta
| | - Sergio Caravita
- Istituto Auxologico Italiano, IRCCS Ospedale San Luca, Milano - Dipartimento di Ingegneria Gestionale, dell'Informazione e della Produzione, Università degli Studi di Bergamo, Dalmine (BG)
| | - Nino Camassa
- U.O.C. Cardiologia Ospedaliera, Policlinico di Bari
| | - Marco Vatrano
- U.O.C. Cardiologia, Azienda Ospedaliera "Pugliese-Ciaccio", Catanzaro
| | | | - Loris Roncon
- U.O.C. Cardiologia, Azienda Ospedaliera S. Maria della Misericordia, Rovigo
| | | | - Furio Colivicchi
- U.O.C. Cardiologia, Presidio Ospedaliero San Filippo Neri - ASL Roma 1, Roma
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9
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Becattini C, Agnelli G, Maggioni AP, Dentali F, Fabbri A, Enea I, Pomero F, Ruggieri MP, di Lenarda A, Cimini LA, Pepe G, Cozzio S, Lucci D, Gulizia MM. Contemporary Management and Clinical Course of Acute Pulmonary Embolism: The COPE Study. Thromb Haemost 2023; 123:613-626. [PMID: 36758612 DOI: 10.1055/a-2031-3859] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND New diagnosis, risk stratification, and treatment strategies became recently available for patients with acute pulmonary embolism (PE) leading to changes in clinical practice and potentially influencing short-term patients' outcomes. RESEARCH QUESTION The COntemporary management of PE (COPE) study is aimed at assessing the contemporary clinical management and outcomes in patients with acute symptomatic PE. STUDY DESIGN AND METHODS Prospective, noninterventional, multicenter study. The co-primary study outcomes, in-hospital and 30-day death, were reported overall and by risk categories according to the European Society of Cardiology (ESC) and American Heart Association guidelines. RESULTS Among 5,213 study patients, PE was confirmed by computed tomography in 96.3%. In-hospital, 289 patients underwent reperfusion (5.5%), 92.1% received parenteral anticoagulants; at discharge, 75.6% received direct oral anticoagulants and 6.7% vitamin K antagonists. In-hospital and 30-day mortalities were 3.4 and 4.8%, respectively. In-hospital death occurred in 20.3% high-risk patients (n = 177), in 4.0% intermediate-risk patients (n = 3,281), and in 0.5% low-risk patients (n = 1,702) according to ESC guidelines. Further stratification in intermediate-high and intermediate-low risk patients did not reach statistical significance, but intermediate-risk patients with sPESI > 0 alone had lower mortality compared to those with one or both among right ventricular dilation at echocardiography or increased troponin. Death or clinical deterioration occurred in 1.5, 5.0, and 9.4% of patients at low, intermediate-low, and intermediate-high risk for death according to ESC guidelines. CONCLUSION For the majority of patients with PE, contemporary initial management includes risk stratification and treatment with direct oral anticoagulants. In-hospital mortality remains high in intermediate and high-risk patients calling for and informing research focused on its reduction. TRIAL REGISTRATION NUMBER NCT03631810.
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Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Andrea Fabbri
- Emergency Department, "Presidio Ospedaliero Morgagni-Pierantoni," Forlì, Italy
| | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano," Caserta, Italy
| | - Fulvio Pomero
- Division of Internal Medicine, Michele and Pietro Ferrero Hospital, Verduno, Italy
| | - Maria Pia Ruggieri
- U.O.C. Medicina d'Urgenza e Pronto Soccorso, AO San Giovanni Addolorata, Roma, Italy
| | - Andrea di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Italy
| | - Ludovica Anna Cimini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Giuseppe Pepe
- PS e Medicina d'Urgenza, Nuovo Ospedale Versilia, Lido di Camaiore, Italy
| | - Susanna Cozzio
- Medicina Interna, Ospedale S. Maria del Carmine, Rovereto, Italy
| | - Donata Lucci
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Michele M Gulizia
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
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10
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Zuin M, Rigatelli G, Bongarzoni A, Enea I, Bilato C, Zonzin P, Casazza F, Roncon L. Mean arterial pressure predicts 48 h clinical deterioration in intermediate-high risk patients with acute pulmonary embolism. Eur Heart J Acute Cardiovasc Care 2023; 12:80-86. [PMID: 36580441 DOI: 10.1093/ehjacc/zuac169] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/17/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022]
Abstract
AIMS We assess the prognostic role of mean arterial pressure (MAP) for 48 h clinical deterioration in intermediate-high risk pulmonary embolism (PE) patients after admission. METHODS AND RESULTS A post hoc analysis of intermediate-high-risk PE and intermediate-low-risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. Clinical deterioration within 48 h was defined as patient worsening from a stable to an unstable haemodynamic condition, need of catecholamine infusion, endotracheal intubation, or cardiopulmonary resuscitation. Of 450 intermediate-high risk PE patients (mean age 71.4 ± 13.8 years, 298 males), 40 (8.8%) experienced clinical deterioration within 48 h from admission. Receiver operating characteristic analysis established the optimal cut-off value for MAP, as a predictor of 48 h clinical deterioration, ≤81.5 mmHg [area under curve (AUC) of 0.77 ± 0.3] with sensitivity, specificity, positive predictive value, and negative predictive value were 77.5, 95.0, 63.2, and 97.7%, respectively. Multivariate Cox regression analysis showed that independent risk factors for 48 h clinical deterioration were age [hazard ratio (HR): 1.26, 95% confidence interval (CI): 1.19-1.28, P < 0.0001], history of heart failure (HR: 1.76, 95% CI: 1.72-1.81, P < 0.0001), simplified Pulmonary Embolism Severity Index (HR: 1.52, 95% CI: 1.49-1.58, P = 0.001), systemic thrombolysis (HR: 0.54, 95% CI: 0.30-0.65, P < 0.0001), and a MAP of ≤81.5 mmHg at admission (HR: 3.25, 95% CI: 1.89-5.21, P < 0.0001). The deteriorating group had a significantly higher risk of 30-day mortality (HR: 2.61, 95% CI: 2.54-2.66, P < 0.0001) compared with the non-deteriorating group. CONCLUSION The mean arterial pressure appears to be a useful, bedside, and non-invasive prognostic tool potentially capable of promptly identifying intermediate-high risk PE patients at higher risk of 48 h clinical deterioration.
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Affiliation(s)
- Marco Zuin
- Department of Cardiology, West Vicenza Hospital, Via del Parco 1, 36071 Arzignano, Vicenza, Italy.,Department of Translational Medicine, University of Ferrara, Via Luigi Borsari, 46, 44124 Ferrara, Italy
| | - Gianluca Rigatelli
- Department of Cardiology, Ospedali Riuniti Padova Sud, Monselice, via Albere 30, 35043 Padova, Italy
| | - Amedeo Bongarzoni
- Department of Cardiology, ASST Santi Paolo e Carlo, University of Milan, via Rudinì, 20142 Milano, Italy
| | - Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, via Palasciano, 81100 Caserta, Italy
| | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Via del Parco 1, 36071 Arzignano, Vicenza, Italy
| | - Pietro Zonzin
- Department of Cardiology, Santa Maria della Misericordia Hospital, via Tre Martiri 140, 45100 Rovigo, Italy
| | - Franco Casazza
- Department of Cardiology, San Carlo Borromeo Hospital, via Pio II 3, 20153 Milano, Italy
| | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, via Tre Martiri 140, 45100 Rovigo, Italy
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11
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Francese GM, Aspromonte N, Valente S, Geraci G, Pavan D, Bisceglia I, Caforio ALP, Colavita AR, Cutolo A, De Angelis MC, Di Fusco SA, Enea I, Fiscella D, Frongillo D, Gil Ad V, Giubilato S, Giuffrida C, Ingianni N, Lucà F, Marcantoni L, Martinis F, Marzullo R, Masciocco G, Parrini I, Rakar S, Resta M, Riva L, Rossini R, Russo D, Russo G, Russo MG, Scardovi AB, De Luca L, Gabrielli D, Gulizia MM, Oliva F, Colivicchi F. [ANMCO Position paper: Cardiovascular disease in women - prevention, diagnosis, treatment and organization of care]. G Ital Cardiol (Rome) 2022; 23:775-792. [PMID: 36169129 DOI: 10.1714/3881.38644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Cardiovascular diseases are still the main cause of death among women despite the improvements in treatment and prognosis achieved in the last 30 years of research. The determinant factors and causes have not been completely identified but the role of "gender" is now recognized. It is well known that women tend to develop cardiovascular disease at an older age than men, and have a high probability of manifesting atypical symptoms not often recognized. Other factors may also co-exist in women, which may favor the onset of specific cardiac diseases such as those with a sex-specific etiology (differential effects of estrogens, pregnancy pathologies, etc.) and those with a different gender expression of specific and prevalent risk factors, inflammatory and autoimmune diseases and cancer. Whether the gender differences observed in cardiovascular outcomes are influenced by real biological differences remains a matter of debate.This ANMCO position paper aims at providing the state of the research on this topic, with particular attention to the diagnostic aspects and to care organization.
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Affiliation(s)
- Giuseppina Maura Francese
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
| | - Nadia Aspromonte
- U.O.S. Scompenso Cardiaco, Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
| | - Serafina Valente
- Cardiologia Clinico-Chirurgica (UTIC), Ospedale Santa Maria alle Scotte, A.O.U. Senese, Siena
| | - Giovanna Geraci
- U.O.C. Cardiologia-UTIC ed Emodinamica, P.O. "V. Cervello", Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo
| | - Daniela Pavan
- S.O.C. Cardiologia, Ospedale di San Vito al Tagliamento, Azienda Sanitaria Friuli Occidentale, San Vito al Tagliamento (PN)
| | - Irma Bisceglia
- Servizi Cardiologici Integrati, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Roma
| | | | | | - Ada Cutolo
- U.O. Cardiologia, Ospedale dell'Angelo, Venezia-Mestre, Azienda ULSS 3 Serenissima
| | - Maria Carmen De Angelis
- U.O.C. Cardiologia-UTIC-Emodinamica-Elettrofisiologia-Elettrostimolazione, Ospedale del Mare, Napoli
| | - Stefania Angela Di Fusco
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri, Roma, ASL Roma 1
| | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. Sant'Anna e San Sebastiano, Caserta
| | - Damiana Fiscella
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
| | - Doriana Frongillo
- U.O.C. Cardiologia, Ospedale San Sebastiano Martire, Frascati (RM), ASL Roma 6
| | - Vered Gil Ad
- U.O. Cardiologia, Ospedale Policlinico San Martino, Genova
| | - Simona Giubilato
- U.O.C. Cardiologia con UTIC ed Emodinamica, Azienda Ospedaliera Cannizzaro, Catania
| | - Clea Giuffrida
- Psicologa e Psicoterapeuta Cognitivo Comportamentale, Catania
| | - Nadia Ingianni
- U.O.C. di Cardiologia e UTIC, P.O. Sant'Antonio Abate, Erice (TP), ASP Trapani
| | - Fabiana Lucà
- Cardiologia-UTIC, Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio Calabria
| | - Lina Marcantoni
- U.O.C. Cardiologia, Ospedale Santa Maria della Misericordia, Rovigo, ULSS 5 Polesana
| | - Flavia Martinis
- S.O.C. Cardiologia, Ospedale di San Vito al Tagliamento, Azienda Sanitaria Friuli Occidentale, San Vito al Tagliamento (PN)
| | - Raffaella Marzullo
- U.O.C. Cardiologia Pediatrica, Università della Campania "L. Vanvitelli", Ospedale Monaldi, Napoli
| | - Gabriella Masciocco
- Cardiologia 2-Insufficienza Cardiaca e Trapianti, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Iris Parrini
- Dipartimento di Cardiologia, Ospedale Mauriziano, Torino
| | - Serena Rakar
- S.C. Cardiologia, Dipartimento CardioToracoVascolare, Azienda Sanitaria Universitaria Giuliano Isontina - ASUGI, Trieste
| | | | - Letizia Riva
- U.O.C. Cardiologia, Ospedale Maggiore, Azienda USL di Bologna, Bologna
| | | | | | - Giulia Russo
- S.C. Cardiovascolare e Medicina dello Sport, Dipartimento Cardiotoracovascolare, Azienda Sanitaria Universitaria Giuliano Isontina - ASUGI, Trieste
| | - Maria Giovanna Russo
- U.O.C. Cardiologia Pediatrica, Università della Campania "L. Vanvitelli", Ospedale Monaldi, Napoli
| | | | - Leonardo De Luca
- U.O.C. Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Domenico Gabrielli
- U.O.C. Cardiologia, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania - Fondazione per il Tuo cuore - Heart Care Foundation, Firenze
| | - Fabrizio Oliva
- Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri, Roma, ASL Roma 1
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12
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Caravita S, Picariello C, Garascia A, Misuraca L, De Tommasi E, Imbalzano E, Enea I, Roncon L, Vatrano M. [Pulmonary hypertension: pre- or post-capillary? The role of provocative tests in the cath lab]. G Ital Cardiol (Rome) 2022; 23:533-541. [PMID: 35771019 DOI: 10.1714/3831.38171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The discrimination between heart failure with preserved ejection fraction (HFpEF) and pulmonary arterial hypertension (PAH) requires a multiparametric approach, eventually culminating in right heart catheterization. Solving this differential diagnosis is crucial in order to properly tailor patient treatment, with relevant clinical implications. However, it is not uncommon to be confronted with patients at intermediate or high risk of having HFpEF whose pulmonary artery wedge pressure (PAWP) falls in a grey zone in between 13 and 15 mmHg. In these patients, a provocative test in the cath lab might be considered, with the aim of unmasking an occult form of HFpEF with non-overt hemodynamic manifestations, or to definitely exclude it.Saline load and physical exercise can be viewed as the most suitable provocative tests seeking to help for the differential diagnosis in this specific patient population. Although normative values for the hemodynamic response to these maneuvers have been proposed, supporting evidence is still preliminary or equivocal. In this paper, we will review the pathophysiological background for the application of provocative tests in the cath lab, as well as methodological and interpretative aspects to discriminate between HFpEF and PAH, highlighting strengths and weaknesses of fluid load and physical exercise.
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Affiliation(s)
- Sergio Caravita
- Centro per la Dispnea e l'Ipertensione Polmonare, Dipartimento di Cardiologia, Istituto Auxologico Italiano IRCCS Ospedale San Luca, Milano - Dipartimento di Ingegneria Gestionale, dell'Informazione e della Produzione, Università degli Studi di Bergamo, Dalmine (BG)
| | - Claudio Picariello
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Ospedale "Santa Maria della Misericordia", Rovigo
| | - Andrea Garascia
- Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Leonardo Misuraca
- U.O.S.D. Cardiologia Interventistica, Ospedale della Misericordia, Grosseto
| | | | - Egidio Imbalzano
- Dipartimento di Medicina Interna e Terapia Medica, Università degli Studi, Messina
| | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta
| | - Loris Roncon
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Ospedale "Santa Maria della Misericordia", Rovigo
| | - Marco Vatrano
- U.O.C. Cardiologia, Azienda Ospedaliera "Pugliese-Ciaccio", Catanzaro
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13
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Becattini C, Agnelli G, Maggioni AP, Dentali F, Fabbri A, Enea I, Pomero F, Ruggieri MP, Di Lenarda A, Gulizia M. Contemporary clinical management of acute pulmonary embolism: the COPE study. Intern Emerg Med 2022; 17:715-723. [PMID: 34982399 PMCID: PMC9018669 DOI: 10.1007/s11739-021-02855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND New management, risk stratification and treatment strategies have become available over the last years for patients with acute pulmonary embolism (PE), potentially leading to changes in clinical practice and improvement of patients' outcome. METHODS The COntemporary management of Pulmonary Embolism (COPE) is a prospective, non-interventional, multicentre study in patients with acute PE evaluated at internal medicine, cardiology and emergency departments in Italy. The aim of the COPE study is to assess contemporary management strategies in patients with acute, symptomatic, objectively confirmed PE concerning diagnosis, risk stratification, hospitalization and treatment and to assess rates and predictors of in-hospital and 30-day mortality. The composite of death (either overall or PE-related) or clinical deterioration at 30 days from the diagnosis of PE, major bleeding occurring in hospital and up to 30 days from the diagnosis of PE and adherence to guidelines of the European Society of Cardiology (ESC) are secondary study outcomes. Participation in controlled trials on the management of acute PE is the only exclusion criteria. Expecting a 10-15%, 3% and 0.5% incidence of death for patients with high, intermediate or low-risk PE, respectively, it is estimated that 400 patients with high, 2100 patients with intermediate and 2500 with low-risk PE should be included in the study. This will allow to have about 100 deaths in study patients and will empower assessment of independent predictors of death. CONCLUSIONS COPE will provide contemporary data on in-hospital and 30-day mortality of patients with documented PE as well as information on guidelines adherence and its impact on clinical outcomes. TRAIL REGISTRATION NCT number: NCT03631810.
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Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy.
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Piazzale Lucio Severi 1, 06129, Perugia, Italy
| | | | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Andrea Fabbri
- Emergency Department, "Presidio ospedaliero Morgagni-Pierantoni", Forlì, Italy
| | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta, Italy
| | - Fulvio Pomero
- Division of Internal Medicine, Michele and Pietro Ferrero Hospital, Verduno, Italy
| | - Maria Pia Ruggieri
- U.O.C. Medicina d'Urgenza e Pronto Soccorso, AO San Giovanni Addolorata, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Trieste, Italy
| | - Michele Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
- Heart Care Foundation, Florence, Italy
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14
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Rubboli A, Fresco C, Paciaroni M, Rocca B, Pecora D, Enea I, Cuccia C, Patti G. How lower doses of direct oral anticoagulants are interpreted in clinical practice: a national survey of the Italian Atherosclerosis, Thrombosis and Vascular Biology (ATVB) Study Group. J Cardiovasc Med (Hagerstown) 2021; 22:924-928. [PMID: 33927142 DOI: 10.2459/jcm.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM To evaluate the current interpretation of the lower doses of direct oral anticoagulants (DOAC) dabigatran, apixaban, edoxaban and rivaroxaban in nonvalvular atrial fibrillation. METHODS A questionnaire of 14 statements to which the possible answers were fully agree/partially agree/partially disagree/fully disagree or yes/no was prepared within the board of the Italian Atherosclerosis, Thrombosis and Vascular Biology Study Group and forwarded to individual Italian physicians. RESULTS A total of 620 complete questionnaires were received from nearly all the Italian regions and physicians of various medical specialists, either enabled or not for the prescription of DOAC. A wide agreement was found as regards the pharmacological, as well as clinical consequences of the administration of the lower dose of factor-Xa inhibitors both in patients with and without clinical and/or laboratory criteria requiring dose reduction. Wide agreement was also found as regards the presence of moderate kidney insufficiency in selecting the dose of DOAC. Instead, more debated were issues regarding the proportionality between dabigatran dose and plasma concentration and selection of dabigatran dose, as well as the role of measuring drug plasma concentration and/or determine the anticoagulant activity of factor-Xa inhibitors when used at the lower dose. CONCLUSION The interpretation of the lower doses of DOAC in current Italian clinical practice appears largely correct and shared. Because of the persistence of some residual uncertainties, essentially regarding dabigatran, however, continuous educational effort still appears warranted.
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Affiliation(s)
- Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna
| | - Claudio Fresco
- Department of Cardiothoracic Sciences, Division of Cardiology, S. Maria della Misericordia Hospital, Udine
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, S. Maria della Misericordia Hospital, Perugia
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome
| | - Domenico Pecora
- Department of Cardiovascular Diseases, Division of Cardiology, Fondazione Poliambulanza, Brescia
| | - Iolanda Enea
- Division of Emergency Medicine and Surgery, S. Anna and S. Sebastiano Hospital, Caserta
| | - Claudio Cuccia
- Department of Cardiovascular Diseases, Division of Cardiology, Fondazione Poliambulanza, Brescia
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
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15
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Roncon L, Picariello C, Vatrano M, Enea I, Caravita S, De Michele L, Vanni S, Casazza F, Zonzin P, Bongarzoni A, D'Agostino C, Azzarito M, Urbinati S, Gulizia MM, Gabrielli D. [Diagnostic and therapeutic models for the management of acute pulmonary embolism: an issue of local available resources]. G Ital Cardiol (Rome) 2020; 21:179-186. [PMID: 32100730 DOI: 10.1714/3306.32766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute pulmonary embolism (PE) still represents the third leading cause of cardiovascular mortality in developed countries. In this regard, the last European guidelines offer important suggestions on the management of the disease in daily clinical practice but, at the same time, they do not take into account the feasibility of the recommendations according to the local available resources, including the presence or lack of adequate healthcare facilities (cardiological intensive care unit, cath-lab) or specialists (cardiologist available on a 24 h basis, interventional cardiologist, cardiac surgeon, etc.) all over the day. In the real clinical practice, those recommendations should be adapted to the local available resources. The aim of this document is to provide some suggestions regarding the diagnosis and treatment of acute PE, according to the possible available resources in different local circumstances.
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Affiliation(s)
- Loris Roncon
- U.O.C. Cardiologia, Ospedale Santa Maria della Misericordia, Rovigo
| | | | - Marco Vatrano
- U.O.C. Cardiologia, Ospedale Pugliese-Ciaccio, Catanzaro
| | - Iolanda Enea
- U.O.C. Medicina d'Urgenza, A.O.R.N. S. Anna e S. Sebastiano, Caserta
| | - Sergio Caravita
- U.O. Cardiologia, IRCCS Ospedale San Luca Istituto Auxologico Italiano, Milano
| | - Lucrezia De Michele
- U.O.C. Cardiologia Ospedaliera, Azienda Ospedaliero-Universitaria Policlinico, Bari
| | - Simone Vanni
- U.O. Medicina d'Urgenza, Ospedale Santa Maria della Misericordia, Empoli
| | | | - Pietro Zonzin
- U.O.C. Cardiologia, Ospedale Santa Maria della Misericordia, Rovigo
| | | | - Carlo D'Agostino
- U.O.C. Cardiologia Ospedaliera, Azienda Ospedaliero-Universitaria Policlinico, Bari
| | | | | | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
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Gulizia Chairperson MM, Parrini Co-Chairperson I, Colivicchi Co-Chairperson F, Bisceglia I, Caiazza F, Gensini GF, Mureddu GF, Santomauro M, Ageno W, Ambrosetti M, Aspromonte N, Barni S, Bellocci F, Caldarola P, Carletti M, De Luca L, Di Fusco SA, Di Lenarda A, Di Nisio M, Domenicucci S, Enea I, Francese GM, Lestuzzi C, Lucà F, Maurea N, Nassiacos D, Pedretti RFE, Pusineri E, Roscio G, Rossini R, Russo A, Volterrani M, Gabrielli Co-Chairperson D. [HCF-ANMCO/AICPR/GIEC/ITAHFA/SICOA/SICP/SIMG/SIT Cardiological Societies Council Consensus document: Anticoagulant therapy in venous thromboembolism and atrial fibrillation of the patient with cancer. Current knowledge and new evidence]. G Ital Cardiol (Rome) 2020; 21:687-738. [PMID: 33094745 DOI: 10.1714/3413.33967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, either symptomatic or incidental, is a common complication in the history of cancer disease. The risk of VTE is 4-7-fold higher in oncology patients, and it represents the second leading cause of death, after cancer itself. In cancer patients, compared with the general population, VTE therapy is associated with higher rates of recurrent thrombosis and/or major bleeding. The need for treatment of VTE in patients with cancer is a challenge for the clinician because of the multiplicity of types of cancer, the disease stage and the imbricated cancer treatment. Historically, in cancer patients, low molecular weight heparins have been preferred for treatment of VTE. More recently, in large randomized clinical trials, direct oral anticoagulants (DOACs) demonstrated to reduce the risk of VTE. However, in the "real life", uncertainties remain on the use of DOACs, especially for the bleeding risk in patients with gastrointestinal cancers and the potential drug-to-drug interactions with specific anticancer therapies.In cancer patients, atrial fibrillation can arise as a perioperative complication or for the side effect of some chemotherapy agents, as well as a consequence of some associated risk factors, including cancer itself. The current clinical scores for predicting thrombotic events (CHA2DS2-VASc) or for predicting bleeding (HAS-BLED), used to guide antithrombotic therapy in the general population, have not yet been validated in cancer patients. Encouraging data for DOAC prescription in patients with atrial fibrillation and cancer are emerging: recent post-hoc analysis showed safety and efficacy of DOACs for the prevention of embolic events compared to warfarin in cancer patients. Currently, anticoagulant therapy of cancer patients should be individualized with multidisciplinary follow-up and frequent reassessment. This consensus document represents an advanced state of the art on the subject and provides useful notes on clinical practice.
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Affiliation(s)
- Michele Massimo Gulizia Chairperson
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania - Fondazione per il Tuo cuore, Firenze - Heart Care Foundation Onlus
| | | | | | - Irma Bisceglia
- U.O.S.D. Servizi Cardiologici Integrati, A.O. San Camillo-Forlanini, Roma
| | | | - Gian Franco Gensini
- Tuscany Region Medical Guideline Authority, IRCCS MultiMedica, Sesto San Giovanni (MI)
| | - Gian Francesco Mureddu
- U.O.C. Cardiologia 2 e Riabilitazione Cardiologica, Ospedale San Giovanni Addolorata, Roma
| | - Maurizio Santomauro
- Dipartimento di Emergenze Cardiovascolari, Medicina Clinica e Geriatria, Università degli Studi "Federico II", Napoli
| | - Walter Ageno
- S.S.D., Università degli Studi dell'Insubria, Varese
| | - Marco Ambrosetti
- U.O. Riabilitazione Cardiologica, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia
| | | | | | - Fulvio Bellocci
- Centro Benito Stirpe per la Prevenzione della Morte Improvvisa nel Giovane, Policlinico Universitario Agostino Gemelli, Roma
| | | | | | | | - Stefania Angela Di Fusco
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma
| | - Andrea Di Lenarda
- S.C. Cardiovascolare e Medicina dello Sport, Ospedale Maggiore di Trieste, ASUGI Trieste
| | | | | | | | - Giuseppina Maura Francese
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
| | - Chiara Lestuzzi
- ASFO Riabilitazione Cardiologica e Cardioncologica, Centro Oncologico di Aviano (PN)
| | - Fabiana Lucà
- Divisione di Cardiololgia, Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio Calabria
| | - Nicola Maurea
- S.C. Cardiologia, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli
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Vatrano M, Picariello C, Enea I, Roncon L, Caravita S, De Tommasi E, Imbalzano E, Garascia A, Manes MT, Misuraca L, Urbinati S, Colivicchi F, Gulizia MM, Gabrielli D. [Proposal for a standardized discharge letter after hospital stay for acute pulmonary embolism]. G Ital Cardiol (Rome) 2020; 21:607-618. [PMID: 32686788 DOI: 10.1714/3405.33895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Pulmonary embolism represents the third leading cause of cardiovascular mortality in developed countries. It requires, in most cases, hospital treatment and always a structured follow-up program. Therefore, at the time of discharge, the communication and the transfer of information from the specialist to the general practitioner, through the discharge letter, represents a crucial opportunity. The aim is to improve the quality of the transmitted content, including information regarding initial assessment, procedures during hospitalization, residual risks, discharge treatments, therapeutic goals and follow-up plan in accordance with the latest guidelines. The discharge letter after hospitalization for pulmonary embolism must include personalized information, especially regarding the anticoagulant regimen in the specific onset setting. Finally, the follow-up program should be accurately described. A standardized discharge letter template, accompanied by some final notes addressed to the general practitioner and patient, could represent a useful tool to improve the quality and time of transmission of information between health professionals after pulmonary embolism.
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Affiliation(s)
- Marco Vatrano
- U.O.C. Cardiologia, A.O. "Pugliese-Ciaccio", Catanzaro
| | | | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta
| | - Loris Roncon
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Rovigo
| | - Sergio Caravita
- U.O.C. Cardiologia, IRCCS Ospedale San Luca, Istituto Auxologico Italiano, Milano
| | | | - Egidio Imbalzano
- Dipartimento di Medicina Interna e Terapia Medica, Università degli Studi, Messina
| | - Andrea Garascia
- Dipartimento Cardiotoracovascolare "De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
| | | | - Leonardo Misuraca
- U.O.S.D. Cardiologia Interventistica, Ospedale della Misericordia, Grosseto
| | | | | | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
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Picariello C, Caravita S, Vatrano M, Enea I, Roncon L, De Tommasi E, Imbalzano E, Garascia A, Manes MT, Misuraca L, Urbinati S, Colivicchi F, Gulizia MM, Gabrielli D. [ANMCO Position paper: Pulmonary circulation diseases and COVID-19]. G Ital Cardiol (Rome) 2020; 21:575-583. [PMID: 32686781 DOI: 10.1714/3405.33888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The new coronavirus disease 2019 (COVID-19), which is causing hundreds of thousands of deaths worldwide, is complex and can present with a multi-organ localization. One of its worst complications is an interstitial pneumonia with acute respiratory failure also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which requires non-invasive or invasive ventilation. A severe coagulopathy with poor prognosis is found in 5-10% of cases. SARS-CoV-2 is manifesting as a multi-dimensional disease and, recently, unique co-existing pathophysiological and clinical aspects are being defined: (i) an increased immune and inflammatory response with the activation of a cytokine storm and consequent coagulopathy, which promote both venous thromboembolic events and in situ thrombosis localized in small arterioles and pulmonary alveolar capillaries; (ii) a high intrapulmonary shunt, which often accounts for the severity of respiratory failure, due to reduced hypoxic pulmonary vasoconstriction with pulmonary neo-angiogenetic phenomena. Furthermore, the high incidence of venous thromboembolism in COVID-19 patients admitted to the intensive care unit and the autoptic findings of in situ micro-thrombosis at the pulmonary vascular level, suggest that in this disease coagulopathy, unlike septic disseminated intravascular coagulation, is driven towards a hyper-thrombogenic state, giving rise to a debate (with ongoing studies) about the preventive use of anticoagulant doses of heparin to reduce mortality. The aim of this position paper from the Italian Association of Hospital Cardiologists (ANMCO) is to highlight the main implications that COVID-19 infection has on the pulmonary circulation from a pathophysiological, clinical and management point of view.
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Affiliation(s)
- Claudio Picariello
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Ospedale Santa Maria della Misericordia, Rovigo
| | - Sergio Caravita
- Dipartimento di Ingegneria Gestionale, dell'Informazione e della Produzione, Università degli Studi di Bergamo, Dalmine (BG) - U.O.C. Cardiologia, IRCCS Ospedale San Luca, Istituto Auxologico Italiano, Milano
| | - Marco Vatrano
- U.O.C. Cardiologia, Azienda Ospedaliera "Pugliese-Ciaccio", Catanzaro
| | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta
| | - Loris Roncon
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Ospedale Santa Maria della Misericordia, Rovigo
| | | | - Egidio Imbalzano
- Dipartimento di Medicina Interna e Terapia Medica, Università degli Studi, Messina
| | - Andrea Garascia
- Dipartimento Cardiotoracovascolare "De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano
| | | | - Leonardo Misuraca
- U.O.S.D. Cardiologia Interventistica, Ospedale della Misericordia, Grosseto
| | | | | | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
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Enea I, Bongarzoni A, Vedovati MC, Vatrano M, Misuraca L, Picariello C, Roncon L, Gabrielli D, Gulizia MM. [2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism: what's new?]. G Ital Cardiol (Rome) 2020; 21:175-178. [PMID: 32100729 DOI: 10.1714/3306.32765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O.R.N. "S. Anna e S. Sebastiano", Caserta
| | - Amedeo Bongarzoni
- U.O.C. Cardiologia, ASST "Santi Paolo e Carlo", Polo San Carlo, Milano
| | - Maria Cristina Vedovati
- Medicina Interna e Vascolare, Ospedale S. Maria della Misericordia, Università degli Studi, Perugia
| | - Marco Vatrano
- U.O.C. UTIC-Emodinamica e Cardiologia Interventistica, Ospedale Civile Pugliese, Catanzaro
| | - Leonardo Misuraca
- U.O.S.D. Cardiologia Interventistica, Ospedale della Misericordia, Grosseto
| | | | - Loris Roncon
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Rovigo
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Nardi F, Pino PG, Gabrielli D, Colivicchi F, Abrignani MG, Amico AF, Aspromonte N, Benedetto FA, Bertella E, Boccardi LM, Bucciarelli Ducci C, Caldarola P, Campana M, Caso P, Citro R, Costante AM, De Chiara BC, Di Cesare E, Di Fusco SA, Domenicucci S, Enea I, Erba P, Faganello G, Favilli S, Geraci G, Giubbini R, Giunta N, Guido V, Imazio M, Khoury G, La Canna G, Mele D, Moreo AM, Mercuro GG, Musumeci G, Neglia D, Parrini I, Pinamonti B, Pollarolo L, Pontone G, Privitera C, Riccio C, Sinagra G, Urbinati S, Varbella F, Berisso MZ, Zuin G, Di Lenarda A, Gulizia MM. [ANMCO/SICI-GISE/SIC/SIECVI/SIRM Consensus document: Appropriateness of multimodality imaging in cardiovascular disease]. G Ital Cardiol (Rome) 2020; 21:34-88. [PMID: 31960833 DOI: 10.1714/3285.32588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The complexity of cardiovascular diseases has led to an extensive use of technological instruments and the development of multimodality imaging. This extensive use of different cardiovascular imaging tests in the same patient has increased costs and waiting times.The concept of appropriateness has changed over time. Appropriateness criteria address the need for specific cardiovascular imaging tests in well-defined clinical scenarios, and define the kind of cardiovascular imaging that is appropriated for each clinical scenario in different stages of the disease. The concept of appropriateness criteria has replaced the old idea of appropriate use criteria and reflects the increasing effort of the international Scientific Societies to create and review in a critical way the management of diagnostic tests used by clinicians.The aim of this Italian consensus document is to address the use of multimodality imaging in the diagnosis and management of the major cardiovascular clinical scenarios, taking into consideration not only the international guidelines and scientific documents already published, but also the reality of Italian laws as well as the various professional profiles involved in patient management and availability of technological diagnostic instruments.
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Affiliation(s)
- Federico Nardi
- S.C. Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL)
| | - Paolo Giuseppe Pino
- U.O.S.D. Diagnostica Cuore, Dipartimento Cardiovascolare, Ospedale San Camillo, A.O. San Camillo-Forlanini, Roma
| | | | - Furio Colivicchi
- U.O.C. Cardiologia-UTIC, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma
| | | | | | | | | | | | | | | | | | - Marco Campana
- U.O. Cardiologia, Istituto Ospedaliero Fondazione Poliambulanza, Brescia
| | - Pio Caso
- U.O.C. Cardiologia, A.O.R.N. Ospedale dei Colli, P.O. Vincenzo Monaldi, Napoli
| | - Rodolfo Citro
- U.O.C. Cardiologia, Dipartimento Cuore, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Salerno
| | - Anna Maria Costante
- S.C. Cardiologia, Ospedale Civile SS. Antonio e Biagio e Cesare Arrigo, Alessandria
| | - Benedetta Carla De Chiara
- Cardiologia 4 - Diagnostica e Riabilitativa, ASST Grande Ospedale Metropolitano Niguarda, Milano - Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milano
| | - Ernesto Di Cesare
- Dipartimento di Medicina Clinica, Sanità Pubblica, Scienze della Vita e dell'Ambiente, Sezione di Medicina Clinica e Molecolare, Università degli Studi, L'Aquila
| | | | | | - Iolanda Enea
- U.O.C. Medicina e Chirurgia d'Urgenza, A.O. Sant'Anna e San Sebastiano, Caserta
| | - Paola Erba
- Centro Regionale di Medicina Nucleare, Azienda Ospedaliero-Universitaria Pisana, Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina, Università degli Studi, Pisa
| | - Giorgio Faganello
- S.C. Cardiovascolare e Medicina dello Sport, Azienda Sanitaria Universitaria Integrata di Trieste
| | | | - Giovanna Geraci
- U.O. Cardiologia, A.O.R. Villa Sofia-Cervello, P.O. Cervello, Palermo
| | - Raffaele Giubbini
- Dipartimento Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica, Divisione di Medicina Nucleare, Università degli Studi, Brescia
| | - Nicola Giunta
- U.O.C. Cardiologia-UTIC, Azienda di Rilievo Nazionale e Alta Specializzazione, P.O. Civico e Benfratelli, Palermo
| | | | - Massimo Imazio
- Cardiologia, Presidio Molinette, A.O.U. Città della Salute e della Scienza di Torino, Torino
| | | | | | - Donato Mele
- S.S.D. Cardiologia Non Invasiva, Azienda Ospedaliero-Universitaria di Ferrara, Arcispedale Sant'Anna, Ferrara
| | - Antonella Maurizia Moreo
- Cardiologia 4 - Diagnostica e Riabilitativa, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | | | | | - Danilo Neglia
- Cardiologia e Medicina Cardiovascolare, Fondazione Toscana Gabriele Monasterio, Pisa
| | - Iris Parrini
- S.C. Cardiologia, Ospedale Mauriziano Umberto I, Torino
| | - Bruno Pinamonti
- S.C. Cardiologia, DAI Cardiovascolare, Azienda Sanitaria Universitaria Integrata di Trieste, Università degli Studi, Trieste
| | - Luigi Pollarolo
- S.C. Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL)
| | - Gianluca Pontone
- U.O. Risonanza Magnetica, Centro Cardiologico Monzino, IRCCS, Milano
| | | | - Carmine Riccio
- U.O.S.D. Follow-Up del Paziente Post-Acuto, A.O. Sant'Anna e San Sebastiano, Caserta
| | - Gianfranco Sinagra
- S.C. Cardiologia, DAI Cardiovascolare, Azienda Sanitaria Universitaria Integrata di Trieste, Università degli Studi, Trieste
| | | | | | | | | | - Andrea Di Lenarda
- S.C. Cardiovascolare e Medicina dello Sport, Azienda Sanitaria Universitaria Integrata di Trieste
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania - Presidente Fondazione per il Tuo cuore
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Abrignani MG, Enea I, Colivicchi F, Roncon L, Aiello A, Becattini C, Bongarzoni A, Caravita S, Dasseni N, De Michele L, Faggiano PM, Mureddu GF, Picariello C, Rao CM, Riccio C, Urbinati S, Vanni S, Vatrano M, Di Lenarda A, Gabrielli D, Gulizia MM. [ANMCO statement: Arterial and venous thromboembolism: what implications for clinical practice?]. G Ital Cardiol (Rome) 2019; 20:671-684. [PMID: 31697276 DOI: 10.1714/3254.32230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Acute myocardial infarction, stroke, peripheral arterial disease and pulmonary embolism share thrombosis as a common mechanism. Some well-known risk factors for arterial thromboembolism are recognized as "weak risk factors" of venous one, too. Arterial and venous thrombosis share also some pathophysiological mechanisms, including inflammation, endothelial damage, and hypercoagulability. It is likely, thus, that any disease related to arterial and venous thrombosis belong to the same "pan-vascular syndrome", that constitutes itself a chronic, recurrent inflammatory disease. According to the available data, there are elements for implementing an omni-comprehensive cardiovascular evaluation after an episode of venous thromboembolism, requiring the investigations, in addition to the known unrecognized prothrombotic conditions, also of indirect signs and risk factors for a possible arterial thromboembolic event. Large, prospective studies are needed to establish the more appropriate therapeutic strategies in this context.The aim of the present statement is to make aware all the physicians involved in the management of arterial and venous diseases and to provide some tools for evaluating the implications of related major risk factors. Thus, it could be possible to lay the foundation for a reduction of total cardiovascular risk, in terms of primary and secondary prevention of arterial and venous thromboembolism.
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Affiliation(s)
| | - Iolanda Enea
- U.O.C. Medicina d'Urgenza, A.O.R.N. S. Anna e S. Sebastiano, Caserta
| | | | - Loris Roncon
- U.O.C. Cardiologia, Azienda ULSS 5 Polesana, Rovigo
| | | | - Cecilia Becattini
- Medicina Interna e Vascolare, Azienda Ospedaliera di Perugia, Perugia
| | | | - Sergio Caravita
- Cardiologia, Ospedale San Luca, IRCCS Istituto Auxologico Italiano, Milano
| | - Nicolò Dasseni
- U.O. Cardiologia, Spedali Civili e Università degli Studi di Brescia
| | | | | | - Gian Francesco Mureddu
- U.O.S. Prevenzione Cardiovascolare Secondaria e Riabilitazione Cardiologica, Cardiologia 2, A.O. San Giovanni-Addolorata, Roma
| | | | | | - Carmine Riccio
- U.O. Cardiologia e Riabilitazione Cardiologica, A.O. S. Anna e S. Sebastiano, Caserta
| | | | - Simone Vanni
- U.O. Medicina d'Urgenza, Ospedale San Giuseppe, Empoli, Azienda Ospedaliera Toscana Centro
| | - Marco Vatrano
- UTIC-Emodinamica e Cardiologia Interventistica, Ospedale Civile Pugliese, Catanzaro
| | - Andrea Di Lenarda
- S.C. Centro Cardiovascolare, Azienda Sanitaria Universitaria Integrata, Trieste
| | | | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
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Bova C, Vanni S, Prandoni P, Morello F, Dentali F, Bernardi E, Mumoli N, Bucherini E, Barbar S, Picariello C, Enea I, Pesavento R, Bottino F, Jiménez D. A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism. Thromb Res 2018; 165:107-111. [PMID: 29631073 DOI: 10.1016/j.thromres.2018.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/17/2018] [Accepted: 04/02/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Bova score has shown usefulness in the identification of intermediate-high risk patients with acute pulmonary embolism (PE), but lacks prospective validation. The aim of this study was to prospectively validate the Bova score in different settings from the original derivation cohort. METHODS Consecutive, normotensive patients with acute PE recruited at 13 academic or general hospitals were stratified, using their baseline data, into the three Bova risk stages (I-III). The primary outcome was the 30-day composite of PE-related mortality, hemodynamic collapse and non-fatal PE recurrences in the three risk categories. RESULTS In the study period, 639 patients were enrolled. The primary end point occurred in 45 patients (7.0%; 95% Confidence Intervals, 5.2%-9.3%). Risk stage correlated with the PE-related complication rate (stage I, 2.9%; stage II, 17%; stage III, 27%). Patients classified as stage III by the Bova score had a 6.5-fold increased risk for adverse outcomes (3.1-13.5, p < 0.001) compared with stages I and II combined. Rescue thrombolysis increased from stage I to stage III (0.6%, 12% and 15% respectively). All-cause mortality (5.3%) did not substantially differ among the stages. CONCLUSIONS The Bova score accurately stratifies normotensive patients with acute PE into stages of increasing risk of 30-day PE-related complications.
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Affiliation(s)
- Carlo Bova
- Department of Internal Medicine, Azienda Ospedaliera (Coordinating Center), Cosenza, Italy.
| | - Simone Vanni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Paolo Prandoni
- Department of Cardiovascular Sciences, Vascular Medicine Unit, University of Padua, Italy
| | - Fulvio Morello
- Emergency Department, A.O.U. Città della Salute e della Scienza di Torino, Ospedale Molinette, Torino, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Enrico Bernardi
- Department of Emergency Medicine, ULSS n.7, Conegliano, TV, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Civile Livorno, Italy
| | | | - Sofia Barbar
- Department of Internal and Emergency Medicine, Civic Hospital of Camposampiero (PD), Italy
| | - Claudio Picariello
- Unit of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Iolanda Enea
- Emergency Care Department, Anna e S. Sebastiano Hospital, Caserta, Italy
| | | | | | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcalá de Henares University, Madrid, Spain
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D'Agostino C, Zonzin P, Enea I, Gulizia MM, Ageno W, Agostoni P, Azzarito M, Becattini C, Bongarzoni A, Bux F, Casazza F, Corrieri N, D'Alto M, D'Amato N, D'Armini AM, De Natale MG, Di Minno G, Favretto G, Filippi L, Grazioli V, Palareti G, Pesavento R, Roncon L, Scelsi L, Tufano A. ANMCO Position Paper: long-term follow-up of patients with pulmonary thromboembolism. Eur Heart J Suppl 2017; 19:D309-D332. [PMID: 28751848 PMCID: PMC5520763 DOI: 10.1093/eurheartj/sux030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, is the third most common cause of cardiovascular death. The management of the acute phase of VTE has already been described in several guidelines. However, the management of the follow-up (FU) of these patients has been poorly defined. This consensus document, created by the Italian cardiologists, wants to clarify this issue using the currently available evidence in VTE. Clinical and instrumental data acquired during the acute phase of the disease are the cornerstone for planning the FU. Acquired or congenital thrombophilic disorders could be identified in apparently unprovoked VTE during the FU. In other cases, an occult cancer could be discovered after a VTE. The main targets of the post-acute management are to prevent recurrence of VTE and to identify the patients who can develop a chronic thromboembolic pulmonary hypertension. Knowledge of pathophysiology and therapeutic approaches is fundamental to decide the most appropriate long-term treatment. Moreover, prognostic stratification during the FU should be constantly updated on the basis of the new evidence acquired. Currently, the cornerstone of VTE treatment is represented by both the oral and the parenteral anticoagulation. Novel oral anticoagulants should be an interesting alternative in the long-term treatment.
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Affiliation(s)
- Carlo D'Agostino
- Department of Cardiology, Cardiologia Ospedaliera, University General Hospital, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Piazza G. Cesare, 11, 70124 Bari, Italy
| | - Pietro Zonzin
- Department of Cardiology, Presidio Ospedaliero, Rovigo, Italy
| | - Iolanda Enea
- Emergency Care Department, Anna e S. Sebastiano Hospital, Caserta, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Garibaldi Nesima Hospital, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | | | | | - Cecilia Becattini
- Department of Internal and Vascular Medicine, Perugia General Hospital, Perugia, Italy
| | | | - Francesca Bux
- Coronary Care Unit, Department of Cardiology, Di Venere ASL Hospital, Bari, Italy
| | | | - Nicoletta Corrieri
- Department of Clinical Sciences and Community, University of Milan, Milan, Italy
| | - Michele D'Alto
- Cardiology SUN Department, Colli and Monaldi Hospital, Naples, Italy
| | - Nicola D'Amato
- Coronary Care Unit, Department of Cardiology, Di Venere ASL Hospital, Bari, Italy
| | - Andrea Maria D'Armini
- Cardio-Thoracic Surgery Department, University of Pavia, IRCCS Foundation San Matteo General Hospital, Pavia, Italy
| | | | | | - Giuseppe Favretto
- Cardiac Rehabilitation and Preventive Unit, High Specialization Rehabilitation Hospital, Motta di Livenza, Treviso, Italy
| | - Lucia Filippi
- Thoracic and Vascular Department, University of Padova, Cardiological Sciences, Padova, Italy
| | - Valentina Grazioli
- Cardio-Thoracic Surgery Department, University of Pavia, IRCCS Foundation San Matteo General Hospital, Pavia, Italy
| | - Gualtiero Palareti
- Angiology and Blood Coagulation Unit, S. Orsola-Malpighi General Hospital, University of Bologna, Bologna, Italy
| | - Raffaele Pesavento
- Thoracic and Vascular Department, University of Padova, Cardiological Sciences, Padova, Italy
| | - Loris Roncon
- Cardiology Department, S. Maria della Misericordia Hospital, Rovigo, Italy
| | - Laura Scelsi
- Department of Cardiology, University of Pavia, IRCCS Foundation San Matteo General Hospital, Pavia, Italy
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Nardi F, Gulizia MM, Colivicchi F, Abrignani MG, Di Fusco SA, Di Lenarda A, Di Tano G, Geraci G, Moschini L, Riccio C, Verdecchia P, Enea I. ANMCO Position Paper: direct oral anticoagulants for stroke prevention in atrial fibrillation: clinical scenarios and future perspectives. Eur Heart J Suppl 2017; 19:D70-D88. [PMID: 28751836 PMCID: PMC5526472 DOI: 10.1093/eurheartj/sux007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
It is now 4 years since the introduction of the new direct oral anticoagulants into clinical practice. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) has deemed necessary to update the previous position paper on the prevention of thrombo-embolic complications in patients with non-valvular atrial fibrillation, which was published in 2013. All available scientific evidence has been reviewed, focusing on data derived from both clinical trials and observational registries. In addition, all issues relevant to the practical clinical management of oral anticoagulation with the new direct inhibitors have been considered. Specific clinical pathways for optimal use of oral anticoagulation with the new directly acting agents are also developed and proposed for clinical implementation. Special attention is finally paid to the development of clinical algorithms for medium and long-term follow-up of patients treated with new oral direct anticoagulants.
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Affiliation(s)
- Federico Nardi
- Cardiology Department, S.O.C. Cardiologia, Ospedale Castelli, ASL VCO, Via Fiume 18, 28922, Verbania, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy
| | - Furio Colivicchi
- CCU-Cardiology Department, Presidio Ospedaliero San Filippo Neri, Rome, Italy
| | | | | | - Andrea Di Lenarda
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Giuseppe Di Tano
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello Palermo, Italy
| | - Giovanna Geraci
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello Palermo, Italy
| | | | - Carmine Riccio
- Prevention and cardiac rehabilitation Department, A.O. Sant'Anna e San Sebastiano, Caserta, Italy
| | - Paolo Verdecchia
- Internal Medicine Unit, Ospedale di Assisi, Assisi, Perugia, Italy
| | - Iolanda Enea
- Emergency Care Department, S. Anna e S. Sebastiano Hospital, Caserta, Italy
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25
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Enea I, Roncon L, Gulizia MM, Azzarito M, Becattini C, Bongarzoni A, Casazza F, Cuccia C, D’Agostino C, Rugolotto M, Vatrano M, Vinci E, Fenaroli P, Formigli D, Silvestri P, Nardi F, Vedovati MC, Scherillo M. ANMCO Position Paper: the use of non-vitamin K dependent new oral anticoagulant(s) in pulmonary embolism therapy and prevention. Eur Heart J Suppl 2017; 19:D293-D308. [PMID: 28751847 PMCID: PMC5526474 DOI: 10.1093/eurheartj/sux026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The new oral anticoagulants (NOACs) have radically changed the approach to the treatment and prevention of thromboembolic pulmonary embolism. The authors of this position paper face, in succession, issues concerning NOACs, including (i) their mechanism of action, pharmacodynamics, and pharmacokinetics; (ii) the use in the acute phase with the 'double drug single dose' approach or with 'single drug double dose'; (iii) the use in the extended phase with demonstrated efficacy and with low incidence of bleeding events; (iv) the encouraging use of NOACs in particular subgroups of patients such as those with cancer, the ones under- or overweight, with renal insufficiency (creatinine clearance > 30 mL/min), the elderly (>75 years); (v) they propose a possible laboratory clinical pathway for follow-up; and (vi) carry out an examination on the main drug interactions, their potential bleeding risk, and the way to deal with some bleeding complications. The authors conclude that the use of NOACs both in the acute phase and in the extended phase is equally effective to conventional therapy and associated with fewer major bleeding events, which make their use in patients at higher risk of recurrences safer.
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Affiliation(s)
- Iolanda Enea
- Emergency Care Department, S. Anna e S. Sebastiano Hospital, Via G. Tescione, 1. 81100 Casert, Italy
| | - Loris Roncon
- Cardiology Department, S. Maria della Misericordia Hospital, Rovigo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Garibaldi-Nesima Hospital, Azienda di Rilievo Nazionale e Alta Specializazione “Garibaldi”, Catania, Italy
| | | | - Cecilia Becattini
- Department of Internal and Vascular Medicine, Perugia General Hospital, Perugia, Italy
| | | | | | - Claudio Cuccia
- Cardiology Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | | | - Marco Vatrano
- CCU-Hemodynamics and Interventional Cardiology Department, Civil Pugliese Hospital, Catanzaro, Italy
| | - Eugenio Vinci
- Cardiology-CCU Department, Umberto I Hospital, Siracusa, Italy
| | - Paride Fenaroli
- Nephrology and Dialysis Unit, Salvatore Maugeri Foundation, University of Pavia, Pavia, Italy
| | - Dario Formigli
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Paolo Silvestri
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Federico Nardi
- Cardiology Department, Castelli Hospital, Verbania, Italy
| | - Maria Cristina Vedovati
- Department of Internale and Vascular Medicine, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Marino Scherillo
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
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Prandoni P, Vedovetto V, Ciammaichella M, Bucherini E, Corradini S, Enea I, Cosmi B, Mumoli N, Visonà A, Barillari G, Bova C, Quintavalla R, Zanatta N, Pedrini S, Villalta S, Camporese G, Testa S, Parisi R, Becattini C, Cuppini S, Pengo V, Palareti G. Residual vein thrombosis and serial D-dimer for the long-term management of patients with deep venous thrombosis. Thromb Res 2017; 154:35-41. [PMID: 28407492 DOI: 10.1016/j.thromres.2017.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/31/2017] [Accepted: 04/02/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND The optimal long-term strategy for preventing recurrent venous thromboembolism (VTE) in patients with deep-vein thrombosis (DVT) is uncertain. METHODS In 620 consecutive outpatients with a first proximal DVT who had completed at least three months of anticoagulation (unprovoked in 483, associated with minor risk factors in 137), the ultrasound presence of residual vein thrombosis (RVT) was assessed and defined as an incompressibility of at least 4mm. In 517 patients without RVT and with negative D-dimer, anticoagulation was stopped and D-dimer was repeated after one and three months. Anticoagulation was resumed in 63 of the 72 patients in whom D-dimer reverted to positivity. RESULTS During a mean follow-up of three years, recurrent VTE developed in 40 (7.7%) of the 517 patients, leading to an annual rate of 3.6% (95% CI, 2.6 to 4.9): 4.1% (95% CI, 2.9 to 5.7) in individuals with unprovoked DVT, and 2.2% (95% CI, 1.1 to 4.5) in those with DVT associated with minor risk factors. Of the 233 males with unprovoked DVT, 17 (7.3%) developed events in the first year of follow-up. Major bleeding complications occurred in 8 patients while on anticoagulation, leading to an annual rate of 1.2% (95% CI, 0.6 to 2.4). CONCLUSIONS Discontinuing anticoagulation in patients with a first episode of proximal DVT based on the assessment of RVT and serial D-dimer leads to an overall annual rate of recurrent VTE lower than 5.0%, which is the rate deemed as acceptable by the Subcommittee on Control of Anticoagulation of the ISTH. However, in males with unprovoked DVT there is room for further improving the long-term strategy of VTE prevention. (ClinicalTrials.gov number, NCT01285661).
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Affiliation(s)
- Paolo Prandoni
- Department of Cardiovascular Sciences, University Hospital of Padua, Italy.
| | - Valentina Vedovetto
- Department of Cardiovascular Sciences, University Hospital of Padua, Italy; Division of Internal Medicine, Civic Hospital of Conegliano Veneto, Italy
| | | | | | - Sara Corradini
- Division of Internal and Cardiovascular Medicine, Civic Hospital of Reggio Emilia, Italy
| | - Iolanda Enea
- Emergency Medicine, Civic Hospital of Caserta, Italy
| | - Benilde Cosmi
- Department of Experimental, Diagnostic and Specialty Medicine, Angiology and Blood Coagulation Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Civic Hospital of Livorno, Italy
| | - Adriana Visonà
- Division of Angiology, Civic Hospital of Castelfranco Veneto, Italy
| | | | - Carlo Bova
- Division of Internal Medicine, Civic Hospital of Cosenza, Italy
| | | | - Nello Zanatta
- Internal Medicine, Angiology and Coagulation Unit, University Hospital of Parma, Italy
| | - Simona Pedrini
- Laboratory Medicine, Poliambulanza Foundation, Brescia, Italy
| | - Sabina Villalta
- Department of Internal Medicine, University Hospital of Treviso, Italy
| | | | - Sofie Testa
- Department of Laboratory Medicine, Haemostasis and Thrombosis Center, Civic Hospital of Cremona, Italy
| | - Roberto Parisi
- Internal Medicine and Angiology Unit, S. Giovanni and Paolo Hospital, Venice, Italy
| | - Cecilia Becattini
- Emergency and Internal Medicine, Unversity Hospital of Perugia, Italy
| | - Stefano Cuppini
- Division of Internal Medicine, Angiology Unit, Civic Hospital of Rovigo, Italy
| | - Vittorio Pengo
- Department of Cardiovascular Sciences, University Hospital of Padua, Italy
| | - Gualtiero Palareti
- Department of Experimental, Diagnostic and Specialty Medicine, Angiology and Blood Coagulation Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
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27
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Nardi F, Gulizia MM, Colivicchi F, Abrignani MG, Di Fusco SA, Di Lenarda A, Di Tano G, Moschini L, Riccio C, Verdecchia P, Enea I. [ANMCO Position paper: Direct new oral anticoagulants for the prevention of thromboembolic complications in patients with atrial fibrillation: clinical scenarios and future perspectives]. G Ital Cardiol (Rome) 2016; 17:3S-28. [PMID: 27869891 DOI: 10.1714/2450.25666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
It is now 4 years since the introduction of the new direct oral anticoagulants into clinical practice. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) has deemed necessary to update the previous position paper on the prevention of thromboembolic complications in patients with non-valvular atrial fibrillation, which was published in 2013. All available scientific evidence has been reviewed, focusing on data derived from both clinical trials and observational registries. In addition, all issues relevant to the practical clinical management of oral anticoagulation with the new direct inhibitors have been considered. Specific clinical pathways for optimal use of oral anticoagulation with the new directly acting agents are also developed and proposed for clinical implementation. Special attention is finally paid to the development of clinical algorithms for medium and long-term follow-up of patients treated with new oral direct anticoagulants.
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Affiliation(s)
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
| | - Furio Colivicchi
- U.O.C. Cardiologia-UTIC, Presidio Ospedaliero San Filippo Neri, Roma
| | | | | | - Andrea Di Lenarda
- S.C. Centro Cardiovascolare, Azienda Sanitaria Universitaria Integrata, Trieste
| | | | | | - Carmine Riccio
- Prevenzione e Riabilitazione Cardiopatico, A.O. Sant'Anna e San Sebastiano, Caserta
| | | | - Iolanda Enea
- U.O.C. Medicina d'Urgenza, A.O.R.N. S. Anna e S. Sebastiano, Caserta
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28
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Zuin M, Rigatelli G, Picariello C, D'Elia K, Bortolazzi A, Zuliani G, Zonzin P, Enea I, Roncon L. Is time to consider diet as modifiable risk factor for venous thromboembolism? Int J Cardiol 2016; 222:797-798. [DOI: 10.1016/j.ijcard.2016.08.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 08/07/2016] [Indexed: 11/25/2022]
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29
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Casazza F, Becattini C, Rulli E, Pacchetti I, Floriani I, Biancardi M, Scardovi AB, Enea I, Bongarzoni A, Pignataro L, Agnelli G. Clinical presentation and in-hospital death in acute pulmonary embolism: does cancer matter? Intern Emerg Med 2016; 11:817-24. [PMID: 27023066 DOI: 10.1007/s11739-016-1431-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/28/2016] [Indexed: 10/22/2022]
Abstract
Cancer is one of the most common risk factors for acute pulmonary embolism (PE), but only few studies report on the short-term outcome of patients with PE and a history of cancer. The aim of the study was to assess whether a cancer diagnosis affects the clinical presentation and short-term outcome in patients hospitalized for PE who were included in the Italian Pulmonary Embolism Registry. All-cause and PE-related in-hospital deaths were also analyzed. Out of 1702 patients, 451 (26.5 %) of patients had a diagnosis of cancer: cancer was known at presentation in 365, or diagnosed during the hospital stay for PE in 86 (19 % of cancer patients). Patients with and without cancer were similar concerning clinical status at presentation. Patients with cancer less commonly received thrombolytic therapy, and more often had an inferior vena cava filter inserted. Major or intracranial bleeding was not different between groups. In-hospital all-cause death occurred in 8.4 and 5.9 % of patients with and without cancer, respectively. At multivariate analysis, cancer (OR 2.24, 95 % CI 1.27-3.98; P = 0.006) was an independent predictor of in-hospital death. Clinical instability, PE recurrence, age ≥75 years, recent bed rest ≥3 days, but not cancer, were independent predictors of in-hospital death due to PE. Cancer seems a weaker predictor of all-cause in-hospital death compared to other factors; the mere presence of cancer, without other risk factors, leads to a probability of early death of 2 %. In patients with acute PE, cancer increases the probability of in-hospital all-cause death, but does not seem to affect the clinical presentation or the risk of in-hospital PE-related death.
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Affiliation(s)
- Franco Casazza
- Cardiology Division, Ospedale San Carlo Borromeo, Milan, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Via G Dottori 1, Perugia, Italy.
| | - Eliana Rulli
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Ilaria Pacchetti
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Irene Floriani
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Marco Biancardi
- Division of Internal Medicine, Ospedale San Carlo Borromeo, Milan, Italy
| | | | - Iolanda Enea
- UO Medicina d'Urgenza, AORN S. Anna e S. Sebastiano, Caserta, Italy
| | | | - Luigi Pignataro
- Cardiology Division, Ospedale San Carlo Borromeo, Milan, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Via G Dottori 1, Perugia, Italy
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30
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D'Agostino C, Zonzin P, Enea I, Gulizia MM, Ageno W, Agostoni P, Azzarito M, Becattini C, Bongarzoni A, Bux F, Casazza F, Corrieri N, D'Alto M, D'Amato N, D'Armini AM, De Natale MG, Di Minno G, Favretto G, Filippi L, Grazioli V, Palareti G, Pesavento R, Roncon L, Scelsi L, Tufano A. [ANMCO Position paper: Recommendations for the follow-up of patients with pulmonary thromboembolism]. G Ital Cardiol (Rome) 2016; 17:68S-109. [PMID: 27869893 DOI: 10.1714/2450.25670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is the third most common cause of cardiovascular death. The management of the acute phase of VTE is well described in several papers and guidelines, whereas the management of the follow-up of the patients affected from VTE is less defined. This position paper of the Italian Association of Hospital Cardiologists (ANMCO) tries to fill the gap using currently available evidence and the opinion of the experts to suggest the most useful way to manage patients in the chronic phase.The clinical and laboratory tests acquired during the acute phase of the disease drives the decision of the following period. Acquired or congenital thrombophilic factors may be identified to explain an apparently not provoked VTE. In some patients, a not yet clinically evident cancer could be the trigger of VTE and this could lead to a different strategy. The main target of the post-acute management is to prevent relapse of the disease and to identify those patients who could worsen or develop chronic thromboembolic pulmonary hypertension. The knowledge of the etiopathogenetic ground is important to address the therapeutic approach, choosing the best antithrombotic strategy and deciding how long therapy should last. During the follow-up period, prognostic stratification should be updated on the basis of new evidences eventually acquired.Treatment of VTE is mainly based on oral or parenteral anticoagulation. Oral direct inhibitors of coagulation represent an interesting new therapy for the acute and extended period of treatment.
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Affiliation(s)
- Carlo D'Agostino
- U.O.C. Cardiologia Ospedaliera, Azienda Ospedaliero-Universitaria Policlinico, Bari
| | | | - Iolanda Enea
- U.O.C. Medicina d'Urgenza, A.O.R.N. S. Anna e S. Sebastiano, Caserta
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
| | - Walter Ageno
- Dipartimento di Medicina Clinica e Sperimentale, Università dell'Insubria, Varese
| | | | | | - Cecilia Becattini
- Medicina Interna e Vascolare, Azienda Ospedaliera di Perugia, Perugia
| | | | - Francesca Bux
- U.O.C. Cardiologia-UTIC, Ospedale Di Venere ASL, Bari
| | | | - Nicoletta Corrieri
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi, Milano
| | - Michele D'Alto
- U.O.C. Cardiologia-SUN, A.O.R.N. dei Colli-A.O. Monaldi, Napoli
| | | | - Andrea Maria D'Armini
- Chirurgia Cardio-Toracica, Università degli Studi, Fondazione IRCSS Policlinico San Matteo, Pavia
| | | | - Giovanni Di Minno
- Centro per le Coagulopatie, Università degli Studi "Federico II", Napoli
| | - Giuseppe Favretto
- U.O. Cardiologia Riabilitativa e Preventiva, Ospedale Riabilitativo Alta Specializzazione, Motta di Livenza (TV)
| | - Lucia Filippi
- Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi, Padova
| | - Valentina Grazioli
- Chirurgia Cardio-Toracica, Università degli Studi, Fondazione IRCSS Policlinico San Matteo, Pavia
| | - Gualtiero Palareti
- Divisione di Angiologia e Malattie della Coagulazione, Policlinico S. Orsola-Malpighi, Università degli Studi, Bologna
| | - Raffaele Pesavento
- Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi, Padova
| | - Loris Roncon
- U.O.C. Cardiologia, Ospedale S. Maria della Misericordia, Rovigo
| | - Laura Scelsi
- S.C. Cardiologia, Fondazione IRCSS Policlinico San Matteo, Pavia
| | - Antonella Tufano
- Centro per le Coagulopatie, Università degli Studi "Federico II", Napoli
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31
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Enea I, Roncon L, Gulizia MM, Azzarito M, Becattini C, Bongarzoni A, Casazza F, Cuccia C, D'Agostino C, Rugolotto M, Vatrano M, Vinci E, Fenaroli P, Formigli D, Silvestri P, Nardi F, Vedovati MC, Scherillo M. [ANMCO position paper: Use of new oral anticoagulants for the treatment and prevention of pulmonary thromboembolism]. G Ital Cardiol (Rome) 2016; 17:29S-67. [PMID: 27869892 DOI: 10.1714/2450.25668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The new oral anticoagulants (NOACs) have radically changed the approach to the treatment and prevention of thromboembolic pulmonary embolism. The authors of this position paper face, in succession, issues concerning NOACs, including 1) their mechanism of action, pharmacodynamics and pharmacokinetics; 2) the use in the acute phase with the "double drug single dose" approach or with "single drug double dose"; 3) the use in the extended phase with demonstrated efficacy and with low incidence of bleeding events; 4) the encouraging use of NOACs in particular subgroups of patients such as those with cancer, the ones under- or overweight, with renal insufficiency (creatinine clearance >30 ml/min), the elderly (>75 years); 5) they propose a possible laboratory clinical pathway for follow-up; 6) carry out an examination on the main drug interactions, their potential bleeding risk, and the way to deal with some bleeding complications. The authors conclude that the use of NOACs both in the acute phase and in the extended phase is equally effective to conventional therapy and associated with fewer major bleeding events, which make their use in patients at higher risk of recurrences safer.
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Affiliation(s)
- Iolanda Enea
- U.O.C. Medicina d'Urgenza, A.O.R.N. S. Anna e S. Sebastiano, Caserta
| | - Loris Roncon
- U.O.C. Cardiologia, Ospedale S. Maria della Misericordia, Rovigo
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
| | | | - Cecilia Becattini
- Medicina Interna e Vascolare, Azienda Ospedaliera di Perugia, Perugia
| | | | | | - Claudio Cuccia
- U.O. Cardiologia, Istituto Ospedaliero Fondazione Poliambulanza, Brescia
| | - Carlo D'Agostino
- U.O.C. Cardiologia Ospedaliera, Azienda Ospedaliero-Universitaria Policlinico, Bari
| | | | - Marco Vatrano
- UTIC-Emodinamica e Cardiologia Interventistica, Ospedale Civile Pugliese, Catanzaro
| | - Eugenio Vinci
- U.O.C. Cardiologia-UTIC, Ospedale Umberto I, Siracusa
| | - Paride Fenaroli
- U.O. Nefrologia e Dialisi, IRCCS Fondazione Salvatore Maugeri, Università degli Studi, Pavia
| | - Dario Formigli
- Cardiologia Interventistica-UTIC, A.O. G. Rummo, Benevento
| | | | | | - Maria Cristina Vedovati
- Medicina Interna e Vascolare, Ospedale S. Maria della Misericordia, Università degli Studi, Perugia
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Roncon L, Casazza F, Zuin M, Zonzin P, Galli M, Enea I. [Percutaneous treatment of pulmonary embolism: diffusion and use of the technique in Italian interventional cardiology centers. Results of the PETER survey]. G Ital Cardiol (Rome) 2016; 17:268-72. [PMID: 27093210 DOI: 10.1714/2214.23900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Reperfusion in acute pulmonary embolism (PE) by percutaneous techniques is a valid therapeutic option when there is a formal contraindication to or failure of thrombolysis. In the last years, an increasing number of patients with acute PE have been treated with these techniques. METHODS In order to obtain a map of current availability and use of percutaneous techniques in PE, on behalf of the ANMCO Pulmonary Circulation Area, 56 Italian interventional cardiology and radiology departments, equipped with technology for percutaneous embolectomy, were invited to participate in a national survey. Questionnaires were e-mailed to each department from April to May 2015. RESULTS Thirty-one out of 56 centers (54.8% in the North, 9.7% in the Center and 35.5% in the South of Italy) answered to the questionnaire. Percutaneous techniques were available in 90% of the cardiology departments involved, reporting also a good experience with their use in PE (77.4%). Only two responders were interventional radiology departments. AngioJet(®) and EkoSonic Endovascular System(®) (64.7% and 19.4%, respectively) were the most common devices used. Overall, in 2014, 62 patients were treated with percutaneous techniques, mainly in the North of the country. With regard to local diagnostic and therapeutic protocols, 61.3% of respondents reported owning one. Great interest was provided by participants in adhering to this national multicenter registry. CONCLUSIONS Our results show the interest of Italian cardiology departments about percutaneous techniques as a therapeutic option for acute PE. Percutaneous techniques are largely available but still underused in routine clinical practice.
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Affiliation(s)
- Loris Roncon
- U.O.C. Cardiologia, Ospedale S. Maria della Misericordia, Rovigo
| | - Franco Casazza
- Divisione di Cardiologia, Ospedale San Carlo Borromeo, Milano
| | - Marco Zuin
- U.O.C. Cardiologia, Ospedale S. Maria della Misericordia, Rovigo
| | - Pietro Zonzin
- U.O.C. Cardiologia, Ospedale S. Maria della Misericordia, Rovigo
| | | | - Iolanda Enea
- U.O.C. Medicina d'Urgenza, A.O. S. Anna e S. Sebastiano, Caserta
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Enea I, Roncon L, Azzarito M, Bongarzoni A, Casazza F, D'Agostino C, Favretto G, Rubboli A, Zonzin P. [Diagnosis and therapy of pulmonary arterial hypertension in Italy: results of the INCIPIT2 survey]. G Ital Cardiol (Rome) 2014; 15:710-716. [PMID: 25533120 DOI: 10.1714/1718.18776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a rare clinical condition characterized by increased pulmonary vascular resistance and premature death. It is necessary to activate a pathway from the screening of pulmonary hypertension to the diagnosis of PAH, so as to use the drugs able to improve the outcome. Nowadays, in Italy, there are no data about the management of PAH in peripheral centers and about the integration of peripheral centers with those of excellence. METHODS In order to have a map of the actual Italian pathway for diagnosis and therapy of PAH, on behalf of the ANMCO Pulmonary Circulation Area, 923 Italian cardiology departments were asked to reply, on a special electronic file, to a few simple questions about their organization, from December 2012 to May 2013. RESULTS 101/923 centers (48 in the North, 18 in the Middle, 35 in the South) answered correctly. 32% has no organization for PAH, 68% has a pathway for PAH diagnosis and management, and two thirds of them collaborate with excellence centers. 36 centers perform right heart catheterization with vascular reactivity (21 with nitric oxide, 8 with adenosine, 5 with epoprostenol, 2 with nitric oxide or epoprostenol). 61/101 are prescriber centers: 33 perform right heart catheterization with vascular reactivity test, 23 send their patients to the reference center for right heart catheterization, 5 perform no right heart catheterization before the prescription of specific drugs for PAH, and only 14 prescribe intravenous prostanoids. In 2011, the participating centers followed 561 patients with PAH, of whom 126 (23%) were in independent centers. With regard to the network organization of the groups, the participating centers are partly independent of the diagnostic pathway, partly refer to outside regions; in others there is a structured regional network and there are 3 Italian regions with Hub & Spoke networks that receive patients coming from other regions. CONCLUSIONS Our results show the interest of Italian Cardiology to find a pathway for the diagnosis of PAH and a heterogeneity suggesting the need for a shareable pathway, thus improving the collaboration between peripheral cardiology departments and the excellence centers for PAH in a functional Hub & Spoke network.
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Blanco-Molina A, Enea I, Gadelha T, Tufano A, Bura-Riviere A, Di Micco P, Bounameaux H, González J, Villalta J, Monreal M. Sex differences in patients receiving anticoagulant therapy for venous thromboembolism. Medicine (Baltimore) 2014; 93:309-317. [PMID: 25398066 PMCID: PMC4602415 DOI: 10.1097/md.0000000000000114] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In patients with venous thromboembolism (VTE), the outcome during the course of anticoagulant therapy may differ according to the patient's sex. We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to compare the rate of VTE recurrences, major bleeding, and mortality due to these events according to sex.As of August 2013, 47,499 patients were enrolled in RIETE, of whom 24,280 (51%) were women. Women were older, more likely presented with pulmonary embolism (PE), and were more likely to have recent immobilization but less likely to have cancer than men. During the course of anticoagulation (mean duration: 253 d), 659 patients developed recurrent deep vein thrombosis (DVT), 576 recurrent PE, 1368 bled, and 4506 died. Compared with men, women had a lower rate of DVT recurrences (hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.67-0.91), a similar rate of PE recurrences (HR: 0.98; 95% CI: 0.83-1.15), a higher rate of major bleeding (HR: 1.21; 95% CI: 1.09-1.35), and higher mortality due to PE (HR: 1.24; 95% CI: 1.04-1.47). On multivariable analysis, any influence of sex on the risk for recurrent DVT (HR: 0.88; 95% CI: 0.75-1.03), major bleeding (HR: 1.10; 95% CI: 0.98-1.24), or fatal PE (HR: 1.01; 95% CI: 0.84-1.22) was no longer statistically significant.In conclusion, women had fewer DVT recurrences and more bleeds than men during the course of anticoagulation. These differences were not due to sex, but very likely to other patient characteristics more common in female patients and differences in treatment choice.
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Affiliation(s)
- Angeles Blanco-Molina
- From Department of Internal Medicine (ABM), Hospital Universitario Reina Sofia, Córdoba, Spain; Department of Emergency Medicine, Ospedale San Sebastiano, Caserta, Italy; Department of Haematology and Hemotherapy (TG), Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil; Department of Clinical and Experimental Medicine (AT), Università degli Studi di Napoli Federico II, Naples, Italy; Department of Vascular Medicine (ABR), Hôpital de Rangueil, Toulouse, France; Department of Internal Medicine (PDM), Ospedale Buonconsiglio Fatebenefratelli, Naples, Italy; Division of Angiology and Haemostasis (HB), University Hospital of Geneva, Geneva, Switzerland; Department of Internal Medicine (JG), ALTHAIA, Xarxa Assistencial de Manresa, Spain; Department of Internal Medicine (JV), Hospital Clinic, Barcelona, Spain; and Department of Internal Medicine (MM), Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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Enea I, Ghio S, Bongarzoni A, Casazza F, D'Armini AM, Favretto G, Roncon L, Rubboli A, Serafini O, Zonzin P, D'Agostino C. [Echocardiographic alterations suggestive of pulmonary hypertension in the Italian ultrasonography laboratories. Epidemiological data from the INCIPIT study (INCidence of Pulmonary Hypertension in Italian ulTrasonography laboratories)]. G Ital Cardiol (Rome) 2010; 11:402-407. [PMID: 20860160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Pulmonary hypertension is characterized by an increase in pulmonary vascular resistance and premature death. Echocardiography is useful in the screening of patients with suspected pulmonary hypertension by estimation of the systolic regurgitant tricuspid flow velocity according to the simplified Bernoulli equation. On this basis, the survey INCIPIT was created aiming at evaluating the frequency of suspected pulmonary hypertension among Italian patients. METHODS From November 10 to 29, 2008, echo laboratories were invited to report on a special electronic file the number of echocardiographic examinations performed and the number of those showing a peak tricuspid regurgitant flow velocity > or = 3 m/s. RESULTS 123 echo labs participated in the study. 21 483 echocardiograms were evaluated from 110 centers (58, 17 and 35 in North, Center and South Italy, respectively); 1410 (6.6%) exams showed a systolic regurgitant flow velocity > or = 3 m/s (median value 3.3 and interquartile range 0.46). Patients were predominantly female (female to male ratio 734/676), with a mean age of 71.8 +/- 11.8 years, median body mass index of 25.7 kg/m2 (interquartile range 5.5). Overall, 21.4% patients had no symptoms, 48.7% had dyspnea, 11.2% had asthenia, 3.9% had chest pain, and 7.4% had dyspnea and asthenia. Among the 1410 patients with a tricuspid regurgitant flow velocity > or = 3 m/s, 52.62% had left heart disease, 7.52% lung disease, 1.35% chronic thromboembolic pulmonary hypertension, 0.92% collagen disease, 0.43% congenital heart disease, 0.14% liver disease, 0.07% HIV, 26.45% more than one disease, and 10.5% presented suspected pulmonary hypertension of unknown cause. CONCLUSIONS In the Italian echo labs, the occurrence of suspected pulmonary hypertension is not uncommon. Cardiologists should be encouraged to refer patients with suspected pulmonary hypertension of unknown origin to specialized centers in order to define the cause of pulmonary hypertension and to institute the appropriate therapy.
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Affiliation(s)
- Iolanda Enea
- Dipartimento d'Emergenza, AORN 5. Anna e San Sebastiano, Caserta.
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Becattini C, Agnelli G, Salvi A, Grifoni S, Pancaldi LG, Enea I, Balsemin F, Campanini M, Ghirarduzzi A, Casazza F. Bolus tenecteplase for right ventricle dysfunction in hemodynamically stable patients with pulmonary embolism. Thromb Res 2010; 125:e82-6. [PMID: 19833379 DOI: 10.1016/j.thromres.2009.09.017] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 09/08/2009] [Accepted: 09/21/2009] [Indexed: 11/18/2022]
Affiliation(s)
- Cecilia Becattini
- Medicina Interna e Cardiovascolare-Stroke Unit, Università di Perugia, Perugia, Italy.
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Bova C, Pesavento R, Marchiori A, Palla A, Enea I, Pengo V, Visonà A, Noto A, Prandoni P. Risk stratification and outcomes in hemodynamically stable patients with acute pulmonary embolism: a prospective, multicentre, cohort study with three months of follow-up. J Thromb Haemost 2009; 7:938-44. [PMID: 19302447 DOI: 10.1111/j.1538-7836.2009.03345.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND The role of risk stratification in normotensive patients with acute pulmonary embolism (PE) is still unclear. OBJECTIVES We evaluated, in these patients, the usefulness of six prognostic markers for predicting in-hospital adverse events related to PE and 3-month mortality. PATIENTS/METHODS Two hundred and one consecutive patients with confirmed acute PE and normal blood pressure, who were administered conventional anticoagulation, were recruited in a multicentre prospective cohort study with 3 months of follow-up. At baseline, they received a comprehensive risk-evaluation including echocardiographic assessment of right ventricular dysfunction, determination of troponin I, brain natriuretic peptide and D-dimer, arterial blood gas analysis and a clinical score. Primary outcome of the study was PE-related in-hospital death or clinical deterioration. Secondary outcomes were in-hospital and 3-month all-cause mortality. RESULTS The primary outcome occurred in one patient (0.5%), who died from PE during hospitalization. The in-hospital and 3-month all-cause mortality were 2% and 9%, respectively. None of the prognostic markers was predictive of the primary outcome. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality (P = 0.02, 0.01 and < 0.01, respectively). Clinical score (HR, 4.7; 95% CI, 1.9-12.0), D-dimer (4.8; 1.4-16.3), hypoxemia (5.7; 2.1-15.1) and troponin I (7.5; 2.5-22.7) were predictors of 3-month all-cause mortality on univariate analysis. On multivariate analysis clinical score and troponin I remained independently predictive. CONCLUSIONS We did not find prognostic markers useful as predictors of in-hospital PE-related adverse events. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality. Clinical score and troponin I independently predicted 3-month all-cause mortality.
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Affiliation(s)
- C Bova
- Department of Internal Medicine, Azienda ospedaliera, Cosenza, Italy.
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Enea I, Ceparano G, Mazzarella G, Di Sarno R, Cangiano G, Busino CA. [Biohumoral markers and right ventricular dysfunction in acute pulmonary embolism: the answer to thrombolytic therapy]. Ital Heart J Suppl 2004; 5:29-35. [PMID: 15253142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND Recent data suggest that brain natriuretic peptide (BNP) and troponin I (TnII) are useful markers of right ventricular dysfunction (RVD) and initial myocardial injury in acute pulmonary embolism. The aim of this study was to evaluate biohumoral activation and right ventricular function in patients with acute pulmonary embolism diagnosed at pulmonary scintigraphy. METHODS We observed 12 patients with massive pulmonary embolism (MPE), 8 with non-massive pulmonary embolism (NMPE) and RVD, 6 with NMPE without RVD. All the patients with MPE and 5 patients with NMPE-RVD received thrombolytic therapy (urokinase or recombinant tissue-type plasminogen activator), the others were treated with heparin. At the beginning and after pharmacological treatment all the 26 patients underwent standard echocardiography and blood test analysis. RESULTS BNP and Tn1 were significantly high in MPE (BNP p < 0.001 and Tn1I p < 0.005 vs NMPE) and in NMPE-RVD (BNP p < 0.03 and Tnl p < 0.02 vs NMPE). MPE and NMPE-RVD had similar RVD (p = NS), thrombolysis significantly reduced BNP, TnI, systolic pulmonary pressure, both in MPE (p < 0.001) and in NMNPE-RVD (BNP and Tnl p < 0.05, systolic pulmonary pressure p < 0.001). COULSION: Our data sustain the utility of BNP and Tnl as markers of RVD in acute pulmonary embolism; they focus on patients with NMPE-RVD and high levels of BNP and Tnl in whom an aggressive therapy as the thrombolytic one is necessary; they suggest the importance of biohumoral markers as indicators of the efficacy of pharmacological treatment in patients with acute pulmonary embolism.
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Affiliation(s)
- Iolanda Enea
- UO di Medicina d'Urgenza, Ospedale San Sebastiano, Caserta.
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Enea I, De Paolis P, Porcellini A, Piras O, Savoia C, Russo R, Giliberti R, Gigante B, Rubattu S, Conte G, Ganten D, Volpe M. Defective suppression of the aldosterone biosynthesis during stroke permissive diet in the stroke-prone phenotype of the spontaneously hypertensive rat. Basic Res Cardiol 2000; 95:84-92. [PMID: 10826499 DOI: 10.1007/s003950050168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Previous studies have shown that short-term high salt intake unmasks blunted plasma aldosterone suppression in stroke-prone spontaneously hypertensive rats (SHRsp). The aim of this study was to evaluate the response of aldosterone biosynthesis and production to a sustained exposure to the stroke-permissive Japanese-style diet (JD) in young stroke-prone and stroke-resistant SHRs. For this purpose, 6-week old male rats from both strains were divided into 2 dietary groups and received regular diet (SHR = 37, SHRsp = 32) or the JD and 1% saline to drink (SHR = 34, SHRsp = 30) for 4 weeks. All measurements were carried out at the end of the dietary periods. After JD, plasma aldosterone levels were significantly decreased in SHR (from 357.8 +/- 57 to 163.3 +/- 31.5 pg/ml, p < 0.05) but markedly increased in SHRsp (from 442 +/- 56.5 to 739 +/- 125.7 pg/ml, p < 0.05). Consistently, the adrenal aldosterone synthase expression was reduced by JD in SHR (p < 0.05), whereas it was even slightly raised by JD in SHRsp so that, at the end of JD, aldosterone synthase mRNA was 5-fold higher in SHRsp than in SHR. Urinary sodium excretion (mEq/24h) achieved lower levels in SHRsp, so that fractional excretion of sodium was 80.2 +/- 9% in SHR and 40.3 +/- 8% in SHRsp (p < 0.05) in balance studies performed at the end of JD. These different responses of mineralocorticoid biosynthesis and urinary sodium excretion to JD were not accounted for by different adaptations of the renin-angiotensin and atrial natriuretic peptide systems, of serum potassium levels, or of adrenal 11beta-hydroxylase expression in the two strains. Systolic blood pressure was comparable in both strains throughout the experiment. These results demonstrate enhanced aldosterone biosynthesis, associated with reduced urinary excretion of sodium in response to JD in SHRsp before the onset of stroke. This abnormality may play a role in the higher susceptibility to stroke of this model.
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Affiliation(s)
- I Enea
- Istituto Neurologico Mediterraneo Neuromed, Camerelle Pozzilli, Italy
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Volpe M, Gigante B, Enea I, Porcellini A, Russo R, Lee MA, Magri P, Condorelli G, Savoia C, Lindpaintner K, Rubattu S. Role of tissue renin in the regulation of aldosterone biosynthesis in the adrenal cortex of nephrectomized rats. Circ Res 1997; 81:857-64. [PMID: 9351460 DOI: 10.1161/01.res.81.5.857] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The aim of the study was to investigate whether the adrenal renin-angiotensin system plays an independent role in the regulation of mineralocorticoid biosynthesis in the adrenal gland and to explore the mechanisms of this action. Twelve-week-old male Sprague-Dawley rats were studied: 22 rats were maintained on a regular diet; 27 and 22 rats received a low salt diet with and without treatment, respectively, with the angiotensin II (Ang II) AT1-subtype receptor antagonist losartan (10 mg/kg per day). A fraction of each group of rats underwent bilateral nephrectomy (n = 12, 15, and 10, respectively) and was killed 48 hours later. In an additional group of 24 (12 intact and 12 nephrectomized) rats, the effects of the Ang II AT2-subtype receptor antagonist PD123319 were investigated. In intact rats, plasma renin activity (PRA) and adrenal renin activity and expression were progressively raised by salt restriction and losartan, whereas aldosterone synthase mRNA and plasma aldosterone (PA) levels were increased by salt restriction and reduced by losartan. Forty-eight hours after nephrectomy, PRA fell to undetectable levels; in contrast, adrenal renin expression, assessed by semiquantitative reverse-transcriptase polymerase chain reaction (using GAPDH as a standard for gene expression), showed an 18-fold increase and was further increased after salt restriction and losartan (all P < .05). Also, adrenal renin activity was raised after nephrectomy and further increased after salt restriction (P < .05) and losartan. Cytochrome P450 aldosterone synthase expression in the adrenal cortex was stimulated by nephrectomy alone and by nephrectomy combined with low salt intake (P < .05), with consequent increases in PA concentrations. In losartan-treated salt-restricted nephrectomized rats, cytochrome P450 aldosterone synthase expression (P < .05 versus nephrectomy alone and nephrectomy plus salt restriction) and PA concentrations were diminished (P < .05) in spite of the observed increases of adrenal renin expression. The AT2-receptor antagonism did not significantly affect PRA, adrenal renin, and aldosterone biosynthesis and production in either intact or nephrectomized salt-restricted rats. These results demonstrate that the adrenal renin-angiotensin system plays an independent role in the regulation of mineralocorticoid biosynthesis in vivo. This action is mediated primarily via the Ang II AT1-subtype receptors.
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Affiliation(s)
- M Volpe
- Istituto di Medicina Interna e Cardiologia, Universita' di Napoli, Italy.
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Gigante B, Rubattu S, Russo R, Porcellini A, Enea I, De Paolis P, Savoia C, Natale A, Piras O, Volpe M. Opposite feedback control of renin and aldosterone biosynthesis in the adrenal cortex by angiotensin II AT1-subtype receptors. Hypertension 1997; 30:563-8. [PMID: 9322982 DOI: 10.1161/01.hyp.30.3.563] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The aims of this study were to identify whether tissue renin is regulated by a negative-feedback mechanism produced by locally generated angiotensin (Ang II) in the adrenal cortex and to detect the pathway of Ang II modulation. For this purpose, in 36 12-week old, salt-restricted, nephrectomized Sprague-Dawley rats, we studied the effects of the Ang II AT1-subtype receptor antagonist losartan and of the Ang II AT2-subtype receptor antagonist PD123319 on renin mRNA and activity, aldosterone synthase mRNA, and AT1a-, AT1b-, and AT2-subtype receptor expression in the adrenal cortex. Ten additional rats, kept on a regular diet and then nephrectomized, were also studied. In salt-restricted, nephrectomized rats, losartan administration caused increases of adrenal renin mRNA (P<.05) and activity (P<.05) and a concomitant reduction of aldosterone synthase mRNA (P<.05). In addition, after losartan AT1b, receptor mRNA was reduced (P<.05), AT1a receptor mRNA was unchanged, and AT2 mRNA was increased (P<.05). PD123319 did not significantly modify any of these parameters. In conclusion, in salt-restricted, nephrectomized rats, selective antagonism of AT1-subtype receptors stimulates the expression and the activity of renin in the adrenal cortex. This observation demonstrates that Ang II locally formed in the adrenal cortex exerts a modulatory negative-feedback action on adrenal renin biosynthesis independent of the influence of the circulating renin-Ang system; this action is largely mediated through the AT1b-subtype receptors.
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Affiliation(s)
- B Gigante
- Department of Internal Medicine Federico II University Naples, Italy
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Cappelli-Bigazzi M, Rubattu S, Battaglia C, Russo R, Enea I, Ambrosio G, Chiariello M, Volpe M. Effects of high-cholesterol and atherogenic diets on vascular relaxation in spontaneously hypertensive rats. Am J Physiol 1997; 273:H647-54. [PMID: 9277480 DOI: 10.1152/ajpheart.1997.273.2.h647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hypercholesterolemia is associated with more rapid development of atherosclerosis, and hypertension is frequently associated with abnormal vascular function. Therefore, to investigate the role of hypercholesterolemia and hypertension on vascular function, we studied three groups of male rats (aged 6 wk): normotensive Wistar-Kyoto rats (WKY) as a control group and spontaneously hypertensive rats (SHR) receiving either standard diet (SD; SHR-SD) or high-cholesterol (1%) diet (ChD; SHR-ChD). Vascular reactivity was tested on isolated aortic rings at 4 wk and at 3 and 6 mo of diet. At 3 mo, endothelium-dependent relaxation to acetylcholine (ACh) and ADP was significantly reduced in SHR-ChD but not in SHR-SD compared with WKY. At 6 mo, relaxations to ACh were further impaired in both SHR groups compared with WKY. Endothelium-independent vasodilation to nitroglycerin (NTG) was not different in the three groups of animals throughout 6 mo of diet. In additional experiments, we evaluated vascular reactivity in rats fed with ChD enriched with an excess of vitamin D [atherogenic diet (AD)] capable of producing vascular atherosclerotic lesions. In particular, we studied three additional groups of WKY and SHR rats fed with SD, AD, or AD plus a nonhypotensive dose of the calcium antagonist nitrendipine (Nit). Vasodilation to ACh and ADP was significantly blunted in WKY-AD compared with WKY-SD, whereas it was partially improved in WKY-Nit. There were no differences in endothelium-independent relaxation to NTG in the three WKY groups. In contrast, SHR-AD showed a marked reduction of endothelium-dependent and -independent vasodilation, but only endothelium-dependent vasodilation was preserved by addition of Nit to the diet. These data suggest that the development of vascular dysfunction in rat genetic hypertension is accelerated by ChD, in absence of detectable vascular lesions. Our study also shows that AD alters both vascular smooth muscle and endothelium-dependent relaxation. Low doses of Nit partially preserve endothelium-dependent vasodilation but do not affect the impairment of smooth muscle function in these rats.
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Affiliation(s)
- M Cappelli-Bigazzi
- Division of Cardiology and Internal Medicine, Federico II School of Medicine, Naples, Italy
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Volpe M, Magri P, Rao MA, Cangianiello S, DeNicola L, Mele AF, Memoli B, Enea I, Rubattu S, Gigante B, Trimarco B, Epstein M, Condorelli M. Intrarenal determinants of sodium retention in mild heart failure: effects of angiotensin-converting enzyme inhibition. Hypertension 1997; 30:168-76. [PMID: 9260976 DOI: 10.1161/01.hyp.30.2.168] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The onset and the mechanisms leading to Na+ retention in incipient congestive heart failure (CHF) have not been systematically investigated. To investigate renal Na+ handling in the early or mild stages of CHF, Na+ balance and renal clearances were assessed in 10 asymptomatic patients with idiopathic or ischemic dilated cardiomyopathy and mild heart failure (HF) off treatment (left ventricular ejection fraction, 29.7+/-2%) and in 10 matched normal subjects during a diet containing 100 mmol/d of NaCl and after 8 days of high salt intake (250 mmol/d). Six patients were studied again after 6 weeks of treatment with enalapril (5 mg/d P.O.). At the end of the high salt diet, in patients with mild HF the cumulative Na+ balance exceeded by 110 mmol that of normal subjects (F=3.86, P<.001). During high salt intake, renal plasma flow and glomerular filtration rate were similarly increased in both normal subjects and mild HF patients. In spite of comparable increases of filtered Na+ in the two groups, fractional excretion of Na+, fractional clearance of free water, and fractional excretion of K+ (indexes of distal delivery of Na+) increased in normal subjects and were reduced in patients with mild HF. During enalapril treatment, in the mild HF patients the cumulative Na+ balance was restored to normal; furthermore, enalapril significantly attenuated the abnormalities in the distal delivery of Na+. Our results indicate that a defective adaptation of Na+ reabsorption in the proximal nephron is associated with Na+ retention in response to increased salt intake in the early or mild stages of HF. These abnormalities of renal Na+ handling are largely reversed by enalapril.
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Affiliation(s)
- M Volpe
- 1a Clinica Medica, Universita Federico II, Naples, Italy.
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44
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Volpe M, Rao MA, Tritto C, Pisani A, Mele AF, Enea I, Condorelli M. Transition from asymptomatic left ventricular dysfunction to congestive heart failure. J Card Fail 1995; 1:409-19. [PMID: 12836716 DOI: 10.1016/s1071-9164(05)80010-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
One of the main goals of modern management and care of heart failure is to prevent the disease to progress toward congestion and death. The achievement of such an objective may, in fact, guarantee a sufficient quality of life and reduce the exposure of patients to the most common life-threatening complications associated with the congestive stage of the disease. Early identification of left ventricular dysfunction as well as a better knowledge of the mechanisms that favor the progression to more advanced stages of heart failure are fundamental requirements for the proper treatment of asymptomatic heart failure and for preventing the transition to symptomatic and more severe heart failure. The authors reviewed the literature on this topic, with emphasis on a series of studies they performed, to characterize the pathophysiologic profile of mild heart failure and the mechanisms that are possibly involved in the progression to congestive heart failure.
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Affiliation(s)
- M Volpe
- Clinica Medico, University of Federico II, Napoli, Italy
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45
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Volpe M, Rao MA, Cuocolo A, Russo R, Nappi A, Mele AF, Enea I, Trimarco B, Condorelli M. Radionuclide monitoring of cardiac adaptations to volume loading in patients with dilated cardiomyopathy and mild heart failure. Effects of angiotensin-converting enzyme inhibition. Circulation 1995; 92:2511-8. [PMID: 7586352 DOI: 10.1161/01.cir.92.9.2511] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cardiac adaptations to volume overload have been poorly investigated in heart failure. The aim of this study was to assess dynamic left ventricular responses to acute volume loading by continuous radionuclide monitoring in patients with asymptomatic to mildly symptomatic left ventricular dysfunction. METHODS AND RESULTS Left ventricular end-diastolic (EDV) and end-systolic (ESV) volumes, ejection fraction (EF), and peak filling rate (PFR) were monitored by a radionuclide detector (Vest) before and during volume expansion (sodium chloride, 0.9%, 0.25 mL.kg-1.min-1 for 2 hours) in 10 patients with idiopathic dilated cardiomyopathy (DCM) and mild heart failure (New York Heart Association class I or II, ejection fraction < 50%). The patients were studied off treatment and after 6 to 8 weeks of oral treatment with enalapril (5 mg/d). A control group of 11 age- and sex-matched healthy volunteers (N group) was also studied. In the N group, volume loading caused prompt and sustained increases of EDV, EF, and PFR (all P < .001), whereas ESV was progressively reduced (P < .001), and heart rate and blood pressure did not change. In contrast, in DCM, EDV showed a smaller increase than in the N group (two-way ANOVA: F = 5.98, P < .001), ESV increased (P < .001), and EF and PFR remained unchanged. After enalapril, the cardiac adaptations to volume loading were restored to normal. In particular, EDV, EF, and PFR increased (P < .001), and ESV was reduced (P < .001). In 6 additional DCM patients studied before and after 6 to 8 weeks of placebo treatment, left ventricular responses to volume loading remained unchanged. CONCLUSIONS Left ventricular dynamic adaptations to acute volume loading are compromised in patients with idiopathic DCM and mild heart failure. These impaired responses are ameliorated by treatment with enalapril.
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Affiliation(s)
- M Volpe
- Prima Clinica Medica, Federico II University, Naples, Italy
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46
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Volpe M, Rubattu S, Gigante B, Ganten D, Porcellini A, Russo R, Romano M, Enea I, Lee MA, Trimarco B. Regulation of aldosterone biosynthesis by adrenal renin is mediated through AT1 receptors in renin transgenic rats. Circ Res 1995; 77:73-9. [PMID: 7788884 DOI: 10.1161/01.res.77.1.73] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The transgenic (TG) rat (mREN2)27 is characterized by overexpression of the additional mouse Ren-2d gene in the adrenal cortex with marked suppression of renal renin. We have previously shown that in salt-depleted TG rats enhanced activation of mineralocorticoid biosynthesis is associated with selective stimulation of adrenal renin. To investigate whether the local renin-angiotensin system regulates aldosterone biosynthesis in the adrenal cortex of TG rats, we studied the effects of the AT1-angiotensin subtype receptor antagonist DuP 753 on aldosterone production in 5-week-old TG rats during salt restriction. All the rats (n = 56) were shifted from regular chow to a diet containing only 0.04% NaCl for 1 week. The AT1-receptor antagonist DuP 753 (10 mg/kg per day in drinking water) was administered to 27 of these rats during low-salt diet. Subgroups of rats were killed at 0,4, and 7 days. Low-salt diet increased both adrenal renin activity (from 31 +/- 3 to 77 +/- 4 and 85 +/- 2 ng angiotensin I.h-1.mg protein-1 at 4 and 7 days, respectively; P < .001) and mRNA (by 68.4 +/- 10% and 80 +/- 17% from baseline, P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M Volpe
- Department of Internal Medicine, School of Medicine, Federico II University, Napoli, Italy
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47
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Focaccio A, Ambrosio G, Enea I, Russo R, Balestrieri P, Chiariello M, Volpe M. Influence of O2 deprivation, reduced flow, and temperature on release of ANP from rabbit hearts. Am J Physiol 1995; 268:H2352-7. [PMID: 7611487 DOI: 10.1152/ajpheart.1995.268.6.h2352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The separate effects of hypoxia and ischemia on atrial natriuretic peptide (ANP) release were evaluated in Langendorff-perfused rabbit hearts. Heart rate, coronary flow, and atrial and ventricular volumes were kept constant. Hypoxia was induced for 20 min at room temperature in seven hearts and at 37 degrees C in a second group of seven hearts. A third group of eight hearts was subjected to global ischemia for 20 min by reducing coronary flow to 1 ml/min at room temperature. All hearts were reoxygenated/reperfused at 37 degrees C for 30 min. Hypoxia at 37 degrees C induced a significant increase in ANP release. In contrast, both room temperature hypoxia and ischemia were characterized by a significant decrease in ANP release, despite hemodynamic alterations similar to those recorded during hypoxia at 37 degrees C. Both reoxygenation and reperfusion induced a prompt reversal of the changes of ANP release observed during the period of oxygen deprivation. These data demonstrate that decreased oxygen availability and reduced coronary flow are not the primary factors affecting release of ANP during ischemia and that alterations of myocardial temperature may play a major role in this phenomenon.
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Affiliation(s)
- A Focaccio
- Department of Medicine, Federico II School of Medicine, Naples, Italy
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48
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Rubattu S, Enea I, Ganten D, Salvatore D, Condorelli G, Condorelli G, Russo R, Romano M, Gigante B, Trimarco B. Enhanced adrenal renin and aldosterone biosynthesis during sodium restriction in TGR (mREN2)27. Am J Physiol 1994; 267:E515-20. [PMID: 7943299 DOI: 10.1152/ajpendo.1994.267.4.e515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of the study was to investigate the relationships between tissue renin and the steroid production in the adrenal cortex during dietary sodium restriction in the transgenic rat (TGR) (mREN2)27. Thus the effects of a 1-wk low-sodium intake (0.04% NaCl) were studied in 5-wk-old male TGR (n = 33, systolic blood pressure = 151 +/- 3 mmHg) and in 24 age- and sex-matched outbred normotensive Sprague-Dawley (SD) rats. Measurements of plasma and tissue hormones were obtained at 0, 4, and 7 days of a low-sodium diet. Sodium restriction caused sustained increases of adrenal renin activity (from 28.5 +/- 3.5 to 87.5 +/- 4.5 ng.mg protein-1.h-1 on day 7) and of adrenal renin mRNA (+63 +/- 13 and +43 +/- 7% on days 4 and 7, respectively), whereas plasma renin activity (from 3.3 +/- 0.3 to 4.4 +/- 0.6 ng.ml-1.h-1) and renal renin activity (from 0.85 +/- 0.25 to 0.7 +/- 0.4 microgram.mg protein-1.h-1) did not change. The stimulation of the adrenal renin-angiotensin system was associated with a large increase of the aldosterone synthase cytochrome P-450 mRNA (+165 +/- 35 and +184 +/- 44%, on days 4 and 7) and of plasma aldosterone levels (from 125 +/- 32 to 338 +/- 59 pg/ml, P < 0.01). In SD rats, in spite of a more consistent increase in renal and circulating renin, mineralocorticoid production did not increase significantly. These results demonstrate that the exaggerated biosynthesis of aldosterone in TGR during sodium restriction is associated with an activation of renin in the adrenal cortex but not in the kidney.
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Affiliation(s)
- S Rubattu
- Department of Internal Medicine, School of Medicine, Federico II University, Naples, Italy
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49
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Volpe M, Tritto C, Testa U, Rao MA, Martucci R, Mirante A, Enea I, Russo R, Rubattu S, Condorelli GL. Blood levels of erythropoietin in congestive heart failure and correlation with clinical, hemodynamic, and hormonal profiles. Am J Cardiol 1994; 74:468-73. [PMID: 8059727 DOI: 10.1016/0002-9149(94)90905-9] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Plasma levels of erythropoietin (mU/ml) were measured in patients with congestive heart failure (CHF) (n = 108) and in a control group of normal subjects (n = 45). In normal subjects, plasma levels of erythropoietin were 1.9 +/- 0.2. In patients with CHF, plasma levels of erythropoietin increased progressively according to New York Heart Association (NYHA) class (I: 1.4 +/- 0.2, n = 28; II: 5.4 +/- 0.8, n = 27; III: 9.6 +/- 2, n = 32; IV: 34 +/- 8, n = 21; F = 57.7, p < 0.001) and were significantly higher in NYHA classes II, III, and IV than in normal subjects. Plasma erythropoietin significantly decreased (from 43 +/- 14 to 12 +/- 3 mU/ml, p < 0.01) in patients with severe CHF (n = 9) when enalapril (20 mg/day administered orally) was added to long-term treatment for 3 weeks. Finally, in a subgroup of patients with NYHA class IV CHF (n = 9) and high plasma erythropoietin levels (37 +/- 9 mU/ml), packed red blood cell volume, assessed by the iodine-125-albumin dilution method, was higher than that in normal subjects (n = 11) (2,616 +/- 235 vs 2,028 +/- 119 ml, p < 0.05). The present study demonstrates that plasma erythropoietin levels are elevated in a large cohort of patients with CHF of varying etiology, and that this increase is related to the progression of the disease. The increase in circulating erythropoietin is associated with augmented packed red blood cell volume in patients with severe CHF. These results suggest a participation of erythropoietin in the complex neurohormonal response that occurs in CHF.
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Affiliation(s)
- M Volpe
- Department of Internal Medicine, School of Medicine, University of Napoli Federico II, Naples, Italy
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50
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Rubattu S, Volpe M, Enea I, Russo R, Romano M, Trimarco B. Influence of hypercholesterolemia on adrenal steroid metabolism and electrolyte balance in spontaneously hypertensive rats. Endocrinology 1993; 133:2015-21. [PMID: 8404648 DOI: 10.1210/endo.133.5.8404648] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Hypercholesterolemia and hypertension are frequently associated risk factors for cardiovascular diseases. The interactions between hypercholesterolemia and the regulatory mechanisms of blood pressure are poorly understood. In this study we investigated the effects of hypercholesterolemia on salt metabolism and its hormonal control mechanisms in spontaneously hypertensive rats (SHR). Six-week-old SHR were randomly assigned to either a high (1%) cholesterol diet or a matched regular diet for 6 weeks, followed by a 2-week dietary washout. A group of normotensive Wistar-Kyoto rats received the high cholesterol diet and was used as a control. Plasma cholesterol increased significantly (P < 0.001) in both cholesterol-fed SHR and Wistar-Kyoto rats. Blood pressure was unaffected by 6 weeks of a high cholesterol diet. Hypercholesterolemia caused a significant increase in aldosterone (by analysis of variance: F = 8.40; P < 0.01) associated with a significant decrease in corticosterone (F = 4.64; P < 0.05) in the SHR, but not in the normotensive rats. In addition, in the cholesterol-fed SHR, urinary sodium excretion was reduced (P < 0.01), and the urinary potassium/sodium ratio was increased (P < 0.01) compared to those in the remaining groups of rats. The hormonal and urinary differences between the hypertensive subgroups were not detectable after withdrawal of cholesterol. These results demonstrate that diet-induced hypercholesterolemia specifically promotes reversible mineralocorticoid accumulation and sodium retention in SHR.
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Affiliation(s)
- S Rubattu
- Department of Internal Medicine, University of Naples School of Medicine (Federico II), Italy
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