Background and Methods Aldosterone is important in the pathophysiology of heart failure. In a double-blind study, we enrolled 1663 patients who had severe heart failure and a left ventricular ejection fraction of no more than 35 percent and who were being treated with an angiotensin-converting–enzyme inhibitor, a loop diuretic, and in most cases digoxin. A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily, and 841 to receive placebo. The primary end point was death from all causes. Results The trial was discontinued early, after a mean follow-up period of 24 months, because an interim analysis determined that spironolactone was efficacious. There were 386 deaths in the placebo group (46 percent) and 284 in the spironolactone group (35 percent; relative risk of death, 0.70; 95 percent confidence interval, 0.60 to 0.82; P<0.001). This 30 percent reduction in the risk of death among patients in the spironolactone group was attributed to a lower risk of both death from prog...

https://www.nejm.org/doi/pdf/10.1056/NEJM199909023411001

The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.

Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk S2

The goals of the …

/pdf/2013-acc-aha-guideline-on-the-treatment-of-blood-cholesterol-pvngcav7fq.pdf

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

ACC/AHA
: American College of Cardiology/American Heart Association
ACCF/AHA
: American College of Cardiology Foundation/American Heart Association
ACE
: angiotensin-converting enzyme
ACEI
: angiotensin-converting enzyme inhibitor
ACS
: acute coronary syndrome
AF
: atrial fibrillation

/pdf/2016-esc-guidelines-for-the-diagnosis-and-treatment-of-acute-53v7yllhiz.pdf

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins.

ALAT
: alanine aminotransferase
ASAT
: aspartate aminotransferase
APAH
: associated pulmonary arterial hypertension
BAS
: balloon atrial septostomy
BMPR2
: bone morphogenetic protein receptor 2
BNP
: brain natriuretic peptide
BPA
: balloon pulmonary angioplasty
BREATHE
: Bosentan

/pdf/2015-esc-ers-guidelines-for-the-diagnosis-and-treatment-of-y26yabnnom.pdf

2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT).

The diagnostic accuracy of transesophageal echocardiography and its relevance on the decision making process were evaluated in 80 patients with suspected aortic dissection during a 37-month period. The diagnosis was proven by aortography and/or magnetic resonance and/or computerized tomography and/or surgery and/or autopsy in each case. Transesophageal echocardiography had no serious complication. A correct diagnosis of aortic dissection was made in 39 of 40 patients (sensitivity, 97.5%; specificity, 100%) and the type of dissection was correctly demonstrated in each case. Thrombi in the false lumen were detected in 16 patients. The primary entry site was correctly identified in 33 patients (85%). Aortic regurgitation was detected in 25 cases (severe in 9) and pericardial effusion in 14 (with tamponade in 2). Transesophageal echocardiography was more accurate than aortography in the diagnosis of noncommunicating intramural dissection (2 cases) and identified more precisely the retrograde extension of the dissection in DeBakey type III patients (4 cases). In 9 cases surgical indication was based on clinical data and transesophageal echocardiography alone. We conclude that transesophageal echocardiography allows a bedside, safe and accurate diagnosis of aortic dissection. In the majority of the patients it provides the minimal diagnostic information necessary to the therapeutical decision making.

Role of transesophageal echography in the diagnosis of aortic dissection and in therapy programming

Ittero colestatico a comparsa ritardata dopo trattamento per un mese con ticlopidina

Subacute stent thrombosis and hemorrhagic complications due to intensive anticoagulant therapy limit the clinical benefit of coronary stenting. Antithrombotic therapy after coronary stent placement has not been standardized yet. From January 1994 to December 1995 a total of 338 Palmaz-Schatz stents were implanted in 285 patients. Procedural success rate was 98.8%. In the initial period, after stent placement, patients were treated with acetylsalicylic acid (ASA) and warfarin (135 patients, Group A), while subsequently, according to the results of other studies, patients were treated with ASA plus ticlopidine (146 patients, Group B). Two hours after sheath removal, Group A patients were treated with intravenous heparin until therapeutic INR (2.5-3.5) was reached; warfarin was stopped 3 months later. In Group B patients 2 hours after sheath removal a treatment with subcutaneous heparin 25,000 IU/die plus ticlopidine 500 mg/die was started. Subcutaneous heparin was maintained until hospital discharge, ticlopidine was stopped after 1 month and ASA was maintained indefinitely. There were no significant differences in baseline characteristics between the two groups. Most patients had unstable angina and in the majority of cases the stent was implanted due to intimal dissection after balloon dilation. Eleven patients had subacute thrombosis of the stent (3.9%): 9 patients were in Group A (6%) and 2 patients were in Group B (1.3%; p = 0.04). Seven patients (6 in Group A, 1 in Group B) were treated with emergency coronary angioplasty and 3 (2 in Group A, 1 in Group B) with coronary bypass; nevertheless 7 patients (6 in Group A, 1 in Group B) had an acute myocardial infarction. Eight patients (6 in Group A, 2 in Group B) had major bleeding due to a large groin hematoma requiring blood transfusion or vascular surgery. In conclusion, after coronary stenting antithrombotic therapy with ASA plus ticlopidine, as compared with anticoagulant therapy, reduces the incidence of both cardiac events and hemorrhagic complications.

Antithrombotic therapy after coronary stent placement

A series of antiarrhythmic agents have been demonstrated to be highly effective in terminating recent-onset atrial fibrillation, class IC agents being the most effective [1, 2]. In contrast with the high efficacy shown in treating recent-onset atrial fibrillation, results obtained in preventing recurrences of atrial fibrillation are scanty [3–6]. Table 1 summarizes reported data from the literature. As shown, the percentage of patients who maintain sinus rhythm without arrhythmia recurrence under placebo treatment is around 30% after 3–6 months and around 20%–25% after 12 months. Antiarrhythmic agents may increase the percentage of patients who maintain sinus rhythm, but the overall efficacy is limited and, except for amiodarone, no more than 50% of the treated patients are free from arrhythmia recurrences after 6–12 months. For amiodarone, efficacy rates of 75%–78.5% at 6 months and of 50%–73% at 12 months have been reported.

Which Is the Ideal Drug for Chronic Prophylaxis of Atrial Fibrillation

Primary angioplasty (P-PCI) is the preferred treatment of patients with ST-segment elevation myocardial infarction (STEMI) in both American and European guidelines. The reason for this preference is the evidence that the mechanical approach improves coronary patency, TIMIflow rates and ultimately the overall survival. Nevertheless, P-PCI has its own drawbacks: it needs skill and must be delivered in a timely fashion (two contrasting requirements, in that skill is linked to activity volume which, in turn, decreases along with catheterization laboratories proliferation); not to mention the costs. So far, in no single study has P-PCI been shown to reduce mortality, a goal whose achievement has been suggested only in an overview of small trials. Moreover, the advantage fades when P-PCI is compared with contemporary lytic regimens [1]. Therefore, it may be asked whether this apparent small advantage of P-PCI may be generalized to the real world. Indeed, it has been recognized for a long time that trials show what can be accomplished under careful observation and certain restricted conditions. The same results may not invariably or necessarily be observed when the treatment passes into general use. The above considerations have stimulated the establishment of registries, which are supposed to monitor treatment quality by providers. The overview of Italian registries (BLITZ-1, MISTRAL, VENERE, GESTIMA and PRIMA) shows that there is no difference in mortality between P-PCI and thrombolysis (7.0 vs 6.8%, P = NS). Registries show interesting data, worth discussing in the scientific community, but usually are flawed by the voluntary nature of data entry and, often, by the lack of an audit process. As a result, outcomes in registries are in between those observed in trials and those taking place in the real world. Balzi et al. [2] should be congratulated for their excellent work, describing in detail the way STEMI patients are managed in the Florence health district (years 2000–2001). Not only they have collected all relevant clinical data, but they have also cross-checked the registry patients with patients showing a discharge ICD9-CM 410 code in the same area. Data pertaining to those patients discharged with a 410 code who had not been entered in the registry, were submitted to an audit process before final entry. The most interesting finding of the study is the low reperfusion rate (with either P-PCI or thrombolysis): 54.4% overall, 71% among patients less than 65 years old, 60% for those 65–74 years old, 43% in the 75–84 age range and 31% for those patients 85 or more years old. It is not clear what was the reason for such a low reperfusion yield. The Florence health district is a busy area, well equipped in transportation facilities, with a short distance from spoke to hub hospitals, and with a good catheter laboratory available on a 24-h basis. Multivariable analysis identified age and co-morbidities as important constraints upon reperfusion, but also the type of hospital was strongly associated with the probability of reperfusion. Being admitted to the hospital where P-PCI was available increased 5-fold the probability of reperfusion. It may be concluded that the perception of the importance of reperfusion is different in spoke versus hub hospitals, particularly for those higher-risk patients with advanced age and co-morbidity. G. Melandri (&) F. Semprini S. Nanni D. Calabrese F. Vagnarelli A. Branzi Dipartimento Cardio-Toraco-Vascolare, Istituto di Cardiologia, Policlinico S.Orsola, via Massarenti 9, 40138 Bologna, Italy e-mail: giovanni.melandri@aosp.bo.it

Angelo Branzi

Papers

Role of transesophageal echography in the diagnosis of aortic dissection and in therapy programming

Ittero colestatico a comparsa ritardata dopo trattamento per un mese con ticlopidina

Antithrombotic therapy after coronary stent placement

Which Is the Ideal Drug for Chronic Prophylaxis of Atrial Fibrillation

STEMI management: trials, registries, and the real world.