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Article ; Online: Secondary cardiovascular prevention in clinical practice

Gian Francesco Mureddu

Monaldi Archives for Chest Disease, Vol 89, Iss

what do we need today?

2019 Volume 3

Abstract: In the last decades, the post-hospital mortality from coronary artery disease (CAD) has significantly increased. This new trend in the epidemiology of CAD has been largely attributed to the improvement of survival from acute coronary syndromes that ... ...

Abstract	In the last decades, the post-hospital mortality from coronary artery disease (CAD) has significantly increased. This new trend in the epidemiology of CAD has been largely attributed to the improvement of survival from acute coronary syndromes that generated increasing incidence of population at high risk of recurrences and rehospitalization for major adverse cardiovascular events (MACE) and heart failure (HF). Thus, much longer after the acute event than we had thought, we have now been facing with higher complexity of “chronic” CAD phenotypes which deserve high clinical attention and more and more intricate pharmacological management. Although the guidelines recommend implementing secondary prevention programs through cardiac rehabilitation (CR) facilities in order to achieve a better outcome, i.e. decreased morbidity, re-hospitalization and increased adherence to evidence-based interventions, the referral rate to CR is paradoxically scarce. The Italian Association of Clinical Preventive Cardiology and Rehabilitation (AICPR) has been launching a survey involving the Network of Italian CR centers, which will make possible to observe trends, implement guidelines recommendations and then verify the effectiveness of the interventions and outcomes in post-acute and chronic CAD.
Keywords	Cardiac rehabilitation ; preventive cardiology ; term cardiovascular risk ; Medicine ; R
Subject code	610
Language	English
Publishing date	2019-09-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Arterial hypertension. Does the J curve exist? And then?

Gian Francesco Mureddu

Monaldi Archives for Chest Disease, Vol 88, Iss

2018 Volume 2

Abstract: The concept that ‘the lower the blood pressure (BP) achieved the better the outcome’ rests on the demonstration of a direct relationship between BP and incident outcomes, down to levels of 115 mmHg of systolic BP (sBP) and 75 mmHg of diastolic BP (dBP) ... ...

Abstract	The concept that ‘the lower the blood pressure (BP) achieved the better the outcome’ rests on the demonstration of a direct relationship between BP and incident outcomes, down to levels of 115 mmHg of systolic BP (sBP) and 75 mmHg of diastolic BP (dBP) carried out in 1 million individuals from 61 cohorts recruited between 1950 and 1990 and followed for about 14 years. The alternative to the ‘lower the better’ concept is the hypothesis of a J-shaped relationship, according to which the benefits of reducing sBP or dBP to low values may be dangerous leading even to an increase in total mortality and/or in CV outcomes. Data from contemporary epidemiologic observations, (CALIBER study), showed that the relationships between rising BP and increased incidence of outcomes rise continuous even over 85 years of age without the evidence of a J-shaped association with any of the outcomes at any age strata. In the English Longitudinal Study of Ageing study (ELSA), a tailored analysis for octogenarians showed that the increase in mortality rates associated with BP ranges appears at sBP <110 mmHg and ≥170 mmHg. In randomized controlled trials (SPRINT, HYVET and INVEST), the J curve seems to concern mainly patients with an extensive atherosclerotic burden, rather than. An impaired autoregulation of coronary blood flow (CBF) leading to a fall in diastolic BP and resulting in a lowering in the perfusion pressure distal to the epicardial coronary artery stenosis, can eventually lead to myocardial ischemia. Diastolic dysfunction can concur in worsening CBF in diastole. These features are often seen in elderly patients with heart failure with preserved ejection fraction. The steeper position of the slope of the end-systolic elastance can lead to dramatic increases and decreases in BP for the same change in afterload or preload. This may explain why elderly hypertensives are more prone to suffer of hypertensive crisis and/or hypotension than younger hypertensives. “Pseudo-hypertension” caused by structural sclerotic changes in the ...
Keywords	Arterial hypertension ; elderly people ; blood pressure targets ; excess mortality ; Medicine ; R
Subject code	610
Language	English
Publishing date	2018-06-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Utility and limitations of ejection fraction and of diastolic dysfunction in heart failure patients

Gian Francesco Mureddu / Andrea Faggiano

Monaldi Archives for Chest Disease, Vol 89, Iss

2019 Volume 1

Abstract: The echocardiographic evaluation of left ventricular (LV) systolic function, and especially of ejection fraction (EF) plays a central role in the diagnosis of heart failure (HF) due to its undisputed prognostic value. Limitations of EF are substantially: ...

Abstract	The echocardiographic evaluation of left ventricular (LV) systolic function, and especially of ejection fraction (EF) plays a central role in the diagnosis of heart failure (HF) due to its undisputed prognostic value. Limitations of EF are substantially: i) the variability and reproducibility of measurements, and ii) the load-dependence. Measurement of stroke volume, longitudinal function and myocardial strain can overcome the limitations of EF in assessing the contractile reserve of patients with HF and may help to define both the phenotype and prognosis of the disease. The recognition of diastolic dysfunction (mainly by echocardiography) is the pathophysiological basis to make diagnosis of HF with preserved ejection fraction (HFpEF). The limitations are essentially related to its feasibility, since performing a multi-parametric quantitative echocardiographic evaluation, as indicated by the guidelines, may be difficult in clinical practice. Difficulties in method standardization, the poor attitude of cardiologists to test their reproducibility (test-retest, variability) favor the evaluation “at-a-glance” of LV structural and functional LV abnormalities.
Keywords	Ejection fraction (EF) ; heart failure (HF) ; diastolic dysfunction ; preserved EF ; mid-range EF ; Medicine ; R
Subject code	610
Language	English
Publishing date	2019-04-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Current multivariate risk scores in patients undergoing non-cardiac surgery

Gian Francesco Mureddu

Monaldi Archives for Chest Disease, Vol 87, Iss

2017 Volume 2

Abstract: Several indexes to predict perioperative cardiovascular risk have been proposed overtime. The most widely used is the Revised Cardiac Risk Index (RCRI) developed by Lee since 1999. It predicts major cardiac outcomes from five independent clinical ... ...

Abstract	Several indexes to predict perioperative cardiovascular risk have been proposed overtime. The most widely used is the Revised Cardiac Risk Index (RCRI) developed by Lee since 1999. It predicts major cardiac outcomes from five independent clinical determinants: history of ischemic heart disease, history of cardiovascular disease, heart failure, insulin-dependent diabetes mellitus, and chronic renal failure (i.e. serum creatinine >2 mg/dl). In external validation studies, the RCRI showed high negative predictive value in all groups of age, indicating that it may be used to identify people at low risk for perioperative adverse cardiovascular events in noncardiac surgery. However its accuracy is suboptimal in many clinical settings. More recently the National Surgical Quality Improvement Program database) (NSQIP) hasdeveloped a new index to predict perioperative myocardial infarction (MI) or cardiac arrest (MICA) from a cohort of 211,410 patients (the Gupta index) and afterwards a universal surgical risk estimation tool has been developed, using standardized clinical data from 393 ACSNSQIP hospitals in US (a cohort based on 1,414,006 patients), showing a good performance for mortality (C-statistic = 0.944) and morbidity (C-statistic =0.816) as compared with procedure-specific models. Other risk scores include the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION), which has evaluated cardiac complications in 15,065 patients, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the large Preoperative Score to Predict Postoperative Mortality (POSPOM) that was built up from data collected in the National Hospital Discharge Data Base (NHDBB) including a cohort of 7.059.447 patients. In Italy a new risk index (the Orion score) builkt up from a cohort of 9000 patients generated four classes of major cardiovascular adverse events perioperative risk ranging from 1 (0.6%); 2 (2.4%); 3 (7.4%) and 4 (23.1%). The AUROC curves showed higher accuracy ...
Keywords	Noncardiac surgery ; cardiac complications ; 30-day mortality ; risk predictions ; myocardial injury ; Medicine ; R
Subject code	610
Language	English
Publishing date	2017-07-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Arterial hypertension

Gian Francesco Mureddu

Monaldi Archives for Chest Disease, Vol 84, Iss 1-

which targets in over-75-year people?

2016 Volume 2

Abstract: Arterial hypertension has always been considered the main risk factor in cardiovascular prevention. However, the goals of anti-hypertensive treatment (targets) in the elderly has long been under discussion. The results of the studies in favor of the ... ...

Abstract	Arterial hypertension has always been considered the main risk factor in cardiovascular prevention. However, the goals of anti-hypertensive treatment (targets) in the elderly has long been under discussion. The results of the studies in favor of the hypothesis "the lower the better" than those that argue against the existence of the phenomenon of the J-curve, that is, the hypothesis according to which mortality increases to too low pressure values lower than 115/75 mmHg, are still controversial. However, in elderly patients the association between blood pressure lowering and increased cardiovascular events seems to depend on the general health status, that means the presence of comorbidity, frailty and / or disability. Recent data from the SPRINT study show that the benefit of an intensive blood pressure target (SBP <120 mmHg) compared to a usual target (SBP <140 mmHg), appears to be greater in the oldest hypertensive patients (≥75 years). The cardio-geriatric functional assessment can provide useful information to better stratify the elderly and to define more accurately the pressure targets, the choice is individual. Riassunto L’ipertensione arteriosa è da sempre considerata il fattore di rischio centrale in prevenzione cardiovascolare. Tuttavia gli obbiettivi del trattamento anti-ipertensivo (target pressori) nei soggetti anziani è da molti anni oggetto di discussione. Il risultati degli studi a favore dell’ipotesi “the lower the better” rispetto a quelli contrari che sostengono l’esistenza del fenomeno della cosiddetta curva J, l’ipotesi cioè secondo la quale la mortalità aumenta per valori di pressione troppo bassi, inferiori a 115/75 mmHg, sono tutt’ora controversi. Tuttavia in pazienti anziani l’associazione tra riduzione dei valori di pressione arteriosa e aumento degli eventi cardiovascolari sembra dipendere dallo stato di salute generale, ovvero alla presenza di comorbidità, fragilità e/o disabilità. I recenti dati dello studio SPRINT. Mostrano che il beneficio di un target pressorio intensivo ...
Keywords	High blood pressure ; blood pressure targets ; elderly ; comorbidity ; frailty ; geriatric assessment ; Medicine ; R
Language	English
Publishing date	2016-06-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: COVID-19 pandemic

Carlo Vigorito / Pompilio Faggiano / Gian Francesco Mureddu

what consequences for cardiac rehabilitation?

2020

Abstract: The ongoing COVID-19 pandemic spreading all around the world has stressed over its capabilities and determined profound changes in the health systems in all countries and has caused hundreds of thousand deaths. Health professionals have been called to a ... ...

Abstract	The ongoing COVID-19 pandemic spreading all around the world has stressed over its capabilities and determined profound changes in the health systems in all countries and has caused hundreds of thousand deaths. Health professionals have been called to a tremendous effort to deal with this emergency, often contaminating or succumbing themselves to the disease.
Keywords	COVID-19 ; Pulmonary and Respiratory Medicine ; Cardiology and Cardiovascular Medicine ; covid19
Language	English
Publishing date	2020-04-01
Publishing country	it
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: COVID-19 pandemic

Carlo Vigorito / Pompilio Faggiano / Gian Francesco Mureddu

Monaldi Archives for Chest Disease, Vol 90, Iss

what consequences for cardiac rehabilitation?

2020 Volume 1

Abstract	The ongoing COVID-19 pandemic spreading all around the world has stressed over its capabilities and determined profound changes in the health systems in all countries and has caused hundreds of thousand deaths. Health professionals have been called to a tremendous effort to deal with this emergency, often contaminating or succumbing themselves to the disease.
Keywords	COVID-19 ; pandemic ; cardiac rehabilitation ; Medicine ; R ; covid19
Language	English
Publishing date	2020-04-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Preoperative evaluation before non cardiac surgery in subjects older than 65 years

Gian Francesco Mureddu / Pompilio Faggiano / Francesco Fattirolli

Monaldi Archives for Chest Disease, Vol 82, Iss

2015 Volume 1

Abstract: Non cardiac surgery is becoming increasingly common in elderly patients; they are usually affected by overt cardiac disease or show multiple risk factors, responsible for a higher incidence of perioperative fatal or nonfatal cardiac events. Of interest, ... ...

Abstract	Non cardiac surgery is becoming increasingly common in elderly patients; they are usually affected by overt cardiac disease or show multiple risk factors, responsible for a higher incidence of perioperative fatal or nonfatal cardiac events. Of interest, acute myocardial infarction occurring in the perioperative period shows a high mortality rate in people over 65 years old. The cardiovascular risk stratification and perioperative management of subjects undergoing noncardiac surgery have been recently updated in the 2014 European Society of Cardiology Guidelines. However, several critical points still lack of strong evidence and are based on expert opinions only. For example, the use of drugs, such as betablockers, before, during and after the surgery, presents many uncertainties regarding the selection of patients more likely to benefit, dosage and duration of therapy, and effects on outcome. Data on elderly patients undergoing non cardiac surgery are scarce. Accordingly, a prospective registry enrolling a large number of aged subjects undergoing non cardiac surgery (particularly at high or intermediate risk) should be able to give us adequate insights on the management strategies currently used, on the incidence of death or cardiovascular events in the postoperative period and on the areas of potential improvement in care. Furthermore, the effects on outcome of structured programs of Guidelines implementation in the clinical practice of cardiologists, anesthesiologists and other health personnel involved in perioperative care, could be positive and should be evaluated.
Keywords	non cardiac surgery ; perioperative management ; risk stratification ; elderly ; Medicine ; R
Subject code	610
Language	English
Publishing date	2015-08-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Cardiovascular risk prediction in the real world. The discouraging evidences coming from literature

Gian Francesco Mureddu / Pompilio Faggiano / Fausto Rigo

Monaldi Archives for Chest Disease, Vol 78, Iss

2015 Volume 4

Abstract: Risk prediction plays a leading role in cardiovascular (CV) prevention. Thus, several risk charts have been developed in different Countries in the attempt to identify subjects at high risk who might benefit from more aggressive and early interventions. ... ...

Abstract	Risk prediction plays a leading role in cardiovascular (CV) prevention. Thus, several risk charts have been developed in different Countries in the attempt to identify subjects at high risk who might benefit from more aggressive and early interventions. However despite the availability of several risk charts, they are underutilized in clinical practice. Indeed risk charts show main limitations: they estimate absolute, but not individual risk; their performance is affected by changes on the incidence of CV diseases; they do not take into account the duration of risk exposure, which is related to the progression of atherosclerosis. Moreover, risk estimate might be less accurate in younger, in women, and in the elderly. Addition of novel risk markers have substantially failed to improve risk charts’ discrimination power. Imaging has recently gained relevance in CV risk stratification for its ability to detect subclinical atherosclerosis. Among imaging techniques coronary artery calcium score(CACS) emerged as the most powerful and independent predictor of CV events. Hence, a CACSbased screening strategy have been proposed in all asymptomatic middle-aged people. However since CACS it is still quite expensive and not-radiation free, it is not recommended by most scientific guidelines. Conversely, detecting subclinical organ damage (SOD) like LV hypertrophy, carotid plaque, renal failure, microalbuminuria or the metabolic syndrome in subjects at intermediate risk is pretty cost-effective yielding to reclassification of subjects into higher-risk strata. Thus, merging information coming from different tools (risk scores, biomarkers, and non-invasive imaging) individual risk might be better stratified saving costs. In the next future, an integrated, semi-automated, high-reproducible and inexpensive ultrasound approach could represent a key point to approach the individual risk.
Keywords	cardiovascular prevention ; CV risk prediction and stratification ; subclincal organ damage ; non-invasive imaging ; Medicine ; R
Subject code	332 ; 610
Language	English
Publishing date	2015-12-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: High thrombotic risk increases adverse clinical events up to 5 years after acute myocardial infarction. A nationwide retrospective cohort study

Gian Francesco Mureddu / Cesare Greco / Stefano Rosato / Paola D'Errigo / Leonardo De Luca / Gabriella Badoni / Pompilio Faggiano / Fulvia Seccareccia

Monaldi Archives for Chest Disease, Vol 89, Iss

2019 Volume 3

Abstract: The risk of recurrent events among survivors of acute myocardial infarction (AMI) is understudied. The aim of this analysis was to investigate the role of residual high thrombotic risk (HTR) as a predictor of recurrent in-hospital events after AMI. This ... ...

Abstract	The risk of recurrent events among survivors of acute myocardial infarction (AMI) is understudied. The aim of this analysis was to investigate the role of residual high thrombotic risk (HTR) as a predictor of recurrent in-hospital events after AMI. This retrospective cohort study included 186,646 patients admitted with AMI from 2009 to 2010 in all Italian hospitals who were alive 30 days after the index event. HTR was defined as at least one of the following in the 5 years preceding AMI: previous myocardial infarction, ischemic stroke/other vascular disease, type 2 diabetes mellitus, renal failure. Risk adjustment was performed in all multivariate survival analyses. Rates of major cardiac and cerebrovascular events (MACCE) within the following 5 years were calculated in both patients without fatal readmissions at 30 days and in those free from in-hospital MACCE at 1 year from the index hospitalization. The overall 5-year risk of MACCE was higher in patients with HTR than in those without HTR, in both survivors at 30 days [hazard ratio (HR), 1.49; 95% confidence interval (CI), 1.45-1.52; p<0.0001] and in those free from MACCE at 1 year (HR, 1.46; 95% CI, 1.41-1.51; p<0.0001). The risk of recurrent MACCE increased in the first 18 months after AMI (HR, 1.49) and then remained stable over 5 years. The risk of MACCE after an AMI endures over 5 years in patients with HTR. This is also true for patients who did not have any new cardiovascular event in the first year after an AMI. All patients with HTR should be identified and addressed to intensive preventive care strategies.
Keywords	Acute myocardial infarction ; high thrombotic risk ; MACCE ; long-term mortality ; trend ; Medicine ; R
Subject code	610
Language	English
Publishing date	2019-11-01T00:00:00Z
Publisher	PAGEPress Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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