[Gaps in evidence in recent cardiovascular guidelines: uncertainties in chronic coronary syndrome].

The clinical guidelines, while representing an objective reference to perform correct therapeutic choices, contain grey zones, where the recommendations are not supported by solid evidence. In the fifth National Congress Grey Zones held in Bergamo in June 2022, an attempt was made to highlight some of the main grey zones in Cardiology and, through a comparison between experts, to draw shared conclusions that can illuminate our clinical practice. This manuscript contains the statements of the symposium concerning the controversies regarding ischemic cardiomyopathy.

Association between heart and dementia… keep an eye on the left atrium.

Atrial fibrillation is associated with an increased risk of cognitive impairment and dementia. The mechanisms are not well known, but they are probably multifactorial and involve atrial myopathy, cardio-embolism, cerebral hypoperfusion, and comorbidities (systemic vascular sclerosis, disease of the small cerebral vessels, inflammation, etc.).

The older patient with cardiovascular disease: background and clinical implications of the comprehensive geriatric assessment.

Principles and processes of comprehensive geriatric assessment (CGA) are increasingly being applied to subspecialties and subspecialty conditions, including cardiovascular patients (i.e., infective endocarditis; considerations of surgery or transcatheter aortic valve replacement, TAVR, for patients with aortic stenosis; vascular surgery) and postoperative mortality risk.

Role of new drug therapies and innovative procedures in older patients with heart failure: from trials to clinical practice.

During earliest years, new drug-therapies and novel interventional therapies have been tested to modify the detrimental effect of secondary valve diseases, adverse ventricular remodelling and persistent fluid overload in HF patients. However, the increased prevalence of older or very old patients with HF has made their widespread implementation more problematic due to complex comorbidity, frailty, or overt disability. This growing older population, often excluded by randomized trials, but with elevated risk of hospitalization, required a different clinical and management approach that allows clinicians to take full advantage in reducing mortality and morbidity from these new pharmacological and instrumental therapies.

Severe aortic stenosis and transcatheter aortic valve replacement in elderly patients: utility vs. futility.

Recently, transcatheter aortic valve replacement (TAVR) has emerged as established standard treatment for symptomatic severe aortic stenosis, providing an effective, less-invasive alternative to open cardiac surgery for inoperable or high-risk older patients. In order to assess the anticipated benefit of aortic replacement, considerable interest now lies in better identifying factors likely to predict outcome. In the elderly population frailty and medical comorbidities have been shown to significantly predict mortality, functional recovery and quality of life after transcatheter aortic valve replacement.

Evidence and uncertainties in the management of atrial fibrillation in the elderly.

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to most patients affected from AF. Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications.

Hypertension in the elderly: why one size does not fit all.

Over recent years, managing hypertension in older people has gained increasing attention, with reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data.

Relapse of chronic obstructive pulmonary disease and myocardial infarction: what is the connection?

Albeit largely underappreciated, chronic obstructive pulmonary disease (COPD) constitutes a major risk factor for cardiovascular diseases in general and for coronary disease in particular. The incidence of myocardial infarction, in fact increases rapidly, after relapse of COPD, with a peak event rate during the first week in the worst forms (those requiring hospitalization). Even though the precise mechanism is not completely defined, it is likely derived from two pathogenetic causes: (i) mismatch between myocardial demand and offer of O (not fully demonstrated and limited to few cases); (ii) acute coronary thrombosis, probably due to a systemic inflammatory reaction, brought upon by multiple interaction between the infective agent and the host immune system.

Pheochromocytoma presenting as an acute coronary syndrome complicated by acute heart failure: The challenge of a great mimic.

Pheochromocytoma is a rare neuroendocrine tumor with a highly variable clinical presentation. The serious and potentially lethal cardiovascular complications of these tumors are related to the effects of secreted catecholamines. We describe a case of a 50-year-old woman urgently admitted to our hospital because of symptoms and clinical and instrumental findings consistent with an acute coronary syndrome complicated by acute heart failure.

Aspirin use for primary prevention in elderly patients.

The net clinical benefit of aspirin in primary prevention is uncertain as the reduction in occlusive events needs to be balanced against the increase in gastro-intestinal and cerebral bleedings. The meta-analysis of ATT (Anti Thrombotic Trialists) Collaboration in 2009 showed that aspirin therapy in primary prevention was associated with 12% reduction in cardio-vascular events, due mainly to a reduction in non-fatal myocardial infarction (0.18% vs 0.

Myocardial infarction and rupture after bronchial artery embolization.

Bronchial artery embolization is a well-known treatment for hemoptysis. Adverse events of this procedure include multiple systemic embolism and infarction. Myocardial infarction has been recently reported during bronchial artery embolization, owing to the presence of a coronary-to-bronchial artery fistula.

[The serotonin syndrome: why should cardiologists be aware and scared of it].

The serotonin syndrome (SS) represents a life-threatening adverse drug reaction, caused by serotonin overload in the central and peripheral nervous system, producing autonomic instability, neuromuscular and cardiovascular abnormalities, and cognitive alterations. The incidence of SS has been growing over the last few years, as a consequence of population aging and the steadily increasing use of pro-serotoninergic agents in clinical practice, in the presence of various comorbidities, mainly cardiovascular. Cardiologists often use combination therapies including serotoninergic agents, and should therefore consider the risk of serotoninergic adverse events caused by inappropriate drug interactions.

[Polytherapy and polypharmacy in elderly patients with chronic heart failure].

Population aging is associated with an increasing prevalence of chronic diseases (including chronic heart failure) and comorbidities (the presence of one or more diseases in addition to an index disease, potentially contributing to disability) which, in turn, expands the need for healthcare services. Therefore, the already elevated costs in the National Health Services are expected to rise further over the next decades, along with increasing aging of the population. This epidemiologic trend is responsible for the increasing occurrence of polytherapy (multiple medications prescribed to an individual patient) and polypharmacy (multiple medications not directly prescribed by a physician).

[Statins and the "Cabala": the new Note 13].

The new Note 13 introduces significant changes in the regulation of statin reimbursement. Although cardiovascular risk assessment still plays a key role, cardiovascular risk estimation has shifted from the "risk charts" to the more simple "sum of risk factors". In addition, the new Note 13 expands drug reimbursement to subjects at intermediate risk, who represent the main source of cardiovascular events because of the size of the population.

Simultaneous analysis of kynurenine and tryptophan in human plasma by capillary electrophoresis with UV detection.

Plasma kynurenine (Kyn)/tryptophan ratio has been proposed as a useful marker for the monitoring activation of the cellular immune system. Here, we describe an easy capillary electrophoresis method with UV detection for the separation and detection of Kyn and tryptophan in human plasma using methltryptophan as internal standard. The plasma samples were simply treated with acentonitrile for the elimination of proteins, the supernatant was evaporated, and the dried sample was resuspended with water and directly injected on the capillary without sample derivatization procedures.

Low density lipoprotein S-homocysteinylation is increased in acute myocardial infarction patients.

Objectives: We have investigated on the levels of homocysteine linked to LDL in acute myocardial infarction patients.

Design And Methods: We used capillary electrophoresis to measure LDL-bound thiols in 16 AMI individuals and 32 healthy volunteers.

Results: We found a significant increase of apo-B homocysteine and cysteine levels in LDL fraction of AMI subjects.

A double left anterior descending coronary artery emerging from the right Valsalva sinus: a case report and a brief literature review.

Anomalies of the coronary artery are incidentally detected during coronary angiography and are seldom found in daily clinical practice. In the reported studies, the incidence ranges from 0.6 to 1.

Coronary collateral for left anterior descending coronary artery from a developed right ventricular branch arising from the right sinus of Valsalva.

A 65-year-old man with stable angina refractory to medical therapy and with a low-threshold myocardial ischemia at ECG stress testing was referred for coronary angiography. The coronary angiogram showed an ostial subocclusive stenosis of a developed first diagonal branch located just upstream of a subocclusive stenosis of the mid left anterior descending (LAD) coronary artery, occluded distally, and a coronary collateral for LAD from a developed right ventricular branch arising with separate ostia from the right sinus of Valsalva. We discuss the diagnostic interpretation of this coronary anomaly and some aspects regarding the percutaneous treatment of bifurcations.