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Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a “shock team” consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61–80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1–8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Heart failure is a syndrome with a high clinical and healthcare impact. Currently, the incidence in Europe is approximately 5/1000 people/year in the adult population, with a prevalence of 1-2%. The prognosis is burdened by a still high mortality and hospitalization rate. The phase immediately following the hospitalization is defined as the \"vulnerable period\" because it is characterized by the greatest number of clinical events: 30% risk of rehospitalization and 10% risk of death. Taking care of the patients in this phase is crucial and must be accompanied by a risk stratification process, essential for planning a follow-up that is as personalized as possible, also necessary for resource optimization. In the chronic phase of the disease, risk stratification appears similarly important, as it could represent a support tool in the patient's transition from hospital to the community. The aims of this paper are to review the recommendations for the follow-up of the European and American guidelines, describe the tools available to the clinician to stratify the prognosis and diversify the pathway, and finally hypothesize a follow-up scheme both in the post-acute and chronic phases.

Chronic kidney disease, diabetes mellitus and heart failure represent three chronic conditions closely linked to each other from a pathophysiological and prognostic point of view. This link has led to an ever-increasing emphasis in recent years on the need for a holistic approach to patients who are affected by optimizing the therapeutic management of what has recently been defined as cardio-kidney-metabolic syndrome. The cardiorenal and metabolic approach has gained relevance thanks to recent studies on new drug classes. Initially in diabetic patients and later in those suffering from heart failure and chronic kidney disease, these new drugs have demonstrated their effectiveness in reducing cardiovascular risk, the progression of heart failure and chronic kidney disease. This review aims to address the main pharmacological aspects of two of these new classes, that of sodium-glucose co-transporter 2 inhibitors and the more recent one of non-steroidal mineralocorticoid receptor antagonists.

Home-based inotropic therapy represents a therapeutic strategy in patients with advanced heart failure (AdvHF), both for a bridge to life-saving treatments such as heart transplant or ventricular assist devices and for palliative care in patients not eligible for these therapeutic options. In this review, we explore the role of home-administered inotropes, specifically dobutamine, milrinone, dopamine, and levosimendan, in the management of AdvHF patients through a summary of current literature and the presentation of management models adopted in selected Italian centers. Reported experiences suggest improved quality of life, reduced hospital admissions, and enhanced clinical stability in patients with AdvHF. These models may serve as practical examples for organizing care pathways in a clinical context that remains poorly defined by current guidelines.

Despite the wealth of evidence in favour of SGLT2 inhibitor use in patients with chronic heart failure, their role in the very early stages of heart failure is still unclear. While the latest update of the European Society of Cardiology guidelines on heart failure advocates the use SGLT2 inhibitors in the acute phases of heart failure based on the results of the latest trials, it does not clarify the appropriate timing to start this therapy, leaving the clinician to decide whether SGLT2 inhibitors should be started directly during hospitalization or at discharge. Conversely, the recently published focused update of the American College of Cardiology expert consensus decision pathway on the clinical assessment, management, and trajectory of patients hospitalized with heart failure clearly supports the safety and early clinical benefit use of SGLT2 inhibitors based on evidence coming from the EMPULSE and SOLOIST-WHF trials. The expert consensus decision pathway states that SGLT2 inhibitors can be initiated regardless of left ventricular ejection fraction at any time during hospitalization and places a greater emphasis on implementing the other pillars of therapy for heart failure with reduced ejection fraction after stabilization. Moreover, the results of the very recent DAPA ACT HF–TIMI 68 trial on dapagliflozin in patients with acute heart failure, although limited by a follow-up of only 2 months, did not show a reduction in mortality or heart failure hospitalizations. Based on the currently available published data, we will review what is already known about the use of these drugs in the early phases of acute heart failure and analyze their pathophysiological rationale from a practical perspective.

Heart failure (HF) is a clinical syndrome with high morbidity and mortality, characterized by periods of relative clinical stability and exacerbations of HF, known as worsening heart failure (WHF). WHF is currently defined as a deterioration of HF signs and symptoms, necessitating an intensification of medical therapy, often identified by an increase in diuretic therapy. Episodes of WHF, whether they result in patient hospitalization or outpatient management, suggest clinical progression of HF with significant worsening of the prognosis. Although the prognostic impact of WHF is well documented in the literature, its current definition has limitations, and its management remains suboptimal and non-standardized, particularly in outpatient settings. Additionally, early detection of WHF episodes, preventing possible patient hospitalization, is crucial for improving prognosis and is still underemphasized in major HF clinical trials. This review aims to report the prevalence of WHF and the limitations of its current definition, and to provide suggestions for the appropriate management of WHF episodes, with a special focus on early and outpatient recognition.

Mineralocorticoid receptor antagonists (MRAs) represent one of the cornerstones of treatment for heart failure with reduced ejection fraction. Post-hoc data from the TOPCAT trial, conducted in patients with heart failure mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), suggest the possible clinical benefit of MRAs, particularly for slightly reduced ejection fraction values. The advent of non-steroidal MRAs, including finerenone, seems to represent a turning point in the treatment for HFmrEF/HFpEF. The favorable results of the trials conducted with finerenone in diabetic patients with chronic kidney disease suggested that this MRA might indeed improve outcomes in HFmrEF and HFpEF, considering that these comorbidities are strongly represented in this patient population. The anti-fibrotic and anti-inflammatory effects of finerenone represents the pathophysiological background for benefit in these patients. Moreover, due to its peculiar pharmacokinetic and pharmacodynamic properties, finerenone was found to be effective in reducing the risk of adverse events typically associated with MRAs. The results of the FINEARTS-HF trial, a phase 3 study including patients with HFmrEF and HFpEF randomized to receive finerenone or placebo, were presented at the 2024 ESC congress: finerenone was associated with a lower rate of heart failure-related events and cardiovascular mortality and may thus represent a new therapeutic option in this patient population.

Advanced heart failure (AdHF) is a progressive condition with a high morbidity and mortality burden despite optimal medical therapy. Heart transplant (HT) and left ventricular assist device (LVAD) represent the only two life-prolonging options in AdHF. Unfortunately, only a minority of AdHF patients are eligible for these life-saving therapies, and even patients who are candidates for HT usually incur prolonged waiting list times. Intermittent or continuous home-based inotropic therapy offers a potential solution to improve quality of life, reduce recurrent hospitalizations, and maintain organ function, both for the stabilization of patients who are ultimately candidates for life-saving therapies and for palliative care in those without other therapeutic options. In this review, we summarize the current literature on the role of home inotropes in managing AdHF, emphasizing the current evidence on the most adopted agents, the practical considerations for their administration, and the possible different preferred utilization of these agents. Finally, we address gaps in the literature and outline future research directions to enhance therapeutic options and outcomes.

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical entity frequently associated with chronic kidney disease (CKD). Recent studies indicate that 50-60% of HFpEF patients also have CKD, and the prevalence of HFpEF among CKD patients is similarly high. Chronic low-grade systemic inflammation is common to both conditions and is linked to risk factors such as obesity, insulin resistance, and diabetes. The hyperactivation of the mineralocorticoid receptor plays a central role in this process, contributing to interstitial fibrosis and inflammation. Additional factors, including metabolic acidosis, gut dysbiosis, and reduced expression of the α-Klotho protein, amplify the inflammatory response. This systemic inflammation reduces nitric oxide production, impairing cardiac diastolic function and, together with metabolic syndrome and aging, further exacerbates the already complex cardiac pathology. Therapeutic strategies aimed at reducing inflammation, such as renin-angiotensin-aldosterone system inhibitors and sodium-glucose cotransporter 2 inhibitors, show promising potential. Additionally, the use of anti-inflammatory drugs and novel interventions to restore gut microbiota balance may offer new opportunities to improve prognosis in patients with HFpEF and CKD. Further studies are needed to clarify the clinical efficacy of these approaches and their role in optimizing the management of this complex patient population.