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Radiation exposure is an important issue for interventional cardiologists that is often underevaluated. Our aim was to evaluate determinants of operator radiation exposure during percutaneous coronary procedures. The RADIANT (NCT01974453) is a prospective, single-center observational study involving 4 expert operators and 2 fellows performing percutaneous coronary procedures. The operator radiation dose was evaluated using dedicated electronic dosimeters in 2,028 procedures: 1,897 transradial access (TRA; 1,120 right and 777 left TRA) and 131 transfemoral access (TFA). In the whole population, operator radiation dose at the thorax did not differ between TFA (9μSv [interquartile range 5-18μSv]) and TRA (9μSv [4-21μSv]), but after propensity score matching analysis, TFA showed lower dose (9μSv [5-18μSv]) compared with TRA (17μSv [9-28μSv], P<.001). In the whole transradial group, left TRA (5μSv [2-12μSv]) was associated with significant lower operator dose compared with right TRA (13μSv [6-26μSv], P<.001).The use of adjunctive protective pelvic drapes was significantly associated with lower radiation doses compared with procedures performed without drapes (P<.001). Among the operators, an inverse relation between height and dose was observed. Finally, left projections and the use of angiographic systems not dedicated for coronary and high frame rates were all associated with a significant higher operator radiation exposure. In a high-volume center for transradial procedures, TFA is associated with lower operator radiation dose compared with TRA. The use of adjunctive anti-rx drapes seems a valuable tool to reduce the higher operator radiation exposure associated with TRA. [Display omitted]

Intravenous (IV) infusion of adenosine represents the gold standard for measuring fractional flow reserve (FFR). However, IV adenosine is more expensive and time-consuming compared with intracoronary (IC) boluses of adenosine. We conducted a meta-analysis of studies comparing IC with IV adenosine for FFR assessment in the same coronary lesions. We searched for studies comparing IC with IV adenosine and reporting absolute FFR values or rate of abnormal FFR for both routes. Prespecified subgroup analysis was performed to appraise studies using low-dose (<100 μg) or high-dose IC adenosine (≥100 μg). We retrieved 11 studies amounting to 587 patients and 621 lesions. Six studies evaluated low-dose IC boluses (15 to 80 μg) and 5 studies high-dose boluses (120 to 600 μg). Absolute FFR values were slightly, yet significantly lower with IV adenosine compared with IC adenosine (mean difference 0.02, 95% confidence interval [CI] 0.00 to 0.03, p = 0.02). This difference, however, did not translate into a significant difference in the rate of abnormal FFR between IC and IV adenosine (hazard ratio 0.93, 95% CI 0.76 to 1.13, p = 0.57); moreover, no statistically significant difference was observed between low-dose and high-dose IC adenosine subgroups. Adverse events were less frequent with IC adenosine compared with IV adenosine (risk ratio 0.17, 95% CI 0.07 to 0.43, p <0.001). In conclusion, IC administration of adenosine, although inducing a slightly lower amount of hyperemia compared with IV infusion of adenosine, yields a similar diagnostic accuracy in identifying hemodynamically significant coronary stenosis and is better tolerated by the patients.

ImportanceDuring the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.ObjectiveThis paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient’s relatives under circumstances of complete isolation.Evidence reviewPubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.FindingsTen statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.Conclusions and relevanceThe statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Background and Objectives: Hemolysis is reported to be present in up to 10% of blood gas specimens in the central lab; however, few data on the incidence of hemolysis using a point-of-care testing (POCT) blood gas analysis are available in the setting of the emergency department. The aims of this study were: (1) to analyze the prevalence of hemolysis in blood gas samples collected in the ED using a POCT device; and (2) to evaluate the impact of hemolysis on blood sample results and its clinical consequences. Materials and Methods: We collected 525 consecutive POCT arterial blood gas samples using syringes with electrolyte-balanced heparin within 3 different EDs in the metropolitan area of Rome. Immediately after the collection, the blood samples were checked for the presence of hemolysis with a POCT instrument (i.e., HEMCHECK, H-10 ®). The samples were then subsequently processed for blood gasses, and an electrolytes analysis by a second operator blinded for the hemolysis results. A venous blood sample was simultaneously collected, analyzed for it’s potassium value, and used as a reference. Results: Of the samples, 472 were considered for the statistics, while 53 were excluded due to the high percentage of hemolysis due to operator fault in carrying out the measurement. The final mean hemolysis per operator was 12% (±13% SD), and the total final hemolysis was 14.4%.Potassium (K+) was significantly higher in the hemolyzed group compared with the non-hemolyzed sample (4.60 ± 0.11 vs. 3.99 ± 0.03 mEq/L; p < 0.001), and there were differences between arterial potassium versus venous potassium (D(a-v) K+, 0.29 ± 0.06 vs.−0.19 ± 0.02 mEq/L, p < 0.01). A Bland–Altman analysis confirmed that hemolysis significantly overestimated blood potassium level. Conclusion: Almost 12% of POCT blood gas analysis samples performed in the ED could be hemolyzed, and the presence of this hemolysis is not routinely detected. This could cause an error in the interpretation of the results, leading to the consideration of potassium concentrations being below the lower limit within the normal limits and also leading to the diagnosis of false hyperkalemia, which would have potential clinical consequences in therapeutic decision-making in the ED. The routine use of a POCT hemolysis detector could help prevent any misdiagnoses.

Background and Objectives: In patients with acute heart failure (AHF), there is no definite evidence on the relationship between high-sensitivity cardiac troponin (hs-cTnI) and the left ventricular ejection fraction (LVEF) comparing the reduced and preserved EF conditions. Materials and Methods: Between January and April 2022, we retrospectively analyzed the data from 386 patients admitted to the emergency departments (ED) of five hospitals in Rome, Italy, for AHF. The criteria for inclusion were a final diagnosis of AHF; a cardiac ultrasound and hs-cTnI evaluations in the ED; and age > 18 yrs. We excluded patients with acute coronary syndrome (ACS). Based on echocardiography and hs-cTnI evaluations, the patients were grouped for (1) preserved (HFpEF) or (2) reduced LVEF (HFrEF) and a a) negative (within the normal range value) or b) positive (above the normal range value) of hs-cTnI, respectively. Results: There was a significant negative relationship between a positive test for hs-cTnI and LVEF. When compared to the group with a negative hs-cTnI test, the patients with a positive test, both from the HFpEF and HFrEF subgroups, were significantly more likely to have an adverse outcome, such as being admitted to the intensive care unit (ICU) or dying in the ED. Moreover, a reduced ejection fraction was linked with a final disposition to a higher level of care. Conclusions: In patients admitted to the ED for AHF without ACS, there is a negative relationship between hs-cTnI and a reduced LVEF, although a significant percentage of patients with a preserved LVEF also resulted to have high levels of hs-cTnI. In the absence of ACS, hs-cTnI seems to be a reliable biomarker of myocardial injury in AHF in the ED and should be considered as a risk stratification parameter for these subjects regardless of the left ventricular function. Further larger prospective studies are needed to confirm these preliminary data.

Negli ultimi decenni si è assistito ad un’incredibile evoluzione delle terapie antitrombotiche per il trattamento dei pazienti affetti da aterosclerosi, fibrillazione atriale e tromboembolia venosa, portando alla disponibilità di farmaci sempre più sicuri. Tuttavia, le complicanze emorragiche associate a tali farmaci esercitano ancora un importante impatto sanitario, sociale ed economico. Recentemente, con la finalità di migliorare la gestione in acuto dei pazienti con o a rischio di eventi emorragici maggiori, sono stati sviluppati specifici agenti di reversione dei farmaci antitrombotici. Sebbene tali agenti abbiano dimostrato la loro efficacia in piccoli studi di farmacodinamica o trial clinici, è importante considerare che il beneficio della reversione di un farmaco antiaggregante o anticoagulante deve essere sempre controbilanciato dal possibile effetto protrombotico causato dalla rimozione della protezione antitrombotica nonché dai meccanismi protrombotici correlati al sanguinamento, alla chirurgia maggiore o al trauma.In questo documento di consenso ANMCO/SIMEU riassumiamo le principali caratteristiche e gli studi di efficacia degli agenti di reversione attualmente disponibili e presentiamo delle possibili flow-chart operative in cui suggeriamo il loro possibile impiego nei pazienti con sanguinamento in atto o ad alto rischio di eventi emorragici maggiori.

La fibrillazione atriale (FA) è responsabile del 2% circa degli accessi al Dipartimento di Emergenza-Urgenza (DEU) e rappresenta la più frequente causa aritmica di ricovero ospedaliero. La FA aumenta notevolmente il rischio di eventi tromboembolici e spesso si associa ad una serie di comorbilità che impattano negativamente sulla qualità di vita e sulla prognosi dei pazienti. La FA, inoltre, ha un notevole impatto socio-economico, che impone un’adeguata e coordinata gestione di tale aritmia per evitare gravi complicanze e consentire un appropriato utilizzo di risorse tecnologiche e farmacologiche. L’approccio a tale aritmia è abbastanza disomogeneo nelle varie realtà regionali ed ospedaliere; diverso l’utilizzo dei farmaci anticoagulanti e ancora poco diffuso l’utilizzo precoce degli anticoagulanti orali diretti, diverso il ricorso alla cardioversione elettrica. Il DEU rappresenta spesso il punto di primo accesso alle cure per pazienti con FA. La corretta gestione in acuto di tale aritmia ha un notevole impatto non solo per la qualità di vita del paziente e per il suo outcome clinico, ma anche per la razionalizzazione e la corretta gestione delle risorse impiegate. Ne deriva la necessità di rendere univoco e ben definito il percorso clinico-diagnostico del paziente che afferisce al DEU con FA, basato su di una stretta collaborazione tra differenti figure professionali – il medico dell’emergenza-urgenza, il cardiologo, l’internista e l’anestesista-rianimatore. Lo scopo di questo documento di consenso, elaborato dalle società scientifiche ANMCO e SIMEU, è di proporre raccomandazioni condivise tra i Dipartimenti dell’Emergenza e delle Malattie Cardiovascolari per una gestione integrata, puntuale e aggiornata del paziente affetto da FA, per migliorare e rendere omogenea su tutto il territorio nazionale la gestione dei pazienti che giungono in Pronto Soccorso per e con FA.

Ischemic heart disease is increasing dramatically in the Sub-Saharan Africa (SSA), despite an increasing prevalence of risk factors, and some characteristics of the African people that make the African population subject to the effects of major cardiovascular risk factors. The pace and direction of economic development, rates of urbanization, the changes in life expectancy, associated with different pathophysiological factors are causing an increased rate of atherosclerotic disease in these countries. The prevalence of ischemic heart disease in SSA has shown a significant rise in the next two following decades due to the rising prevalence of risk factors, especially hypertension, diabetes, overweight and obesity, physical ictivity, tobacco use and the dyslipidemia, mainly due to an increase in urbanization. Moreover, thanks to new knowledge, it has been pointed out the difference of individual risk factors in the African population and other populations due to genetic differences. It is estimated that age-standardized approach for ischemic heart disease mortality rates will rise by 27% in African men and 25% in women by 2015 and by 70 and 74%, respectively by 2030. More research is needed in Africa to provide evidence for cardiovascular prevention and treatment to mitigate the oncoming epidemic. Health interventions are needed for preventing or reducing the morbidity/ mortality and should be addressed to both children and adults, including score of the risk stratification modified, starting early and aggressive therapy, if necessary.

Background: In 2011 the European Society of Cardiology published the new guidelines for the treatment and magement of acute corory syndrome without elevation of the ST segment (NSTEMI). For the treatment of the syndrome, the use of P2Y12 inhibitors in addition to aspirin was strongly recommended (evidence IA). We studied the application of this recommendation in the setting of the emergency department in the vast and uneven area of the Italian region Lazio, three years after the release of these drugs in Italy. Methods: 121 consecutive patients (65% older than 65 years) affected by NSTEMI were recruited between May and July 2013. During the transition in the emergency department data was collected on patient's symptoms, syndrome severity and type & timing of treatments chosen. Adherence to the guidelines was evaluated considering the number of €œgood treated€ patients: these being the patients that received at least 80% of the main five recommendations on percutaneous corory intervention (PCI) timing, antiplatelet and anti-coagulant therapy suggested by the European Cardiology Task Force (ESC guidelines, 2011) for the very acute phase of NSTEMI. Results: Patients were treated with: 1) 35% of cases with double antiplatelet therapy and anticoagulation (DAPT+AC), 2) 22% of cases with single antiplatelet and anticoagulation (SAPT+AC), 3) 6% of cases with a single antiplatelet therapy (SAPT), 4) 6% of cases with a double antiplatelet therapy (DAPT) and 5) 24% of cases did not receive any therapy. Data on PCI was available for 95 patients and, of these, only 82% of the patients underwent the procedure. The percentage of €œgood treated€ patients were among of 20-40%, depending on PCI timing €“ as guidelines suggested €“ was considered as mandatory (20,5%) or as the extreme time limit (40%). Significant differences were found between patients treated in a central hospital with a hemodymic laboratory active 24/24hr (HUB) and patients treated in the other hospital (SPOKE). HUBs showed a higher percent of €œgood treated€ patients, a higher percentage of early invasive treated and a better adherence to recommended pharmacological therapy. Conclusions: A significant number of patients did not receive adequate treatment during the emergency department stay. The absence of hemodymic services increases the risk of idequate treatment.