Publications (20)55.09 Total impact
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Article: Catheter ablation of atrioventricular nodal reentrant tachycardia in patients with a prolonged PR interval at sinus rhythm.
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ABSTRACT: Radiofrequency transcatheter ablation is an effective and safe treatment for atrioventricular node reentry tachycardia. Slow pathway ablation is considered the ablative technique of choice, but when atrioventricular nodal reentrant tachycardia is associated with a prolonged PR interval at sinus rhythm, a higher risk of delayed atrioventricular (AV) block has been reported. Studies on the subject are few, enrolling low numbers of patients with variable selection criteria and producing different results. Hence, optimal ablation strategy remains controversial. The aim of this study is to review the available knowledge on the topic. Experience from our centers is also briefly reported.Journal of Cardiovascular Medicine 02/2012; 13(5):325-9. · 1.51 Impact Factor -
Article: The impact of drug eluting stents availability on the treatment choice among medical therapy, percutaneous or surgical revascularisation and on 4-year clinical outcome in patients with coronary artery disease: a cohort study.
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ABSTRACT: To investigate the influence of the availability of drug eluting stents (DES) on treatment choice (TC) among medical therapy (MT), coronary by-pass surgery (CABG) or percutaneous coronary interventions (PCI) and the consequent clinical outcomes in patients hospitalised because of coronary artery disease (CAD). Observational study comparing two cohorts hospitalised immediately before, and 3 years after DES availability. Thirteen hospitals with cardiology facilities. 2131 consecutive patients with at least one coronary stenosis >50% at coronary angiography (CA) after exclusion of those with acute myocardial infarction or previous CABG or associated relevant valvular disease. Treatment choice after CA and 4-year clinical outcomes. TC among MT (27% vs 29.2%), PCI (58.6% vs 55.5%) and CABG (14.5% vs 15.3%) was similar in the DES and bare metal stent (BMS) periods (p = 0.51). At least one DES was implanted in 57% of patients treated with PCI in 2005. After 4 years, no difference in mortality (13.8% vs 13.2%, p = 0.72), hospital admissions for myocardial infarction (6.6% vs 5.2%, p = 0.26), stroke (2.2% vs 1.7%, p = 0.49) and further revascularisations (22.3% vs 19.7%, p = 0.25) were observed in patients enrolled in the DES and BMS periods. Only in patients with Syntax score 23-32 a significant change of TC (p = 0.0002) occurred in the DES versus BMS period: MT in 17.4% vs 31%, PCI in 62.2% vs 35.8%, CABG in 20.3% vs 33.2%, with similar 4-year combined end-point of mortality, stroke, myocardial infarction and further revascularisations (45.3% vs 34.2%, p = 0.087). Three years after DES availability, the TC in patients with CAD has not changed significantly as well as the 4-year incidence of death, myocardial infarction, stroke and further revascularisations. In subgroup with Syntax score 23-32, a significant increase of indications to PCI was observed in the DES period, without any improvement of the 4-year clinical outcome.BMJ open. 01/2012; 2(5). -
Article: [Double antiaggregant therapy in patients with acute coronary syndrome undergoing coronary angioplasty revascularization. Pending clinical problems and effects of therapy non-compliance].
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ABSTRACT: Acute coronary syndromes (ACS) are the most frequent cause of hospitalization in intensive cardiac care units and are associated with a high risk of early complications. As a consequence, medical attention and healthcare are mainly directed towards the treatment of the acute phase of ACS, when the risk is higher. However, the risk associated with ACS is not simply confined to the hospitalization period, but may persist for months or years because of the frequent recurrence of ischemic events and related outcomes. Although more aggressive invasive strategies and powerful therapies with anticoagulants and antiplatelet agents have strongly improved the acute prognosis of ACS, the prognosis still remains unfavorable. Notwithstanding this, cardiologists mostly focus on the acute phase of ACS, while adopting a less aggressive approach after patient discharge and during outpatient follow-up. However, secondary prevention measures are as important as acute therapy and should be largely applied, including accurate estimation of the residual risk for the individual patient, appropriate implementation of secondary prevention, and close monitoring of adherence to suggested treatments, such as dual antiplatelet therapy. In conclusion, adherence to therapy is a clinically relevant factor, and efforts towards its improvement should be actively pursued. Moreover, appropriate prescriptions may stimulate therapy adherence with favorable effects, resulting in better clinical outcomes and healthcare cost containment. This holds particularly true for patients with ACS undergoing percutaneous revascularization.Giornale italiano di cardiologia (2006) 02/2011; 12(2 Suppl 1):3S-14S. -
Article: Prognostic value of isolated troponin I elevation after percutaneous coronary intervention.
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ABSTRACT: Mild elevations of cardiac troponin are frequent after percutaneous coronary intervention (PCI). Their prognostic value is uncertain in the absence of changes in creatine kinase-MB (CK-MB). We evaluated the relation between isolated elevations of cardiac troponin I (cTnI) and all-cause mortality. We studied 3494 consecutive patients who underwent PCI in 16 Italian tertiary cardiology centers. CK-MB and cTnI were analyzed in a central laboratory. Duration of follow-up was 2 years. The present analysis was restricted to 2362 patients with normal CK-MB and cTnI values at baseline and no CK-MB elevation after PCI. A rise in cTnI after PCI >0.15 ng/mL, the upper reference limit, was found in 932 patients (39.4%). A rise >0.45 ng/mL (>3×upper reference limit) was found in 467 patients (19.7%). Compared with patients with normal cTnI, those with cTnI elevation >0.15 ng/mL showed a slightly increased mortality (3.8% versus 2.6%; hazard ratio, 1.53; 95% confidence interval, 0.97 to 2.42; P=0.069). A cTnI elevation >0.45 ng/mL was associated with a higher risk of mortality (4.5% versus 2.7%; hazard ratio, 1.68; 95% confidence interval, 1.01 to 2.80; P=0.044), which, however, did not remain significant after adjustment for concomitant risk factors (hazard ratio, 1.45; 95% confidence interval, 0.86 to 2.46; P=0.162). Postprocedural cTnI elevation was associated with coronary and clinical features consistent with a worse risk profile. In the absence of a rise in CK-MB, elevated cTnI levels after PCI are associated with a modest increased risk of death. However, this is not independent of the concomitant adverse baseline clinical characteristics of these patients.Circulation Cardiovascular Interventions 10/2010; 3(5):431-5. · 6.06 Impact Factor -
Article: Infective endocarditis in patients with diabetes mellitus.
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ABSTRACT: Numerous studies have been conducted to investigate the conditions associated with poor outcome among patients with infective endocarditis (IE). Yet, diabetes mellitus alone has rarely been analyzed as participating in the prognosis, and few data are available relating to the clinical characteristics of IE in diabetics. The study aim was to assess the influence of diabetes mellitus on the characteristics and prognosis of IE, and to identify predictors of poor outcome among diabetic patients with this condition. The study included consecutive patients with IE who had presented to a tertiary center between 1990 and 2006. All patients underwent transthoracic and transesophageal echocardiography. Three or more blood cultures were collected from each patient. Records of all patients were collected prospectively into a computerized database. Among 309 patients with definitive IE (according to modified Duke criteria), 38 (12%) had diabetes mellitus. Typically, diabetic patients were older than non-diabetics (67.1 +/- 10.4 versus 60.7 +/- 15.8 years; p < 0.001), had more serious comorbidities (Charlson index 2.8 +/- 0.7 versus 1.2 +/- 0.5; p = 0.005), and a higher frequency of enterococcal endocarditis. No differences were noted between patients with or without diabetes mellitus for the valve involved, nor for the subvalvular involvement. In a multivariate analysis, diabetes mellitus was identified as an independent predictor of mortality (OR 2.49; 95% CI 1.15-5.62). Surgery was performed in the active phase in 139 patients: surgical mortality was higher for diabetic patients (29% versus 10% p = 0.049). In-hospital mortality was significantly higher among diabetic patients (34%) than in non-diabetics (20%) (p = 0.002). Enterococcal endocarditis, left ventricular ejection fraction < 0.45, multi-organ failure, heart failure, persistent fever after one week of antibiotic therapy, and a Charlson index > 3 were associated with an increased mortality among diabetic patients. Diabetes mellitus represents a relevant risk factor for a worse clinical course and outcome of IE.The Journal of heart valve disease 05/2010; 19(3):312-20. · 0.81 Impact Factor -
Article: Spontaneous dissections of coronary arteries and acute coronary syndromes: rationale and design of the DISCOVERY, a multicenter prospective registry with a case-control group.
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ABSTRACT: Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischemia that in almost 50% of cases is followed by sudden death. The increasing frequency of SCAD diagnosis may reflect the widespread use of coronary angiography and percutaneous coronary interventions in acute coronary syndromes (ACS). The incidence of SCAD is estimated between 0.1 and 0.28% of all ACS or sudden deaths evaluated by angiography or by anatomical examination, respectively. Most published data available so far deal with single case reports and probably the real incidence of this disease is underestimated. Some predisposing conditions to SCAD are well known and include Marfan syndrome, pregnancy and peripartum state, drug abuse and some anatomical abnormalities of the coronary arteries like aneurysms and severe kinking. The most appropriate therapeutic approach to SCAD is still controversial and decision making is often based on the clinical presentation, extent of dissection and amount of ischemic myocardium. The purpose of this multicenter prospective registry, named DISCOVERY (DISsection of COronary arteries: Veneto and Emilia RegistrY), with a case-control group is to try to assess the role of SCAD in the pathogenesis of ACS. The primary endpoint is the occurrence of major adverse cardiovascular events related to the therapeutic strategy in the acute phase and in the mid-term follow-up. The secondary endpoints are the estimation of the prevalence of SCAD in the pathogenesis of ACS, the association or disassociation of SCAD with presumptive predisposing factors, the appreciation of the timing and extent of multivessel involvement when present, the occurrence of vascular and ocular comorbidities (i.e. carotid dissection and ocular lens abnormalities), the evaluation of the immediate success and the mid-term outcome of percutaneous coronary interventions and the definition of the role of intravascular ultrasound in diagnosis and treatment of SCAD. The enrollment of approximately 50 patients with SCAD is planned. A planned control group of patients of comparable age, sex and clinical presentation will allow us to identify potential peculiar or specific aspects of SCAD in any phase of the disease. The DISCOVERY multicenter registry, with a case-control group, is the first large prospective study aimed at assessing the role of SCAD in the pathogenesis of ACS and at identifying the role of different therapeutic strategies in this unusual, multifaceted and probably underestimated pathologic condition.Journal of Cardiovascular Medicine 02/2009; 10(1):94-9. · 1.51 Impact Factor -
Article: European registry on patients with ST-elevation myocardial infarction transferred for mechanical reperfusion with a special focus on early administration of abciximab -- EUROTRANSFER Registry.
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ABSTRACT: Abciximab is established as adjunct to primary percutaneous coronary intervention (PCI). Based on some smaller studies, ST-segment elevation myocardial infarction (STEMI) networks in various European countries have adopted the start of abciximab before transfer to the catheterization laboratory (cathlab) hospital as part of their routine treatment options. Although a recently published study did not reveal improved clinical outcome when starting abciximab before the cathlab, a potential benefit from such early administration, in particular in the setting of transfer networks, remains unclear and has been the subject of debate. Data of consecutive patients with STEMI transferred for primary PCI in hospital/ambulance-feeded STEMI networks treated between November 2005 and January 2007 at 15 PCI centers from 7 European countries were collected in the web-based EUROTRANSFER Registry. Data from a total of 1,650 patients were collected. Abciximab was administered to 1086 patients (66%), of whom 727 received early abciximab (EA group: abciximab started before admission to cathlab, at least 30 minutes before balloon). Another 359 patients received late abciximab (LA group: periprocedural administration of abciximab in the cathlab). Preprocedural TIMI 3 flow was observed in 17.7% of patients with EA and in 8.9% in the LA group (P < .0001). Thirty-day mortality was 3.9% in the EA group versus 7.5% with LA (OR 0.49, 95% CI 0.29-0.85, P = .011), and composite 30-day outcome including death, repeated myocardial infarction, and urgent revascularization was present in 5.5% and 10.3%, respectively (OR 0.51, 95% CI 0.32-0.81, P = .004). These differences remain statistically significant in favor of early abciximab after accounting and adjustment for differences between the groups by means of a multivariate regression model and propensity score. Patients in STEMI networks transferred for primary PCI who have received abciximab before transfer rather than in the cathlab had more patent arteries before PCI and showed lower rates for death and the composite clinical outcome at 30-day follow-up.American heart journal 01/2009; 156(6):1147-54. · 4.65 Impact Factor -
Article: Outcome observations with drug-eluting stents.
Journal of Cardiovascular Medicine 03/2008; 9(2):110-2. · 1.51 Impact Factor -
Article: Clinical and anatomical characteristics of subtle-discrete dissection of the ascending aorta.
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ABSTRACT: Subtle or discrete (class 3 in the classification of the European Society of Cardiology) dissection is the most neglected variant of aortic dissection. This study was conducted to define the clinical manifestations, diagnostic findings, and outcomes of subtle or discrete dissection involving the ascending aorta. The clinical and surgical records, preoperative studies, and outcomes of 109 consecutive patients with ascending aortic dissection observed from 1995 to 2005 were reviewed. Eight patients (7.3%) had discrete dissection. Five patients presented with acute anterior chest pain, 2 with abdominal pain, and 4 with syncope. The mean diameter of the ascending aorta was 44 +/- 8.8 mm. The intimal tears were located in all patients on the posterior aspect of the ascending aorta 1 to 40 mm above the left coronary ostium; its length varied from 2.8 to 12.3 mm. Preoperative aortography, magnetic resonance imaging, and computed tomography could not identify the discrete intimal tears. Transesophageal echocardiography provided unique diagnostic information on (1) subtle intimal discontinuity, (2) circumscribed intramural hematoma, and (3) discrete pericardial fluid around the dissected aorta. Six patients underwent emergency surgery on the basis of echocardiographic findings, and they were all alive at follow-up. Compared with patients with classic aortic dissection, those with discrete dissection had lower operative mortality (0% vs 26%, p = 0.11), shorter hospital stay (7.2 +/- 2.8 vs 21 +/- 19 days, p = 0.01), and less frequent need for blood transfusions (0% vs 39%, p = 0.02). In conclusion, elevated clinical suspicion and detailed transesophageal echocardiographic examination are important for the early identification of discrete aortic dissection, leading to prompt surgery, shorter hospital stays, and better outcomes.The American Journal of Cardiology 11/2007; 100(8):1314-9. · 3.37 Impact Factor -
Chapter: Predicting Heart Failure Events in CRT Patients: Future Challenges
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ABSTRACT: Advanced heart failure (HF) and related acute decompensations have become the single most costly medical syndrome in cardiology. HF leads to frequent re-hospitalizations: in the US alone, yearly HF hospitalizations number more than 1 million [1]. A recent analysis carried out in all European countries led to the conclusion that 75% of all HF-related costs have to be attributed to HF hospitalizations [2].12/2006: pages 129-136; -
Article: Anatomical and electrophysiological approach to atrial fibrillation ablation: technical limitations.
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ABSTRACT: Pulmonary vein (PV) disconnection by radiofrequency (RF) catheter ablation has been reported to cure atrial fibrillation (AF). Different techniques have been proposed. The aim of this study was to evaluate the technical limitations of both anatomical and electrophysiological approaches. A total of 110 PVs were ablated in 26 consecutive patients (23 male, 3 female, mean age 51 +/- 9.5 years) with paroxysmal (n = 19, 73%), persistent (n = 3, 12%) or permanent (n = 4, 15%) AF. Accurate reconstructions of the PV ostia were obtained using fluoroscopy, electrophysiology, and the CARTO mapping system. Electrophysiological mapping was attempted in all PVs by means of a decapolar circular catheter. RF ablation was performed in a single-blind fashion in order to anatomically create circumferential lines around each PV. Completeness of anatomically-guided, circumferential RF lesions around the PVs was established by the physician using the CARTO system, who was unaware of the decapolar circular catheter electrophysiological recordings of the PVs. If PV potentials persisted, RF delivery was targeted to the electrophysiological breakthroughs. All PV ostia were anatomically ablated by performing circumferential RF lesions. Among 110 PVs, 73 (66%) were fully mapped by use of circular catheters. After anatomical ablation, electrical disconnection was achieved in 44/73 PVs (60%). In the remaining 29 PVs (40%), a median of one RF pulse (mean 1.8 +/- 1.4) was necessary to achieve complete PV disconnection. Total procedure duration, fluoroscopy time, and RF delivery time were 232 +/- 29, 50 +/- 16 and 39 +/- 11 min, respectively. Pericardial effusion occurred in one patient after the procedure. After 10.5 +/- 6.4 months, 21 patients (81%) were in stable sinus rhythm and 13 of them (62%) discontinued all drugs after 6 months. Only 4 patients (15%) required two procedures. Electrical PV disconnection cannot be achieved in many PVs by means of a pure anatomical approach. On the other hand, electrophysiological mapping cannot be performed in many PVs owing to anatomical variations. An integrated approach might overcome these limitations.Journal of Cardiovascular Medicine 09/2006; 7(8):586-91. · 1.51 Impact Factor -
Article: Effect of the new diagnostic criteria for ST-elevation and non-ST-elevation acute myocardial infarction on 4-year hospitalization: an analysis of hospital discharge records in the Veneto Region.
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ABSTRACT: To assess the burden of hospitalization for acute coronary syndrome (ACS) and the impact of the new diagnostic criteria for acute myocardial infarction on epidemiology of ACSs. We analysed the hospital discharge record archives of the Veneto Region in the period 2000-2003, including admissions of regional residents outside the study area. We defined a list of ICD-9-CM codes for the identification of different types of ACS. We examined trends in standardized hospitalization rates as well as patient characteristics (age, sex) and pattern of care (setting, invasive revascularization, length of hospital stay, in-hospital mortality). The hospitalization rate for non-ST-elevation myocardial infarction increased by about 70%, with a parallel decrease in hospitalizations for unstable angina, whereas the hospitalization rate for ST-elevation myocardial infarction remained unchanged. These trends are likely influenced by the new diagnostic criteria for acute myocardial infarction. At the end of the study period, although the main patient characteristics did not vary substantially, the pattern of care turned out to be more aggressive. Despite some limitations, our results indicate that the new diagnostic criteria for acute myocardial infarction have a major impact on epidemiological evaluation. These data may be relevant when comparing epidemiological data of different periods and planning healthcare policies. Further studies are needed in order to evaluate the accuracy of ICD-9-CM codes in the diagnosis of ACSs.Journal of Cardiovascular Medicine 02/2006; 7(1):45-50. · 1.51 Impact Factor -
Article: [Impact of reperfusion strategies on in-hospital outcome in ST-elevation myocardial infarction in a context of interhospital network: data from the prospective VENERE registry (VENEto acute myocardial infarction REgistry].
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ABSTRACT: Primary angioplasty (pPCI) is the most effective reperfusion treatment of acute ST-elevation myocardial infarction (STEMI), but logistic- and organization-related problems could affect the outcome. The aim of this study was to investigate the in-hospital outcome according to reperfusion strategy in the Veneto Region cardiology network. A treatment protocol, aimed to treat patients with high-risk STEMI by pPCI on-site or after transport, was developed and shared by the majority of cardiology departments in the Veneto Region. Data of all consecutive patients with STEMI were prospectively recorded during a 6-month period. 999 patients with symptom onset < 12 hours were admitted to the 28 participating hospitals: 860 were treated on-site and 139 were transferred from the admitting hospital to an interventional center for PCI. Overall, 82% of patients were treated with reperfusion therapy. Ten patients died immediately before any treatment could be initiated. In 170 patients who did not receive any reperfusion treatment, in 302 patients who received fibrinolysis (and eventually rescue PCI) and in 517 patients sent to pPCI, the following in-hospital outcome was observed respectively: mortality rate 10, 6.95 and 6.57%; reinfarction rate 0.6, 1 and 0.4%; incidence of stroke 1.7, 1.4 and 0.9%; the need for urgent revascularization procedure 6.5, 10 and 2.3%. After adjustment for confounding variables, the in-hospital occurrence of the combined events was significantly lower in patients treated with pP-CI (odds ratio 0.33, confidence interval 0.20-0.53, p < 0.01) as well as a trend for a reduced in-hospital mortality was observed (odds ratio 0.51, confidence interval 0.26-1.03, p = 0.06). In the VENERE registry, patients treated with pPCI had a better in-hospital outcome as compared to those treated with fibrinolytic strategy.Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 12/2005; 6(12):804-11. -
Article: [Hospital epidemiology of ST-segment elevation myocardial infarction and feasibility of primary percutaneous coronary intervention in an interhospital network: data from a multicenter, prospective and observational study VENERE (VENEto acute myocardial infarction REgistry].
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ABSTRACT: Primary percutaneous coronary intervention (pPCI) is the most effective reperfusion treatment of acute ST-segment elevation myocardial infarction (STEMI), but logistic- and organization-related problems affect its feasibility. The aim of this study was to investigate a) the requirements of reperfusion therapies, and b) the feasibility of pPCI as suggested by the current guidelines, in the Veneto Region. With the aim to treat with pPCI most of the patients with high-risk STEMI regardless of the type of admitting hospital, a single treatment protocol was developed and shared by the majority of Cardiology Departments in the Veneto Region. Data of all consecutive patients with STEMI were prospectively recorded and subsequently and independently compared with administrative data. In 28 participating hospitals, 1160 consecutive patients with STEMI were enrolled during a 6-month period: in 999 symptom onset was < 12 hours. Based on the registry data, it is possible to estimate that 697 patients/million of inhabitants/year are admitted in Cardiology Departments with the initial diagnosis of STEMI: 86% are admitted < 12 hours from symptom onset and 58% of them have at least one characteristic of high risk. The strategy of immediate coronary angiography and possible PCI was carried out in 52.3% of eligible patients: in 55.8 and 47.5% of high- and low-risk STEMI and from 17.1 to 75.1% based on the type of admitting hospital. Recanalization with pPCI was obtained < 90 min from the diagnosis in 70 and 32% of patients treated on site and transferred, respectively. The absolute number of patients with STEMI eligible for reperfusion therapies is lower than previously reported. The reperfusion strategy based on pPCI was much more related to the type of admitting hospital than to the clinical characteristics of the patients. pPCI performed as suggested by the current guidelines is feasible in patients admitted in hospitals with interventional facilities available 24 hours/day, but in those who need to be transferred it is necessary to modify the existing pathways and/or treatment protocols.Italian heart journal: official journal of the Italian Federation of Cardiology 11/2005; 6 Suppl 6:57S-64S. -
Article: Impact of the elevation of biochemical markers of myocardial damage on long-term mortality after percutaneous coronary intervention: results of the CK-MB and PCI study.
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ABSTRACT: Retrospective studies and post hoc analyses have suggested that mild elevations in the creatine kinase-MB (CK-MB) isoenzyme following percutaneous coronary intervention (PCI) may be associated with an increased risk of death in the long term. However, this finding is still controversial, and the prognostic significance of elevations of more sensitive markers of myocardial damage, such as the cardiac troponins, has not been established. In this multicentre prospective cohort study, we evaluated the influence of post-procedural elevations of CK-MB and troponin I (cTnI) on long-term mortality. The CK-MB and PCI study included 3494 consecutive patients undergoing PCI from February 2000 to October 2000 in 16 Italian tertiary centres. Blood samples were collected at baseline, and at 8-12 and 18-24 h after the procedure, and were analysed in a core biochemistry laboratory. CK-MB elevation was detected in 16% of the patients, and was associated with increased 2-year mortality [7.2 vs. 3.8%; odds ratio (OR): 1.9; 95% confidence interval (CI): 1.3-2.8; P<0.001). The degree of CK-MB elevation (peak CK-MB ratio) independently predicted the risk of death (adjusted OR per unit: 1.04; 95% CI: 1.01-1.07; P=0.009). A cTnI elevation was detected in 44.2% of the cases and was not associated with a significant increase in mortality (4.9 vs. 4.0%; OR: 1.2; 95% CI: 0.9-1.7; P=0.2). Post-procedural elevations of CK-MB, but not cTnI, influence 2-year mortality.European Heart Journal 09/2005; 26(15):1494-8. · 10.48 Impact Factor -
Article: Hospital networks for the treatment of acute myocardial infarction.
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ABSTRACT: Patients with ST-elevation myocardial infarction (STEMI) may have a survival benefit, as well as a reduced occurrence of reinfarction and stroke, if treated with primary percutaneous coronary intervention (PCI) instead of fibrinolysis. Furthermore, there are no other reperfusion options for patients with absolute contraindications to fibrinolysis or after failed fibrinolysis or in shock. Unfortunately, primary PCI programs require a relatively high number of experienced interventional cardiologists as well as other specialized personnel to guarantee a 24-hour call schedule together with a high level of skill. Since these conditions may be achieved only in a minority of hospitals with high volumes of interventional procedures, most of the patients with STEMI will be admitted to hospitals without a primary PCI program. The implementation of hospital networks based on a Hub-and-Spoke model is the only way to allow the choice of a reperfusion treatment on the basis of clinical needs and not only on the basis of the hospital characteristics. In Italy this process should be driven by regional authorities that have to establish the distribution of Hub centers, in close cooperation with cardiologists and physicians involved in emergency departments and 118 Service. Several key points, such as the collaboration between cardiologists and emergency physicians, common diagnostic and therapeutic protocols, prehospital diagnosis and treatment, transportation difficulties, overflow of the patients in the Hub centers, public campaigns for the use of the 118 Service and registries for all patients with STEMI, should be adequately addressed and implemented. In hospitals with well established primary PCI programs, all patients with STEMI should receive a mechanical reperfusion. The selection of patients with STEMI who might benefit most from mechanical reperfusion even after transfer, should be made considering the patient's risk profile, the time interval from symptom onset and the time interval to a primary PCI: in late comers (> 3 hours of symptom onset) and in the elderly, primary PCI should be the treatment of choice, but in early comers and younger patients, if an excessive time delay is necessary to perform a primary PCI, fibrinolysis might be a good initial option. In the latter, a systematic immediate transfer of high-risk patients to a primary PCI center for facilitated or rescue PCI should be considered.Italian heart journal: official journal of the Italian Federation of Cardiology 07/2005; 6(6):459-64. -
Article: ST-elevation acute myocardial infarction: can we improve the results of primary percutaneous coronary intervention?
Italian heart journal: official journal of the Italian Federation of Cardiology 10/2004; 5(9):684-7. -
Article: Combined Abciximab REteplase Stent Study in acute myocardial infarction (CARESS in AMI).
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ABSTRACT: Most patients with acute myocardial infarction (AMI) are admitted to hospitals without percutaneous transluminal coronary angioplasty (PTCA) facilities or are initially managed in a prehospital mobile unit. Thrombolysis remains the most readily available reperfusion treatment in those settings, but the optimal subsequent strategy in those patients is unclear. If a mechanical recanalization is likely to be performed in an emergency, it is probably desirable that the patient receives abciximab, the glycoprotein IIb/IIIa antagonist with the strongest evidence of benefit for angioplasty in AMI. The aim of this trial is to compare the effects on clinical outcome and cost-effectiveness of 2 strategies after immediate treatment with abciximab and half-dose reteplase for ST-elevation AMI: to manage the patients conservatively (referring them for rescue PTCA only if needed) or to immediately send all patients for emergency coronary angioplasty. The Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction (CARESS in AMI) is an open, prospective, randomized, multicenter clinical trial conducted in patients with high-risk ST-segment elevation AMI treated within 12 hours from symptom onset in hospitals without PTCA facilities or in a prehospital mobile intensive care unit. Apart from contraindications to thrombolysis, the main exclusion criteria are age > or =75 years and a past history of CABG surgery or a percutaneous coronary intervention procedure involving the infarct-related artery. Enrollment will be performed in hospitals without PTCA facilities or directly in the ambulance if a dedicated system is in place for prehospital diagnosis and treatment of AMI. Patients will receive half-dose reteplase and full-dose abciximab and will subsequently be randomized to conventional medical therapy (with referral for emergency rescue PTCA allowed in selected cases) or emergency angioplasty. The primary end point is the 30-day combined incidence of mortality, reinfarction, and refractory ischemia. In order to obtain a 95% power (2-sided) to detect a 42% reduction in the primary end point, 900 patients are required in each arm of the study. Secondary end points include the 1-year composite end point of mortality, reinfarction, refractory ischemia, and hospital readmission because of heart failure; resource use at 30 days and 1 year; and the incidence of inhospital stroke and bleeding complications in the 2 groups. Seventy-four patients have been randomized (as of March 10, 2004); results are expected in June 2005. This study will establish whether angioplasty must be started as soon as possible in all patients who receive combined pharmacologic reperfusion with the glycoprotein IIb/IIIa inhibitor abciximab and half-dose thrombolysis or whether it can be postponed or skipped in patients with signs of successful reperfusion, with obvious organizational advantages.American heart journal 09/2004; 148(3):378-85. · 4.65 Impact Factor -
Article: Usefulness of dipyridamole stress echocardiography for predicting graft patency after coronary artery bypass grafting.
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ABSTRACT: Noninvasive techniques often provide controversial results in patients who have coronary artery bypass grafts (CABGs). Vasodilator stress echocardiography allows semi-simultaneous imaging of CABG flow and segmental left ventricular wall motion. To assess the comparative and additive value of regional flow and function for noninvasive evaluation of graft patency status, we evaluated 110 consecutive patients who underwent CABG and who were scheduled for coronary angiography. All patients underwent stress echocardiography with dipyridamole (0.84 mg/kg) and atropine (1 mg), including wall motion analysis by 2-dimensional echocardiography and Doppler evaluation of flow reserve of each CABG. Echocardiographic findings were compared with angiographic data. Four patients had inadequate acoustic windows. The remaining 106 patients had 226 grafts performed. Stress echocardiography showed 67% sensitivity, 91% specificity, and 71% accuracy for identification of 50% to 100% stenosis in the graft or in the recipient coronary vessel. There was a fair agreement with angiography (kappa coefficient 0.60). Identification of impaired coronary bypass flow reserve (i.e., <1.9 for internal mammary grafts and <1.6 for saphenous vein grafts) by Doppler had 91% sensitivity, 88% specificity, and 89% accuracy for graft stenosis. There was good agreement with angiographic findings (kappa 0.77). The combination of the 2 techniques achieved 93% sensitivity, 93% specificity, and 93% accuracy, showing a very good agreement with the patency status of the grafts as evaluated at angiography (kappa 0.85). The combined assessment of wall motion and flow reserve in patients who underwent CABG is feasible and provides an accurate estimate of graft patency status by increasing sensitivity of stress echocardiography and specificity of Doppler flow reserve.The American Journal of Cardiology 02/2004; 93(1):24-30. · 3.37 Impact Factor -
Article: Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE).
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ABSTRACT: We sought to investigate the success rate and the acute and 12-month clinical outcome of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in the contemporary era. The technique of PCI involving CTO has improved over time. However, limited data on acute and follow-up results in patients treated with PCI on CTO in recent years are available. Four hundred nineteen consecutive patients scheduled for PCI of CTO of > or =30 days of duration were enrolled in 29 centers; 390 CTOs were confirmed in 376 patients in an independent core laboratory. The end points were technical and procedural success, in-hospital and 12-month major adverse cardiac events (MACE) occurrence, and 12-month symptomatic status. Technical and procedural success was obtained in 77.2% and 73.3% of lesions, respectively. In-hospital major adverse cardiac events occurred in 5.1% of patients. Multivariate analysis identified CTO length >15 mm or not measurable, moderate to severe calcifications, duration > or =180 days, and multivessel disease as significant predictors of PCI failure. At 12 months, patients with a successful procedure experienced a lower incidence of cardiac deaths or myocardial infarction (1.05% vs. 7.23%, p = 0.005), a reduced need for coronary artery bypass surgery (2.45% vs. 15.7%, p < 0.0001), and were more frequently free of angina (88.7% vs. 75.0%, p = 0.008) compared with patients who had an unsuccessful procedure. Successful PCI was achieved in a high percentage of CTOs with a low incidence of complications. At one-year follow-up, patients with successful PCI of a CTO had a significantly better clinical outcome than those whose PCI was unsuccessful.Journal of the American College of Cardiology 05/2003; 41(10):1672-8. · 14.16 Impact Factor
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2005–2007
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Azienda ULSS numero 9 Treviso
Treviso, Veneto, Italy
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