Giuseppe Boriani

University of Bologna, Bolonia, Emilia-Romagna, Italy

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Publications (419)1780.79 Total impact

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    ABSTRACT: To evaluate the potential impact of the different definitions of non-valvular atrial fibrillation reported in the literature and to analyse the possible implications for eligibility for novel oral anticoagulants (NOACs) in clinical practice. We derived the definitions of 'non-valvular atrial fibrillation' from the exclusion criteria of the trials on NOACs, and then assessed the number and percentage of patients fulfilling the various definitions in a cohort of 500 consecutive atrial fibrillation patients, undergoing clinical and echocardiographic evaluation in our cardiology department, as either in-patients or out-patients. Among the 500 atrial fibrillation patients (mean age 71.2 ± 12.6 years), with permanent atrial fibrillation in 45.2% of the cases, hypertension was very common, either as the main diagnosis or as an associated disease. Valvular heart disease as the main diagnosis (including valvular prosthesis) accounted for 22.8% of the cases. At the echocardiographic evaluation, valvular alterations were very common, especially mitral regurgitation (present, with a variable degree of severity in 63.6% of the cases). Application of the RE-LY exclusion criteria with regard to valvular disease resulted in 116 (23.2%) patients of our cohort classified as valvular atrial fibrillation. This percentage was reduced to 12.2 and 8.8% if ROCKET-AF and ARISTOTLE/ENGAGE-AF criteria, respectively, were applied. Non-valvular atrial fibrillation is a common clinical entity, but without a unified definition in the literature. The impact in daily practice of the different definitions adopted in trials is noteworthy, since in one patient out of seven, the eligibility for NOACs can be questioned, simply as a consequence of adopting a more or less restrictive definition.
    Journal of cardiovascular medicine (Hagerstown, Md.). 01/2015;
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    ABSTRACT: Atrial fibrillation is often asymptomatic but outcomes need further characterization. To investigate clinical presentation, management and outcomes in asymptomatic and symptomatic atrial fibrillation patients prospectively enrolled in the EurObservational Research Programme - Atrial Fibrillation (EORP-AF) Pilot General Registry. A total of 3119 patients were enrolled, and 1237 (39.7%) were asymptomatic (EHRA score I). Among symptomatic patients, 963 (51.2%) had mild symptoms (EHRA score II) while 919 (48.8%) had severe or disabling symptoms (EHRA III-IV). Permanent atrial fibrillation was threefold more common in asymptomatic than in symptomatic patients. On multivariate analysis, male gender (OR 1.630, 95% CI 1.384-1.921), older age (OR 1.019, 95% CI 1.012-1.026), previous myocardial infarction (OR 1.681, 95% CI 1.350-2.093), and limited physical activity (OR 1.757, 95% CI 1.495-2.064) were significantly associated with asymptomatic (EHRA I) atrial fibrillation. Fully asymptomatic atrial fibrillation (absence of current and previous symptoms) was present in 520 patients (16.7%), and was independently associated with male gender, age and previous myocardial infarction. Appropriate guideline-based prescription of oral anticoagulants was lower in these patients, while aspirin was more frequently prescribed. In asymptomatic patients, mortality at 1 year was more than two-fold higher compared to symptomatic patients (9.4 vs. 4.2%, p<0.0001), and was independently associated with older age and comorbidities, including chronic kidney disease and chronic heart failure. Asymptomatic atrial fibrillation is common in daily cardiology practice, being associated with elderly age and more co-morbidities, as well as high thromboembolic risks. A higher 1-year mortality was found in asymptomatic compared to symptomatic patients. Copyright © 2014 Elsevier Inc. All rights reserved.
    The American Journal of Medicine 12/2014; · 5.30 Impact Factor
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    ABSTRACT: Cardiac resynchronization is a well tolerated and effective therapy for heart failure, but 30% of patients still do not respond to biventricular pacing. Optimization of device settings, in particular interventricular delay value, represents a plausible target for improving these results, but available literature is discordant. We aimed our study at the identification of the best suitable candidates to interventricular delay optimization. A total of 77 consecutive patients with optimized drugs therapy underwent clinical, echocardiographic and electrocardiographic evaluation before and after 6 months from implantation of a biventricular defibrillator in accordance to current guidelines. In each patient, atrioventricular and interventricular delay values were optimized at predischarge with echocardiogram. The only predictor of an optimized interventricular delay value different from simultaneous (i.e. standard shipment setting), at both univariate and multivariate analyses, was a QRS duration greater than 160 ms (odds ratio 22.958; P = 0.003) with a sensitivity of 70.9%. Candidates to cardiac resynchronization therapy with a basal QRS greater than 160 ms have a higher chance of requiring echo-guided tailoring of interventricular delay value. A strategy based on these data can potentially improve device programming, reducing by one-third the need for optimization, according to our findings, and at the same time avoid unnecessary time-consuming procedures.
    Journal of Cardiovascular Medicine 12/2014; · 1.41 Impact Factor
  • European Heart Journal 12/2014; · 14.72 Impact Factor
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    ABSTRACT: The Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block (BLOCK HF) trial, published in April 2013 [Curtis AB, Worley SJ, Adamson PB, et al; Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block (BLOCK HF) Trial Investigators. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med 2013; 368:1585-1593], explored whether cardiac resynchronization therapy (CRT) was superior to conventional pacing in patients with conventional indications for pacing, left ventricular dysfunction and NYHA (New York Heart Association) class I-III. The trial took 8 years and a source of concern is selection bias, because participating centers had an average of two patients enrolled per center, per year. Both the internal and external validity of the trial merit some comments. BLOCK HF showed a relatively low treatment effect of CRT as compared with other CRT trials. As a matter of fact, the absolute risk reduction for death or hospitalization because of heart failure was 4.8%, in a relatively long follow-up, with a number needed to treat (NNT) of 21, much higher than the NNT of other CRT trials. We estimate that at least one third of patients in BLOCK HF could meet current indications for CRT. Moreover, the study did not consider the additional risks and costs of CRT versus conventional pacing, both having important implications for cost-effectiveness estimates. For these and other reasons, uncertainties arise as to how far BLOCK HF extends current recommendations for CRT and how much it should be implemented in daily clinical practice.
    Journal of cardiovascular medicine (Hagerstown, Md.). 11/2014;
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    ABSTRACT: The EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot) provides systematic collection of contemporary data regarding the management and treatment of 3119 subjects with AF from 9 member European Society of Cardiology (ESC) countries. In this analysis, we report the development of symptoms, use of antithrombotic therapy and rate vs. rhythm strategies, as well as determinants of mortality and/or stroke/transient ischaemic attack (TIA)/peripheral embolism during 1-year follow-up in this contemporary European registry of AF patients.
    European Heart Journal 08/2014; · 14.72 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) may occur in the absence of identifiable causes, co-morbidities or structural cardiac disease (lone AF). Silent AF is common and patients may have a completely asymptomatic arrhythmia or may experience both symptomatic and asymptomatic AF episodes. It has been estimated that among patients with recognized AF, one third has no appreciable symptoms. In contemporary clinical practice, AF remains largely underdiagnosed and 25% of patients with AF-associated cardioembolic stroke have not been previously diagnosed with AF. The strategies for AF screening include opportunistic and systematic screening. Several methods for AF detection are nowadays available: from very simple (pulse palpation) to more advanced technologies proposed for ambulatory external monitoring of variable time duration. In patients previously implanted with cardiac electrical devices with an atrial lead, according to current clinical indications, the ability to continuously detect AF and to monitor its evolution is magnified, and AF burden can be precisely measured and monitored along with time. Similar information on AF burden can be also obtained by implantation of subcutaneous cardiac monitors that rely on the analysis of consecutive RR intervals for the diagnosis of AF. The prognosis is generally favorable for patients presenting with lone AF, but adverse outcomes, including stroke and thromboembolic events may occur at long term, in association with aging, or the development of underlying heart disease, or progression from paroxysmal to permanent AF. In this respect, the role of new technologies and diagnostic tools for AF detection and monitoring should be fully defined.
    Current Pharmaceutical Design 08/2014; · 3.29 Impact Factor
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    ABSTRACT: Country differences in management practices are evident, and the publication of management guidelines by the European Society of Cardiology (ESC) and other learned societies has tried to recommend a uniform evidence-based approach to management. Despite the availability of guidelines and efforts to improve implementation, differences in guideline adherence are evident, and differences between countries and regions within Europe are therefore likely.
    Europace 08/2014; · 3.05 Impact Factor
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    ABSTRACT: Alterations of the cardiac autonomic nervous system play an important role in the pathway of many heart diseases. Nuclear imaging tools have been demonstrated to be useful for global and regional assessment of myocardial innervation. We used 11C-meta-hydroxy-ephedrine (11C-mHED), a catecholamine analogue, as a radiotracer usable with a PET/CT scanner to study the cardiac sympathetic system. After a fast and automatic synthesis of mHED and its labeling with 11C, we acquired cardiac images by using a PET/ CT scanner. In this paper we present our preliminary results showing the radiotracer bio-distribution in humans 10 minutes post injection. The present study assesses the feasibility of PET/CT with the radiolabeled catecholamine analogue (11C-mHED) in order to determine sympathetic innervation in the human heart.
    Current Radiopharmaceuticals 07/2014;
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    ABSTRACT: Sex differences in the epidemiology and clinical management of AF are evident. Of note, females are more symptomatic and if age >65, are at higher risk of thromboembolism if incident AF develops, compared with males.
    Europace 06/2014; 17(1). · 3.05 Impact Factor
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    ABSTRACT: The increase in incidence/prevalence of infections of implantable pacemakers and defibrillators (implantable cardioverter defibrillator, ICD) is outweighing that of the implanting procedures, mainly favored by the changes in patient profile. Despite the high impact on patient's outcome and related costs for healthcare systems, we lack specific evidence on the preventive measures with the exception of antibiotic prophylaxis. The aim of this study is to focus on common approaches to pacemaker/ICD implantation to identify the practical preventive strategies and choices that can (potentially) impact on the occurrence of this feared complication. After a brief introduction on clinical presentation, pathogenesis, and risk factors, we will present the results from a survey on the preventive strategies adopted by different operators from the 25 centers of the Emilia Romagna region in the northern Italy (4.4 million inhabitants). These data will provide the basis for reviewing available literature on this topic and identifying the gray areas. The last part of the article will cover the available evidence about pacemaker/ICD implantation, focusing on prophylaxis of pacemaker/ICD infection as a 'continuum' starting before the surgical procedure (from indications to patient preparation), which follows during (operator, room, and techniques) and after the procedure (patient and device follow-up). We will conclude by evaluating the relationship between adherence to the available evidence and the volume of procedures of the implanting centers or operators' experience according to the results of our survey.
    Journal of Cardiovascular Medicine 05/2014; · 1.41 Impact Factor
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    ABSTRACT: Heart failure (HF) is a common condition in elderly patients. Despite great improvements in medical therapy, HF mortality remains high. Implantable cardioverter defibrillator (ICD) significantly lengthens the survival rate of subjects with severe HF, but little evidence exists on its effect in elderly persons. Aim of this study was to compare the age-related determinants of prognosis in a large population of patients with ICD. We divided all patients who underwent an ICD implantation in 117 Italian centers of the "ClinicalService Project" into 3 age groups (<65, 65 to 74, ≥75 years), and collected clinical and instrumental variables at baseline and during follow-up (median length: 27 months). Between 2004 and 2011, 6,311 patients were enrolled (5,174 men; left ventricular ejection fraction 29% ± 9%); 1,510 subjects were ≥75 years (23.9%; mean age 78 ± 3 years). The prevalence of co-morbidities increased with age. HF was most frequently due to coronary artery disease in the elderly, who also showed the worst New York Heart Association class. At multivariate analysis, older age, coronary artery disease, chronic obstructive pulmonary disease, chronic renal failure, diabetes, complex ventricular arrhythmias, and left ventricular ejection fraction were significant predictors of all-cause mortality. After adjustment, the hazard ratioage group for mortality was 22.6% less than at univariate analysis. When groups were analyzed separately, age alone predicted mortality in the oldest. In conclusion, a large proportion of our population was aged ≥75 years. Mortality was related to age and several co-morbidities, except for the oldest patients in whom age alone resulted predictive.
    The American journal of cardiology 05/2014; 113(10):1691-6. · 3.58 Impact Factor
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    ABSTRACT: Infective endocarditis (IE) is widely underdiagnosed or diagnosed after a major delay. The diagnosis is currently based on the modified DUKE criteria, where the only validated imaging technique is echocardiography, and remains challenging especially in patients with an implantable cardiac device. The aim of this study was to assess the incremental diagnostic role of (18)F-FDG PET/CT in patients with an implanted cardiac device and suspected IE. We prospectively analysed 27 consecutive patients with an implantable device evaluated for suspected device-related IE between January 2011 and June 2013. The diagnostic probability of IE was defined at presentation according to the modified DUKE criteria. PET/CT was performed as soon as possible following the clinical suspicion of IE. Patients then underwent medical or surgical treatment based on the overall clinical evaluation. During follow-up, we considered: lead cultures in patients who underwent extraction, direct inspection and lead cultures in those who underwent surgery, and a clinical/instrumental reevaluation after at least 6 months in patients who received antimicrobial treatment or had an alternative diagnosis and were not treated for IE. After the follow-up period, the diagnosis was systematically reviewed by the multidisciplinary team using the modified DUKE criteria and considering the new findings. Among the ten patients with a positive PET/CT scan, seven received a final diagnosis of "definite IE", one of "possible IE" and two of "IE rejected". Among the 17 patients with a negative PET/CT scan, four were false-negative and received a final diagnosis of definite IE. These patients underwent PET/CT after having started antibiotic therapy (≥48 h) or had a technically suboptimal examination. In patients with a cardiac device, PET/CT increases the diagnostic accuracy of the modified Duke criteria for IE, particularly in the subset of patients with possible IE in whom it may help the clinician manage a challenging situation.
    European Journal of Nuclear Medicine 05/2014; · 4.53 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) is a common comorbidity in bradycardia patients. Advanced pacemakers feature atrial preventive pacing and atrial antitachycardia pacing (DDDRP) and managed ventricular pacing (MVP), which minimizes unnecessary right ventricular pacing. We evaluated whether DDDRP and MVP might reduce mortality, morbidity, or progression to permanent AF when compared with standard dual-chamber pacing (Control DDDR). In a randomized, parallel, single-blind, multi-centre trial we enrolled 1300 patients with bradycardia and previous atrial tachyarrhythmias, in whom a DDDRP pacemaker had recently been implanted. History of permanent AF and third-degree atrioventricular block were exclusion criteria. After a 1-month run-in period, 1166 eligible patients, aged 74 ± 9 years, 50% females, were randomized to Control DDDR, DDDRP + MVP, or MVP. Analysis was intention-to-treat.The primary outcome, i.e. the 2-year incidence of a combined endpoint composed of death, cardiovascular hospitalizations, or permanent AF, occurred in 102/385 (26.5%) Control DDDR patients, in 76/383 (19.8%) DDDRP + MVP patients [hazard ratio (HR) = 0.74, 95% confidence interval 0.55-0.99, P = 0.04 vs. Control DDDR] and in 85/398 (21.4%) MVP patients (HR = 0.89, 95% confidence interval 0.77-1.03, P = 0.125 vs. Control DDDR). When compared with Control DDDR, DDDRP + MVP reduced the risk for AF longer than 1 day (HR = 0.66, 95% CI 0.52-0.85, P < 0.001), AF longer than 7 days (HR = 0.52, 95% CI 0.36-0.73, P < 0.001), and permanent AF (HR = 0.39, 95% CI 0.21-0.75, P = 0.004). In patients with bradycardia and atrial tachyarrhythmias, DDDRP + MVP is superior to standard dual-chamber pacing. The primary endpoint was significantly lowered through the reduction of the progression of atrial tachyarrhythmias to permanent AF. NCT00262119.
    European Heart Journal 04/2014; · 14.72 Impact Factor
  • Journal of Cardiovascular Medicine 04/2014; 15(4):269-72. · 1.41 Impact Factor
  • Europace 04/2014; 16 Suppl 1:i1-i78. · 3.05 Impact Factor
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    ABSTRACT: Inappropriate implantable cardioverter defibrillators (ICD) therapies have been associated with multiple adverse effects, including worse quality of life and prognosis. We evaluated the possibility of predicting atrial fibrillation (AF)-related inappropriate ICD shocks through continuous monitoring of device diagnostics. 1404 ICD patients were prospectively followed in an observational research by 74 Italian cardiology centres. Device diagnostics stored daily information on AF duration and ventricular rate (VR) during AF. Uncontrolled VR was defined as mean VR>80 beats per minute (bpm) and maximum VR>110 bpm. Expert electrophysiologists reviewed the ventricular tachycardia/ventricular fibrillation (VT/VF) episodes electrograms, stored in the device memory, and classified appropriate detections, inappropriate detection mechanisms and ICD therapy outcomes. Over a median follow-up of 31 months, 511 (36%) patients suffered spontaneous VT/VF, which were treated by ICD shocks in a subgroup of 189 (13%) patients. Inappropriate detections occurred in 232 (16%) patients, and inappropriate ICD shocks in 101 (7%) patients. AF was the cause of inappropriate shocks in 60 patients. AF caused 144 inappropriate shocks: 53% of all inappropriate shocks. The likelihood of experiencing AF-related inappropriate shocks was 2.4% at 1 year and 6% at 5 years. Uncontrolled VR during AF proved to be an independent predictor of AF-related inappropriate shocks (OR=3.02, p=0.006); an alarm set at a VR>90 bpm or 100 bpm was associated with prediction of AF-related inappropriate shocks with a sensitivity of 73% or 62%, respectively. AF is the most common cause of inappropriate shocks in ICD patients. Continuous remote monitoring of VR during AF would promptly and efficiently predict AF-related inappropriate shocks.
    Heart (British Cardiac Society) 03/2014; · 6.02 Impact Factor
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    ABSTRACT: Asymptomatic atrial fibrillation (AF) is common and in view of its prognostic impact (the same as of clinically overt AF) knowledge of the overall AF burden (defined as the amount of time spent in AF) appears to be important, both for scientific and clinical reasons. Data collected on more than 12,000 patients indicate that cardiac implantable electrical devices (CIEDs) are validated tools for measuring AF burden and that AF burden is associated with an increased risk of stroke. A maximum daily AF burden of ≥ 1 h carries important negative prognostic implications and may be a clinically relevant parameter for improving risk stratification for stroke. Decision-making should primarily consider the context in which asymptomatic, subclinical arrhythmias are detected (i.e. primary or secondary prevention of stroke and systemic embolism) and the risk profile of every individual patient with regard to thromboembolic and haemorrhagic risk, as well as patient preferences and values. Continuous monitoring using CIEDs with extensive data storage capabilities allow in-depth study of the temporal relationship between AF and ischaemic stroke. The relationships between AF and stroke are complex. AF is certainly a risk factor for cardioembolic stroke, with a cause-effect relationship between the arrhythmia and a thromboembolic event, the latter being related to atrial thrombi. However, AF can also be a simple 'marker of risk', with a non-causal association between the arrhythmia and stroke, the latter being possibly related to atheroemboli from the aorta, the carotid arteries or from other sources.
    International Journal of Clinical Practice 02/2014; · 2.54 Impact Factor
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    ABSTRACT: The OPTI-MIND study aims to collect 2-year clinical outcomes of pacemaker patients in real-world clinical practice, overall and according to patient characteristics and pacemaker settings.METHODS AND RESULTS: The present analysis of the OPTI-MIND study describes the programmed device settings after discharge from the pacemaker implant. The objective was to determine whether these settings fit recent guidelines for device-programmed physiological pacing based on the preservation of atrioventricular synchrony, avoiding unnecessary pacing, ensuring rate increase during exercise or preventing neurally mediated symptoms. A total of 1740 patients were enroled at 68 centres worldwide. Baseline patient characteristics and device programming settings are available in 1674 of 1740 patients (96%). Guidelines to ensure physiological pacing were followed in 41% of patients: in patients with sinus node disease (SND), and without atrioventricular block (AVB), device programming could have led to unnecessary right ventricular pacing in 38% of patients. In SND patients with chronotropic incompetence, assisted rate increase during exercise was not programmed in 42% of patients. In 11% of patients with AVB, atrioventricular (AV) synchrony was not pursued; the main drivers being advanced age and history of atrial fibrillation. Patients with both SND and AVB were generally programmed physiologically (87%).CONCLUSION: The present analysis showed that frequent deviations occurred when comparing the device settings at discharge from the pacemaker implant in clinical practice to the available guidelines on pacing mode selection. Analysis of 2-year outcomes in the OPTI-MIND study will provide an insight into whether specific physiological settings could improve the quality of pacing with a positive effect on patient outcome.
    Europace 02/2014; · 3.05 Impact Factor
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    ABSTRACT: Current guidelines strongly recommend that oral anticoagulation can be offered to patients with atrial fibrillation and ≥1 stroke risk factors. Also, the guidelines recommend that oral anticoagulation should still be used in the presence of stroke risk factors irrespective of rate or rhythm control METHODS AND RESULTS: In an analysis from the dataset of the Euro Observational Research Programme on Atrial Fibrillation (EORP-AF) Pilot survey (n=3119), we examined antithrombotic therapy prescribing, with particular focus on the risk factors determining oral anticoagulation or antiplatelet therapy use. Where oral anticoagulation was used amongst admitted patients in whom no pharmacological cardioversion, electrical cardioversion or catheter ablation was performed or planned, the majority were prescribed Vitamin K Antagonist therapy (72.2%) whilst novel oral anticoagulants were used on the minority (7.7%). There were no significant difference in bleeding risk factors between the patients treated on the different types of antithrombotic therapies, except for chronic kidney disease, where oral anticoagulation was less commonly used (p=0.0318). Antiplatelet therapy was more commonly used in patients with high HAS-BLED score (≥2) (p<0.0001). Higher oral anticoagulation use was associated with female gender(p=0.0245). Less novel oral anticoagulants use was associated with valvular heart disease (p<0.0001), chronic heart failure(p=0.0010), coronary artery disease(p<0.0001) and peripheral artery disease (p=0.0092). Coronary artery disease was the strongest reason for combination therapy with oral anticoagulation plus antiplatelet drug (OR 8.54, p<0.0001). When the CHA2DS2-VASc score was used, 95.6% with a score of ≥1 received antithrombotic therapy, with 80.5% with a score of ≥1 receiving oral anticoagulation. Of note, 83.7% of those with a score ≥2 received Antithrombotic Therapy; of the latter, 70.9% of those with a score ≥2 received oral anticoagulation. Of the latter, Vitamin K Antagonists were used in 64.1% and novel oral anticoagulants in 6.9%. The EORP-AF Pilot survey provides contemporary data on oral anticoagulation prescribing by European cardiologists for atrial fibrillation. Whilst the uptake of oral anticoagulation (mostly Vitamin K Antagonist therapy) has improved since the EuroHeart survey a decade ago, antiplatelet therapy is still commonly prescribed, with or without oral anticoagulation, whilst elderly patients are commonly undertreated with oral anticoagulation.
    The American journal of medicine 01/2014; · 5.30 Impact Factor

Publication Stats

5k Citations
1,780.79 Total Impact Points


  • 1990–2014
    • University of Bologna
      • Institute of Cardiology
      Bolonia, Emilia-Romagna, Italy
  • 2009–2012
    • Istituto Superiore di Sanità
      • Department of Technology and Health
      Roma, Latium, Italy
    • Imperial College London
      • Cardiovascular Sciences
      London, ENG, United Kingdom
  • 2005–2012
    • Hospital Civile Ramazzini
      Carpi, Emilia-Romagna, Italy
    • University of Hamburg
      Hamburg, Hamburg, Germany
    • University of Münster
      • Department of Cardiology
      Münster, North Rhine-Westphalia, Germany
  • 2011
    • Universitätsklinikum Münster
      Muenster, North Rhine-Westphalia, Germany
    • Università commerciale Luigi Bocconi
      Milano, Lombardy, Italy
    • Policlinico San Matteo Pavia Fondazione IRCCS
      Ticinum, Lombardy, Italy
    • Εθνική Σχολή Δημόσιας Υγείας
      Athínai, Attica, Greece
    • University Hospital of Heraklion
      Irákleio, Attica, Greece
  • 2007–2011
    • A.C.O. San Filippo Neri
      Roma, Latium, Italy
    • Policlinico S.Orsola-Malpighi
      Bolonia, Emilia-Romagna, Italy
  • 2005–2011
    • University of Florence
      • Dipartimento di Chirurgia e Medicina Traslazionale (DCMT)
      Florence, Tuscany, Italy
  • 2010
    • University of Geneva
      Genève, Geneva, Switzerland
    • Italian National Institute of Statistics
      Roma, Latium, Italy
    • Galliera Hospital
      Genova, Liguria, Italy
  • 2009–2010
    • Leiden University Medical Centre
      • Department of Cardiology
      Leiden, South Holland, Netherlands
  • 2008–2009
    • Istituto Clinico Humanitas IRCCS
      • Department of Cardiology
      Rozzano, Lombardy, Italy
    • Università degli studi di Foggia
      Foggia, Apulia, Italy
    • Philipps University of Marburg
      Marburg, Hesse, Germany
    • Karolinska Institutet
      • Institutionen för medicin, Huddinge
      Solna, Stockholm, Sweden
  • 1992–2009
    • Università degli Studi di Siena
      Siena, Tuscany, Italy
  • 2006
    • The University of Calgary
      • Libin Cardiovascular Institute of Alberta
      Calgary, Alberta, Canada
  • 2004
    • Ospedale Maggiore Carlo Alberto Pizzardi di Bologna
      Bolonia, Emilia-Romagna, Italy
  • 1990–2001
    • Università degli Studi del Sannio
      Benevento, Campania, Italy