Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era

Abstract

Abstract

Aims: To evaluate the impact of the COVID-19 pandemic on patient admissions to Italian cardiac care units (CCUs).

Methods and results: We conducted a multicentre, observational, nationwide survey to collect data on admissions for acute myocardial infarction (AMI) at Italian CCUs throughout a 1 week period during the COVID-19 outbreak, compared with the equivalent week in 2019. We observed a 48.4% reduction in admissions for AMI compared with the equivalent week in 2019 (P < 0.001). The reduction was significant for both ST-segment elevation myocardial infarction [STEMI; 26.5%, 95% confidence interval (CI) 21.7-32.3; P = 0.009] and non-STEMI (NSTEMI; 65.1%, 95% CI 60.3-70.3; P < 0.001). Among STEMIs, the reduction was higher for women (41.2%; P = 0.011) than men (17.8%; P = 0.191). A similar reduction in AMI admissions was registered in North Italy (52.1%), Central Italy (59.3%), and South Italy (52.1%). The STEMI case fatality rate during the pandemic was substantially increased compared with 2019 [risk ratio (RR) = 3.3, 95% CI 1.7-6.6; P < 0.001]. A parallel increase in complications was also registered (RR = 1.8, 95% CI 1.1-2.8; P = 0.009).

Conclusion: Admissions for AMI were significantly reduced during the COVID-19 pandemic across Italy, with a parallel increase in fatality and complication rates. This constitutes a serious social issue, demanding attention by the scientific and healthcare communities and public regulatory agencies.

Full text

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Reduction of hospitalizations for myocardial
infarction in Italy in the COVID-19 era
Salvatore De Rosa
1,2†
, Carmen Spaccarotella
1,2†
, Cristina Basso
1,3
,
Maria Pia Calabro`
1,4
, Antonio Curcio
1,2
, Pasquale Perrone Filardi
1,5
,
Massimo Mancone
1,6
, Giuseppe Mercuro
1,7
, Saverio Muscoli
1,8
, Savina Nodari
1,9
,
Roberto Pedrinelli
1,10
, Gianfranco Sinagra
1,11
, and Ciro Indolfi
1,2
*; on behalf of
Societa` Italiana di Cardiologia and the CCU Academy investigators group
1
Italian Society of Cardiology, Via Po 24, 00198 Rome, Italy;
2
Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy;
3
Cardiovascular Pathology
Unit, University of Padua, Padua, Italy;
4
Department of Human Pathology, University of Messina, Messina, Italy;
5
Department of Advanced Biomedical Sciences, Federico II
University, Naples and Mediterranea Cardiocentro, Naples Italy
6
Sapienza University of Rome, Rome, Italy;
7
Department of Medical Sciences and Public Health, University of
Cagliari, Cagliari, Italy;
8
Department of Medicine, ‘Tor Vergata’ University of Rome, Rome, Italy;
9
Department of Cardiology, University of Brescia and ASST Spedali Civili di
Brescia, Brescia, Italy;
10
Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy; and
11
Cardiovascular Department, University of Trieste, Trieste, Italy
Received 7 April 2020; revised 23 April 2020; editorial decision 29 April 2020; accepted 29 April 2020
Aims To evaluate the impact of the COVID-19 pandemic on patient admissions to Italian cardiac care units (CCUs).
........................................................................ ............. ............. ............. .................. ......................................................... .........
Methods
and Results
We conducted a multicentre, observational, nationwide survey to collect data on admissions for acute myocardial
infarction (AMI) at Italian CCUs throughout a 1 week period during the COVID-19 outbreak, compared with the
equivalent week in 2019. We observed a 48.4% reduction in admissions for AMI compared with the equivalent
week in 2019 (P< 0.001). The reduction was significant for both ST-segment elevation myocardial infarction
[STEMI; 26.5%, 95% confidence interval (CI) 21.7–32.3; P= 0.009] and non-STEMI (NSTEMI; 65.1%, 95% CI 60.3–
70.3; P< 0.001). Among STEMIs, the reduction was higher for women (41.2%; P= 0.011) than men (17.8%; P=
0.191). A similar reduction in AMI admissions was registered in North Italy (52.1%), Central Italy (59.3%), and
South Italy (52.1%). The STEMI case fatality rate during the pandemic was substantially increased compared with
2019 [risk ratio (RR) = 3.3, 95% CI 1.7–6.6; P< 0.001]. A parallel increase in complications was also registered (RR
= 1.8, 95% CI 1.1–2.8; P= 0.009).
........................................................................ ............. ............. ............. .................. ......................................................... .........
Conclusion Admissions for AMI were significantly reduced during the COVID-19 pandemic across Italy, with a parallel increase
in fatality and complication rates. This constitutes a serious social issue, demanding attention by the scientific and
healthcare communities and public regulatory agencies.
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Keywords COVID-19 •SARS-CoV2 •Acute myocardial infarction •STEMI •Cardiac care units
Introduction
The ongoing pandemic caused by the novel SARS-CoV-2 has al-
ready been associated with thousands of deaths worldwide. Italy
was one of the first Nations in Europe to be affected.
1
During
data collection, the most affected area in Italy was the north of
the country, where the healthcare system was overwhelmed
with the huge number of patients in need of mechanical ventila-
tion or intensive care.
2
As a way to contain the disease, the gov-
ernment established a stepwise strategy starting from the
complete lockdown of initial foci in northern Italy on 20
February 2020 and subsequent adoption of progressively more
stringent lockdown measures of the entire nation as of 11
March.
3,4
* Corresponding author. Tel : þ39 06 85355854, Fax: þ39 06 84081665, E-mail: indolfi@unicz.it, Twitter Handle: @SIC_CARDIOLOGIA
†
These authors contributed equally to this work.
Published on behalf of the European Society of Cardiology. All rights reserved. V
CThe Author(s) 2020. For permissions, please email: journals.permissions@oup.com.
European Heart Journal (2020) 0, 1–6 CLINICAL RESEARCH
doi:10.1093/eurheartj/ehaa409
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Already during the initial outbreak, many healthcare workers
noticed a reduction in patient admissions for acute myocardial infarc-
tion (AMI), raising concern among cardiologists across Italy.
Methods
We conducted a multicentre, observational, nationwide survey aimed at
evaluating consecutive patients with AMI admitted to Italian intensive car-
diac care units (CCUs) throughout a 1 week period during the COVID-
19 outbreak in Italy: 12–19 March. The same data were also collected for
the equivalent week of 2019. All consecutive AMI patients admitted dur-
ing the 1 week window were included, independently of their age. AMI
was defined according to the Fourth Universal Definition of Acute
Myocardial Infarction.
5
Major complications were defined as cardiogenic
shock, life-threatening arrhythmias, and cardiac rupture/ventricular septal
defect (VSD) or severe functional mitral regurgitation.
Data were analysed for two pre-specified groups of patients: (i) ST-
segment elevation myocardial infarction (STEMI); and (ii) non-ST-
segment elevation MI (NSTEMI). Additional analyses were planned on
patients with CCU admission for heart failure (HF), atrial fibrillation (AF),
failure of the implantable device (DF), and pulmonary embolism (PE),
even though the collection of these data was optional.
The Italian Society of Cardiology (Societa` Italiana di Cardiologia, SIC)
invited all affiliated and associated Italian hospitals to participate through
the CCU Academy network (https://www.sicardiologia.it/sito/publicFiles/
2019_11_27_Roma_UTIC%20programma.pdf) including academic and
non-academic hospitals with CCUs receiving AMI patients.
Data collection and data quality
Data on the number of patients admitted for each of the above-reported
diagnoses at CCUs were recorded, along with patients’ age and gender.
Collection of data about patients admitted for AMI in both 1 week peri-
ods in 2020 and 2019 was mandatory for participation in this survey.
Information on admission for HF, AF, DF, and PE was optional, together
with the total delay from symptom onset to coronary angiography and
the time from first medical contact to revascularization for STEMI
patients.
At each site, a coordinating investigator was responsible for screening
consecutive patients admitted to the CCU and for data collection. Data
were collected at single centres from their institutional records using
case report forms provided by the coordinating unit. Data on CCU
admissions and patient-related information were cross-checked against
records of catheterization laboratories and COVID-19 wards of the
same institution. Centres that did not use electronic records of admis-
sions were asked to verify data with their Department of Management.
After collection, participating centres submitted filled-in case report
forms to the coordinating unit at Magna Graecia University, in charge of
reporting all data onto the central electronic database. Data were finally
checked for missing or contradictory entries and for values out of the
normal range at the coordinating centre.
Statistical analysis
Categorical variables are presented as absolute numbers, percentages,
and risk ratio (RR) with 95% confidence interval (95% CI), and compared
by the v
2
test. Continuous variables are presented as mean and standard
deviation (SD) and compared by the Student’s t-test, and weighted re-
gression analysis was used to assess the impact of factors on case fatality
and complication rates. IBM SPSS Statistics 23 was used for all analyses.
Results
A total of 54 hospitals participated in the study. Of these, 28 (51.9%)
were academic hospitals and 26 (48.1%) non-academic hospitals.
Among them, 48 (88.9%) were coordinating hubs within the STEMI
network, 51 (94.4%) had cardiac catheterization facilities, and 32
(59.3%) had a cardiac surgery unit.
A total of 319 AMIs were registered during the 2020 week, with a
48.4% reduction (95% CI 44.6–52.5) compared with the equivalent
week in 2019 (P< 0.001), when 618 patients were hospitalized for
thesamediagnosis(Figure 1). More detailed results are reported in
Table 1. Looking at single subgroups, weekly STEMI admissions were
reduced from 268 in 2019 to 197 in 2020 (26.5% reduction; 95% CI
21.7–32.3; P= 0.009). No difference was registered in mean patient
age (65.1% in 2019 vs. 66.5 in 2020; P= 0.495). Within the STEMI
Figure 1 Admissions for acute myocardial infarction across Italy.
The figure reports the number of admissions registered among
Italian cardiac care units (CCUs) during the week 12–19 March 2020,
in the midst of the COVID-19 emergency (yellow bars) and during
thesameweekofthepreviousyear(bluebars)forcomparison.
Figure 2 Case fatality rates for acute myocardial infarction. The
figure reports case fatality rates among patients admitted for AMI
during the week 12–19 March 2020, in the midst of the COVID-19
emergency (yellow bars) and during the same week of the previous
year (blue bars).
2
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subgroup, a lower proportion of women were registered in 2020
(20.3%) compared with 2019 (25.4%) (P< 0.001). The reduction of
admissions for STEMI was higher among women (41.2%; P= 0.011)
than men (17.8%; P= 0.191). The reduction in admission for STEMI
was comparable among academic (21.5%) and non-academic hospi-
tals (19.5%) (P= 0.473). Coronary angiography rates were compar-
able between 2020 and the previous year (94.9% vs. 94.5%; P=
0.562).
The STEMI case fatality rate during the pandemic was substantially
increased to 13.7% compared with the4.1% registered in 2019 (RR =
3.3, 95% CI 1.7–6.6; P<0.001)(Table 2). Major complications were
registered in 18.8% of cases in 2020 and in 10.4% in 2019 (RR = 1.8,
95% CI 1.1–2.8; P=0.025)(Table 3).
Among STEMI patients, 21 (10.7%) were SARS-CoV2 positive.
The case fatality rate among SARS-CoV2-positive STEMIs was sub-
stantially higher (28.6%) compared with all other STEMI patients reg-
istered during the same week in 2020 (11.9%). Nevertheless, the
STEMI fatality rate in 2020 remained significantly higher than in 2019
even after excluding SARS-CoV2-positive patients (P= 0.018).
Both patient- and system-related declared delays were substantial-
ly increased during the COVID-19 outbreak. In fact, the time from
symptom onset to coronary angiography was increased by 39.2% in
2020 compared with the equivalent week in 2019, while the time
from first medical contact to coronary revascularization was
increased by 31.5%.
Weekly hospitalizations for NSTEMI went down from 350 in 2019
to 122 in 2020 (65.4% reduction; 95% CI 60.3–70.3; P<0.001)
(Figure 1). No difference was registered in mean patient age (68.9 in
2019vs.69.6in2020;P= 0.812). The proportion of female patients
among NSTEMI cases was similar in 2020 (29.8%) and 2019 (30.9%).
The reduction of admission for NSTEMI was also similar among
women (66.7%; P< 0.001) and among men (65.4%; P<0.001).The
proportion of NSTEMI patients undergoing percutaneous coronary
intervention (PCI) was reduced by 13.3% (P= 0.023) from 2019
(76.7% of NSTEMIs) to 2020 (66.1% of NSTEMIs). The reduction in
admissions for NSTEMI was comparable among academic (66.4%)
and non-academic hospitals (58.7%) (P= 0.163). The NSTEMI case
fatality rate was 3.3% during the pandemic, compared with 1.7% in
2019 (RR = 1.9, 95% CI 0.5–6.7; P= 0.309). Major complications
were registered in 10.7% of cases in 2020 and in 5.1% in 2019 (RR =
2.1, 95% CI 1.05–4.1; P= 0.037). Among NSTEMI patients, 12 (9.8%)
were SARS-CoV2 positive. No deaths were registered among these.
Since the time course of the COVID-19 outbreak was not syn-
chronous across Italy, we divided the country into three macro-areas
to look for possible variations. However, a similar reduction in AMI
admissions was registered in North Italy (52.1%), Central Italy
(59.3%), and South Italy (52.1%).
A similar reduction in hospitalizations was also registered for HF.
In fact, only 82 patients were hospitalized for HF during the 2020
week, compared with 154 during the equivalent week in 2019 (46.8%
................................................ ................................................
....................................................................................................................................................................................................................
Table 1 Admissions for specific diagnoses
2019 2020
Centres Adm Sex
F
Age Adm Sex
F
Age Change 95%CI P-value
AMI 54 618 176 67.1 ± 9.5 319 76 68.0 ± 9.0 48.4% 44.6–52.5 <0.001
STEMI 54 268 68 65.4 ± 9.7 197 40 66.5 ± 10.2 26.5% 21.7–32.3 0.009
NSTEMI 54 350 108 68.9 ± 9.3 122 36 69.6 ± 8.1 65.1% 60.3–70.3 <0.001
HF 50 154 59 72.3 ± 10.1 82 30 72.9 ± 9.7 46.8% 39.5–55.3 0.005
AF 48 88 29 70.0 ± 7.5 41 17 64.6 ± 12.3 53.4% 43.9–64.9 0.017
DF 49 19 6 76.9 ± 5.4 7 3 70.6 ± 15.2 63.2% 0.45–0.89 0.349
PE 34 17 6 69.1±13.3 12 2 70.8 ± 11.2 29.4% 0.14–0.61 0.667
Absolute number of patients admitted during the 2019 (light blue columns) and the 2020 (yellow-shaded columns) index weeks are reported, along with sex and age.
Percentage change in admissions in 2020 compared with 2020 is reported (Change). 95% confidence intervals (95% CI) are also reported, followed by the P-value.
Every line reports data on a single disease: AMI = acute myocardial infarction; STEMI = ST-segment elevation myocardial infarction; NSTEMI = non-ST-segment elevation myo-
cardial infarction; HF = heart failure; AF = atrial fibrillation; DF = device failure; PE = pulmonary embolism; Adm = admissions; Sex
F
= number of females.
................ .... .. .. .... .. .. .... .. ............................ .... .. .. ..
....................................................................................................................................................................................................................
Table 2 Case fatality rate
2019 2020
Centres Adm Dead (%) Adm Dead (%) RR (95%CI) P-value
AMI 54 618 17 (2.8) 319 31 (9.7) 3.6 (2.0–6.4) <0.001
STEMI 54 268 11 (4.1) 197 27 (13.7) 3.3 (1.7–6.6) <0.001
NSTEMI 54 350 6 (1.7) 122 4 (3.3) 1.9 (0.5–6.7) 0.309
Absolute number of patients admitted and the number of deaths during the 2019 (light blue columns) and the 2020 (yellow-shaded columns) index weeks are reported. Risk
ratios are reported in the next column, together with their 95% confidence intervals (95% CI), followed by the P-value.
Every line reports data on a single disease: AMI = acute myocardial infarction; STEMI = ST-segment elevation myocardial infarction; NSTEMI = non-ST-segment elevation myo-
cardial infarction; Adm = admissions; RR = risk ratio.
AMI during COVID-19 in Italy 3
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reduction, 95% CI 39.5–55.3; P= 0.005). The mean age of HF patients
was 72.3 ± 10.1 years in 2019 and 72.9 ± 9.7 in 2020 (P= 0.769). The
reduction of admissions for HF was similar among men (44.1%; P=
0.017) and women (49.2%; P=0.010).
A substantial reduction in hospitalizations was noted for AF. In
fact, a total of 41 AF-related hospitalizations were registered during
the 2020 week, with a 53.4% reduction (95% CI 43.9–64.9) com-
pared with the equivalent week in 2019 (P= 0.017), when 88 patients
were hospitalized for the same diagnosis. The mean age of AF
patients was 70.0 ± 7.5 years in 2019 and 64.6 ± 12.3 in 2020 (P=
0.139).
Finally, a 29.4% reduction (95% CI 0.45–0.89) was registered for
DF (P= 0.349) while a 63.2% reduction (95% CI 0.14–0.61) was
found for PE (P=0.667).
Discussion
The main finding of the present study is the dramatic reduction in
the number of hospitalizations for AMI across Italy during the
COVID-19 pandemic. In fact, admissions for AMI were halved dur-
ing the pandemic compared with the equivalent period of the pre-
vious year. The identification of the mechanisms leading to the
reduction in admissions for myocardial infarction are beyond the
scope of the present work. Nevertheless, it is tempting to specu-
late that probably a multiplicity of factors, rather than a unique
mechanism, contributed to the phenomenon. First, it is possible
that the fear of contagion at the hospital has discouraged access to
emergency medical services (EMS), particularly after the media dif-
fused the news that the infection was largely spread across hospi-
talized patients and healthcare personnel due to the lack of
personal protection equipment. The similar reduction in AMI
admissions across Italy, despite the fact that one might have
expected a stronger impact in the North, the most affected area,
seems to point in that direction.
2
A second hypothesis is linked to
the fact that the emergency medical system was focused on
COVID-19 and most healthcare resources were relocated to man-
age the pandemic. This might have induced an attitude towards de-
ferral of less urgent cases, at both the patient and the healthcare
system levels. In line with this hypothesis, the reduction in hospital-
izations for STEMI (26.5%) was less striking than with NSTEMI
(65.1%). These results are in line with contemporary findings,
where an estimated 38% reduction in STEMI activations was
reported by US cardiac catheterization laboratories,
6
while a 40%
reduction was noticed in Spain.
7
Of note, this seems to also be
true for the in-hospital management of AMI patients. In fact, des-
pite the proportion of patients undergoing primary PCIs remaining
very high among those admitted for STEMI also during the
COVID-19 pandemic, the rate of PCI performed among admitted
NSTEMI patients dropped significantly. Despite some CCUs being
switched to COVID-19 beds, the reduction of admission for AMI
was not linked to the lack of non-COVID-19 beds, as CCU beds in
non-COVID-19 areas remained available. Finally, we cannot com-
pletely exclude that a true reduction in the incidence of acute car-
diovascular disease as the potential result of low physical stress
and widespread prevalence of the resting state during the quaran-
tine, especially in the initial phase of the social containment, might
have partly contributed to the lower number of admissions for
AMI. However, this latter hypothesis is not entirely in line with the
delay that we and others observed between symptom onset and
hospital admissions for STEMI.
8
It should also be pointed out that in this COVID-19 outbreak, the
time from first medical contact to coronary revascularization was
substantially increased in STEMI patients. This is a very important
issue since it has been previously demonstrated that primary PCI and
reperfusion therapies are necessary, but not sufficient: the efficiency
of the care pathway in expediting each step of the process matters
tremendously for STEMI patients,
10–13
butisalsoveryrelevantto
other coronary syndromes.
14
In this regard, the substantial increase
in case fatality and complication rates observed during the pandemic
points in the same direction.
These data return a frightening picture of about half of AMI
patients not reaching out to the hospital at all, which will probably sig-
nificantly increase mortality for AMI and bring with it a number of
patients with post-MI HF, despite the fact that acute coronary syn-
drome management protocols were promptly implemented.
15
In
addition to that, the higher case fatality and major complication rates
registered during the hospitalization in this report must sound an
alarm bell to healthcare professionals and public regulatory agencies.
The higher reduction of admissions for STEMI among women
(41.2%) compared with men (25.4%) extends the proportion of the
problem, as the already intolerable gender gap in the treatment of
AMI is further widened by this social emergency and will most prob-
ably result in a further increase in cardiovascular mortality and mor-
bidity among women.
10,11
The lower admission rate for HF (46.8%),
PE (63.2%), DF (29.4%), and AF (53.4%) is also worrisome.
............................................. ......................................... ....
....................................................................................................................................................................................................................
Table 3 Major complications rates
2019 2020
Centres Adm Complications Adm Complications RR (95%CI) P-value
AMI 54 618 46 (7.4) 319 50 (15.7) 2.1 (1.4–3.1) <0.001
STEMI 54 268 28 (10.4) 197 37 (18.8) 1.8 (1.1–2.8) 0.009
NSTEMI 54 350 18 (5.1) 122 13 (10.7) 2.1 (1.05–4.1) 0.037
Absolute number of patients admitted and the number of major complications during the 2019 (light blue columns) and the 2020 (yellow-shaded columns) index weeks are
reported. Risk ratios are reported in the next column, together with 95% confidence intervals (95% CI), followed by the P-value.
Every line reports data on a single disease: AMI = acute myocardial infarction; STEMI = ST-segment elevation myocardial infarction; NSTEMI = non-ST-segment elevation myo-
cardial infarction; Adm = admissions; RR = risk asratio.
4
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Study limitations
Collecting clinical data during a pandemic emergency is challenging
and is exposed to several risks. First, the organization of in-hospital
cardiology assistance has certainly been impacted by the situation, as
many hospitals underwent functional reorganization to assist
COVID-19 patients. For this reason, to avoid under-reporting, we
asked participating centres to cross-check their records against
records from their catheterization laboratories and COVID-19
wards, as well as with their medical management. Nevertheless, a re-
sidual risk might have persisted. Secondly, the management of the
pandemic drained most resources, and extensive data collection was
not possible, especially during the initial phase. For this reason, we
had no choice but to leave out non-essential but potentially relevant
variables, such as infarct size, clinical risk scores, or the time from
symptom onset to admission for NSTEMI cases. For the same reason,
the study period was limited to 2 weeks. Despite no relevant differ-
ences in weather conditions and no environmental alerts being
recorded between those weeks in 2019 and 2020, the use of such a
short period for data collection still represents a source for potential
bias. Finally, as this is an observational study, we just describe a phe-
nomenon. No demonstration of cause can be drawn from this study.
In conclusion, while healthcare systems along with public opinion,
media, and patients were focused on the COVID-19 pandemic, a
worrying reduction in admissions for AMI was observed across Italy
with a parallel increase in case fatality and complication rates. Timely
adoption of countermeasures must be considered to avoid a large
and long-standing social impact.
Acknowledegements
We thank all participating centres and the researchers that collected
the data: Filippo Angelini (CCU, AOU S. Giovanni Battista, Turin),
Francesco Barilla`(CCU B ‘A. Reale’, Umberto I University Hospital,
Rome), Antonio Bartorelli (Centro Cardiologico Monzino, IRCCS
and Department of Biomedical and Clinical Sciences ‘Luigi Sacco’,
University of Milan, Milan), Francesco Benedetto (Bianchi Melacrino
Morelli Hospital, Reggio Calabria), Paola Bernabo`(Ospedali
Galliera, Genova), Leonardo Bolognese (CCU, Ospedale S.
Donato,Arezzo),MartinaBriani (CCU, Humanitas Research
Hospital, Rozzano), Luisa Cacciavillani (Azienda Ospedaliera,
Padova), Alice Calabrese (CCU, ASST Papa Giovanni XXIII,
Bergamo), Paolo Calabro`(CCU,AORNS.AnnaeS.Sebastiano,
Vanvitelli University, Caserta), Luigi Caliendo (CCU, ASL Napoli 3 -
Nola), Leonardo Calo`(Policlinico Casilino, Rome), Gianni Casella
(UTIC, Ospedale Maggiore, AUSL Bologna, Bologna), Gavino Casu
(CCU, Ospedale S. Francesco, Nuoro), Claudio Cavallini (AO di
Perugia, Perugia), Quirino Ciampi (CCU, AO ‘Fatebenefratelli’,
Benevento), Marco Ciccone (CCU, Policlinico di Bari, University of
Bari,Bari),MicheleComito (CCU,OspedaleG.Jazzolino,Vibo
Valentia), Elena Corrada (CCU, Humanitas Research Hospital,
Rozzano), Filippo Crea (CCU, Policlinico A. Gemelli, Catholic
University,Rome),AntonelloD’Andrea (CCU, ‘Umberto I’
Hospital, Nocera Inferiore), Maurizio D’Urbano (CCU, Ospedale di
Legnano, Legnano), Raffaele De Caterina (CCU, CCU AOU
Pisana, University of Pisa), Gaetano De Ferrari (CCU, AOU S.
Giovanni Battista, Turin), Roberto De Ponti (CCU, OSPEDALE
ASST Sette Laghi, Varese), Alessio Della Mattia (CCU, AAS 5
‘Friuli Occidentale’, Pordenone), Carlo Di Mario (CCU, AOU
Careggi, University of Florence, Firenze), Luca Donnazzan (CCU,
Ospedale di Bolzano, Bolzano), Giovanni Esposito (CCU, AOU
Policlinico Federico II, Federico II University, Naples), Francesco
Fedele (CCU A, Umberto I University Hospital, Rome), Alessandro
Ferraro (CCU, AO Pugliese Ciaccio, Catanzaro), Gennaro Galasso
(CCU, AOU S. Giovanni di Dio e Ruggi D’aragona, Salerno),
Nazzareno Galie`(AOU S. Orsola, University of Bologna, Bologna),
Massimiliano Gnecchi (Policlinico S. Matteo, Univeristy of Pavia,
Pavia), Paolo Golino (CCU, University Vanvitelli, Naples), Bruno
Golia (CCU, Clinica Mediterranea, Naples), Pasquale Guarini (Villa
dei Fiori Hospital, Acerra), Ciro Indolfi (AOU Mater Domini, Magna
Graecia University, Catanzaro), Sergio Leonardi (Policlinico S.
Matteo, Univeristy of Pavia, Pavia), Nicola Locuratolo (CCU,
Ospedale S. Paolo, Bari), Francesco Luzza (AOU Policlinico G.
Martino, University of Messina, Messina), Vincenzo Manganiello
(CCU, AO S. Giuseppe Moscati, Aversa), Maria Francesca
Marchetti (CCU, AOU D. Casula, Monserrato), Giancarlo
Marenzi (Centro Cardiologico Monzino, IRCCS and Department of
Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan,
Milan), Alberto Margonato (CCU, Ospedale San Raffaele,
University of Milan, Milan), Luigi Meloni (CCU, University Cagliari,
Cagliari), Marco Metra (Spedali Civili, Brescia University, Brescia),
Marco Milo (CCU,ASUGI,UniversityofTrieste,Trieste),Annalisa
Mongiardo (AOU Mater Domini, Magna Graecia University,
Catanzaro), Luca Monzo (Policlinico Casilino, Rome), Carmine
Morisco (CCU, AOU Policlinico Federico II, Federico II University,
Naples), Savina Nodari (Spedali Civili, Brescia University, Brescia),
Giuseppina Novo (CCU, AOUP P. Giaccone, University Palermo,
Palermo), Stefano Pancaldi (UTIC 1, AOU S. Orsola, University of
Bologna, Bologna), Matteo Parollo (CCU, CCU AOU Pisana,
University of Pisa), Giovanni Paterno`(CCU,AOS.Carlo,Potenza),
Giuseppe Patti (CCU, Ospedale Maggiore, UPO, Novara), Silvia
Priori (Policlinico S. Matteo, Univeristy of Pavia, Pavia), Amelia
Ravera (CCU, AOU S. Giovanni di Dio e Ruggi D’aragona, Salerno),
Antonio Giuseppe Rebuzzi (CCU, Policlinico A. Gemelli, Catholic
University, Rome), Massimo Rossi (CCU, Ospedale di Locri), Marino
Scherillo (CCU,AORNS.Pio,Benevento),FrancoSemprini
(UTIC 1, AOU S. Orsola, University of Bologna, Bologna), Michele
Senni (CCU, ASST Papa Giovanni XXIII, Bergamo), Gerolamo
Sibilio (CCU, AO S. Maria delle Grazie, Pozzuoli), Gianfranco
Sinagra (CCU, ASU GI, University of Trieste, Trieste), Massimo
Siviglia (Bianchi Melacrino Morelli Hospital, Reggio Calabria),
Corrado Tamburino (CCU, University of Catania), Gianfranco
To r t o r i c i (UTIC, Ospedale Bentivoglio, AUSL Bologna, Bologna),
Francesco Vers a c e (CCU,OspedaleS.MariaGoretti,Latina),Bruno
Villari (CCU, AO ‘Fatebenefratelli’, Benevento), Massimo Vol p e
(CCU, AO Sant’Andrea University Hospital, Rome).
Conflict of interest: none declared.
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