Angelo Branzi

Policlinico S.Orsola-Malpighi, Bolonia, Emilia-Romagna, Italy

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Publications (502)2276.72 Total impact

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    ABSTRACT: Aims: The use of high-sensitivity cardiac Troponin T (hs-cTnT) assay might lead to overdiagnosis and overtreatment of Acute Coronary Syndromes (ACS). This study assessed the epidemiological, clinical and prognostic impact of introducing hs-cTnT in the everyday clinical practice of an Emergency Department. Methods and results: We compared all consecutive patients presenting with suspected ACS at the Emergency Department, for whom troponin levels were measured. In particular, we considered 597 patients presenting during March 2010, when standard cardiac Troponin T (cTnT) assay was used, and 629 patients presenting during March 2011, when hs-cTnT test was used. Patients with suspected ACS and troponin levels above the 99th percentile (Upper Reference Limit, URL) significantly increased when using an hs-cTnT assay (17.2% vs. 37.4%, p< 0.001). Accordingly, also the mean GRACE risk score increased (124.2 ± 37.2 vs. 136.7 ± 32.2; p< 0.001). However, the final diagnosis of Acute Myocardial Infarction (AMI) did not change significantly (8.7% vs. 6.8%, p=0.263) by using a rising and/or falling pattern of hs-cTnT (change ≥ 50% or ≥ 20% depending on baseline values). In addition, no significant differences were found between the two study groups with respect to in-hospital (2.7% vs. 1.9%, p=0.366) and 1-year mortality (9.8% vs. 7.6%, p=0.216). Conclusions: We did not observe overdiagnosis and overtreatment issues in presenters with suspected ACS managed by appropriate changes in hs-cTnT levels, despite the increase in the number of patients presenting with abnormal troponin levels. This occurred without a rise in short-term and mid-term mortality.
    No preview · Article · Aug 2014 · European Heart Journal: Acute Cardiovascular Care
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    ABSTRACT: To evaluate the relationship between ECG patterns and infarct related artery (IRA) in an all-comer population with ST-segment elevation myocardial infarction (STEMI) and validate current criteria for identifying IRA (right coronary artery (RCA) versus left circumflex artery (LCA)) in inferior STEMI and for diagnosing left main (LM) or left anterior descendent artery occlusion (LAD) in anterior STEMI. We retrospectively analysed ECGs at presentation and coronary angiogram in 885 consecutive patients undergoing primary percutaneous coronary intervention. Six ECG patterns were identified: anterior-STEMI (n=433; 49.0%), inferior-STEMI (i=365; 43.0%), lateral-STEMI (n=43; 5.0%), left bundle branch block (n=26; 3.0%), posterior-STEMI (n=7; 1.0%) and de Winter sign (n=7; 1.0%). The last two ECG patterns were univocally associated with LCA and proximal LAD occlusion respectively. In patients with inferior STEMI, predefined ECG algorithms showed high sensitivity(>90%) for RCA occlusion and high specificity(>90%) for LCA. The diagnostic performance was mainly determined by RCA dominance. In anterior STEMI the vectorial analysis of ST deviation in both frontal and horizontal planes could identify patients with LM/proximal LAD occlusion (adjusted-odds ratio for in-hospital mortality =2.45, 95% confidence interval: 1.31-4.56, p = 0.005) with low sensitivity (maximum 60%; using ST-depression in lead II, III, aVF + ΣSTE aVR + V1-ST depression V6≥0) and high specificity (maximum 95%; using ST-depression in inferior leads + ST-depression in V6). In STEMI undergoing primary percutaneous coronary intervention, six ECG patterns can be identified with a non-univocal relationship to the IRA. In inferior STEMI, vectorial analysis of ST deviation identifies IRA with a high appropriateness only when RCA is the dominant artery. In anterior STEMI, criteria derived from both frontal and horizontal planes identify LM/proximal LAD occlusion with high specificity but low sensitivity.
    No preview · Article · Apr 2014
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    Full-text · Dataset · Dec 2013
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    ABSTRACT: The objective was to report recent trends in the incidence, adoption of evidence-based treatment, and clinical outcomes for first-time hospitalization for acute myocardial infarction. This is a large retrospective population-based cohort study using medical administrative data (International Classification of Diseases, Ninth Revision, Clinical Modification, codes) performed in the Emilia-Romagna Region of Italy (approximately 4.5 million inhabitants). We identified 60,673 patients with a first hospitalization for acute myocardial infarction from 2002 through 2009. The standardized incidence rate per 100,000 person-years of acute myocardial infarction increased from 173 cases in 2002 to a peak of 197 cases in 2004 and then decreased each year thereafter to 167 cases in 2009. The proportion of patients who underwent coronary angiography and angioplasty in the acute phase increased over time, respectively, from 45.4% and 27.1% to 72.3% and 57.2% (P < .001). Medication use within 12 months of discharge increased for aspirin, β-blockers, and statins. A reduction in crude and adjusted in-hospital all-cause (16.1% in 2002 vs 12.8% in 2009, P < .001) and cardiovascular mortality (13.6% in 2002 vs 9.5% in 2009, P < .001) was observed over time. At 1 year after hospital discharge, no significant variations occurred in adjusted risk for all-cause mortality or cardiovascular mortality. Notably, crude and adjusted risk for in-hospital and postdischarge bleeding showed a significant increment. The utilization of evidence-based treatments in patients with myocardial infarction increased between 2002 and 2009. These changes in practice over time favored a reduction in early case fatality at the cost of a significant increase in bleeding.
    No preview · Article · Nov 2013 · American heart journal
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    Full-text · Article · Oct 2013 · European Heart Journal
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    ABSTRACT: Purpose: We sought to investigate whether coagulant active Tissue Factor (TF) can be retrieved in thrombi of patients with ST-Segment Elevation acute Myocardial Infarction (STEMI) undergoing primary Percutaneous Coronary Intervention (PCI). Methods: Nineteen patients with STEMI referred for primary PCI were enrolled in this study. Coronary thrombi aspirated from coronary arteries using manual thrombectomy devices were routinely processed for paraffin embedding and histological evaluation (4 patients) or immediately snap frozen for evaluation of TF activity using a modified aPTT test (15 patients). Immunoprecipitation followed by immunoblotting was also performed in 12 patients. Results: Thrombi aspirated from coronary arteries showed large and irregular areas of TF staining within platelet aggregates, and in close contact with inflammatory cells. Some platelet aggregates stained positive for TF, whereas others did not. Monocytes consistently stained strongly for TF, neutrophils had weak and irregular TF staining, and red blood cells did not demonstrate staining for TF. Median clotting time of plasma samples containing homogenized thrombi incubated with a monoclonal antibody that specifically inhibits TF-mediated coagulation activity (mAb 5G9) were significantly longer than their respective controls (88.9 seconds versus 76.5 seconds, respectively; p<0.001). TF was also identified by immunoprecipitation in 10 patients, with significant variability among band intensities. Conclusions: Active TF is present in coronary artery thrombi of patients with STEMI, suggesting that TF may contribute to thrombus growth and propagation during the acute phase of STEMI.
    Full-text · Article · Sep 2013 · PLoS ONE
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    ABSTRACT: First generation drug-eluting stents (DES) which impart the controlled release of sirolimus or paclitaxel from durable polymers to the vessel wall have been consistently shown to reduce the risk of restenosis and target vessel revascularization compared to bare metal stents (BMS). However, stent thrombosis (ST) emerged as a major safety concern with first generation DES early after their adoption in clinical practice, requiring prolonged dual anti-platelet therapy. Pathological studies have shown that first generation DES are associated with delayed arterial healing and polymer hypersensitivity reactions resulting in chronic inflammation, predisposing to late and very late ST. Second generation DES have been developed to overcome these issues with improved stent designs and construction and the use of biocompatible and bioabsorbable polymers. Meta-analyses have shown that the thin-strut, fluoropolymer coated cobalt-chromium everolimus-eluting stent (CoCr-EES) may be associated with lower rates of definite ST than other DES, and unexpectedly, even lower than BMS. The thin-strut structure of the stent platform, the thromboresistant properties of the fluoropolymer, and the reduced polymer and drug load may contribute to the low rate of ST with CoCr-EES. The notion of a DES being safer than a BMS represents a paradigm shift in the evolution of percutaneous coronary intervention. The relative safety and efficacy of fluoropolymer coated CoCr-EES, DES with bioabsorbable polymers and fully bioresorbable scaffolds is the subject of numerous ongoing large-scale trials.
    Full-text · Article · Sep 2013 · Journal of the American College of Cardiology
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    ABSTRACT: IMPORTANCE Type 2 diabetes mellitus and associated chronic kidney disease (CKD) have become major public health problems. Little is known about the influence of diet on the incidence or progression of CKD among individuals with type 2 diabetes. OBJECTIVE To examine the association between (healthy) diet, alcohol, protein, and sodium intake, and incidence or progression of CKD among individuals with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS All 6213 individuals with type 2 diabetes without macroalbuminuria from the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) were included in this observational study. Recruitment spanned from January 2002 to July 2003, with prospective follow-up through January 2008. MAIN OUTCOMES AND MEASURES Chronic kidney disease was defined as new microalbuminuria or macroalbuminuria or glomerular filtration rate decline of more than 5% per year at 5.5 years of follow-up. We assessed diet using the modified Alternate Healthy Eating Index (mAHEI). The analyses were adjusted for known risk factors, and competing risk of death was considered. RESULTS After 5.5 years of follow-up, 31.7% of participants had developed CKD and 8.3% had died. Compared with participants in the least healthy tertile of mAHEI score, participants in the healthiest tertile had a lower risk of CKD (adjusted odds ratio [OR], 0.74; 95% CI, 0.64-0.84) and lower risk of mortality (OR, 0.61; 95% CI, 0.48-0.78). Participants consuming more than 3 servings of fruits per week had a lower risk of CKD compared with participants consuming these food items less frequently. Participants in the lowest tertile of total and animal protein intake had an increased risk of CKD compared with participants in the highest tertile (total protein OR, 1.16; 95% CI, 1.05-1.30). Sodium intake was not associated with CKD. Moderate alcohol intake reduced the risk of CKD (OR, 0.75; 95% CI, 0.65-0.87) and mortality (OR, 0.69; 95% CI, 0.53-0.89). CONCLUSIONS AND RELEVANCE A healthy diet and moderate intake of alcohol may decrease the incidence or progression of CKD among individuals with type 2 diabetes. Sodium intake, within a wide range, and normal protein intake are not associated with CKD. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00153101.
    Full-text · Article · Aug 2013 · JAMA Internal Medicine
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    ABSTRACT: Background: Mitral regurgitation (MR) is one of the most common valvular heart disease with high morbidity and mortality. Recent studies in patients with organic MR emphasized the role of cardiopulmonary exercise test (CPET) and NT-proBNP in predicting need of surgery or hospitalization for atrial fibrillation (AF) and heart failure (HF). Since most part of patients with moderate to severe organic MR have normal cardiopulmonary functional capacity and low NT-proBNP level we sought to evaluate the prognostic role of echocardiographic variables in this setting. Methods: Between September 2006 and December 2012 patients with moderate to severe organic MR (regurgitant volume (RV) > 40 ml) were evaluated. All patients underwent complete echocardiographic evaluation with 3 methods of MR quantification (PISA, doppler and volumetric methods), cardiopulmonary exercise test and NT-proBNP measurement. Only patients with normal CPET (peak VO2 > 85% of predicted) and low NT-proBNP level (<150 pg/ml) were included in the study. First event rates were estimated with the Kaplan-Meier method, Cox proportional hazards modeling for long-term first events predictors Results: Among 78 patients with moderate to severe organic MR evaluated, 31 had normal CPET (peak VO2>85% of predicted) and low NT-pro BNP level (<150 pg/ml) and were included in the study. NT-proBNP was 69±29 pg/ml (median 74 pg/ml, 25%-75% 55-95), peak VO2 was 27±5 ml/kg/min, RV (Regurgitant Volume) mean (average of 3 quantification methods) 55±15 ml/beat, ERO (Effective Regurgitant Orifice) mean 0,30±0,08 cm2, end diastolic left ventricular (EDLV) volume 165±31 ml, EDLV volume/BSA (Body Surface Area) 89±15 ml/m2, end systolic left ventricular (ESLV) volume 43±18 ml, ESLV volume/BSA 23±9 ml/m2; LA volume 77±26 ml, LA volume/BSA 41±11 ml/m2, LV mass 198±34 g, LV mass/BSA 106±14 g/m2.19 patients (41%) underwent surgery correction of MR and 4 patients (10%) developed new AF. At univariate analysis predictors of need of surgery and/or AF were LV mass (p=0,01), E velocity (p=0,001), EDLV volume (p<0,001), ESLV volume (p=0,001), ERO mean (0<0,001), RV mean (p<0,001). Independent predictors of need of surgery/AF were E velocity (p<0,001), ESLV volume (p=0,02), ERO mean (p=0,006), RV mean (p=0,002) Conclusions: In patients with moderate to severe organic mitral regurgitation, normal cardiopulmonary functional capacity and low NT-proBNP level, E velocity, ESLV volume, ERO, RV, RV/LA volume ratio and PVF reversal are strictly related to need of surgery and/or new AF during follow-up and should be carefully assessed and evaluated.
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Purpose: Intra-aortic balloon pump (IABP) is increasingly used among patients with end-stage heart failure (HF) but its efficacy in successfully bridging candidates to heart transplantation (HTx) and effective transplant benefit of patients receiving IABP are unexplored. Herein we compare success rate in achieving HTx and post-transplant survival between transplant candidates who needed IABP support and those stabilized with medical therapy. Methods: All HTx candidates followed between 1998 and 2012 were eligible for this retrospective study. Outcome events were: transplant, death/deterioration while on waiting list, improved and excluded from transplant program. Kaplan Meyer method was used to analyze the occurrence of events. Results: Out of 585 patients included, 35 (6%) needed IABP while 550 (94%) could be managed by medical therapy alone. Mean age was similar in the two groups (50.8±13.5 vs. 50.3±14.4 ys). As expected, need for IABP identified patients at significantly higher risk for mortality (estimated 2-year death rate: 30±3% vs 55±20%, p < 0.01). Of note IABP in progressive deteriorating chronic HF showed 100% mortality rate 3 months after support placement, whereas those who needed IABP for acute HF as initial presentation had 10% death rate during the same span of time. Thanks to listing prioritization, succes rate in achieving HTX in IABP patients was similar to medically treated, with about 80% of patients transplanted in both groups. Importantly, ten-year estimated post-transplant survival was similar in the two groups (68±3 vs. 60±15%, p=0.8; Figure 1).
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Purpose: Atrial fibrillation (AF) is a frequent complication of acute coronary syndromes (ACS). Most AF studies in ACS have been done in patients presenting with ST-segment elevation (STE-ACS) whereas those including non- ST-segment elevation cases (NSTE-ACS) are few. Actually, there is little information about the prognostic yield of AF across the whole spectrum of ACS. Furthermore, the available data come from clinical trials, so their extension to the real world is uncertain. The aim of this study was to evaluate the prognostic impact of AF on the short-, mid- and long-term outcome in the whole spectrum of ACS, including both STE-ACS and NSTE-ACS. Methods: 2046 consecutive patients hospitalized at our Institution for ACS (896 STE-ACS and 1150 NSTE-ACS) between 2004-2006 were followed up for 5 years after discharge. The whole population was divided into two groups according to the presence of AF during index hospitalization. Clinical outcomes were divided into the acute phase (0– 30 days) and the chronic phase (landmark analysis at 30 days-1 year and 1 year - 5 years). AF was identified during the hospital stay, regardless of its time of onset. The relationship between AF and clinical outcomes was evaluated by multivariable Cox regression analysis. Results: Overall, AF during hospitalization occurred in 190 patients (9.3%): 4.9% STE-ACS and 12.7% NSTE-ACS (p<0.01). Patients with AF were older and had a higher prevalence of cardiovascular risk factors and comorbidities such as chronic kidney disease and COPD; they were more likely to present with Killip class III/IV and less likely to undergo PCI/CABG. 30-day, 1-year and 5-year mortality rates were higher for patients with AF than for those without: 18.7% vs. 4.5%, 34.2% vs. 19.7%, 69.6% vs 41.9%, respectively (all p < 0.001). Similar trends were seen both in STE-ACS and NSTE-ACS, within each time window. After adjusting for confounders, the association of AF with 30-day mortality was not confirmed (HR 1.028, 95% CI 0.65-1.63, p = 0.9), whereas AF independently affected both mid-term (30 day-1 year, HR 1.45, 95% CI 1.03-2.04, p = 0.03) and long-term mortality (1-year – 5 years, HR 1.48, 95% CI 1.15-2.25, p = 0.02). Similar results were found for both STE-ACS and NSTE-ACS. Conclusions: Although AF identifies a worse prognosis in all patients with ACS, its independent role appears only in the medium and long run, irrespective of the electrocardiographic presentation (STE/NSTE).
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Background: Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH) patients. It is unclear whether the outcome of patients with inoperable CTEPH is influenced by the use of pulmonary arterial hypertension (PAH)-specific drugs. Aim: To compare the survival of operable CTEPH patients who underwent PEA (OP-PEA), inoperable CTEPH patients medically treated with PAH-specific drugs (INOP-MT) and a control group of inoperable untreated CTEPH patients (INOP-C) in a single center. Methods: Between July 1996 and February 2013 we included 261 consecutive patients with CTEPH. All patients underwent right heart catheterization and 6-minute walk test (6MWT). Kaplan-Meier curves were used to estimate the survival of the three groups. Results: The mean follow-up period was 43±37 months. One hundred and nine patients were included in the OP-PEA group, 118 in the INOP-MT group and 34 in the INOP-C group. In the INOP-MT group, 54 patients received phosphodiesterase type-5 inhibitors, 36 endothelin receptor antagonists, 5 prostanoids and 23 combination therapy. Age was 63±14, 64±17 and 57±16 years in INOP-C, INOP-MT and OP-PEA respectively (P = 0.063 and < 0.001 for OP-PEA vs INOP-C and INOP-MT respectively). Baseline 6MWT was 324±125, 354±138 and 387±123 m in INOP-C, INOP-MT and OP-PEA respectively (P = 0.042 and 0.057 for OP-PEA vs INOP-C and INOP-MT respectively). Pulmonary Vascular Resistance was 9.9±5.9, 9.8±4.9 and 9.7±0.4 WU in INOP-C, INOP-MT and OP-PEA respectively (NS). Kaplan-Meier survival of the three groups is reported in the table. View this table:Enlarge table
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Background: Thromboembolic events (TE), especially ischemic stroke (IS), are serious complications of cardiac surgery. TE incidence was reported mostly after coronary artery bypass grafting but is less known after surgery for mitral regurgitation (MR), particularly for organic MR. We sought to evaluate risk and predictors of TE after surgery for organic MR, making comparison between mitral repair (MRep), mechanical mitral valve replacement (MVRm) and biological mitral valve replacement (MVRb) Methods: In 228 patients (age 57±12 years), consecutively operated for organic MR (procedures: 149 MVRm, 14 MVRb and 65 MRep) between January 1980 and December 2005 at the University Hospital, Bologna, TE and IS during follow-up were assessed. Event rates were accounted for by yearly linearized rates, expressed in percent per year±SE. Cox proportional hazards modeling was used to define long-term first events predictors. Logistic regression was used to predict first events at specific intervals. Results: TE occurred in 43 patients, 33 in MVRm, 3 in MVRb and 7 in MRep; IS occurred in 27 patients, 23 in MVRm, 1 in MVRb and 3 in Mrep. 30% of patients had history of atrial fibrillation (AF), 36% in MVRm, 14% in MVRb and 17% in MRep (p=0,008). Early (< 30 post-op days) TE incidence was 5%, 5% in MVRm, 7% in MVRb and 5% in MRep (P=0,1). After 15 years MRep had the lowest TE incidence, 12±4%, compared with MVRm, 24±4% and MVRb, 26±13% (p=0,08). MRep had the lowest long term incidence of IS, 5±3% after 15 years, compared with MVRm, 15±4%, and MVRb, 20±17% (p=0,07). TE yearly linearized-rate was 1,25±0,1%PY, higher in MVRm, 1,5±0,1%PY, and MVRb, 1,4±0,1% compared to MRep 0,7±0,1% PY (p=0,04). Independent predictors of TE long-term were age (p=0,01) and history of AF (p=0,05). Predictor of early TE was history of AF associated to post-op AF (p=0,02) Conclusion: MRep provides the lowest long term TE and IS rates and is confirmed as the preferred correction of organic MR. Despite chronic anticoagulation therapy MVRm shows notable TE risk and is least desirable for MR correction. Age and AF were risk factors for TE long-term emphasizing the need of early surgical correction. In the early post-operative period incidence of TE was similar in the different groups and was influenced mostly by AF: aggressive anticoagulant therapy should be evaluated in this setting.
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Purpose: Although atrial fibrillation (AF) is a well known complication of amyloidotic cardiomyopathy (AC), a precise clinical, pathophysiological and prognostic characterization is not available. The aim of our study was to evaluate prevalence, incidence, risk factors for AF and prognostic significance of AF in the three main etiological subgroups of AC: light-chain (AL), hereditary transthyretin-related (ATTR) and non-mutant transthyretin-related (wtTTR). Methods: We studied 255 patients with AC (121 AL, 92 ATTR, 42 wtTTR) and assessed clinical, ECG, echocardiographic and hemodynamic details at presentation. Results: Prevalence of AF at first evaluation was 15% overall: 9% in AL, 11% in ATTR and 40% in wtTTR. During a median follow up of 1.2 (IQR 0.4–2.9) years, seven other patients developed AF (1.5% person-years). At univariate analysis, age (OR 1.1, 95% CI 1.05–1.13), NYHA class III-IV (OR 4.12, 95% CI 1.99–8.55), wtTTR etiology (OR 6.8, 95% CI 2.84–16.30), left ventricular ejection fraction (LVEF) (OR 0.95, 95% CI 0.93–0.98), right atrial pressure (OR 1.13, 95% CI 1.04–1.23) and pulmonary capillary wedge pressure (OR 1.07, 95% CI 1.01–1.14) were significantly (p<0.01) associated with the risk of AF. At multivariate analysis however, only age (OR 1.08, 95% CI 1.04–1.14), LVEF (OR 0.96, 95% CI 0.93–0.99) and right atrial pressure (OR 1.14, 95% CI 1.03–1.26) remained associated as independent variables. Left ventricular wall thickness was not associated with AF in any of the three etiological subgroups. Warfarin was prescribed to all AF patients and none suffered thromboembolic events. AF was not associated with an increased mortality even though survival free from heart failure was significantly lower in patients with AF in the ATTR (event rate 14.6% vs 1.1% person-years, p=0.0001) and wtTTR groups (event rate 15.2% vs 5.4% person-years, p=0.05). Conclusions: Prevalence of AF at presentation was 15% in the entire cohort, with a maximum rate of 40% in wtTTR patients. Left ventricular systolic and diastolic dysfunction, but not wall thickness, were associated with AF. AF was an incremental risk factor for mortality or heart failure in patients with TTR-related amyloidosis.
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Purpose: Autosomal dominant inheritance of germline mutations of the bone morphogenetic protein receptor type 2 (BMPR2) gene are a major risk factor for heritable pulmonary arterial hypertension. In fact, germline mutations in BMPR2 have been found in familial as well as in clinically sporadic forms of idiopathic pulmonary arterial hypertension. This study was performed to investigate the rate of BMPR2 gene mutations in cases with clinically familial or sporadic IPAH followed in a single center and to evaluate the correlation between genotype and phenotype. Methods: Tests for BMPR2 mutations were performed in 238 IPAH patients (22 with a family history of and 216 clinically sporadic). Clinical and haemodynamic characteristics were compared between BMPR2 mutation carriers (BMPR2+) and not-carriers (BMPR2-). Results: We identified mutations in 17 of 22 (77%) patients with a family history and in 38 of 216 (18%) with clinically sporadic IPAH patients. A BMPR2 mutation was also identified in 45 of 140 unaffected relatives (32%) who accepted to undergo the test. The mean age was 36±13 years in BMPR2+ (n=55) patients and 45±20 in BMPR2 – (n=183) (p<0.0001). The right atrial pressure was 8±4 mmHg in BMPR2+ and 7±5 mmHg in BMPR2- (p 0.4); mean pulmonary arterial pressure was 59±13 mmHg in BMPR2+ and 54±16 mmHg in BMPR2- (p 0.03); pulmonary vascular resistance was 15±7 WU in BMPR2+ and 12±8 WU in BMPR2- (p 0.019); cardiac index was 2.4±0.7 L/min/m2 in BMPR2+ and 2.7±0.9 L/min/m2 in BMPR2- (p 0.017). 6MWD was 445±97 meters in BMPR2+ and 395±121 meters in BMPR2- (p 0.002). Survival at 1, 3 and 5 years was 98%, 94% and 86% in BMPR2 – patients and 98%, 95% and 92% in BMPR2+ patients (P=0.9). Conclusion: The presence of a BMPR2 mutation in patients with IPAH (either clinically familial or sporadic) is associated with a younger age and a more severe hemodynamic impairment at diagnosis but not with a worse exercise capacity and prognosis. The younger age of BMPR2+ patients may explain the similar survival and exercise capacity despite a worse haemodynamics as compared with BMPR2- patients.
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: The presence of cerebrovascular disease (CVD) in patients with stable coronary artery disease is associated with an increased long-term mortality. However, prognostic significance of CVD in patients with acute coronary syndrome (ACS) is less well understood, especially in the long run. Purpose: To evaluate the effect of the presence of CVD on long-term outcome of a large cohort of unselected patients hospitalized for ACS. Methods: Between 2004 and 2006, 2046 consecutive patients were hospitalized at our Institution for ACS (896 STE-ACS and 1150 NSTE-ACS). They were followed up for 5 years after discharge. The whole population was divided into two groups according to the presence of CVD. CVD was designated for patients with a history of prior stroke. The main study endpoint was 5-year all-cause mortality. The Kaplan Meyer method was used to analyze the occurrence of death in the two study groups and Log-rank test was used for comparison. Multivariable Cox regression analysis was then performed. Results: CVD had been diagnosed in 128 (6.3%%) of the 2.046 patients. Patients with CVD had higher prevalence of hypertension, diabetes mellitus and chronic kidney disease and were significantly less likely to undergo PCI/CABG. 5-year mortality rate was significantly greater among the patients with CVD compared to those without CVD (69.8% vs 41.3%, p<0.001). After adjusting for baseline clinical, laboratory findings, medication and interventions, CVD remained an independent predictor of 5-year mortality (HR 1.59, 95% confidence interval 1.24-2.04, p<0.001).
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Background: The efficacy of Bosentan (B) and Sildenafil (S) for the treatment of PAH appears to be similar according to specific randomized controlled trials. Limited data is available on the direct comparison between these two drugs. Objectives: to compare short-term hemodynamic and functional data and long-term outcome of PAH patients treated with first-line B (125 mg bid) or first-line S therapy (20 mg tid). Methods: From November 2006 to January 2013 consecutive naïve patients were randomized to receive B or S. Short-term analysis was made by clinical assessment, 6-minute walk test [6MWT] and right-heart catheterization [RHC] at baseline and after 4.1±1.2 months of therapy. In the long-term comparison we evaluated time to clinical worsening defined as the time from randomization to the first occurrence of death (all causes), hospitalization for worsening of PAH or addition of any specific therapy for PAH. Statistical analysis: Wilcoxon-Mann-Whitney test and Kaplan-Meier method. Results: 205 PAH patients were randomized: 100 to the B group (mean age 55±17; 41% idiopathic-PAH [IPAH]; 24% PAH associated with congenital heart disease [PAH-CHD]; 18% PAH associated with connective tissue disease [PAH-CTD]; 11% PAH associated with portal hypertension [PoPAH]; 6% PAH associated with HIV infection [PAH-HIV]) and 105 to the S group (mean age 53±17; 40% IPAH; 20% PAH-CHD; 21% PAH-CTD; 14% PO-PAH; 5% PAH-HIV). Twenty patients (20%) in the B group and 13 (12%) in the S group did not complete the short term evaluation because of death, adverse events, protocol violations, lack of hemodynamic data or were lost to follow-up. Eighty patients in the B group and 92 in the S group completed the short term study; no statistically significant differences were found in hemodynamics and 6MWT median percent changes among the two treatments. In the long-term study the mean duration of follow up was 26±18 months. The event-free survival estimates at 1, 2 and 3 years were 64%, 51% and 41% in B group and 70%, 60% and 47% in S group (P=0.366), respectively. At 1, 2, and 3 years 81%, 72% and 61% patients in B group and 83%, 73% and 64% in S group (P=0.852) had no hospitalizations or mortality for all causes. The overall survival estimates at 1, 2 and 3 years were 89%, 79% and 71% in B group and 90%, 86% and 81% in S group (P=0.287), respectively. Conclusions: Short and long term comparison between first line treatment with S or B did not show statistically significant differences in clinical, exercise capacity, hemodynamic and outcome parameters.
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: Purpose: Little is known about the occurence of heart failure (HF) and its impact on all-cause mortality after hospital discharge for acute coronary syndrome (ACS). Moreover, as far as long-term follow-up is concerned, few data are available especially in a "real world" context. The aim of this study was to evaluate the impact of HF on mid-term and long-term mortality after ACS in an unselected cohort of patients, with special reference to the comparison between STE vs NSTE presentation. Methods: 2046 consecutive patients hospitalized for ACS in 2004-2006 were enrolled. 5-year follow-up was available for 1703 patients (734 STE, 969 NSTE). The impact of HF during follow-up was evaluated by the rate of cause-specific death at mid-term (1 year) and long-term (5 years), in the whole population and in STE/NSTE groups as well. Results: The mean age was 71.6±13.0 years. Patients with NSTE-ACS were older and had a higher prevalence of atrial fibrillation, Killip class III-IV and comorbidities compared to patients with STE-ACS. Primary PCI was performed in 84% of STE-ACS and 70% of NSTE-ACS were managed invasively. At 1 year HF-related death rate was similar in STE-ACS and NSTE-ACS (2.1% vs. 3.2%, p = 0.72). Overall, during the 5-year follow-up, all-cause death occurred in 737 (43.2%) patients: 296 (40.3%) in the STE group and 441 (45.5%) in the NSTE group (p = 0.07). At 5 years 85 (5.0%) patients died due to HF, 29 (4.0%) in the STE group and 56 (5.8%) in the NSTE group (p 0.09). HF-related death was responsible for 11.5% of all-cause mortality (STE 9.8%; NSTE 12.7%). Of note, non-cardiovascular causes accounted for 34% of all deaths in the whole population. View this table:Enlarge table
    Preview · Article · Aug 2013 · European Heart Journal
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    ABSTRACT: HLA antibodies (HLA ab) in transplant candidates have been associated with poor outcome. However, clinical relevance of noncytotoxic antibodies after heart transplant (HT) is controversial. By using a Luminex-based HLA screening, we retested pretransplant sera from HT recipients testing negative for cytotoxic HLA ab and for prospective crossmatch. Out of the 173 consecutive patients assayed (52 ± 13y; 16% females; 47% ischemic etiology), 32 (18%) showed pretransplant HLA ab, and 12 (7%) tested positive against both class I and class II HLA. Recipients with any HLA ab had poorer survival than those without (65 ± 9 versus 82 ± 3%; P = 0.02), accounting for a doubled independent mortality risk (P = 0.04). In addition, HLA-ab detection was associated with increased prevalence of early graft failure (35 versus 15%; P = 0.05) and late cellular rejection (29 versus 11%; P = 0.03). Of the subgroup of 37 patients suspected for antibody mediated rejection (AMR), the 9 with pretransplant HLA ab were more likely to display pathological AMR grade 2 (P = 0.04). By an inexpensive, luminex-based, HLA-screening assay, we were able to detect non-cytotoxic HLA ab predicting fatal and nonfatal adverse outcomes after heart transplant. Allocation strategies and desensitization protocols need to be developed and prospectively tested in these patients.
    Full-text · Article · Jul 2013 · Journal of Transplantation
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    ABSTRACT: Background: Although some trials have reported that on-pump coronary artery bypass graft (CABG) surgery may be associated with higher rates of stroke than percutaneous coronary intervention (PCI), whether stroke is more common after off-pump CABG compared with PCI is unknown. We therefore sought to determine whether off-pump CABG is associated with an increased risk of stroke compared with PCI by means of network meta-analysis. Methods: Randomized controlled trials (RCTs) comparing CABG vs PCI were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. Results: Eighty-three RCTs with 22,729 patients randomized to on-pump CABG (n = 10,957), off-pump CABG (n = 7,119), or PCI (n = 4,653) were analyzed. Thirty-day rates of stroke were significantly lower in patients treated with PCI compared with either off-pump CABG (odds ratio [OR]; 0.39, 95% CI, 0.19-0.83) or on-pump CABG (OR, 0.26; 95% CI, 0.12-0.47). Compared with on-pump CABG, off-pump CABG was associated with significantly lower 30-day risk of stroke (OR, 0.67; 95% CI, 0.41-0.95). However, in sensitivity analyses restricted to high-quality studies, studies with more than either 100 or 1,000 patients, or studies with protocol definition or adjudication of stroke by a clinical events committee, the precision of the point estimate for the 30-day risk of stroke between off-pump vs on-pump CABG was markedly reduced. Conclusions: Percutaneous coronary intervention is associated with lower 30-day rates of stroke than both off-pump and on-pump CABG. Further studies are required to determine whether the risk of stroke is reduced with off-pump CABG compared with on-pump CABG.
    No preview · Article · Jun 2013 · American heart journal

Publication Stats

10k Citations
2,276.72 Total Impact Points

Institutions

  • 1996-2013
    • Policlinico S.Orsola-Malpighi
      Bolonia, Emilia-Romagna, Italy
  • 1982-2013
    • University of Bologna
      • • Institute of Cardiology
      • • Department of Biomedical Science and Neuromotor Sciences DIBINEM
      Bolonia, Emilia-Romagna, Italy
  • 2009
    • Azienda Ospedaliero Universitaria Foggia
      Foggia, Apulia, Italy
  • 1988-2003
    • Università degli Studi di Siena
      Siena, Tuscany, Italy
  • 1999
    • Università degli Studi G. d'Annunzio Chieti e Pescara
      Chieta, Abruzzo, Italy
  • 1998
    • Cineca
      Casalecchio di Reno, Emilia-Romagna, Italy
  • 1988-1993
    • Università Politecnica delle Marche
      Ancona, The Marches, Italy
  • 1984
    • Università degli Studi del Sannio
      Benevento, Campania, Italy