Giornale italiano di cardiologia : organo ufficiale della Federazione italiana di cardiologia : organo ufficiale della Società italiana di chirurgia cardiaca
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G Ital Cardiol (Rome) · Oct 2018
[ANMCO position paper on sacubitril/valsartan in the management of patients with heart failure].
Sacubitril/valsartan, the first-in-class angiotensin receptor neprilysin inhibitor (ARNI), is the first medication to demonstrate a mortality benefit in patients with chronic heart failure and reduced ejection fraction (HFrEF) since the early 2000s. Sacubitril/valsartan simultaneously suppresses renin-angiotensin-aldosterone system activation through blockade of angiotensin II type 1 receptors and enhances the activity of vasoactive peptides including natriuretic peptides, through inhibition of neprilysin, the enzyme responsible for their degradation. In the landmark PARADIGM-HF trial, patients with HFrEF treated with sacubitril/valsartan had a 20% reduction in the primary composite endpoint of cardiovascular death or heart failure hospitalization, a 20% lower risk of cardiovascular death, a 21% to 20% lower risk of a first heart failure hospitalization, and a 16% to 20% lower risk of death from any cause, compared with subjects allocated to enalapril (all p<0.001). ⋯ In this position paper, we discuss the current role of sacubitril/valsartan in the management of chronic HFrEF, treatment eligibility and the modulating role of patients' characteristics. Moreover, we address concerns elicited by the PARADIGM-HF study and shortcomings of this novel drug, to clarify the place of this new therapy in the context of global care of heart failure in Italy. Our aim is to provide clinical cardiologists with a concise and practical guidance on when and how to use sacubitril/valsartan, to assist clinicians in closing the gap between scientific innovation and real-world experience.
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G Ital Cardiol (Rome) · Oct 2018
Review[Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome].
Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome is a difficult challenge because of the need of taking into consideration three different issues: the cardiac ischemic risk related to coronary artery disease and its treatment with angioplasty and stenting; the thromboembolic risk associated with atrial fibrillation; and the hemorrhagic risk related to the combined use of antiplatelet therapy (with one or two agents) and oral anticoagulant therapy. Data from many trials and meta-analyses currently support a combination therapy with oral anticoagulants (vitamin K antagonists or direct oral anticoagulants) and antiplatelet agents (aspirin and clopidogrel in dual or single antiplatelet therapy). Recently completed and ongoing trials aim to tackle the still controversial issues of this therapy: the choice of the anticoagulant agent and its dosage; the choice of the antiplatelet agent; the use of single or dual antiplatelet therapy and its duration.