Giornale italiano di cardiologia : organo ufficiale della Federazione italiana di cardiologia : organo ufficiale della Società italiana di chirurgia cardiaca
-
G Ital Cardiol (Rome) · Jul 2012
[Coronary stenting and surgery: perioperative management of antiplatelet therapy in patients undergoing surgery after coronary stent implantation].
The management of antiplatelet therapy in patients with coronary stents undergoing surgery is a growing clinical problem and often represents a matter of debate between cardiologists and surgeons. It has been estimated that about 4-8% of patients undergoing coronary stenting need to undergo surgery within the next year. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. ⋯ A consensus on the most appropriate antiplatelet regimen in the perioperative phase has been reached on the basis of the ischemic and hemorrhagic risk. Dual antiplatelet therapy should not be withdrawn for surgery at low bleeding risk, whereas aspirin should be continued perioperatively in the majority of surgical operations. In the event of interventions at high risk for both bleeding and ischemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be considered.
-
G Ital Cardiol (Rome) · Jul 2012
Review[Aspirin in primary prevention of cardiovascular diseases: how to balance risks and benefits].
While the use of aspirin in the secondary prevention of cardiovascular atherothrombotic disease is well established, many aspects of primary prevention are still unclear. Uncertainties mostly depend on a doubtful risk-benefit ratio, because of the low atherothrombotic risk of populations involved on the one hand, and the non-negligible bleeding risk of treatment on the other. ⋯ Based on the results of a number of clinical trials and meta-analyses, and especially considering the absolute figures of the benefit (major cardiovascular events avoided) and of the harm (major bleeding events occurred related to aspirin), the authors recommend to limit primary cardiovascular prevention with aspirin (in apparently healthy subjects with no previous cardiovascular events) to subjects with an estimated global cardiovascular risk ≥2 major cardiovascular events per 100 patients-year, as assessed by the risk score assessments proposed in the Italian "Progetto Cuore" (www.progettocuore.it). This cut-off should also be adopted for primary prevention in patients with type 2 diabetes and/or asymptomatic peripheral arterial disease.
-
The role of a gender effect (that means differences in clinical manifestations, access to therapies and response to treatments according to gender) in cardiomyopathies remains a matter of debate. Although recent studies have evaluated the differences in the clinical features and prognosis between the two sexes, many issues remain to be elucidated. At present, the only sex-specific condition that affects females is peripartum cardiomyopathy. ⋯ Conversely, women who are symptomatic before pregnancy or have severe hypertrophy with important outflow tract gradient are at higher risk and should be referred to a tertiary center to be evaluated on a case by case basis. Pregnancy in women with dilated cardiomyopathy and significant left ventricular systolic dysfunction represents a high-risk condition. In addition, information on the clinical course and potential complications in pregnant women with arrhythmogenic right ventricular cardiomyopathy or restrictive cardiomyopathy is limited to individual reports.
-
G Ital Cardiol (Rome) · Jun 2012
Comparative Study[Female gender and pulmonary arterial hypertension: a complex relationship].
Pulmonary arterial hypertension (PAH) is a severe clinical condition defined as mean pulmonary artery pressure ≥25 mmHg and normal pulmonary capillary wedge pressure (≤15 mmHg). In PAH the increase in pulmonary pressure is due to an intrinsic disease of the small pulmonary arteries (resistance vessels) characterized by vascular proliferation and remodeling. The increase in pulmonary vascular resistance with subsequent elevation of the right ventricular afterload leads to right ventricular failure after variable periods of time. ⋯ As such, the current clinical recommendation is that pregnancy should strongly be discouraged and if it occurs, early termination is advised. When PAH is not diagnosed until late in pregnancy, close follow-up of the mother is mandatory and elective planned delivery is recommended: care of pregnant women with PAH requires a highly planned, multidisciplinary approach, involving obstetricians, pulmonary hypertension specialists, anesthesiologists and intensivists, preferably in a dedicated PAH referral center. Use of female hormones for birth control and postmenopausal replacement therapy in PAH patients still remains controversial; in fact, although it has been suspected to be a trigger factor for PAH development, a formal association based on case-control studies has not been documented.