Abstract Scope. The aim of the study was to evaluate how the Covid–19 state of emergency affected the activity of the Syncope Unit (SU). During the lockdown, the outpatient activities of the SU were suspended(1). Materials. From March 2020 to March 2021, approximately 95 patients booked for the Tilt–up test were medically evaluated by teleconsultation and televiewer. Vasovagal syncope (VVS) (61%), orthostatic hypotension (OH) (5%) was diagnosed. The patients were trained, through television and video tutorials, in the use of counter pressure maneuvers (PCM) and tilt training, while dietary indications were provided and the importance of adequate oral hydration and the need to take, as recommended by the guidelines, 2–3l of water per day. We retrospectively observed the result at the end of the lockdown period: patients with VVS and OH called by the SU no longer needed to perform tilt up tests because they had obtained a significant reduction in syncope in 90% of cases. Discussion Reflex syncope is the most frequent, representing 21% of all types of syncope (2). Accurate history and physical examination are necessary for the diagnosis, sometimes a guided path in the SU in the unexplained forms. The indicated therapy is non–pharmacological (increase the salt and water content in the diet, avoid triggers, tilt training)(2) and, especially in young people, has been shown to prevent recurrences(2). Back pressure maneuvers (PCM) are effective in preventing syncope(3); oral hydration increases blood volume and improves symptoms(4). Conclusions The Covid–19 state of emergency, through the use of telemedicine tools, has made it possible to reach the diagnosis of reflex syncope through an accurate anamnestic evaluation, has allowed patients to be reassured about the benignity of the events and has motivated patients to implement the recommended non–pharmacological therapies. This has made it possible to reduce the number of tilt tests to be performed when the SU reopens.

54–year–old woman with a family history of systemic sclerosis, with no significant cardiological history. She underwent anti–Covid vaccination in February and March 2021 with Spikevax (Moderna) and a booster dose (Spikevax) on 09/12/21. A few hours after this last administration, the patient presented with palpitations, asthenia, and intermittent chest tightness. In the following days, because of dyspnea for mild exertion, she went to the emergency department. ECG showed low QRS voltages in the peripheral leads, poor septal r wave growth and negative T waves in inferior leads and from V3 to V6. Echocardiography showed akinesia of apical and middle segments, LVEF 40%, mitral obstructive systolic anterior motion, moderate mitral regurgitation and mild pericardial effusion. In blood tests: increase in myocardiospecific enzymes and NTproBNP, modest increase in indices of inflammation. The patient was admitted to Cardiology Unit, where coronary angiography showed coronary arteries free from stenosing lesions and Takotsubo–like appearance on ventriculography. Cardiac MRI confirmed alterations in parietal kinetics, hyperintensity in the STIR sequences referable to apical and middle segments edema compatible with Takotsubo cardiomyopathy (CMT). Capillaroscopy excluded scleroderma pattern. The patient presented a progressive reduction of troponins and, the echocardiogram before discharge showed improved LV systolic function, regression of mitral obstructive systolic anterior motion with reduction of mitral regurgitation. Rare case reports of CMT after influenza vaccination [1] and a similar case to the one we described after Spikevax vaccine [2] and ChAdOx1 nCov–19 (AstraZeneca) [3] have been presented in the literature. The underlying pathophysiological mechanism appears to be related to a stress–induced systemic reaction with a predominantly adrenergic sympatho–vagal imbalance [4]. In this clinical setting, cardiac MRI can offer added value in the diagnostic process, especially to exclude post–vaccine myocarditis, which in our case seemed unlikely given the immediate onset of symptoms.

Abstract Background Dual antiplatelet therapy (DAPT) has important implications for clinical outcomes in coronary disease. Nevertheless, the risk for bleeding often impact on the long–term administration of DAPT. The aim of this study was to evaluate the determinants of bleeding risk after ACS. Methods This was a subanalysis of the PONTE ACS study. The PONTE ACS study is a prospective, longitudinal, cohort study which enrolled patients who were discharged from HUB centres of ASL BARI after coronary revascularization and/or ACS. They underwent clinical evaluation at 30 days, 3, 6 and 1 year–follow–up. The data were collected after including the data in the electronic medical record of the PONTE ACS study. Anthropometric, clinical and pharmacological parameters, instrumental and laboratory examinations were included. Data were computed in order to evaluate the major determinants of all–cause bleeding at one–year follow–up. Results We finally enrolled 2476 patients (77.4% male, mean age: 67.2±12.0 years). Pharmacological treatments were optimized during the follow–up visits. According to anti–thrombotic therapies, 92.1% of patients persisted on DAPT at one–year follow–up. The number of patients on DAPT+anticoagulant were: 4.4%. All–cause bleeding occurred in 2.2% of patients. Anthropometric characteristics (height [β: –0.04594 ± 0.01610, p = 0.0044] and weight [β: –0.03043 ± 0.01035, p = 0.033]), male gender [β: –0.7008 ± 0.2818, p = 0.0129], and age [β: 0.02535 ± 0.01219, p = 0.0376] were the major determinants of all–cause bleeding at univariate regression analysis but they were not confirmed at multivariate regression analysis (p=ns). Kaplan Meier curve points out the impact of age on all–cause bleeding (Figure 1). Nor DAPT or triple therapy remained associated with all–cause bleeding at one year follow–up. Conclusions Long–term DAPT is not a predictor of all–cause bleeding in patients who suffered ACS and/or coronary revascularization.

Pregnancy may predispose to paroxysmal supraventricular tachycardia ( SVT ), in subjects with or without identifiable heart disease. Many physiological conditions such as autonomic nervous system changes, altered systemic hemodynamics, etc. can contribute to the onset of arrhythmias during pregnancy. Some cases reported the occurrence of arrhythmias in relation to systemic fluid variations. We report the case of a pregnant woman who experienced SVT due to fluid depletion, detected by bioimpedance vector analysis ( BIVA ), which was successfully treated by water repletion under tight BIVA monitoring. Emergency physicians can overcome dangerous drug administration by considering historical examination and using fast and reproducible techniques such as BIVA .

Acute chest pain in patients referring to emergency room (ER) may derive from several causes [ [1] Kohn M.A. Kwan E. Gupta M. Tabas J.A. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med. 2005; 29: 383-390 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar ]. Major cardiovascular disease such as acute coronary syndrome, pulmonary embolism and aortic dissection, however, account cumulatively for less than 8% of all ER visits for chest pain [ [1] Kohn M.A. Kwan E. Gupta M. Tabas J.A. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med. 2005; 29: 383-390 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar ].

Background Our study investigates whether rheumatic autoimmune conditions are associated with an increased Carotid Intima-Media Thickness (C-IMT) when compared with healthy control subjects and evaluates possible discrepancies existing among the different rheumatic diseases types. Methods A total of 108 patients, 15 males and 93 females, aged between 18 and 82 years (mean age 51±14 years), fulfilling the ACR criteria for SLE, APS, SSc, PM/DM, MCTD, SS attending the Rheumatology Unit at Univeristy of Bari – Policlinico, were recruited between November 2010 and March 2011. Patients were subdivided into the following two groups: 1) Group SSc (Sclerodermic patients): 60 patients, 7 males and 53 females, mean age 52±14 years; 2) Group NoSSc (Non-Sclerodermic patients): 48 patients, 8 males and 40 females, mean age 50±15 years. We also enrolled 108 healthy controls, matched by sex and age with patients. All patients underwent to structured interview, physical examination, laboratory evaluation and two-dimensional echo-color Doppler of the carotid arteries. Results There were no significant differences between SSc and NoSSc regarding any of the demographics and traditional cardiovascular risk factors, except from total cholesterol that was significantly higher in SSc group, compared with the NoSSc group. The mean duration of disease since diagnosis was 8 (range 3 to 13) years, comparable in the two groups (a little longer in NoSSc). Total cholesterol was significantly higher in SSc patients (mean value 224, range 196-252 mg/dL) than in NoSSc patients (mean value 203, range 194-212 mg/dL). HDL cholesterol value was slightly raised, if compared with a cut-off value of 45 (mean value 47, range 37-57 mg/dL), and was substantially similar in the two groups. Idem for LDL and triglycerids values that were a little raised in comparison with the cut-off values. The distribution of cardiovascular risk factors was similar in the two groups. We found a mean C-IMT value of 0.86 mm (range 0.73 to 0.99 mm) that resulted from the following values: 0.91±0.1 mm in SSc group, 0.80±0.14 in NoSSc group. The difference between groups was significant (p-value <0.05). We also evaluated C-IMT in control subjects, obtaining the following result: 0.83±0.13 mm. The percentage of carotid plaques in each group was 12% for SSc and 17% for NoSSc, with a mean value of 14%. Conclusions We found no signs of increased atherosclerosis, as assessed by C-IMT measurement, among patients with rheumatic autoimmune diseases and healthy controls, and a strong evidence of higher risk in patients with SSc respect to patients with SLE, PM/DM, APS, MCTD and SS. Considering the current state of knowledge, the necessity of optimising prevention and treatment of CVD in patients with systemic rheumatic disease, in particular way those affected by SSc, must be emphasised. A comprehensive identification of cardiovascular risk profile in those diseases is an opportunity to improve prognosis of these patients, since most of the identified risk factors are susceptible of modification. Certainly, further researches are favourable in order to improve life duration and cardiovascular outcomes of these patients. Disclosure of Interest None Declared

We report the case of a 22 year-old-male patient affected by Sotos syndrome was preoperatively and urgently evaluated for tracheal stent implantation due to respiratory insufficiency caused by idiopathic tracheal stenosis.Rest electrocardiogram detected a ventricular pre excitation; a transthoracic echocardiography showed a classic pattern fulfilling criteria for isolated left ventricular non compaction.At the best of our knowledge this is the first report of a patient suffering from Sotos syndrome and simultaneously affected by isolated left ventricular non compaction and ventricular pre excitation.

Purpose: According to the literature, estradiol has a direct vasodilator action by means of endothelium-derived relaxing factor synthesis. The present study aims to evaluate the acute hemodynamic effects of intranasal 17-β-estradiol on cerebral and lower limb arterial circulation in postmenopausal women. Methods: Sixteen healthy women in natural menopause (mean age: 54 ± 3 years) were investigated for at least 6 months, each receiving 300 µg of intranasal 17-β-estradiol. We evaluated the heart rate, systolic/diastolic blood pressure, peak systolic velocity, end-diastolic velocity, and velocity–time integral (VTI) at the level of internal carotid and posterior tibial arteries, before and after 30, 60, and 180 minutes of drug administration. Results: After intranasal 17-β-estradiol administration, the internal carotid artery VTI showed statistically significant ( P < .05) variations at all the time intervals after administration of the drug (30, 60, and 180 minutes) when compared with “time zero” (T0, ie, the speed recorded at baseline before drug administration). No significant variation was found at the posterior tibial artery. The systolic/diastolic blood pressure and heart rate did not significantly differ before and after drug administration. Conclusions: The administration of a single intranasal dose of 17-β-estradiol in healthy postmenopausal women increased cerebral perfusions, whereas the effect on peripheral circulation was much more limited.

We describe a rare case of multiple coronary artery-left ventricular fistulas associated with apical hypertrophic cardiomyopathy in a 62 year asymptomatic old male admitted to our department for a perioperative evaluation of non cardiac surgery, already diagnosed for multiple coronary artery-left fistulae.He underwent transthoracic echocardiography and then to accelerated dipiridamole stress-echo.The case is interesting because rise up the question of a possible differential diagnosis between angina due to the natural history of hypertrophic cardiomyopathy or due to a coronary steal.Furthermore, the association between apical hypertrophic cardiomyopathy and coronary fistula is very rare and doubts still remain about a common origin of such a cardiac muscle disease and fistula presences: further cases allow us to understand the real incidence of this morphological picture.Transthoracic echocardiography could be a good basic technique able to outline both apical hypertrophic cardiomyopathy and fistula, while stress echocardiography improve hemodynamic evaluation of the fistula.

AIMSDolichocarotids(DCs) represent a rare(2-6%) carotid imaging finding in the general population that may be free of clinical significance or be associated with cerebrovascular events. Their detection is traditionally assigned to carotid echo-color Doppler(ECD) and selective angiography(the standard method). The primary aim of this study was to estimate the sensitivity, specificity and accuracy of ECD in detecting DCs. Moreover, we monitored the DC curvature angle and the incidence of TIA, ischemic stroke, myocardial infarction and cardiovascular death over a five-year followup period.METHODSA total of 112 consecutive patients with DCs(80 men, mean age: 61±7 years) were recruited for carotid ECD and carotid angiography due to the persistence of neurological symptoms not well explained on ultrasound evaluations, according to the current guidelines.RESULTSECD proved to have 100% sensitivity in detecting tortuosity and coiling and 96% sensitivity in detecting kinking, with an overall accuracy ranging from 92% to 100%. The specificity was 75% for tortuosity, 91% for kinking and 100% for coiling. During the five-year follow-up period, there was a statistically significant increase in tortuosity(61±11° at baseline versus 81±11° after five years, p＜0.001) and the kinking curvature angle(97±3° at baseline versus 100±3° at five years, p＜0.001), whilst no differences were observed with respect to coiling(136±10° at baseline versus 138±11° at five years, p=ns). Moreover, kinking was found to be more frequently statistically associated with cardiovascular death than tortuosity(p=0.005).CONCLUSIONSDCs predispose patients to potentially disabling and fatal events. ECD plays a primary role in the detection of DCs and therefore should be considered to be a secure and reproducible technique.

Obstructive sleep apnea syndrome (OSAS) in children can induce endothelial dysfunction, a well-known early marker of atherosclerosis. The study aimed to evaluate a link among endothelial function (measured by flow-mediated vasodilation (FMD)), obesity (evaluated by body mass index (BMI)), and sleep disordered breathing (SDB), assessed with apnoea/hypopnoea index (AHI), in a paediatric population. We demonstrated that our little OSAS patients showed an impaired endothelial function as compared to controls. In particular, the higher the AHI, the worst the FMD values and thus the endothelial function. Although the population sample is small, this study demonstrated that OSAS could impair endothelial function and worsen cardiovascular risk profile since childhood.

Background: Aim of our study was to investigate whether rheumatic autoimmune diseases are associated with an increased Carotid Intima-Media Thickness (C-IMT) and to evaluate possible discrepancies existing among the single pathological identities. Methods: This study involved a total of 216 subjects, 108 patients with systemic rheumatic diseases and 108 healthy controls. Our patients (15 males, age 51±14 yrs), all fulfilling the ACR criteria for rheumatic autoimmune diseases were subdivided into two groups: 1) Group SSc (Sclerodermic pts): 62 patients (7 males, age 52±14 yrs); 2) Group NoSSc (Non-Sclerodermic pts): 46 patients (8 males, age 51±14 yrs). All patients underwent to structured interview, physical examination, laboratory evaluation and echo-color Doppler of the carotid arteries. Results: We found that total cholesterol (TC) was higher in patients than controls (207±36 vs. 174±31 mg/dL, p<0.05), as well as LDL-C (131±30 vs. 104±29 mg/dL, p<0.05) and triglycerides (148±65 vs. 99±40 mg/dL, p<0.05). HDL-C was significantly lower, indeed, in patients than controls (47±10 vs. 50±10 mg/dL, p<0.05). Blood fasting glucose was similar in both patients and controls (105±18 mg/dL vs. 105±16 mg/dL, p=ns). Mean Body mass index was identical in the two groups, (mean value: 25±4 kg/m2). Comparing SSc group and NoSSc group, we observed that TC (209±36 vs. 204±37 mg/dL), LDL-C (137±31 vs. 124±27mg/dL) and triglycerides (139±61Vs 160±70 mg/dL) were significantly higher in SSc, whereas HDL-C, blood fasting glucose and BMI were not significantly different. In autoimmune pts C-IMT was 0.86 mm (range 0.73 to 0.99 mm), statistically different from C-IMT in control subjects, that was 0.65±0.17 mm (p<0.05), and resulted from the following values: 0.92±0.1 mm in SSc group and 0.78±0.13 in NoSSc group. The difference between group was significant (p<0.05). Conclusions: Patients with rheumatic autoimmune diseases had clear signs of subclinical atherosclerosis (assessed by means of C-IMT) than healthy controls, thus have an overall increased cardiovascular risk profile. Further researches are needed in order to improve life duration and cardiovascular outcomes of these patients.

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy (TCM) is a unique syndrome, characterized by transient left ventricular (LV) apical ballooning without significant coronary arteries stenosis, affecting mainly menopausal women. We present the case of a 70 year old woman with subacute stent thrombosis (ST) at the level of the right coronary artery and transient apical ballooning with normal flow of left and circumflex coronary arteries. TCM is frequently associated with emotional stress, but to date no case of ST triggering TCM have been reported.

The authors of the above-mentioned paper would like to add the following to the Acknowledgments section of their article:The authors thank Storz Medical, Kreuzlingen, Switzerland, for financial support in the publication of this paper. Storz Medical had no influence on the design, process, analysis, results, or interpretation of the study data.The authors thank Springer Healthcare for publishing the correction.