Pubblicazioni - Sacco Dott.ssa Alice

• Heart-Kidney Transplanted patient affected by COVID-19 pneumonia treated with tocilizumab on top of immunosuppressive maintenance therapy.
  Int J Cardiol Heart Vasc

  2020 Aug;29():100596. doi: 10.1016/j.ijcha.2020.100596.
  
  Ammirati Enrico, Travi Giovanna, Orcese Carloandrea, Sacco Alice, Auricchio Sara, Frigerio Maria, Puoti Massimo
  
  
  
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• Impact of admission serum acid uric levels on in-hospital outcomes in patients with acute coronary syndrome.
  Eur J Intern Med

  2020 Jul;():. doi: S0953-6205(20)30296-X.
  
  Centola Marco, Maloberti Alessandro, Castini Diego, Persampieri Simone, Sabatelli Ludovico, Ferrante Giulia, Lucreziotti Stefano, Morici Nuccia, Sacco Alice, Oliva Fabrizio, Rebora Paola, Giannattasio Cristina, Mafrici Antonio, Carugo Stefano
  
  Abstract
  
  BACKGROUND:
  To assess the association between admission serum uric acid (SUA) levels and in-hospital outcomes in a real-world patients population with acute coronary syndrome (ACS) and to investigate the potential incremental prognostic value of SUA added to GRACE score (GRACE-SUA score).
  
  METHODS:
  The data of consecutive ACS patients admitted to Coronary Care Unit of San Paolo and Niguarda hospitals in Milan (Italy) were retrospectively analyzed.
  
  RESULTS:
  1088 patients (24% female) were enrolled. Mean age was 68 years (IQR 60-78). STEMI and NSTE-ACS patients were 504 (46%) and 584 (54%) respectively. SUA (OR 1.72 95%CI 1.33-2.22, p < 0.0001) and GRACE score (OR 1.04 95%CI 1.02-1.06, p < 0.0001) were significantly associated with an increased risk of in-hospital death at the multivariate analysis. Admission values of SUA were stratified in four quartiles. Rates of acute kidney injury, implantation of intra-aortic balloon pump and non-invasive ventilation use were significantly higher in the last quartile compared to Q1, Q2 and Q3 (p < 0.01). The areas under the ROC curve (AUC) for GRACE score and for SUA were 0.91 (95% CI 0.89-0.93, p < 0.0001) and 0.79 (95% CI 0.76-0.81, p < 0.0001) respectively. The AUC was larger for predicting in-hospital mortality with the GRACE-SUA score (0.94; 95% CI 0.93-0.95).
  
  CONCLUSIONS:
  High admission levels of SUA are independently associated with in-hospital adverse outcomes and mortality in a contemporary population of ACS patients. The inclusion of SUA to GRACE risk score seems to lead to a more accurate prediction of in-hospital mortality in this study population.
  
  Copyright © 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
  
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• Long-Term Risk of Major Adverse Cardiovascular Events in Patients With Acute Coronary Syndrome: Prognostic Role of Complete Blood Cell Count.
  Angiology

  2020 Jul;():3319720938619. doi: 10.1177/0003319720938619.
  
  Morici Nuccia, Molinari Valentina, Cantoni Silvia, Rubboli Andrea, Antolini Laura, Sacco Alice, Cattaneo Marco, Alicandro Gianfranco, Oreglia Jacopo A, Oliva Fabrizio, Giannattasio Cristina, Brunelli Dario, La Vecchia Carlo, Valgimigli Marco, Savonitto Stefano
  
  Abstract
  
  Individual parameters of complete blood count (CBC) have been associated with worse outcome in patients with acute coronary syndrome (ACS). However, the prognostic role of CBC taken as a whole has never been evaluated for long-term incidence of major adverse cardiovascular events (MACEs). Patients were grouped according to their hematopoietic cells' inflammatory response at different time points during hospital stay. Patients with admission white blood cell count >10 × 10/L, discharge hemoglobin <120 g/L, and discharge platelet count >250 × 10/L were defined as "high-risk CBC." Among 1076 patients with ACS discharged alive, 129 (12%) had a "high-risk CBC" and 947 (88%) had a "low-risk CBC." Patients with "high-risk CBC" were older and had more comorbidities. Over a median follow-up of 665 days, they experienced a higher incidence of MACE compared to "low-risk CBC" patients (18.6% vs 8.1%). After adjustment for age, age-adjusted Charlson comorbidity index, female sex, cardiac arrest, suboptimal discharge therapy, coronary artery bypass, and ejection fraction, a high-risk CBC was significantly associated with increased MACE occurrence (adjusted hazard ratio 1.80; 95% CI: 1.09-3.00). The CBC was a prognostic marker in patients with ACS, and its evaluation at admission and discharge could better classify patient's risk and improve therapeutic management.
  
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• Clinical outcome in solid organ transplant recipients with COVID-19: A single-center experience.
  Am J Transplant

  2020 May;():. doi: 10.1111/ajt.16069.
  
  Travi Giovanna, Rossotti Roberto, Merli Marco, Sacco Alice, Perricone Giovanni, Lauterio Andrea, Colombo Valeriana G, De Carlis Luciano, Frigerio Maria, Minetti Enrico, Belli Luca S, Puoti Massimo
  
  
  
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• [Relevance of complete blood count parameters in the assessment of acute coronary syndromes: a combined hematological and cardiological perspective].
  G Ital Cardiol (Rome)

  2019 Dec;20(12):694-705. doi: 10.1714/3271.32379.
  
  Morici Nuccia, Cantoni Silvia, Soriano Francesco, Viola Giovanna, De Stefano Valerio, Veas Nicolas, Oreglia Jacopo A, Esposito Giuseppe, Sacco Alice, Savonitto Stefano
  
  Abstract
  
  The aim of this review is to explore the available evidence concerning the relationship between the different parameters of the complete blood count, its pathophysiological changes and cardiovascular disease, specifically focusing on the acute ischemic setting. Erythrocytes, leukocytes and platelets undergo significant and more or less durable changes over time in response to conditions of systemic inflammatory, infectious and neoplastic disease. This is the reason why blood cell count parameters can (and should) be implemented in the global assessment of the patient with acute coronary syndrome.From the literature review it emerges that anemia and thrombocytopenia have an independent negative prognostic role in the medium and long term, being markers of the overall frailty of patients with ischemic heart disease. On the other hand, essential thrombocythemia and polycythemia vera, two chronic myeloproliferative neoplasms, are characterized by an important increase in thrombotic risk. Both conditions are given a brief description for the particular importance of the close collaboration between cardiologists and hematologists in the diagnosis and treatment of these diseases in the context of ischemic heart disease.
  
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• Recurrent stent thrombosis in a patient with acute coronary syndrome and ischemic colitis: between life-threatening thrombosis and life-threatening bleeding.
  Platelets

  2020 Aug;31(6):820-824. doi: 10.1080/09537104.2019.1678122.
  
  Morici Nuccia, Cantoni Silvia, Soriano Francesco, Sacco Alice, Viola Giovanna, Esposito Giuseppe, Oreglia Jacopo A, Cattaneo Marco, Savonitto Stefano
  
  Abstract
  
  Complete blood count should always be considered to tailor diagnosis and appropriate management in patients with acute ischemic heart disease. We present a challenging case of recurrent acute coronary syndrome, in the context of very high thrombotic risk due to concomitant inflammatory disease. Although no general guidelines exist for the switch between antiplatelet agents, particularly in the acute setting, in specific cases, the availability of different orally- and i.v.-acting agents and platelet function tests may allow to discriminate among multiple possible mechanisms of drug failure or side effects in the individual patient.
  
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• Getting to the heart of the matter in a multisystem disorder: Erdheim-Chester disease.
  Lancet

  2019 Aug;394(10198):e19. doi: S0140-6736(19)31787-8.
  
  Buono Andrea, Bassi Ilaria, Santolamazza Caterina, Moreo Antonella, Pedrotti Patrizia, Sacco Alice, Morici Nuccia, Giannattasio Cristina, Oliva Fabrizio, Ammirati Enrico
  
  
  
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• Use of PRECISE-DAPT Score and Admission Platelet Count to Predict Mortality Risk in Patients With Acute Coronary Syndrome.
  Angiology

  2019 Oct;70(9):867-877. doi: 10.1177/0003319719848547.
  
  Morici Nuccia, Tavecchia Giovanni A, Antolini Laura, Caporale Maria R, Cantoni Silvia, Bertuccio Paola, Sacco Alice, Meani Paolo, Viola Giovanna, Brunelli Dario, Oliva Fabrizio, Lombardi Federico, Segreto Antonio, Oreglia Jacopo A, La Vecchia Carlo, Cattaneo Marco, Valgimigli Marco, Savonitto Stefano
  
  Abstract
  
  The PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Antiplatelet Therapy (PRECISE-DAPT) score has been validated to predict bleeding complications in patients undergoing stent implantation and dual antiplatelet therapy. This score does not include the platelet count (PC), which has been shown to be an independent marker of mortality in patients with acute coronary syndrome (ACS). We assessed the role of the PRECISE-DAPT score calculated on admission for mortality risk prediction and evaluated whether the predictive accuracy of this score improved by adding the PC. In a retrospective cohort study of 1000 patients with ACS, after adjustment for relevant covariates, a PRECISE-DAPT score ?25 was independently associated with mortality (hazard ratio [HR]: 7.91; 95% confidence interval [CI]: 4.37-14.30). When this score was combined with PC, compared to patients with PRECISE-DAPT <25 and PC ?150 × 10/L, the adjusted HR was 7.2 (95% CI 2.4-21.6) for those with PRECISE-DAPT <25 and PC <150 × 10/L; 10.7 (95% CI: 5.2-21.9) for those with PRECISE-DAPT ?25 and PC ?150 × 10/L; and 17.9 (95% CI 7.0-45.4) for those with PRECISE-DAPT ?25 and PC <150 × 10/L. Selecting thresholds for high-risk designation, the PRECISE-DAPT score integrated with PC had a higher prediction value, compared to the PRECISE-DAPT and Global Registry of Acute Coronary Events scores.
  
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• Acute myocardial infarction complicating ischemic stroke: is there room for cangrelor?
  Platelets

  2020 ;31(1):120-123. doi: 10.1080/09537104.2019.1609663.
  
  Morici Nuccia, Nava Stefano, Sacco Alice, Viola Giovanna, Oreglia Jacopo, Meani Paolo, Oliva Fabrizio, Ranucci Marco, Leonardi Sergio, Rossini Roberta
  
  Abstract
  
  Acute myocardial infarction (AMI) complicating ischemic stroke is a well known and undertreated event. A conservative management is not infrequent in these settings, due to the fear of hemorrhagic complications related to antithrombotic therapy. Notably, an invasive approach with a primary percutaneous coronary intervention (PCI) has been shown to be associated with a lower in-hospital mortality in patients with concomitant ischemic stroke and AMI. The optimal antiplatelet regimen in these cases has been not clearly defined, yet. We report two cases of patients with AMI complicating ischemic stroke, successfully treated with cangrelor infusion, which was started during PCI and maintained up to 48 h at bridge therapy dosage (0.75 mcg/kg/min). Both patients underwent successful PCI in the acute phase, and neither ischemic nor hemorrhagic complications occurred during in-hospital stay.
  
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• Letter to the editor regarding the results of the retrospective study "Predictors of intra-aortic balloon pump hemodynamic failure in non-acute myocardial infarction cardiogenic shock" published in the American Heart Journal.
  Am Heart J

  2019 07;213():123. doi: S0002-8703(19)30056-0.
  
  Sacco Alice, Morici Nuccia, Oliva Fabrizio
  
  
  
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• Cardiogenic shock: old and new circulatory assist devices: the role of counter-pulsation.
  Eur Heart J Suppl

  2019 Mar;21(Suppl B):B59-B60. doi: 10.1093/eurheartj/suz020.
  
  Viola Giovanna, Morici Nuccia, Sacco Alice, Stucchi Miriam, Brunelli Dario, Cipriani Manlio, Garascia Andrea, Bottiroli Maurizio, Frigerio Maria, Oliva Fabrizio
  
  
  
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• Long-term survival and major outcomes in post-cardiotomy extracorporeal membrane oxygenation for adult patients in cardiogenic shock.
  Ann Cardiothorac Surg

  2019 Jan;8(1):116-122. doi: 10.21037/acs.2018.12.04.
  
  Meani Paolo, Matteucci Matteo, Jiritano Federica, Fina Dario, Panzeri Francesco, Raffa Giuseppe M, Kowalewski Mariusz, Morici Nuccia, Viola Giovanna, Sacco Alice, Oliva Fabrizio, Alyousif Amal, Heuts Sam, Gilbers Martijn, Schreurs Rick, Maessen Jos, Lorusso Roberto
  
  Abstract
  
  Extracorporeal membrane oxygenation (ECMO) in the veno-arterial (VA) configuration is an established method for the treatment of refractory cardiogenic shock. Such a condition characterizes the postoperative course of approximatively 1% of cardiac surgery patients. Although some studies have reported ECMO-related short-term results, little is known about the long-term outcomes of VA-ECMO therapy in the post-cardiotomy setting. Therefore, an extensive literature search was conducted regarding articles published after 1990 reporting postoperative ECMO use. PubMed, EMBASE and Web of Science were searched for sources. In-hospital mortality was high in post-cardiotomy VA-ECMO patients, ranging from 24.8% to 52%. Long-term results were poorly reported. However, based on the limited information available, hospital survivors showed a favorable outcome, with improvement in overall clinical condition, quality of life and limited hospital readmission for cardiac-related events. To conclude, in-hospital outcome in post-cardiotomy ECMO is often unfavorable, post-discharge results show satisfactory condition, with stable improvement of overall patient clinical status and low rate of hospital readmission and cardiac-related adverse events. Data reporting is, however, scarce and hence new and detailed studies are still warranted to investigate such aspects.
  
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• Management of cardiogenic shock in acute decompensated chronic heart failure: The ALTSHOCK phase II clinical trial.
  Am Heart J

  2018 10;204():196-201. doi: S0002-8703(18)30217-5.
  
  Morici Nuccia, Oliva Fabrizio, Ajello Silvia, Stucchi Miriam, Sacco Alice, Cipriani Manlio Gianni, De Bonis Michele, Garascia Andrea, Gagliardone Maria Pia, Melisurgo Giulio, Russo Claudio Francesco, La Vecchia Carlo, Frigerio Maria, Pappalardo Federico
  
  Abstract
  
  Management of acute decompensated heart failure patients presenting with cardiogenic shock (CS) is not straightforward, as few data are available from clinical trials. Stabilization before left ventricle assist device (LVAD) or heart transplantation (HTx) is strongly advocated, as patients undergoing LVAD implant or HTx in critical status have worse outcomes. This was a multicenter phase II study with a Simon 2-stage design, including 24 consecutive patients treated with low-moderate epinephrine doses, whose refractory CS prompted implantation of intra-aortic balloon pump (IABP) which was subsequently upgraded with peripheral venoarterial extracorporeal membrane oxygenation. At admission, patients had severe left ventricular dysfunction and overt CS, 7 patients could be managed only with inotropic therapy, and 16 patients were transitioned to IABP and 1 to IABP and venoarterial extracorporeal membrane oxygenation; the median duration of epinephrine therapy was 7?days (interquartile range 6-15), and the median dose was 0.08 ?g/kg/min (interquartile range 0.05-0.1); 21 patients (87.5%) survived at 60?days (primary outcome); among them, 13 (61.9%) underwent LVAD implantation, 2 (9.5%) underwent HTx, and 6 (28.6%) improved on medical treatment, indicating that early and intensive treatment of CS in chronic advanced heart failure patients with low-dose epinephrine and timely short-term mechanical circulatory support leads to satisfactory outcomes.
  
  Copyright © 2018 Elsevier Inc. All rights reserved.
  
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• Protracted aortic valve closure during peripheral veno-arterial extracorporeal life support: is intra-aortic balloon pump an effective solution?
  Perfusion

  2019 01;34(1):35-41. doi: 10.1177/0267659118787426.
  
  Meani Paolo, Delnoij Thijs, Raffa Giuseppe M, Morici Nuccia, Viola Giovanna, Sacco Alice, Oliva Fabrizio, Heuts Sam, Sels Jan-Willem, Driessen Rob, Roekaerts Paul, Gilbers Martijn, Bidar Elham, Schreurs Rick, Natour Ehsan, Veenstra Leo, Kats Suzanne, Maessen Jos, Lorusso Roberto
  
  Abstract
  
  BACKGROUND:
  Left ventricular (LV) afterload increase with protracted aortic valve (AV) closure may represent a complication of veno-arterial extracorporeal membrane oxygenation (V-A ECMO). The aim of the present study was to assess the effects of an intra-aortic balloon pump (IABP) to overcome such a hemodynamic shortcoming in patients submitted to peripheral V-A ECMO.
  
  METHODS:
  Among 184 adult patients who were treated with peripheral V-A ECMO support at Medical University Center Maastricht Hospital between 2007 and 2018, patients submitted to IABP implant for protracted AV closure after V-A ECMO implant were retrospectively identified. All clinical and hemodynamic data, including echocardiographic monitoring, were collected and analyzed.
  
  RESULTS:
  During the study period, 10 subjects (mean age 60 years old, 80% males) underwent IABP implant after peripheral V-A ECMO positioning due to the diagnosis of protracted AV closure and inefficient LV unloading as assessed by echocardiography and an absence of pulsation in the arterial pressure wave. Recovery of blood pressure pulsatility and enhanced LV unloading were observed in 8 patients after IABP placement, with no significant differences in the main hemodynamic parameters, inotropic therapy or in the ECMO flow (p=0.48). The weaning rate in this patient subgroup (mean ECMO duration 8 days), however, was only 10%, with another patient finally transplanted, leading to a 20% survival-to-hospital discharge.
  
  CONCLUSION:
  IABP placement was an effective solution in order to reverse the protracted AV closure and impaired LV unloading observed during peripheral V-A ECMO support. However, the impact on the weaning rate and survival needs further investigations.
  
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• Real-world application of currently available decision models for dual antiplatelet therapy duration in acute coronary syndrome.
  J Cardiovasc Med (Hagerstown)

  2018 06;19(6):310-313. doi: 10.2459/JCM.0000000000000655.
  
  Morici Nuccia, Piccinelli Enrico, Brunelli Dario, Sacco Alice, Viola Giovanna, Oreglia Jacopo A, Oliva Fabrizio, Valgimigli Marco
  
  
  
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• von Willebrand factor and its cleaving protease ADAMTS13 balance in coronary artery vessels: Lessons learned from thrombotic thrombocytopenic purpura. A narrative review.
  Thromb Res

  2017 Jul;155():78-85. doi: S0049-3848(17)30326-2.
  
  Morici Nuccia, Cantoni Silvia, Panzeri Francesco, Sacco Alice, Rusconi Chiara, Stucchi Miriam, Oliva Fabrizio, Cattaneo Marco
  
  Abstract
  
  BACKGROUND:
  Deficiency of the von Willebrand factor-cleaving protease ADAMTS13 is central to the pathophysiology of thrombotic thrombocytopenic purpura (TTP), a microangiopathic syndrome that presents as an acute medical emergency. In this review we will explore the evidence of a two-way relationship between TTP and ACS. Moreover, we will review the evidence emerged from epidemiological studies of an inverse relationship between the plasma levels of ADAMTS13 and the risk of ACS.
  
  METHODS AND RESULTS:
  Pubmed, MEDLINE and EMBASE, CINHAL, COCHRANE and Google Scholar databases were searched from inception to January 2017. The search yielded 43 studies representing 23 unique patient cases, 5 case series, 5 cohort studies and 10 case-control studies. Most ACS cases developing in the setting of TTP resolved with standard treatment of the underlying microangiopathy, with only a few requiring coronary invasive management. Antiplatelet therapy was not usually prescribed and all of the currently used P2Y were felt to be a potential trigger for a TTP-like syndrome, although our review revealed that the occurrence of TTP in patients treated with new P2Y antagonists is rare. Most studies confirmed the inverse association among ADAMTS13 levels and ACS.
  
  CONCLUSIONS:
  The heart is a definite target organ in TTP. The clinical spectrum of its involvement is probably influenced by local factors that add on to the systemic deficiency characteristic of TTP. It follows that patients with TTP should be carefully monitored for ACS events, especially when multiple risk factors for coronary disease exist.
  
  Copyright © 2017 Elsevier Ltd. All rights reserved.
  
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• Vasopressors and inotropes in cardiogenic shock: is there room for "adrenaline resuscitation"?
  Crit Care

  2016 Sep;20(1):302.
  
  Morici Nuccia, Stucchi Miriam, Sacco Alice, Bottiroli Maurizio A, Oliva Fabrizio,
  
  
  
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• Allogeneic peripheral blood stem cell transplantation and accelerated atherosclerosis: An intriguing association needing targeted surveillance. Lessons from a rare case of acute anterior myocardial infarction.
  Eur Heart J Acute Cardiovasc Care

  2016 May;():. doi: 2048872616652311.
  
  Scudiero Laura, Soriano Francesco, Morici Nuccia, Grillo Giovanni, Belli Oriana, Sacco Alice, Cipriani Manlio, Pedrotti Patrizia, Quattrocchi Giuseppina, Klugmann Silvio, Oliva Fabrizio
  
  Abstract
  
  We report the case of a 23-year-old man who developed an acute ST-elevation myocardial infarction secondary to acute thrombotic occlusion of the proximal left anterior descending coronary artery five years after undergoing chemotherapy, radiotherapy, haematopoietic stem cell transplantation for acute lymphoblastic leukaemia and bulky mediastinal mass involving the pleura and pericardium. His medical history also included Graft versus Host Disease developed 13 months after transplantation and acute myocarditis three months before the actual hospital admission. To the best of our knowledge, coronary artery disease as a complication of haematopoietic stem cell transplantation and low-dose mediastinal radiation therapy in young patients has been rarely reported in the medical literature. Clinicians should have a high degree of suspicion of coronary artery disease in patients treated with allogeneic haematopoietic stem cell transplantation, especially in patients previously treated with target mediastinal radiotherapy, as a group at risk of premature and significantly accelerated atherosclerosis, in order to make a timely and correct diagnosis.
  
  © The European Society of Cardiology 2016.
  
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• Cardiogenic shock: How to overcome a clinical dilemma. Unmet needs in Emergency medicine.
  Int J Cardiol

  2015 ;186():19-21. doi: 10.1016/j.ijcard.2015.02.111.
  
  Morici Nuccia, Sacco Alice, Paino Roberto, Oreglia Jacopo Andrea, Bottiroli Maurizio, Senni Michele, Nichelatti Michele, Canova Paolo, Russo Claudio, Garascia Andrea, Kulgmann Silvio, Frigerio Maria, Oliva Fabrizio
  
  
  
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• Delayed, severe thrombocytemia after abciximab infusion for primary angioplasty in acute coronary syndromes: Moving between systemic bleeding and stent thrombosis.
  Platelets

  2015 ;26(5):498-500. doi: 10.3109/09537104.2014.898181.
  
  Giupponi Luca, Cantoni Silvia, Morici Nuccia, Sacco Alice, Giannattasio Cristina, Klugmann Silvio, Savonitto Stefano
  
  
  
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• Bridge with intravenous antiplatelet therapy during temporary withdrawal of oral agents for surgical procedures: a systematic review.
  Intern Emerg Med

  2014 Mar;9(2):225-35. doi: 10.1007/s11739-013-1041-8.
  
  Morici Nuccia, Moja Lorenzo, Rosato Valentina, Sacco Alice, Mafrici Antonio, Klugmann Silvio, D'Urbano Maurizio, La Vecchia Carlo, De Servi Stefano, Savonitto Stefano
  
  Abstract
  
  Patients needing surgery within 1 year after drug-eluting cardiac stent implantation are challenging to manage because of an increased thrombotic and bleeding risk. A "bridge therapy" with short-acting antiplatelet agents in the perioperative period is an option. We assessed the outcome and safety of such a bridge therapy in cardiovascular and non-cardiovascular surgery. We performed a comprehensive search of MEDLINE, EMBASE, the Cochrane Library, and ongoing trial registers, irrespective of type of design. Our primary outcome was the success rate of bridge therapy in terms of freedom from cardiac ischaemic adverse events, whereas secondary outcome was freedom from bleeding/transfusion. We also performed combined success rate for each bridge therapy drug (tirofiban, eptifibatide, and cangrelor). We included eight case series and one randomised controlled trial. Among the 420 patients included, the technique was effective 96.2 % of the times [95 % confidence interval (CI) 94.4-98.0 %]. The success rate was 100 % for tirofiban (4 studies), 93.8 % for eptifibatide (4 studies), and 96.2 % for cangrelor (1 study). Freedom from bleeding/transfusion events was observed in 72.6 % of the times (95 % CI 68.4-76.9 %), and was higher with cangrelor (88.7 %; 95 % CI 82.7-94.7 %) than with other drugs (81.0 % for tirofiban and 58.6 % for eptifibatide). Evidence from case series and one randomised controlled trial suggests that, in patients with recent coronary stenting undergoing major surgery, perioperative bridge therapy with intravenous antiplatelet agents is an effective and safe treatment option to ensure low rate of ischaemic events.
  
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• Time from adenosine di-phosphate receptor antagonist discontinuation to coronary bypass surgery in patients with acute coronary syndrome: meta-analysis and meta-regression.
  Int J Cardiol

  2013 Oct;168(3):1955-64. doi: 10.1016/j.ijcard.2012.12.087.
  
  Morici Nuccia, Moja Lorenzo, Rosato Valentina, Oreglia Jacopo Andrea, Sacco Alice, De Marco Federico, Bruschi Giuseppe, Klugmann Silvio, La Vecchia Carlo, Savonitto Stefano
  
  Abstract
  
  BACKGROUND:
  Adenosine di-phosphate receptor antagonists (ADPRAs) blunt hemostasis for several days after administration. This effect, aimed at preventing cardiac ischemic complications particularly in patients with acute coronary syndromes (ACS), may increase perioperative bleeding in the case of cardiac surgery. Practice Guidelines recommend withholding ADPRAs for at least 5days prior to surgery, though with a weak base of evidence. The purpose of this study was to systematically review observational and experimental studies of early or late preoperative discontinuation of ADPRAs prior to coronary artery bypass grafting (CABG) for patients with ACS.
  
  METHODS:
  MEDLINE, EMBASE, the Cochrane Library databases up to December 2011; and reference lists. Observational and experimental studies that compared early ADPRA discontinuation with late discontinuation, or no discontinuation, in patients with ACS undergoing CABG.
  
  RESULTS:
  There were 19 studies, including 14,046 participants, 395 deaths and 309 reoperations due to bleeding. ADPRA late discontinuation up to CABG was associated with an increased risk of postoperative mortality (OR 1.46, 95% confidence interval (CI) 1.10 to 1.93) and reoperations due to bleeding (OR 2.18; 95% CI 1.47 to 2.62). Between-study heterogeneity was low. Meta-analysis limited to high quality or prospective studies gave consistent results. In most instances, the 95% prediction intervals for summary risk estimates confirmed the risk across study groups.
  
  CONCLUSIONS:
  ADPRA late discontinuation prior to CABG is associated with an increased risk of death and reoperations due to bleeding in patients with ACS. The confidence in the estimates of risk for late discontinuation is moderate to high.
  
  Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
  
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• Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial.
  JACC Cardiovasc Interv

  2012 Sep;5(9):906-16. doi: 10.1016/j.jcin.2012.06.008.
  
  Savonitto Stefano, Cavallini Claudio, Petronio A Sonia, Murena Ernesto, Antonicelli Roberto, Sacco Alice, Steffenino Giuseppe, Bonechi Francesco, Mossuti Ernesto, Manari Antonio, Tolaro Salvatore, Toso Anna, Daniotti Alessandro, Piscione Federico, Morici Nuccia, Cesana Bruno M, Jori M Cristina, De Servi Stefano,
  
  Abstract
  
  OBJECTIVES:
  This study sought to determine the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non-ST-segment elevation acute coronary syndromes (NSTEACS).
  
  BACKGROUND:
  Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS.
  
  METHODS:
  A total of 313 patients ? 75 years of age (mean 82 years) with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 h) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year.
  
  RESULTS:
  During admission, 88% of the patients in the EA group underwent angiography (55% revascularization), compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.53 to 1.19; p = 0.26). The rates of mortality (HR: 0.87; 95% CI: 0.49 to 1.56), myocardial infarction (HR: 0.67; 95% CI: 0.33 to 1.36), and repeat hospital stay (HR: 0.81; 95% CI: 0.45 to 1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction = 0.03).
  
  CONCLUSIONS:
  The present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial. (Italian Elderly ACS Study; NCT00510185).
  
  Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
  
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• Tako-Tsubo like syndrome triggered by meperidine.
  Med J Malaysia

  2011 Dec;66(5):520-1.
  
  Sacco Alice, Morici Nuccia, Belli Oriana, Bossi Irene, Mafrici Antonio, Klugmann Silvio
  
  Abstract
  
  We present a case of "inverted Tako-Tsubo" syndrome in a woman sedated with meperidine before undergoing a colonscopy. We discuss possible etiology of this ventricular dysfunction.
  
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• Epinephrine for acute decompensated heart failure and low output state: friend or foe?
  Int J Cardiol

  2011 Jun;149(3):384-5. doi: 10.1016/j.ijcard.2011.03.006.
  
  Morici Nuccia, Sacco Alice, Oliva Fabrizio, Ferrari Stefano, Paino Roberto, Milazzo Filippo, Frigerio Maria, Pirola Roberto, Klugmann Silvio, Mafrici Antonio
  
  
  
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• Target populations and relevant therapeutic end points to further improve outcomes in NSTEACS patients.
  Future Cardiol

  2009 Jan;5(1):27-41. doi: 10.2217/14796678.5.1.27.
  
  Savonitto Stefano, Morici Nuccia, Sacco Alice, Klugmann Silvio
  
  Abstract
  
  An aggressive pharmaco-interventional approach has been shown to improve long-term outcome among high-risk patients with acute coronary syndromes without ST-segment elevation (NSTEACS). However, these patients continue to represent a minority among those enrolled in clinical trials, thus precluding the possibility to further improve therapeutic efficacy. Target populations that are not adequately addressed by the majority of therapeutic trials are mainly the elderly and those with reduced renal function, who all show unfavorable outcome after an episode of NSTEACS. In order to allow comparison among different studies, a prerequisite for the planning of meaningful trials should be a uniform definition of the study end points besides mortality, particularly with reference to recurrent myocardial infarction, and rehospitalization owing to cardiovascular instability or severe bleeding. In addition to trial design issues, improvements in the regulatory rules for drug development and in hospital networking conceal significant opportunities to improve treatment of NSTEACS.
  
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• [Diagnosis and treatment of non-ST-elevation acute coronary syndromes. Common clinical lessons and a few differences between the ESC and the ACC/AHA guidelines published in 2007].
  G Ital Cardiol (Rome)

  2008 May;9(5):314-9.
  
  Savonitto Stefano, Caracciolo Michela, Sacco Alice, Klugmann Silvio
  
  
  
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