Atrial fibrillation
It is an abnormality of heart rhythm (arrhythmia) originating from the atria (the upper chambers of the heart) which is triggered by electrical impulses from myocardial muscle cells. In atrial fibrillation, the heart rate becomes irregular compared to its normal functioning, thus increasing the risk of thromboembolism
Typically, atrial fibrillation appears when there are structural heart diseases (hypertensive heart disease, ischaemic heart disease, heart valve disease, cardiac surgery) or conditions facilitating its development, like hypothyroidism. In some cases (less than 30%), atrial fibrillation can also occur without known or detectable heart disease (lone fibrillation)
It affects 0.5-1% of the population. The risk of developing it increases considerably with age (8-10% over 80 years of age) and men are more commonly affected than women

Hypertension (high blood pressure)
It is defined by levels of systolic pressure (maximum) ≥140 mmHg or diastolic pressure (minimum) ≥90 mmHg. These parameters represent a standard based on clinical trial results within which patients with these levels benefited from lowering blood pressure thanks to treatment. The classification is applicable to young, adult and elderly subjects, while in children and adolescents different percentage-based criteria are applied. The risk of developing diseases affecting the vessels (arterial heart disease), the heart (heart disease), the brain (stroke and dementia) and the kidneys (kidney failure) grows with the increase of blood pressure levels

Pulmonary hypertension 
It can include many conditions with different origins. The main characteristic is the narrowing of the vascular lumen of pulmonary artery branches which progressively leads to heart failure
Pulmonary hypertension is caused by excessive blood pressure in pulmonary vessels. It is a primary condition, i.e. not secondary to concomitant causes like other heart diseases, lung diseases and forms of chronic thromboembolic pulmonary hypertension
The diagnosis is made through right heart catheterisation, i.e. the introduction through large calibre veins of a specific catheter that measures pressure inside heart chambers and pulmonary vessels. This is an invasive procedure that must be performed by expert personnel

Acute myocardial infarction (AMI) 
It is a disease characterised by the death (necrosis) of groups of cells of the cardiac tissue (myocytes) which can cause permanent damage to the heart. Necrosis can occur due to a prolonged lack of blood (ischaemia) caused by an imbalance between oxygen supply and demand. This usually happens following the occlusion of a coronary artery caused by a thrombus. If coronary obstruction results in a total stop of blood flow in the area supplied by the affected artery, the infarction is called a STEMI (ST elevation myocardial infarction). If instead coronary obstruction is partial or transient, the event is defined as NSTEMI (Non-ST elevation myocardial infarction)
The heart supplies blood to all organs in order to provide those nutrients which help keep them alive and preserve their function

Chronic heart failure 
It is a disease that appears when the heart’s pump function is decreased and therefore the blood tends to stagnate more in the lungs, the abdomen and the legs. This malfunctioning can be due to:
- infarction
- infection
- inflammation
- inadequately controlled chronic hypertension
- valve diseases
- arrhythmia
- alcohol abuse
- cancer therapies 
- ageing of the heart (degenerative heart disease)

Syncope 
It is the total loss of consciousness and is sometimes accompanied by lipothymia, a transient loss of consciousness. These two conditions can occur because of neurologic causes and because of cardiac causes, too. In this case, a pacemaker implant is required. In other cases, syncope and lipothymia can be secondary to severe arrhythmias which can put the patient’s life at risk, especially if there is dilation following a left ventricle infarction. In this case it is necessary to use a defibrillator acting as a “life saver”

Hypertension
In general, it is asymptomatic. In some cases it can be accompanied by: 
- headache, occasionally pulsating and more often upon waking
- tires easily 
- exertional dyspnoea (difficulty breathing with rhythm and frequency abnormalities)
- epistaxis (nosebleeds)
- vision problems
- scotoma (dark spots or sparking in the field of vision)
- floaters (bright moving spots that disturb the vision)
- tinnitus (buzzing or ringing in the ears)

In the months and years before a medical condition like a stroke or infarction, hypertension causes damage to the different organs and systems. There are clinical conditions requiring the initiation of a drug therapy even with levels not within the range of hypertension. Blood pressure levels equal or higher than 140 mm Hg with regards to systolic pressure or equal or higher than 90 mm Hg for diastolic require therapeutic intervention

Atrial fibrillation 
It is often associated with symptoms like:
- palpitations 
- dyspnoea (difficulty breathing)
- weakness 
- tires easily 
- syncope or chest pain (rarely)
- In some cases it can be totally asymptomatic or, when there are symptoms they are not recognised by the patients, who only intervene by modifying their lifestyle

Depending on its presentation, atrial fibrillation is classified into 3 main forms:
1. Paroxysmal: when events occur and spontaneously resolve within less than a week; 
2. Persistent: when the arrhythmia event does not stop spontaneously but only following a therapeutic intervention from healthcare professionals; 
3. Permanent: when therapeutic interventions have failed or a cardioversion (administration of drugs or delivery of electrical impulses) proves to be ineffective

Pulmonary hypertension 
Among its initial symptoms there are:
- dyspnoea
- syncope
- angina (chest pain)
- reduced tolerance to exertion

Acute myocardial infarction 
- Chest pain is the most common symptom and it is usually located in the area behind the breastbone. It tends to spread towards the shoulder and the left arm, though it is also possible to observe pain in the neck or the left shoulder blade
- In case of inferior myocardial (or “diaphragmatic”) infarction, pain starts from the epigastric area (the area above the stomach) and it can be confused with abdominal or stomach pain
- Diffusion of pain to the jaw, elbows and wrists is less common
- Often, hypertension and tachycardia can be observed during anterior or lateral infarction and hypotension associated with reduced heart rate (bradycardia) in the inferior ones
- When there are signs of heart failure or insufficiency, as it happens in one third of the patients, the subject suffers from dyspnoea
- In older patients there can be signs of cerebral hypoxia (lack of oxygen) associated with disorientation and mental confusion

Chronic heart failure
When there is a gradual progression of the heart disease, the heart puts in place some mechanisms aimed at maintaining a balanced blood supply to tissues and the patient experiences chronic heart failure

In the advanced stages of failure, fluids start building up in the liver and in the gastrointestinal tract and there is the onset of:
- lack of appetite
- nausea
- anorexia
- weight loss

In this phase, the patient cannot perform normal daily activities and the consequence of a further worsening of the chronic heart failure is acute heart failure

Syncope 
The main symptom is total or partial loss of consciousness. It appears suddenly and is often accompanied by so-called neuro-vegetative prodromal symptoms (cold sweats, dizziness, nausea, vomiting, discharge of faeces and urine)

Atrial fibrillation
the recommendations, widely shared by experts, on the therapeutic choice are based on the alternative between:
- Rhythm control (i.e. restoring and maintaining sinus rhythm through antiarrhythmic drugs or a transcatheter ablation procedure)
- Heart rate control with drugs regulating the conduction of atrial stimuli to the ventricles

In both cases, by following appropriate therapies and undergoing regular specialist follow-ups, the patient can easily live with the condition

Hypertension 
An adequate lifestyle helps prevent and treat hypertension and delay the initiation of drug therapy in high risk patients. Lifestyle modifications also contribute to control other cardiovascular risk factors and treat any associated diseases. The interventions which have proven to be effective in reducing blood pressure levels are:
- reducing the intake of salt
- reducing the intake of alcohol
- eating large quantities of fruits and vegetables
- following a low-fat diet or other types of diet
- reducing body weight 
- exercising regularly
- stopping smoking cigarettes as this could increase blood pressure

When lifestyle modifications are not sufficient to reduce blood pressure levels it is necessary to use drug therapy. By customising the treatment for each patient it is possible to ensure an excellent quality of life by limiting or eliminating side effects

Pulmonary hypertension 
It is a chronic disease and depending on the type there is a treatment with specific drugs which can limit or relieve symptoms, but they cannot irreversibly stop the disease
The wide use of percutaneous transluminal coronary angioplasty (PTCA) and progresses in drug therapies in the past few years has led to a reduction of mortality linked with acute myocardial infarction (currently lower than 10%) and a return to “normal” life after the disease in the majority of cases
Of course, in case of an extended infarction the patient will not be able to perform strenuous physical activities because the heart’s pumping function will be reduced

Chronic heart failure 
It is important to learn how to live with the disease and, depending on its severity, with the functional limitations it causes
It is useful to follow some hygiene and general behavioural norms as to avoid excessive fluid retention and reduce the risk of a new hospitalisation. Below you will find some of them: 
- Weigh yourself every morning: sudden weight gain is not correlated to increased food intake and an increase of fat mass and it can be due to fluid accumulation
- Regulate fluid intake: fluid intake has to be controlled and you should drink a maximum of 1.5-2 l of water per day. It is therefore important to control the ratio between fluid intake and fluid loss through the urine, which should be equivalent
- Measure blood pressure and heart rate
- Reduce the intake of salt as it is responsible for an accumulation of water and overloading the heart
- Reduce alcohol consumption and, if the cause of the heart disease is the alcohol, it needs to be stopped (one glass of red wine during meals is recommended)
- Stop smoking or avoid passive smoke: smoking worsens heart and lung function
- Regulate physical activity
- Manage sexual activity: there are no contraindications unless it causes excessive stress. If specific drugs are required, consult a medical professional.
- Vaccinate against influenza and pneumococcal pneumonia: infections worsen heart failure
- Regularly and precisely take the drug therapy prescribed by the cardiologist, adhering to the dosage and the time the tablet must be taken

Syncope 
Once the causes of the disease have been identified and the devices (pacemakers, catheter leads, defibrillators) have been implanted, the patient will have to live with them

Atrial fibrillation 
It is often secondary to hypertension or other heart diseases: it is necessary to perform regular blood pressure measurements and to start the appropriate therapeutic regimen for heart diseases, if any, by seeing a cardiologist to prevent arrhythmia recurrences.
To prevent thromboembolic complications, many patients with atrial fibrillation take a Warfarin-based anticoagulant therapy or new oral anticoagulants (NOACs). In both cases, it would be desirable for the patient to be followed by an Anticoagulation Therapy Clinic (also available in the INRCA in Ancona), which will perform all the necessary blood chemistry and clinical tests. 

Hypertension
A multidisciplinary approach is essential for effective management. This means that several professionals are involved: the general practitioner, who manages the majority of hypertensive patients; different types of physicians based on the nature of the hypertension and the challenges posed by its treatment; specifically trained nurses to follow the patients during the treatment, and pharmacists, who have to manage physicians’ prescriptions, directly address the patient’s problems and answer their questions
It is recommended to perform: 
- Lab tests: to assess the presence of additional risk factors, search for secondary hypertension and organ damage
- Instrumental tests: 
  • a 12-lead ECG can be one of the routine tests for all hypertensive subjects
  • an ECG allows to better define organ damage, particularly in left ventricular hypertrophy
  • a carotid Doppler ultrasound can indicate the risk of stroke and myocardial infarction early
  • a fundoscopy allows an immediate assessment of hypertensive retinopathy

Pulmonary hypertension 
It is recommended to perform:
- cardiac examinations once every six months 
  • blood chemistry tests
  • 6-minute walking test to assess resistance to physical exertion 
  • short admission in the outpatient clinic to perform right heart catheterisation (if necessary)

Acute myocardial infarction 
After discharge, cardiac examinations are scheduled and, if the patient’s health status allows it, the patient is included in a cardiac rehabilitation regimen. This is essential to regain a good quality of life and an improved prognosis

Chronic heart failure 
If symptoms persist despite the therapy, a cardiology examination is recommended; the cardiologist will then decide whether to request further tests
In the area of chronic heart failure, the Department of Cardiology-CCU-Centre for Telemedicine of INRCA has organised several initiatives. In partnership with the associations “Cuore Vivo” and AdriHealthMob Aicare COOSS Marche, have started several monitoring programmes for patients at home or in nursing homes. They were provided with kits for the daily measurement of vital signs with the weekly intervention of a nurse to conduct an ECG
Along this line, another project was completed in cooperation with the city of Castelfidardo (“Castelcuore” programme)

Syncope
Cardiology examinations and control of implanted devices (pacemakers, catheter leads, defibrillators) are performed. Examinations have to be conducted by qualified medical personnel in the field of electrostimulation with sophisticated dedicated instruments and the support of professionals like biomedical engineers

Atrial fibrillation 
Care can be challenging, especially when the patient suffers from sporadic arrhythmic attacks which cannot always be detected. In fact, it often happens that once the subject reaches the Emergency Room the attacks have spontaneously resolved
There have been more advances in the techniques of Telemedicine and Home Telecare

Hypertension
Hypertensive subjects do not face many limitations in their daily activities. They must be encouraged to modify their lifestyle, to exercise regularly and follow a low-sodium and low-fat diet (reduce salt and fats). Moreover, overweight subjects are recommended to lose weight and smokers to stop smoking

Pulmonary hypertension 
Extreme attention must be paid to side effects of medications. Patients can experience relapses and worsening, face difficulties performing the simplest daily tasks and also experience depressive psychosis

Acute myocardial infarction 
Caregivers mainly have to provide psychological support: encourage the patient to regularly take their prescribed medications and not abandon rehabilitation, convince them to stop smoking and follow the proper diet

Chronic heart failure
We recommend caregivers follow the suggestions contained in the section “Living with the disease”

Syncope
No particular care is required for patients with an implanted device (pacemakers, catheter leads, defibrillators).
Particular caution is required with elderly patients, especially in the first 3 months after the implant. In this phase, in fact, an abrupt movement of the arm or pectoral muscle contraction could inadvertently displace the catheter leads positioned inside the heart during the procedure. They should instead remain in place until developing a fibrosis around the tip to ensure permanent anchoring

In overweight patients with suspected concomitant sleep apnoea, we recommend a careful assessment of the problem, which, if present, requires the use of a home ventilator
The lack of treatment results in restrictions to the use of a driving licence
When an implanted device is required, as in the case of syncope, the patient is informed on the potential risks and benefits of the procedure. They can still refuse to undergo the procedure even though by doing so they could put their lives at risk

Associations

“Cuore Vivo Onlus” 
Via della Montagnola, 81 60131 Ancona 
Phone: 071 800 3374 (Tuesdays and Thursdays from 9:30am to 12:00pm)
Email: info@cuorevivo.org

With regards to hypertension, there are several national and international associations, like: SIIA: Società Italiana Ipertensione Arteriosa - Italian Society for Hypertension
European Society for Hypertension 
International Society for Hypertension

Medical associations and companies manufacturing antihypertensive drugs sponsor randomised clinical trials aimed at defining both diagnostic and therapeutic aspects (genetic studies or studies using communication technologies to help treatment adherence)

With regards to pulmonary hypertension, INRCA is currently working on the Victoria trial with the Cardiology Clinic. The study will assess the treatment with vericiguat (an sGC receptor agonist belonging to the class of drugs approved for the treatment of pulmonary hypertension) in patients with severe left ventricular dysfunction

For many years the Cardiology/CCU/Telecardiology Operational Unit has taken part in multicentre national and international studies involving patients with acute myocardial infarction. ATPCI and POSTER are currently ongoing, while in recent years Elderly and Elderly II tried to search for the best treatment for infarction in elderly patients

With regards to syncope, a research project in collaboration with neurologists has just started to identify the silent phases of atrial fibrillation in patients with high cardioembolic risk (CHADVASC score >2) in sinus rhythm with cryptogenic stroke without apparent history of fibrillation. These patients will be implanted with a loop-recorder (a sort of Holter ECG connected via online telemetry) that identifies atrial fibrillation phases and therefore allows the appropriate therapeutic switch