Heart failure (HF) is a complex, multifactorial, progressive clinical condition affecting 64.3 million people worldwide, with a strong impact in terms of morbidity, mortality and public health costs. In the last 50 years, along with a better understanding of HF physiopathology and in agreement with the four main models of HF, many therapeutic options have been developed. Recently, the European Society of Cardiology (ESC) HF guidelines enthusiastically introduced inhibitors of the sodium-glucose cotransporter (SGLT2i) as first line therapy for HF with reduced ejection fraction (HFrEF) in order to reduce hospitalizations and mortality. Despite drugs developed as hypoglycemic agents, data from the EMPA-REG OUTCOME trial encouraged the evaluation of the possible cardiovascular effects, showing SGLT2i beneficial effects on loading conditions, neurohormonal axes, heart cells’ biochemistry and vascular stiffness, determining an improvement of each HF model. We want to give a boost to their use by increasing the knowledge of SGLT2-I and understanding the probable mechanisms of this new class of drugs, highlighting strengths and weaknesses, and providing a brief comment on major trials that made Gliflozins a cornerstone in HF therapy. Finally, aspects that may hinder SGLT2-i widespread utilization among different types of specialists, despite the guidelines’ indications, will be discussed.
Background Spontaneous coronary intramural hematoma (SCIH) is a rare but underdiagnosed condition, with dynamic evolution. Clinical presentation A 45-year-old woman was admitted to the emergency department with chest pain and fever in the previous days. Markers of myocardial injury were elevated, white blood cell count and C-reactive protein were mildly elevated, whereas D-dimer, chest X-ray and ECG were normal. Transthoracic echocardiography showed inferior wall hypokinesia, so an urgent coronary angiogram was performed showing no evidence of obstructive coronary artery disease. Investigations Cardiac magnetic resonance (CMR) was performed two days later showing inferior wall ischemic pattern (Figure 1) and ECG showed changes in the inferior leads with T waves inversion. A second coronary angiogram with planned intravascular imaging was than performed and showed a critical stenosis of the mid-distal right coronary artery determining functional vessel occlusion (Figure 2). Coronary vasospasm was ruled-out after intracoronary nitrates infusion and intravascular ultrasound (IVUS) showed diffuse intramural hematoma of the ostial, proximal and mid-segment of the right coronary artery with subocclusive stenosis at the mid segment with no evidence of atherosclerosis (Figure 3). Management Considering the clinical and radiological evidence of evolving myocardial injury, conservative management was excluded, and direct stenting of the lesion was performed with IVUS guided implantation of four overlapping drug-eluting stents. Conclusion Our case highlights the dynamic and treacherous nature of spontaneous coronary intramural hematoma, causing initial symptoms of myocardial ischemia without evident coronary obstruction, and then rapidly evolving in a severe and life-threatening coronary occlusion upon hematoma expansion. Higher level diagnostic testing such as CMR and intravascular imaging were instrumental for correct diagnosis and treatment in this complex scenario. Figure 1 Figure 2 Figure 3
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