[Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)]

In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA's Less Is More and BMJ's Too Much Medicine series, and the American College of Physicians' High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody's proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation's Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.

The etiology-filling pattern-pulmonary artery pressure score: a simple tool for risk stratification of patients with systolic heart failure

Heart failure (HF) is a leading cause of morbidity and mortality. The detection of patients at high risk for death is a major challenge in HF management. The authors compared the prognostic value of 23 clinical Doppler echocardiography and cardiopulmonary exercise indexes in a stable, moderately symptomatic, systolic HF outpatient population receiving optimal medical therapy. The end point was the incidence of overall mortality. Between January 2002 and December 2008, a total of 146 patients with left ventricular (LV) ejection fraction 0.31±0.8 and New York Heart Association functional class II or III were enrolled. The prognostic power of single variables was assessed using chi-square test for categoric variables and t test for continuous variables. Variables associated with the prespecified end point were included as predictors in a binary logistic regression multivariate model. At multivariate analysis, "restrictive" LV filling pattern (P=.004), ischemic etiology (P=.022), pulmonary artery systolic pressure (PASP) ≥50 mm Hg (P=.027), and peak oxygen uptake (VO(2) ) <15.9 mL/kg/min (P=.046) resulted independent predictors of the outcome. A simple risk score was then obtained using these significant independent variables, excluding peak VO(2) because of only borderline significance. Patients with ischemic etiology, restrictive LV filling pattern, and PASP ≥50 mm Hg have a very high risk of death (odds ratio, 33.77; 95% confidence interval, 5.74-198.8; P<.001, compared with patients with no risk factors). In this high-risk group, evaluation of peak VO(2) could be superfluous. A very simple clinical echocardiographic model based on etiology-LV filling and pulmonary pressure is a powerful tool for risk stratification of systolic HF in ambulatory patients.

Clinical, resting echo and dipyridamole stress echocardiography findings for the screening of renal transplant candidates

BACKGROUND

Preoperative screening for coronary artery disease is recommended in high-risk renal transplant candidates. Aim of this study was to prospectively assess the value of a comprehensive risk stratification strategy including clinical, resting echo, and dipyridamole stress echo findings before renal transplantation.

METHODS

The study group consisted of 71 renal transplant candidates (47 men; age 54+/-11 years) fulfilling one or more of the following high-risk clinical criteria: history of coronary artery disease, wall motion abnormalities at resting echo, dialysis dependency lasting >5 years, presence of 2 or more risk factors. Clinical history, resting echo, and dipyridamole stress echo (up to 0.84 mg over 10 min + atropine up to 1 mg) were obtained in all subjects.

RESULTS

Mean number of risk factors was 2.5+/-1.0. Known coronary artery disease and diabetes were present, respectively, in 2 (3%) and 11 (15%) persons. No patient had left ventricular ejection fraction <45%. Left ventricular hypertrophy was found in 53 (74%) cases. Stress echo showed 100% safety and 97% overall feasibility. Inducible ischemia (new wall motion abnormalities) was detected in 3 (4%) subjects. During follow-up (36+/-12 months), 8 (11%) cardiac events occurred: 2 deaths, 2 myocardial infarctions, 3 coronary interventions, and 1 pulmonary edema. The perioperative period and subsequent follow-up (22+/-12 months) was uneventful among 32 patients who received renal transplantation. Four-year event-free survival was 92% in those without ischemia; it was 96% in the non-diabetic population. Diabetes (HR=4.78), age (HR=1.14), and left ventricular mass index (HR=1.02) were independent prognostic indicators among clinical and resting echo variables. The global chi-square of the statistical model was 18.8; it increased to 27.3 (+45%) after the addition of stress echo result.

CONCLUSIONS

Renal transplant candidates can undergo effective stratification of risk by combining clinical, resting echo and dipyridamole stress echo findings.

Heart rate response to graded exercise correlates with aerobic and ventilatory capacity in patients with heart failure

BACKGROUND

Autonomic dysfunction and reduced exercise tolerance are typical features of patients with congestive heart failure (CHF). Baro-chemoreflex balance and organ response may have a common role in conditioning exercise tolerance, ventilation, and chronotropic competence in patients with CHF.

HYPOTHESIS

We tested the hypothesis that there is a relationship between functional capacity and chronotropic competence to exercise in CHF.

METHODS

In all, 48 stable outpatients with CHF (age 65 +/- 10 years, 41 men, NYHA class 2.1 +/- 0, ejection fraction 31 +/- 7%, peak VO2 16 +/- 4 ml/kg/min) performed cardiopulmonary exercise testing (CPX). Heart rate (HR) response to exercise was assessed by the chronotropic index (CRI). The CRI was calculated by the following formula: CRI = peak HR - rest HR/220 - age - rest HR x 100 (normal value > 80%). The relationship of CRI to peak oxygen consumption (VO2) and ventilation/carbon dioxide production (VE/VCO2) ratio was examined. A group of 33 healthy controls underwent CPX as well.

RESULTS

The CRI correlated directly with peak VO2 (r = 0.638, p < 0.001) and inversely with VE/VCO2 (r = -0.492, p < 0.001) in patients with CHF. A CRI < 78% identified patients with CHF and a peak VO2 < 20 ml/kg/min, area under the receiver operating curve (AUROC): 0.76, 95% confidence interval (CI) 0.60-0.92. A CRI < 74% predicted exercise hyperventilation in CHF (AUROC: 0.71 for VE/VCO2 > 30, 95% CI 0.53-0.88). The CRI was not significantly related either to peak VO2 or to VE/VCO2 in the control group.

CONCLUSIONS

In patients with mild to moderate CHF, CRI correlates with functional capacity. This relationship adds new data on pathophysiologic grounds and supports the routine incorporation of CRI into CPX interpretation.

[Physical training in the elderly with heart failure]

Limited functional capacity has an important negative predictive value both in normal subjects and in patients with heart disease. In heart failure patients the improvement in physical capacity produces an increase in survival and a reduction in morbidity and hospital admission. The main cause of physical capacity reduction in heart failure elderly patients is represented by structural modifications of peripheral muscles and reduced vasodilating capacity of perimuscular vessels. Physical training induces a regression of these alterations, restore endothelial function and has favorable effects on left ventricular diastolic function and on ventilatory alterations. Data on the effects of physical training in older patients with heart failure are numerically limited, but it is possible to affirm that a minimum of 20 min of physical training for 3 days a week at 40% of maximal effort capacity are able to produce beneficial effects. Physical training in patients with heart failure, also in advanced age, is safe, has to be encouraged, and induces a significant improvement in quality of life and survival.

[Significance of exercise capacity in cardiology]

Exercise capacity is reduced in many patients with cardiovascular disease. In post-acute myocardial infarction, ischemic heart disease and heart failure patients, exercise capacity has a strong independent prognostic impact. Even in subjects without history of heart disease, the lower the cardiorespiratory fitness the higher is the risk for cardiovascular events and mortality. With appropriate physical activity, exercise capacity is improved in most individuals. Improvement of functional capacity is associated with improvement of survival.

Vasodilator stress echocardiography for risk stratification of medically stabilized unstable angina

AIMS

The aims of this study were to assess the safety, feasibility and prognostic value of dipyridamole-atropine stress echo in patients with medically stabilized unstable angina.

METHODS

The initial population consisted of 173 patients consecutively admitted at two different Coronary Care Units with class IIIB unstable angina. Of these, 56 were excluded: five had poor acoustic window, 24 did not stabilize with medical therapy and underwent urgent coronary angiography, 26 evolved in non-Q wave myocardial infarction and one patient died. The remaining 117 patients underwent dipyridamole-atropine stress echo after 48 h without symptoms or electrocardiographic evidence of myocardial ischaemia.

RESULTS

No complications or side effects occurred. An ischaemic response was found in 61 patients. During follow-up (10+/-9 months), three cardiac deaths, eight infarctions, 13 unstable anginas, and seven late (>3 months from stress testing) revascularizations occurred. There were 22 events (36%) in patients with, and nine events (16%) in patients without, inducible ischaemia (P=0.01). At Cox analysis peak-stress wall-motion score index (HR=5.5; 95% CI, 1.9 to 15.5; P=0.0015), and admission ST-segment depression (HR=4.2; 95% CI, 1.7 to 10.7; P=0.0022) were independent predictors of spontaneous events (cardiac death, infarction, unstable angina). The 12-month event-free survival was 69% for ischaemic and 83% for non-ischaemic group (P=0.03). In considering major events as end-points (spontaneous events, and late revascularization), again multivariate prognostic indicators were peak-stress wall-motion score index (HR=14.2; 95% CI, 2.6 to 76.6; P=0.0021), and admission ST-segment depression (HR=3.1; 95% CI, 1.4 to 6.9; P=0.0055). The 12-month event-free survival rate was 58% for ischaemic and 81% for non-ischaemic group (P=0.002). With an interactive stepwise procedure, stress echo findings were found to provide incremental prognostic contribution to that of clinical data alone.

CONCLUSIONS

With proper selection of patients, dipyridamole-atropine stress echo is extremely safe and feasible in patients with medically stabilized unstable angina, and can be useful in identification of subjects at risk for future cardiac events.

The stress echo prognostic gender gap

AIMS

To investigate whether myocardial ischaemia elicitable during pharmacological stress echocardiography portends different prognosis in men and women.

METHODS AND RESULTS

The study group was made by 1733 patients (941 men, 792 women) who underwent dipyridamole (n=1008) or dobutamine (n=725) stress echo for evaluation of known or suspected coronary artery disease. An ischaemic response was found in 460 patients (308 men, 152 women). Considering the whole ischaemic population, women were older (P<0.0001) and more likely to have hypertension (P=0.02) and hypercholesterolaemia (P=0.04) than men. No difference in age and risk factors was evidenced between the two sexes in the subset of 203 patients with ischaemia and suspected coronary artery disease. During follow-up (25 +/- 24 months for the ischaemic and 37 +/- 25 months for the non-ischaemic sample), there were 113 cardiac events (45 deaths and 68 infarctions) and 232 revascularizations. Revascularization rate in ischaemic population was similar in both sexes (P=0.36). Multivariate predictors of cardiac events in the whole ischaemic group were resting WMSI (HR=2.7, 95% CI 1.3--3.3;P=0.0050), female gender (HR=2.2, 95% CI 1.2--3.7;P=0.0062), age > or = l65 years (HR=1.9, 95% CI=1.0--3.6;P=0.0427), and Delta WMSI (HR=2.1, 95% CI=1.0--3.7;P=0.0447). Female gender (HR=2.7, 95% CI 1.1--6.3;P=0.0233) was the only independent prognostic predictor in patients with ischaemia and suspected coronary artery disease. Five-year infarction-free survival was 82% in men and 71% in women in the whole ischaemic population (P=0.0041) as well as in the ischaemic group with suspected coronary artery disease (CAD) (P=0.0175). In the non-ischaemic sample resting WMSI (HR=4.8), history of myocardial infarction (HR=2.5), and hypercholesterolaemia (HR=1.8) were independent predictors of outcome at multivariate analysis, whilst the gender had no prognostic importance.

CONCLUSIONS

Our results show that female gender is an independent predictor of cardiac events in patients with myocardial ischaemia induced by pharmacological stress echocardiography.

[Diagnostic accuracy of exercise testing for diagnosis of coronary artery disease: the need for a critical review]

In this review the meaning of exercise electrocardiographic changes and interpretative pitfalls in particular clinical conditions are critically reassessed. Existing studies have been carried out on different populations and with different gold standards, nevertheless exercise testing if correctly analyzed and interpreted, can provide invaluable information for diagnosis of coronary artery disease. Given its feasibility, diffusion and low risk, it remains indeed the first choice test in the diagnostic algorithm of ischemic heart disease. The use of more sophisticated and expensive tests have to be limited to selected groups of patients in whom exercise testing, correctly interpreted, remains really doubtful or prematurely interrupted.

Cardiac damage following therapeutic chest irradiation. Importance, evaluation and treatment

Radiation induced heart disease, with its clinical manifestations, is becoming a growing problem. Its prevalence is increasing, keeping pace with the increased survival of many malignancies. The majority of patients with radiation induced heart disease is constituted by Hodgkin's disease survivors, followed by non Hodgkin's disease, esophageal carcinoma, thymoma, lung cancer, breast cancer and metastatic seminoma. Pericardial disease is the most well known expression of radiation induced heart disease, although the whole cardiac structure is compromised because of the structural and consequently functional impairment. Myocardial damage can lead to a congestive heart failure, typically due to a restrictive cardiomyopathy. Coronary artery obstructive disease frequently involves ostial coronary segments and the left main, for this reason it does appear particularly harmful. All patients undergoing chest irradiation require serial cardiological evaluation. Important risk factors of radiation induced heart disease are previous chemotherapy, radiation exposition exceeding 4000 Rad, administration next to the heart and on the left side of the chest must be taken into particular consideration. The cardiac damage limitation basically is founded on prevention. Significant results have been obtained with fractional exposition, high energy utilization and "split" zone covering. The radiotherapeutic technical improvement with the comprehensive individual patient risk evaluation will provide a substantial benefit for the future. The consultant cardiologist should cooperate with the oncologist and the radiotherapist, providing specific competence and continuative care.

[Balanced beta--alpha-blocker treatment with carvedilol in mild-moderate arterial hypertension]

The search for the ideal antihypertensive drug is ongoing. Carvedilol is a new beta-adrenoceptor antagonist which also causes peripheral vasodilation primarily via alpha 1-adrenergic blockade. Twenty patients with mild to moderate essential hypertension and previous intolerance and side effects to other antihypertensive drugs were studied. After initial baseline assessment, patients received 25 mg carvedilol orally q.d. The treatment lasted 60 days. In our study carvedilol was well tolerated and no important side effect was recorded. Blood pressure decreased significantly to normal values, without orthostatic blood pressure decreases. Heart rate decreased significantly too, but no significant bradycardia was induced. No negative effects on serum lipids and no clinical evidence of increase in peripheral resistance were observed. Ventricular arrhythmia on Holter monitoring were significantly reduced after treatment with carvedilol.

[Neurohormonal mechanisms in cardiac insufficiency. Possible therapeutic implications]

Neurohormonal mechanisms play an important role in pathogenesis of left ventricular dysfunction. Analysis of traditional therapeutic strategies for heart failure used in the past is disappointing. Recent therapeutic strategy that aims to treat earlier patients with ventricular dysfunction with agents that counteract neurohormonal activation, seems to be more effective. However conventional drugs such as vasodilator agents, digitalis and diuretics are still useful for treatment of overt heart failure, due to their proven hemodynamic benefits. A lot of current clinical trials, in the future, can help us to solve this problem. In this issue evolving concepts of pathophysiology of chronic heart failure and how these pathophysiologic concepts lead to the rational treatment are discussed.

[Arterial hypertension and cardiovascular risk. Epidemiological studies, trials and therapeutic implications]

From the analysis of the epidemiological observational studies, among which one of the most famous is the Framingham study that has lasted for more than 30 years, it is evident that the risk of cardiac events and strokes is closely related to the levels of arterial systolic and diastolic blood pressure. Nevertheless, the link between hypertension and cardiovascular risk has very often been discussed, due to the results of therapeutic intervention trials, which have proved satisfactory for cardiovascular risk reduction but disappointing results for coronary disease reduction risk. Possible explanations for these poor results of antihypertensive therapy on coronary disease are different and very numerous. According to many Authors, the blood pressure was not reduced to the programmed levels in all trials and the drug used (diuretics, beta-blockers) possibly had negative effects on the lipid profile. Therefore, waiting data for new trials, will perhaps produce better results in the future taking into consideration all risks of our patient, monitoring a rigorous and steady blood pressure reduction and selecting drugs like calcium-channel blockers and ACE-inhibitors which contain characteristics similar to those ideal for the modern antihypertensive agent.

[The echocardiographic examination associated with the cold pressor test or the isometric force test in the evaluation of ischemic heart disease]

Sixteen angina patients were submitted to echocardiographic examination during the cold pressor test and during hand grip. Certain left ventricular function echocardiographic parameters were assessed in these subjects and in a further 14 patients presenting negative histories for cardiovascular diseases who represented the control group. Of the two tests associated with echocardiography, the cold pressor test appeared capable of inducing the more evident changes on left ventricular function compared to isometric effort in subjects suffering from ischaemic cardiopathy.

Thalassemic cardiomyopathy: echocardiographic difference between major and intermediate thalassemia at rest and during isometric effort: yearly follow-up

Left ventricular (LV) performance was studied in young patients with severe chronic anemia due to beta-thalassemia major, intermedia, and in healthy control subjects. M-mode echocardiograms were recorded in each patient and semiautomatic computerized analysis of the tracings provided data relating to LV performance. Then a statistical analysis of the difference between each specific thalassemic group and the normal subjects was made using Student's t-test for unpaired data. The study showed that cardiac dysfunction is more serious in major than in intermediate beta thalassemia. A follow-up one year later showed a progressive deterioration of the cardiac indices, in spite of treatment with desferrioxamine. A handgrip test was performed in the follow-up study, which permitted us to distinguish different groups relative to the changes in LV performance indices. Our findings indicate that echocardiography provides a simple noninvasive means for assessing changes in the cardiac structure and function, which should also prove useful in the serial evaluation of patients at risk of developing myocardial iron deposition.

Bicycle ergometer and echocardiographic study in healthy subjects and patients with angina pectoris after administration of L-carnitine: semiautomatic computerized analysis of M-mode tracing

The discovery tha carnitine takes an active part in the transportation of long-chain acyl residues across the inner mitochondrial membrane dates back to 1958. It has been shown experimentally tha a reduction in myocardial carnitine content takes place after 15-30 min of ischemia. L-carnitine was administered orally in doses of 3 g/day for 30 days to 16 subjects with effort-induced angina and to 14 healthy subjects. A bicycle ergometer exercise test revealed a 1.5 mm (mean) depression of the ST-T segment in the angina subjects after pharmacological wash-out and a 1 mm depression in the same subjects after carnitine treatment. M-code echocardiography showed positive changes in a number of ventricular function parameters in the angina subjects and also, to a lesser extent, in the healthy controls.