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Argirò A, Silverii MV, Burgisser C, Fattirolli F, Baldasseroni S, di Mario C, Zampieri M, Biagioni G, Mazzoni C, Chiti C, Allinovi M, Ungar A, Perfetto F, Cappelli F. Serial Changes in Cardiopulmonary Exercise Testing Parameters in Untreated Patients With Transthyretin Cardiac Amyloidosis. Can J Cardiol 2024; 40:364-369. [PMID: 37793568 DOI: 10.1016/j.cjca.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/08/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Transthyretin amyloid cardiomyopathy (ATTR-CM) is associated with a progressive reduction of functional capacity. The progression of cardiopulmonary exercise testing (CPET) parameters over time is still unknown. METHODS In this study, 55 patients with ATTR-CM underwent 2 serial cardiologic evaluations and CPETs in a national referral center for cardiac amyloidosis (Careggi University Hospital, Florence). RESULTS Forty-three patients (78%) had wild-type ATTR. Median age was 80 years (interquartile range [IQR] 76-83 years), and 50 of the patients (91%) were men. At baseline, median peak oxygen consumption (pVO2) was 15 mL/kg/min (IQR 12-18 mL/kg/min), percentage of predicted pVO2 (%ppVO2) was 71% (IQR 60%-83%) and VE/VCO2 slope was 31 (IQR 26-34). After a median follow-up of 14 months (IQR 13-16 months), pVO2, %ppVO2 and VE/VCO2 slope were significantly worsened (-1.29 mL/kg/min [95% confidence interval (CI): -1.85 to -0.74; P < 0.01], -4.5% [95% CI: -6.9 to -2.02; P < 0.01], and 8.6 [95% CI 6-11; P < 0.01], respectively). Furthermore, exercise time (-39 s, 95% CI: -59 to -19; P < 0.01), exercise tolerance (-0.47 metabolic equivalents, 95% CI: -0.69 to -0.2; P < 0.01), and peak systolic pressure (-10.8 mm Hg, 95% CI: -16.2 to -5.4; P < 0.01) were significantly reduced. The worsening in CPET variables did not correspond with a significant change in echocardiographic parameters. CONCLUSIONS Cardiorespiratory response to exercise significantly worsened over a short period of time in patients with ATTR-CM. Serial CPET may be useful to identify early disease progression.
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Affiliation(s)
- Alessia Argirò
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Maria Vittoria Silverii
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Costanza Burgisser
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Fattirolli
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Samuele Baldasseroni
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Carlo di Mario
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.
| | - Giulia Biagioni
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Carlotta Mazzoni
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Chiara Chiti
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Marco Allinovi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Andrea Ungar
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
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Baldasseroni S, Bari MD, Pratesi A, Rivasi G, Stefàno P, Olivo G, Meo MLD, Orso F, Pace SD, Ungar A, Marchionni N. Prediction of worsening postoperative renal function in older candidates to elective cardiac surgery: Choosing the best eGFR formula may not be enough. Heart Lung 2023; 62:28-34. [PMID: 37295187 DOI: 10.1016/j.hrtlng.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Though renal impairment is highly prevalent in older patients and influence post-operative outcomes in cardiac surgery; its prognostic relevance is debated and not fully assessed by surgical risk scores. OBJECTIVE We investigated the predictive role of estimated glomerular filtration rate formulas for in-hospital worsening renal function (WRF) after cardiac surgery. METHODS We prospectively enrolled in single-center cohort study, patients aged ≥ 75 years candidate to elective cardiac surgery. Four creatinine-based equations were used to calculate estimated glomerular filtration rate (eGFR) formulas: Cockroft-Gault, Modification of Diet in Renal Disease, Chronic Kidney Disease Epidemiology, and Berlin Initiative Study 1 formulas. Each patient underwent geriatric and clinical evaluation before surgery with calculation of the Society of Thoracic Surgeons scores. In-hospital WRF was defined as a composite of an increase in SCr ≥0.5 mg/dl or the occurrence of grade III KDIGO acute kidney injury. The association between each eGFR equation, alone and in models including clinical variables, and WRF was analyzed using logistic regressions and ROC analysis. RESULTS WRF occurred in 69 patients (19.8%), and the predictors of WRF were previous acute myocardial infarction, hypertension, 4-mt gait speed performance, and preoperative eGFR, irrespective of the equation used. With all equations, inclusion of these additional variables in the logistic regression models improved the prediction of WRF (AUCs 0.798-0.810). CONCLUSIONS An accurate assessment of renal function and of physical performance should be incorporated into cardiac surgery risk scores to improve prediction of in-hospital WRF and, hence, risk stratification in older adults undergoing elective cardiac surgery.
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Affiliation(s)
- Samuele Baldasseroni
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Mauro Di Bari
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Alessandra Pratesi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Pierluigi Stefàno
- Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Giuseppe Olivo
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Maria Laura Di Meo
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesco Orso
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Del Pace
- Division of General Cardiology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital, Florence, Italy; Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
| | - Niccolò Marchionni
- Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Clinical and Experimental Medicine, University of Florence, Italy
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Baldasseroni S, Silverii MV, Herbst A, Orso F, Di Bari M, Pratesi A, Burgisser C, Ungar A, Marchionni N, Fattirolli F. Predictors of physical frailty improvement in older patients enrolled in a multidisciplinary cardiac rehabilitation program. Heart Vessels 2023; 38:1056-1064. [PMID: 36991137 PMCID: PMC10289976 DOI: 10.1007/s00380-023-02254-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 02/16/2023] [Indexed: 03/31/2023]
Abstract
Cardiac rehabilitation (CR) improves clinical and functional recovery in older patients after acute cardiac syndromes, whose outcome is influenced by cardiac disease severity, but also by comorbidity and frailty. The aim of the study was to analyze the predictors of physical frailty improvement during the CR program. Data were collected in all patients aged > 75 years consecutively admitted from 1 January to December 2017 to our CR, consisting of 5-day-per-week of 30-min session of biking or calisthenics on alternate days for 4 weeks. Physical frailty was measured with short physical performance battery (SPPB) at the entry and the end of CR. Outcome was represented by an increase of at least 1 point in the SPPB score from baseline to the end of the CR program. In our study population of 100 patients, mean age 81 years, we demonstrated that a strong predictor of improvement in SPPB score was the poorer performance in the test at baseline; for Δ-1 point of score, we registered an OR 2.50 (95% CI = 1.64-3.85; p = 0.001) of probability to improve the physical performance at the end of CR. Interestingly those patients with worse performance at SPPB balance and chair standing task showed greater probability of ameliorating their physical frailty profile at the end of CR. Our data strongly suggest that CR program after acute cardiac syndrome produces a significant physical frailty improvement in those patients with worse frailty phenotype with an impairment in chair standing or balance at entry.
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Affiliation(s)
- Samuele Baldasseroni
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Maria Vittoria Silverii
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Andrea Herbst
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesco Orso
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Mauro Di Bari
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Alessandra Pratesi
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Costanza Burgisser
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy.
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Silverii MV, Argirò A, Baldasseroni S, Fumagalli C, Zampieri M, Guerrieri L, Bartolini S, Mazzoni C, Burgisser C, Tomberli A, Di Mario C, Marchionni N, Olivotto I, Perfetto F, Fattirolli F, Cappelli F. Prognostic value of cardiopulmonary exercise testing in patients with transthyretin cardiac amyloidosis. Intern Emerg Med 2023; 18:585-593. [PMID: 36396841 DOI: 10.1007/s11739-022-03125-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/06/2022] [Indexed: 11/19/2022]
Abstract
The aim of this study is to evaluate the prognostic value of cardiopulmonary testing (CPET) in a cohort of patients with transthyretin cardiac amyloidosis (ATTR-CA). ATTR-CA is associated with a progressive reduction in functional capacity. The prognostic role of CPET parameters and in particular of normalized peak VO2 (%ppVO2) remains to be thoroughly evaluated. In this study, 75 patients with ATTR-CA underwent cardiological evaluation and CPET in a National Referral Center for cardiac amyloidosis (Careggi University Hospital, Florence). Fifty-seven patients (76%) had wild-type ATTR. Median age was 80 (75-83) years, 68 patients (91%) were men. Peak oxygen consumption (14.1 ± 4.1 ml/kg/min) and %ppVO2 (68.4 ± 18.8%) were blunted. Twenty-seven (36%) patients had an abnormal pressure response to exercise. After a median follow-up of 25 (12-31) months, the composite outcome of death or heart failure hospitalization was registered in 19 (25.3%) patients. At univariate analysis %ppVO2 was a stronger predictor for the composite outcome than peak VO2. %ppVO2 and NT-proBNP remained associated with the composite outcome at multivariate analysis. The optimal predictive threshold for %ppVO2 was 62% (sensitivity: 71%; specificity: 68%; AUC: 0.77, CI 0.65-0.88). Patients with %ppVO2 ≤ 62%and NT-proBNP > 3000 pg had a worse prognosis with 1- and 2-year survival of 69 ± 9% and 50 ± 10%, respectively. CPET is a safe and useful prognostic tool in patients with ATTR-CA. CPET may help to identify patients with advanced disease that may benefit from targeted therapy.
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Affiliation(s)
- Maria Vittoria Silverii
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessia Argirò
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Cardiomyopathy Unit Largo, Careggi University Hospital, Brambilla 3, 50141, Florence, Italy
| | | | - Carlo Fumagalli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.
- Cardiomyopathy Unit Largo, Careggi University Hospital, Brambilla 3, 50141, Florence, Italy.
| | - Ludovica Guerrieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Simone Bartolini
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Carlotta Mazzoni
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Costanza Burgisser
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessia Tomberli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Cardiomyopathy Unit Largo, Careggi University Hospital, Brambilla 3, 50141, Florence, Italy
| | - Carlo Di Mario
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, Division of General Cardiology, University of Florence, Careggi University Hospital, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit Largo, Careggi University Hospital, Brambilla 3, 50141, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Fattirolli
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
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Silverii MV, Argiro A, Baldasseroni S, Zampieri M, Fumagalli C, Mazzoni C, Di Mario C, Perfetto F, Fattirolli F, Olivotto I, Cappelli F. 965 PROGNOSTIC VALUE OF CARDIOPULMONARY EXERCISE TESTING IN PATIENTS WITH TRANSTHYRETIN CARDIAC AMYLOIDOSIS. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
ATTR-CA is associated with a progressive reduction in functional capacity. The prognostic role of CPET parameters and in particular of normalized peak VO2 (%ppVO2) remains to be thoroughly evaluated.
Methods
In this study 75 patients with ATTR-CA underwent cardiological evaluation and CPET in a National Referral Center for cardiac amyloidosis (Careggi University hospital, Florence).
Results
Fifty-seven patients (76%) had wild type ATTR. Median age was 80 (75-83) years, 68 patients (91%) were men. Peak oxygen consumption (14.1±4.1 ml/kg/min) and %ppVO2 (68.4±18.8%) were blunted. Twenty-seven (36%) patients had an abnormal pressure response to exercise. After a median follow-up of 25 (12-31) months the composite outcome of death or heart failure hospitalization was registered in 19 (25.3%) patients. At univariate analysis %ppVO2 was a stronger predictor for the composite outcome than peak VO2. %ppVO2 and NTproBNP remained associated with the composite outcome at multivariate analysis. The optimal predictive threshold for %ppVO2 was 62% (sensitivity: 71%; specificity: 68%; AUC:0.77, CI: 0.65-0.88). Patients with %ppVO2 ≤ 62%and NTproBNP >3000pg had the worse prognosis with 1- and 2-year survival of 69±9% and 50±10%, respectively.
Conclusions
CPET is a safe and useful prognostic tool in patients with ATTR-CA. CPET may help to identify patients with advanced disease that may benefit of targeted therapy.
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Affiliation(s)
- Maria Vittoria Silverii
- Cardiac Rehabilitation Unit, Department Of Experimental And Clinical Medicine, University Of Florence
| | - Alessia Argiro
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
| | | | - Mattia Zampieri
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
| | - Carlo Fumagalli
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
- Geriatric Medicine And Utig, Careggi University Hospital , Florence
| | - Carlotta Mazzoni
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
| | - Carlo Di Mario
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
| | - Francesco Fattirolli
- Cardiac Rehabilitation Unit, Department Of Experimental And Clinical Medicine, University Of Florence
| | - Iacopo Olivotto
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Center, Careggi University Hospital , Florence
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Fumagalli C, Nardi G, Bonanni F, Credi G, Demola P, Carrabba N, Valenti R, Meucci F, Stefano P, Scheggi V, Di Mario C, Ungar A, Baldasseroni S, Marchionni N. 569 IMPACT OF FRAILTY ON VERY LONG-TERM OUTCOME IN PATIENTS UNDERGOING PERCUTANEOUS TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) IN A HIGH-FLOW REFERRAL CENTER: A PROSPECTIVE STUDY. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Transcatheter strategies for aortic stenosis (AS) are a therapeutic option in older patients not amenable for open heart surgery. Guidelines recommend surgical scores like the Society of Thoracic Surgeons (STS) for risk stratification. However, the long-term predictive power of these scores in older patients is limited.
Purpose
To assess the impact of frailty status on the very long-term mortality in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care center.
Methods
Consecutive patients >80 years referred to TAVI from January to December 2019 at our tertiary care institution were prospectively screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the Multidimensional Prognostic Index (MPI).
The MPI is a three-level score used to stratify frailty and risk of mortality (low, intermediate, or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility, and risk of pressure sores, multimorbidity, polypharmacy and co-habitation).
Frailty was defined by an intermediate-high MPI. Patients were also analyzed by STS score (<4%: low risk; 4-8%: intermediate risk; >8%: high risk). All patients prospectively called at 1, 2 and 3 years from TAVI.
Results
Overall, 134 patients were referred for TAVI (mean age: 84±4 years; >90 years: 12%, women 67%). Average STS score was 4.6 ± 3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3±3.7 (SPPB <6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group.
After 3 years, 17 (12.7%) patients died, and 40 (29.9%) were hospitalized: 21 (15.7%) for cardiovascular complications (N=11 for acute heart failure, N=6 for major bleeding, N=4 for stroke). Four patients (2.9%) implanted a pacemaker. One patient (0.7%) required a de-novo intervention.
At Cox multivariable analysis, only frailty (MPI intermediate-high) was associated with mortality (HR 5.42, 95% C.I. 1.88-12.11, p=0.002) while a high STS score showed a trend towards higher mortality risk (HR 1.63, 95% C.I. 0.91-2.91, p=0.101). Overall, at Kaplan Meier survival analysis, patients considered fit (non-frail) were characterized by a better prognosis irrespective of STS score (<8 vs >8).
Conclusions
In a prospectively enrolled cohort of old TAVI candidates, frailty status was able to identify patients at higher risk of mortality irrespective of STS risk. Frailty assessment could be a useful tool, coupled with other scores, for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure.
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Herbst A, Orso F, Camartini V, Virciglio S, D‘Errico G, Salucci C, Verga F, Fattirolli F, Marchionni N, Di Bari M, Ungar A, Baldasseroni S. P239 TOLERABILITY OF SACUBITRIL/VALSARTAN TREATMENT IN OLDER PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION: PRELIMINARY DATA FROM THE REAL–WORLD AGING–HF REGISTRY. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartj/suac012.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Although older patients with heart failure (HF) with reduced ejection fraction enrolled in PARADIGM–HF showed a good tolerance to sacubitril/valsartan (Sa/Va), more real–word data are needed to define their tolerability in this population. Aim: To describe the Sa/Va tolerability and titration in older HFrEF patients followed by our HF outpatient.
Methods
HFrEF patients aged ≥65 years and treated with Sa/Va from November 2016 to June 2021 were enrolled, assessing Sa/Va tolerability at six months and its clinical and hemodynamic effects.
Results
We enrolled 101 patients with a mean age of 78 years (⁓20% female). The aetiology was ischemic in 59% of cases while the mean ejection fraction was 31%. Sa/Va was prescribed at the starting dose (24/26mg) and intermediate dose (49/51mg) in 91% and 9% of cases, respectively. After six months, 9 of the 100 patients still alive had discontinued treatment with Sa/Va (4 for symptomatic hypotension, 3 for suspected allergic reaction and 2 for worsening renal function). Of the 91 patients still on therapy, only 17 had reached the target dose (97/103mg) while 28 were at the intermediate dose (Figure 1). Symptomatic hypotension (62%), hyperkalaemia (15%) and worsening of renal function (4%) were the main causes of maintaining Sa/Va therapy at the starting dose; note, in 15% of cases a specific cause of non–titration was not identified. Comparing HF treatment between starting dose vs higher–dose patients, after six months in low–dose patients there was a slight improvement in mineralcorticosteroid receptor antagonist (MRA) prescription and in combination therapy (Sa/Va, beta–blocker and MRA) while in patients at higher–doses there was a significant decrease (Figure 2). In patients still receiving Sa/Va, significant clinical improvement was observed while renal function, K+ levels and systolic blood pressure remained stable (Figure 3).
Conclusions
After six months of treatment, Sa/Va was well tolerated in most of our older patients and used in combination with a beta–blocker and an MRA in a high percentage of cases, although a reduction in MRA prescription is observed in patients taking higher dosages of Sa/Va. In addition, there was a marked improvement in the clinical variables.
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Verga F, Orso F, Herbst A, Camartini V, Virciglio S, D‘Errico G, Salucci C, Di Bari M, Marchionni N, Ungar A, Fattirolli F, Baldasseroni S. P252 PROTOCOL FOR TELEHEALTH MANAGEMENT AND STRATIFICATION RISK OF ELDERLY PATIENTS WITH CHRONIC HEART FAILURE DURING THE COVID–19 PANDEMIC: A MID–TERM PROGNOSTIC EVALUTATION BY TELEHFCOVID–19 SCORE. Eur Heart J Suppl 2022. [PMCID: PMC9383990 DOI: 10.1093/eurheartj/suac012.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The Coronavirus Disease (COVID–19) pandemic and its consequences has forced physicians to develop telematic methods in order to follow up patients with cronic diseases, such as heart failure (HF). Objectives To evaluate TeleHFCovid–19 score as a mid–term (six months) prognostic score in terms of prediction of hospitalitazion and cardiovascular mortality in patients with chronic HF during Covid–19 pandemic. Methods During COVID–19 pandemic (from March 2020 to May 2020), we were forced to cancel nearly all follow–up checks in our HF outpatient clinic. We hence standardized a telephone follow–up by developing a questionnaire (Fig. 1) from which we then obtained a score, later called the “TeleHFCovid–19 score” (0–29). This score stratified patients in three risk score groups: green (0–3), yellow (4–8), and red (≥9), for which the next telefonic evaluation was planned after 4, 2 and 1 weeks, respectively. Results 146 patients were enrolled: 112 were classified as green, 21 as yellow and 13 as red. Mean age was 81 years, females were 40%. Approximately one third had EF < 40%. At six months, compared to red (69.2%) and yellow patients (33.3%), green patients (8.9%) presented a significantly lower rate of the composite outcome of cardiovascular death and/or HF hospitalization, (p < 0.001, Fig 2). Multivariate analysis showed that high levels of creatinine (OR 5.960, 95% CI 1.627–21.837, p = 0.007), dyspnea at rest or for basic activities (OR 2.469, 95% CI 1.216–5.013, p = 0.012) and a high loop–diuretic dosage (OR 6.224, 95% CI 1.504–25.753, p = 0.012) were indipendently associated with the outcome. Moreover, ROC analysis showed a high sensibility and specificity for our score at six months (AUC =0.789, 95% CI 0.682–0.896, p < 0.001), with a score < 4.5 (very close to the green group cut–off) that identified lower–risk subjects (Fig 3). Conclusions The TeleHFCovid–19 score was able to correctly identify patients with good outcomes at six months. Furthermore, it has the ability to stratify the adverse event risk and this could represent a useful tool to appropriately schedule the reevaluation timing of these patients and to identify those who may need urgent hospital evaluation.
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D‘Errico G, Herbst A, Orso F, Baldasseroni S, Fattirolli F, Virciglio S, Camartini V, Di Bari M, Marchionni N, Ungar A, Salucci C, Verga F. P250 PROTOCOL FOR TELEHEALTH EVALUATION AND FOLLOW–UP OF PATIENTS WITH CHRONIC HEART FAILURE DURING THE COVID–19 PANDEMIC. Eur Heart J Suppl 2022. [PMCID: PMC9384072 DOI: 10.1093/eurheartj/suac012.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background After the lockdown imposed by the COVID19 pandemic, physicians had to limite ambulatory visits to exceptional cases to reduce interpersonal contact. We structured a telephone follow–up developing a standardized 23 item questionnaire to administrate to our HF outpatient clinic and from whom we obtained the Covid–19–HFscore. Methods The patients were identified by a numeric code, date of birth and gender. The questionnaire was designed for rapid administration during telephone interview (on average 6 minutes) and was administered directly by physicians to patients and/or to their caregiver. It was built to reproduce our usual clinical evaluation. Results As shown in Figure 1, we investigated seven domains: 1) social and functional condition 2) mood 3) adherence to pharmacological and non–pharmacological recommendations (blood pressure, heart rate, weight monitoring and fluid intake control) 4) clinical and hemodynamic status 5) recording of laboratory tests 6) current pharmacological treatment 7) recent evaluation by family physician or need to contact emergency services followed or not by hospitalisation. General and pharmacological recommendations as well as the following telephone contact were finally recorded. To determine the timing of the next telephonic evaluation, we decided to weight questions regarding clinical and hemodynamic status, adherence to pharmacological and non–pharmacological recommendations, therapeutic changes and need for hospitalisation by scoring the answers (from 1 to 3) to build a score. The sum of individual scores represented the novel TeleHFCovid19–score, ranging from 0 to 29. Based on such score, three groups of patients were identified by arbitrary cut–off levels: the green (score <4), the yellow (score 4–8) and the red (score ≥9) group, for which next telephonic evaluation was planned respectively after four, two and one week respectively. Alternatively, the red group could receive recommendation for urgent hospital evaluation. Conclusion During this emergency situation this questionnaire could be a useful clinical tool to help physicians maintaining a regular FU of their patients and identifying patients at greatest risk of imminent instability. Furthermore, this instrument could also represent a useful resource in the management of low–risk HF patients.
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Affiliation(s)
- G D‘Errico
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - A Herbst
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - F Orso
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - S Baldasseroni
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - F Fattirolli
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - S Virciglio
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - V Camartini
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - M Di Bari
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - N Marchionni
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - A Ungar
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - C Salucci
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
| | - F Verga
- AMBULATORIO SCOMPENSO CARDIACO AOU CAREGGI, FIRENZE; RIABILITAZIONE CARDIOLOGICA AOU CAREGGI, FIRENZE; AOU CAREGGI UTIG–GERIATRIA, FIRENZE; AOU CAREGGI DIPARTIMENTO CARDIO–TORACO–VASCOLARE, FIRENZE
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Virciglio S, Orso F, Herbst A, Camartini V, Girardi E, Ghiara C, Perfetti G, Pratesi A, Di Bari M, Ungar A, Fattirolli F, Marchionni N, Baldasseroni S. P253 INDEPENDENT PREDICTORS OF 1–YEAR MORTALITY IN OLDEST OLD PATIENTS MANAGED BY A GERIATRIC–CARDIOLOGY HF UNIT OF AOU CAREGGI. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartj/suac012.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background
A multidisciplinary heart team and continuum care approach seems to be the most appropriate clinical strategy in order to reduce mortality, functional decline and disability of frail and clinical complex oldest old patients affected by heart failure (HF). We analysed the independent predictors of 1 year–total mortality in our cohort of oldest old HF patients.
Methods
All patients aged > 85 years referred to our Heart Failure Unit of a Tertiary teaching hospital were consecutively enrolled in the study and were evaluated at first visit with a comprehensive assessment recording cardiological, geriatric and bio–humoral variables. Then we assessed with a multivariable Cox regression analysis the independent predictors of 1–year all–cause mortality.
Results
87 patients were enrolled (mean age 89 ± 2.7 years, range 86–96 years); 48.9% were females, 57.9% were in NYHA class III or IV, 43.2% had HFpEF, 36.4% had an ischemic aethiology, 69.3% had a history of atrial fibrillation, 19.3% were living alone, the mean number of prescribed drugs was 8.8 ± 2.2, EVEREST congestion score was 5.2 ± 2.6, mean NT–proBNP was 8187 ± 11170 pg/ml. In the year after enrolment, 25 patients (34.1%) had more than one HF hospitalisation and 17 patients (19%) died. Among all clinical variables, living alone, having had one or more HF hospitalisation and HF–type (HFpEF, HFmrEF, HFrEF), EVEREST congestion score, trans–tricuspid gradient and tricuspid annular plane systolic excursion were significantly (p < 0.05) associated with 1–year mortality. At multivariable Cox–regression model only living alone (HR 3.34; 95% CI: 1.16–9.64) and EVEREST congestion score (HR 1.24; 95% CI: 1.04–1.46) resulted significantly associated with 1–year mortality. In the Figure we report the Kaplan–Meier curves according to the EVEREST congestion score (dichotomized according to a median value of 4) and living alone (yes vs not).
Conclusions
In a cohort of HF oldest old patients tightly managed in a dedicated cardiologic and geriatric Heart Failure Unit, 1–year all–cause mortality was independently predicted by a clinical score of congestion and by living alone status.
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Affiliation(s)
- S Virciglio
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - F Orso
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - A Herbst
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - V Camartini
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - E Girardi
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - C Ghiara
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - G Perfetti
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - A Pratesi
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - M Di Bari
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - A Ungar
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - F Fattirolli
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - N Marchionni
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
| | - S Baldasseroni
- AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, AMBULATORIO SCOMPENSO CARDIACO, UTIG, FIRENZE; OSPEDALE DI EMPOLI, GERIATRIA, EMPOLI; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO DI GERIATRIA, UTIG, FIRENZE; AZIENDA OSPEDALIERA UNIVERSITARIA CAREGGI (AOUC), DIPARTIMENTO CARDIOTORACOVASCOLARE, RIABILITAZIONE CARDIOLOGICA, FIRENZE; AZIENDA OSPEDALIERA
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Salucci C, Girardi E, Orso F, Herbst A, Migliorini M, Ghiara C, Virciglio S, Camartini V, Tognelli S, Fortini G, Di Bari M, Baldasseroni S, Ungar A, Marchionni N, Fattirolli F. P248 THE SCORE TELEHFCOVID19, ONE MONTH FOLLOW UP : A TELEHEALTH APPROACH TO MANAGE ELDERLY PATIENTS WITH CHRONIC HEART FAILURE DURING COVID–19 PANDEMIC. Eur Heart J Suppl 2022. [PMCID: PMC9384048 DOI: 10.1093/eurheartj/suac012.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Due to the total lockdown during COVID–19 pandemic, clinicians were forced to organize telephone visits or tele–monitoring. We developed a standardized multiparametric questionnaire, suitable for telephone administration to older heart failure (HF) patients and/or their caregivers. Purpose To compare clinical characteristics of the three groups (green, yellow, red) of patients classified by baseline TeleHFCovid19–Score and evaluate its ability to predict one–month in elderly patients with chronic HF. Methods The TeleHFCovid–19 score was obtained from a multiparametric questionnaire administered, from April 2020, during televisits to patients (or caregivers), which were divided in progressively increasing risk groups: green (0–3), yellow (4–8) and red (≥9). The primary study outcome was a composite of death from cardiovascular causes and/or hospitalization for HF, which individually were secondary outcomes. Results We enrolled 146 patients. Mean age was 81±9 years, females were 40%. In all the study population there was a high prevalence of self–reported adherence to guidelines–recommended drug treatments and behavioural measures, as well as a broad intake of diuretic therapy. Patients in green group had lower use of high dose loop diuretic (p < 0.001) or thiazide–like diuretic and had reported less frequently dyspnoea at rest or for basic activities, new/worsening extremities oedema or weight increase (all p < 0.001). Through scheduled phone contacts we were able to improve the overall clinical status of our patients even over a short (1 month) follow–up.The primary composite outcome of CV death and/or HF hospitalisation occurred in 8.2%, with a significantly lower prevalence in the green than in the yellow and red groups, and when analysing separately, we found that death for CV causes occurred more frequently in the red group than in the other two, while HF hospitalisations were significantly less frequent in the green group than in the red or yellow. ROC analysis confirmed the high sensibility and specificity of our score (AUC=0.883, 95% CI 0.806–0.959) with a score <4.5 (very close to green group cut–off) that identified lower–risk subjects (p < 0.001).
Conclusions The TeleHFCovid19–Score score was able to correctly recognize a low risk, green group. Therefore, the score could be used to identify low risk patients which could be followed remotely, reserving a tighter on–site clinical follow–up to higher events risk patients.
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Affiliation(s)
- C Salucci
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | - E Girardi
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | - F Orso
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | - A Herbst
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | | | - C Ghiara
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | | | | | - S Tognelli
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | - G Fortini
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | - M Di Bari
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
| | | | - A Ungar
- AOU CAREGGI, FIRENZE; AOU CAREGGI, FIRENZE
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Camartini V, Orso F, Herbst A, Virciglio S, Salucci C, Verga F, D‘Errico G, Di Bari M, Ungar A, Fattirolli F, Marchionni N, Baldasseroni S. P260 PRELIMINARY EXPERIENCE OF REPEATED LEVOSIMENDAN INFUSIONS IN ELDERLY OUTPATIENTS WITH ADVANCED HEART FAILURE. Eur Heart J Suppl 2022. [PMCID: PMC9383975 DOI: 10.1093/eurheartj/suac012.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background The use of intermittent infusion of Levosimendan (L) demonstrated to be able to reduce hospitalisations and to improve functional capacity and quality of life in patients with advanced heart failure (HF). Purpose To describe our preliminary experience regarding L intermittent infusions in advanced HF older outpatients. Methods A maximum of three consecutive L infusions were carried out 14 days apart. The duration of each session was 8 hours. The starting infusion rate was 0.05 μg/Kg/min, titrated every 30/60‘ up to a maximum of 0.2 μg/Kg/min based on blood pressure, heart rate and arrhythmias recorded during telemetry. We evaluated patients by clinical, laboratory and echocardiographic controls at baseline and two weeks after the end of treatment. Results Since November 2020 we enrolled 17 patients with a mean age of 77 years; 12% were women. HF etiology was ischemic in 64% of cases and the mean ejection fraction was 30%. A total of 41 infusions were performed, the mean dose of L administered was 5.4 mg/infusion. Three patients did not complete the expected treatment, one due to an intercurrent COVID–19 infection and two because of social issues. In 28 sessions the maximum infusion rate was reached, while in 12 a lower rate; in one case drug infusion was suspended (Figure 1). The main complication observed was marked non–symptomatic hypotension, followed by the onset of atrial fibrillation or frequently ventricular extrasystole. As shown in Figure 2, at the end of the infusion cycles, there was an improvement of clinical and hemodynamic parameters. Moreover, at the end of the infusion cycles, we observed a reduction in the mean dose of loop diuretic prescribed and an increase in the prescription of disease–modify treatment, according to HF guidelines (Figure 3).
Conclusions In our preliminary experience repeated infusions of L appear to be well tolerated in older patients with advanced HF. Although there was an improvement in congestion parameters and targeted therapy for HF, more data will be needed in the future to confirm its safety and efficacy, also in terms of guidelines–directed medical therapy.
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Baldasseroni S, Silverii MV, Pratesi A, Burgisser C, Orso F, Lucarelli G, Turrin G, Ungar A, Marchionni N, Fattirolli F. Cardiac Rehabilitation in Advanced aGE after PCI for acute coronary syndromes: predictors of exercise capacity improvement in the CR-AGE ACS study. Aging Clin Exp Res 2022; 34:2195-2203. [PMID: 35451734 PMCID: PMC9464170 DOI: 10.1007/s40520-022-02130-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/24/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The positive effect of cardiac rehabilitation (CR) on outcomes after acute coronary syndromes (ACS) is established. Nevertheless, enrollment rates into CR programs remain low, although ACS carry a high risk of functional decline particularly in the elderly. AIM We aimed to determine if a multidisciplinary CR improves exercise capacity in an older population discharged after ACS systematically treated with PCI. METHODS CR-AGE ACS is a prospective, single-center, cohort study. All patients aged 75+ years consecutively referred to Cardiac Rehabilitation outpatient Unit at Careggi University Hospital, were screened for eligibility. Moderate/severe cognitive impairment, disability in 2+ basic activities of daily living, musculoskeletal diseases, contraindication to Cardiopulmonary Exercise Test, and diseases with an expected survival < 6 months, were exclusion criteria. Participants attended a CR program, based on 5-day-per-week aerobic training sessions for 4 weeks. RESULTS We enrolled 253 post-ACS patients with a mean age 80.6 ± 4.4 years. After CR, 136 (56.2%) 77 (31.3%) patients obtained, respectively, at least a moderate (∆+5%) or an optimal (∆+15%) increase in VO2peak. Baseline VO2peak (- 1 ml/kg/min: OR 1.18; 95% CI 1.09-1.28), the number of training sessions (+1 session: OR 1.07; 95% CI 1.01-1.15), and mild-to-moderate baseline disability (yes vs. no: OR 0.22; 95% CI 0.01-0.57) were the predictors of VO2peak changes. CONCLUSIONS A CR program started early after discharge from ACS produces a significant increase in exercise capacity in very old patients with mild-to-moderate post-acute physical impairment. Baseline VO2peak, the number of training sessions, and the level of baseline disability are the independent predictors of improvement.
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Baldasseroni S, Di Bari M, Stefàno P, Pratesi A, Mossello E, Ungar A, Del Pace S, Orso F, Herbst A, Lucarelli G, Fumagalli C, Olivo G, Marchionni N. Lower extremity performance predicts length of hospital stay in older candidates to elective cardiac surgery. Exp Gerontol 2022; 164:111801. [DOI: 10.1016/j.exger.2022.111801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/17/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
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15
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Baldasseroni S, Orso F, Herbst A, Bo M, Boccanelli A, Desideri GB, Rozzini R, Terrosu P, Alboni P, Marchionni N, Ungar A. Role of new drug therapies and innovative procedures in older patients with heart failure: from trials to clinical practice. Minerva Med 2022; 113:647-666. [PMID: 35332760 DOI: 10.23736/s0026-4806.22.08082-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Samuele Baldasseroni
- Unit of Geriatric Intensive Care Medicine, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy - .,Department of Clinical and Experimental medicine, University of Florence, Florence, Italy - .,Società Italiana di Cardiologia Geriatrica-SICGE, Florence, Italy -
| | - Francesco Orso
- Unit of Geriatric Intensive Care Medicine, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy.,Department of Clinical and Experimental medicine, University of Florence, Florence, Italy
| | - Andrea Herbst
- Unit of Geriatric Intensive Care Medicine, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy.,Department of Clinical and Experimental medicine, University of Florence, Florence, Italy
| | - Mario Bo
- Società Italiana di Cardiologia Geriatrica-SICGE, Florence, Italy
| | | | | | - Renzo Rozzini
- Società Italiana di Cardiologia Geriatrica-SICGE, Florence, Italy
| | | | - Paolo Alboni
- Società Italiana di Cardiologia Geriatrica-SICGE, Florence, Italy
| | - Niccolò Marchionni
- Department of Clinical and Experimental medicine, University of Florence, Florence, Italy.,Società Italiana di Cardiologia Geriatrica-SICGE, Florence, Italy.,Division of Cardiology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Andrea Ungar
- Unit of Geriatric Intensive Care Medicine, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy.,Department of Clinical and Experimental medicine, University of Florence, Florence, Italy.,Società Italiana di Cardiologia Geriatrica-SICGE, Florence, Italy
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Rozzini R, Bianchetti A, Alboni P, Baldasseroni S, Bo M, Boccanelli A, Desideri G, Marchionni N, Palazzo G, Terrosu P, Ungar A, Vetta F, Zito G. The older patient with cardiovascular disease: background and clinical implications of the comprehensive geriatric assessment (CGA). Minerva Med 2022; 113:609-615. [PMID: 35332761 DOI: 10.23736/s0026-4806.22.08086-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Principles and processes of Comprehensive Geriatric Assessment (CGA) are increasingly being applied to subspecialties and subspecialty conditions, including cardiovascular patients (i.e. infective endocarditis; considerations of surgery or transcatheter aortic valve replacement, TAVR, for patients with aortic stenosis; vascular surgery) and postoperative mortality risk. In cardiovascular field CGA has mainly the aim to define ideal management according to the different typology of older adult patients (eg, robust versus intermediate versus physical and cognitively disabled versus end-stage or dying), allowing physicians to select different therapeutic goals according to life expectancy; Aspect to be valued are by CGA are global health status and patient's decision-making capacity: CGA allows the individualized treatment definition and optimize the preprocedure condition.
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Affiliation(s)
- Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy - .,Fondazione Poliambulanza, Istituto Ospedaliero, Brescia, Italy -
| | | | - Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | | | | | - Giuseppe Palazzo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Andrea Ungar
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
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17
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Orso F, Herbst A, Migliorini M, Ghiara C, Virciglio S, Camartini V, Tognelli S, Lucarelli G, Fortini G, Pratesi A, Di Bari M, Marchionni N, Ungar A, Fattirolli F, Baldasseroni S. Telehealth Management and Risk Stratification of Older Patients With Chronic Heart Failure During COVID-19 Pandemic: Prognostic Evaluation of the TeleHFCovid19-Score. J Am Med Dir Assoc 2021; 23:421-427. [PMID: 35041828 PMCID: PMC8702408 DOI: 10.1016/j.jamda.2021.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/12/2021] [Accepted: 12/14/2021] [Indexed: 12/03/2022]
Abstract
Objectives To evaluate 6-month risk stratification capacity of the newly developed TeleHFCovid19-Score for remote management of older patients with heart failure (HF) during the coronavirus disease 2019 pandemic. Design Monocentric observational prospective study. Setting and Participants Older HF outpatients remotely managed during the first pandemic wave. Methods The TeleHFCovid19-Score (0-29) was obtained by an ad hoc developed multiparametric standardized questionnaire administered during telephone visits to older HF patients (and/or caregivers) followed at our HF clinic. Questions were weighed on the basis of clinical judgment and review of current HF literature. According to the score, patients were divided in progressively increasing risk groups: green (0-3), yellow (4-8), and red (≥9). Results A total of 146 patients composed our study population: at baseline, 112, 21, and 13 were classified as green, yellow, and red, respectively. Mean age was 81±9 years, and women were 40%. Compared to patients of red and yellow groups, those in the green group had a lower use of high-dose loop diuretics (P < .001) or thiazide-like diuretics (P = .027) and had reported less frequently dyspnea at rest or for basic activities, new or worsening extremity edema, or weight increase (all P < .001). At 6 months, compared with red (62.2%) and yellow patients (33.3%), green patients (8.9%) presented a significantly lower rate of the composite outcome of cardiovascular death and/or HF hospitalization (P < .001). Moreover, receiver operating characteristic curve analysis showed a high sensibility and specificity of our score at 6 months (area under the curve = 0.789, 95% CI 0.682-0.896, P < .001) with a score <4.5 (very close to green group cutoff) that identified lower-risk subjects. Conclusions and Implications The TeleHFCovid19-Score was able to correctly identify patients with midterm favorable outcome. Therefore, our questionnaire might be used to identify low-risk chronic HF patients who could be temporarily managed remotely, allowing to devote more efforts to the care of higher-risk patients who need closer and on-site clinical evaluations.
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Affiliation(s)
- Francesco Orso
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Andrea Herbst
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marta Migliorini
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Camilla Ghiara
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Simona Virciglio
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Viola Camartini
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Silvia Tognelli
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Lucarelli
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giacomo Fortini
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandra Pratesi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mauro Di Bari
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Samuele Baldasseroni
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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18
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Di Bari M, Tonarelli F, Balzi D, Giordano A, Ungar A, Baldasseroni S, Onder G, Mechi MT, Carreras G. COVID-19, Vulnerability, and Long-Term Mortality in Hospitalized and Nonhospitalized Older Persons. J Am Med Dir Assoc 2021; 23:414-420.e1. [PMID: 34990587 PMCID: PMC8673732 DOI: 10.1016/j.jamda.2021.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/24/2021] [Accepted: 12/09/2021] [Indexed: 02/09/2023]
Abstract
Objective Studies suggesting that vulnerability increased short-term mortality in older patients with COVID-19 enrolled hospitalized patients and lacked COVID-negative comparators. Aim of this study was to examine the relationship between frailty and 1-year mortality in older patients with and without COVID-19, hospitalized and nonhospitalized. Design Cohort study. Setting and Participants Patients over 75 years old accessing the emergency departments (ED) were identified from the ED archives in Florence, Italy. Methods Vulnerability status was estimated with the Dynamic Silver Code (DSC). COVID-19 hospital discharges (HC+) were compared with non-COVID-19 discharges (HC-). Linkage with a national COVID-19 registry identified nonhospitalized ED visitors with (NHC+) or without COVID-19 (NHC-). Results In 1 year, 48.4% and 33.9% of 1745 HC+ and 15,846 HC- participants died (P < .001). Mortality increased from 27.5% to 64.0% in HC+ and from 19.9% to 51.1% in HC- across DSC classes I to IV, with HC+ vs HC- hazard ratios between 1.6 and 2.2. Out of 1039 NHC+ and 18,722 NHC- participants, 18% and 8.7% died (P < .001). Mortality increased from 14.2% to 46.7% in NHC+ and from 2.9% to 26% in NHC- across DSC; NHC+ vs NHC- hazard ratios decreased from 5.3 in class I to 2.0 in class IV. Conclusions and Implications In hospitalized older patients, mortality increases with vulnerability similarly in the presence and in the absence of COVID-19. In nonhospitalized patients, vulnerability-associated excess mortality is milder in individuals with than in those without COVID-19. The disease reduces survival even when background risk is low. Thus, apparently uncomplicated patients deserve closer clinical monitoring than commonly applied.
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Affiliation(s)
- Mauro Di Bari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Unit of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Francesco Tonarelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Daniela Balzi
- Department of Epidemiology, Azienda USL Toscana Centro, Florence, Italy
| | - Antonella Giordano
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Unit of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Samuele Baldasseroni
- Unit of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Italy
| | - M Teresa Mechi
- Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giulia Carreras
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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19
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Fumagalli C, Nardi G, Demola P, Meucci F, Valenti R, Scheggi V, Carrabba N, Mario CD, Baldasseroni S, Ungar A, Marchionni N. 775 Impact of frailty on medium-term follow-up in patients undergoing transcatheter aortic valve implantation in a high flow referral centre with high volumes. Eur Heart J Suppl 2021. [DOI: 10.1093/eurheartj/suab134.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Transcatheter strategies to treat aortic stenosis (AS) are an established therapeutic option in older patients not candidate for open heart surgery. Guidelines recommend the adoption of surgical scores like the Society of Thoracic Surgeons (STS) as tools for risk stratification. However, these scores may have limited predictive value in older patients. To assess the impact of frailty status on a composite endpoint comprising all-cause death and cardiovascular (CV) events in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care centre.
Methods and results
Consecutive patients >80 years referred to TAVI from January to December 2019 at our institution were screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the multidimensional prognostic index (MPI). Physical function was evaluated by the short physical performance battery (SPPB), a tool exploring balance, gait speed, strength and endurance that produces a score ranging from 0 to 12 (lowest to highest performance). The SPPB <6 is an established strong predictor of mortality and disability. The MPI is a three-level score used to stratify risk of mortality (low, intermediate, or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility and risk of pressure sores, multimorbidity, polypharmacy, and co-habitation). Data on mortality and CV events at 6 and 12 months were retrieved via administrative records and/or telephone follow-up. Overall, 134 patients were referred for TAVI (mean age: 84 ± 4 years; >90 years: 12%, women 67%). The STS risk score was 4.6 ± 3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3 ± 3.7 (SPPB <6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group. SPPB and MPI scores were moderately correlated with STS (Spearman correlation coefficient: SPPB R = 0.31, P = 0.01, MPI R = 0.29, P = 0.03, Figure 1A and B). At 1 year, 3 (2.2%) patients died, and 11 (8.2%) were hospitalized for CV events: major bleeding, N = 6(4.5%); stroke: N = 4 (3.0%); re-do: N = 1 (0.7%). The probability of the composite endpoint was higher for patients at intermediate/high MPI risk (HR intermediate/high risk vs. low risk: HR: 2.9, 95% CI: 1.1–6.8, P = 0.031, Figure 1C), while no association with STS (P = 0.332) was found.
Conclusions
In a prospective cohort of TAVI candidates, frailty stratified short- and medium-term prognosis. The integrated frailty assessment could be a useful tool for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure. 120 Figure
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20
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Fumagalli C, Blandina A, Nardi G, Campicelli S, Bandini G, Marchetti F, Demola P, Meucci F, Scheggi V, Baldasseroni S, Carrabba N, Di Mario C, Ungar A, Marchionni N. Impact of frailty status on medium-term follow up in patients undergoing percutaneous transcatheter aortic valve implantation in a high-flow referral center with high procedural volumes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Transcatheter strategies to treat aortic stenosis (AS) are an established therapeutic option in older patients not candidate for open heart surgery. Current guidelines recommend the adoption of surgical scores like the Society of Thoracic Surgeons (STS) as tools for risk stratification. However, these scores may have limited predictive value in older patients.
Purpose
To assess the impact of frailty status on a composite endpoint comprising mortality and cardiovascular (CV) events in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care center.
Methods
Consecutive patients >80 years referred to TAVI from January to December 2019 at our tertiary care institution were prospectively screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the Multidimensional Prognostic Index (MPI). Physical function was evaluated by the Short Physical Performance Battery (SPPB), a tool exploring balance, gait speed, strength and endurance that produces a score ranging from 0 to 12 (lowest to highest performance). The SPPB <6 is an established strong predictor of mortality and disability.
The MPI is a three-level score used to stratify risk of mortality (low, intermediate or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility and risk of pressure sores, multimorbidity, polypharmacy and co-habitation).
Data on mortality and CV events at 6 and 12 months were retrieved via administrative records and/or telephone follow-up.
Results
Overall, 134 patients were referred for TAVI (mean age: 84±4 years; >90 years: 12%, women 67%). The average STS risk score was 4.6±3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3±3.7 (SPPB <6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group. SPPB and MPI scores were moderately correlated with STS (Spearman correlation coefficient: SPPB R=0.31, p=0.01, MPI R=0.29, p=0.03, Figure Panel A and B).
At 12 months, 3 (2.2%) patients died, and 11 (8.2%) were hospitalized for CV events: major bleeding, N=6 (4.5%); stroke: N=4 (3.0%); re-do: N=1 (0.7%). The probability of the composite endpoint was higher for patients at intermediate/high MPI risk (HR intermediate/high risk vs low risk: HR 2.9, 95% CI 1.1–6.8, p=0.031, Figure 1 Panel C), while no association with STS (p=0.332) was found.
Conclusions
In a prospectively enrolled cohort of TAVI candidates, frailty indices stratified short- and medium-term prognosis. The integrated frailty assessment could be a useful tool for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- C Fumagalli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - A Blandina
- Careggi University Hospital, Florence, Italy
| | - G Nardi
- Careggi University Hospital, Florence, Italy
| | | | - G Bandini
- Careggi University Hospital, Florence, Italy
| | - F Marchetti
- Careggi University Hospital, Florence, Italy
| | - P Demola
- Careggi University Hospital, Florence, Italy
| | - F Meucci
- Careggi University Hospital, Florence, Italy
| | - V Scheggi
- Careggi University Hospital, Florence, Italy
| | | | - N Carrabba
- Careggi University Hospital, Florence, Italy
| | - C Di Mario
- Careggi University Hospital, Florence, Italy
| | - A Ungar
- Careggi University Hospital, Florence, Italy
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21
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Terrosu P, Boccanelli A, Sabino G, Alboni P, Baldasseroni S, Bo M, Desideri G, Marchionni N, Palazzo G, Rozzini R, Ungar A, Vetta F, Zito G. Severe aortic stenosis and transcatheter aortic valve replacement in elderly patients: utility vs futility. Minerva Med 2021; 113:640-646. [PMID: 34542953 DOI: 10.23736/s0026-4806.21.07777-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Recently, transcatheter aortic valve replacement (TAVR) has emerged as established standard treatment for symptomatic severe aortic stenosis, providing an effective, less-invasive alternative to open cardiac surgery for inoperable or high-risk older patients. EVIDENCE ACQUISITION In order to assess the anticipated benefit of aortic replacement, considerable interest now lies in better identifying factors likely to predict outcome. In the elderly population frailty and medical comorbidities have been shown to significantly predict mortality, functional recovery and quality of life after transcatheter aortic valve replacement. Scientific literature focused on the three items will be discussed. EVIDENCE SYNTHESIS High likelihood of futility is described in patients with severe chronic lung, kidney, liver disease and/or frailty. The addition of frailty components to conventional risk prediction has been shown to result in improved discrimination for death and disability following the procedure and identifies those individuals least likely to derive benefit. Several dedicated risk score have been proposed to provide new insights into predicted "futile" outcome. However, assessment of frailty according to a limited number of variables is not sufficient, while a multi-dimensional geriatric assessment significantly improves risk prediction. CONCLUSIONS A multidisciplinary heart team that includes geriatricians can allow the customization of therapeutic interventions in elderly patients to optimise care and avoid futility.
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Affiliation(s)
| | | | - Giuseppe Sabino
- UOC di Cardiologia, AOU-Ospedale SS. Annunziata, Sassari, Italy
| | - Paolo Alboni
- SICGe - Società Italiana di Cardiologia Geriatrica, Firenze, Italy
| | | | - Mario Bo
- SICGe - Società Italiana di Cardiologia Geriatrica, Firenze, Italy
| | | | | | - Giuseppe Palazzo
- SICGe - Società Italiana di Cardiologia Geriatrica, Firenze, Italy
| | - Renzo Rozzini
- SICGe - Società Italiana di Cardiologia Geriatrica, Firenze, Italy
| | - Andrea Ungar
- SICGe - Società Italiana di Cardiologia Geriatrica, Firenze, Italy
| | - Francesco Vetta
- SICGe - Società Italiana di Cardiologia Geriatrica, Firenze, Italy
| | - Giovanni Zito
- SICGe - Società Italiana di Cardiologia Geriatrica, Firenze, Italy
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22
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Orso F, Herbst A, Pratesi A, Fattirolli F, Ungar A, Marchionni N, Baldasseroni S. New Drugs for Heart Failure: What is the Evidence in Older Patients? J Card Fail 2021; 28:316-329. [PMID: 34358663 DOI: 10.1016/j.cardfail.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/09/2021] [Accepted: 07/19/2021] [Indexed: 01/10/2023]
Abstract
Heart failure (HF) is a major public health concern, with a high prevalence in the older population. The majority of randomized clinical trials evaluating new emerging pharmacologic agents for HF (eg, angiotensin receptor-neprilysin inhibitors, sodium-glucose cotransporter 2 inhibitors, intravenous iron for deficiency treatment, transthyretin stabilizers, soluble guanylate cyclase stimulators, cardiac myosin activators, and new potassium binders) have found positive results on various clinical outcomes, particularly in patients with reduced ejection fraction. These treatments might have an important role in the management of older patients as well. Nevertheless, trials demonstrating benefit of these drugs have involved patients significantly younger (on average, approximately 10 years) and fewer comorbidities than those commonly encountered in clinical practice. We describe the recent evidence regarding the newest HF drugs and their applicability to older individuals in terms of efficacy and safety, and we discuss their effects on outcomes particularly valuable to older patients, such as preservation of cognitive function, functional status, independence, and quality of life. Although available subgroup analyses seem to confirm efficacy and safety across the age spectrum for some of these drugs, their effects on older patients centered outcomes often have been neglected. Future HF trials should be designed to include older patients more representative of the real clinical practice, to overcome generalizability biases.
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Affiliation(s)
- Francesco Orso
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Andrea Herbst
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandra Pratesi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Andrea Ungar
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - NiccolÒ Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Samuele Baldasseroni
- Heart Failure Clinic, Division of Geriatric Medicine and Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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23
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Alboni P, Bo M, Fumagalli S, Vetta F, Isaia G, Brunetti E, Baldasseroni S, Boccanelli A, Desideri G, Marchionni N, Rozzini R, Terrosu P, Ungar A, Zito G. Evidence and uncertainties in the management of atrial fibrillation in older persons. Minerva Med 2021; 113:626-639. [PMID: 33832216 DOI: 10.23736/s0026-4806.21.07525-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to the vast majority of patients affected from AF. EVIDENCE ACQUISITION Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. EVIDENCE SYNTHESIS Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications and potential clinical benefit of LAAO and CA in selected older AF patients. CONCLUSIONS Older people carry the greatest burden of AF in real world practice. Within a shared decision making process, the patient centered approach need to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.
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Affiliation(s)
- Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Gianluca Isaia
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza Molinette Hospital, University of Turin, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza Molinette Hospital, University of Turin, Turin, Italy -
| | | | | | | | | | - Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Andrea Ungar
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
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24
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Ungar A, Rivasi G, Coscarelli A, Boccanelli A, Marchionni N, Alboni P, Baldasseroni S, Bo M, Palazzo G, Rozzini R, Terrosu P, Vetta F, Zito G, Desideri G. Hypertension in older persons: why one size does not fit all. Minerva Med 2021; 113:616-625. [PMID: 33832215 DOI: 10.23736/s0026-4806.21.07502-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over recent years, managing hypertension in older people has gained increasing attention, with particular reference to very old, frailer individuals. In these patients, hypertension treatment may be challenging due to a higher risk of hypotension-related adverse events which commonly overlaps with a higher cardiovascular risk. Additionally, frailer older adults rarely satisfy inclusion criteria of randomized clinical trials, which determines a substantial lack of scientific data. Although limited, available evidence suggests that the association between blood pressure and adverse outcomes significantly varies at advanced age according to frailty status. In particular, the negative prognostic impact of hypertension seems to attenuate or even revert in individuals with older biological age, e.g. patients with disability, cognitive impairment, and poor physical performance. Consequently, one size doesn't fit all and personalized treatment strategies are needed, customized to individuals' frailty and functional status. Similar to other cardiovascular diseases, hypertension management in older people should be characterized by a geriatric approach based on biological rather than chronological age and a geriatric comprehensive evaluation including frailty assessment is required to provide the most appropriate treatment, tailored to patients' prognosis and health care goals. This review illustrates the importance of a patient-centered geriatric approach to hypertension management in older people with the final purpose to promote a wider implementation of frailty assessment in routine practice.
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Affiliation(s)
- Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy - .,SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy -
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy
| | - Antonio Coscarelli
- Department of Geriatric and Intensive Care Medicine, Hypertension Clinic, Careggi Hospital and University of Florence, Florence, Italy
| | | | | | - Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giuseppe Palazzo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovambattista Desideri
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy.,Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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25
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Bartolini S, Baldasseroni S, Fattirolli F, Silverii MV, Piccioli L, Perfetto F, Marchionni N, Di Mario C, Martone R, Taborchi G, Morini S, Vignini E, Cappelli F. Poor right ventricular function is associated with impaired exercise capacity and ventilatory efficiency in transthyretin cardiac amyloid patients. Intern Emerg Med 2021; 16:653-660. [PMID: 32918156 DOI: 10.1007/s11739-020-02474-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/08/2020] [Indexed: 01/09/2023]
Abstract
CardioPulmonary Exercise Test (CPET) is the gold standard to evaluate functional capacity in patients at high risk of heart failure (HF). Few studies with a limited number of subjects and conflicting results, analyzed the role of CPET in patients with systemic amyloidosis. Aims of our study were the assessment of the response to exercise in patients with Transthyretin amyloid (ATTR) cardiomyopathy (CA), and the correlation of clinical, biohumoral and echocardiographic parameters with CPET parameters, such as VO2 peak and VE/VCO2 slope. From February 2018 to March 2019, 72 cardiac ATTR patients were prospectively enrolled and underwent a complete clinical, biohumoral, echocardiographic and CPET assessment. All patients completed the exercise stress test protocol, without any adverse event. At CPET, they achieved a mean VO2 peak of 14 mL/Kg/min and a mean VE/VCO2 slope of 31. The blood pressure response to exercise was inadequate in 26 (36%) patients (flat in 25 and hypotensive in 1), while 49/72 patients (69%) showed an inadequate heart rate recovery. In multivariate analysis, s' tricuspidalic was the only independent predictor of VO2 peak, while in the two test models performed to avoid collinearity, both TAPSE and s' tricuspidalic were the strongest independent predictors of VE/VCO2 slope. Our data demonstrate the role of right ventricular function as an independent predictor of exercise capacity and ventilatory efficiency in ATTR. In CPET evaluation, a significant proportion of patients presented an abnormal arterial pressure response and heart rate variation to exercise.
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Affiliation(s)
- Simone Bartolini
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Cardiology Department, Azienda Sanitaria Firenze (ASF), Florence, Italy
| | | | - Francesco Fattirolli
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Vittoria Silverii
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lucrezia Piccioli
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, Division of General Cardiology, University of Florence, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Department of Experimental and Clinical Medicine, Division of General Cardiology, University of Florence, Careggi University Hospital, Florence, Italy
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Raffaele Martone
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Giulia Taborchi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Sofia Morini
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Elisa Vignini
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy.
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26
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Baldasseroni S, Pratesi A, Stefàno P, Del Pace S, Campagnolo V, Baroncini AC, Lo Forte A, Marella AG, Ungar A, Di Bari M, Marchionni N. Pre-operative physical performance as a predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery. Eur J Intern Med 2021; 84:80-87. [PMID: 33144037 DOI: 10.1016/j.ejim.2020.10.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/24/2020] [Accepted: 10/26/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Risk stratification of cardiac surgery patients is usually based on the Society of Thoracic Surgeons (STS) score, that has limited predictive value in older persons. We aimed assessing whether the Short Physical Performance Battery (SPPB) improves, beyond the STS score, assessment of hospital prognosis in older patients undergoing elective cardiac surgery. METHODS All patients aged 75+ years referred for elective cardiac surgery to Careggi University Hospital (Florence, Italy) from April 2013 to March 2017 were evaluated pre-operatively. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM): low (<4%), intermediate (4 to 8%), and high risk (>8%). Primary study outcomes were hospital mortality and STS-defined major morbidity. Length of hospital stay was an additional outcome. RESULTS Out of 235 participants (females: 46.5%; mean age: 79.6 years), 144 (61.3%) were at low, 67 (28.5%) at intermediate and 24 (10.2%) at high risk, based on the STS-PROM. SPPB (mean±SEM) was 8.8 ± 0.2, 7.0 ± 0.5, and 6.0 ± 0.8 in participants at low, intermediate, and high risk, respectively (p<0.001). The primary outcome occurred in 62 participants (26.4%). In low-risk participants, the SPPB score predicted the primary endpoint (adjusted OR 0.77, 95% CI 0.66-0.89 per each point increase; p<0.001) controlling for STS-Major Morbidity or Operative Mortality (STS-MM) score. This result was not observed in the intermediate-high risk group. CONCLUSIONS SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, classified as low risk with the STS risk score. The SPPB, applied preoperatively, might improve risk stratification in older patients undergoing elective cardiac surgery.
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Affiliation(s)
- Samuele Baldasseroni
- Division of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandra Pratesi
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Pierluigi Stefàno
- Division of Cardiac Surgery, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Stefano Del Pace
- Division of General Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Valter Campagnolo
- Division of Cardiac Anesthesiology, Department of Anesthesia, Careggi University Hospital, Florence, Italy
| | - Anna Chiara Baroncini
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Aldo Lo Forte
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Andrea Giosafat Marella
- Division of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Ungar
- Division of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mauro Di Bari
- Division of Geriatrics, Department of Medicine and Geriatrics, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Niccolò Marchionni
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Division of General Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
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27
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Mossello E, Baroncini C, Pecorella L, Giulietti C, Chiti M, Caldi F, Cavallini MC, Simoni D, Baldasseroni S, Fumagalli S, Valoti P, Stroppa S, Parenti K, Ungar A, Masotti G, Marchionni N, Bari MD. Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms. Eur Heart J Acute Cardiovasc Care 2019; 9:771-778. [PMID: 31617374 DOI: 10.1177/2048872619882359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Delirium is a common and potentially preventable condition in older individuals admitted to acute and intensive care wards, associated with negative prognostic effects. Its clinical relevance is being increasingly recognised also in cardiology settings. The aim of the present study was to assess the prevalence, incidence, predictors and prognostic role of delirium in older individuals admitted to two cardiology intensive care units. METHODS All patients aged over 65 years consecutively admitted to the two participating cardiology intensive care units were enrolled. Assessment on admission included acute physiological derangement (modified rapid emergency medicine score, REMS), chronic comorbidity, premorbid disability and dementia. The Confusion Assessment Method-Intensive Care Unit was applied daily for delirium detection. RESULTS Of 497 patients (40% women, mean age 79 years), 18% had delirium over the entire cardiology intensive care unit course, half of whom more than 24 hours after admission (incident delirium). Advanced age, a main diagnosis of ST-segment elevation myocardial infarction or acute respiratory failure, modified REMS, comorbidity and dementia were independent predictors of delirium. Adjusting for patient's features on admission, incident delirium was predicted by invasive procedures (insertion of peripheral arterial catheter, urinary catheter, central venous catheter, naso-gastric tube and intra-aortic balloon pump). In a logistic regression model, delirium was an independent predictor of inhospital mortality (odds ratio 3.18, 95% confidence interval 1.02, 9.93). CONCLUSIONS Eighteen per cent of older cardiology intensive care unit patients had delirium, with half of the cases being incident, thus potentially preventable. Invasive procedures were independently associated with incident delirium. Delirium was an independent predictor of inhospital mortality. Awareness of delirium should be increased in the cardiology intensive care unit setting and prevention studies are warranted.
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Affiliation(s)
- Enrico Mossello
- Division of Geriatric Medicine and Cardiology, AOU Careggi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Caterina Baroncini
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Laura Pecorella
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Chiara Giulietti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Maurizio Chiti
- Division of Cardiology, Pistoia, Azienda USL Toscana Centro, Italy
| | - Francesca Caldi
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | | | - David Simoni
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | | | - Stefano Fumagalli
- Division of Geriatric Medicine and Cardiology, AOU Careggi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Paolo Valoti
- Division of Geriatric Medicine and Cardiology, AOU Careggi, Firenze, Italy
| | - Stefano Stroppa
- Division of Cardiology, Pistoia, Azienda USL Toscana Centro, Italy
| | - Katia Parenti
- Division of Cardiology, Pistoia, Azienda USL Toscana Centro, Italy
| | - Andrea Ungar
- Division of Geriatric Medicine and Cardiology, AOU Careggi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Giulio Masotti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Niccolò Marchionni
- Division of Geriatric Medicine and Cardiology, AOU Careggi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Mauro Di Bari
- Division of Geriatric Medicine and Cardiology, AOU Careggi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Italy
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28
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Pratesi A, Baldasseroni S, Stefano P, Del Pace S, Campagnolo V, Baroncini AC, Lo Forte A, Carrassi E, Ghiara C, Lucarelli G, Marella AJ, Orso F, Ungar A, Marchionni N, Di Bari M. P5983Pre-operative physical performance as an independent predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Risk stratification of patients candidate to cardiac surgery is usually based on the Society of Thoracic Surgeons (STS) score or on the Euroscore II. However, these risk scores has limited predictive value in elderly patients.
Purpose
We conducted a study to determine whether the Short Physical Performance Battery (SPPB), a tool assessing physical performance, predicts hospital death and major morbidity, beyond STS risk score. The outcome was a composite end-point as defined by STS Major Morbidity or Operative Mortality (STS-MM) in STS Risk Model Outcomes: operative mortality, stroke, renal failure, prolonged mechanical ventilation, deep sternal wound infection, and reoperation.
Methods
In this prospective, single-center, cohort, hospital-based study, conducted at Careggi University Hospital, Florence, Italy, all patients aged 75+ years referred for an elective coronary aortic by-pass grafting, valvular surgery or combined cardiac surgery were evaluated pre-operatively. Assessment included SPPB, cognitive and functional status and evaluation of comorbidity. Patients receiving emergency/urgent cardiac surgery or a procedure not considered in the STS risk score calculator, who reported previous cardiac surgery or were clinically unstable were excluded. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM) as at low (<4%), intermediate (4 to 8%) or high risk (>8%).
Results
Out of 250 participants (females: 48.4%; mean age: 79.9 years), 148 (59.2%) were at low, 73 (29.2%) at intermediate and 29 (11.6%) at high risk, based on the STS-PROM. Mean±SEM SPPB score was 8.8±0.2, 7.1±0.4 and 6.0±0.7 in participants at low, intermediate, and high risk, respectively (p<0.001). The outcome occurred in 67 subjects (26.8%). SPPB score predicted the outcome in the entire study sample, controlling for STS-MM score, CKD, and anaemia (adjusted OR: 0.89, 95% CI 0.81–0.98 per each point increase; p 0.017). When analyses were repeated separately in participants with STS-PROM indicative of low (<4%) and in those at medium-high risk, the predictive value of SPPB was enhanced in the formers (adjusted OR 0.73, 95% CI 0.62–0.86 per each point increase; p<0.001- controlling for STS score), whereas was lost in the latter. An alternative model was subsequently tested, where STS score was not included and peripheral artery disease and creatinine (variables contributing to the STS score) were individually entered: SPPB was confirmed as a significant predictor also in this model, controlling for anaemia, peripheral artery disease, and creatinine. The corresponding AUC was 0.813 (Figure 1).
Figure 1
Conclusions
SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, in particular in those classified as low-risk with the STS risk score. Use of SPPB should therefore be recommended to improve preoperative risk stratification of older patients.
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Affiliation(s)
- A Pratesi
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
| | - S Baldasseroni
- Careggi University Hospital (AOUC), Unit of Geriatrics, Department of Medicine and Geriatrics, Florence, Italy
| | - P Stefano
- Careggi University Hospital (AOUC), Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, Florence, Italy
| | - S Del Pace
- Careggi University Hospital (AOUC), General Cardiology, Cardio-Thoracic-Vascular Department, Florence, Italy
| | - V Campagnolo
- Careggi University Hospital (AOUC), Cardiac Anesthesiology Unit, Cardio-Thoracic-Vascular Department, Florence, Italy
| | - A C Baroncini
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
| | - A Lo Forte
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
| | | | - C Ghiara
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
| | - G Lucarelli
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
| | - A J Marella
- Careggi University Hospital (AOUC), Unit of Geriatrics, Department of Medicine and Geriatrics, Florence, Italy
| | - F Orso
- Careggi University Hospital (AOUC), Unit of Geriatrics, Department of Medicine and Geriatrics, Florence, Italy
| | - A Ungar
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
| | - N Marchionni
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
| | - M Di Bari
- Careggi University Hospital (AOUC), Department of Experimental and Clinical Medicine, Florence, Italy
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29
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Pratesi A, Baldasseroni S, Burgisser C, Orso F, Barucci R, Silverii MV, Venturini S, Ungar A, Marchionni N, Fattirolli F. Long-term functional outcomes after cardiac rehabilitation in older patients. Data from the Cardiac Rehabilitation in Advanced aGE: EXercise TRaining and Active follow-up (CR-AGE EXTRA) randomised study. Eur J Prev Cardiol 2019; 26:1470-1478. [DOI: 10.1177/2047487319854141] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aim Cardiac rehabilitation promotes functional recovery after cardiac events. Our study aimed at evaluating whether, compared to usual care, a home-based exercise programme with monthly reinforcement sessions adds long-term functional benefits to those obtained with cardiac rehabilitation in the elderly. Methods After a 4-week outpatient cardiac rehabilitation, 160 of 197 patients aged 75 years and older screened for eligibility with different indications for cardiac rehabilitation, were randomly assigned to a control (C) or an active treatment (T) group. During a 12-month follow-up, C patients received usual care, while T patients were prescribed a standardised set of home-based exercises with centre-based monthly reinforcements for the first 6 months. The main (peak oxygen consumption) and three secondary outcome measures (distance walked in 6 minutes, inferior limbs peak 90° Torque strength, health-related quality of life) were assessed at baseline, at random assignment and at 6 and 12-month follow-ups with the cardiopulmonary exercise test, 6-minute walking test, isokinetic dynamometer and the Short Form-36 questionnaire, respectively. Results Both C and T groups obtained a significant and similar improvement from baseline to the end of the 4-week cardiac rehabilitation programme in the three functional outcome measures. However, at univariable and age and gender-adjusted analysis of variance for repeated measures, changes from random assignment to 6 or 12-month follow-up in any outcome measure were similar in the C and T groups. Conclusion Results from this randomised study suggest that a home-based exercise programme with monthly reinforcements does not add any long-term functional benefit beyond those offered by a conventional, 4-week outpatient cardiac rehabilitation programme. Trial registration ClinicalTrial.gov Identifier: NCT00641134.
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Affiliation(s)
- Alessandra Pratesi
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Samuele Baldasseroni
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Costanza Burgisser
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Francesco Orso
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Riccardo Barucci
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Maria Vittoria Silverii
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Simone Venturini
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Italy
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30
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Martinese L, Vignini E, Carrassa G, Taverna C, Valente S, Baldasseroni S, Pradella S, Sciagrà R, Olivotto I. [Ventricular storm in a young man with primary hypokinetic dilated cardiomyopathy: why thinking of sarcoidosis?]. G Ital Cardiol (Rome) 2019; 20:392-395. [PMID: 31184326 DOI: 10.1714/3165.31473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The diagnostic approach to patients with cardiac sarcoidosis is challenging, as the disease may occur as a subclinical entity or have heterogeneous clinical manifestations ranging from ventricular arrhythmias to advanced cardiac failure. Therefore, while clinical suspicion remains key, imaging techniques such as nuclear magnetic resonance imaging and myocardial scintigraphy play an important confirmatory role. Final diagnosis requires histological proof on cardiac or extracardiac biopsy. A multidisciplinary context is essential for appropriate diagnosis, staging and management. We present the case of a young man with dilated cardiomyopathy in whom, following the onset of malignant and recurrent ventricular arrhythmias, a final diagnosis of cardiac sarcoidosis was reached based on a host of invasive and non-invasive diagnostic techniques, allowing tailored treatment.
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Affiliation(s)
- Lucia Martinese
- Centro di Riferimento per le Cardiomiopatie, Azienda Ospedaliero-Universitaria Careggi, Firenze
| | - Elisa Vignini
- Centro di Riferimento per le Cardiomiopatie, Azienda Ospedaliero-Universitaria Careggi, Firenze
| | - Gianmarco Carrassa
- Centro di Riferimento per le Cardiomiopatie, Azienda Ospedaliero-Universitaria Careggi, Firenze
| | - Cecilia Taverna
- Istologia Patologica e Diagnostica Molecolare, Azienda Ospedaliero-Universitaria Careggi, Firenze
| | - Serafina Valente
- U.O. Cardiologia, Azienda Ospedaliero-Universitaria Senese, Siena
| | | | - Silvia Pradella
- Radiodiagnostica di Emergenza-Urgenza, Azienda Ospedaliero-Universitaria Careggi, Firenze
| | - Roberto Sciagrà
- Medicina Nucleare, Azienda Ospedaliero-Universitaria Careggi, Firenze
| | - Iacopo Olivotto
- Centro di Riferimento per le Cardiomiopatie, Azienda Ospedaliero-Universitaria Careggi, Firenze
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Baldasseroni S, Bo M, Brambati T, Marchionni N. [How much frailty is important in cardiology?]. G Ital Cardiol (Rome) 2019; 20:210-222. [PMID: 30920548 DOI: 10.1714/3126.31074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Prevalence and incidence of cardiovascular diseases increase dramatically with advancing age, and older subjects account for the vast majority of patients seeking care either for acute and chronic cardiovascular disorders. In the same time, availability and improvements in drugs and devices, and innovative techniques in interventional cardiology and heart surgery procedures, increased as well, posing crucial challenges in clinical decision-making mainly in older people. Elderly subjects represent a very heterogeneous population and the interplay between underlying physiological change, chronic disease and multimorbidity can result in health states in older ages that are not fully captured by traditional disease classifications and that are often missing in disease-based assessments of health. Geriatric syndromes have been widely recognized as an essential determinant of health status and well-being of older people, although there is some debate as to what disorders these include. Foremost among the geriatric syndromes is frailty, which can be regarded as a progressive age-related deterioration in physiological systems that results in greater vulnerability to stressors and increased risk of adverse outcomes, including care dependence and death. This complexity of health states in older ages means that disease-based conceptualizations are inadequate proxies for health in an older person. Rather than the presence or absence of disease, the most important consideration for older subjects is likely to be their functioning. The Comprehensive Geriatric Assessment (CGA), which evaluates through the use of standardized scales several domains - including comorbidity, cognitive and mood disorders, functional abilities, nutritional status, sarcopenia and frailty - has been demonstrated to be a much better predictor of survival and other outcomes than the presence of diseases or even the extent of comorbidities. Therefore, physicians should be aware that age by itself is probably not the best criterion to rely on for challenging clinical decision-making in this setting. In this clinical context, it becomes mandatory that, beyond age-based decisions or an "eyeballing" perception of "frailty" or "vulnerability", standardized and valid measures aimed at selecting those patients who may potentially derive the greatest benefit from medical or interventional procedures are made available for daily clinical use.
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Affiliation(s)
- Samuele Baldasseroni
- Unità di Terapia Intensiva e Subintensiva Geriatrica, Dipartimento Medico-Geriatrico, Azienda Ospedaliero-Universitaria Careggi, Firenze
| | - Mario Bo
- S.C.D.U. Geriatria e Malattie Metaboliche dell'Osso, A.O.U. Città della Salute e della Scienza-Presidio Molinette, Torino
| | - Tiziana Brambati
- S.C.D.U. Geriatria e Malattie Metaboliche dell'Osso, A.O.U. Città della Salute e della Scienza-Presidio Molinette, Torino
| | - Niccolò Marchionni
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi, Firenze, e S.O.D. Cardiologia Generale, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliero-Universitaria Careggi, Firenze
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Pratesi A, Orso F, Ghiara C, Lo Forte A, Baroncini AC, Di Meo ML, Carassi E, Baldasseroni S. Cardiac surgery in the elderly: What goals of care? Monaldi Arch Chest Dis 2017; 87:852. [DOI: 10.4081/monaldi.2017.852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 11/22/2022] Open
Abstract
<p>At present, the majority of cardiac surgery interventions have been performed in the elderly with successful short-term mortality and morbidity, however significant difficulties must to be underlined about our capacity to predict long-term outcomes such as disability, worsening quality of life and loss of functional capacity.<br />The reason probably resides on inability to capture preoperative frailty phenotype with current cardiac surgery risk scores and consequently we are unable to outline the postoperative trajectory of an important patients’ centered outcome such as disability free survival. In this perspective, more than one geriatric statements have stressed the systematic underuse of patient reported outcomes in cardiovascular trials even after taking account of their relevance to older feel and wishes. Thus, in the next future is mandatory for geriatric cardiology community closes this gap of evidences through planning of trials in which patients’ centered outcomes are considered as primary goals of therapies as well as cardiovascular ones.</p>
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Pulignano G, Gulizia MM, Baldasseroni S, Bedogni F, Cioffi G, Indolfi C, Romeo F, Murrone A, Musumeci F, Parolari A, Patanè L, Pino PG, Mongiardo A, Spaccarotella C, Di Bartolomeo R, Musumeci G. ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement. Eur Heart J Suppl 2017; 19:D354-D369. [PMID: 28751850 PMCID: PMC5520760 DOI: 10.1093/eurheartj/sux012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.
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Affiliation(s)
- Giovanni Pulignano
- Cardiology Department 1, Ospedale San Camillo-Forlanini, Via O. Regnoli, 8 00152 Rome, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi" Catania, Italy
| | | | - Francesco Bedogni
- CCU-Cardiology Unit, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy
| | - Giovanni Cioffi
- Cardiology and Medicine Unit, Casa di Cura Villa Bianca, Trento, Italy
| | - Ciro Indolfi
- Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
| | - Francesco Romeo
- Cardiology and Interventional Cardiology Department, Policlinico "Tor Vergata", Rome, Italy
| | - Adriano Murrone
- Cardiology and Cardiovascular Pathophysiology Department, Azienda Ospedaliera di Perugia, Perugia, Italy
| | | | - Alessandro Parolari
- Heart Surgery Unit, Centro Cardiologico Monzino IRCCS, Università degli Studi, Milano, Italy
| | - Leonardo Patanè
- Cardiology Cardiac Surgery Department (Centro Cuore), Centro Clinico Diagnostico G.B. Morgagni, Pedara (Catania), Italy
| | | | - Annalisa Mongiardo
- Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
| | - Carmen Spaccarotella
- Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
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Cappelli F, Baldasseroni S, Bergesio F, Spini V, Fabbri A, Angelotti P, Grifoni E, Attanà P, Tarantini F, Marchionni N, Moggi Pignone A, Perfetto F. Liver dysfunction as predictor of prognosis in patients with amyloidosis: utility of the Model for End-stage Liver disease (MELD) scoring system. Intern Emerg Med 2017; 12:23-30. [PMID: 27480755 DOI: 10.1007/s11739-016-1500-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/01/2016] [Indexed: 11/30/2022]
Abstract
Amyloidosis prognosis is often related to the onset of heart failure and a worsening that is concomitant with kidney-liver dysfunction; thus the Model for End-stage Liver disease (MELD) may be an ideal instrument to summarize renal-liver function. Our aim has been to test the MELD score as a prognostic tool in amyloidosis. We evaluated 128 patients, 46 with TTR-related amyloidosis and 82 with AL amyloidosis. All patients had a complete clinical and echocardiography evaluation; overall biohumoral assessment included troponin I, NT-proBNP, creatinine, total bilirubin and INR ratio. The study population was dichotomized at the 12 cut-off level of MELD scores; those with MELD score >12 had a lower survival compared to controls in the study cohort (40.7 vs 66.3 %; p = 0.006). Either as a continuous and dichotomized variable, MELD shows its independent prognostic value at multivariable analysis (HR = 1.199, 95 % CI 1.082-1.329; HR = 2.707, 95 % CI 1.075-6.817, respectively). MELD shows a lower prognostic sensitivity/specificity ratio than troponin I and NT-proBNP in the whole study population and AL subgroup, while in TTR patients MELD has a higher sensitivity/specificity ratio compared to troponin and NT-proBNP (ROC analysis-AUC: 0.853 vs 0.726 vs 0.659). MELD is able to predict prognosis in amyloidosis. A MELD score >12 selects a subgroup of patients with a higher risk of death. The predictive accuracy seems to be more evident in TTR patients in whom currently no effective scoring systems have been validated.
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Affiliation(s)
- Francesco Cappelli
- Intensive Cardiac Unit, Department of Heart and Vessels, University of Florence and Azienda Ospedaliero-Universitaria Careggi [AOUC], Largo Brambilla 3, 50134, Florence, Italy.
- Regional Amyloid Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Samuele Baldasseroni
- Intensive Cardiac Unit, Department of Heart and Vessels, University of Florence and Azienda Ospedaliero-Universitaria Careggi [AOUC], Largo Brambilla 3, 50134, Florence, Italy
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Franco Bergesio
- Regional Amyloid Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Valentina Spini
- Intensive Cardiac Unit, Department of Heart and Vessels, University of Florence and Azienda Ospedaliero-Universitaria Careggi [AOUC], Largo Brambilla 3, 50134, Florence, Italy
| | - Alessia Fabbri
- Department of Heart and Vessels, University of Florence, Florence, Italy
| | - Paola Angelotti
- Department of Heart and Vessels, University of Florence, Florence, Italy
| | - Elisa Grifoni
- Department of Internal Medicine, University of Florence, Florence, Italy
| | - Paola Attanà
- Department of Internal Medicine, University of Florence, Florence, Italy
| | - Francesca Tarantini
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Federico Perfetto
- Regional Amyloid Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
- Department of Internal Medicine, University of Florence, Florence, Italy
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Pulignano G, Gulizia MM, Baldasseroni S, Bedogni F, Cioffi G, Indolfi C, Romeo F, Murrone A, Musumeci F, Parolari A, Patanè L, Pino PG, Mongiardo A, Spaccarotella C, Di Bartolomeo R, Musumeci G. [ANMCO/SIC/SICI-GISE/SICCH Consensus document: Risk stratification in elderly patients undergoing cardiac surgery and transcatheter aortic valve implantation]. G Ital Cardiol (Rome) 2016; 17:756-789. [PMID: 27869890 DOI: 10.1714/2448.25664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Aortic stenosis is one the most frequent valvular diseases in developed countries, and its impact on public healthcare resources and assistance is increasing. A substantial proportion of elderly patients with severe aortic stenosis is frequently not eligible for surgery because of advanced age, frailty and multiple comorbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant proportion of patients die or do not achieve an improvement of quality of life in the short to medium-term follow-up. It is important to determine: 1) whether and how much patient frailty influences the procedural risk; 2) whether quality of life and the individual patient survival are influenced by aortic valve disease alone or by other associated factors; 3) whether a geriatric specialist intervention to evaluate and correct other diseases with their potential or already evident disabilities can improve the results of TAVI, in particular patient quality of life. Consequently, in addition to risk stratification with conventional tools, a number of factors including multimorbidity, disability, frailty and cognitive function should be considered in order to assess the expected benefit of TAVI. Preoperative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, renal) that can potentially worsen the reduced physiological reserves characteristic of frailty. The systematic implementation into clinical practice of multidimensional assessment instruments of frailty and cognitive function for screening and exercise, and the adoption of specific care pathways should facilitate this task.
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Affiliation(s)
| | - Michele Massimo Gulizia
- U.O.C. Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania
| | | | - Francesco Bedogni
- U.O. Cardiologia-UTIC, IRCCS Policlinico San Donato, San Donato Milanese (MI)
| | - Giovanni Cioffi
- U.O. Cardiologia e Medicina, Casa di Cura Villa Bianca, Trento
| | - Ciro Indolfi
- U.O. Cardiologia - Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro
| | - Francesco Romeo
- U.O.C. Cardiologia e Cardiologia Interventistica, Policlinico "Tor Vergata", Roma
| | - Adriano Murrone
- Cardiologia e Fisiopatologia Cardiovascolare, Azienda Ospedaliera di Perugia, Perugia
| | | | - Alessandro Parolari
- U.O. Cardiochirurgia, Centro Cardiologico Monzino IRCCS, Università degli Studi, Milano
| | - Leonardo Patanè
- Presidio Cardiologico Cardiochirurgico (Centro Cuore), Centro Clinico Diagnostico G.B. Morgagni, Pedara (CT)
| | | | - Annalisa Mongiardo
- U.O. Cardiologia - Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro
| | - Carmen Spaccarotella
- U.O. Cardiologia - Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro
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Baldasseroni S, Pratesi A, Francini S, Pallante R, Barucci R, Orso F, Burgisser C, Marchionni N, Fattirolli F. Cardiac Rehabilitation in Very Old Adults: Effect of Baseline Functional Capacity on Treatment Effectiveness. J Am Geriatr Soc 2016; 64:1640-5. [DOI: 10.1111/jgs.14239] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Samuele Baldasseroni
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Alessandra Pratesi
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Sara Francini
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Rachele Pallante
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Riccardo Barucci
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Francesco Orso
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Costanza Burgisser
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine; University of Florence and Azienda Ospedaliero Universitaria Careggi; Florence Italy
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Pratesi A, Valoti P, Baldasseroni S, Marchionni N, Tarantini F. Sudden cardiac arrest in a 73-year-old woman caused by systemic capillary leak syndrome. Intern Emerg Med 2016; 11:719-20. [PMID: 27056382 DOI: 10.1007/s11739-016-1449-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 03/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Alessandra Pratesi
- Department of Geriatric Medicine, Geriatric Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Paolo Valoti
- Department of Geriatric Medicine, Geriatric Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Samuele Baldasseroni
- Department of Geriatric Medicine, Geriatric Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
- Department of Geriatric Medicine, Geriatric Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Francesca Tarantini
- Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
- Department of Geriatric Medicine, Geriatric Intensive Care Unit, AOU Careggi, Florence, Italy.
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Pratesi A, Di Serio C, Orso F, Foschini A, Bartoli N, Marella A, Fumagalli S, Di Bari M, Marchionni N, Tarantini F, Baldasseroni S. Prognostic value of adiponectin in coronary artery disease: Role of diabetes and left ventricular systolic dysfunction. Diabetes Res Clin Pract 2016; 118:58-66. [PMID: 27344545 DOI: 10.1016/j.diabres.2016.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 03/16/2016] [Accepted: 04/14/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Adiponectin (AD) promotes insulin sensitivity and has anti-atherogenic properties. However, the role of AD on clinical outcomes in coronary artery disease (CAD) is controversial. We analyzed whether AD was an independent predictor of all-cause mortality and hospitalization in patients with CAD. METHOD We prospectively enrolled 138 patients with stable CAD, with or without type 2 diabetes and with or without left ventricular dysfunction. A telephone follow-up was conducted to register long term outcomes. Sensitivity/specificity ratio for AD was investigated with ROC analysis and the independent role of AD on outcome was evaluated with Cox regression model of analysis. The survival rate was represented by Kaplan Meyer curves. RESULTS Of 138 patients, 61 had type 2 diabetes and 71 left ventricular systolic dysfunction (EF<40%). Median time of follow-up was 1384days; mortality rate was 18.8% (26 deaths) and hospitalization rate was 47.1% (65 events). Mean concentration of AD was 9.87±7.53ng/ml; the analysis of the ROC curve identified an AD cut-off level of 13.2ng/ml (AUC 0.779; p<0.0001). Patients with AD >13.2ng/ml had a significantly higher risk of death (HR=6.50; 95% CI: 2.40-17.70), but not of cardiovascular hospitalization (HR=0.87; 95% CI: 0.31-2.44). AD predictivity remained significant also in patients with type 2 diabetes and with left ventricular systolic dysfunction. CONCLUSION In stable CAD, an AD value of >13.2ng/ml independently predicts a 6-fold increased risk of all-cause mortality.
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Affiliation(s)
- Alessandra Pratesi
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Claudia Di Serio
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Francesco Orso
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Alice Foschini
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Nadia Bartoli
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Andrea Marella
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Stefano Fumagalli
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Mauro Di Bari
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Francesca Tarantini
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Samuele Baldasseroni
- Division of Geriatric Cardiology and Medicine, Research Unit of Medicine of Ageing, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy; Intensive Care Unit, Division of Cardiology, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy.
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Di Bari M, Degli Esposti L, Veronesi C, Pecorelli S, Fini M, Baldasseroni S, Mossello E, Fumagalli S, Scatigna M, Marchionni N. Combination evidence-based therapy is effective in the oldest 'old patients' following myocardial infarction. The "Salute e Benessere nell'Anziano" (SeBA) observational study. Intern Emerg Med 2016; 11:677-85. [PMID: 26843198 DOI: 10.1007/s11739-016-1391-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 01/07/2016] [Indexed: 02/04/2023]
Abstract
Antiplatelet drugs, statins, angiotensinogen-converting enzyme inhibitors or angiotensin-II receptor blockers, and β-blockers improve survival following myocardial infarction (MI). However, in old age they are under-prescribed, and their effectiveness in combination regimens is unproven. The aim of the study was to evaluate prescription of recommended cardiovascular drug classes and impact of a combination regimen on long-term mortality and hospitalizations. Records of 65+ years MI survivors, discharged from hospitals in four Local Health Units in Italy, were selected from administrative databases and analyzed. All-cause mortality and cardiovascular re-hospitalization in 12 months were compared across participants prescribed 0, 1, 2, 3, or 4 recommended drug classes. Out of 2626 participants (56 % men, 25 % aged 85+ years), 42 % were prescribed all, 14 % none of the recommended drug classes. The prescription rate decreased with advancing age. At all ages, mortality decreased with increasing number of drug classes prescribed: in participants aged 85+ years, adjusted hazard ratios (95 % confidence interval) for death were 0.74 (0.47-1.17), 0.52 (0.33-0.82), 0.30 (1.19-0.48), and 0.33 (0.20-0.53) for 1, 2, 3, and 4 classes prescribed, compared with none. The risk of cardiovascular re-hospitalizations decreased with an increasing number of drug classes prescribed through the age of 84 years. After MI, a combination regimen of recommended drug classes prevents long-term mortality at any age, and cardiovascular re-hospitalizations through the age of 84. Enhancing compliance with treatment guidelines may reduce the burden of mortality and hospitalizations in older MI survivors.
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Affiliation(s)
- Mauro Di Bari
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini, 18, 50139, Florence, Italy.
- Division of Geriatric Cardiology and Medicine, Department of Geriatrics and Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | | | - Chiara Veronesi
- CliCon srl Health, Economics and Outcomes Research, Ravenna, Italy
| | | | | | - Samuele Baldasseroni
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini, 18, 50139, Florence, Italy
- Division of Geriatric Cardiology and Medicine, Department of Geriatrics and Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Enrico Mossello
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini, 18, 50139, Florence, Italy
- Division of Geriatric Cardiology and Medicine, Department of Geriatrics and Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Fumagalli
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini, 18, 50139, Florence, Italy
- Division of Geriatric Cardiology and Medicine, Department of Geriatrics and Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | | - Niccolò Marchionni
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Viale Pieraccini, 18, 50139, Florence, Italy
- Division of Geriatric Cardiology and Medicine, Department of Geriatrics and Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Giovannelli F, Simoni D, Gavazzi G, Giganti F, Olivotto I, Cincotta M, Pratesi A, Baldasseroni S, Viggiano MP. Electrophysiological correlates of word recognition memory process in patients with ischemic left ventricular dysfunction. Clin Neurophysiol 2016; 127:3007-3013. [PMID: 27469528 DOI: 10.1016/j.clinph.2016.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The relationship between left ventricular ejection fraction (LVEF) and cognitive performance in patients with coronary artery disease without overt heart failure is still under debate. In this study we combine behavioral measures and event-related potentials (ERPs) to verify whether electrophysiological correlates of recognition memory (old/new effect) are modulated differently as a function of LVEF. METHODS Twenty-three male patients (12 without [LVEF>55%] and 11 with [LVEF<40%] left ventricular dysfunction), and a Mini Mental State Examination score >25 were enrolled. ERPs were recorded while participants performed an old/new visual word recognition task. RESULTS A late positive ERP component between 350 and 550ms was differentially modulated in the two groups: a clear old/new effect (enhanced mean amplitude for old respect to new items) was observed in patients without LVEF dysfunction; whereas patients with overt LVEF dysfunction did not show such effect. In contrast, no significant differences emerged for behavioral performance and neuropsychological evaluations. CONCLUSIONS These data suggest that ERPs may reveal functional brain abnormalities that are not observed at behavioral level. SIGNIFICANCE Detecting sub-clinical measures of cognitive decline may contribute to set appropriate treatments and to monitor asymptomatic or mildly symptomatic patients with LVEF dysfunction.
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Affiliation(s)
- Fabio Giovannelli
- Department of Neuroscience, Psychology, Drug Research, Child Health, University of Florence, Florence, Italy; Unit of Neurology, Florence Health Authority, Florence, Italy
| | - David Simoni
- Department of Heart and Vessels, Geriatric Cardiology and Medicine Unit University of Florence and Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Gioele Gavazzi
- Department of Neuroscience, Psychology, Drug Research, Child Health, University of Florence, Florence, Italy
| | - Fiorenza Giganti
- Department of Neuroscience, Psychology, Drug Research, Child Health, University of Florence, Florence, Italy
| | | | | | - Alessandra Pratesi
- Department of Heart and Vessels, Geriatric Cardiology and Medicine Unit University of Florence and Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Samuele Baldasseroni
- Department of Heart and Vessels, Geriatric Cardiology and Medicine Unit University of Florence and Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Maria Pia Viggiano
- Department of Neuroscience, Psychology, Drug Research, Child Health, University of Florence, Florence, Italy.
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Ungar A, Pratesi A, Baldereschi GJ, Meucci F, Valoti P, Fumagalli S, Di Bari M, Baldasseroni S, Marchionni N. Pushing Age Limits Forward: How Should Acute Coronary Syndromes Be Treated in Centenarians? Discussion of Some Clinical Cases. J Am Geriatr Soc 2016; 64:680-2. [PMID: 27000361 DOI: 10.1111/jgs.13982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Andrea Ungar
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
| | - Alessandra Pratesi
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
| | - Giorgio J Baldereschi
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
| | - Francesco Meucci
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
| | - Paolo Valoti
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
| | - Stefano Fumagalli
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
| | - Mauro Di Bari
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
| | | | - Niccolò Marchionni
- Research Unit of Medicine of Aging, University of Florence, Florence, Italy.,Division of Geriatric Cardiology and Medicine, Geriatric Medical Department, Careggi University Hospital, Florence, Italy
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Maggioni AP, Orso F, Calabria S, Rossi E, Cinconze E, Baldasseroni S, Martini N. The real-world evidence of heart failure: findings from 41 413 patients of the ARNO database. Eur J Heart Fail 2016; 18:402-10. [DOI: 10.1002/ejhf.471] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/24/2015] [Accepted: 11/27/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Francesco Orso
- ANMCO Research Center; Florence Italy
- Azienda Ospedaliero-Universitaria Careggi; Department of Geriatrics, Section of Geriatric Medicine and Cardiology; Florence Italy
| | | | - Elisa Rossi
- CINECA Interuniversity Consortium; Casalecchio di Reno; Bologna Italy
| | - Elisa Cinconze
- CINECA Interuniversity Consortium; Casalecchio di Reno; Bologna Italy
| | - Samuele Baldasseroni
- Azienda Ospedaliero-Universitaria Careggi; Department of Heart and Vessel, Section Internal Medicine and Cardiology; Florence Italy
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Ferrucci L, Baldasseroni S, Bandinelli S, De Alfieri W, Cartei A, Calvani D, Baldini A, Masotti G, Marchionni N. Disease Severity and Health-Related Quality of Life Across Different Chronic Conditions. J Am Geriatr Soc 2015. [DOI: 10.1111/jgs.2000.48.11.1490] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Simoni D, Rafanelli M, Ungar A, Mossello E, Marchionni N, Baldasseroni S. Neurocognitive profile of patients with continuous flow left ventricular assist device. Monaldi Arch Chest Dis 2015; 82:75-9. [PMID: 25845090 DOI: 10.4081/monaldi.2014.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The increase of severe heart failure and the consequent reduction of the organ availability for transplantation has led to, in recent years, the introduction of the LVAD as replacement therapy to heart transplantation. Severe Heart Failure patients show cognitive deficits in various domains especially in executive functions, memory and speed of proceedings, due to different neurophysiopathological processes including chronic hypoperfusion and subsequent damage to hippocampal and para-hippocampal cortical areas. It is also known that these deficits improve after heart transplantation. We carried out a literature review selecting studies that analyzed the cognitive changes in patients with severe heart failure after implantation of the Continuous Flow Left Ventricular Assist Device. According to the inclusion criteria, we selected four studies since 2005 that presented a comprehensive neurocognitive assessment. The results show that the cognitive profile, with the implantation of LVAD improves in memory and executive domains, and this improvements results stable in short-medium time. The effects would also be independent of the type of flow produced by the device (pulsatile vs continuous). We believe that further studies are required to explore the relationship between LVAD and cognitive function in severe heart failure.
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45
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Mossello E, Pieraccioli M, Nesti N, Bulgaresi M, Lorenzi C, Caleri V, Tonon E, Cavallini MC, Baroncini C, Di Bari M, Baldasseroni S, Cantini C, Biagini CA, Marchionni N, Ungar A. Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs. JAMA Intern Med 2015; 175:578-85. [PMID: 25730775 DOI: 10.1001/jamainternmed.2014.8164] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The prognostic role of high blood pressure and the aggressiveness of blood pressure lowering in dementia are not well characterized. OBJECTIVE To assess whether office blood pressure, ambulatory blood pressure monitoring, or the use of antihypertensive drugs (AHDs) predict the progression of cognitive decline in patients with overt dementia and mild cognitive impairment (MCI). DESIGN, SETTING, AND PARTICIPANTS Cohort study between June 1, 2009, and December 31, 2012, with a median 9-month follow-up of patients with dementia and MCI in 2 outpatient memory clinics. MAIN OUTCOMES AND MEASURES Cognitive decline, defined as a Mini-Mental State Examination (MMSE) score change between baseline and follow-up. RESULTS We analyzed 172 patients, with a mean (SD) age of 79 (5) years and a mean (SD) MMSE score of 22.1 (4.4). Among them, 68.0% had dementia, 32.0% had MCI, and 69.8% were being treated with AHDs. Patients in the lowest tertile of daytime systolic blood pressure (SBP) (≤ 128 mm Hg) showed a greater MMSE score change (mean [SD], -2.8 [3.8]) compared with patients in the intermediate tertile (129-144 mm Hg) (mean [SD], -0.7 [2.5]; P = .002) and patients in the highest tertile (≥ 145 mm Hg) (mean [SD], -0.7 [3.7]; P = .003). The association was significant in the dementia and MCI subgroups only among patients treated with AHDs. In a multivariable model that included age, baseline MMSE score, and vascular comorbidity score, the interaction term between low daytime SBP tertile and AHD treatment was independently associated with a greater cognitive decline in both subgroups. The association between office SBP and MMSE score change was weaker. Other ambulatory blood pressure monitoring variables were not associated with MMSE score change. CONCLUSIONS AND RELEVANCE Low daytime SBP was independently associated with a greater progression of cognitive decline in older patients with dementia and MCI among those treated with AHDs. Excessive SBP lowering may be harmful for older patients with cognitive impairment. Ambulatory blood pressure monitoring can be useful to help avoid high blood pressure overtreatment in this population.
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Affiliation(s)
- Enrico Mossello
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Mariachiara Pieraccioli
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Nicola Nesti
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Matteo Bulgaresi
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Chiara Lorenzi
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Veronica Caleri
- Division of Geriatric Medicine, Azienda Unità Sanitaria Locale 3, Pistoia, Italy
| | - Elisabetta Tonon
- Division of Geriatric Medicine, Azienda Unità Sanitaria Locale 3, Pistoia, Italy
| | - M Chiara Cavallini
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Caterina Baroncini
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Mauro Di Bari
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Samuele Baldasseroni
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Claudia Cantini
- Division of Geriatric Medicine, Azienda Unità Sanitaria Locale 3, Pistoia, Italy
| | - Carlo A Biagini
- Division of Geriatric Medicine, Azienda Unità Sanitaria Locale 3, Pistoia, Italy
| | - Niccolò Marchionni
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric Cardiology and Medicine, Department of Medicine and Geriatrics, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
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Minneci C, Mello AM, Mossello E, Baldasseroni S, Macchi L, Cipolletti S, Marchionni N, Di Bari M. Comparative study of four physical performance measures as predictors of death, incident disability, and falls in unselected older persons: the insufficienza Cardiaca negli Anziani Residenti a Dicomano Study. J Am Geriatr Soc 2015; 63:136-41. [PMID: 25597564 DOI: 10.1111/jgs.13195] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the ability of the Short Physical Performance Battery (SPPB), 4-m walk test (4mWT), 6-minute walk test (6MWT), and handgrip strength to predict mortality, incident disability, worsening mobility, and falls in older community dwellers. DESIGN Cohort study. SETTING Population-based. PARTICIPANTS Individuals aged 65 and older n = 561) without prevalent basic activity of daily living (ADL) disability participating. MEASUREMENTS Separate logistic regression models were developed to predict incident ADL disability, worsening mobility, and falls in 3 years, and Cox regression models were used to assess 7-year risk of death as a function of the four tests, adjusting for covariates. RESULTS Performance tests were reciprocally correlated at baseline. After 3 years, 33 (7.3%) of 453 participants reexamined were disabled in ADLs, 87 (20%) had worsening mobility, and 99 (22%) reported falls. Of the 561 baseline participants, 141 (25%) died over the 7 years. All measures predicted incident ADL disability, with adjusted odds ratios (ORs) per unit increase of 0.85 (95% confidence interval (CI) = 0.77-0.93) for handgrip strength, 0.08 (95% CI = 0.02-0.36) for 4mWT, 0.74 (95% CI = 0.61-0.89) for SPPB, and 0.993 (95% CI = 0.988-0.997) for 6MWT. Handgrip strength (OR = 0.88, 95% CI = 0.83-0.93), 4mWT (OR = 0.33, 95% CI = 0.11-0.94), and SPPB (OR = 0.81, 95%CI = 0.71-0.93) predicted worsening mobility. No measure predicted falls; only SPPB (hazard ratio (HR) = 0.92, 95% CI = 0.85-0.997) and 6MWT (HR = 0.997, 95% CI = 0.995-0.999) predicted death. CONCLUSION Performance measures are independent predictors of relevant health outcomes, with the exception of falls. Because SPPB is easily applied and is the only measure predicting incident ADL disability, worsening mobility, and death, it is preferable to the other tests.
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Affiliation(s)
- Cristina Minneci
- Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Starbene SrL Rehabilitation Centre, Cerreto Guidi, Italy
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47
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Cappelli F, Baldasseroni S, Bergesio F, Perlini S, Salinaro F, Padeletti L, Attanà P, Paoletti Perini A, Moggi Pignone A, Grifoni E, Fabbri A, Marchionni N, Gensini GF, Perfetto F. Echocardiographic and biohumoral characteristics in patients with AL and TTR amyloidosis at diagnosis. Clin Cardiol 2015; 38:69-75. [PMID: 25645201 DOI: 10.1002/clc.22353] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 10/01/2014] [Accepted: 10/03/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Few studies have analyzed the clinical and echocardiographic differences between light-chain (AL) and transthyretin (TTR) amyloidosis. HYPOTHESIS The aim of the present research was to compare, in a real-world setting, the clinical and echocardiographic profiles of these kinds of amyloidosis, at the time of diagnosis, using new-generation echocardiography. METHODS Seventy-nine patients with AL and 48 patients with TTR amyloidosis were studied. RESULTS According to the criterion of mean left ventricular (LV) thickness >12 mm, 45 AL (C-AL) and all TTR patients had cardiac amyloidotic involvement, whereas 34 AL patients did not. TTR patients had increased right ventricular (RV) and LV chambers with increased RV and LV wall thickness and reduced LV ejection fraction and fractional shortening. Furthermore, TTR patients showed lower N-terminal pro Brain Natriuretic Peptide concentrations and New York Heart Association functional class when compared with C-AL. CONCLUSIONS Our data show that at time of first diagnosis, TTR patients have a more advanced amyloidotic involvement of the heart, despite less severe symptoms and biohumoral signs of heart failure. We can hypothesize that we observed different diseases at different stages. In fact, AL amyloidosis is a multiorgan disease with quick progression rate, that becomes rapidly symptomatic, whereas TTR amyloidosis might have a slow progression rate and might remain poorly symptomatic for a greater amount of time.
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Affiliation(s)
- Francesco Cappelli
- Intensive Cardiac Care Unit, Heart and Vessel Department, University Hospital Careggi, Florence, Italy; Tuscan Regional Amyloid Center, University Hospital Careggi, Florence, Italy
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Giovannelli F, Simoni D, Baldasseroni S, Tarantini F, Pratesi A, Bartoli N, Foschini A, Giganti F, Cincotta M, Viggiano M. 32. Event-related potential correlates of word recognition memory in patients with coronary artery disease. Clin Neurophysiol 2015. [DOI: 10.1016/j.clinph.2014.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Baldasseroni S, Pratesi A, Orso F, Di Serio C, Foschini A, Marella AG, Bartoli N, Di Bari M, Fumagalli S, Marchionni N, Tarantini F. Epicardial adipose tissue and insulin resistance in patients with coronary artery disease with or without left ventricular dysfunction. Monaldi Arch Chest Dis 2014; 80:170-6. [PMID: 25087293 DOI: 10.4081/monaldi.2013.5233] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Epicardial adipose tissue (EAT) is a visceral fat that fulfills two important functions: lipid-storage and secretion of adipokines with pro-inflammatory and pro-atherogenic properties. It has been suggested that EAT may affect the pathogenesis of atherosclerosis and the clinical course of coronary artery disease (CAD). In patients with obesity, diabetes and metabolic syndrome, the epicardial adipose tissue is enlarged. Little is known about the role of EAT in left ventricular dysfunction. Aim of this study was to evaluate the ability of insulin resistance to predict EAT thickness in patients with significant CAD and systolic dysfunction. METHODS We enrolled 114 subjects diagnosed with CAD by angiography. The majority underwent revascularization after an acute coronary syndrome. Patients were considered affected by significant left ventricular dysfunction when EF was < or = 40%. Three indexes of insulin resistance, the HOMA IR index, the insulin sensitivity QUICKI index, and the novel adiponectin/resistin index (ADIPO-IRAR) were calculated and correlated to EAT thickness. Epicardial fat was measured by echocardiography according to standardized methods. RESULTS Subjects with diabetes and with a history of hypercholesterolemia had thicker EAT compared to controls. Potassium levels and all three indexes of insulin resistance were the best independent predictors of EAT in the study population as a whole and in the subset of patients with left ventricular dysfunction. In the latter group the novel ADIPO-IRAR index displayed the strongest predictivity. CONCLUSION Insulin resistance is an independent predictor of EAT thickness in patients affected by CAD, also in the presence of significant left ventricular dysfunction.
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Mannarino G, Piccioli L, Baldasseroni S, Marchionni N, Stolcova M, Santoro G, Ungar A. P502: Transcatether aortic valve implantation in urgency. A case report from Transcatheter Aortic Valve Implantation Registry with Comprehensive Geriatric Assessment (CGA-TAVI). Eur Geriatr Med 2014. [DOI: 10.1016/s1878-7649(14)70667-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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