[ANMCO Position paper in collaboration with ITACARE-P: Cardio-oncology rehabilitation. Are we ready?]

Cardio-oncology rehabilitation (CORE) is not only an essential component of cancer rehabilitation, but also a pillar of preventive cardio-oncology. CORE is a comprehensive model based on a multitargeted approach and its efficacy has been widely documented; when compared to an "exercise only" program, comprehensive CORE demonstrates a better outcome. It involves nutritional counseling, psychological support and cardiovascular risk assessment, and it is directed to a very demanding population with a heavy burden of cardiovascular diseases driven by physical inactivity, cancer therapy-induced metabolic derangements and cancer therapy-related cardiovascular toxicities. Despite its usefulness, CORE is still underused in cancer patients and we are still at the dawning of remote models of rehabilitation (telerehabilitation). Not all cardio-oncology rehabilitation is created equal: a careful screening procedure to identify patients who will benefit the most from CORE and a multidisciplinary customized approach are mandatory to achieve a better outcome for cancer survivors throughout their cancer journey.The aim of this position paper is to provide an updated review of CORE not only for cardiologists dealing with this peculiar patient population, but also for oncologists, primary care providers, patients and caregivers. This multidisciplinary team should help cancer patients to maintain a healthy and active life before, during and after cancer treatment, in order to improve quality of life and to fight health inequities.

Cardio-oncology rehabilitation: are we ready?

Cardio-oncology rehabilitation (CORE) is not only an essential component of cancer rehabilitation but also a pillar of preventive cardio-oncology. Cardio-oncology rehabilitation is a comprehensive model based on a multitargeted approach and its efficacy has been widely documented; when compared with an 'exercise only' programme, comprehensive CORE demonstrates a better outcome. It involves nutritional counselling, psychological support, and cardiovascular (CV) risk assessment, and it is directed to a very demanding population with a heavy burden of CV diseases driven by physical inactivity, cancer therapy-induced metabolic derangements, and cancer therapy-related CV toxicities. Despite its usefulness, CORE is still underused in cancer patients and we are still at the dawning of remote models of rehabilitation (tele-rehabilitation). Not all CORE is created equally: a careful screening procedure to identify patients who will benefit the most from CORE and a multidisciplinary customized approach are mandatory to achieve a better outcome for cancer survivors throughout their cancer journey. The aim of this paper is to provide an updated review of CORE not only for cardiologists dealing with this peculiar population of patients but also for oncologists, primary care providers, patients, and caregivers. This multidisciplinary team should help cancer patients to maintain a healthy and active life before, during, and after cancer treatment, in order to improve quality of life and to fight health inequities.

Women's Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation's First Global Assessment

BACKGROUND

Cardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers in women, and women's greatest barriers according to enrollment status.

METHODS

In this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale was administered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated.

RESULTS

Participants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women's barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5).

CONCLUSIONS

CR barriers-men's and women's-vary significantly according to region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women's barriers in particular.

[Management of patients with type 2 diabetes during cardiac prevention and rehabilitation. An expert opinion from the Italian Alliance for Cardiovascular Rehabilitation and Prevention (ITACARE-P)]

Patients with diabetes, regardless of their cardiovascular disease and their index event, are more and more often referred to Cardiac Rehabilitation Units. These patients usually show high or very high cardiovascular risk, marked disability and poor quality of life. Furthermore, those with older age, frailty, and female sex have even more rehabilitative needs, thus requiring fine individualized approaches. Consequently, in order to identify their therapeutic goals, the glycemic target should be pursued together with the effective reduction of the global cardiovascular risk. Modern exercise protocols are based on the synergic effect of both aerobic and strength training of moderate and high effort intensities, in order to achieve improvements of cardiorespiratory fitness and glycemic values as well. Exercise training and nutritional intervention are strictly related during the rehabilitation program, thus promoting better lifestyle in the long term too. New antidiabetic drugs (such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists) should be included into a specific "patient journey" along with other core components of the rehabilitation program. Therefore, the active role of all allied professionals (namely nurses, physiotherapists, dietitians and psychologists) is essential to the success of the cardiometabolic team. Diabetes should be routinely included in the outcome evaluation of cardiac rehabilitation programs and in every follow-up plan through a successful crosstalk among cardiologists, diabetologists and patients.

Baseline Troponin Level and Cardiac Toxicity in HER2-positive Early Breast Cancer Patients Receiving Trastuzumab

BACKGROUND/AIM

There is controversy around the use of high-sensitive troponin T (hs-TnT) as an early biomarker of cardiac toxicity in patients with breast cancer on trastuzumab (T).

PATIENTS AND METHODS

Patients receiving adjuvant or neo-adjuvant T for early HER2-positive breast cancer were prospectively included. Transthoracic echocardiograms and matched hs-TnT before T and at 3, 6, and 9 months were performed on all patients. Congestive heart failure, cardiac death, a decline in left ventricular ejection fraction (LVEF) of more than 10% from baseline even if it is still within the normal range, or a drop in LVEF below 55% were all considered signs of cardiac toxicity.

RESULTS

In total, 24 patients (median age: 57; range=39-79 years) were enrolled. Anthracyclines were administered to all patients but three as part of neo/adjuvant treatment before T. Cardiovascular toxicity was observed in 3 out of 24 (12.5%) patients: two non-symptomatic LVEF declines (8.3%) and one heart failure episode (4.2%). In the entire population, the mean baseline hs-TnT level was 10.1±8.8 pg/ml, and after 3, 6, and 12 months, no appreciable change was observed. Patients with cardiac toxicity had mean hs-TnT levels higher than those without (18.3±12.3 vs. 8.2±7.2 pg/ml; p=0.049). A definite trend was evident in the chi-square test (chi2=3.52; p=0.06).

CONCLUSION

In anthracycline-exposed patients with early breast cancer, hs-TnT may be able to identify those at risk of developing cardiac toxicity during neo/adjuvant T treatment.

Effects of Sacubitril/Valsartan on Exercise Capacity in Patients with Heart Failure with Reduced Ejection Fraction and the Role of Percentage of Delayed Enhancement Measured by Cardiac Magnetic Resonance in Predicting Therapeutic Response: A Multicentre Study

Background: This study aims to evaluate the cardiopulmonary effects of sacubitril/valsartan therapy in patients with heart failure with reduced ejection fraction (HFrEF), investigating a possible correlation with the degree of myocardial fibrosis, as assessed by cardiac magnetic resonance. Methods: A total of 134 outpatients with HFrEF were enrolled. Results: After a mean follow-up of 13.3 ± 6.6 months, an improvement in ejection fraction and a reduction in E/A ratio, inferior vena cava size and N-terminal pro-B-type natriuretic peptide levels were observed. At follow-up, we observed an increase in VO₂ peak of 16% (p<0.0001) and in O₂ pulse of 13% (p=0.0002) as well as an improvement in ventilatory response associated with a 7% reduction in the VE/VCO₂ slope (p=0.0001). An 8% increase in the ΔVO₂/Δ work ratio and an 18% increase in exercise tolerance were also observed. Multivariate logistic regression analysis showed that the main predictors of events during follow-up were VE/VCO₂ slope >34 (OR 3.98; 95% CI [1.59-10.54]; p=0.0028); ventilatory oscillatory pattern (OR 4.65; 95% CI [1.55-16.13]; p=0.0052); and haemoglobin level (OR 0.35; 95% CI [0.21-0.55]; p<0.0001). In patients who had cardiac magnetic resonance, when delayed enhancement >4.6% was detected, a lower response after sacubitril/valsartan therapy was observed as expressed by improvement in ΔVO₂ peak, O₂ pulse, LVEF and N-terminal pro-B-type natriuretic peptide. No significant differences were observed in ΔVO₂/Δ work and VE/VCO₂ slope. Conclusion:Sacubitril/valsartan improves cardiopulmonary functional capacity in HFrEF patients. The presence of myocardial fibrosis on cardiac magnetic resonance is a predictor of response to therapy.

Exercise Training in Elderly Cancer Patients: A Systematic Review

Due to the aging of the population, in 70% of cases, a new cancer diagnosis equals a cancer diagnosis in a geriatric patient. In this population, beyond the concept of mortality and morbidity, functional capacity, disability, and quality of life remain crucial. In fact, when the functional status is preserved, the pathogenetic curve towards disability will stop or even regress. The present systematic review investigated the effectiveness of physical exercise, as part of a holistic assessment of the patient, for preventing disability and improving the patient’s quality of life, and partially reducing all-cause mortality. This evidence must point towards decentralization of care by implementing the development of rehabilitation programs for elderly cancer patients either before or after anti-cancer therapy.

Potential Role of Global Longitudinal Strain in Cardiac and Oncological Patients Undergoing Cardio-Oncology Rehabilitation (CORE)

Although shown to be effective in improving survival and quality of life in patients with cancer, some treatments are well-known causes of cardiotoxicity, such as anthracyclines, monoclonal antibodies against human epidermal growth factor receptor 2 (HER2) and radiotherapy. To prevent cardiovascular disease (CVD) in patients living with cancer, cardiologists and oncologists promoted the development of cardio-oncology, an interdisciplinary field which aims to further improving life expectancy in these patients. Cardio-oncology rehabilitation (CORE), through correction of risk factors, prescription of drug therapies and structured exercise programs, tries to improve symptoms, quality of life, cardiorespiratory fitness (CRF) and survival in patients with cancer. Different imaging modalities can be used to evaluate the real effectiveness of exercise training on cardiac function. Among these, the global longitudinal strain (GLS) has recently aroused interest, thanks to its high sensitivity and specificity for cardiac dysfunction detection due to advanced ultrasound programs. This review summarizes the evidence on the usefulness of GLS in patients with cancer undergoing cardiac rehabilitation programs.

P395 INFECTIVE ENDOCARDITIS: A SUBTLE PRESENTATION

Background

Infective endocarditis is still a serious and deadly disease. Despite improvements in its management, the diagnosis it is not always easy and thus it is still associated with high mortality and severe complications. This is especially true for patients with prosthetic valves, that have higher risk of developing infective endocarditis and more often associated with severe complications and a higher rate of mortality.

Case Description

A 75–years–old woman presented to the ED for persistent low–grade fever and mild dyspnoea. She had an aortic biologic prosthetic valve implanted the year before for severe aortic stenosis. She also complained a persistent back pain, present for about three months and irresponsive to pharmacological therapy and also physiotherapy. Getting back in time, she had been hospitalized few months before for genitourinary tract infection from multi–resistant E. faecalis, treated with antibiotic therapy and then discharged after few days. She underwent a transthoracic echocardiogram in ED that showed an apparently intraprosthetic moderate aortic regurgitation, never described in the previous cardiologic controls. In the strong suspect of endocarditis complicated by systemic embolization, she also underwent transoesophageal echocardiography, that showed dehiscence of the prosthetic valve with severe paravalvular abscess and regurgitation, without rocking motion of the prosthesis. A TC scan and then a spine MRI confirmed the presence of infectious spondylodiscitis, responsible for that persistent back pain. The patient was therefore urgently sent to cardiac surgery: a Bentall procedure (aortic valve and aortic root replacement) was performed. The patient, despite the severity of the sepsis and the cardiac endocarditis, survived the surgery and after 3 weeks of intensive care hospitalization was discharged and sent back to our Department for Cardiac Rehabilitation. Entering the ward, the patient was severely deconditioned, but after about 45 days of hospitalization she was discharged fit, with good functional capacity.

Conclusion

This case shows the subtle but serious evolution that usually controlled infections can have in patients with high risk of endocarditis, as patients with prosthetic valves. This underlines on one hand the importance of antibiotic prophylaxis in this subset of patients, on the other hand the role of multimodality imaging for diagnosis and management of infective endocarditis and its complications.

P147 RECOVERY OF CHEMOTHERAPY RELATED ACUTE HEART FAILURE BY THE COMBINED USE OF SACUBITRIL VALSARTAN AND WEARABLE CARDIOVERTER DEFIBRILLATOR. A NOVEL WINNING COMBINATION IN CARDIO–ONCOLOGY

Effective anticancer treatments have dramatically improved the outcome of cancer patients but cardiac toxicity reduces their clinical efficacy in a non–negligible percentage of patients. Sacubitril/valsartan is a new paradigm in the treatment of chronic heart failure with reduced ejection fraction due to the enhancement of natriuretic peptides’ properties when coupled with a blocking effect on the AT1 angiotensin receptors. As with other clinical conditions of heart failure with potentially reversible declines in cardiac function, the wearable cardioverter defibrillator is a valid tool for protection against sudden death until recovery occurs. We report a case series of four patients with chemotherapy–related acute cardiac failure with severely reduced cardiac function. They were successfully treated with sacubitril/valsartan while being protected from malignant arrhythmias by the use of a wearable cardioverter defibrillator until the recovery of cardiac function. Sacubitril/valsartan was confirmed to be effective in anthracycline–related cardiac toxicity and the wearable cardioverter defibrillator should be considered as a support tool even in the oncology patient.

Treatment of iron deficiency anemia after cardiac surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Iron deficiency anemia (IDA) after cardiac surgery (CS) increases mortality, serious adverse events and length of stay. Aim of the study was to compare the efficacy of Sucrosomal Iron (SI) on IDA and hematinic deficiencies (HD) in patients (P) after CS, compared to i.v. Ferric Carboxymaltose (FCM). SI was chosen for its peculiar intestinal absorption properties such as to overcome the hepcidin's block.

Methods

106 consecutive anemic P were tested for HD after the admission in Cardiac Rehabilitation and alternately treated with SI (56) or FCM (54). The study design included a single dose of 1000 mg of FCM at T1 (8-10 days CS) or a dose of 120 mg of SI per day from T1 to T2 (on the day of discharge 10 days after T1); since then the SI was reduced to 30 mg per day until T3 (follow-up, 10 days after T2). Measures of efficacy included changes from baseline in Hb, HD, natriuretic peptides (NP), C-reactive protein (CRP), and the 6-minute-walking-test (6MWT).

Results

The data are shown in the Table. At T1, two treatment groups did not show statistically significant differences. Hb increased significantly (p&lt;0.001), with no differences between SI and FCM. Transferrin saturation and sideremia significantly increased, albeit more rapidly with FCM. Ferritin, elevated at baseline for inflammation due to CS, decreases to T3 with SI, while significantly increases in the FCM group. NP were reduced with both treatments, but not significantly; CRP, on the other hand, was significantly reduced over time. At 6MWT the distance increased significantly with no difference between SI and FCM.

Conclusions

SI and FCM show similar efficacy on HD, starting from Hb, in P with IDA, after CS. The quick response to treatment, comparable between SI and FCM, could support the choice of oral iron, with organizational and cost benefits. In addition, was shown a positive impact on functional capacity, assessed with the 6MWT, for the first time similar between an oral and i.v. iron. Inflammation was reduced, but only SI is able to recover Hb levels, avoiding the risk of hyperferritinemia.

Case Series: Recovery of Chemotherapy-Related Acute Heart Failure by the Combined Use of Sacubitril Valsartan and Wearable Cardioverter Defibrillator: A Novel Winning Combination in Cardio-Oncology

Effective anticancer treatments have dramatically improved the outcome of patients with cancer, but cardiac toxicity reduces their clinical efficacy in a non-negligible percentage of patients. Sacubitril/valsartan is a new paradigm in the treatment of chronic heart failure, with a reduced ejection fraction due to the enhancement of natriuretic peptides' properties when coupled with a blocking effect on the angiotensin II type 1 (AT1) receptors. As with other clinical conditions of heart failure with potentially reversible declines in cardiac function, a wearable cardioverter defibrillator (WCD) is a valid tool for protection against sudden death until recovery occurs. We report a case series of four patients with chemotherapy-related acute cardiac failure with severely reduced cardiac function. They were successfully treated with sacubitril/valsartan while being protected from malignant arrhythmias using a wearable cardioverter defibrillator until the recovery of cardiac function. Sacubitril/valsartan was confirmed to be effective in anthracycline-related cardiac toxicity and the wearable cardioverter defibrillator should be considered as a support tool even in the oncology patient.

Short and medium-term impact of a cardiac rehabilitation (CR) program in COVID-19 patients after acute care hospitalization

Background

COVID-19 (C-19) infection can acutely cause organ dysfunctions, especially cardiorespiratory, even with a long recovery period, inducing a significant functional deficit. Aim of the study was to evaluate the impact of a holistic hospital intensive rehabilitation program, based on CR, on C-19 patients (P), after acute care, to improve their fitness, in order to return to their life in the best conditions.

Methods

In the period april-august 2020, 30 P (mean age 73 years, 60% male) were admitted to the rehabilitation centre at a mean distance of 31±11 days from the onset of C-19; 34% of them had undergone prolonged invasive ventilation, 34% non invasive ventilation and 32% required high flow oxygen. Comorbidities were: hypertension (77%), diabetes (13%) and chronic coronary syndrome (10%); 18 P were unable to stand, and 12 showed impaired trunk control. No P had impaired LVEF or significant valvular disease. Initially, the program focused on training for trunk and sitting control; then on exercises for straightening the upper and lower limbs. From the second week, started a CR training on the cycle ergometer 10–20 minutes a day for 6 days a week, similar protocol to that used in P with heart failure. The aerobic training was of moderate intensity, not exceeding 40–60% of the maximum heart rate, Borg scale 10–12, starting with zero load, gradually increasing by 10–15 watts and up to a minimum target of 25–30 watts. The impact of the protocol on motor functions [MRC Muscle Strenght Scale, Short Physical Performance Battery (SPPB)] on functional capacity [6 Minutes Walking Test (6MWT)] on anxiety (A) and depression (D) [Hamilton Anxiety Rating scale (HAMA) and Hamilton Depression Rating scale (HAMD)] and on basic activities of daily life [Barthel Index (BI)] were evaluated. The assessment was done on the admission (T0), at the discharge (T1, on average after 31 days) and after a follow-up of 55 days (T3).

Results

The results are shown in the table below. Only 4 P were able to perform the 6MWT at T0. The motor function improves rapidly and then reaches a plateau and its trend is reflected in the BI. Functional capacity, on the other hand, improves significantly even at a distance. A and D decreased rapidly but increased over time.

Conclusions

A rehabilitation protocol, centered on CR, induces a rapid increase in motor capacity, even in severely compromised subjects such as C-19. The improvement in fitness over time, as demonstrated by the 6MWT, probably is due to the severe muscle deconditioning, for the long stay in acute care. The long-term worsening of A and D may depend on various causes: no longer living in a “protected and safe” place, the fear of relapse, returning home and discovering new deaths and mournings. A program, CR-like, can counteract many of the negative consequences of C-19; however these P deserve an outpatient rehabilitation to maintain and consolidate the positive results over time.

Funding Acknowledgement

Type of funding sources: None. Table 1

Enhanced diffuse optical tomographic reconstruction using concurrent ultrasound information

Multimodal imaging is an active branch of research as it has the potential to improve common medical imaging techniques. Diffuse optical tomography (DOT) is an example of a low resolution, functional imaging modality that typically has very low resolution due to the ill-posedness of its underlying inverse problem. Combining the functional information of DOT with a high resolution structural imaging modality has been studied widely. In particular, the combination of DOT with ultrasound (US) could serve as a useful tool for clinicians for the formulation of accurate diagnosis of breast lesions. In this paper, we propose a novel method for US-guided DOT reconstruction using a portable time-domain measurement system. B-mode US imaging is used to retrieve morphological information on the probed tissues by means of a semi-automatical segmentation procedure based on active contour fitting. A two-dimensional to three-dimensional extrapolation procedure, based on the concept of distance transform, is then applied to generate a three-dimensional edge-weighting prior for the regularization of DOT. The reconstruction procedure has been tested on experimental data obtained on specifically designed dual-modality silicon phantoms. Results show a substantial quantification improvement upon the application of the implemented technique. This article is part of the theme issue 'Synergistic tomographic image reconstruction: part 2'.

Delphi consensus recommendations on how to provide cardiovascular rehabilitation in the COVID-19 era

This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from -5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 'for' and 10 'against' respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.

Comparison between the 6-minute walking test (6MWT) and gait speed (GS) during outpatient cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): USL TOSCANA CENTRO USL TOSCANA NORD-OVEST

Background

6MWT is the gold standard for the functional and prognostic evaluation of patients (P) undergoing cardiac rehabilitation (CR), documenting the increase in exercise capacity induced by CR intervention. However, 6MWT requires an adequate space of at least 30 meters and a non-negligible operator time. GS has been proposed as a test of rapid execution, that can be performed even in a small space. Due to the limited experiences, the aim of the present study was to validate GS in CR in comparison with 6MWT.

Material and Methods

44 P (31 males and 13 females; age 68.2 ± 11.9 years) were enrolled consecutively in an outpatient rehabilitation program; 20 of them after cardiac surgery, 18 after acute cardiac syndrome and 6 with heart failure. After evaluating equilibrium and gait with the Tinetti scale (score ≥ 19), P performed 6MWT and GS at the beginning and at the end of the CR program. The speed at GS was calculated as the average of 3 tests. Data were expressed as mean ± SD. The results of 6MWT and GS at the initial and the final evaluation were compared with Student’s t-test for paired data (statistical significance at p &lt;0.05). The Pearson correlation index (r) was calculated to evaluate the linearity relationship between distance traveled at 6MWT and velocity at GS; the  statistical significance was tested with ANOVA. The Statistical Package SPSS (version 24) was used for statistical analysis.

Results

the meters traveled at the initial and the final 6MWT were 434 ± 100 and 491 ± 96 respectively (p &lt;0.001). The velocity in m/sec at the initial and the final GS was 1.68 ± 0.42 and 1.80 ± 0.44 respectively (p &lt;0.001). The correlation between meters traveled and velocity is strong at baseline (r = 0.896) and after CR (r = 0.859), with p &lt;0.001 in both cases.

Conclusions

certainly, aerobic capacity and resistance to exercise are better described by 6MWT. However, given the strong correlation between the distance traveled at 6MWT and the speed at GS, the latter test can be proposed as a tool for a rapid, precise and repeatable functional evaluation, even in clinical settings other than CR.

Frailty in Acute and Chronic Coronary Syndrome Patients Entering Cardiac Rehabilitation

Worldwide population ageing is partly due to advanced standard of care, leading to increased incidence and prevalence of geriatric syndromes such as frailty and disability. Hence, the age at the onset of acute coronary syndromes (ACS) keeps growing as well. Moreover, ageing is a risk factor for both frailty and cardiovascular disease (CVD). Frailty and CVD in the elderly share pathophysiological mechanisms and associated conditions, such as malnutrition, sarcopenia, anemia, polypharmacy and both increased bleeding/thrombotic risk, leading to a negative impact on outcomes. In geriatric populations ACS is associated with an increased frailty degree that has a negative effect on re-hospitalization and mortality outcomes. Frail elderly patients are increasingly referred to cardiac rehabilitation (CR) programs after ACS; however, plans of care must be tailored on individual's clinical complexity in terms of functional capacity, nutritional status and comorbidities, cognitive status, socio-economic support. Completing rehabilitative intervention with a reduced frailty degree, disability prevention, improvement in functional state and quality of life and reduction of re-hospitalization are the goals of CR program. Tools for detecting frailty and guidelines for management of frail elderly patients post-ACS are still debated. This review focused on the need of an early identification of frail patients in elderly with ACS and at elaborating personalized plans of care and secondary prevention in CR setting.

Inhibitors of Protein Convertase Subtilisin/Kexin 9 (PCSK9) and Acute Coronary Syndrome (ACS): The State-of-the-Art

Acute Coronary Syndrome (ACS) remains one of the most frequent causes of morbidity and mortality in the world. Although the age- and gender-adjusted incidence of ACS is decreasing, the mortality associated with this condition remains high, especially 1-year after the acute event. Several studies demonstrated that PCSK9 inhibitors therapy determine a significant reduction of major adverse cardiovascular events (MACE) in post-ACS patients, through a process of plaque modification, by intervening in lipid metabolism and platelet aggregation and finally determining an improvement in endothelial function. In the EVACS (Evolocumab in Acute Coronary Syndrome) study, evolocumab allows >90% of patients to achieve LDL-C < 55 mg/dL according to ESC/EAS guidelines compared to 11% of patients who only receive statins. In the EVOPACS (EVOlocumab for Early Reduction of low-density lipoprotein (LDL)-cholesterol Levels in Patients With Acute Coronary Syndromes) study, evolocumab determined LDL levels reduction of 40.7% (95% CI: 45.2 to 36.2; p < 0.001) and allowed 95.7% of patients to achieve LDL levels <55 mg/dL. In ODYSSEY Outcome trial, alirocumab reduced the overall risk of MACE by 15% (HR = 0.85; CI: 0.78-0.93; p = 0.0003), with a reduced risk of all-cause mortality (HR = 0.85; CI: 0.73-0.98: nominal p = 0026), and fewer deaths for coronary heart disease (CHD) compared to the control group (HR = 0.92; CI: 0.76-1.11; p = 0.38). The present review aimed at describing the beneficial effect of PCSK9 inhibitors therapy early after ACS in reducing LDL circulating levels (LDL-C) and the risk of major adverse cardiovascular events, which was very high in the first year and persists higher later after the acute event.

Exercise for slowing the progression of atherosclerotic process: effects on inflammatory markers

Atherosclerosis is a dynamic process driven by all cardiovascular risk factors that can be briefly divided into an early and a late phase. Inflammation is one of the fundamental substrates that initiates the atherosclerotic process in the early stages and promotes and maintains it in the final stages. In the last decades, clinical and experimental data have shown that inflammation is supported by mediators that respond to physical activity. The present review aimed at investigating the effect of physical exercise on inflammatory mediators, both the positive ones that have a proinflammatory effect (interleukin 6, c-reactive protein and tumor necrosis factor α, interferon γ, high-mobility group box-1), and the negative ones which have an anti-inflammatory effect (interleukin 10). Pooled data support the evidence that physical exercise can directly modulate the activity of inflammatory cytokines slowing down or preventing the formation of the atherosclerotic stage.

The core components of cardio-oncology rehabilitation

The increased efficacy of cancer therapy has resulted in greater cancer survival and increasing number of people with cancer and cardiovascular diseases. The sharing of risk factors, the bidirectional relationship between cancer and cardiovascular diseases and the cardiotoxic effect of chemotherapy and radiotherapy, are the cause of the rapid expansion of cardio-oncology. All strategies to preserve cardiovascular health and mitigate the negative effect of cancer therapy, by reducing the cardiovascular risk, must be pursued to enable the timely and complete delivery of anticancer therapy and to achieve the longest remission of the disease. Comprehensive cardiac rehabilitation is an easy-to-use model, even in cancer care, and is the basis of Cardio-Oncology REhabilitation (CORE), an exercise-based multi-component intervention. In addition, CORE, besides using the rationale and knowledge of cardiac rehabilitation, can leverage the network of cardiac rehabilitation services to offer to cancer patients exercise programs, control of risk factors, psychological support, and nutrition counseling. The core components of CORE will be discussed, describing the beneficial effect on cardiorespiratory fitness, quality of life, psychological and physical well-being, and weight management. Furthermore, particular attention will be paid to how CORE can counterbalance the negative effect of therapies in those at heightened cardiovascular risk after a cancer diagnosis. Barriers for implementation, including personal, family, social and of the health care system barriers for a widespread diffusion of the CORE will also be discussed. Finally, there will be a call-to-action, for randomized clinical trials that can test the impact of CORE, on morbidity and mortality.

Is kinesiophobia a predictor of early functional performance after total hip replacement? A prospective prognostic cohort study

Background

Considerable attention has been paid to the role of kinesiophobia with respect to knee prosthesis but it has not yet been studied as a prognostic factor of short-term functional performance following total hip replacement. The main purpose of the present study is to examine the possible predictors of early functional performance of patients undergoing total primary hip arthroplasty, including demographics as age, sex and body mass index, preoperative functional ability, type of anaesthesia, level of haemoglobin, pain and level of kinesiophobia before surgery. Secondly, we want to describe the main characteristics of the population with the highest levels of kinesiophobia.

Methods

A prospective, prognostic cohort study was carried out. Patients undergoing primary hip replacement were recruited consecutively. The main outcome is the early functional performance achieved by patients after surgery and measured using the Iowa Level of Assistance (ILOA) scale on the fifth postoperative day. Preoperative kinesiophobia was measured by the Tampa Scale and the preoperative functional ability by the Western Ontario and McMaster Osteoarthritis Index (WOMAC). The multivariate analysis was performed by the General Linear Model. The analysis of the population with high levels of kinesiophobia was conducted by identifying a cut-off of 40 compared to the Tampa Scale.

Results

Statistical analysis was performed on 269 patients. The average ILOA score recorded was 19.5 (DS 8.3). The levels of kinesiophobia, showed an average score of 35.1 (7.8) and it was not associated with early functional performance. The independent predictive factors include age, sex and body mass index. Kinesiophobia high levels were recorded in 30% of the population and this population had a higher level of pre-operative WOMAC score.

Conclusions

Early functional performance after hip replacement surgery was not correlated with the level of kinesiophobia. Three significant factors that describe a population most at risk of not achieving optimal functional performance are increased age, being female and increase in body mass index. In the preoperative phase, high levels of kinesiophobia were associated with more impaired preoperative functional ability.

Trial registration

Current Controlled Trials NCT02786121, May 2016. Retrospectively registered.

Clinical Discussions in Antithrombotic Therapy Management in Patients With Atrial Fibrillation: A Delphi Consensus Panel

Background

In recent years, direct-acting oral anticoagulants (DOACs) have entered clinical practice for stroke prevention in non-valvular atrial fibrillation or prevention and treatment of venous thromboembolism. However, remaining uncertainty regarding DOAC use in some clinical scenarios commonly encountered in the real world has not been fully explored in clinical trials.

Methods

We report on use of a Delphi consensus process on DOAC use in non-valvular atrial fibrillation patients. The consensus process dealt with 9 main topics: (i) DOACs vs vitamin K antagonists in atrial fibrillation (AF) patients; (ii) therapeutic options for patients with stable total time in range treated with vitamin K antagonists; (iii) therapeutic options for patients aged > 85 years; (iv) therapeutic management of hyperfiltering patients; (v) pharmacologic interactions; (vi) therapeutic options in the long-term treatment (prevention) of patients with AF and acute coronary syndrome after the triple therapy; (vii) low doses of DOACs in AF patients; (viii) ischemic stroke in patients inappropriately treated with low doses of DOACs; (ix) management of patients taking DOACs with left atrial appendage thrombosis.

Results

A total of 101 physicians (cardiologists, internists, geriatricians, and hematologists) from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = somewhat agree; 4 = agree; 5 = strongly agree). Votes 1-2 were considered to be disagreement; votes 3-5 were considered to be agreement. Agreement among the respondents of ≥ 66% for each statement was considered consensus. A brief discussion of the results for each topic is also reported.

Conclusions

In clinical practice, there is still uncertainty on DOAC use, especially in elderly, fragile, comorbid, and hyperfiltering patients.

Cardiac rehabilitation activities during the COVID-19 pandemic in Italy. Position Paper of the AICPR (Italian Association of Clinical Cardiology, Prevention and Rehabilitation)

The COVID-19 outbreak is having a significant impact on both cardiac rehabilitation (CR) inpatient and outpatient healthcare organization. The variety of clinical and care scenarios we are observing in Italy depends on the region, the organization of local services and the hospital involved. Some hospital wards have been closed to make room to dedicated beds or to quarantine the exposed health personnel. In other cases, CR units have been converted or transformed into COVID-19 units.  The present document aims at defining the state of the art of CR during COVID-19 pandemic, through the description of the clinical and management scenarios frequently observed during this period and the exploration of the future frontiers in the management of cardiac rehabilitation programs after the COVID-19 outbreak.

Oncology and Cardiac Rehabilitation: An Underrated Relationship

Cancer and cardiovascular diseases are globally the leading causes of mortality and morbidity. These conditions are closely related, beyond that of sharing many risk factors. The term bidirectional relationship indicates that cardiovascular diseases increase the likelihood of getting cancer and vice versa. The biological and biochemical pathways underlying this close relationship will be analyzed. In this new overlapping scenario, physical activity and exercise are proven protective behaviors against both cardiovascular diseases and cancer. Many observational studies link an increase in physical activity to a reduction in either the development or progression of cancer, as well as to a reduction in risk in cardiovascular diseases, a non-negligible cause of death for long-term cancer survivors. Exercise is an effective tool for improving cardio-respiratory fitness, quality of life, psychological wellbeing, reducing fatigue, anxiety and depression. Finally, it can counteract the toxic effects of cancer therapy. The protection obtained from physical activity and exercise will be discussed in the various stages of the cancer continuum, from diagnosis, to adjuvant therapy, and from the metastatic phase to long-term effects. Particular attention will be paid to the shelter against chemotherapy, radiotherapy, cardiovascular risk factors or new onset cardiovascular diseases. Cardio-Oncology Rehabilitation is an exercise-based multi-component intervention, starting from the model of Cardiac Rehabilitation, with few modifications, to improve care and the prognosis of a patient's cancer. The network of professionals dedicated to Cardiac Rehabilitation is a ready-to-use resource, for implementing Cardio-Oncology Rehabilitation.

Association between Very Low-Density Lipoprotein Cholesterol (VLDL-C) and Carotid Intima-Media Thickness in Postmenopausal Women Without Overt Cardiovascular Disease and on LDL-C Target Levels

Background: atherosclerotic process inexorably advances in patients reaching low-density lipoprotein cholesterol (LDL-C) targets. An attractive hypothesis is that lipoprotein particles (very low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL)), could contribute to residual risk. The present study aims to investigate the relationship between carotid intima-media thickness (IMT) and different lipoprotein subfractions in a cohort of healthy postmenopausal women. Methods: 75 postmenopausal women, at LDL-C target levels without overt cardiovascular disease, underwent biochemical analyses (including subfraction assay of plasma lipoproteins) and carotid ultrasound examination. Results: a statistically significant correlation between VLDL and carotid IMT (p < 0.001) was found. No significant correlation was found between carotid IMT and LDL-C (p = 0.179), IDL-C (p = 0.815), high-density lipoprotein (HDL) (p = 0.855), and LDL score (p = 0.240). Moreover, IMT is significantly correlated to LDL particle diameter (p = 0.044). After adjusting for age, systolic blood pressure, body mass index, smoking habits, glucose plasma concentration, and Lipoprotein(a) (Lpa) levels, multivariate analysis showed that women in the third tertile of VLDL-C, compared with those in the first tertile, were significantly associated to the highest IMT (p = 0.04). Conclusions: in this cohort of postmenopausal women, VLDL-C was significantly associated to carotid IMT, independent of main cardiovascular risk factors. These findings pave the way for targeting circulating concentrations of VLDL-C to reduce cardiovascular events in patients with target LDL-C levels.

Cardiovascular Risk Factors and Timing of Anthracyclines and Trastuzumab Cardiac Toxicity

BACKGROUND/AIM

Cardiovascular risk factors (CVRFs) predict cardiotoxicity in cancer patients but their role in late cardiac toxicity is less clear.

PATIENTS AND METHODS

This was a retrospective analysis of patients treated with anthracyclines (A) and/or trastuzumab (T) and a correlation with early (≤5 years) or late (>5 years) cardiac toxicity, and baseline CVRFs and CVRFs at toxicity time.

RESULTS

A total of 610 patients were included, 422 with (Group A) and 188 without (Group B) baseline CVRFs. In group A toxicity incidence was 4.7% with all events during treatment or immediately after [mean onset time 0.7 years (range=0.2-1.6)]. Events rate was 3.2% in group B with all events after five years [mean time onset 6.9 years (range=5.2-7.5)]. All group B patients who developed late cardiac toxicity presented with CVRFs at the time of toxicity not reported before.

CONCLUSION

CVRFs could predict late cardiac toxicity and their control should be part of the survivorship program.

Prediction of Chemoresistance in Women Undergoing Neo-Adjuvant Chemotherapy for Locally Advanced Breast Cancer: Volumetric Analysis of First-Order Textural Features Extracted from Multiparametric MRI

Purpose

To assess correlations between volumetric first-order texture parameters on baseline MRI and pathological response after neoadjuvant chemotherapy (NAC) for locally advanced breast cancer (BC).

Materials and Methods

69 patients with locally advanced BC candidate to neoadjuvant chemotherapy underwent MRI within 4 weeks from the start of therapeutic regimen. T2, DWI, and DCE sequences were analyzed and maps were generated for Apparent Diffusion Coefficient (ADC), T2 signal intensity, and the following dynamic parameters: k-trans, peak enhancement, area under curve (AUC), time to maximal enhancement (TME), wash-in rate, and washout rate. Volumetric analysis of these parameters was performed, yielding a histogram analysis including first-order texture kinetics (percentiles, maximum value, minimum value, range, standard deviation, mean, median, mode, skewness, and kurtosis). Finally, correlations between these values and response to NAC (evaluated on the surgical specimen according to RECIST 1.1 criteria) were assessed.

Results

Out of 69 tumors, 33 (47.8%) achieved complete pathological response, 26 (37.7%) partial response, and 10 (14.5%) no response. Higher levels of AUCmax (p value = 0.0338), AUCrange (p value = 0.0311), and TME75 (p value = 0.0452) and lower levels of washout10 (p value = 0.0417), washout20 (p value = 0.0138), washout25 (p value = 0.0114), and washout30 (p value = 0.05) were predictive of noncomplete response.

Conclusion

Histogram-derived texture analysis of MRI images allows finding quantitative parameters predictive of nonresponse to NAC in women affected by locally advanced BC.

Mortality for chronic-degenerative diseases in Tuscany: Ecological study comparing neighboring areas with substantial differences in environmental pollution

OBJECTIVES

Environmental pollution is associated with morbidity and mortality for chronic-degenerative diseases. Recent data points out a relationship between proximity to industrial plants and mortality due to neoplasms. The aim of this study has been to compare mortality due to chronic-degenerative diseases in the area of Tuscany (Bassa Val di Cecina), Italy, characterized by the presence of 2 neighboring municipalities similar in terms of size but with substantial differences in industrial activities: Rosignano (the site of chemical, energy production and waste processing industries) and Cecina (with no polluting activity).

MATERIAL AND METHODS

Standardized mortality rates for the 2001-2010 decade were calculated; the data of the whole Tuscany was assumed as reference. Environmental levels of pollutants were obtained by databases of the Environmental Protection Agency of Tuscany Region (Agenzia Regionale per la Protezione Ambientale della Toscana - ARPAT). Maximum tolerated pollutant levels set by national laws were assumed as reference.

RESULTS

In the whole Bassa Val di Cecina, significantly elevated standardized mortality rates due to mesothelioma, ischemic heart diseases, cerebrovascular diseases and Alzheimer and other degenerative diseases of nervous system were observed. In the municipality of Rosignano, a significant excess of mortality for all these groups of diseases was confirmed. On the contrary, the municipality of Cecina showed only significantly higher mortality rates for ischemic heart diseases. Elevated levels of heavy metals in sea water and of particulate matter which contains particles of diameter ≤ 10 mm (PM₁₀) and ozone in air were detected in Rosignano.

CONCLUSIONS

This study shows an excess of mortality for chronic-degenerative diseases in the area with elevated concentration of polluting factories. Proximity to industrial plants seems to represent a risk factor for those diseases. Int J Occup Med Environ Health 2017;30(4):641-653.

Optimizing the management of children with latent tuberculosis infection

INTRODUCTION

The management of latent tuberculosis (LTBI) in children represents an important issue for paediatricians because of the disease burden, the lack of a gold standard for the diagnosis and the high annual risk of progression to active disease. Areas covered: A review of English language articles on LTBI in children, published between the 1st of January 2010 and the 1st of July 2016, was conducted using multiple keywords and standardized terminology in PubMed database. This review provides an updated overview of the available tests for LTBI diagnosis in children, management strategies and treatment options. Expert commentary: Two tests are available for LTBI diagnosis: tuberculin skin test and interferon-gamma release assays, both with a suboptimal specificity and sensitivity, and both with the lack of capability in distinguishing between infection and disease. Several new markers have been identified but further studies are needed. Among all treatment regimes, because of the high safety and efficacy profile showed and to avoid the poor completion rate, the treatment with a three-month course of isoniazid and rifampicin is currently recommended. New vaccines are needed because of the spread of the disease despite BCG vaccination in high risk countries. Currently, 15 new vaccines are in the pipeline.

Use, abuse and misuse of biomarkers in paediatrics

Currently, a gold standard for distinguishing between infectious, inflammatory, auto-immune diseases and malignancy in infants and children is not available. The combination of biomarkers with clinical features and other diagnostic tests could help clinicians in the diagnostic process. Ideally, a biomarker should have high sensitivity, specificity, and predictive value, as well as being easily obtained also in preterm babies and infants, requiring a small amount of blood and being quickly measured. The available literature agrees on the fact that a “perfect” biomarker is not currently available in paediatric practice. Thus, clinicians must consider time by time the balance between marker characteristics and their sensitivity and specificity in different conditions. The development of new tests with higher sensitivity and specificity in distinguishing different pathological situations is auspicable. Moreover, future efforts should be focused on validating also in children the recently developed biomarkers including CD64, IL-27 and IL-8.

Does robot-assisted gait training ameliorate gait abnormalities in multiple sclerosis? A pilot randomized-control trial

BACKGROUND

Gait disorders are common in multiple sclerosis (MS) and lead to a progressive reduction of function and quality of life.

OBJECTIVE

Test the effects of robot-assisted gait rehabilitation in MS subjects through a pilot randomized-controlled study.

METHODS

We enrolled MS subjects with Expanded Disability Status Scale scores within 4.5-6.5. The experimental group received 12 robot-assisted gait training sessions over 6 weeks. The control group received the same amount of conventional physiotherapy. Outcomes measures were both biomechanical assessment of gait, including kinematics and spatio-temporal parameters, and clinical test of walking endurance (six-minute walk test) and mobility (Up and Go Test).

RESULTS

16 subjects (n = 8 experimental group, n = 8 control group) were included in the final analysis. At baseline the two groups were similar in all variables, except for step length. Data showed walking endurance, as well as spatio-temporal gait parameters improvements after robot-assisted gait training. Pelvic antiversion and reduced hip extension during terminal stance ameliorated after aforementioned intervention.

CONCLUSIONS

Robot-assisted gait training seems to be effective in increasing walking competency in MS subjects. Moreover, it could be helpful in restoring the kinematic of the hip and pelvis.

Delayed multifocal recurrent stress-induced cardiomyopathy after antidepressants withdrawal

Stress-induced cardiomyopathy is an acute disease characterized by a large left ventricular apical dyskinesia ("apical ballooning"), triggered by intense emotional or physical stress, acute illnesses or, rarely, by alcohol or opiates withdrawal. Connection to stress and apical asynergy suggest a catecholamine-mediated pathogenesis. We recently observed a typical apical stress-induced cardiomyopathy, arising two weeks after a long-lasting antidepressant treatment withdrawal and recurring, a week later, with evidence of inferior wall akinesia. The reported case has several unusual features: 1) both episodes were not preceded by relevant triggering event (except antidepressant discontinuation); 2) early heterozonal relapse was observed; 3) the latency between antidepressant discontinuation and stress-induced cardiomyopathy onset is unusually long. The lack of relevant triggering stress and the evidence of multifocal asynergies could support the hypothesis of a non-catecholaminergic pathogenesis. Moreover, the long latency after antidepressant withdrawal may suggest that prolonged antidepressant treatments may have delayed pathological consequences, possibly related to their known neuroplastic effects.

Risk management in acute pulmonary embolism: correlation between right heart dysfunction, pulmonary clots distribution, biomarkers and prognosis

BACKGROUND Right heart dysfunction (RHD) is related to adverse outcomes in acute pulmonary embolism (PE). AIM OF THE STUDY To evaluate the relation between RHD, pulmonary clots distribution and biomarkers and prognosis of patients with PE. METHODS We analysed echocardiographic data of 70 patients with diagnosis of PE confirmed by pulmonary computer tomography, hCT. We considered the enddiastolic right/left ventricles ratio > 1 as index of RHD; echocardiographic data were compared with clots distribution in pulmonary vascular tree such as hCT findings and biomarkers. For each patient we calculated the shock index (heart rate/systolic blood pressure ratio, shock defined as ratio ≥ 1). RESULTS Hospital mortality was 8.5%. Mean age of dead patients was significantly higher compared to alive (85.67 vs 71.57 years, p < 0.05). 41% of patients revealed unilateral PE, 59% had bilateral. In 10% of patients main pulmonary artery was interested by clot, 48% of patients had involved one of the main branches, 90% had involved at least one of the lobar branches, 59% one of segmental branches of pulmonary arteries. 52% of patients had RHD. Mortality in RHD patients was 14.8% vs 8% in no RHD, p < 0.05. Mean values of troponin I and D-dimer were significantly higher in RHD patients. Shock index was ≥ 1 in 37.5% of RHD and 20% in no RHD. RHD patients showed significantly higher involvement of main pulmonary artery and its branches and higher bilateral involvement. CONCLUSIONS RHD is related to proximal and bilateral pulmonary clots distribution and troponin I and D-dimer values and poorer prognosis.

Single coronary artery from the right sinus of Valsalva

We describe a case of a single coronary artery originating from the right coronary sinus and bifurcating into the left coronary artery (LCA) and right coronary artery (RCA) in a 74-year old woman, with a non-ST elevation acute myocardial infarction (NSTEMI). Diagnosis was made by coronary angiography which ruled out stenosis, and showed normal LCA and RCA branching. The connection path of LCA, with the opposite cusp, was defined retroaortic by multislice computed tomography (CT). The variants of this coronary anomaly, together with their clinical implications and pathophysiology of acute myocardial infarction (AMI) are discussed. Multislice CT is fundamental for clinical decision making.

Clinical applicability of D-dimer assay in the diagnosis of pulmonary embolism reduces with aging

Despite modern algorithms have been proposed for diagnosis of pulmonary embolism (PE), it remains understimed and often missed in clinical practice, especially in elderly patients, resulting in high morbidity and mortality when early and correctly untreated. One of the main controversial issue is represented by the role and applicability of D-dimer in the diagnostic work up of geriatric patients. Most recent guidelines in young-adult patients suggest to perform D-dimer assay by ELISA or immunoturbidimetric methods only in non high pre-test clinical probability (PTP) patients; in these patients negative D-dimer can safely rule out the diagnosis of PE. This strategy is safe also in elderly patients; however the percentage of patients with non high PTP and negative D-dimer reduces progressively with age, making difficult its clinical applicability. The Authors, starting from two case reports, up date the diagnostic management of PE underling the limitations of D-dimer assay in elderly patients.

BNP after Cardiac Surgery in Patients with Normal Ventricular Function

Background: Brain natriuretic peptide (BNP) is proven marker for diagnosis and stratification of patients (P) with heart failure; furthermore it can be useful for differential diagnosis of dyspnea, for detection of diastolic dysfunction and as guide and monitoring of therapy. Acute coronary syndrome, atrial fibrillation (AF), aortic stenosis and hypertrophic cardiomyopathy are other conditions in which the BNP can be raised. Little is know about the level of BNP in P undergone cardiac surgery. Aim of the study was to detect the concentration of BNP immediately after CABG and to follow the course during cardiac rehabilitation (CR). Methods: we studied 18 P (mean age 67.8±11.2 yrs) 9.1±3.6 days after surgery and we repeated the evaluation after our program of CR, in average 56 days of distance from CABG. In each P was performed an echocardiogram (inclusive study of right ventricle, diastolic function and DTI), a determination of BNP (NT-proBNP) and also the six-minute walking test (SMWT). Every effort was made for not varying the therapy during the period of observation. Exclusion criteria were: MI in the last 3 months, heart and renal failure, use of inotropics drugs and AF after cardiac surgery. Results: the concentration of BNP was high in both determinations even if it lowered in the second (BNP1 vsBNP2: pg/ml 1225.1±873.2 vs 708.7±741 P < 0.001); also the left atrial volume decreased ( ml 50.7±11.6 vs 46.4±8.8 P < 0.01) while the ejection fraction didn't vary, (EF1 vs EF2: 57.2±6.7 vs 59.8±9.1 ns). There was an increase of the distance crossed to the SMWT ( mt 254.7±65.4 vs 435.3±69.6 P < 0.001); glycaemia and creatinine values were normal in both determinations while the hemoglobin increased (11.5±1.2 vs 13.2±1.3 P < 0.01). Other echo parameters(E/A, E/Em, TAPSE, PAPs ) were not meaningfully varied with the exception of DT (221.6±66.3 vs 253.8±72.3 P < 0.05). We have not found correlations between Ä BNP and: Ä LAV, Ä SMWT, Ä E/A or Ä E/Em. Instead, the relationship was statistically significant with the DT (r: 0.78 P < 0.01). Also the second determination of the BNP had the followings relationships: *** Table in Full Text PDF. *** Conclusion: after CABG, the level of BNP is elevated also in P with normal ventricular function; the most elevated values were in the immediate proximity of surgery for then being reduced during CR program. The improvement of the diastolic function, pointed out by the increase of the DT, it seems to correlate with the reduction of natriuretic peptides; the relationship of the other indexes of diastolic function, of the EF and of the PAPs with the BNP is detectable only at the second collecting. Is possible to infer that conditions in narrow relationship with the surgery (extracorporeal circulation, quick variations of circulating volume, direct stimulation of the myocardium and impaired lung function due to sternotomy) can induce the liberation of the BNP; this can conceal the association between the incretion of BNP and the indexes of ventricular function.

Is pretreatment with ibutilide useful for atrial fibrillation cardioversion when combined with biphasic shock?

OBJECTIVE

Cardioversion of atrial fibrillation by means of a monophasic transthoracic shock is facilitated by pretreatment with ibutilide. The aim of this study was to randomly and prospectively compare the energy requirements of transthoracic biphasic cardioversion of atrial fibrillation with and without ibutilide pretreatment.

METHODS

Fifty patients were enrolled and randomized into two groups: immediate cardioversion with biphasic shock (group 1) or ibutilide pretreatment followed by cardioversion with biphasic shock (group 2). In group 2, ibutilide was administered intravenously in 10 min at a dose of 0.01 mg/kg. A pause of 10 min was observed before the patients underwent cardioversion.

RESULTS

All patients of both groups were successfully cardioverted (100%). Energy and number of shocks were significantly lower in group 2 than in group 1 (P< 0.02). Eleven of 25 patients (44%) in group 1 and 15 of 23 patients (65%) in group 2 were cardioverted at the first attempt with 50 J. The number of patients cardioverted at the first attempt with 50 J was significantly higher in group 2 than in group 1 (P = 0.018).

CONCLUSIONS

Although not essential for a successful outcome, pretreatment with ibutilide can lower energy requirements in transthoracic biphasic cardioversion.