Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented.

Greater functional improvement in patients with diabetes after rehabilitation following cardiac surgery

BACKGROUND

Diabetes increases the risk of in-hospital complications in medical or surgical patients. Few data are available in the rehabilitation phase after cardiac surgery.

AIM

To assess the influence of diabetes on outcome and complication rate in the rehabilitation phase after cardiac surgery.

METHODS

Data prospectively recorded in the Hospital Information System from 5261 patients consecutively admitted between 1 January 2008 and 31 May 2013 for a comprehensive cardiac rehabilitation programme directly after cardiac surgery were analysed retrospectively.

RESULTS

The study cohort included 1285 (24%) patients with diabetes and 3976 (76%) without. Coronary artery bypass graft (CABG) was more frequent in patients with diabetes (58% vs. 37%, P < 0.01), and valvular surgery was more frequent in patients without diabetes (37% vs. 22%, P < 0.01). Patients with diabetes were more disabled after surgery, with severe disability (Barthel Index < 60) observed in 22% (vs. 17% in patients without diabetes, P < 0.001). During rehabilitation, complications were more frequent in patients with diabetes than those without (28% vs. 21%, P < 0.01); in particular, patients with diabetes had more infections, heart failure and more difficult surgical wound healing. However, the improvement in the Barthel Index was greater in patients with diabetes (+16 ± 15) than without (+13 ± 15, P < 0.001).

CONCLUSIONS

In a large cohort of patients directly admitted to an early inpatient rehabilitation programme after cardiac surgery, those with diabetes were more disabled. Nonetheless, and despite the higher rate of complications, patients with diabetes had the greatest benefit in terms of functional improvement.

Extradural spinal cord lesion in a dog: first case study of canine neurological histoplasmosis in Italy

A 7-year-old intact male mixed dog was presented with a history of acute and progressive paraparesis. Abnormal clinical signs consisted of non-ambulatory paraparesis, hind limbs hypertonia and severe thoracolumbar pain. Magnetic resonance imaging demonstrated an isointense in T1 and T2 WI epidural lesion, with good contrast enhancement, extending from T-10 to T-13. Laminectomy was carried out to remove the epidural mass. Histological examination revealed a pyogranulomatous lesion characterized by numerous macrophages containing yeast-like Grocott and PAS-positive bodies. Immunohistochemistry and PCR performed on formalin-fixed paraffin-embedded tissue confirmed Histoplasma capsulatum as the causative agent. H. capsulatum has a worldwide distribution in temperate and subtropical climates but its presence as an autochthonous fungus in Europe is now recognized. To the authors' knowledge this is the first report of canine histoplasmosis in Italy with lesion confined to the central nervous system.

Tissue factor gene polymorphisms and haplotypes and the risk of ischemic vascular events: four studies and a meta-analysis

OBJECTIVE

The exposure of tissue factor (TF) to blood flow is the initial step in the coagulation process and plays an important role in thrombogenesis. We investigated the role of genetic polymorphisms and haplotypes of the TF gene in the risk of ischemic vascular disease.

METHODS

Four hundred and twenty-two Italian patients with juvenile myocardial infarction (MI) and 434 controls, 808 US cases with MI and 1005 controls, 267 Italian cases with juvenile ischemic stroke and 209 controls and 148 German cases with juvenile ischemic stroke and 191 controls were studied. rs1361600, rs3917629 (rs3354 in the US population), rs1324214 and rs3917639 Tag single nucleotide polymorphisms were genotyped. Additionally, a meta-analysis of all previous studies on TF loci and the risk of ischemic coronary disease (ICD) was performed.

RESULTS

After multivariable analysis none of the SNPs, major SNP haplotypes or haplotype-pairs showed any consistent association with MI. Pooled meta-analysis of six studies also suggested that TF polymorphisms are not associated with CHD. A significant, independent association between SNP rs1324214 (C/T) and juvenile stroke was found in Italian and German populations (OR for TT homozygotes = 0.47, 95% CI 0.24-0.92, in combined analysis). Pooled analysis also showed a significant association for haplotype H3 (OR = 0.76, 95% CI 0.57-1.00) and haplotype-pair H3-H3 (OR = 0.43, 95% CI 0.20-0.92).

CONCLUSIONS

TF genetic variations were associated with the risk of ischemic stroke at young age, but did not affect ischemic coronary disease.

Right ventricular functional recovery after acute myocardial infarction: relation with left ventricular function and interventricular septum motion. GISSI-3 echo substudy

OBJECTIVE

To evaluate the pattern of right ventricular (RV) functional recovery and its relation with left ventricular (LV) function and interventricular septal (IVS) motion in low risk patients after acute myocardial infarction (AMI).

DESIGN AND SETTING

Multicentre clinical trial carried out in 47 Italian coronary care units.

PATIENTS

500 patients from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico) -3 echo substudy, who underwent serial echocardiograms 24-48 hours after symptom onset and at discharge, six weeks, and six months after AMI.

RESULTS

Tricuspid annular plane systolic excursion (TAPSE) increased significantly during follow up (mean (SD) 1.79 (0.46) cm at 24-48 hours to 1.92 (0.46) cm at six months, p < 0.001) and the increase was already significant at discharge (1.88 (0.47) cm, p < 0.001). LV ejection fraction (LVEF) was the best correlate of TAPSE at 24-48 hours (r = 0.15, p = 0.001). TAPSE increased significantly in patients both with reduced (< 45%) and with preserved (> or = 45%) LVEF, but the magnitude of increase was higher in patients with lower initial LVEF (p = 0.001). Improvement in IVS wall motion score index (IVS-WMSI) was the only independent predictor of TAPSE changes during follow up (r = -0.12, p = 0.007).

CONCLUSIONS

In low risk patients after AMI, RV function recovered throughout six months of follow up and was already significant at discharge. TAPSE was significantly related to LVEF at 24-48 hours. The magnitude of RV functional recovery was higher in patients with lower initial LVEF. RV functional recovery is best related to IVS-WMSI improvement, suggesting that IVS motion has an important role in RV functional improvement in this setting.

Polymorphisms of the Interleukin-1β Gene Affect the Risk of Myocardial Infarction and Ischemic Stroke at Young Age and the Response of Mononuclear Cells to Stimulation In Vitro

Objectives— To investigate the role of interleukin-1β (IL-1β) gene polymorphisms as a link between inflammation, coagulation, and risk of ischemic vascular disease at young age.

Methods and Results— A total of 406 patients with myocardial infarction (MI) at young age, frequency-matched for age, sex, and recruitment center, with 419 healthy population-based controls and 134 patients with ischemic stroke at young age, matched by age and sex, with 134 healthy population-based controls, were studied. Subjects carrying the TT genotype of the −511C/T IL-1β polymorphism showed a decreased risk of MI (odds ratio [OR], 0.36; 95% CI, 0.20 to 0.64) and stroke (OR, 0.32; 95% CI, 0.13 to 0.81) after adjustment for conventional risk factors. In both studies, the T allele showed a codominant effect ( P =0.0020 in MI; P =0.021 in stroke). Mononuclear cells from volunteers carrying the T allele showed a decreased release of IL-1β and a decreased expression of tissue factor after stimulation with lipopolysaccharide compared with CC homozygotes. The presence of a monoclonal antibody against IL-1β during cell stimulation resulted in a marked reduction of tissue factor activity expression.

Conclusions— -511C/T IL-1β gene polymorphism affects the risk of MI and ischemic stroke at young age and the response of mononuclear cells to inflammatory stimulation.

Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology

The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.

["Bad" sleepers... Causes, effects, and diagnosis of sleep-related breathing disorders in cardiac patients]

Cardiovascular and cerebrovascular disease are the most common life-threatening disease in the industrialized world. There is high interest in sleep apnea and cardiovascular disease: several studies have demonstrated an association between sleep apnea and cardiovascular and cerebrovascular events. The aim of this review is to critically appraise the possible adverse physiological consequences of sleep apnea on the cardiovascular system and to assess whether such adverse effects constitute a risk for the development of cardiovascular disease.

Relation between early mitral regurgitation and left ventricular thrombus formation after acute myocardial infarction: results of the GISSI-3 echo substudy

OBJECTIVE

To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus.

DESIGN AND SETTING

Multicentre clinical trial carried out in 47 Italian coronary care units.

PATIENTS AND METHODS

757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24-48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views.

RESULTS

In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v 59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v 48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m(2), p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m(2), p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction.

CONCLUSIONS

Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only independent determinant of left ventricular thrombosis is the extent of the akinetic-dyskinetic area detected on echocardiography between 24-48 hours from symptom onset.

Prediction of 6 months left ventricular dilatation after myocardial infarction in relation to cardiac morbidity and mortality. Application of a new dilatation model to GISSI-3 data

AIMS

To predict the long-term left ventricular volume index early after myocardial infarction and to investigate the relationship between long-term left ventricular dilatation risk and clinical outcome.

METHODS AND RESULTS

By applying a previously developed dilatation model, we predicted the 6-month left ventricular volume index early after myocardial infarction (median 9 days) in 13,679 GISSI-3 patients, to identify patients at high risk of long-term left ventricular dilatation. The left ventricular systolic and diastolic volume indexes at 6 months were predicted with r=0.72 and r=0.68, respectively, in the subgroup of patients in whom a pre-discharge echo was available (n=7842). Patients predicted to be at risk for long-term left ventricular dilatation had an increased risk of mortality (RR 1.87, 95% CI: 1.48 to 2.36) and heart failure at 6 months (RR 2.59, 95% CI:2.04 to 3.28), but no increased risk of reinfarction at 6 months (RR 1.12, 95% CI: 0.87 to 1.45) or of angina pectoris (RR 1.07, 95% CI: 0.95 to 1.20).

CONCLUSION

Our prediction of long-term left ventricular dilatation, obtained by applying our new dilatation model in over 13,000 GISSI-3 patients, correlated well with mortality and heart failure after myocardial infarction. Therefore, our new dilatation model may contribute to more efficient risk stratification early after myocardial infarction.

Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.

Chlamydia pneumoniae and cytomegalovirus seropositivity, inflammatory markers, and the risk of myocardial infarction at a young age

BACKGROUND

Pathogens causing chronic infections may promote atherosclerosis. The aim of our study was to evaluate the association of Chlamydia pneumoniae (Cp) and cytomegalovirus (CMV) infection and of inflammatory activation with premature myocardial infarction (MI).

METHODS

Specific anti-Cp and anti-CMV immunoglobulin G (IgG), fibrinogen, white blood cells (WBC), and C-reactive protein (CRP) were measured in 120 post-MI patients </=50 years old and in 120 age-matched controls.

RESULTS

Seropositivity to Cp and elevated concentrations of anti-Cp and anti-CMV IgGs were more frequent (P =.01) in patients than in control subjects, and fibrinogen, CRP, and WBC levels (P =.02) were more elevated. After adjustment for coronary risk factors and socioeconomic status, the odds ratios (95% confidence intervals) for premature MI were 2.4 (1.3-4.6) for Cp infection and 2.9 (1.5-5.8) for CMV. The risk of Cp infection was greater in smokers (3.7, 1.8-7.6). When both infections were present (35% of patients vs 8% of controls, P =.001), CRP was higher (P =.01) and the risk increased by 12 times (12.5, 4-38.9) compared with that in subjects without any infection and by 5 times (4.9, 2.2-10.9) if only one was present.

CONCLUSIONS

After adjustment for confounders, seropositivity to both Cp and CMV infections is associated with the diagnosis of premature MI. The combination of both infections is associated with an enhanced inflammatory response and a markedly increased risk of premature MI.

Electrocardiographic evolution after Q-wave anterior myocardial infarction: correlations between QRS score and changes in left ventricular perfusion and function

BACKGROUND

In the thrombolytic era, conflicting data have been reported on the usefulness of the QRS score in estimating the amount of left ventricular (LV) damage after acute myocardial infarction (MI).

METHODS AND RESULTS

We correlated the QRS score with the extent of LV hypoperfusion and ejection fraction (EF) in 95 consecutive male patients with a first anterior Q-wave MI; the 6-month evolution of QRS score and changes in LV perfusion and function were also compared. The Selvester-Wagner QRS score was computed from the digitized 12-lead electrocardiogram, both at predischarge and 6 months later; at the same time, resting sestamibi first-pass ventriculography and single photon emission computed tomography imaging were performed. A reduction in QRS score occurred at 6 months (6.7 +/- 3.4 vs 7.8 +/- 2.9 at predischarge; P <.001); the perfusion defect extent also decreased (P <.01), and LV EF improved (P <.05). At predischarge, no correlation was found between QRS score and hypoperfusion extent or EF; in contrast, a weak correlation was observed 6 months later (r = 0.55; P <.001; and r = 0.48; P <.01, respectively). QRS score changes from predischarge to 6 months showed limited accuracy in predicting clinically meaningful changes of perfusion or EF (receiver operating characteristic area under the curve, 0.58 and 0.61, respectively). Thrombolytic therapy did not influence the relationship between QRS score and scintigraphic findings.

CONCLUSIONS

In patients with recent anterior Q-wave MI, QRS scoring showed a weak, delayed correlation with the amount of LV damage, as estimated by radionuclide techniques. Spontaneous changes in QRS score from predischarge to 6 months seem to be of limited value in identifying patients with late improvement in LV perfusion and function.

Accurate noninvasive estimation of pulmonary vascular resistance by Doppler echocardiography in patients with chronic failure heart failure

OBJECTIVES

This study was undertaken to explore further the relationship between Doppler-derived parameters of pulmonary flow and pulmonary vascular resistance (PVR) and to determine whether PVR could be accurately estimated noninvasively from Doppler flow velocity measurements in patients with chronic heart failure.

BACKGROUND

The assessment of PVR is of great importance in the management of patients with heart failure. However, because of the inconclusive and conflicting data available, Doppler estimation of PVR is still considered unreliable.

METHODS

Simultaneous Doppler echocardiographic examination and right heart catheterization were performed in 63 consecutive sinus rhythm heart failure patients with severe left ventricular systolic dysfunction. Hemodynamic PVR was calculated with the standard formula. The following Doppler variables on pulmonary flow and tricuspid regurgitation velocity curve were correlated with PVR: maximal systolic flow velocity, pre-ejection period (PEP), acceleration time (AcT), ejection time, total systolic time (TT), velocity time integral, and right atrium-ventricular gradient.

RESULTS

At univariate analysis, all variables except maximal systolic flow velocity and velocity time integral showed a significant, although weak, correlation with PVR. The best correlation found was between AcT and PVR (r = -0.68). By regression analysis, only PEP, AcT and TT entered into the final equation, with a cumulative r = 0.87. When the function (PEP/AcT)/TT was correlated with PVR, the correlation coefficient further improved to 0.96. Of note, this function prospectively predicted PVR (r = 0.94) after effective unloading manipulations.

CONCLUSIONS

The analysis of Doppler-derived pulmonary systolic flow is a reliable and accurate tool for estimating and monitoring PVR in patients with chronic heart failure due to left ventricular systolic dysfunction.

Restrictive left ventricular filling pattern as a strong predictor of depressed baroreflex sensitivity in heart failure

BACKGROUND

The aim of this study was to test the hypothesis that a restrictive left ventricular diastolic filling pattern, as an index of elevated pulmonary wedge pressure, would predict a depressed baroreflex sensitivity (BRS) in patients with chronic heart failure.

METHODS

A total of 189 consecutive patients with an ejection fraction < or = 40% at echocardiography, in sinus rhythm and clinically stable for at least 1 month in oral therapy, underwent clinical examination, echo-Doppler study and the phenylephrine test.

RESULTS

The correlations between the NYHA functional class, echo-Doppler variables and BRS were weak, although significant (r ranging from -0.15 to 0.40). However, patients with a deceleration time < 140 ms as an expression of restrictive filling, compared to those with a deceleration time > or = 140 ms, had a lower BRS (3 +/- 4 vs 6 +/- 4 ms/mmHg, p < 0.00001), a lower ejection fraction (20 +/- 6 vs 28 +/- 7%, p < 0.00001), greater left ventricular (end-diastolic volume index 137 +/- 43 vs 113 +/- 45 ml/m2, p < 0.00001) and left atrial dimensions (25 +/- 6 vs 20 +/- 5 cm2, p < 0.00001), more severe mitral regurgitation (3 +/- 1 vs 2.3 +/- 1, p < 0.00001) and were in a higher NYHA class (2.3 +/- 0.6 vs 1.8 +/- 0.5, p < 0.00001). Medications at the time of the study were similar in the two groups. At stepwise regression analysis, the deceleration time emerged as the most powerful independent predictor of a depressed BRS (< 3 ms/mmHg), followed by mitral regurgitation, age, and NYHA class (all data p = 0.0001).

CONCLUSIONS

In patients with chronic heart failure, the presence of a restrictive left ventricular filling pattern is highly predictive of autonomic derangement as expressed by low values of BRS.

The E27 beta2-adrenergic receptor polymorphism reduces the risk of myocardial infarction in dyslipidemic young males

In the present study we evaluated whether two polymorphisms of beta2-adrenergic receptors (beta2-AR) gene (R16G and Q27E) could modify the risk of myocardial infarction (MI). Using a case-control design, we analyzed the data from 125 male patients who had experienced a first episode of MI before the age of 45 years and 108 male controls matched for age. The allele frequencies for R16G and Q27E were: G16=0.56 and E27=0.36 in patients with MI and G16=0.61 and E27=0.42 in the control group. There was a trend (not statistically significant) of decreasing MI risk according to E27 or G16 alleles. Combined effect between E27 allele and history of dyslipidemia has been observed. Whereas dyslipidemia conferred a relative risk of MI of 4.8 (P<0.001) compared with normolipidemia in the entire study population, the relative risk increased to 9.0 (P<0.001) in Q27 homozygotes with dyslipidemia, and decreased to 1.8 (P=0.36) in E27 homozygotes. Our results show that the E27 allele of the beta2-adrenergic receptor has a significant protective effect on MI in dyslipidemic young male.

Heterogeneity of left ventricular remodeling after acute myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-3 Echo Substudy

BACKGROUND

Left ventricular (LV) remodeling after acute myocardial infarction has still to be clarified in the thrombolytic era.

METHODS

To evaluate timing and the magnitude and pattern of postinfarct LV remodeling, a subset of 614 patients enrolled in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-3 Echo Substudy underwent serial 2-dimensional echocardiograms at 24 to 48 hours from symptom onset (S1), at hospital discharge (S2), at 6 weeks (S3), and at 6 months (S4) after acute myocardial infarction.

RESULTS

During the study period the end-diastolic volume index (EDVi) increased (P <.001) and wall motion abnormalities (%WMA) decreased (P <.001), whereas ejection fraction (EF) remained unchanged. Nineteen percent of patients showed a > 20% increase in EDVi at S2 compared with S1 (severe early dilation), and 16% of patients showed a > 20% dilation at S4 compared with S2 (severe late dilation). Independent predictors of severe in-hospital LV dilation were relatively small EDVi (odds ratio [OR] 0.961, 95% confidence interval [CI] 0.947-0.974, P =.0001) and relatively large %WMA (OR 1.030, 95% CI 1.013-1.048, P =.0005). Similarly, smaller predischarge EDVi (OR 0.975, 95% CI 0. 963-0.987, P =.0001), greater %WMA (OR 1.026, 95% CI 1.008-1.045, P =.0042), and moderate to severe mitral regurgitation (OR 2.261, 95% CI 1.031-4.958, P = 0.0417) independently predicted severe late dilation. Importantly, 92% of the patients with severe early dilation did not have further dilation at S4, and 91% of patients with severe late dilation did not have in-hospital dilation. EF was unchanged over time in patients with early dilation, whereas it significantly decreased in those with late dilation.

CONCLUSIONS

Although in-hospital LV enlargement is not predictive of subsequent dilation and dysfunction, late remodeling is associated with progressive deterioration of global ventricular function over time: patients with extensive %WMA and not significantly enlarged ventricular volume before discharge are at higher risk for progressive dilation and dysfunction.

Independent and incremental prognostic value of (201)Tl lung uptake at rest in patients with severe postischemic left ventricular dysfunction

BACKGROUND

An elevated (201)Tl lung uptake after stress is related to an adverse prognosis.

METHODS AND RESULTS

The functional and prognostic significance of resting (201)Tl lung uptake was assessed in 124 consecutive patients with ischemic heart disease and ejection fraction </=35% undergoing rest-redistribution tomography to evaluate myocardial viability. (201)Tl lung uptake significantly correlated with pulmonary wedge pressure (r=0.66; P:<0.01) and with a restrictive physiology by Doppler echocardiography (P:<0.001). During a 13+/-13-month follow-up, 13 patients died and 23 patients required hospitalization as the result of worsening heart failure or nonfatal myocardial infarction (cumulative events rate 29%). Patients with events had a significantly higher (201)Tl lung/heart ratio (L/H) (P:<0.001). A L/H value >0.61 best separated patients with and without events (ROC area under curve 0.82). Event-free survival was significantly lower in patients with L/H >0.61 (P:<0. 001); L/H >0.61 (chi(2)=10.8; P:<0.001) and a restrictive filling pattern (chi(2)=3.6; P:<0.05) were independent predictors of events. The prognostic value of L/H was incremental over that obtained by clinical, echographic and Doppler data (global chi(2)=20.8).

CONCLUSIONS

In patients with severe postischemic left ventricular dysfunction undergoing rest-redistribution (201)Tl imaging, an increased lung tracer uptake showed incremental prognostic value over clinical and other imaging findings, providing clinically useful risk assessment.

[Remodeling of the left ventricle]

Left ventricular remodeling is a frequent and unfavorable evolution of both ischemic and non-ischemic dilative cardiomyopathy with a significant reduction in left ventricular systolic and diastolic performance. By the term "remodeling" we refer to a variety of alterations in left ventricular morphology and volume; while patients with non-ischemic cardiomyopathy frequently show global and quite homogeneous enlargement of the left ventricle, transmural myocardial infarctions can be followed initially by regional expansion and only in a second stage by a global increase in ventricular size. Cardiologists have a number of therapeutic options from which to choose: ACE-inhibitors and probably angiotensin II antagonists can contrast the unfavorable progression of the phenomenon, while beta-blockers such as metoprolol and carvedilol probably can reverse the process. In addition, moderate exercise training not only produces no detrimental effects on infarct size or left ventricular topography, but can prevent the progression of left ventricular dysfunction and its attendant morbidity and mortality in selected populations.

[Non-invasive evaluation of the hemodynamic profile in patients with heart failure: estimation of right atrial pressure]

The estimation of right atrial pressure is often needed for the diagnosis, management and monitoring of various pathologic hemodynamic conditions and plays a significant role in patients with chronic heart failure. In the past decade several attempts have been made to non-invasively estimate right atrial pressure, and echocardiography has always been considered the most reliable tool. Morphologic parameters such as respiratory motion of the inferior vena cava, its respiratory diameters and percent collapse (caval index), left hepatic vein diameter or right atrial dimension (areas, volumes) were initially studied. More recently, functional data such as left hepatic or tricuspid flow variables have been considered. Some of these indexes, however, offer only semiquantitative measures of right atrial pressure, and have failed to demonstrate any prognostic value. Others, although highly sensitive and specific, are useful only in selected groups of patients because of technical or clinical limitations. In recent years, attention has focused on Doppler diastolic tricuspid flow as a means of predicting mean right atrial pressure. Analyzing the Doppler tricuspid velocity profile and mean right atrial pressure (Swan-Ganz catheter) simultaneously recorded in patients with severe left ventricular systolic dysfunction and chronic heart failure, acceleration rate of early filling emerged as the strongest independent predictor of right atrial pressure both in patients in sinus rhythm and in those with atrial fibrillation (r = 0.98), irrespective of whether the recordings are at baseline or after acute loading manipulations.

[Systolic-diastolic arterial hypertension versus isolated systolic hypertension]

The presence of elevated values of both diastolic and systolic arterial blood pressure is one of the most important risk factors for coronary heart disease, stroke, and heart failure; in patients with hypertension, the pharmacological reduction of blood pressure decreases the risk of adverse cardiovascular events, though the optimal blood pressure goal is still being debated. During recent years there has been an increasing interest in isolated systolic hypertension, both as an independent risk factor for cardiovascular disease and as a clinical entity requiring treatment in its own right. The definition of what constitutes isolated systolic hypertension still remains controversial and arbitrary; the criteria generally used is a systolic blood pressure > or = 140 mmHg and a diastolic blood pressure < 90 mmHg. Not only the cut-off levels used to define isolated systolic hypertension, but also the number of occasions on which blood pressure is measured can significantly affect the prevalence of isolated systolic hypertension in the total population. The use of 24-hour ambulatory blood pressure monitoring is a relatively new method for overcoming transient elevations in blood pressure that often occur during clinic measurement; it has a good reproducibility, is subject to little "white-coat" or placebo effect, and finally provides blood pressure measurements within a subject's normal environment. Borderline isolated systolic hypertension (defined as a systolic blood pressure between 140 and 159 mmHg and a diastolic blood pressure < 90 mmHg) is probably the most common type of untreated hypertension among adults over the age of 60; in the following 20 years, about 80% of patients with borderline isolated systolic hypertension will show progression to definite hypertension with increased risk of development of cardiovascular disease. The increase in systolic and diastolic blood pressure with age is typical of Western societies, while it is not observed among some "unacculturated" populations, who tend to be lean and physically active, with a lower daily sodium intake. Maybe environmental, rather than genetic factors may contribute more to the determination of blood pressure throughout life. Pharmacological treatment of isolated systolic hypertension can lead to a significant reduction in total stroke, coronary heart disease, and cardiovascular disease. The question of which antihypertensive agents are most effective is still to be fully elucidated with specifically addressed trials.

[The assessment of breathing during sleep: a curiosity or clinical necessity?]

The study of sleep, which initially focused on the neurophysiological mechanisms and cardiorespiratory function during the night, has shown the presence of sleep-related breathing disorders that epidemiological, pathophysiological and clinical data have indicated to be associated with increased cardiovascular morbidity and mortality: the obstructive sleep apnea syndrome (OSAS) and the central sleep apnea syndrome (CSAS). OSAS is a condition characterized by repetitive respiratory pauses due to the pharynx wall collapse, with a subsequent obstruction to the airflow. The hemodynamic consequences due to the markedly increased negative intrathoracic pressure (induced by the respiratory muscle effort towards the closed upper airways), the progressive hypercapnic hypoxemia and the arousal terminating the apneas, are the pathophysiological keys of the cardiovascular effects of OSAS and may explain the association between OSAS and the documented increase of cardiovascular morbidity and mortality. CSAS is a breathing disorder characterized by recurrent episodes of central hypopneas or apneas and hyperventilation which, is the classical form described by Cheyne and Stokes, show a crescendo-decrescendo pattern of respiration. Pathophysiological and epidemiological data clearly indicate the link between CSAS and heart failure, also showing a correlation between respiratory disorders and the severity of hemodynamic impairment. However, other mechanisms are involved in the genesis of CSAS in explaining the variable presence of CSAS independent of cardiac function and, more importantly, the impact of CSAS on poor prognosis in heart failure. In conclusion, the data available indicate the need to include screening for sleep-related breathing disorders in the evaluation of cardiac patients who are at risk for OSAS and, particularly, in patients with heart failure, who could really benefit from treatment of the respiratory disorder.

Habitual activities and peak aerobic capacity in patients with asymptomatic and symptomatic left ventricular dysfunction

BACKGROUND

A reduced level of daily activities is thought to be an important determinant of aerobic exercise intolerance in patients with chronic heart failure chronic heart failure; however, few data exist about the relationship between habitual physical activity level and peak aerobic capacity in patients at different clinical stages of left ventricular dysfunction.

STUDY OBJECTIVES

The purposes of this study were as follow: (1) to validate a simple interviewer-administered scoring system for evaluation of habitual physical activity level of patients with chronic heart failure and asymptomatic left ventricular dysfunction (ALVD); (2) to determine the relationship between habitual physical activity level and peak aerobic capacity in chronic heart failure and ALVD patients; and (3) to compare habitual activity levels among different New York Heart Association (NYHA) classes in these populations.

SETTING

Cardiology division at a tertiary-care hospital.

STUDY POPULATION

We studied 167 consecutive patients with chronic heart failure (NYHA class I to III), 40 patients with ALVD, and 52 healthy subjects (HS).

MEASUREMENTS AND RESULTS

Habitual physical activity level was evaluated by means of an interview-based activity scoring system considering leisure time and occupational activities and also recent deconditioning events (eg, hospital admissions); a final activity score (AS) ranging from 0.8 to 5 was obtained. All patients and HS performed a symptom-limited cardiopulmonary exercise test up to a respiratory exchange ratio of > or = 1.1. AS was an independent predictor of peak oxygen consumption (VO(2)) in all groups, with a significantly higher VO(2) vs AS relationship slope in the ALVD and HS groups than in the chronic heart failure group. Moreover, AS was found to be significantly lower in chronic heart failure than in ALVD patients and HS (1.6 +/- 0.6 vs 2.2 +/- 0.7 vs 3.5 +/- 1.1, respectively; p < 0.0001), as was peak VO(2) (14.7 +/- 3.7 mL/kg/min vs 20 +/- 4 mL/kg/min vs 33.1 +/- 10 mL/kg/min, respectively; p < 0.0001), but the latter differences were canceled after adjusting for AS values. Significant AS and peak VO(2) reductions were observed in chronic heart failure patients with NYHA class progression from I to III.

CONCLUSIONS

Habitual physical activity level is progressively decreased with worsening of heart failure symptoms and is related to peak aerobic capacity in both chronic heart failure and ALVD patients. However, this relationship appears to be weak in patients with chronic heart failure, whereas daily activity is a strong independent predictor of peak aerobic capacity both in ALVD patients and HS. This may be related to the intervention of factors other than skeletal muscle deconditioning in the exercise pathophysiology of chronic heart failure patients.

Doppler-derived acceleration rate of right ventricular early filling reliably predicts mean right atrial pressure at baseline and after loading manipulations in patients with chronic heart failure

BACKGROUND

We investigated whether Doppler-derived variables of tricuspid flow could estimate mean right atrial pressure and monitor its changes after loading manipulations in patients with chronic heart failure.

METHODS

Simultaneous mean right atrial pressure (Swan-Ganz catheterization) and tricuspid Doppler recordings were initially evaluated in 136 patients (23 with atrial fibrillation) with chronic heart failure and severe left ventricular systolic dysfunction, and then were repeated in 18 patients after unloading (sodium nitroprusside infusion) and in 13 patients after overloading (active leg elevation) manipulations.

RESULTS

A significant correlation was observed between mean right atrial pressure and peak E velocity (r = 0.70), early deceleration time (r = -0.72) and acceleration time (r = -0.75). However, the best correlation found was between the acceleration rate of early flow and mean right atrial pressure, and it was identical in patients in sinus rhythm or with atrial fibrillation (r = 0.98). Moreover, after acute effective unloading or overloading manipulations, although all Doppler tricuspid variables changed significantly, the acceleration rate of early flow still emerged as the strongest independent predictor of mean right atrial pressure (r = 0.95 and 0.99, respectively).

CONCLUSIONS

Doppler-derived acceleration rate of early diastolic tricuspid flow is a powerful tool to predict mean right atrial pressure and to monitor its changes after loading manipulations.

Electrocardiographic evolutionary changes and left ventricular remodeling after acute myocardial infarction: results of the GISSI-3 Echo substudy

OBJECTIVES

The aim of this study was to describe the electrocardiographic (ECG) evolutionary changes after an acute myocardial infarction (AMI) and to evaluate their correlation with left ventricular function and remodeling.

BACKGROUND

The QRS complex changes after AMI have been correlated with infarct size and left ventricular function. By contrast, the significance of T wave changes is controversial.

METHODS

We studied 536 patients enrolled in the GISSI-3-Echo substudy who underwent ECG and echocardiographic studies at 24 to 48 h (S1), at hospital discharge (S2), at six weeks (S3) and six months (S4) after AMI.

RESULTS

The number of Qwaves (nQ) and QRS quantitative score (QRSs) did not change over time. From S2 to S4, the number of negative T waves (nT NEG) decreased (p < 0.0001), wall motion abnormalities (%WMA) improved (p < 0.001), ventricular volumes increased (p < 0.0001) while ejection fraction remained stable. According to the T wave changes after hospital discharge, patients were divided into four groups: stable positive T waves (group 1, n = 35), patients who showed a decrease > or =1 in nT NEG (group 2, n = 361), patients with no change in nT NEG (group 3, n = 64) and those with an increase > or =1 in nT NEG (group 4, n = 76). The QRSs and nQ remained stable in all groups. Groups 3 and 4 showed less recovery in %WMA, more pronounced ventricular enlargement and progressive decline in ejection fraction than groups 1 and 2 (interaction time x groups p < 0.0001).

CONCLUSIONS

The analysis of serial ECG can predict postinfarct left ventricular remodeling. Normalization of negative T waves during the follow-up appears more strictly related to recovery of regional dysfunction than QRS changes. Lack of resolution and late appearance of new negative T predict unfavorable remodeling with progressive deterioration of ventricular function.

Comparison between spectral analysis and the phenylephrine method for the assessment of baroreflex sensitivity in chronic heart failure

Baroreflex sensitivity assessed by means of the phenylephrine test plays a prognostic role in patients with previous myocardial infarction, but the need for drug injection limits the use of this technique. Recently, several non-invasive methods based on spectral analysis of systolic arterial pressure and heart period have been proposed, but their agreement with the phenylephrine test has not been investigated in patients with heart failure. The two methods (phenylephrine test and spectral analysis) were compared in a group of 49 patients with chronic congestive heart failure both at rest and during controlled breathing. The linear correlation and the limits of agreement between the phenylephrine test slope and the alpha-index [alpha(c); corrected by the coherence function between the interbeat interval (RR interval) and systolic arterial pressure] were evaluated. Only 16 patients had a measurable alpha-index at rest in both the low-frequency (LF) and high-frequency (HF) bands; the alpha(c)-index allowed measurements in all patients. It correlated moderately with the phenylephrine test slope at rest (r=0. 71 and P<0.001 in LF; r=0.57 and P<0.001 in HF) and during controlled breathing (r=0.51 and P<0.001 in LF; r=0.63 and P<0.001 in HF). Multivariate regression analysis showed that only alpha(c)LF during rest and alpha(c)HF during controlled breathing contributed significantly to baroreflex gain estimation. However, the agreement between methods was weak; the normalized limits of agreement and bias were -162 to 243% (0.46 ms/mmHg) for alpha(c)LF and -185 to 151% (-0.99 ms/mmHg) for alpha(c)HF. Thus the comparison between baroreflex sensitivity measurements obtained by the phenylephrine test and spectral analysis showed a moderate correlation between the two methods; however, despite the linear association, a consistent lack of agreement between the two techniques was found. Because both systematic and random factors contribute to the difference, these two techniques cannot be considered as alternatives for the assessment of heart failure.

Transient left ventricular dilation at quantitative stress-rest sestamibi tomography: clinical, electrocardiographic, and angiographic correlates

BACKGROUND

Few data are available regarding the incidence and significance of transient left ventricular (LV) dilation on stress sestamibi single photon emission computed tomography (SPECT), which is different from thallium-201 studies because images are acquired late after tracer injection.

METHODS

We studied 234 patients with ischemic heart disease and interpretable electrocardiograms undergoing stress-rest sestamibi SPECT on separate days. Sestamibi uptake defect extent was quantified on SPECT polar maps. Epicardial and endocardial transient dilation indexes (TDI) were also calculated.

RESULTS

According to our normal TDI values, 148 patients (63%) had no dilation and 86 patients (37%) had abnormal endocardial TDI; a global LV dilation (abnormal endocardial and epicardial TDI) was observed in 19 patients (8%). ST-segment depression was more frequent in patients with transient LV dilation (55%) than in those without (36%; P < .01), as were the extent of stress hypoperfusion (13% +/- 12% vs 6% +/- 7% in patients with no dilation; P < .001) and the angiographic severity score (11.4 +/- 5.9 vs 9.2 +/- 3.7; P < .05). At multivariate analysis, stress hypoperfusion was the sole predictor of transient LV dilation.

CONCLUSIONS

Transient LV cavity dilation is frequent on stress sestamibi SPECT. Ventricular cavity dilation is more common than global dilation and suggests subendocardial ischemia. It is related to a greater amount of jeopardized myocardium and is strongly associated with electro-cardiographic signs of ischemia.

Prognostic value of nocturnal Cheyne-Stokes respiration in chronic heart failure

BACKGROUND

Nocturnal Cheyne-Stokes respiration (CSR) occurs frequently in patients with chronic heart failure (CHF), and it may be associated with sympathetic activation. The aim of the present study was to evaluate whether CSR could affect prognosis in patients with CHF.

METHODS AND RESULTS

Sixty-two CHF patients with left ventricular ejection fraction </=35%, in NYHA class II to III, underwent clinical evaluation, Doppler echocardiography, ergospirometry, phenylephrine test, Holter recording, and a sleep study to evaluate the occurrence of CSR, expressed as percentage of periodic breathing, and apnea/hypopnea index (AHI) (ie, the number of apneas and hypopneas per hour of recording). During a mean follow-up of 28+/-13 months, 15 patients died of cardiac causes. Nonsurvivors were in a higher NYHA functional class than survivors (P<0.001) and had a more depressed left ventricular ejection fraction (P<0.03), a shorter deceleration time of early filling (P<0. 05), larger left and right atria (P<0.05 and P<0.02, respectively) and a lower peak V(O2) (P<0.05). Nonsurvivors also spent a greater percentage of the night in periodic breathing (P<0.01) with a greater AHI (P<0.03) and showed lower values of diurnal baroreflex sensitivity (P<0.05) and of heart rate variability (sdNN: P<0.01). Multivariate analysis revealed the AHI (chi2, 10.4; P<0.01), followed by left atrial area (chi2, 5.7; P<0.01), as the only independent and additional predictors of subsequent cardiac death. Patients at very high risk for fatal outcome could be identified by an AHI >/=30/h and left atria >/=25 cm2.

CONCLUSIONS

The AHI is a powerful independent predictor of poor prognosis in clinically stable patients with CHF. The presence of an AHI >/=30/h adds prognostic information compared with other clinical, echocardiographic, and autonomic data and identifies patients at very high risk for subsequent cardiac death.

Estimation of pulmonary wedge pressure by transmitral Doppler in patients with chronic heart failure and atrial fibrillation

Previous studies have demonstrated that left ventricular (LV) filling pressures can be estimated from transmitral Doppler recording in patients in sinus rhythm who have a broad spectrum of cardiac diseases. However, the correlation between pulmonary wedge pressure (PWP) and mitral Doppler profile has not yet been clearly defined in patients with atrial fibrillation, particularly in the presence of severe LV systolic dysfunction. The aim of this study was to evaluate the correlations between PWP and transmitral Doppler variables in patients with atrial fibrillation and chronic heart failure due to dilated cardiomyopathy. PWP and the mitral Doppler profile were simultaneously recorded in 35 consecutive heart failure patients (28 men, 7 women; mean age, 69 +/- 9 years) with severe LV dysfunction (mean ejection fraction 22% +/- 5%). Doppler measurements were averaged over 10 cardiac cycles. In addition, left atrial areas were derived from the apical 4-chamber view. Significant relations were observed between PWP and several parameters derived from the mitral flow: isovolumic relaxation time (r = -70), acceleration rate (r = 0.78), deceleration rate (r = 0.82), and deceleration time (r = -0.95). However, by stepwise multivariate analysis, deceleration time emerged as the sole independent predictor of PWP (r2 = 0.95, F = 590). The analysis led to the following equation: PWP = 51 - 0.26 (deceleration time). Our data suggest that mitral Doppler echocardiography is a useful tool for predicting PWP in heart failure patients with severe LV dysfunction even in the presence of atrial fibrillation.

Heterogeneous fate of perfusion and contraction after anterior wall acute myocardial infarction and effects on left ventricular remodeling

After acute myocardial infarction, patency of infarct vessel and extent of left venticular (LV) dysfunction are major determinants of ventricular remodeling. Spontaneous, delayed reperfusion in the infarct zone occurs in a sizeable number of patients well after the subacute phase. The aim of this study was to determine the relation between the occurrence of this spontaneous, delayed reperfusion and LV remodeling. In 84 patients, resting LV volumes, topography, regional function, and perfusion were quantitatively evaluated by 2-dimensional echocardiography and sestamibi tomography 5 weeks (study 1) and 7 months (study 2) after anterior Q-wave infarction. At study 2, LV end-diastolic volume increased by > 15% in 17 patients (20%, LV remodeling); they had already had at study 1 significantly larger LV volumes, more severe hypoperfusion and wall motion abnormalities, and greater regional dilation than patients with stable LV volumes. Delayed reperfusion occurred in 8 of 17 patients with and in 42 of 67 patients without LV remodeling (47% vs 63%; p=NS). At study 2, LV regional dilation and end-diastolic volumes were stable in patients with, but increased in patients without, spontaneous reperfusion (from 25+/-24% to 29+/-26% at study 2 [p<0.05] and from 65+/-14 to 68+/-18 ml/m2 [p <0.05]). At multivariate analysis, however, regional ventricular dilation at study 1 was the sole predictor of further LV remodeling. Thus, after acute myocardial infarction, spontaneous reperfusion occurring after 5 weeks plays only a minor role in influencing LV remodeling. Benefits from delayed reperfusion seem limited to patients with preserved LV volumes; patients with an enlarged left ventricle 5 weeks after acute infarction are prone to further LV remodeling, irrespective of delayed reperfusion.

[Pulmonary uptake of thallium-201 at rest and diastolic function in patients with ischemic cardiopathy and left ventricular dysfunction]

An elevated thallium-201 lung uptake after stress is currently considered a marker of severe coronary artery involvement and related to adverse prognosis. The meaning of this scintigraphic finding on rest thallium-201 images is yet poorly investigated. We compared the thallium-201 lung uptake and the left ventricular diastolic function from mitral Doppler in 24 patients (64 +/- 10 years) with ischemic heart disease and severe left ventricular dysfunction (ejection fraction 28 +/- 10%). All patients underwent a 3-view planar rest-redistribution thallium-201 and 2D-echo studies within 6 days, while clinically stable. The amount of thallium-201 lung uptake was quantified as the ratio (L/H) between the activity in a left lung region of interest (L) and that observed in the left ventricle (H). From mitral Doppler, early (E) and late (A) filling velocities, the E/A ratio and the deceleration time of early filling (DecT) were calculated. An elevated L/H (> or = 0.54) was observed in 9 patients (37%). They showed a lower ejection fraction (20 +/- 4% vs 33 +/- 10% in patients with normal L/H; p < 0.01) and a higher wall motion score index (2.5 +/- 0.4 vs 2.1 +/- 0.4, p < 0.05). A significant inverse linear relation was observed between L/H and the left ventricular ejection fraction (r = -0.70); no significant relation was observed between L/H and left ventricular end-diastolic volumes or wall motion score index. A significant linear relation was also observed between L/H and E/A (r = 0.74; p < 0.001) as well as L/H and DecT (r = -0.61; p < 0.001); an even stronger, inverse, relation was found between L/H and A (r = -0.81; p < 0.001). An abnormal L/H identified 80% of patients with a restrictive filling pattern (specificity 93% and accuracy 88%, respectively). In conclusion, in stable patients with ischemic heart disease and ventricular dysfunction, L/H on rest thallium-201 images is closely correlated with Doppler indexes of left ventricular diastolic filling dynamic; an abnormal L/H is highly predictive of a restrictive filling pattern.

Reversible restrictive left ventricular diastolic filling with optimized oral therapy predicts a more favorable prognosis in patients with chronic heart failure

OBJECTIVES

We sought to assess whether in clinically stable patients with chronic heart failure (CHF) the prolongation (i.e., increase) of an initially short (< or = 125 ms) Doppler transmitral deceleration time (DT) of early filling obtained with long-term optimal oral therapy predicts a more favorable prognosis.

BACKGROUND

It has been recently demonstrated that transmitral early DT is a powerful independent predictor of poor prognosis in patients with left ventricular dysfunction. However, DT may change over time according to loading conditions and medical treatment.

METHOD

One hundred forty-four patients with CHF and a short DT (< or = 125 ms) underwent repeat Doppler echocardiographic study 6 months after the initial examination, while clinically stable with optimal oral therapy, and were then followed up for a mean period of 26 +/- 7 months.

RESULTS

After 6 months, DT had not changed in 80 patients (group 1), whereas it was significantly prolonged (> 125 ms) in the remaining 64 patients (group 2). Baseline Doppler echocardiographic features were similar in the two groups. No changes were found after 6 months in group 1, whereas group 2 showed a slight but significant (p < 0.01) reduction in end-systolic volume, an improvement in left ventricular ejection fraction (p < 0.01) and a decrease (p < 0.01) in the degree of tricuspid regurgitation. During follow-up, 37% of patients in group 1 experienced cardiac death versus 11% in group 2 (p < 0.0005). By Cox model analysis, prolongation of a short DT emerged as the single best predictor of survival (chi-square 15.70).

CONCLUSIONS

The prolongation of an initially short DT obtained with long-term optimal oral therapy predicts a more favorable outcome in clinically stable patients with CHF.

[The usefulness of the clinical interview in the psychological evaluation of the patient with heart failure]

AIM

To develop a model for assessing cognitive-behavioral dysfunction in patients with heart failure, through the analysis of data gathered from clinical interviews.

SAMPLE

One hundred sixty-six consecutive inpatients with previous or current heart failure: 125 males and 41 females, mean age 59 +/- 9.3 yrs.

METHOD

Three professional psychologists independently analyzed the clinical reports of the interviews. The cognitive-behavioral dysfunction recorded was correlated to age and sex, history of heart failure and cardiac function indices (ejection fraction, NYHA Class).

RESULTS

The concordance index among the three psychologists was 97%. Illness management was found to be more difficult for younger subjects (p = 0.03), in those with a longer history of heart failure (p = 0.04) and in those with advanced NYHA class (p = 0.008). An incorrect behavioral style, as defined by the variables "type A", "risk factors", and "vital exhaustion", was significantly correlated with the level of cardiac impairment (ejection fraction) (p = 0.04) and with inadequate illness management (p = 0.02).

CONCLUSIONS

Clinical interviews seem to be a simple and accurate tool for assessing cognitive behavioral dysfunction in patients with heart failure and for detecting the areas that require further investigation and more adequate psychological support. The key element that emerges with regard to both diagnosis and treatment is a dysadaptive behavioral style, as defined by the "type A" variables, "risk factors" and "vital exhaustion".

[Peritoneal dialysis and chronic dobutamine, two experiences contrasted. Possible role and indications in refractory cardiac decompensation]

The number of patients who develop heart failure (HF) is increasing and is expected to increase further in the next decade. Despite the availability of an ever-widening array of pharmacological therapy, patients with end-stage HF have a poor long-term prognosis. Little attention has been paid to alternative non-conventional therapy for these patients. The aim of this non-randomized study was to describe two non-conventional approaches in patients with HF, refractory to conventional medical therapy. The feasibility and long-term efficacy of a continuous ambulatory peritoneal dialysis (CPAD: 20 patients) or dobutamine intermittent infusions (DOB: 11 patients) was analysed: the mean dobutamin dose was 5 gamma/kg/min, and the interval period treatment ranged from 12 hours/day to 12 hours/week.

RESULTS

Both treatments were feasible and non major procedure complications occurred. The 6 and 12 month survival rates were 55% (14/20 patients), 35% (9/20 patients) and 36% (6/11 patients), 18% (3/11 patients) in the CAPD patients and DOB patients, respectively. All patients survived at one year (38% = 12/31 patients) documented a significant functional improvement and quality of life. The conclusions is drawn that the use of CAPD and DOB should be considered in those with refractory HF, in whom medical therapy has failed and in whom home training is considered feasible. Further studies are necessary to define those patients who will benefit from one of these strategies and to confirm these preliminary data.