Triple therapy at discharge from internal medicine wards in heart failure patients with reduced ejection fraction: results from an observational study

BACKGROUND

Guidelines recommend triple therapy (TT) with ACE inhibitors or ARBs, beta-blockers and mineralcorticoid receptor antagonists in symptomatic heart failure patients with ejection fraction <35 % (HFrEF). Nevertheless, many patients remain untreated. This study was aimed to evaluate the use of TT in HFrEF patients discharged from internal medicine wards of Tuscany, Italy.

METHODS AND RESULTS

We analyzed the database of a multicenter observational study which included 770 patients consecutively hospitalized for HF in 32out of 36 Internal Medicine Units of Tuscany, Italy. The value of ejection fraction was available in 490 of the 725 patients discharged alive. Of the 117 patients with HFrEF, only 46 (39.3%) were on TT at discharge while 71 (60.7%) were not. In the latter group we observed a significantly greater percentage of patients with cognitive deficit (25.3% vs 10.8%, p=0.05). In the same group there was a slightly greater percentage of patients with hypertension (61.9% vs 58.6%), diabetes (43.6% vs 36.9%), GFR<60 ml/min (74.6% vs 67.3%), anemia (52.1% vs 45.6%) and atrial fibrillation (40.8% vs 34.7%), but the differences were not statistically significant.

CONSLUSIONS

These results indicate that TT is underutilized in internal medicine wards of Tuscany. Untreated patients had a greater rate of cognitive deficit and were probably sicker, more complex and fragile.

Markers of hypercoagulability and inflammation predict mortality in patients with heart failure

BACKGROUND AND AIMS

Plasma levels of inflammatory markers are increased in chronic heart failure (HF) and are also subclinical indicators of future HF. Inflammation is strictly correlated with clotting activation, but the association between inflammation, hypercoagulability and prognosis in HF has not been previously reported.

METHODS AND RESULTS

Markers of inflammation (interleukin-6; IL-6, and C-reactive protein; CRP) and hypercoagulability (D-dimer; DD, and thrombin-antithrombin III complex; TAT) were prospectively assessed in 214 subjects with New York Heart Association (NYHA) functional class II-IV HF. During a median follow-up of 8.5 months, 32 patients had an event: 13 died and 19 were hospitalized because of worsening of HF. IL-6, DD and TAT levels were all significantly associated with increased risk of death after adjustment for other known HF prognostic factors (age, gender, traditional cardiovascular risk factors, NYHA class, systolic left ventricular function, renal failure, hemoglobin, serum sodium) in a Cox multivariate proportional hazard model (P = 0.003, P = 0.01 and P = 0.02, respectively). When these markers were added simultaneously to the known prognostic factors in a new Cox multivariate model, only DD levels were significant predictors of mortality (hazard ratio [95% confidence interval; CI]: 11 [2.7-45.1], P = 0.001). The Kaplan-Meier curve revealed a significantly better outcome in patients with DD below 450 ng mL(-1). NT-pro-BNP was the only significant predictor of rehospitalization (HR [95% CI]: 5.3 [2.0-13.8], P < 0.001).

CONCLUSION

Hypercoagulability and inflammation, as assessed by DD, TAT and IL-6 levels, are associated with an increased mortality risk in HF.

[Therapeutic infusion of heparin. Application of a nomogram correlated with weight]

We performed a retrospective study to determine whether the use of a nomogram in General Medicine Wards is superior to the empiric method for the adjustment of heparin dosage. In the period october 1998-september 1999 we treated 138 patients with continuous infusion of heparin using a weight-based nomogram. Then we compared these data (nomogram group) with data from period october 1997-september 1998, when we had treated 155 patients with heparin, using empiric method for dose adjustments (empiric group). The proportion of patients reaching the therapeutic aPTT 24 hours after the start of therapy was 90.5% in nomogram group compared with 56.1% in the empiric group (P < 0.001). The proportion of nontherapeutic and subtherapeutic aPTT was significantly reduced in the nomogram group (6.0% vs. 11.1%, P < 0.001; 13.7% vs. 19.3%, P < 0.001). Furthermore, in the nomogram group the proportion of consecutive nontherapeutic or overtherapeutic values were significantly reduced (0.1% vs. 2.2%, P < 0.001; 1.8% vs. 2.3%, P < 0.001). We conclude that a weight-based heparin nomogram adapted for own aPTT range is successfully used in General Medical Wards of a community hospital.

Cirrhosis associated with homozygous alpha-1 antitrypsin deficiency in the adult: a case report

A 34 year old woman admitted to the department of Gastroenterology of Florence hospital was diagnosed as suffering from liver cirrhosis with an alpha-1 antitrypsin deficiency (PiZZ phenotype). Liver biopsy showed the presence of intra-hepatocyte PAS-positive inclusions and the presence of alpha-1 antitrypsin was confirmed using the immunoperoxidase technique. No other organ appeared to be affected and respiratory function tests were within normal limits. The quantitative assay of alpha-1 antitrypsin was higher than values reported in the literature for PiZZ homozygotes. The authors report the case and discuss some aspects of this disease.