[ANMCO Position paper: From acute to chronic disease: the needs of complex cardiac patients]. / Position paper ANMCO: Bisogni assistenziali del malato cardiopatico complesso: dalla fase acuta alla fase cronica.

Managing a patient suffering from a chronic disease requires a multidisciplinary team that can take care of them beyond the simple coordination of various specialties. In this context, a central role in the treatment of chronic heart disease is the continuity of care that should promote organic integration among different hospital departments, hospital and community. This position paper of the Italian Association of Hospital Cardiologists (ANMCO) aims at defining the general principles to inspire care for complex cardiac patients at different phases of the disease. A multidisciplinary integrated holistic approach uses analytical tools able to understand the elements that characterize complexity and therefore suggest appropriate management strategies: (i) care pathways aimed at optimizing treatments; (ii) care pathways in intensive care and ward in a multidisciplinary perspective; (iii) integration of social and health needs; (iv) nursing role in the context of continuity of outpatient, community and home care; (v) promotion of educational interventions.

Bioimpedance vector analysis predicts hospital length of stay in acute heart failure.

OBJECTIVE: Congestion in acute heart failure (AHF) affects survival curves and hospital length of stay (LOS). The evaluation of congestion, however, is not totally objective. The aim of this study was to verify the accuracy of bioelectrical impedance vector analysis (BIVA) in predicting the LOS in AHF patients. METHODS: This is a retrospective study. A total of 706 patients (367 male; mean age: 78 ± 10 y) who had been admitted to hospital with an AHF event were enrolled. All underwent anthropometric and clinical evaluation, baseline transthoracic echocardiography, and biochemical and BIVA evaluations. RESULTS: The comparison among the clinical characteristics of congestion, LOS, and hyperhydration status revealed that the higher the hydration status, the longer the LOS (from 7.36 d [interquartile range: 7.34-7.39 d] in normohydrated patients to 9.04 d [interquartile range: 8.85- 9.19 d] in severe hyperhydrated patients; P < 0.05). At univariate analysis, brain natriuretic peptide, blood urea nitrogen, New York Heart Association class, hemoglobin, hydration index, and peripheral edema all had a statistically significant influence on LOS. At multivariate analysis, only brain natriuretic peptide (P < 0.0001), blood urea nitrogen (P = 0.011), and hydration index (P < 0.0001) were significantly associated to LOS. CONCLUSIONS: Congestion evaluated by BIVA is an independent predictor of length of total hospital stay in HF patients with acute decompensation. The quick and reliable detection of congestion permits the administration of target therapy for AHF, thus reducing LOS and treatment costs.

What constitutes the 'Minimal Care' interventions of the nurse, physiotherapist, dietician and psychologist in Cardiovascular Rehabilitation and secondary prevention: A position paper from the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology.

BACKGROUND: In cardiovascular prevention and rehabilitation, care activities are carried out by different professionals in coordination, each with their own specific competence. This GICR-IACPR position paper has analysed the interventions performed by the nurse, physiotherapist, dietician and psychologist in order to identify what constitutes minimal care, and it lists the activities that are fundamental and indispensable for each team member to perform in clinical practice. RESULTS: In analysing each type of intervention, the following dimensions were considered: the level of clinical care complexity, determined both by the disease and by environmental factors; the 'area' complexity, i.e. the specific level of competence required of the professional in each professional section; organisational factors, i.e. whether the care is performed in an inpatient or outpatient setting; duration of the rehabilitation intervention. The specific contents of minimal care have been identified for each professional area together with the specific goals, the assessment tools and the main essential interventions. For the assessments, only a few validated tools have been indicated, leaving the choice of which instrument to use to the individual professional based on experience and usual practice. CONCLUSION: For the interventions, attention has been focused on conditions of major complexity requiring special care, taking into account the different care settings, the clinical conditions secondary to the disease event, and the distinct tasks of each area according to the operator's specific role. The final report performed by each professional has also been included.

How often we need to measure brain natriuretic peptide (BNP) blood levels in patients admitted to the hospital for acute severe heart failure? Role of serial measurements to improve short-term prognostic stratification.

BACKGROUND: Brain natriuretic peptide (BNP) is increasingly used in the management of patients with heart failure (HF). It is still unclear how to use serial BNP measurement in HF. AIM: To evaluate the usefulness of three consecutive measurements of BNP in patients (pts) hospitalized for acute HF. METHODS: Clinical evaluation, BNP levels and echocardiography were assessed in 150 pts (67% males, age: 69+/-12 years; left ventricular ejection fraction: 34+/-14%) admitted for severe HF (NYHA class III-IV: 146/150). BNP measurements were obtained: at admission (basal, T0), at discharge (T1) and at first ambulatory control (T2), after optimization of medical therapy in those with discharge BNP level >250 pg/mL. End-points were death and hospital readmission during 6-month follow-up. RESULTS: According to BNP levels 3 groups of patients were identified: Group 1 (62 pts, 41%), in whom discharge (T1) BNP was high and persisted elevated at T2 despite aggressive medical therapy; at 6-month follow-up 72% died or were hospitalized for HF. Group 2 (36 pts, 24%), in whom discharge (T1) BNP was high but decreased after medical therapy (T2); death and HF-readmission were observed in 8 pts (26%). Group 3 (52 pts, 35%), in whom discharge (T1) BNP levels were <250 pg/mL and persisted below this value at T2; death and HF-hospital readmission were observed in 6 pts (12%). Event rate differences among groups were statistically significant (p<0.001). At Cox-analysis discharge BNP cutoff of 250 pg/mL was the only parameter predictive of a worse outcome. CONCLUSION: These data suggest that 3 BNP measurements, at admission, at discharge and few weeks later can allow to identify HF pts whom, despite a further potentiation of medical therapy, will present a worsening or even will die during short-term follow-up.

Plasma brain natriuretic peptide predicts short-term clinical outcome in heart failure patients with restrictive filling pattern.

OBJECTIVE: Plasma brain natriuretic peptide (BNP) is an important parameter of severity in congestive heart failure (CHF). We analyzed if BNP might stratify 6-month clinical outcome in outpatients with CHF with restrictive mitral filling pattern. METHODS: All subjects with New York Heart Association (NYHA) class II to IV and restrictive filling pattern were enrolled at hospital discharge after an acute decompensation. NYHA class, BNP, and echocardiogram for the evaluation of left ventricular ejection fraction (LVEF) and diastolic function were analyzed. Death and hospital readmission for CHF were the clinical events observed. RESULTS: A total of 250 patients (66% were male, mean age 73 years) were enrolled. The mean NYHA class was 2.5 +/- 0.6, LVEF was 38% +/- 15%, and mean deceleration time was 120 +/- 16 ms. The mean BNP was 643 +/- 566 pg/mL. During the 6-month follow-up, 35 patients (14%) died and 106 patients (42.4%) were readmitted for CHF (event group); in 109 patients (43.6%) no events were observed (no-event group). Higher NYHA class (2.7 +/- 0.6 vs 2.4 +/- 0.6, P = .001) and reduced LVEF (34% +/- 13% vs 42% +/- 17%, P = .01) but similar deceleration time (119 +/- 16 ms vs 122 +/- 17 ms, P = not significant) were observed in the event group. A higher level of mean BNP (833 +/- 604 pg/mL vs 397 +/- 396 pg/mL, P = .01) was recorded in the event group. The multivariate Cox analysis confirmed that LVEF (P = .04), NYHA class (P = .02), and plasma BNP (P = .0001) were associated with adverse short-term clinical outcome. CONCLUSION: Patients with CHF with a restrictive diastolic pattern had poor short-term clinical outcome. NYHA class and LVEF at discharge might predict cardiovascular events, but plasma BNP proved to be the strongest predictor.

B-type natriuretic Peptide-guided treatment for predicting outcome in patients hospitalized in sub-intensive care unit with acute heart failure.

BACKGROUND: Studies with natriuretic peptides have suggested that physicians do not treat heart acute failure (AHF) aggressively enough, and predischarge B-type natriuretic peptide (BNP) levels may be a useful reminder that more treatment is required. The purpose of this study was to demonstrate that variations in BNP levels during hormone-guided treatment and measured body hydration status enable the timing of the patient's discharge to be optimized. METHODS AND RESULTS: We retrospectively evaluated 186 patients admitted for AHF. All subjects underwent serial bioelectrical impedance analysis and BNP measurement. Therapy was titrated according to BNP value to reach a BNP value of <250 pg/mL, whenever is possible. A BNP value on discharge of <250 pg/mL (obtained in 54% of the patients) predicted a 16% event rate within 6 months, whereas a value >250 pg/mL was associated with a far higher percentage (78%) of adverse events. Among the former, no significant differences in event rate were seen in relation to the time necessary to obtain a reduction in BNP values below 250 pg/mL (14 versus 18%, chi-square = 0.3, NS). Cox regression showed that a BNP cutoff value of 250 pg/mL is the most accurate predictors of events. CONCLUSIONS: Our study demonstrates the usefulness of BNP in intrahospital stratification of AHF, in the decision-making process, and as a tool for "tailored therapy." Integrating this approach into the routine assessment of HF patients would allow clinicians to more accurately identify high-risk patients, who may derive increased benefit from intensive in-hospital management strategies.

Fall in readmission rate for heart failure after implementation of B-type natriuretic peptide testing for discharge decision: a retrospective study.

BACKGROUND: B-type natriuretic peptide is the most powerful predictor of long term prognosis in patients hospitalised with heart failure. On an outsetting basis, a decrease in B-type natriuretic peptide levels is associated to a decrease in event rate for outpatients managed using the neuro-hormone levels as the target in heart failure therapy. We have retrospectively checked whether the addition of pre-discharge B-type natriuretic peptide levels to a clinical-instrumental decisional score for discharge decision in patients admitted for heart failure reduced readmission rate for heart failure and related cost. METHODS: We studied two series of consecutive patients admitted to the Heart Failure Unit due to acute heart failure as a main diagnosis. One-hundred and forty-nine patients discharged on the basis of the sole clinical acumen were compared to one hundred and sixty-six subjects discharged adding B-type natriuretic peptide levels to the decisional score. RESULTS: During a six-month follow-up period, there were 52 readmissions (35%) among the clinical group (n=149) compared with 38 (23%) readmissions in the B-type natriuretic peptide group (n=166) (chi(2)=5.5; P=0.02). Survival did not differ between groups (87%). Changes in B-type natriuretic peptide values were correlated to clinical events: a B-type natriuretic peptide value on discharge of < or =250 pg/ml or a reduction of > or =30% in B-type natriuretic peptide values predicted a 23% event rate (death, plus readmission for heart failure), whereas a far higher percentage (71%) were observed in the remaining patients (chi(2)=32.7; P=0.001). Likewise, the overall costs of care were lower (-7%) in the B-type natriuretic peptide group: 2.781+/-923 vs 2.978+/-1.057 euros per patient respectively. CONCLUSIONS: our study suggest that the addition of pre-discharge B-type natriuretic peptide levels to a clinical-instrumental decisional score for discharge decision in patients admitted for heart failure may contribute to reduce the number of readmissions and related cost.

[Heart failure in Eastern Veneto: prevalence, hospitalization rate, adherence to guidelines and social costs]. / Lo scompenso cardiaco nel veneto orientale: prevalenza, ospedalizzazione, aderenza alle linee guida e costi sociali.

Heart failure is a prominent problem of public health, requiring innovating methods of health services organization. Nevertheless, data are still not available on prevalence, hospitalization rate, adherence to Guidelines and social costs in the general Italian population. The necessity to identifying patients with heart failure derives from the efficacy of new therapeutic interventions in reducing morbidity and mortality. In this study we aimed to identify, in a subset of the Eastern Veneto population, patients with heart failure through a pharmacologic-epidemiologic survey. The study was divided in 5 phases: (1) identification of patients on furosemide in the year 2000 in the ASL 10 of Eastern Veneto general population, through an analysis of a specific pharmaceutic service database; (2) definition of the actual prevalence of heart failure in a casual sample of these patients, through data base belonging to general practitioners, cardiologists, or others. Diagnosis was based on the following criteria: (a) previous diagnosis of heart failure; (b) previous hospitalization for heart failure; (c) clinical evidence, with echocardiographic control in unclear cases; (3) survey of hospitalizations; (4) evaluation of adhesion to guidelines, through both databases and questionnaires; (5) analysis of the social costs of the disease, with a retrospective "bottom up" approach. From a total population of 198,000 subjects, we identified 4502 patients on furosemide. In a casual sample of 10,661 subjects we defined a prevalence of heart failure in Eastern Veneto of 1.1%, that increased to 7.1% in octagenarians. The prescription of life saving drugs was satisfactory, while rather poor was the indication to echocardiography and to cardiologic consultation. Hospitalization rate for DRG 127 was low: 2.1/1000 inhabitants/year in the general population and 12.5 /1000 inhabitants/year in patients >70 years of age. Yearly mortality was 10.3%. Social costs were elevated (15.394 Euros/patient/year), due to a relevant sanitary component (hospital 53%, drugs 28%) and particularly a to an indirect cost component. In conclusion, the assumption of furosemide lends itself as a good marker for identifying patients with heart failure. Patient identification is simple, cheap and cost-efficient, and can be easily reproduced in other regional areas.

B-type natriuretic peptide predicts postdischarge prognosis in elderly patients admitted due to cardiogenic pulmonary edema.

To examine the prognostic role of predischarge B-type natriuretic peptide (BNP) levels in elderly patients admitted to the hospital due to cardiogenic pulmonary edema, 203 patients consecutively admitted to the Heart Failure Unit of the Cardiology Department were retrospectively evaluated. The primary clinical end point selected was a combination of: 1) deaths; plus 2) readmissions to the hospital for heart failure in the 6 months after discharge. Thirty-one deaths (15.3%) and 44 readmissions for heart failure (21.7%) were recorded. Cox multivariate regression analysis confirmed that BNP cutoff values (identified on receiver-operated curve analysis) are the most accurate predictor of events. Hazard ratios (HRs) increased from the lowest, for BNP < or = 200 pg/mL (HR=1), through BNP 201-499 pg/mL (HR=2.3200; p=0.0174), to the highest, for BNP > or = 500 pg/mL (HR=3.6233; p=0.0009). This study demonstrates that BNP is useful in predischarge risk stratification of elderly patients with cardiogenic pulmonary edema.

B-type natriuretic peptide can predict the medium-term risk in patients with acute heart failure and preserved systolic function.

BACKGROUND: Half of patients with heart failure (HF) have preserved left ventricular ejection fraction (LVEF). Neurohormonal activation characterizes the disease and measurement of plasma B-type natriuretic peptide (BNP) indicates the severity of left ventricular dysfunction. The purpose of this study was to test the hypothesis that measurement of BNP levels in ambulatory patients with HF and preserved LVEF can predict the occurrence of cardiovascular events in the next 6 months. METHODS AND RESULTS: We enrolled 233 consecutive patients admitted to the Outpatient Heart Failure Clinic (OHFC), on stabilization after an episode of acute HF, with a LVEF > 50%. Standard echocardiography was performed and left ventricular systolic/diastolic function was assessed. Plasma BNP levels were measured on admission to OHFC. Patients were followed for 6 months; the main endpoint combined cardiovascular death or readmission for HF. Among the 233 patients discharged, 48 endpoints occurred (death: n = 15; readmission: n = 33). Receiver operated curve analysis shows that BNP levels are strong predictors of subsequent events (area under the curve = 0.84; CI = 0.78-0.88). Multivariate Cox regression showed that the cutoff values identified by receiver operated curve analysis (200-500 pg/mL) of the neurohormone are the most accurate predictors of events: HR = 2.2 (P < .04) and HR = 5.8 (P < .001), respectively, for 201-499 pg/mL and > or = 500 pg/mL ranges. CONCLUSION: BNP level is a strong predictor for cardiovascular mortality and early readmission in patients with diastolic HF. The results suggest that BNP levels might be used successfully to guide the intensity of follow-up after a decompensation, because increased BNP levels were associated with a progressively bad prognosis.

The NT-proBNP assay identifies very elderly nursing home residents suffering from pre-clinical heart failure.

BACKGROUND: Little is known about the prevalence of heart failure among very old people, although hospitalisation rates for chronic heart failure are very high. Recently, brain natriuretic peptides have emerged as important diagnostic and prognostic serum markers for congestive heart failure. AIMS: The main purpose of our study was to determine whether there is a cut-off for NT-proBNP for detecting the echocardiographic features of left ventricular systolic and/or diastolic dysfunction and clinical heart failure among old people living in nursing homes. Secondarily, we investigated the medium-term prognostic power of the neurohormone levels. METHODS: We screened 101 old people (80% females, aged 84+/-9 years) from two nursing homes. We prospectively evaluated whether we could effectively stratify patients using a combination of (1) restrictive clinical criteria, (2) NT-proBNP measurements (Elecsys System, Roche Diagnostics) and (3) echocardiography for all patients. RESULTS: Forty-two percent of the subjects had left ventricular dysfunction: 11% systolic, 23% diastolic and 8% both systolic and diastolic. The mean NT-proBNP concentration was 2806+/-7028 pg/ml in the 42 patients with left ventricular systolic and/or diastolic dysfunction, compared with 365+/-456 pg/ml in the 59 patients with normal left ventricular function (p<0.01, Z=-4.8 Mann-Whitney U test). The neurohormone proved to be a good predictor of events within 6 months [area under the receiver-operated curve (ROC)=0.79]. CONCLUSIONS: Blood NT-proBNP concentrations can play an important role in stratifying old people into left ventricular dysfunction risk groups. The neurohormone is an independent marker for death or admission for heart failure in the medium term.