[Ambulatory cardiac rehabilitation in Trieste: protocols of intervention, activities and outcomes]. / Riabilitazione cardiologica ambulatoriale a Trieste: protocolli, attività ed esiti.

BACKGROUND: Cardiac rehabilitation (CR) is a model of care proven to reduce mortality and morbidity in patients with coronary artery disease. The aim of this study is to describe the ambulatory CR model of the Cardiovascular Department of Trieste (Italy), analyzing the outcome of the population. METHODS: We analyzed clinical and instrumental characteristics of all consecutive patients after ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), coronary artery bypass graft with or without valve surgery (CABG/CABGV), or planned percutaneous coronary intervention (PCI), referred for CR from January 1, 2009, to December 31, 2015. All patients were included in a registry. During CR and at 1-year follow-up, the incidence of new hospitalizations due to cardiovascular causes was assessed. Total and cardiovascular mortality was also evaluated at longer follow-up. RESULTS: Overall, 3088 patients (28% female, mean age 70 ± 11 years; 35% older than 75 years) were referred for CR, 30% after STEMI, 23% after NSTEMI, 29% after CABG/CABGV, and 19% after PCI. At enrollment, 9% of patients had an ejection fraction <40%, 76% were hypertensive, 61% dyslipidemic, 19% diabetics, and 27% smokers. CR lasted 5 ± 4 months. At the end of the CR program, 96% of patients were on antiplatelets, 79% on beta-blockers, 73% on angiotensin-converting enzyme inhibitors, 25% on angiotensin II receptor blockers, and 87% on statins with achievement of the following secondary prevention targets: LDL cholesterol 85 ± 30 mg/dl, glycated hemoglobin 7.2 ± 4%, heart rate 64 ± 11 bpm, systolic/diastolic blood pressure 137 ± 32/78 ± 14 mmHg. During CR, new hospitalizations occurred in 11% of patients, 1% within 1 year after CR. At a mean follow-up of 4.4 ± 2 years, 11% of patients died, 3% for cardiovascular causes, 0.7% within 1 year. Cardiovascular mortality was significantly higher in elderly patients (6 vs 2%, p=0.000), women (4 vs 3%, p=0.038), diabetics (5 vs 3%, p=0.004), and in patients with left ventricular dysfunction (8 vs 3%, p=0.000). CONCLUSIONS: Our findings show the feasibility of a CR program in an unselected population, characterized by advanced age, risk factors and comorbidities. A critical analysis of the registry data allowed us to achieve good results in secondary prevention and outcomes.

'PERFSCORE' - a multidimensional score: a simple way to predict the success of cardiac rehabilitation.

BACKGROUND: We propose a simple and reliable score, performance score ('PERFSCORE'), that allows cardiologists to assess the achievement of therapeutic goals. METHODS: We identified six indicators of cardiac rehabilitation performance: heart rate (HR) less than 70 beats/min; blood pressure (BP) less than 140/90 mmHg; smoking cessation or non-smokers; left ventricular ejection fraction (LVEF) more than 40%; LDLc less than 100 mg/dl or more than 70 mg/dl if diabetic; and on treatment at least with three drugs among angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARBs), ß-blockers, statins, and ASA. These six indicators are considered to be the collective expression of a latent variable measuring performance. To assess the relative contribution of each indicator in the definition of cardiac rehabilitation performance, we fitted a structural equation model using the 'Stata 13' system. RESULTS: A total of 839 consecutive patients were analyzed; 49% had recent ST- elevation myocardial infarction/non-ST elevation myocardial infarction and 51% had undergone elective percutaneous coronary intervention/coronary artery bypass graft. At the end of cardiac rehabilitation, LVEF was 55 ±â€Š11%; HR, 69 ±â€Š13 beats/min; SBP, 135 ±â€Š20 mmHg; DBP, 79 ±â€Š10 mmHg; LDLc, 88 ±â€Š29 mg/dl; 56% had stopped smoking; 71% were on ß-blockers; 78% ACE inhibitors or ARBs; 87% were on statins, and 96% were on ASA. Weights for each indicator in the PERFSCORE were 0.57 for HR, 0.40 for BP, 0.87 for LVEF, 0.78 for smoking, 0.42 for LDLc, and 0.75 for drugs, multiplied by 1 if the target has been reached, otherwise by 0. Higher performance values correspond to better cardiac rehabilitation results. The point range was 0-36: less than 24, not satisfying cardiac rehabilitation; 24-29, satisfying cardiac rehabilitation; and more than 29, optimal cardiac rehabilitation. CONCLUSION: In conclusion, we propose an easy algorithm to calculate the success of cardiac rehabilitation.

A risk factor analysis for in-hospital mortality after surgery for infective endocarditis and a proposal of a new predictive scoring system.

PURPOSE: Risk stratification is of utmost importance for patients with infective endocarditis (IE) who need surgery. However, for these critically ill patients, aspecific scoring systems are used to predict the risk of death after surgery. The aim of this study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE and to create a mortality risk score based on the results of this analysis. METHODS: Outcomes of 138 consecutive patients (mean age 60.6 ± 8.5 years) who had undergone surgery for IE in an Italian cardiac surgery center between 1999 and 2015 were reviewed retrospectively and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver-operating characteristic (ROC) curve analysis. RESULTS: Twenty-eight (20.3%) patients died in hospital following surgery. Anemia [odds ratio (OR) 11.0, p = 0.035), New York Heart Association class IV (OR 2.61, p = 0.09), critical state (OR 4.97, p = 0.016), large intracardiac destruction (OR 6.45, p = 0.0014), and surgery of the thoracic aorta (OR 7.51, p = 0.041) were independent predictors of hospital death. A new scoring system was devised to predict in-hospital death after surgery for IE (area under ROC curve, 0.828, 95% confidence interval, 0.754-0.887). The score outperformed six of seven scoring systems, for early death after cardiac surgery, that were considered. CONCLUSIONS: A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk after surgery for IE. Prospective studies are needed for the score validation.