Clinical outcome of renal tubular damage in chronic heart failure.

AIMS: Both reduced glomerular filtration and increased urinary albumin excretion independently determine outcome in patients with chronic heart failure (HF). However, tubulo-interstitial injury might indicate renal damage, even in the presence of normal glomerular filtration. We studied the relationship between tubular damage, glomerular filtration, urinary albumin excretion, and outcome in HF patients. METHODS AND RESULTS: In 2130 patients participating in the GISSI-HF trial, we measured urinary albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), and three urinary markers of tubular damage: N-acetyl-beta-D-glucosaminidase (NAG), kidney injury molecule 1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL). We assessed the relationship between the individual tubular damage markers and the combined endpoint of all-cause mortality and HF hospitalizations. Mean age was 67 ± 11 years, and 21% were female. Urinary NAG 13.7 (7.8-22) U/gCr, KIM-1 1939 (671-3871) ng/gCr, and NGAL 36 (14-94) µg/gCr were markedly elevated above normal levels. All individual tubular markers were independently associated with the combined endpoint: NAG: adjusted hazard ratio (HR) 1.22; 95% confidence interval (CI), 1.10-1.36; P< 0.001, KIM-1 HR 1.13; 95% CI, 1.02-1.24; P= 0.018 and NGAL HR 1.10; 95% CI, 1.00-1.20; P= 0.042; all per log standard deviation increase). Even in patients with a normal eGFR, increased tubular markers were related to a poorer outcome. The combination of impaired eGFR, increased UACR, and high NAG was associated with a HR of 3.00; 95% CI, 2.29-3.95; P< 0.001, compared with those without these abnormalities. CONCLUSION: Tubular damage is related to a poor clinical outcome in HF patients even when eGFR is normal.

[Third phase of cardiac rehabilitation: a nurse-based "home-control" model]. / Terza fase della riabilitazione: sperimentazione di un modello gestionale "home-control".

BACKGROUND: Phase 3 is a critical point for cardiac rehabilitation: many problems don't allow achieving a correct secondary prevention, in particular regarding the relationship between patient and cardiologist. Aiming at ensuring continuity of care of phase 3 cardiac rehabilitation patients, we have developed a telemetric educational program to stimulate in them the will and capacity to become active comanagers of their disease. METHODS: Nurses specialized in cardiac rehabilitation, with the collaboration of the general practitioners, contact the patients by scheduled phone calls to collect questionnaires about their health status and the result of biochemistry. All the results are analyzed by the nurses and discussed with each patient (educational reinforcement). The effects of this program of comanagement of cardiac disease and secondary prevention are analyzed comparing each patient data at the discharge with data after one year and those coming from our archive (retrospective analysis). RESULTS: The patients enrolled in this study pay much more attention to the amount of food they eat; they tend not to gain weight, and they restart smoking in a reduced proportion compared to patients not enrolled in the study. However, despite having received better information on their cardiac disease, their compliance to physical training, consumption of healthy food, and pharmacological therapy is not improved. CONCLUSIONS: This study focuses on the role of a continuous educational program of a cardiac rehabilitation unit after the patient's discharge. This home control program conducted by nurses specialized in cardiac rehabilitation, with the assistance of cardiologists, psychologists and physiotherapists, and in collaboration with the general practitioner, was quite cheap, and helped maximizing the knowledge of the disease and reinforcing correct life style in the patients. The results are not as good as expected, probably because one year does not represent a sufficient time, or because the educational intervention needs to be improved.

An elderly-centered, personalized, physiotherapy program early after cardiac surgery.

BACKGROUND: Early post-surgery in-hospital rehabilitation in elderly patients should be aimed at accelerating the recovery of the highest level of functional autonomy and reducing the hospital stay. DESIGN: We designed a personalized physiotherapy program tailored to the frailty level of over-70-year-old patients soon after cardiac surgery. The aims of this study were (a) to validate our frailty-based approach for functional stratification of the patients, and (b) to assess the effect of the individualized program on independence and mobility, and compare it with our usual program. METHODS: We followed 224 consecutive patients aged 70-87 years, who followed either the personalized (n= 150) or usual (n= 74) program. All patients underwent a comprehensive physical functioning evaluation at the baseline and at the end of hospitalization. RESULTS: The frailty-based stratification was successful in identifying those patients at higher risk of falls, with heavy nursing needs, greater dependency, and poorer heath status perception. On discharge, both groups had significantly improved on all measures of independence and mobility, but most of these changes (nursing needs, mobility, balance, and muscle strength) were significantly greater (P < 0.05) in the intervention group. These patients also had a significantly shorter length of stay (17.5 ± 8 vs. 21 ± 4 days, P = 0.0002), and 91% of them could be discharged in a state of substantial independence. CONCLUSION: An elderly-centered stratification based on functional frailty is useful to identify patients with more dependency and greater needs. A consequent personalized physiotherapy program designed to enhance independent mobility soon after cardiac surgery is safe and well accepted, and is more effective then usual physiotherapy.

Nitroprusside in decompensated heart failure: what should a clinician really know?

Sodium nitroprusside is an older intravenous vasodilator appropriate for acute hospital treatment of patients with congestive heart failure. It is a balanced arterial and venous vasodilator with a very short half-life, facilitating rapid titration. In general, it improves hemodynamic and clinical status by reducing systemic vascular resistance, left ventricular filling pressure, and increasing cardiac output. This review summarizes recently published literature and recent data regarding the use of this intravenous vasodilator in decompensated heart failure patients.

Physical and emotional symptom burden of patients with end-stage heart failure: what to measure, how and why.

OBJECTIVE: Much of our understanding about symptom burden near the end of life is based on studies of cancer patients. The aim of this study was to explore physical and emotional symptom experience among end-stage chronic heart failure patients, looking for those symptoms mostly related to their global health status. METHODS: Forty-six patients with end-stage heart failure compiled the following: Edmonton Symptom Assessment Scale (ESAS) and Kansas City Cardiomyopathy Questionnaire (KCCQ). RESULTS: End-stage heart failure patients have many complaints and poor global health status. The most distressing symptoms reported were general discomfort and tiredness followed by anorexia and dyspnea. The KCCQ summary scores were highly correlated with ESAS (r = -0.78; P = 0.0001). Among the domains explored by the KCCQ, social functioning and self-efficacy showed the lowest correlation coefficients with ESAS (r = -0.50; P = 0.001 and r = -0.31; P = 0.003, respectively); concerning the physical limitation domain, the symptom score and the quality-of-life domain, the correlation coefficients were as follows: r = -0.71 (P = 0.0001), r = -0.75 (P = 0.0001) and r = -0.74 (P = 0.0001), respectively. In the multiple regression analysis of ESAS and KCCQ scores, general discomfort, depression and anxiety were the symptoms that mostly related with the results in the domains explored by the KCCQ. No independent predictor was found among symptoms and quality of life. CONCLUSION: General discomfort together with depression and anxiety were the symptoms that were mostly related with the physical limitation domain of global health status, but did not influence the social functioning and the self-efficacy domains. When ESAS is used together with KCCQ, comprehensive and quantitative information on a patient's physical, emotional and social distress is provided.

Adequate energy-protein intake is not enough to improve nutritional and metabolic status in muscle-depleted patients with chronic heart failure.

BACKGROUND: An adequate energy-protein intake (EPI) when combined with amino acid supplementation may have a positive impact on nutritional and metabolic status in patients with chronic heart failure (CHF). METHODS AND RESULTS: Thirty eight stable CHF patients (27 males, 73.5+/-4 years; BMI 22.5+/-1.4 kg/m2), with severe depletion of muscle mass and were randomised to oral supplements of essential amino acids 8 g/day (EAA group; n=21) or no supplements (controls; n=17). All patients had adequate EPI (energy> or =30 kcal/kg; proteins >1.1 g/kg). At baseline and 2-months after randomisation, the patients underwent metabolic (plasma lactate, pyruvate concentration; serum insulin level; estimate of insulin resistance by HOMA index), nutritional (measure of nitrogen balance), and functional (exercise test, walking test) evaluations. Body weight increased by >1 kg in 80% of supplemented patients (mean 2.96 kg) and in 30% of controls (mean 2.3 kg) (interaction <0.05). Changes in arm muscle area, nitrogen balance, and HOMA index were similar between the two treatment groups. Plasma lactate and pyruvate levels increased in controls (p<0.01 for both) but decreased in the supplemented group (p<0.01 and 0.02 respectively). EAA supplemented patients but not controls improved both exercise output and peak oxygen consumption and walking test. CONCLUSIONS: Adequate EPI when combined with essential amino acid supplementation may improve nutritional and metabolic status in most muscle-depleted CHF patients.

Oral amino acid supplements improve exercise capacities in elderly patients with chronic heart failure.

We investigated whether 30 days of oral supplementation with a special mixture of amino acids (AAs), together with conventional therapy, could improve exercise capacity in elderly outpatients with chronic heart failure (CHF). A group of 95 outpatients (12 women and 83 men; New York Heart Association class II-III) aged 65-74 years were studied. This was a randomized, double-blind, placebo-controlled study. The patients performed a basal exercise test and were then randomly assigned to a special oral nutritional mixture of AAs 4 g twice daily (n = 43) or placebo (n = 42). After 30 days we repeated the exercise test. In both tests we measured the following: oxygen consumption (VO2), CO2 production (VCO2), minute ventilation (VE), oxygen cost of ventilation (VO2/VE), CO2 elimination per liter of ventilation (VCO2/VE), respiratory exchange ratio (RER; calculated as VCO2/VO2), oxygen pulse (VO2/heart rate [HR]) and anaerobic metabolism during exercise (ANA-VO2). At day 30, exercise capacity in the AA group had improved (+11 +/- 8 W, p <0.01; +67.5 +/- 44 seconds, p <0.02). This improvement was associated with both reduced circulatory dysfunction and increased peripheral oxygen availability. Indeed, peak VO2 increased by 1.2 +/- 1.1 mL/kg per min (+12.7% +/- 13%; p<0.02) and VO2/HR improved by 1.5 +/- 1.4 mL O2 per heartbeat (p <0.05). ANA-VO2 was reduced by >50% in patients on AAs (from 20.2 +/- 10 mL/kg at day 0 to 10.9 +/- 5 mL/kg at day 30; p <0.02). These variables did not significantly change for patients who received placebo. In conclusion, the study showed that oral AA supplementation, in conjunction with standard pharmacologic therapy, appears to increase exercise capacity by improving circulatory function, muscle oxygen consumption, and aerobic production of energy in elderly outpatients with CHF.

Intra-observer and interobserver reproducibility of right ventricle volumes, function and mass by cardiac magnetic resonance.

OBJECTIVES: Cardiac magnetic resonance (CMR) allows quick and non-invasive evaluation both of right ventricle (RV) volume and function, which are important in many heart diseases. We have evaluated CMR intra- and interobserver reproducibility in different conditions of RV dimension and function. METHODS: We have analysed CMR exams of 45 subjects, randomly selected from our database according to RV end-diastolic volume (EDV; 15-subject groups with EDV < 25th, 25-75th and > 75th percentiles of a normal control population). Selected subjects were of both sexes (male/female 33/12) and of variable age (8-83 years) and body surface (0.9-2.3 m). RV end-diastolic and end-systolic volumes (ESV), ejection fraction (EF) and mass were blindly evaluated by two operators. Bland-Altman bias and coefficient of variability (CoV) were used to assess intra- and interobserver reproducibility. RESULTS: A wide range of EDV (range = 46-239 ml), ESV (20-129 ml) and EF (6-64%) was observed. The intra-observer bias was -5 ml for EDV, -2 ml for ESV, -1% for EF and 5 g for mass, with a CoV of 7-12%. The interobserver bias was 5 ml for EDV, 2 ml for ESV, 2% for EF and 6 g for mass, with a CoV of 8-13%. Analysis by tertiles showed EF assessment variability to be higher in the lower tertiles at intra-observer (P < 0.036) and, above all, at interobserver (P < 0.000) analysis. Mass assessment variability was higher in the upper tertile (P < 0.004) at intra-observer analysis. CONCLUSIONS: Intra- and interobserver reproducibility of RV parameters assessed by CMR are adequate in a wide range of RV dimensions and function. However, caution is required with respect to the significance of small changes of EF and mass in the case of poor function and hypertrophy of the RV, respectively.

[Metabolic frailty in malnourished heart failure patients]. / Precarietà metabolica nei pazienti con scompenso cardiaco cronico e malnutrizione.

UNLABELLED: Muscular wasting (MW) and cardiac cachexia (CC) are often present in patients with chronic heart failure (HF). AIM: To identify whether MW and CC are due to malnutrition or impairment of protein metabolism in HF patients. MATERIAL AND METHOD: In 78 clinically stable HF patients (NYHA class II-III), aged from 32 to 89 years, we measured anthropometrical parameters and nutritional habits. In the identified 35 malnourished patients, we also measured: insulin resistance, gluconeogenetic amino acids blood concentration and nitrogen balance. RESULTS: Seventy-five patients had eating-related symptoms. However we found significant nutritional impairment in 35 patients only. In addition, these 35 patients had: 1) significant increase of blood Alanine independently from both presence of insulin resistance or food intake reduction and 2) positive nitrogen balance. CONCLUSION: Food intake is not impaired in CHF patients. In spite of normal food intake, 35 of 78 patients had nutritional impairment with reduced anthropometric parameters and increased blood Alanine. These findings show alteration of proteins metabolism with proteolysis. We believe that specific physical training with nutritional supplement can be an additional therapy able to prevent protein disarrangement in CHF patients.

Safety and efficacy of carvedilol in very elderly diabetic patients with heart failure.

OBJECTIVE: Beta-blockers are often cautiously prescribed to older heart failure diabetics because of the paucity of published data and their perceived unfavourable effects on glucose metabolism, in spite of the evidence of their effectiveness and safety in middle-aged diabetic patients. The aim of this study was to compare the safety, tolerability and efficacy of long-term administration of carvedilol in a group of elderly patients with chronic heart failure, with and without concomitant diabetes. METHODS: Two hundred and fifty-two patients aged > or =70 years with heart failure and left ventricular ejection fraction < or =40% were followed in specialised heart failure clinics. Diabetes was present in 29.7%. Carvedilol was associated with conventional optimised treatment in 64% of diabetics and 65% of non-diabetics (P = NS). RESULTS: At baseline, diabetics presented with a longer duration of symptoms, higher Charlson comorbidity index, more frequent renal dysfunction and smaller left ventricular volumes than non-diabetics. New York Heart Association functional class and ejection fraction were similar in the two groups. At 1-year follow-up, tolerability (93.7 vs. 92.2%) and mean daily dose (24 +/- 17 vs. 23 +/- 14 mg/day) of carvedilol were similar in diabetics and non-diabetics. No worsening of fasting glucose, glycosylated haemoglobin and creatinine levels as well as the incidence of deaths and hospitalisations was observed in diabetics treated with carvedilol. Similar improvements in New York Heart Association class and mitral regurgitation severity were observed in diabetic and non-diabetic patients taking carvedilol. Ejection fraction showed a significant improvement, more pronounced in non-diabetics than in diabetics (+10 vs. +7 points; improvement of at least 10 points: 15 vs. 36%, P = 0.03). CONCLUSIONS: Similarly to younger ones, also in older patients, diabetes does not negatively influence the safety, tolerability and efficacy of carvedilol. However, diabetes remains a strong prognostic factor limiting the reversibility of left ventricular systolic dysfunction and the effect of treatment on subsequent outcome.

[Elderly patient-centered rehabilitation after cardiac surgery]. / Percorso riabilitativo individualizzato dedicato al paziente ultrasettantenne cardioperato.

The rate of over-70 year post-surgery patients referred to the Cardiac Rehabilitation Units is increasing. Strategies designed to encourage and facilitate participation in rehabilitation programs in the elderly should be developed. Aim of this paper is to present our elderly-centered program, specifically designed on patient's needs and frailty, and its short- and medium-term results in 160 consecutive over-70 year patients, admitted in our Cardiac Rehabilitation Unit soon after cardiac surgery. The program was safe, well accepted by the patients, and effective in improving objective and subjective functional status.

Prevalence, predictors and prognostic value of acute impairment in renal function during intensive unloading therapy in a community population hospitalized for decompensated heart failure.

BACKGROUND AND METHODS: Chronic heart failure (CHF) is often associated with impaired renal function. Diuretics and vasodilators may lead to aggravated renal dysfunction (ARD), particularly among patients with decompensated CHF. Although the prevalence of ARD has been evaluated in patients awaiting heart transplantation, little is known about ARD in the community sample of CHF patients. Accordingly, we prospectively assessed the prevalence, predictors and prognostic value of ARD in 79 consecutive patients admitted to our general community hospital for decompensated CHF undergoing intensive unloading therapy (intravenous nitroprusside and furosemide). ARD was defined as a >or= 25% increase in serum creatinine between admission and maximal value of >or= 2 mg/dl. RESULTS: Sixteen patients (20%) developed ARD with a mean increase in serum creatinine of 31% (from 1.74 +/- 0.6 to 2.27 +/- 0.9 mg/dl). ARD persisted at 8-day evaluation in seven of 16 subjects (44%) whereas it was reversible in nine (56%). Lower creatinine clearance at baseline [exp beta = 0.93, 95% confidence interval (CI)=0.87-0.99] and the higher dose of furosemide (exp beta=1.02, 95% CI=1.01-1.03) emerged as independent predictors of ARD. During a follow-up of 11 +/- 8 months, death and hospitalization for worsening CHF occurred more frequently in ARD than non-ARD patients (69% versus 17%, P=0.0001; 69% versus 29%, P=0.003, respectively). Persistent ARD was a powerful independent predictor of long-term adverse outcome (odds ratio=11.1; 95% CI=1.12-36.1; P=0.04). CONCLUSIONS: Intensive unloading therapy is associated with the development of ARD in one-fifth of the community population hospitalized for decompensated CHF. The magnitude of this phenomenon is not greater than that observed in younger selected populations with advanced CHF, and depends on baseline renal function and increased diuretic dosage. ARD persisting after 8 days from starting intensive unloading is a powerful predictor of subsequent worsened clinical outcome.

Contrast-enhanced cardiac magnetic resonance in a patient with chemotoxic cardiomyopathy.

Gadolinium-enhanced cardiac magnetic resonance was performed in a patient with chemotoxic cardiomyopathy. Intramyocardial midwall linear delayed hyperenhancement was found. Such a finding is consistent with midwall fibrosis and/or myocardial cell loss due to cardiotoxic effect of chemotherapy.

The complex symptom burden of the aged heart failure population.

PURPOSE OF REVIEW: The primary remit of terminal care in heart failure is to relieve suffering, which begins with a routine and standardized assessment of symptoms using validated instruments. The scope of this review is to explore symptom burden and control, and to examine some instruments used to assess and monitor heart failure patients' distress. RECENT FINDINGS: Elderly heart failure patients have many complaints and poor global health status. Symptoms are both of cardiac and noncardiac origin, attributable to the high frequency of comorbidities, side effects of medication and the psychosocial consequences of a chronic progressive illness. SUMMARY: Continuity of care, familiarity with the patient and the quality of inter-personal relationships between patients, relatives, nurses and physicians are essential to obtain high-quality end-of-life care. Validated instruments to measure symptom burden may be useful tools to quantify patients' distress and to evaluate the efficacy of care.

Prognosis and mechanism of death in treated heart failure: data from the placebo arm of Val-HeFT.

The magnitude of benefit on mortality of combined angiotensin-converting enzyme inhibitor (ACEI) and beta-blocker (BB) therapy for heart failure cannot be reliably assessed from prospective randomized trials of individual drugs with intent-to-treat analysis. The placebo arm of the Valsartan Heart Failure Trial (Val-HeFT) included patients who remained on background therapy with ACEIs, BBs, neither, or both. The outcomes in these four subgroups should provide a better guide to mortality benefit. Overall mortality (mean follow-up, 23 months) was 31.6% in those receiving neither neurohormonal blocker, 29% and 39% lower in those on ACEIs or BBs, respectively, and 62% lower (11.9% mortality) in those receiving both drugs. In the neither neurohormonal inhibitor group, 48% of the heart failure-related deaths were adjudicated as sudden, whereas in the group receiving ACEIs and BBs, 79% of the deaths were sudden, and pump failure mortality was only 1% per year. The combination of ACEIs and BBs exerts a greater mortality reduction than suggested from clinical trials and reduces pump failure mortality to 1% per year.

Programme to improve the use of beta-blockers for heart failure in the elderly and in those with severe symptoms: results of the BRING-UP 2 Study.

BACKGROUND: Beta-blockers are underused in HF patients, thus strategies to implement their use are needed. OBJECTIVES: To improve beta-blocker use in elderly and/or patients with severe heart failure (HF) and to evaluate safety and outcome. METHODS: Patients with symptomatic HF and age>/=70 years or left ventricular EF<25% and symptoms at rest were enrolled, including those already on beta-blocker treatment. Patients who were not receiving a beta-blocker were considered for carvedilol treatment. All patients were followed up for 1-year. RESULTS: Of the 1518 elderly patients, 505 were already on beta-blockers, and carvedilol was newly prescribed in 419 patients. At 1-year, patients treated with carvedilol had a lower incidence of death [10.8% vs. 18.0% in already treated (adjusted RR 0.68; 95%CI 0.49-0.96) and 11.2% in newly treated patients (adjusted RR 0.68; 95%CI 0.48-0.97)]. Of the 709 patients with severe HF, 38.4% were already on beta-blockers, and carvedilol was newly prescribed in 189 patients. Patients not treated with carvedilol showed the worst clinical outcome. Total rate of discontinuation (including adverse reaction and non-compliance) was 14% and 9%, respectively, in elderly and severe patients. CONCLUSIONS: In a real world setting, beta-blocker treatment was not associated with an increased risk of adverse events in elderly and severe HF patients.

Does atrial fibrillation in very elderly patients with chronic systolic heart failure limit the use of carvedilol?

BACKGROUND AND AIMS: It is well known that beta-blockers are useful in patients with chronic heart failure (CHF). These favourable effects have recently been observed even in elderly CHF patients. Objectives of the present study were to evaluate the feasibility, tolerability and safety of carvedilol therapy in a cohort of patients > 70 years of age with CHF and left ventricular ejection fraction < 40% with chronic atrial fibrillation. For this purpose, we designed an observational, 12-month prospective study. RESULTS: Among 240 patients who were referred to our centers and met inclusion criteria, 64 had chronic atrial fibrillation (27%). Thirty-nine out of these 64 subjects (61%) were treated with carvedilol, while 25 patients (39%) had contraindications to such treatment. In the cohort of 176 patients with stable sinus rhythm (control group), carvedilol could be administered in 121 patients (69%), while it was not given in 55 (31%, p=ns). Airways disease was the main reason for exclusion from carvedilol in this setting of patients. No difference in 1-year tolerability of study drug was observed among patients with chronic atrial fibrillation (29 of 33 patients=87.9%) and stable sinus rhythm (95 of 102=93.1%). Adverse events leading to the discontinuation of carvedilol in these two populations were rare and never resulted in any disability, death or were life-threatening. CONCLUSION: In over-70 patients with systolic CHF, chronic atrial fibrillation does not limit the possibility of testing beta-blocker therapy. Carvedilol was equally tolerated and safe in patients with atrial fibrillation and sinus rhythm.

Functional evaluation of patients with chronic pulmonary hypertension.

The importance of studying the pathophysiological bases and clinical correlates of exercise limitation in patients with pulmonary arterial hypertension (PAH) is well established. Two modes of exercise testing, the 6-min walk test (6MWT) and the cardiopulmonary exercise test (CPET), are currently proposed for diagnostic, therapeutic and prognostic finalities. The 6MWT is inexpensive, feasible and is thought to better reproduce daily life activities and to reliably detect therapeutic benefits. CPET requires the patient's maximal effort and does not provide a reliable quality of life measure. It is, however, highly reproducible and provides remarkable insights into the pathophysiological mechanisms that lead to exercise intolerance. Due to the limited experience accumulated, CPET is not actually advised for the routine assessment and for the overall clinical decision making of PAH patients. In this review we critically address the knowledge currently acquired on these techniques.

Pharmacological left ventricular reverse remodeling in elderly patients receiving optimal therapy for chronic heart failure.

BACKGROUND AND AIMS: In recent years, reversal of established left ventricular (LV) dilatation has been increasingly recognized in middle-aged patients with dilated cardiomyopathy receiving angiotensin-converting enzyme (ACE) inhibitors and/or beta-blockers. We performed this prospective study to evaluate whether optimized therapy for heart failure also induces LV reverse remodeling in older patients. METHODS: One hundred and twenty-four patients aged >70 years with LV ejection fraction <40% underwent clinical and echocardiographic evaluation at baseline and after 1 year. During the early stage of follow-up, pharmacological therapy was optimized. LV reverse remodeling was defined as a reduction in LV end-diastolic volume >25% from baseline to final evaluation. RESULTS: LV reverse remodeling was recognized in 32 patients (26%). Compared to the subjects who did not improve LV geometry, those with reverse remodeling had, at baseline, higher arterial blood pressure, lower serum creatinine levels, shorter duration of symptoms of heart failure, more frequently received beta-blocker therapy and had predominantly nonischemic aetiology. The variables associated with the development of reverse remodeling in the multivariate analysis were shorter duration of symptoms of heart failure (Odds ratio: 7.7; CI: 2.5-23.3, p=0.0001) and beta-blocker therapy (Odds ratio: 6.0; CI: 1.6-23.3, p=0.01). CONCLUSIONS: LV reverse remodeling takes place in elderly as well as in younger heart failure patients. A significant proportion of elderly patients undergoes this favourable process which occurs prevalently in patients receiving beta-blocker therapy with a short history of cardiac disease.

Scar detection by contrast-enhanced magnetic resonance imaging in chronic coronary artery disease: a comparison with nuclear imaging and echocardiography.

We compared contrast-enhanced MRI (CeMRI) with the most widely used imaging techniques for myocardial infarct (MI) diagnosis, SPECT and Echo, in unselected patients with chronic coronary artery disease (CAD). Two blinded operators assessed scars on MRI, SPECT and Echo images using a 16-segments LV model. We studied 105 consecutive patients: 50 had Q-wave MI (Q-MI), 19 non Q-wave MI or rest angina (nonQ-MI/RA) and 36 effort angina (EA) history. CeMRI was positive, respectively, in 96%, 37%, and 6%, SPECT in 90%, 53%, and 44%, and Echo in 84%, 32%, and 28% of patients (within Q-MI: CeMRI vs. SPECT p < 0.03, vs. Echo p < 0.001; within EA CeMRI vs. SPECT and ECHO p < 0.001; all trends p < 0.001, pseudo r-square: 0.56-0.75 for CeMRI, 0.18-0.28 for SPECT and 0.23-0.37 for Echo). CeMRI and SPECT agreed in 83 patients (79%); negative SPECT with 1 +/- 0 segments subendocardial delayed enhancement (DE) was found in 4 (4%); negative CeMRI with 4 +/- 3 segments perfusion defects in 18 (17%), 16 of whom were obese or showed LBB or sub-occlusion of related coronary. CeMRI and Echo agreed in 78 patients (75%); negative Echo with 2 +/- 1 segments subendocardial DE was found in 13 (12%) and negative CeMRI with 11 +/- 7 segments kinetic abnormalities in 14 (13%), in 10 confirmed by Cine-MRI. In Q-MI, CeMRI detects DE more frequently than perfusion defects and, especially, kinetic abnormalities are found by SPECT and Echo, respectively. CeMRI identifies small areas of DE also in some patients with nonQ-MI or RA but usually not in patients with EA. This biologically plausible decreasing trend is shown by CeMRI more clearly than by SPECT and Echo. Disagreement between CeMRI and SPECT or Echo may be reduced, but perhaps not fully eluded, performing dobutamine Echo and SPECT after maximal epicardial coronary dilatation.