[Diagnosis and treatment of anemia in heart failure patients]. / Diagnosi e trattamento dell'anemia nello scompenso cardiaco.

Anemia is a common comorbidity in patients with acute and chronic heart failure (HF) with preserved and reduced systolic function. It is recognized as a new therapeutic goal in HF since the reduction in hemoglobin levels is considered a significant independent predictive factor of mortality and hospitalization. At present, it is difficult to determine the real magnitude of the problem in terms of actual incidence and prevalence as no consistent definition of anemia associated with HF does exist, and a variety of hemoglobin thresholds have been used in clinical trials and epidemiological studies. The etiology of anemia is multifactorial with the main causes including renal failure, gastrointestinal bleeding and nutritional deficiency. Nevertheless, such criteria are not present in some patients, who show a peculiar type of anemia that may be classified as anemia of chronic diseases, likely due to the chronic inflammatory process of HF. No guidelines for the treatment of anemia in HF patients are available. Most of the previous studies in the literature are limited by small sample sizes. The very few randomized multicenter studies that evaluated the effects of erythropoiesis-stimulating agents associated with intravenous iron therapy did not provide the expected results. Indeed, despite an increase in hemoglobin levels, they did not show any improvement of NYHA functional class, nor of left ventricular ejection fraction. In addition, reasonable hemoglobin levels as a goal of therapy have not been established yet, in particular in relation to the side effects and the cardiovascular risk observed after the administration of erythropoiesis-stimulating agents in oncologic patients. Further studies are warranted to define the magnitude of the problem and establish appropriate therapeutic strategies. It is likely that more reliable data will be derived from an ongoing randomized, double-blind, multicenter study, the RED-HF (Reduction Event with Darbepoetin alfa in Heart Failure), which aims at evaluating morbidity and mortality in a cohort of 2600 HF patients with anemia treated with darbepoetin alfa.

A novel prognostic index to determine the impact of cardiac conditions and co-morbidities on one-year outcome in patients with heart failure.

Prognostic stratification is relevant in clinical decision making in heart failure (HF). Predictors identified during hospitalization or in clinical trials may be unrepresentative of HF in the community. The aim of this study was to derive and validate, in different clinical settings, a risk stratification model for the prediction of stable HF outcomes. The study included 807 patients, 350 enrolled at discharge from the hospital (44%), 309 in the outpatient clinic (38%), and 148 in the home-care setting (18%). There were 292 patients in the derivation cohort and 515 in the validation cohort. A multivariate logistic analysis was performed to obtain the CardioVascular Medicine Heart Failure (CVM-HF) index. One-year mortality was 20.8% in the derivation cohort and 20.7% in the validation cohort. The CVM-HF index included cardiac conditions and co-morbidities and stratified the 1-year mortality risk as low (death rate 4%), average (32%), high (63%), and very high (96%). The area under the curve of the receiver-operating characteristic curve was 0.844 (95% confidence interval [CI] 0.779 to 0.89) for the derivation cohort and 0.812 (95% CI 0.76 to 0.86) for the validation cohort. Model performance was equally good in the 3 different HF settings. In a subgroup of 409 patients, the CVM-HF index (area under the curve 0.821, 95% CI 0.79 to 0.89) outperformed the most-used prognostic models (the Charlson index and the Heart Failure Risk Scoring System). In conclusion, the CVM-HF index, a novel prognostic model that is easy to derive and applicable to unselected patients, may represent a valuable tool for the prognostication of stable HF outcomes.

[Cardiovascular medicine unit: preliminary results of an in-hospital multidisciplinary intervention in heart failure]. / Unità di medicina cardiovascolare: prime esperienze di un approccio intraospedaliero multidisciplinare allo scompenso cardiaco.

BACKGROUND: In Italy the majority of patients with heart failure are admitted to Internal Medicine Divisions, where diagnostic and therapeutic procedures, suggested by guidelines, are less utilized than in Cardiology Divisions. In order to provide a better assistance to patients with heart failure, a Cardiovascular Medicine Unit was founded with interdepartmental valence (Cardiovascular and Internal Medicine) in the "Ospedali Riuniti" Hospital of Bergamo. The purpose of this study was to evaluate the preliminary results, concerning management of heart failure, in the first 6 months of activities carried out at the Cardiovascular Medicine Unit and to compare them with those of other structures that usually manage this disease. METHODS: Analysis of data concerning 150 admissions to the Cardiovascular Medicine Unit for heart failure in 147 patients during the first 6 months of 2003. Comparisons of admittance data for heart failure in the first semester 2001 deriving from the Internal Medicine Division of the "Ospedali Riuniti" Hospital of Bergamo, the TEMISTOCLE study and the Niguarda Ca' Granda Hospital of Milan. RESULTS: A higher prescription of beta-blockers and spironolactone was observed in the Cardiovascular Medicine Unit than in other structures (p < 0.001). Echocardiography and coronary angiography were performed more frequently (p < 0.001) and the number of rehospitalizations was lower for all cases (p < 0.05) as well as for heart failure (p < 0.001). The extensive use of diagnostic procedures and multidisciplinary evaluation of co-morbidities allowed to identify patients who could be managed successfully with surgical therapy; preliminary data suggest a net benefit in terms of NYHA functional class and reduction in rehospitalization in this subgroup of patients. CONCLUSIONS: These data demonstrate that the Cardiovascular Medicine model, based on integration of knowledge between cardiologists and internists, is effective with respect to organization and assistance and allows to optimize heart failure patient management.

[Management of stroke in a ward of internal medicine. Limits and prospects]. / La gestione dell'ictus in un reparto di Medicina Interna. Limiti e prospettive.

Precocious admission to specifically "dedicated" wards proved to improve reduction of mortality and degree of residual disability in patients with stroke, even if their inhomogeneous distribution gets most patients admitted to wards of Internal Medicine. We purposed to evaluate the importance of this problem, to check adhesion to the national guidelines and to show the main problems in management of patients with stroke in the Operative Unit of Internal Medicine, Vascular and Metabolic Diseases of the IRCCS S. Matteo Hospital of Pavia. 143 patients with stroke were admitted in 2001, 126 were ischemic, 17 hemorragic; the mean age was of 73. The most frequent risk factors were hypertension, diabetes, smoke and atrial fibrillation. 59% of patients were admitted within 6 hours from onset of symptoms. Within the ischemic subtypes, 17.5% were atherotrombothic, 16.7% cardioembolic, 23.8% lacunar and 42% with undetermined etiology. Lacunar syndromes were the most part. 80% of patients underwent computed tomography, 50% underwent epiaortic Doppler sonography, 38% echocardiography. 61% of ischemic subtypes underwent acute antiplatelet treatment. Complications were prevalent in oldest patients. Mortality of inpatients was 17%, influenced by age, hypertension, severe sensorial compromission at admission, cardioembolism and complications. This study proved leak of adhesion to national guidelines which brought to inadequate accuracy in diagnosis and difficulty in making correct and coherent therapeutic choices. At least in great hospitals, "dedicated" areas in wards of Internal Medicine with selected, trained and motivated staff should be desirable.