Effectiveness of home-rehabilitation in patients after an acute coronary syndrome and myocardial revascularization.

Physical activity is a mainstay (class IA) of rehabilitation programme after an acute coronary syndrome, but less than 40% of patients is physically active at one year. Home-rehabilitation, initially designed to manage the increasing number of patients in rehabilitation programmes, could result in a better strategy to increase adherence and persistence to physical activity. Objectives: To test such hypothesis, At Cardiac Rehabilitation Centre (Institute of Physical Medicine and Rehabilitation, Udine, Italy), physical activity adherence was compared between patients treated with a standard in-office rehabilitation programme and a cohort where home rehabilitation programme was added. Methods: From February 2017 to February 2019, 372 patients after an acute coronary syndrome (72 were excluded according to study criteria) were included, 193 patients in standard rehabilitation and 179 in home rehabilitation. At the end of follow-up, patients of both groups were called on the telephone to collect physical activity items according to a standardized questionnaire. Results: At a medium follow-up of 30.1 months, there are more physically active patients in home rehabilitation than in standard, respectively 139 vs 108 patients (77,1% vs. 56%, p < 0,0001).At multivariate analysis, including age, gender, and rehabilitation model, the probability to be fully physically active at the end of the rehabilitation programme, is 3 times higher (OR 3.0 CI 1,9-6,0 p < 0,0001) for home rehabilitation programme compared to standard one. Conclusions: Home rehabilitation, when applied to selected populations, resulted in a feasible and effective strategy to promote long term physical activity in secondary prevention after an acute coronary syndrome.

Choosing wisely in cardiology: Five proposals from the Italian Association for Cardiovascular Prevention and Rehabilitation.

We do not always accomplish what is best for our patients. Is "more procedures, more drugs" a real synonym of good and always useful medicine? Probably not. Indeed, it has been highlighted that many tests and treatments, widely used in medical practice, do not bring benefits to patients, but they can be harmful. So, why do we keep performing them? Many reasons, surely one of the main is the constant fear of malpractice legal-medical consequences; this led to the development of a defensive medicine, no longer focused on the health of the patient. For this reason, the Italian Association of Cardiac Prevention and Rehabilitation (GICR-IACPR) joined an international project "Choosing Wisely", supported by the Slow Medicine Initiative, a network which states that "Less is more". The purpose of "Choosing Wisely " project is to improve the quality and safety of health services through the reduction of practices that, according to available scientific knowledge, do not bring significant benefits to the patients, but can, on the contrary, expose them to risks. This GICR-IACPR paper proposes to avoid five widespread practices in cardiology, at risk for inappropriateness and lacking of clinical evidence of benefit: • Do not perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery • Do not perform Computed Tomography for coronary calcium score in patients at high cardiovascular risk • Do not perform Holter electrocardiographic monitoring in patients suffering from syncope, near syncope or dizziness, in whom a non-arrhythmic origin has been documented • Do not routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding prophylaxis in patient with single drug antiplatelet therapy in absence of additional risk factors. • Avoid routine use of infective endocarditis prophylaxis in mild to moderate native valve disease.

Prevalence and management of familial hypercholesterolemia in patients with coronary artery disease: The heredity survey.

BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is a genetic disorder characterized by high levels of low density lipoprotein cholesterol (LDL-C) predisposing to premature cardiovascular disease. Its prevalence varies and has been estimated around 1 in 200-500. The Heredity survey evaluated the prevalence of potential FH and the therapeutic approaches among patients with established coronary artery disease (CAD) or peripheral artery disease (PAD) in which it is less well documented. METHODS: Data were collected in patients admitted to programs of rehabilitation and secondary prevention in Italy. Potential FH was estimated using Dutch Lipid Clinic Network (DLCN) criteria. Potential FH was defined as having a total score≥6. RESULTS: Among the 1438 consecutive patients evaluated, the prevalence of potential FH was 3.7%. The prevalence was inversely related to age, with a putative prevalence of 1:10 in those with <55yrs of age (male) and <60yrs (female). Definite FH (DLCN score>8) had the highest percentages of patients after an ACS (75% vs 52.5% in the whole study population). At discharge, most patients were on high intensity statin therapy, but despite this, potential FH group still had a higher percentage of patients with LDL-C levels not at target and having a distance from the target higher than 50%. CONCLUSIONS: Among patients with established coronary heart disease, the prevalence of potential FH is higher than in the general population; the results suggest that a correct identification of potential FH, especially in younger patients, may help to better manage their high cardiovascular risk.

[Clinical implications of familial occurrence of atrial septal aneurysm]. / Aneurisma del setto interatriale di origine familiare: quali implicazioni?

Familial occurrence of atrial septal aneurysm has been recently described. We report a series of 4 females, a mother and her 3 daughters, with atrial septal aneurysm that confirm a familial cluster of this abnormality. Clinical implications of this observation, with special emphasis on the opportunity of familial screening, are discussed.

The effect of fellows' training in invasive cardiology on radiological exposure of patients.

The aim of this work was to evaluate and quantify the impact of an invasive training of cardiology fellows on some exposure parameters. From 1 January 2000 to 31 December 2002, three staff members performed 2.582 diagnostic procedures (Group 1) that were compared with 819 performed by, or with the participation of five cardiology fellows (Group 2). Exposure parameters were as follows (Group 1/Group 2): fluoroscopy time 3.8 +/- 4.5/5.5 +/- 5.9 min (+38%), mean number of frames 589 +/- 282/642 +/- 260 (+9%), Kerma-area product (KAP) during fluoroscopy 10.6 +/- 14/15.5 +/- 16 Gycm2 (+45%), KAP during cine-angiography 20.8 +/- 14/22.5 +/- 12 (+8%), total KAP 31.5 +/- 28/38.1 +/- 28 (+21%). Differences were all significant (P

Estimation of infarct size by single measurements of creatine kinase levels in patients with a first myocardial infarction.

OBJECTIVE: Enzymatic estimation of infarct size is desirable in the reperfusion era, because a possible discrepancy with the observed asynergic area of the left ventricle may suggest the presence of stunned myocardium. Unfortunately, timely myocardial reperfusion produces a rapid washout of creatine kinase (CK) in blood flow, which overestimates infarct size. In this perspective, we investigated whether the mid-terminal portion of the CK time-activity curve could predict infarct size more reliably. METHODS: Enzymatic infarct size was calculated by peak CK levels, the CK area under the curve and by single CK values, in 103 patients with a first ST-elevation myocardial infarction, and compared to the left ventricular akinetic area. The wall motion asynergy score at follow-up was considered as the actual infarct size. RESULTS: In patients with peak CK within 10 h of symptom onset, CK levels at 30 h showed a high independent correlation (r = 0.83; P < 0.001) with infarct size. In patients with late peak CK (> 10 h), CK levels at 12 h turned out to be the best predictor of infarct size (r = 0.55; P < 0.01). At multivariate regression analysis, peak CK was the best predictor of infarct size in the whole population (r = 0.61; P < 0.001). CONCLUSIONS: In patients with ST-elevation myocardial infarction and early peak CK, infarct size at follow-up could be better estimated with single values of the mid-terminal portion of the CK time-activity curve.

Contrast echocardiographic evaluation of early changes in myocardial perfusion after recanalization therapy in anterior wall acute myocardial infarction and their relation with early contractile recovery.

Temporal changes in myocardial perfusion after recanalization and their relation with functional recovery in patients with acute myocardial infarction (AMI) using intravenous myocardial contrast echocardiography (MCE) have not yet been clarified. To address this issue, 19 patients with first, uncomplicated anterior wall AMI were studied using intravenous MCE within 24 hours of recanalization and before discharge. MCE was performed using harmonic power Doppler. Each asynergic left ventricular (LV) myocardial segment was scored for myocardial perfusion (1 = complete, 0.7 = patchy but >50%, 0.3 = patchy <50%, and 0 = absent) and a regional perfusion index was calculated within the dysfunctioning myocardium. During the day-1 study (11 +/- 2 hours from recanalization), the regional perfusion index was 0.4 +/- 0.3 and the LV wall motion score index was 1.9 +/- 0.2. During the study before discharge (7 +/- 4 days from admission), all but 2 patients showed an improvement of either perfusion index (0.6 +/- 0.3, p <0.0001) or wall motion score index (1.7 +/- 0.4, p <0.0001). Changes in perfusion score from 24-hours to before discharge showed a significant correlation with LV segment contractile recovery at 2-month of follow-up (R(2) = 0.42, 95% confidence interval 0.33 to 0.50, p <0.0001). Thus, our data show that after recanalized AMI, there is a significant amount of microvascular obstruction that recovers in the days after, and the extent of this perfusion improvement appears to be related with early myocardial contractile recovery. Our data provide clinical evidence for a transient microvascular dysfunction after successfully recanalized AMI.