A simple prognostic index in acute heart failure.

BACKGROUND: Rapid effective triage is integral to emergency care in patients hospitalized for heart failure, to guide the type and intensity of therapy. Several indexes and scores have been proposed to predict outcome; most of the them are complex and unfit to use at the bedside. METHODS: We propose a new prognostic index for in hospital mortality in acute heart failure. The index is calculated using the following formula: 220 - age - heart rate + systolic blood pressure - (creatinine ×10). The index was tested in 1628 patients admitted for acute heart failure and enrolled, from November 2007 to December 2009, in the Italian Registry on Heart Failure Outcome (IN-HF); a prospective, multicenter, observational study. RESULTS: The prognostic index was an independent predictor for in hospital mortality risk (AUC=0.74, P<0.0001), together with left ventricular ejection fraction (P=0.001), glycemia (P=0.019) and hemoglobin concentration (P=0.002). CONCLUSIONS: A simple prognostic index based on variables easily assessed can be useful to predict mortality in acute heart failure at the first arrival in hospital. The new index is independent from the left ventricular ejection fraction.

A prognostic index for risk stratification for acute heart failure and death in subjects with ischemic cardiomyopathy and cardiac defibrillator.

To propose a clinical prognostic index for death and heart failure in patients with ischemic cardiomyopathy implanted with an ICD. This prospective study included 192 consecutive patients (age 68 ± 10) recruited from 2004 to 2009 and implanted with an ICD for MADIT II criteria. All patients performed 24-h ambulatory blood pressure monitoring after discharge and common haematological samples. The prognostic index (PI) was built according to the formula: 120 - age + mean 24 h systolic blood pressure--(creatinine 9 10). Other variables were assessed: EF, haemoglobin concentration, mean 24 h heart rate and diastolic blood pressure, sodium level, pacing mode and diabetes. Non-arrhythmic cardiac death and new hospitalizations for heart failure during 1-year follow-up were the combined end point. A total of 48 events (25%) occurred during the follow-up: 7 cardiac deaths and 41 hospitalizations for acute heart failure. Cox proportional hazards model showed that PI was the only predictor of events (HR = 0.96; CI 95% 0.944­0.976, p < 0.0001). ROC curve showed that PI best cut-off was 144, with AUC 0.79, p < 0.0001; sensitivity 77%, specificity 74%, positive predictive value 50%, negative predictive value 90%. PI was predictive of events in a clinical setting where EF had no predictive value. PI works according to the rule ''the lower the worse''. The high negative predictive value (90%) of PI allows to identify subjects at lower risk for death and heart failure. PI can be a practical tool to stratify risk in ischemic cardiomyopathy.

Optimization of the atrioventricular delay in sequential and biventricular pacing: physiological bases, critical review, and new purposes.

Atrioventricular (AV) delay optimization in sequential and biventricular (BiV) pacing, although widely recommended, is often poorly performed in clinical practice as an improper setting can reduce the success of the stimulation. Despite the several methods proposed, the AV delay is frequently programmed in an empirical way or left to a predefined value (usually the manufacturer's setting), without considering the different variables involved in this context, concerning the intra- and interindividual variability of the electromechanical events, the peculiarities of the several cardiopathies, the spontaneous interatrial and AV conduction, the pharmacological therapy, and the pacing mode. The manuscript illustrates the physiological bases of the optimization, describes why and how to programme the best AV delay at rest and during daily activities and discusses critically all methods proposed, divided into three groups: predefined formulas, iterative attempts, and automatic settings. The manuscript is not only a review because it tries to clarify this complex topic, stating the fundamental concept in BiV pacing; the optimal AV delay should be short enough to have always a pre-exitated stimulation and contemporary an optimal left ventricular filling. The paper suggests new purposes and new solutions for this goal, it shows the limits of the actual guidelines and the disappointing results obtained in several studies by automatic methods, goading to find new algorithms.

Ambulatory blood pressure monitoring, 2D-echo and clinical variables relating to cardiac events in ischaemic cardiomyopathy following cardioverter-defibrillator implantation.

AIMS: Evaluation of ambulatory blood pressure monitoring (ABPM), two-dimensional (2D) echo and clinical variables in predicting cardiac death and acute decompensated heart failure in patients with ischaemic cardiomyopathy and receiving a cardioverter-defibrillator implantation. METHODS AND RESULTS: We studied 180 consecutive patients (169 men) on an out-patient basis, with systolic dysfunction (ejection fraction ≤35%) and previous myocardial infarction. All received a cardioverter defibrillator (ICD) (116 dual chamber, 36 monocameral and 28 biventricular), for primary prevention of sudden death and standard medical therapy for heart failure. Mean follow-up was 11.7 months. Two-dimensional echo was performed just before ICD implantation, ABPM and haematological samples 2 weeks later. Age, ejection fraction, creatinine, haemoglobin concentration, mean 24-h systolic blood pressure, mean 24-h diastolic blood pressure, mean 24-h heart rate, brain natriuretic peptide, QRS duration, % paced beats, ventricular scar, biventricular pacing, sex and diabetes were considered. Cox proportional hazards regression analysis was used to explore the relationship between events. ROC curves were built for each independent variable. Events occurred in 47 patients (26%); 7 deaths for refractory heart failure and 40 hospitalizations for acute decompensated heart failure. Low mean 24-h systolic blood pressure [hazard ratio 0.96, 95% confidence interval (CI) 0.93-0.99, P = 0.02], high creatinine (hazard ratio 1.61, 95% CI 1.06-2.47, P = 0.01), low haemoglobin concentration (hazard ratio 0.81, 95% CI 0.65-0.99, P = 0.04) and older age (hazard ratio 1.04, 95% CI 1.01-1.08, P = 0.02) were independent predictors of events. CONCLUSIONS: Ambulatory systolic blood pressure, haemoglobin, creatinine and age can stratify risk of death and acute decompensated heart failure in patients with ischaemic cardiomyopathy and ICD in whom 2D-echo ejection fraction is not predictive.

[Atrioventricular asynchrony and pacing]. / Asincronie atrioventricolari e pacing.

Atrioventricular dissociation and atrioventricular block are the most common types of atrioventricular asynchrony. Less frequently, atrioventricular asynchrony may occur in the pacemaker syndrome or during sequential pacing with programmed asynchronous atrioventricular delay. A rare type of atrioventricular asynchrony that has relevant hemodynamic effects is observed in first-degree atrioventricular block when associated with mitral stenosis or other conditions characterized by an obstruction of the left atrial outflow. Atrioventricular asynchrony can be defined as systolic when both the atrium and ventricle are contracting simultaneously (pacemaker syndrome, sequential pacing with programmed asynchronous atrioventricular interval), or systo-diastolic when atrial systole occurs at the onset of ventricular diastole as observed in patients with very long PR interval. All described asynchronies can be eliminated by sequential pacing with programmed synchronous atrioventricular delay.

A prognostic index relating 24-hour ambulatory blood pressure to cardiac events in ischemic cardiomyopathy following defibrillator implantation.

BACKGROUND: We assessed the role of left ventricular ejection fraction and of ambulatory blood pressure monitoring (ABPM) to predict cardiac death and heart failure in patients with defibrillator fulfilling MADIT II criteria. ABPM variables assessed included: mean 24 hours diastolic and systolic blood pressure, mean 24 hours heart rate, and pulse pressure. METHODS: We studied 105 consecutive patients (age 67 +/- 11), all with a defibrillator and ejection fraction or= 220 n = 71) had clinical events at 12-month follow-up, compared with 61% of patients with low PI (< 220 n = 34) (P < 0.0001). CONCLUSION: The PI built by mean 24 hours diastolic and systolic blood pressure and age could be a simple method to stratify risk of cardiac death and acute heart failure in MADIT II patients, in whom ejection fraction, uniformly depressed, is not predictive.

[The digitalis: should we forget it?]. / La digitale: un farmaco da dimenticare?

For more than 200 years digitalis has been considered of paramount importance in the treatment of heart failure and atrial fibrillation. The IN-CHF Italian registry shows that prescriptions were reduced from 63.3% in the period 1995-1999 to 40% in the period 2000-2005, a very different trend compared to prescriptions of angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, and beta-blockers. The commercial value of digitalis is much lower than other drugs and it does not seem to be of interest for the pharmaceutical companies. Unfortunately, this is a logical trend in the business world. For many years the major indications of digitalis have been heart failure and atrial fibrillation. The most important study on efficacy of digitalis in the treatment of heart failure was the DIG trial (1997), which showed no difference in mortality when compared to placebo but significant beneficial effects in reducing hospital admission rates. Many post-hoc researches evaluated blood levels of digitalis and proved beneficial effects also on mortality when digoxinemia values were 0.5-0.9 ng/ml. In conclusion, digitalis should still be considered effective for the treatment of heart failure; therefore prescription modality as well as the range of normal values of digoxinemia should be updated.

Ambulatory blood pressure monitoring early after acute myocardial infarction: development of a new prognostic index.

OBJECTIVES: The aim of our study was to assess the possible role of a prognostic index based on ambulatory blood pressure monitoring in a large cohort of patients with recent myocardial infarction. METHODS: The study population included 1335 consecutive patients admitted for ST elevation myocardial infarction and discharged alive from 48 Italian hospitals participating in the multicentric IMPRESSIVE (Infarto Miocardico, Pressione arteriosa e frequenza cardiaca. Studio Italiano di Valutazione Epidemiologica) study. Ambulatory blood pressure monitoring was performed 3 weeks after discharge, with a clinical follow-up of 12 months. End-points included cardiac death and new admission for heart failure. A prognostic index was obtained from the ambulatory blood pressure monitoring variables according to the formula: (220-age)-mean 24 h heart rate (m24hHR)+mean 24 h diastolic blood pressure (m24hDBP). RESULTS: Among many potential predictors only left-ventricular ejection fraction, creatinine levels, Killip class and the prognostic index were independently associated with events during the follow-up. In particular, higher values of the prognostic index were associated with a lower incidence of events, with an odds ratio of 0.958 (95% confidence intervals 0.943-0.974) and a 4% reduction in risk for each point of the prognostic index. Overall incidence of cardiac events was 6-fold higher in patients within the lowest quartile of the prognostic index (< or =148) compared with the other three quartiles (12 vs. 2, 1.4 and 2% respectively in the other three quartiles; P<0.0001). CONCLUSIONS: A simple prognostic index based on ambulatory blood pressure monitoring and age may be a useful tool in predicting cardiac death and heart failure in patients with recent myocardial infarction.

[Importance of spinal cord stimulation in the treatment of refractory angina]. / Il ruolo della stimolazione spinale nel trattamento dell'angina refrattaria.

A small non-quantified number of patients is reported to be affected by forms of angina pectoris already treated by traditional therapy but no longer able to achieve better results by drugs or surgery: this is called "refractory angina". Treatments like external counterpulsation, transmyocardial laser revascularization, stem cell transplantation or spinal cord stimulation may be suitable for these patients. The analysis of major studies on spinal cord stimulation based on exercise ECG, Holter monitoring and positron emission tomography, has shown a reduction in anginal attacks and in nitroglycerin pills. Though in small figures, an improved perfusion of the ischemic areas, an increase in the time of ischemia and cardiac mortality comparable to bypass surgery as well as a better quality of life and lower costs with respect to traditional treatment are also evident. Patients who are at high risk of mortality for bypass surgery, and who cannot receive significant benefits from revascularization or improved pharmacological therapy are candidate to spinal cord stimulation. Spinal cord stimulation is safe and effective in about 70% of patients. Some issues have not been investigated yet: the clinical characteristics of "non-responders" and the possibility of avoiding sudden cardiac death in stimulated patients.