ICF-based approach to evaluating functionality in cardiac rehabilitation patients after heart surgery.

BACKGROUND: Heart surgery is a frequent reason for admission to in-patient cardiac rehabilitation programmes. ICF approach has never been used to evaluate cardiac patients after major heart surgery. AIM: The aim was to evaluate and measure functionality in cardiac patients who have undergone heart surgery, using for the first time the ICF-based approach and to assess whether such approach can be feasible and useful in cardiac rehabilitation. DESIGN: Observational study. SETTING: In-patients cardiac Rehabilitation Unit in Milan. POPULATION: Fifty consecutively admitted patients who had undergone heart surgery (34 males, 16 females; mean age 65.7±12.5 years). METHODS: We prepared a ICF-core set short enough to be feasible and practical. Patients were individually interviewed by different healthcare professionals (randomly selected from a group of two physicians, two physiotherapists and two psychologists) at the beginning (T1) and end of cardiac rehabilitation (T2) RESULTS: The sum of the scores of each ICF body function, body structure, activity and participation code significantly decreased between T1 and T2 (P<0.001). The environmental code scores significantly decreased in the case of facilitators between T1 and T2 (P=0.0051), but not in the case of barriers. There were significant correlations between the ICF body function scores and Barthel's index (ρ=0.381; P=0.006), NYHA class (ρ=0.404; P=0.004) and plasma Cr-P levels (r=0.31; P=0.03), between the ICF body structure codes and the Conley scale (ρ=0.306; P=0.02), and between the activity/participation codes and SpO2 (ρ=0.319; P=0.04). There were no correlations between the ICF environmental codes and clinical parameters. CONCLUSION: The ICF-based data provided functional information that was consistent with the patients' clinical course. CLINICAL REHABILITATION IMPACT: The core set used allowed to quantify important body functions and activities, including some areas that are generally insufficiently considered by healthcare professionals during cardiac rehabilitation, and document their improvement.

Heart adaptations to long-term aerobic training in paraplegic subjects: an echocardiographic study.

STUDY DESIGN: Case-control. OBJECTIVES: To execute an echocardiographic comparison between trained and untrained spinal cord injury (SCI) subjects, and to evaluate whether long-term heart adjustments to endurance training are comparable to those observed in able-bodied (ABL) subjects. SETTING: Italy. METHODS: We enrolled: (1) 17 male SCI patients (lesion level T1-L3, 34±8 years, body mass index (BMI) 23.0±2.8 kg m(-2)), 10 of whom were aerobically trained for >5 years (SCI(T)); (2) 18 age-, sex- and BMI-matched ABL subjects (35±6 years, BMI 23.6±2.8 kg m(-2)), 10 of whom were aerobically trained for >5 years (ABL(T)). Training frequency and volume were recorded by a dedicated questionnaire. All subjects underwent a trans-thoracic echocardiography; SCI subjects also performed an exhaustive incremental exercise test. Comparisons were made between ABL and SCI groups, between trained and untrained subjects within each group (analysis of variance). RESULTS: Effects of SCI-Compared with ABL subjects, SCI patients showed lower end-diastolic volume (76±21 vs. 113±23 ml, P<0.05) and ejection fraction (61±7% vs. 65±5%, P<0.05). Effects of training-Compared with untrained status, the intra-ventricular septum thickness (SCI, +18%; ABL, +4%), the posterior wall thickness (SCI, +17%; ABL, +2%) and the total normalized heart mass (SCI, +48%; ABL, +5%) were higher in both SCI(T) and in ABL(T). VO2peak was higher in the SCI(T) subgroup compared with the SCI(U) group. CONCLUSIONS: Heart seems to positively adapt to long-term endurance training in SCI patients. Regular exercise may therefore increase heart size, septum and posterior wall thickness, which likely contributes to improved VO2peak. These morphological and functional changes may reduce cardiovascular risk in SCI individuals.

[Use of nitrates after recent myocardial infarction: when, how, and why]. / Impiego dei farmaci nitroderivati dopo recente infarto miocardico: quando, come e perché.

Nitrates are useful drugs in patients affected by recent myocardial infarction: they have an anti-ischemic and anti-anginal effect; moreover they are effective on left ventricular remodeling, with few side-effects. Meta-analysis studies performed on patients treated with nitrates intravenously for acute myocardial infarction in the pre-thrombolytic era showed a reduction of the necrotic area and of the global mortality. On the contrary experimental studies conducted using nitrates orally showed no significant clinical effects. Two post-thrombolytic studies, ISIS-4 and GISSI-3, enrolling large numbers of patients after an acute myocardial infarction, randomized to assume placebo or nitrates, administered orally and/or transdermally, demonstrated moderate and significant reductions in mortality only in some subgroups of patients treated with the active drug compared to placebo. Nitrates as drugs are "imperfect imitators" of endogenous nitrates and so can produce some negative effects. In this review the different modes of drug administration and the respective posologies of the various sublingual, spray, and oral formulations in standard, long-acting or transdermal preparations are considered. Three problems should be considered by clinicians using nitrates: resistance, tolerance and rebound. The strategies to counteract these phenomena, as well as the clinical indications and the favorable effects that can be obtained using nitrates in post-infarct patients are also discussed.

Risk of rebound phenomenon during nitrate withdrawal.

Organic nitrates are first-line drugs in the therapy and prevention of angina. These compounds, are acutely effective yet some formulations demonstrate a rapid decline in effect with chronic use. In this review the mechanisms of development of nitrate tolerance and the different strategies to prevent it are considered. If frequent dosing, high dosages and long acting preparations giving constant 24 h plasma GTN levels are more likely to cause tolerance, nitrate-low periods seem to be effective in restoring the drug's efficacy. Intermittent therapy with GTN patches, an effective way to prevent tolerance, raises the problem of the rebound phenomenon during the removal period. Considerable variations in its occurrence have been reported and in this review the factors that may influence the incidence of the rebound are discussed. The dangers of rebound can be lessened by concomitant anti-anginal drugs or avoiding any abrupt decline in blood nitrate concentrations. The use of beta-blockers or calcium channel blockers during intermittent therapy with GTN patches and oral preparations of isosorbide dinitrate or isosorbide 5-mononitrate seem to be effective for this purpose.

Intermittent transdermal nitroglycerin monotherapy in stable exercise-induced angina: a comparison with a continuous schedule.

The aim of this study was to investigate nitrate tolerance during continuous treatment with nitroglycerin patches (NTG) as monotherapy, and to assess whether tolerance might be prevented by an overnight nitrate-free interval. Ten male patients, of mean age 53.2 years (range 41-62 years), with pathological coronary angiography and stable exercise-induced angina pectoris took part in a double-blind crossover study (two 15-day periods), during which the continuous and intermittent (12-h nitrate-free interval) application of NTG 20 mg (24 h)-1 patches were compared. Single-blind placebo was given acutely before and at the end of the crossover. Exercise testing was performed on a treadmill according to the Bruce protocol 4 and 12 h after dosing, both during placebo and at the end of the two active treatment periods. In comparison with continuous treatment, the intermittent administration of 20 mg (24 h)-1 NTG patches significantly increased ischaemic threshold and total work time at the 4th and the 12th hour. Night-time withdrawal of NTG transdermal delivery systems determined during the 15-day period a total of 11 night anginal attacks in six out of 10 patients (0.07 attacks per patient per nitrate-free interval).

The effects on exercise tolerance of a new transdermal therapeutic system containing nitroglycerine, in patients with stable angina pectoris.

In two randomized, double blind, placebo-controlled, within patient, studies, the effects of 4 doses of a new transdermal therapeutic system containing nitroglycerin (TTS-NTG) were studied in a total of 15 patients with stable exercise-induced angina pectoris. A single 24-hour application of TTS-NTG 10 cm2, TTS-NTG 20 cm2 and TTS placebo (1st study: 6 patients) and of TTS-NTG 40 cm2, TTS-NTG 80 cm2 and TTS placebo (2nd study: 9 patients) was applied on 3 different days, and a symptom-limited cycloergometric exercise test was performed 3, 12 (only in the 2nd study) and 24 hours after the application of each treatment. In comparison with placebo, the doses tested in the 1st study induced, at the 3rd hour post-dosing, a decrease in standing systolic blood pressure and an improvement in exercise tolerance which, however, were not statistically significant while the effects at the 24th hour were similar to those of placebo. In the 2nd study, in comparison with placebo, both TTS-NTG doses induced, 3 hours post-dosing, a significant decrease in both lying and standing systolic (P less than 0.01) blood pressure at rest, and a significant (P less than 0.01) improvement in exercise tolerance throughout the 24 hours of application. It is concluded that, in patients with exercise-induced angina pectoris due to coronary artery disease, a single application of TTS-NTG 40 cm2 or 80 cm2 results in a 24-hour increase in exercise tolerance.

[Diagnostic reliability of clinical and instrumental data in identifying the presence of coronary disease in women with chest pain]. / Attendibilità diagnostica dei dati clinici e strumentali nell'identificare la presenza di coronaropatia nelle donne con dolore toracico.

The present study was performed to assess the reliability of clinical symptom, rest and exercise electrocardiogram, exercise Thallium myocardial scintigraphy, as well as rest and exercise radionuclide angiocardiography, in order to detect significant coronary artery disease in 85 female patients with chest pain, who underwent coronary angiography. Of these, 54 underwent Thallium myocardial scintigraphy, 53 rest and exercise radionuclide angiocardiography. We have evaluated sensibility, specificity and positive and negative predictive value for each single variable or every possible combination. Within the population examined, Thallium myocardial scintigraphy reaches the highest sensibility (92%), specificity (92.5%), positive predictive (81%) and negative predictive value (97%). In comparison with all other clinical or instrumental parameters, taken either single or in combination. By subdividing the sample in two groups, of 20 and 65 patients respectively on the basis of the clinical symptom angina or thoracoalgy, with different predominance of coronaropathy (60 and 15%), Thallium myocardial scintigraphy is confirmed to be the most reliable diagnostic test (within the angina group sensibility 86%, specificity 100%, positive predictive value 100%, negative predictive value 83%, within the thoracoalgy group sensibility 100%, specificity 91%, positive predictive value 70%, negative predictive value 100%). However, within the thoracoalgy group, a negative maximal exercise test and a normal rest radionuclide angiocardiography detect patients with low probability of coronaropathy (negative predictive value respectively 100% and 93%). Within the angina group only Thallium myocardial scintigraphy significantly increases the predictive value of the angina symptom itself with respect to the presence of coronaropathy (positive predictive value of angina symptom alone 60%, of angina symptom plus Thallium myocardial scintigraphy 100%).

[Myocardial revascularization in patients with severe ventricular impairment. Short-term follow-up]. / L'intervento di rivascolarizzazione miocardica nei pazienti con severa compromissione ventricolare. Follow-up a breve termine.

To assess the influence of aorto-coronary bypass grafting on surgical risk and short-term survival of patients with marked impairment of left ventricular (LV) function, we evaluated--among 435 patients who underwent coronary bypass surgery between January 1981 and December 1982--22 cases with: LV ejection fraction (EF) less than or equal to 0.35 (mean 0.27 +/- 0.06), LV end-diastolic pressure greater than or equal to 15 mmHg (mean 19.9 +/- 6.9 mmHg.), presence of three or more dysfunctional (hypokinetic or akinetic) segments on biplane LV angiography, three vessels disease in 90.1%. All patients but two had angina refractory to medical therapy. Operative mortality rate was 4.5%. Perioperative non fatal infarction rate was 9.1%. There were three late deaths. Mean duration of follow-up was 10.5 +/- 8.3 months with a survival of 81.8%. In the survivors we observed: dramatic improvement in respect to angina (94.5% are asymptomatic) and quality of life; exercise performance improvement (75% of patients have a functional impairment less than or equal to 30% at treadmill test); significant improvement in global and segmental LV function (mean echocardiographic EF 0.37 +/- 0.10, p less than 0.001). Because of relative low surgical risk and encouraging short-term results, aortocoronary bypass grafting can be performed even in patients with important LV disfunction, when associated with severe angina.

[The alkalinization test in the diagnosis of spontaneous angina]. / Il test di alcalinizzazione nella diagnosi di angina spontanea.

The induction of alkalosis has been proposed as provocative test of coronary spasm in patients affected by vasospastic angina. We submitted to the test 43 patients, affected by angina with a previous documentation of spontaneous ischemia (19 patients with ST elevation and 24 patients with ST depression at the EKG registered during pain). Twelve patients had normal coronary arteries; in 14 patients a significant stenosis of a single vessel was present; in 15 patients 2 vessels were involved and in 2 a 3-vessel disease was demonstrated. The test induced ischemia in 17 patients (39.6%). The positivity of the test was strictly dependent on the period of time elapsed between the last documented crisis of angina and the provocative test: it induced ischemia in 75% of the patients who underwent the test in the acute phase: on the other hand it was constantly negative in patients who had not complained of anginal pain for more than 6 months. In the screening of patients with chest pain at rest, the test of alkalosis does not seem, therefore, useful as a diagnostic tool.

[Exercise test in 100 healthy children between 5 and 12 years of age (author's transl)]. / Valutazione ergometrica di 100 bambini normali tra i 5 e i 12 anni.

100 healthy children, between 5 and 12 years of age underwent maximal exercise test on a bicycle ergometer in sitting position. Particularly interesting seem to be the observations on maximal heart rate during exercise, maximum work load, energy cost in terms of heart rate, EGG during exercise. As concerning the maximal heart rate, it was observed a levelling of around 195 beats min. for all the subjects. A low increase of systolic blood pressure was observed during strenuous exercise. The maximum tolerated work load increases accordingly with the increase of body surface area and age; taking into account the maximum value of heart rate during exercise (195 for all subjects), it arises a different energetic cost in terms of beats per min. in favour of 12 years subjects compared to youngers. None rhythm or conduction disturbances was observed during exercise, neither variations of the ventricular repolarization appeared during exercise.

[Clinical and angiographic study of 51 patients with myocardial infarction aged up to 35 years (author's transl)]. / Studio clinico-cineangiocardiografico di 51 casi di infarto miocardico giovanile (35 anni).

The clinical and angiographic data of 51 patients 35 years-old or below with myocardial infarction were studied. The average age of the patients was 30.2 years. Cigarette smoking and familiar history for coronary artery disease (present respectively in 74.5 and 39.1 per cent of the patients) were the most frequent risk factors for coronary disease. The patients were divided into two groups without (group A) and with (group B) post-infarctional complications (angina, dangerous ventricular arrhythmias, left ventricular failure, re-infarction). The coronary arteries were normal in 46.1 per cent of the patients of group A, and in 11.1 per cent of the patients of group B (p less than 0,05). 33.3 per cent of the patients of group A were affected by 1 vessel disease and so were 40.7 per cent of the patients of group B (p = ns). 48.1 per cent of the patients of group B were affected by 2 or 3 vessels disease and so were 25 per cent of patients group A (p = ns). Left ventricular angiography revealed severe impairment of contractility in 70,3 per cent of the patients of group B and in 45.8 per cent in group A. A history of angina before myocardial infarction was connected with the presence of coronary artery disease in 87 per cent of patients.

[Single vessel coronary disease. I. Differences in clinical and prognostic aspects and in surgical results in isolated lesions of the anterior descending branch and of other coronary branches]. / Coronaropatie monovascolari. i) Differenze cliniche, prognostiche e di risultati chirurgici tra lesioni isolate della discendente anteriore e di altri rami coronarici.

This study includes 290 patients having a 75% or greater stenosis of a sinlge coronary vessel, divided into two groups: 205 cases with isolated lesions of the left anterior descending coronary artery (LAD) and 85 with a stenosis of the circumflex (CF) or of the right (RCA) coronary artery. The following data have been compared in the two groups: -- characters of angina; -- results of stress testing; -- extent of left ventricular contraction impairment; -- natural history of unoperated patients; -- surgical risk; -- long term survival of operated patients; -- effect of medical or surgical treatment on symptoms. Results were as follows: -- LAD patients had slightly more severe symptoms and lower exercise tolerance than CF and RCA patients; -- no significant differences were noted as regards left ventricular contraction; -- five year survival rates were only slightly different both regarding unoperated patients (80 +/- 5% survival in LAD disease group; 86 +/- 5% in CF and RCA disease) and operated cases (83 +/- 5% in LAD lesions, 86 +/- 7% in CF and RCA disease); -- surgical risk was relatively low in both groups; -- progress of symptoms after bypass surgery was very favourable. Based on these results, indications for surgery in single coronary vessel disease are discussed.

[Natural history of angina pectoris: follow-up on 519 unoperated patients (author's transl)]. / Storia naturale dell'angina pectoris. Studio longitudinale su 519 pazienti non operati.

519 patients with angina pectoris studied by selective coronary arteriography and left ventriculogram, were followed for a period ranging from 18 months to 7 years. The mean follow-up was 42.2 months. The patients showed a survival probability of 81% at the 7th year. After 5 years the survival probability was 83.2% for patients with typical stable angina, 70.3% for patients with unstable angina, 96.7% for patients with atypical angina. The survival probability was 78.8% for the male sex and 94.6% for the female (at the 5th year). Age, a long-lasting angina, the presence of: previous infarction, myocardial failure, cigarette smoking, hyperlipidemia, cardiomegaly and an ischemic resting EKG were factors with poor prognostic value. The prognostic value of significant coronary stenosis was confirmed. The survival probability at the 5th year of the patients without critical stenosis was 96.6%, of patients with stenosis of 1, 2 and 3 main coronary arteries was respectively: 87.6%, 79% 54.7%. Significative prognostic differences were observed in patients with normal left ventricle kinesia (survival probability at the 5th year: 90%), compared with patients with severe VS ipokinesia (62.7%) and with VS diskinesia (69%). In the follow-up period an incidence of 9% of myocardial infarctions was observed. The degree of each stenosis and the number of vessels involved, the type of angina, the presence of risk factors or previous myocardial infarction did not affect the clinical evolution of angina.