Greater functional improvement in patients with diabetes after rehabilitation following cardiac surgery.

BACKGROUND: Diabetes increases the risk of in-hospital complications in medical or surgical patients. Few data are available in the rehabilitation phase after cardiac surgery. AIM: To assess the influence of diabetes on outcome and complication rate in the rehabilitation phase after cardiac surgery. METHODS: Data prospectively recorded in the Hospital Information System from 5261 patients consecutively admitted between 1 January 2008 and 31 May 2013 for a comprehensive cardiac rehabilitation programme directly after cardiac surgery were analysed retrospectively. RESULTS: The study cohort included 1285 (24%) patients with diabetes and 3976 (76%) without. Coronary artery bypass graft (CABG) was more frequent in patients with diabetes (58% vs. 37%, P < 0.01), and valvular surgery was more frequent in patients without diabetes (37% vs. 22%, P < 0.01). Patients with diabetes were more disabled after surgery, with severe disability (Barthel Index < 60) observed in 22% (vs. 17% in patients without diabetes, P < 0.001). During rehabilitation, complications were more frequent in patients with diabetes than those without (28% vs. 21%, P < 0.01); in particular, patients with diabetes had more infections, heart failure and more difficult surgical wound healing. However, the improvement in the Barthel Index was greater in patients with diabetes (+16 ± 15) than without (+13 ± 15, P < 0.001). CONCLUSIONS: In a large cohort of patients directly admitted to an early inpatient rehabilitation programme after cardiac surgery, those with diabetes were more disabled. Nonetheless, and despite the higher rate of complications, patients with diabetes had the greatest benefit in terms of functional improvement.

Bilateral cervical ribs in a Dobermann Pinscher.

An 11-year-old intact female Doberman Pinscher was presented with the complaint of non-ambulatory tetraparesis. Clinical and neurological examination revealed a caudal cervical spinal cord disfunction (C6-T2 spinal cord segments). Magnetic resonance imaging and computed tomographic (CT) findings of the cervical spine were consistent with caudal cervical spondylomyelopathy (CSM). During the diagnostic work-up for the cervical spine, bilateral bone anomalies involving the seventh cervical vertebra and the first ribs were found on radiographs and CT examination. The rib anomalies found in this dog appear similar to cervical ribs widely described in human medicine. In people, cervical ribs are associated with a high rate of stillbirth, early childhood cancer, and can cause the thoracic outlet syndrome, characterized by neurovascular compression at level of superior aperture of the chest. In dogs, only some sporadic anatomopathological descriptions of cervical ribs exist. In this report the radiographic and CT findings of these particular vertebral and rib anomalies along with their relationships with adjacent vasculature and musculature are shown intravitam in a dog. Specific radiographic and CT findings described in this report may help in reaching a presumptive diagnosis of this anomaly. Finally, their clinical and evolutionary significance are discussed.

Extradural spinal cord lesion in a dog: first case study of canine neurological histoplasmosis in Italy.

A 7-year-old intact male mixed dog was presented with a history of acute and progressive paraparesis. Abnormal clinical signs consisted of non-ambulatory paraparesis, hind limbs hypertonia and severe thoracolumbar pain. Magnetic resonance imaging demonstrated an isointense in T1 and T2 WI epidural lesion, with good contrast enhancement, extending from T-10 to T-13. Laminectomy was carried out to remove the epidural mass. Histological examination revealed a pyogranulomatous lesion characterized by numerous macrophages containing yeast-like Grocott and PAS-positive bodies. Immunohistochemistry and PCR performed on formalin-fixed paraffin-embedded tissue confirmed Histoplasma capsulatum as the causative agent. H. capsulatum has a worldwide distribution in temperate and subtropical climates but its presence as an autochthonous fungus in Europe is now recognized. To the authors' knowledge this is the first report of canine histoplasmosis in Italy with lesion confined to the central nervous system.

Tissue factor gene polymorphisms and haplotypes and the risk of ischemic vascular events: four studies and a meta-analysis.

OBJECTIVE: The exposure of tissue factor (TF) to blood flow is the initial step in the coagulation process and plays an important role in thrombogenesis. We investigated the role of genetic polymorphisms and haplotypes of the TF gene in the risk of ischemic vascular disease. METHODS: Four hundred and twenty-two Italian patients with juvenile myocardial infarction (MI) and 434 controls, 808 US cases with MI and 1005 controls, 267 Italian cases with juvenile ischemic stroke and 209 controls and 148 German cases with juvenile ischemic stroke and 191 controls were studied. rs1361600, rs3917629 (rs3354 in the US population), rs1324214 and rs3917639 Tag single nucleotide polymorphisms were genotyped. Additionally, a meta-analysis of all previous studies on TF loci and the risk of ischemic coronary disease (ICD) was performed. RESULTS: After multivariable analysis none of the SNPs, major SNP haplotypes or haplotype-pairs showed any consistent association with MI. Pooled meta-analysis of six studies also suggested that TF polymorphisms are not associated with CHD. A significant, independent association between SNP rs1324214 (C/T) and juvenile stroke was found in Italian and German populations (OR for TT homozygotes = 0.47, 95% CI 0.24-0.92, in combined analysis). Pooled analysis also showed a significant association for haplotype H3 (OR = 0.76, 95% CI 0.57-1.00) and haplotype-pair H3-H3 (OR = 0.43, 95% CI 0.20-0.92). CONCLUSIONS: TF genetic variations were associated with the risk of ischemic stroke at young age, but did not affect ischemic coronary disease.

Early right coronary vasospasm presenting with malignant arrhythmias in a heart transplantation recipient without allograft vasculopathy.

In heart transplant recipients, the aetiology of coronary vasospasm is largely unknown but it has been reported to be related to coronary vasculopathy or allograft rejection. We report a case of acute, reversible coronary vasospasm which caused malignant arrhythmias in a cardiac transplant recipient one month after transplantation without evidence of coronary vasculopathy or allograft rejection. The patient had a normal post-operative course with no other complications; this case supports the hypothesis that coronary vasospasm is not necessarily related to epicardial coronary artery disease or allograft rejection, but rather may be due to an abnormal reversible vasoreactivity.

Right ventricular functional recovery after acute myocardial infarction: relation with left ventricular function and interventricular septum motion. GISSI-3 echo substudy.

OBJECTIVE: To evaluate the pattern of right ventricular (RV) functional recovery and its relation with left ventricular (LV) function and interventricular septal (IVS) motion in low risk patients after acute myocardial infarction (AMI). DESIGN AND SETTING: Multicentre clinical trial carried out in 47 Italian coronary care units. PATIENTS: 500 patients from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico) -3 echo substudy, who underwent serial echocardiograms 24-48 hours after symptom onset and at discharge, six weeks, and six months after AMI. RESULTS: Tricuspid annular plane systolic excursion (TAPSE) increased significantly during follow up (mean (SD) 1.79 (0.46) cm at 24-48 hours to 1.92 (0.46) cm at six months, p < 0.001) and the increase was already significant at discharge (1.88 (0.47) cm, p < 0.001). LV ejection fraction (LVEF) was the best correlate of TAPSE at 24-48 hours (r = 0.15, p = 0.001). TAPSE increased significantly in patients both with reduced (< 45%) and with preserved (> or = 45%) LVEF, but the magnitude of increase was higher in patients with lower initial LVEF (p = 0.001). Improvement in IVS wall motion score index (IVS-WMSI) was the only independent predictor of TAPSE changes during follow up (r = -0.12, p = 0.007). CONCLUSIONS: In low risk patients after AMI, RV function recovered throughout six months of follow up and was already significant at discharge. TAPSE was significantly related to LVEF at 24-48 hours. The magnitude of RV functional recovery was higher in patients with lower initial LVEF. RV functional recovery is best related to IVS-WMSI improvement, suggesting that IVS motion has an important role in RV functional improvement in this setting.

Polymorphisms of the interleukin-1beta gene affect the risk of myocardial infarction and ischemic stroke at young age and the response of mononuclear cells to stimulation in vitro.

OBJECTIVE: To investigate the role of interleukin-1beta (IL-1beta) gene polymorphisms as a link between inflammation, coagulation, and risk of ischemic vascular disease at young age. METHODS AND RESULTS: A total of 406 patients with myocardial infarction (MI) at young age, frequency-matched for age, sex, and recruitment center, with 419 healthy population-based controls and 134 patients with ischemic stroke at young age, matched by age and sex, with 134 healthy population-based controls, were studied. Subjects carrying the TT genotype of the -511C/T IL-1beta polymorphism showed a decreased risk of MI (odds ratio [OR], 0.36; 95% CI, 0.20 to 0.64) and stroke (OR, 0.32; 95% CI, 0.13 to 0.81) after adjustment for conventional risk factors. In both studies, the T allele showed a codominant effect (P=0.0020 in MI; P=0.021 in stroke). Mononuclear cells from volunteers carrying the T allele showed a decreased release of IL-1beta and a decreased expression of tissue factor after stimulation with lipopolysaccharide compared with CC homozygotes. The presence of a monoclonal antibody against IL-1beta during cell stimulation resulted in a marked reduction of tissue factor activity expression. CONCLUSIONS: -511C/T IL-1beta gene polymorphism affects the risk of MI and ischemic stroke at young age and the response of mononuclear cells to inflammatory stimulation.

Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented.

Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.

["Bad" sleepers... Causes, effects, and diagnosis of sleep-related breathing disorders in cardiac patients]. / Chi dorme "male" ... cause, effetti e diagnosi dei disturbi del respiro durante il sonno del paziente cardiopatico.

Cardiovascular and cerebrovascular disease are the most common life-threatening disease in the industrialized world. There is high interest in sleep apnea and cardiovascular disease: several studies have demonstrated an association between sleep apnea and cardiovascular and cerebrovascular events. The aim of this review is to critically appraise the possible adverse physiological consequences of sleep apnea on the cardiovascular system and to assess whether such adverse effects constitute a risk for the development of cardiovascular disease.

Relation between early mitral regurgitation and left ventricular thrombus formation after acute myocardial infarction: results of the GISSI-3 echo substudy.

OBJECTIVE: To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus. DESIGN AND SETTING: Multicentre clinical trial carried out in 47 Italian coronary care units. PATIENTS AND METHODS: 757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24-48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views. RESULTS: In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v 59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v 48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m(2), p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m(2), p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction. CONCLUSIONS: Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only independent determinant of left ventricular thrombosis is the extent of the akinetic-dyskinetic area detected on echocardiography between 24-48 hours from symptom onset.

Prediction of 6 months left ventricular dilatation after myocardial infarction in relation to cardiac morbidity and mortality. Application of a new dilatation model to GISSI-3 data.

AIMS: To predict the long-term left ventricular volume index early after myocardial infarction and to investigate the relationship between long-term left ventricular dilatation risk and clinical outcome. METHODS AND RESULTS: By applying a previously developed dilatation model, we predicted the 6-month left ventricular volume index early after myocardial infarction (median 9 days) in 13,679 GISSI-3 patients, to identify patients at high risk of long-term left ventricular dilatation. The left ventricular systolic and diastolic volume indexes at 6 months were predicted with r=0.72 and r=0.68, respectively, in the subgroup of patients in whom a pre-discharge echo was available (n=7842). Patients predicted to be at risk for long-term left ventricular dilatation had an increased risk of mortality (RR 1.87, 95% CI: 1.48 to 2.36) and heart failure at 6 months (RR 2.59, 95% CI:2.04 to 3.28), but no increased risk of reinfarction at 6 months (RR 1.12, 95% CI: 0.87 to 1.45) or of angina pectoris (RR 1.07, 95% CI: 0.95 to 1.20). CONCLUSION: Our prediction of long-term left ventricular dilatation, obtained by applying our new dilatation model in over 13,000 GISSI-3 patients, correlated well with mortality and heart failure after myocardial infarction. Therefore, our new dilatation model may contribute to more efficient risk stratification early after myocardial infarction.

Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure.

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.

Chlamydia pneumoniae and cytomegalovirus seropositivity, inflammatory markers, and the risk of myocardial infarction at a young age.

BACKGROUND: Pathogens causing chronic infections may promote atherosclerosis. The aim of our study was to evaluate the association of Chlamydia pneumoniae (Cp) and cytomegalovirus (CMV) infection and of inflammatory activation with premature myocardial infarction (MI). METHODS: Specific anti-Cp and anti-CMV immunoglobulin G (IgG), fibrinogen, white blood cells (WBC), and C-reactive protein (CRP) were measured in 120 post-MI patients

Electrocardiographic evolution after Q-wave anterior myocardial infarction: correlations between QRS score and changes in left ventricular perfusion and function.

BACKGROUND: In the thrombolytic era, conflicting data have been reported on the usefulness of the QRS score in estimating the amount of left ventricular (LV) damage after acute myocardial infarction (MI). METHODS AND RESULTS: We correlated the QRS score with the extent of LV hypoperfusion and ejection fraction (EF) in 95 consecutive male patients with a first anterior Q-wave MI; the 6-month evolution of QRS score and changes in LV perfusion and function were also compared. The Selvester-Wagner QRS score was computed from the digitized 12-lead electrocardiogram, both at predischarge and 6 months later; at the same time, resting sestamibi first-pass ventriculography and single photon emission computed tomography imaging were performed. A reduction in QRS score occurred at 6 months (6.7 +/- 3.4 vs 7.8 +/- 2.9 at predischarge; P <.001); the perfusion defect extent also decreased (P <.01), and LV EF improved (P <.05). At predischarge, no correlation was found between QRS score and hypoperfusion extent or EF; in contrast, a weak correlation was observed 6 months later (r = 0.55; P <.001; and r = 0.48; P <.01, respectively). QRS score changes from predischarge to 6 months showed limited accuracy in predicting clinically meaningful changes of perfusion or EF (receiver operating characteristic area under the curve, 0.58 and 0.61, respectively). Thrombolytic therapy did not influence the relationship between QRS score and scintigraphic findings. CONCLUSIONS: In patients with recent anterior Q-wave MI, QRS scoring showed a weak, delayed correlation with the amount of LV damage, as estimated by radionuclide techniques. Spontaneous changes in QRS score from predischarge to 6 months seem to be of limited value in identifying patients with late improvement in LV perfusion and function.

Restrictive left ventricular filling pattern as a strong predictor of depressed baroreflex sensitivity in heart failure.

BACKGROUND: The aim of this study was to test the hypothesis that a restrictive left ventricular diastolic filling pattern, as an index of elevated pulmonary wedge pressure, would predict a depressed baroreflex sensitivity (BRS) in patients with chronic heart failure. METHODS: A total of 189 consecutive patients with an ejection fraction < or = 40% at echocardiography, in sinus rhythm and clinically stable for at least 1 month in oral therapy, underwent clinical examination, echo-Doppler study and the phenylephrine test. RESULTS: The correlations between the NYHA functional class, echo-Doppler variables and BRS were weak, although significant (r ranging from -0.15 to 0.40). However, patients with a deceleration time < 140 ms as an expression of restrictive filling, compared to those with a deceleration time > or = 140 ms, had a lower BRS (3 +/- 4 vs 6 +/- 4 ms/mmHg, p < 0.00001), a lower ejection fraction (20 +/- 6 vs 28 +/- 7%, p < 0.00001), greater left ventricular (end-diastolic volume index 137 +/- 43 vs 113 +/- 45 ml/m2, p < 0.00001) and left atrial dimensions (25 +/- 6 vs 20 +/- 5 cm2, p < 0.00001), more severe mitral regurgitation (3 +/- 1 vs 2.3 +/- 1, p < 0.00001) and were in a higher NYHA class (2.3 +/- 0.6 vs 1.8 +/- 0.5, p < 0.00001). Medications at the time of the study were similar in the two groups. At stepwise regression analysis, the deceleration time emerged as the most powerful independent predictor of a depressed BRS (< 3 ms/mmHg), followed by mitral regurgitation, age, and NYHA class (all data p = 0.0001). CONCLUSIONS: In patients with chronic heart failure, the presence of a restrictive left ventricular filling pattern is highly predictive of autonomic derangement as expressed by low values of BRS.

Accurate noninvasive estimation of pulmonary vascular resistance by Doppler echocardiography in patients with chronic failure heart failure.

OBJECTIVES: This study was undertaken to explore further the relationship between Doppler-derived parameters of pulmonary flow and pulmonary vascular resistance (PVR) and to determine whether PVR could be accurately estimated noninvasively from Doppler flow velocity measurements in patients with chronic heart failure. BACKGROUND: The assessment of PVR is of great importance in the management of patients with heart failure. However, because of the inconclusive and conflicting data available, Doppler estimation of PVR is still considered unreliable. METHODS: Simultaneous Doppler echocardiographic examination and right heart catheterization were performed in 63 consecutive sinus rhythm heart failure patients with severe left ventricular systolic dysfunction. Hemodynamic PVR was calculated with the standard formula. The following Doppler variables on pulmonary flow and tricuspid regurgitation velocity curve were correlated with PVR: maximal systolic flow velocity, pre-ejection period (PEP), acceleration time (AcT), ejection time, total systolic time (TT), velocity time integral, and right atrium-ventricular gradient. RESULTS: At univariate analysis, all variables except maximal systolic flow velocity and velocity time integral showed a significant, although weak, correlation with PVR. The best correlation found was between AcT and PVR (r = -0.68). By regression analysis, only PEP, AcT and TT entered into the final equation, with a cumulative r = 0.87. When the function (PEP/AcT)/TT was correlated with PVR, the correlation coefficient further improved to 0.96. Of note, this function prospectively predicted PVR (r = 0.94) after effective unloading manipulations. CONCLUSIONS: The analysis of Doppler-derived pulmonary systolic flow is a reliable and accurate tool for estimating and monitoring PVR in patients with chronic heart failure due to left ventricular systolic dysfunction.