[Objectives, organization and activities of a nurse-led clinic for outpatient cardiology care]. / Obiettivi, organizzazione e attività di un Ambulatorio Infermieristico Cardiologico di Continuità Assistenziale.

BACKGROUND: Cardiovascular diseases are the first cause of death worldwide. In the last decades, therapeutic advances have determined an increase in survival rates, with a subsequent rise in the number of elderly people suffering from chronic cardiovascular diseases and associated comorbidities requiring comprehensive, team-based multidisciplinary care. The aim of this study is to describe the organization, purposes and activities of a nurse-led cardiology clinic. METHODS: Between November 1, 2009 and October 31, 2014, the nurse-led clinics located within our Cardiology Outpatient Center provided care to 2081 out of 26 057 patients (8%) with complex healthcare needs, high cardiovascular risk and/or specific therapeutic indications or needs for reassessment; 1875 of these patients received nurse-led interventions: 451 (21.7%) in Chronic Heart Disease (CHD) care; 402 (19.3%) in Heart Failure (HF) care; 1022 (49.1%) at the Oral Anticoagulant Therapy (OAT) care, while 206 patients (9.9%) underwent Nurse Triage. Nursing assessment includes a clinical multidimensional analysis, with identification of relevant health issues and planning of a nursing intervention (education, intensified monitoring, and support to therapy) shared with the cardiologist in a joint report. RESULTS: The clinical characteristics and the social care needs of the patients who received nurse-led care were extremely heterogeneous. Patients with heart failure were the oldest (79 years), most severe (58.2% hospitalized last year), with Charlson index ≥3% (82.8 %); 72.4% were taking ≥7 drugs daily. The majority of them had medium-to-low education levels and more frequently lived alone, with disabilities, inadequate self-monitoring, and self-care behaviors. Patients on anticoagulant therapy were younger (71 years), in 75.9% of cases with atrial fibrillation, most frequently assisted by a caregiver and without functional limitations. The patients of these two nurse-led clinics (HF and OAT) were those who came most frequently after hospital discharge, presented mainly clinical instability and problems of adherence to the therapeutic programs, and needed in most cases a therapeutic intervention associated with an intensification of clinical/behavioral monitoring. CONCLUSIONS: Nursing assessment supports the specialist's intervention by intensifying clinical surveillance and therapeutic intervention in the most complex real-world patients. It provides information to complete the cardiological assessment and is essential to better understand patients' health and social care needs, and to suggest and coordinate a tailor-made plan.

Echocardiographic markers of inducible myocardial ischemia at baseline evaluation preparatory to exercise stress echocardiography.

BACKGROUND: Tissue Doppler Imaging (TDI) is a sensible and feasible method to detect longitudinal left ventricular (LV) systolic dysfunction (LVSD) in patients with diabetes mellitus, hypertension or ischemic heart disease. In this study, we hypothesized that longitudinal LVSD assessed by TDI predicted inducible myocardial ischemia independently of other echocardiographic variables (assessed as coexisting potential markers) in patients at increased cardiovascular (CV) risk. METHODS: Two hundred one patients at high CV risk defined according to the ESC Guidelines 2012 underwent exercise stress echocardiography (ExSEcho) for primary prevention. Echocardiographic parameters were measured at rest and peak exercise. RESULTS: ExSEcho classified 168 (83.6 %) patients as non-ischemic and 33 (16,4 %) as ischemic. Baseline clinical characteristics were similar between the groups, but ischemic had higher blood pressure, received more frequently beta-blockers and antiplatelet agents than non-ischemic patients. The former had greater LV size, lower relative wall thickness and higher left atrial systolic force (LASF) than the latter. LV systolic longitudinal function (measure as peak S') was significantly lower in ischemic than non-ischemic patients (8.7 ± 2.1 vs 9.7 ± 2.7 cm/sec, p = 0.001). The factors independently related to myocardial ischemia at multivariate logistic analysis were: lower peak S', higher LV circumferential end-systolic stress and LASF. CONCLUSIONS: In asymptomatic patients at increased risk for adverse CV events baseline longitudinal LVSD together with higher LV circumferential end-systolic stress and LASF were the factors associated with myocardial ischemia induced by ExSEcho. The assessment of these factors at standard echocardiography might help the physicians for improving the risk stratification among these patients for ExSEcho.

Insights from Cardiac Mechanics after Three Decades from Successfully Repaired Aortic Coarctation.

BACKGROUND AND AIMS: Patients who underwent a successful repair of the aortic coarctation show chronic hyperdynamic state and normal left ventricular (LV) geometry; however, there are few data regarding the LV systolic function in the long term. Accordingly, we assessed LV systolic mechanics and factors associated with LV systolic dysfunction (LVSD) in patients with repaired CoA. METHODS: Clinical and echocardiographic data from 19 repaired CoA were analyzed 28 ± 13 years after surgery. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were analyzed as indexes of LV circumferential and longitudinal systolic function, respectively. Echocardiographic data of CoA patients were compared with 19 patients matched for age and hypertension and 38 healthy controls. Sc-MS was considered impaired if <89%, S' if <8.5 cm/s (10th percentiles of healthy controls, respectively). RESULTS: There were no statistical differences between study groups in LV volumes, mass and geometry. LV ejection fraction and Sc-MS were similar in all groups, however, CoA group had a significantly lower peak S' in comparison with matched and healthy controls (7.1 ± 1.3, 10.3 ± 1.9, and 11.1 ± 1.5, respectively; all P < 0.001). Prevalence of longitudinal LVSD defined as low S' was 84% in CoA, 13% in matched, and 5% in healthy control group (all P<0.05). Multivariate logistic regression analysis revealed that low peak S' was independently related to higher E/E' ratio and the presence of CoA. CONCLUSIONS: Patients who underwent a successful repair of CoA commonly show asymptomatic longitudinal LVSD associated with worse LV diastolic function in the long-term follow-up.

Palliative needs for heart failure or chronic obstructive pulmonary disease: Results of a multicenter observational registry.

BACKGROUND: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) share a common organ failure trajectory marked by prognostic uncertainty, which is a barrier to appropriate provision of palliative care. We describe in a prospective cohort from specialist hospital services the epidemiology and late clinical course of these chronic diseases to trace criteria for transition to palliative care in the community. METHODS AND RESULTS: Seven centers enrolled 267 patients with advanced HF (n=174) or COPD (n=93) using common (multiple hospitalizations or severely impaired functional status or cachexia) and disease-specific (HF: systolic dysfunction, NYHA classes III-IV, end-organ hypoperfusion; COPD: very severe airflow obstruction, hypoxemia, hypercapnia, or long-term oxygen therapy) entry criteria. These patients represented 7.2% and 13% respectively of the overall HF and COPD population hospitalized during one year. They showed similar symptom burden, functional and quality of life impairment, recurrent hospitalizations, and 6-month mortality (39% and 37%, respectively). Organ failure progression was the cause of death in >75%. In-hospital overall stay during the previous year was the main mortality predictor in both. Disease-specific predictors included anemia, hyponatremia, no beta-blockers in HF; older age, hypercapnia in COPD. CONCLUSIONS: Patients with advanced HF/COPD represent almost 10% of subjects hospitalized yearly with a primary diagnosis of HF or COPD, have similarly impaired functional status, disabling symptoms and reduced survival. Overall days spent in-hospital during the previous year, a "red flag" in the late clinical course of both diseases, might be used as a simple, reliable screening tool for appropriate transition to palliative care in the community.

Clinical spectrum of fascicular tachycardia.

AIMS: Ventricular tachycardia spreading from the anterior or posterior division of the left bundle branch is generally called fascicular tachycardia (FT). We will present our experience with FT, a type of ventricular tachycardia not necessarily implying the absence of heart disease and/or sensitivity to selective antiarrhythmic drugs, but only particular routes of left ventricular depolarization. METHODS: Since 1981 we have had the opportunity to study 10 cases of FT (nine men and one woman; aged 28-77 years, mean ±â€ŠSD 55 ±â€Š18.6 years) by means of echocardiography, coronary angiography (seven cases), endomyocardial biopsy (five cases), signal-averaged electrocardiogram (SAECG, nine patients), electrophysiological and electropharmacological evaluation. RESULTS: Seven patients had paroxystic, extrastimulus inducible FT that was sensitive to verapamil given intravenously (group A); three patients, on the other hand, showed repetitive or incessant FT, not modifiable by stimulation techniques and sensitive to class 1 antiarrhythmic drugs (group B). Patients presented histologic substrates ranging from the absence of heart disease to previous myocardial infarction or myocarditis. FT spontaneously disappeared within 2 years in group B, while frequently persisted in the long term in group A. CONCLUSIONS: FT is not a homogeneous group of ventricular tachycardia, as patients may differ according to clinical presentation, mechanisms that are involved in the genesis of the arrhythmia and natural history; the histologic substrate is highly variable, ranging from the total absence of heart disease to severe forms of myocardial involvement.

[Disease management system in patients with chronic heart failure]. / Continuità assistenziale ospedale-territorio per il paziente con scompenso cardiaco cronico: una rivoluzione e una sfida nella cura ambulatoriale.

Healthcare managers are more and more interested in the role of general practitioners (GP) in the treatment of cardiovascular diseases. Continuing adjustments of the health organization are the old/new challenge in improving patient care. The European Society of Cardiology guidelines recommend a disease-management program for heart failure (HF); moreover, observational studies and randomized controlled trials have reported better patient outcomes if patients are in charge of cardiologists rather than GPs or other physicians. Patients with chronic HF are often very old and affected by multiple comorbid conditions, by themselves associated with high rates of morbidity and mortality. Furthermore, too many patients receive neither a correct diagnosis nor treatment until advanced disease occurs. New treatment approaches, some of them requiring the expertise of well-trained cardiologists, are ongoing to improve the clinical outcomes. The optimal management of patients with HF needs teamwork, i.e. GPs, cardiologists, nurses and caregivers, since a multidisciplinary program, only, can embody the best answer for outpatients with chronic HF. Currently, the Cardiovascular Center in Trieste is performing an experimental trial, so far never attempted before, in treating patients with chronic HF using a thorough approach with the full involvement of local cardiologists, GPs and nurses. Such approach is, at the same time, as well a challenge as an opportunity: a challenge because conventional clinical habits must be changed; an opportunity because patients can benefit from a proper whole care-group, aimed at prolonging life and reducing morbidity and symptoms.

[Control of anticoagulant therapy with portable prothrombin time device in patients with mechanical heart valve prostheses: two-year follow-up]. / Il trattamento anticoagulante con coagulometro portatile nei pazienti portatori di protesi valvolari meccaniche: un follow-up di due anni.

BACKGROUND: Monitoring patients on oral anticoagulation is essential to prevent haemorrhage and recurrent thrombosis, but it is still difficult. We studied a group of 348 patients with mechanical heart valve prostheses to verify whether the use of a new portable prothrombin time device might improve the management of oral anticoagulant therapy. METHODS AND MATERIAL: We used a new portable prothrombin time device to check the anticoagulation therapy in a group of 348 patients with mechanical heart valve prostheses to validate its results by comparing to routine I.N.R. determinations (28 pts) and verify its user-friendliness by a face-to-face interview. Furthermore, the incidence of haemorrhagic and thromboembolic events has been studied by a two-year follow-up. RESULTS: Pearson correlation indicated an R2 = 0.9 between I.N.R. values determined by routine or by a new portable prothrombin time device. All patients agreed to replace the routine I.N.R. determinations with those by the new procedure, particularly female, young and those with usually difficult blood collections. During the two-year follow-up period, 21 haemorrhagic (2.6/100/patients/year) and 5 thromboembolic events (0.6/100/patients/year) occurred; but neither replaced valves' thrombi nor fatal events were found out. CONCLUSIONS: I.N.R.s determined using a new portable prothrombin time device are convincing as routine determinations. Such new procedure improves the quality of life, and the therapeutical range of anticoagulation is maintained safer and longer than by routine determinations. These results suggest that the control of anticoagulation in patients to a set I.N.R. therapeutic range is improved by using portable prothrombin time device in expert anticoagulation clinics, such improvement may result in reducing mortality as well as morbidity in patients treated with oral anticoagulants.