Role of gender, age and BMI in prognosis of heart failure.

The prognostic stratification of heart failure remains an urgent need for correct clinical management of the affected patients. In fact, due to the high mortality and morbidity rates, heart failure constantly requires an updated and careful management of all aspects that characterise the disease. In addition to the well-known clinical, laboratory and instrumental characteristics that affect the prognosis of heart failure, gender, age and body mass index have a different impact and deserve specific insights and clarifications. At this scope, the metabolic exercise cardiac kidney index score research group has produced several works in the past, trying to identify the role of these specific factors on the prognosis of heart failure. In particular, the different performances in the cardiopulmonary exercise test of specific categories of heart failure patients, such as women, elderly and obese or overweight individuals, have requested dedicated evaluations of metabolic exercise cardiac kidney index score power.

High Altitude Pulmonary Hypertension.

The effects of hypoxia on the human organism has been considered doubly fascinating by the scientific community. The knowledge of the discrete mechanisms allowing the acclimatization both at genetic level or through the cell mediators production in addition to the macroscopic responses of the cardio-circulatory and ventilatory systems to a hypoxic environment has been progressively developed since the last century; moreover granting a safer stay in hypoxic conditions not only for the residents but also for the different cathegories of workers, sportsmen and tourists has been considered a worthy aim of the medical activity. The effects of hypoxia were simulated in laboratory by means of an induced low pressure environment (normobaric hypoxia) or tested on the subjects at different levels of altitude (hypobaric hypoxia). Far from describing all the physiological and pathological responses of the organism, in this review, the authors expose the state of the art in the knowledge of the responsiveness of the pulmonary circle to the acute or chronic hypoxic condition, its possible progression to the pulmonary arterial hypertension, the latter being more appropriately named High-Altitude Pulmonary Hypertension. The currently available therapeutic options in the treatment of High-Altitude Pulmonary Hypertension are also reviewed.

Multiparametric prognostic scores in chronic heart failure with reduced ejection fraction: a long-term comparison.

AIMS: Risk stratification in heart failure (HF) is crucial for clinical and therapeutic management. A multiparametric approach is the best method to stratify prognosis. In 2012, the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score was proposed to assess the risk of cardiovascular mortality and urgent heart transplantation. The aim of the present study was to compare the prognostic accuracy of MECKI score to that of HF Survival Score (HFSS) and Seattle HF Model (SHFM) in a large, multicentre cohort of HF patients with reduced ejection fraction. METHODS AND RESULTS: We collected data on 6112 HF patients and compared the prognostic accuracy of MECKI score, HFSS, and SHFM at 2- and 4-year follow-up for the combined endpoint of cardiovascular death, urgent cardiac transplantation, or ventricular assist device implantation. Patients were followed up for a median of 3.67 years, and 931 cardiovascular deaths, 160 urgent heart transplantations, and 12 ventricular assist device implantations were recorded. At 2-year follow-up, the prognostic accuracy of MECKI score was significantly superior [area under the curve (AUC) 0.781] to that of SHFM (AUC 0.739) and HFSS (AUC 0.723), and this relationship was also confirmed at 4 years (AUC 0.764, 0.725, and 0.720, respectively). CONCLUSION: In this cohort, the prognostic accuracy of the MECKI score was superior to that of HFSS and SHFM at 2- and 4-year follow-up in HF patients in stable clinical condition. The MECKI score may be useful to improve resource allocation and patient outcome, but prospective evaluation is needed.

Prognostic role of ß-blocker selectivity and dosage regimens in heart failure patients. Insights from the MECKI score database.

AIMS: The use of ß-blockers represents a milestone in the treatment of heart failure with reduced ejection fraction (HFrEF). Few studies have compared ß-blockers in HFrEF, and there is little data on the effects of different doses. The present study aimed to investigate in a large database of HFrEF patients (MECKI score database) the association of ß-blocker treatment with a composite outcome of cardiovascular death, urgent heart transplantation or left ventricular assist device implantation, addressing the role of ß-selectivity and dosage regimens. METHODS AND RESULTS: In 5242 HFrEF patients, we investigated the role of: (i) ß-blocker treatment vs. non-ß-blocker treatment, (ii) ß1-/ß2-receptor-blockers vs. ß1-selective blockers, and (iii) daily ß-blocker dose. Patients were followed for 3.58 years, and 1101 events (18.3%) were observed; 4435 patients (86.8%) were on ß-blockers, while 807 (13.2%) were not. At 5 years, ß-blocker-patients showed a better outcome than non-ß-blocker-subjects [hazard ratio (HR) 0.48, P < 0.0001], while also considering potential confounders. A comparable prognosis was observed at 5 years in the ß1-/ß2-receptor-blocker (n = 2219) vs. ß1-selective group (n = 2216) (HR 0.95, P = ns). A better prognosis was observed in high-dose (>2 5 mg carvedilol equivalent daily dose, n = 1005) patients than in both medium dose (12.5-25 mg, n = 1431) and low dose (<12.5 mg, n = 1960) (HR 1.97, P < 0.001; HR 1.95, P = 0.001, respectively), with no differences between the last two groups (HR 0.84, P = ns). CONCLUSION: In a large population of chronic HFrEF patients, ß-blockers were associated with a more favourable prognosis without any difference between ß1- and ß2-receptor-blockers vs. ß1-selective blockers. A better outcome was observed in subjects receiving a high daily dose.

Effects of an Outpatient Service Rehabilitation Programme in Patients Affected by Pulmonary Arterial Hypertension: An Observational Study.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a rare disease characterised by a severe impairment of functional status and quality of life (QoL). Use of rehabilitative programmes may help to improve outcomes. The aim of this pre/post test case series was to evaluate the impact of a training program, including sessions of aerobic and resistance exercise, inspiratory muscle reinforcement, slow breathing, relaxation, and psychological support, on functional outcomes. METHODS: Fifteen patients affected by PAH, in World Health Organization (WHO) Functional Class (FC) II or III and in stable clinical condition, were included in a 4-week cardiorespiratory training programme conducted in outpatient service. Patients were tested during a routine control visit (T0), one month later at the beginning of the training programme (T1), and at study end (T2). Between T0 and T1, patients continued their normal activities and therapies. At each step, patients underwent respiratory and functional evaluation by spirometry, 6-minute walk test (6-MWT), maximal cardiopulmonary exercise testing (CPET), echocardiography, and levels of brain natriuretic peptide (BNP). QoL was also assessed at T1 and T2 using the Hospital Anxiety and Depression Scale and the EuroQoL-5D questionnaire. The primary endpoint was the effect of training on peak oxygen consumption (peak V̇O2). RESULTS: There were no significant differences in BNP levels, or in any of the respiratory or echocardiographic parameters measured, between T0 and T1. Between T1 and T2, significant improvements were recorded in QoL (HADS-Anxiety mean change 3.5 ± 3.3 and HADS-Depression mean change 1.6 ± 2.0, all p < 0.01). Significant improvements were also observed in functional capacity with distance walked at 6-MWT increasing from 455 ± 115 to 487 ± 120 (+8%, p < 0.01), workload (WR) of CPET increased of 22% (from 73 ± 22 to 87 ± 21 watt, p < 0.001), peak V̇O2 increasing from 17.3 ± 4.2 to 19.9 ± 4.5 mL/kg/min (p < 0.001) and pulse O2 increasing from 7.8 ± 1.8 to 8.8 ± 2.4 mL/beat (p < 0.01). No adverse events or deterioration in clinical status were observed during the training sessions. CONCLUSION: Cardiorespiratory training in a outpatient service is a suitable option for patients with PAH in WHO FC II/III thanks to improved exercise capacity and QoL, which may allow them to achieve better outcomes.

Heart failure and anemia: Effects on prognostic variables.

BACKGROUND: Anemia is frequent in heart failure (HF), and it is associated with higher mortality. The predictive power of established HF prognostic parameters in anemic HF patients is unknown. METHODS: Clinical, laboratory, echocardiographic and cardiopulmonary-exercise-test (CPET) data were analyzed in 3913 HF patients grouped according to hemoglobin (Hb) values. 248 (6%), 857 (22%), 2160 (55%) and 648 (17%) patients had very low (<11g/dL), low (11-12 for females, 11-13 for males), normal (12-15 for females, 13-15 for males) and high (>15) Hb, respectively. RESULTS: Median follow-up was 1363days (606-1883). CPETs were always performed safely. Hb was related to prognosis (Hazard ratio (HR)=0.864). No prognostic difference was observed between normal and high Hb groups. Peak oxygen consumption (VO2), ventilatory efficiency (VE/VCO2 slope), plasma sodium concentration, ejection fraction (LVEF), kidney function and Hb were independently related to prognosis in the entire population. Considering Hb groups separately, peakVO2 (very low Hb HR=0.549, low Hb HR=0.613, normal Hb HR=0.618, high Hb HR=0.542) and LVEF (very low Hb HR=0.49, low Hb HR=0.692, normal Hb HR=0.697, high Hb HR=0.694) maintained their prognostic roles. High VE/VCO2 slope was associated with poor prognosis only in patients with low and normal Hb. CONCLUSIONS: Anemic HF patients have a worse prognosis, but CPET can be safely performed. PeakVO2 and LVEF, but not VE/VCO2 slope, maintain their prognostic power also in HF patients with Hb<11g/dL, suggesting CPET use and a multiparametric approach in HF patients with low Hb. However, the prognostic effect of an anemia-oriented follow-up is unknown.

Respiratory disorders in endurance athletes - how much do they really have to endure?

Respiratory disorders are often a cause of morbidity in top level endurance athletes, more often compromising their performance and rarely being a cause of death. Pathophysiological events occurring during exercise, such as bronchospasm, are sometimes followed by clear pathological symptoms represented by asthma related to physical exertion or rarely by pulmonary edema induced by a strenuous effort. Both bronchospasm and the onset of interstitial edema induced by exercise cannot be considered pathological per se, but are more likely findings that occur in several healthy subjects once physical exhaustion during exertion has been reached. Consequently, we get a vision of the respiratory system perfectly tailored to meet the body's metabolic demands under normal conditions but which is limited when challenged by strenuous exercise, in particular when it happens in an unfavorable environment. As extreme physical effort may elicit a pathological response in healthy subjects, due to the exceeding demand in a perfectly functional system, an overview of the main tools both enabling the diagnosis of respiratory impairment in endurance athletes in a clinical and preclinical phase has also been described.

Fatty acid percentage in erythrocyte membranes of atrial flutter/fibrillation patients and controls.

PURPOSE: Several epidemiological published data support the protective role of omega-3 consumption in coronary artery disease, sudden cardiac death and ventricular arrhythmias, but interestingly, this is not the case for atrial arrhythmias. The purpose of this study is to evaluate different fatty acid profile between AF/AFL subjects and healthy controls. METHODS: Gas chromatography was employed to determine fatty acid percentage of erythrocyte membranes from 40 idiopathic AFL/AF patients and 53 healthy control subjects. RESULTS: AFL/AF erythrocyte membranes had significantly lower percentage of saturated fatty acid (43.1 +/- SD2.2 versus 47.8 +/- SD9.6, p < 0.001), monounsaturated fatty acid (18.2 +/- SD2.5 versus 22.6 +/- SD5.2, p < 0.001) and total trans fatty acid (0.2 +/- SD0.1 vs 1.3 +/- SD1.1, p < 0.001) than controls. Furthermore, fatty acid (FA) profiles of arrhythmic individuals showed an increased percent of total polyunsaturated fatty acid (PUFA) (36.7 +/- SD2.4 versus 26.4 +/- SD10.4, p < 0.001), PUFA n-3 (5.3 +/- SD1.1 versus 2.8 +/- SD1.8, p < 0.001) and n-6 (31.4 +/- SD2.2 versus 23.5 +/- SD9.9, p < 0.001). CONCLUSION: This study shows that the erythrocyte membranes FA composition of AF/AFL subjects differs from that of healthy controls.