The cost of atrial fibrillation in Italy: a five-year analysis of healthcare expenditure in the general population. From the Italian Survey of Atrial Fibrillation Management (ISAF) study.

OBJECTIVE: Atrial fibrillation (AF) is a relevant item of expenditure for the National Healthcare systems. The aim of the study was to estimate the annual costs of AF in Italy. PATIENTS AND METHODS: The Italian Survey of Atrial Fibrillation Management Study enrolled 6.036 patients with AF among 295.906 subjects representative of the Italian population. Data were collected by 233 General Practitioners (GPs) distributed across Italy. Quantities of resources used during the 5 years preceding the ISAF screening were inferred from the survey data and multiplied by the current Italian unit costs of 2015 in order to estimate the mean per patient annual cumulative cost of AF. Patients were subdivided on the basis of the number of hospitalizations, invasive/non-invasive diagnostic tests and invasive therapeutic procedures in 3 different clinical subsets: "low cost", " medium cost" and "high cost clinical scenario". RESULTS: The estimated mean costs per patient per year were 613 €, 891 € and 1213 € for the "Low cost", "Medium cost" and "High Cost Clinical Scenario" respectively. Hospitalizations and inpatient interventional procedures accounted for more than 80% of the cumulative annual costs. The mean annual costs among patients pursuing "Rhythm control" strategy was 956 €. CONCLUSIONS: In Italy, the estimated costs of AF per patient per year are lower than those reported in other developed countries and vary widely related to the different characteristics of AF patients. Hospitalizations and interventional procedures are the main drivers of costs. The mean annual cost of AF is mainly influenced by the duration of the period of observation and the patients' characteristics. Measures to reduce hospitalizations are needed.

Noninvasive prediction of sudden death and sustained ventricular tachycardia after acute myocardial infarction using a neural network algorithm.

BACKGROUND: The early and accurate noninvasive identification of postinfarction patients at risk of sudden death and sustained ventricular tachycardia (arrhythmic events) still remains an unsolved problem. The aim of the present study was to identify the combination of clinical and laboratory noninvasive variables, easy to obtain in most patients, that best predicts the occurrence of arrhythmic events after an acute myocardial infarction. METHODS: Four hundred and four consecutive patients with acute myocardial infarction were enrolled and followed for a median period of 21.4 months. In each patient, 61 clinical and laboratory noninvasive variables were collected before hospital discharge and used for the prediction of arrhythmic events using an artificial neural network. RESULTS: During follow-up, 13 (3.2%) patients died suddenly and 11(2.5%) had sustained ventricular tachycardia. The neural network showed that the combination best predicting arrhythmic events included: left ventricular failure during coronary care stay, ventricular dyskinesis, late potentials, number of ventricular premature depolarizations/hour, nonsustained ventricular tachycardia, left ventricular ejection fraction, bundle branch block and digoxin therapy at discharge. The neural network algorithm allowed identification of a small high-risk patient subgroup (12% of the study population) with an arrhythmic event rate of 46%. The sensitivity and specificity of the test were 96 and 93% respectively. CONCLUSIONS: These results suggest that, in postinfarction patients, it is possible to predict early and accurately arrhythmic events by noninvasive variables easily obtainable in most patients. Patients identified as being at risk are candidates for prophylactic antiarrhythmic therapy.

Value of programmed ventricular stimulation in predicting sudden death and sustained ventricular tachycardia in survivors of acute myocardial infarction.

To assess the prognostic value of the response to programmed ventricular stimulation in selected post-acute myocardial infarction (AMI) patients identified at risk of sudden death and spontaneous sustained ventricular tachycardia (VT) (arrhythmic events) by noninvasive, highly sensitive testing, 286 consecutive patients were evaluated prospectively and followed for 12 months. One hundred three patients (group 1) with either left ventricular ejection fraction < or = 40% or ventricular late potentials or spontaneous complex ventricular arrhythmias were considered at risk of late arrhythmic events and eligible for programmed ventricular stimulation; the remaining 183 patients (group 2) were discharged without any further evaluation. Electrophysiologic study was performed 11 to 20 days after AMI utilizing up to 2 extrastimuli and rapid ventricular burst pacing. At the end of the follow-up period, 10 patients in group 1 and 2 in group 2 died of cardiac causes; in addition, 10 patients in group 1 and 1 in group 2 had arrhythmic events. Sustained monomorphic VT was the only inducible arrhythmia related either to cardiac death (p <0.0005) or to arrhythmic events (p <0.0001). It was induced in 11 patients (3 died suddenly, and 3 had spontaneous VT). Multivariate analysis showed that such arrhythmia was the strongest independent predictor of arrhythmic events (F = 9.76; p <0.0001). In the entire study population, it allowed identification of patients at risk, with a sensitivity, specificity, and positive predictive value of 55%, 99%, and 67%, respectively. We conclude that programmed ventricular stimulation performed in selected post-AMI patients, utilizing a moderately aggressive stimulation protocol, is a specific but less sensitive procedure for predicting arrhythmic events; the induction of sustained monomorphic VT allows the accurate identification of patients who may profit by prophylactic antiarrhythmic therapy.

Prognosis of asymptomatic patients with hypertrophic cardiomyopathy and nonsustained ventricular tachycardia.

BACKGROUND: In the early 1980s, studies performed in highly selected referral patients with hypertrophic cardiomyopathy reported a strong association between the presence of brief episodes of ventricular tachycardia (VT) on ambulatory ECG monitoring and sudden death. These observations led to antiarrhythmic treatment in many patients with hypertrophic cardiomyopathy and brief episodes of VT. In recent years, however, a growing awareness of the potential arrhythmogenic effects of antiarrhythmic medications has raised doubts regarding such a therapeutic approach, particularly in less selected and lower-risk patient populations. METHODS AND RESULTS: In the present study, we examined the prognostic significance of nonsustained VT in a population of 151 patients with hypertrophic cardiomyopathy who were asymptomatic or had only mild symptoms at the time of their initial ambulatory ECG recording. Of the 151 study patients, 42 had episodes of VT and 109 did not. The runs of VT ranged from 3 to 19 beats, with 35 patients (83%) having < 10 beats. The number of runs of VT ranged from 1 to 12 in 24 hours, with 36 patients (86%) having < or = 5 episodes of VT. Thus, in most patients, the episodes of VT were brief and infrequent. Follow-up averaged 4.8 years. Of the 151 study patients, 6 died suddenly, 3 in the group with VT and 3 in the group without VT. Two other patients, both in the group without VT, died of congestive heart failure. The total cardiac mortality rate was 1.4% per year in the patients with VT (95% CI, 0.4% to 3.5%) and 0.9% in those without VT (95% CI, 0.4% to 2.0%; P = .43). The relative risk of cardiac death for patients with VT was 1.4 compared with patients without VT (95% CI, 0.6 to 6.1). The sudden death rate was 1.4% per year in the patients with VT (95% CI, 0.4% to 3.5%) and 0.6% in those without VT (95% CI, 0.2% to 1.5%; P = .24). The relative risk of sudden death for patients with VT compared with those without VT was 2.4 (95% CI, 0.5 to 11.9). Of the 151 patients included in the study, 88 (58%) remained asymptomatic and were not treated with cardioactive medications during follow-up. Of these 88 patients, 20 were in the group with VT and 68 in the group without VT. None of these patients died. CONCLUSIONS: Our results show that cardiac mortality is low in patients with hypertrophic cardiomyopathy who are asymptomatic or only mildly symptomatic and have brief and infrequent episodes of VT on ambulatory ECG monitoring. Our findings also suggest that brief and infrequent episodes of VT should not be considered, per se, an indication for antiarrhythmic treatment in such patients.

Frequency, characteristics and significance of supraventricular tachyarrhythmias detected by 24-hour electrocardiographic recording in the late hospital phase of acute myocardial infarction.

The incidence, characteristics and clinical significance of supraventricular tachyarrhythmias occurring in the late hospital phase of acute myocardial infarction (AMI) were assessed in 209 consecutive patients. Arrhythmias were quantified by 24-hour electrocardiographic recording 16 +/- 3 days after AMI, and were classified according to the degree of complexity in 5 classes. Class 0 = less than 5 premature beats/hr; class 1 = between 5 and 100/hr; class 2 = greater than 100/hr or repetitive premature beats; class 3 = atrial-junctional tachycardia; class 4 = atrial flutter-fibrillation. Supraventricular tachyarrhythmias classes 1 to 2 always occurred in the absence of symptoms in 86 patients (41%); supraventricular tachyarrhythmias classes 3 to 4 (paroxysmal, self-limiting, brief) occurred in 27 patients (13%), symptomatically in 6. The presence of supraventricular tachyarrhythmias classes 2 to 3 was related to age over 55 years and complex ventricular tachyarrhythmias (greater than 20 premature beats/hr, ventricular tachycardia) (both p less than 0.05). Increasing complexity of supraventricular tachyarrhythmias was significantly associated with presence and entity of cardiac enlargement and left ventricular dysfunction (both p less than 0.01). Patients with class 4 showed the most severe cardiac deterioration. During the 2 years after AMI, patients with classes 2, 3 and 4 had a higher incidence of acute pulmonary edema, New York Heart Association functional classes III to IV for congestive heart failure (both p less than 0.005) and a greater need of digitalis and diuretics (p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

The relation between supraventricular tachyarrhythmias and left ventricular dysfunction after acute myocardial infarction.

The clinical characteristics of supraventricular tachyarrhythmias (SVTA) and their relation to left ventricular dysfunction were assessed in 208 consecutive patients with recent myocardial infarction. Arrhythmias were quantified on hospital discharge by 24 hour electrocardiographic recording. All the variables were evaluated between the second and the fourth week after infarction. SVTA occurred in 113 (54%) patients: Supraventricular premature beats (SVPB) in 49 (24%), frequent or repetitive SVPB in 37 (18%), atrial or junctional tachycardia in 23 (11%), atrial flutter or fibrillation in 4 (2%). Most of these arrhythmias occurred in the absence of symptoms, and the most complex forms were always selflimiting. No relation was found among the presence of different forms of SVTA and sex, coronary risk factors, previous history of ischemic heart disease, type or site of acute myocardial infarction, NYHA functional class. Age, left atrial dimension (LAD), cardio-thoracic ratio (CTR) and left ventricular ejection fraction (LVEF) at rest differed significantly among three groups of patients: those without SVTA, those with SVPB less than 100 per hour and those with frequent-repetitive SVPB or atrial-junctional tachycardia. The more SVTA complexity, the worse LAD, CTR, LVEF and the higher the age. Multivariate discriminant analysis showed that CTR was directly and LVEF inversely related to the occurrence of SVPB less than 100 per hour, while the presence of frequent-repetitive SVPB or supraventricular tachycardia was closely related to increasing age, LAD, CTR and decreasing LVEF. Patients with atrial fibrillation always showed the worst values of LAD, CTR, LVEF and age. The results of the present study show that different types of SVTA occurring at discharge from hospital after myocardial infarction are clinically benign, but always suggestive of different degrees of left ventricular dysfunction.

[Efficacy of propafenone in the treatment of ventricular hyperkinetic arrhythmias in subjects with a history of myocardial infarction]. / Efficacia del propafenone nel trattamento delle aritmie ipercinetiche ventricolari in soggetti con pregresso infarto miocardico.

A placebo-controlled single-blind study was performed to evaluate the efficacy of oral propafenone on stable potentially malignant ventricular tachyarrhythmias in 13 patients who had suffered a myocardial infarction two months or longer before the trial. All patients exhibited at a 24 hour Holter monitoring a minimum mean frequency of 10 ventricular premature depolarizations (VPDs) per hour and repetitive VPDs. Ventricular tachyarrhythmias characterization was obtained by means of multiple Holter monitorings and exercise stress testings. Propafenone was considered as effective when a well-defined quantitative and qualitative reduction of ventricular tachyarrhythmias was reached. After an initial placebo phase, patients received propafenone 450 mg or 900 mg daily. Acute effectiveness of propafenone was proved in 8 on 13 patients (62%) who showed a significative reduction of VPDs (89%, p less than 0.02) and a suppression of the most complex forms of ventricular tachyarrhythmic events. The efficacy of propafenone was confirmed, three months later, in each patient, side effects were infrequent, minimal and of no clinical consequence. Oral propafenone can be considered as an effective drug for reducing the level of potentially malignant ventricular tachyarrhythmias in patients with previous myocardial infarction.

Clinical significance of supraventricular tachyarrhythmias after acute myocardial infarction.

160 survivors of acute myocardial infarction (AMI) were evaluated to assess the clinical significance of supraventricular tachyarrhythmias (SVTA) occurring at discharge from the hospital after the acute event. All the variables considered for the study were estimated before hospital discharge; arrhythmias were quantified with a 24 h Holter ECG monitoring system. SVTA occurred in 88 patients (55%). Single or repetitive supraventricular premature beats were found in 65 (41%), paroxysmal atrial or junctional tachycardias in 20 (12%), bouts of atrial flutter or fibrillation in 3 (2%). Bivariate statistical analysis showed no relationship between sex, previous cardiovascular history, type, and location of AMI and SVTA occurrence. A close positive relationship was found between age, left atrial dimension (LAD), cardio-thoracic ratio (CTR) and SVTA occurrence; an inverse relationship was found for left ventricular ejection fraction (LVEF). The presence of SVTA appeared significantly related to age above 55 years, to LAD greater than 40 mm, to LVEF less than 45%, to serum creatine kinase peak levels over 1400 U l-1 and to CTR over 0.49. Multivariate statistical analysis showed that five variables are important in discriminating patients suffering from SVTA: age, LAD, LVEF, left ventricular fractional shortening, and CTR. SVTA occurring at discharge from hospital after AMI are indicative of impaired left ventricular pump function.