Awareness and appropriateness of the management of preclinical heart failure in outpatient clinics in Italy: Insights from the VASTISSIMO study - EValuation of the AppropriateneSs of The preclInical phase (Stage A and Stage B) of Heart FaIlure Management in Outpatient Clinics in Italy.

A key factor in cardiovascular prevention is the detection and appropriate management of preclinical heart failure (HF), but information on the subject is scarce. We designed VASTISSIMO as a prospective, observational study to investigate Outpatient Clinic Cardiologists' skills in detecting and managing preclinical HF in Italy. Quality scores were used to assess the appropriateness of clinical management according to guideline recommendations. The feasibility of making a diagnosis of preclinical HF in a cardiology outpatient clinical setting, cardiologists' awareness of preclinical HF and consistency between physician's perceived risk of HF and the patient's classification into the preclinical HF Stages A [(SAHF) or B (SBHF)] have been investigated. Consistency was defined acceptable if the concordance between perceived risk and actual risk was >70%. Out of 3322 patients included in the study data necessary for identifying SBHF were collected in 2106 (63.4%). Many SBHF patients had their risk underestimated: 16.2% of those with previous acute myocardial infarction (AMI), 23.1% with left ventricular hypertrophy (LVH) at ECG/echocardiography, 30% with systolic/diastolic dysfunction, and 14.3% with valve disease. Cardiologists' awareness of preclinical HF in the outpatient setting should be improved. This is a critical area of cardiovascular prevention that requires attention to improve good clinical practice and adherence to guidelines.

ANMCO/ELAS/SIBioC Consensus Document: biomarkers in heart failure.

Biomarkers have dramatically impacted the way heart failure (HF) patients are evaluated and managed. A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological or pathogenic processes, or pharmacological responses to a therapeutic intervention. Natriuretic peptides [B-type natriuretic peptide (BNP) and N-terminal proBNP] are the gold standard biomarkers in determining the diagnosis and prognosis of HF, and a natriuretic peptide-guided HF management looks promising. In the last few years, an array of additional biomarkers has emerged, each reflecting different pathophysiological processes in the development and progression of HF: myocardial insult, inflammation, fibrosis, and remodelling, but their role in the clinical care of the patient is still partially defined and more studies are needed before to be well validated. Moreover, several new biomarkers have the potential to identify patients with early renal dysfunction and appear to have promise to help the management cardio-renal syndrome. With different biomarkers reflecting HF presence, the various pathways involved in its progression, as well as identifying unique treatment options for HF management, a closer cardiologist-laboratory link, with a multi-biomarker approach to the HF patient, is not far ahead, allowing the unique opportunity for specifically tailoring care to the individual pathological phenotype.

[ANMCO/ELAS/SIBioC Consensus document: Recommendations for the use of cardiac biomarkers in heart failure patients]. / Documento di consenso ANMCO/ELAS/SIBioC: Raccomandazioni sull'impiego dei biomarcatori cardiaci nello scompenso cardiaco.

Biomarkers have dramatically impacted the way heart failure (HF) patients are evaluated and managed. A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological or pathogenic processes, or pharmacological responses to a therapeutic intervention. Natriuretic peptides (B-type natriuretic peptide [BNP] and N-terminal proBNP) are the gold standard biomarkers in determining the diagnosis and prognosis of HF, and a natriuretic peptide-guided HF management looks promising. In the last few years, an array of additional biomarkers has emerged, each reflecting different pathophysiological processes in the development and progression of HF: myocardial insult, inflammation, fibrosis and remodeling, but their role in the clinical care of the patient is still partially defined and more studies are needed before to be well validated. Moreover, several new biomarkers have the potential to identify patients with early renal dysfunction and appear to have promise to help the management cardio-renal syndrome.With different biomarkers reflecting HF presence, the various pathways involved in its progression, as well as identifying unique treatment options for HF management, a closer cardiologist-laboratory link, with a multi-biomarker approach to the HF patient, is not far ahead, allowing the unique opportunity for specifically tailoring care to the individual pathological phenotype.

Evaluation of the appropriateness of the preclinical phase (stage A and stage B) of heart failure Management in Outpatient clinics in Italy rationale and design of the 'VASTISSIMO' study.

Early detection of heart failure, when still preclinical, is fundamental. Therefore, it is important to assess whether preclinical heart failure management by cardiologists is adequate. The VASTISSIMO study ('EValuation of the AppropriateneSs of The preclInical phase (Stage A and Stage B) of heart failure Management in Outpatient clinics in Italy') is a prospective nationwide study aimed to evaluate the appropriateness of diagnosis and management of preclinical heart failure (stages A and B) by cardiologists working in outpatient clinics in Italy. Secondary goals are to verify if an online educational course for cardiologists can improve management of preclinical heart failure, and evaluate how well cardiologists are aware of patients' adherence to medications. The study involves 80 outpatient cardiology clinics distributed throughout Italy, affiliated either to the Hospital Cardiologists Association or to the Regional Association of Outpatient Cardiologists, and is designed with two phases of consecutive outpatient enrolment each lasting 1 month. In phase 1, physicians' awareness of the risk of heart failure and their decision-making process are recorded. Subsequently, half of the cardiologists are randomized to undergo an online educational course aimed to improve preclinical heart failure management through implementation of guideline recommendations. At the end of the course, all cardiologists are evaluated (phase 2) to see whether changes in clinical management have occurred in those who underwent the educational program versus those who did not. Patients' adherence to prescribed medications will be assessed through the Morisky Self-report Questionnaire. This study should provide valuable information about cardiologists' awareness of preclinical heart failure and the appropriateness of clinical practice in outpatient cardiology clinics in Italy.

The 30-day metric in acute heart failure revisited: data from IN-HF Outcome, an Italian nationwide cardiology registry.

AIMS: Unplanned readmissions early after a discharge from acute heart failure hospitalization are common and have become a reimbursement benchmark and marker of hospital quality. However, the competing risk of short-term post-discharge mortality is substantial. METHODS AND RESULTS: Using data from the prospective, nationwide Registry IN-HF Outcome, we analysed the incidence and predictors of 30-day mortality or readmissions and associated days-alive-out-of-hospital (DAOH) in 1520 patients discharged alive after admission for acute heart failure. Within 30 days after discharge, 94 patients (6.2%) were readmitted (91% for cardiovascular causes; 60% recurrent heart failure) and 42 (2.8%) died, 10 of which occurred during readmission. Overall, 126 patients (8.3%) met the combined endpoint. By multivariable logistic regression, worsening chronic heart failure as clinical presentation [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.21-2.77, P = 0.005), inotropes during admission (OR 2.19, 95% CI 1.40-3.43, P = 0.0006), length of stay (OR 1.02, 95% CI 1.01-1.04, P = 0.002) and renin-angiotensin system inhibitors at discharge (OR 0.52, 95%CI 0.35-0.77, P = 0.001) independently predicted 30-day all-cause mortality and/or readmission (c-statistic = 0.695). Per cent 30-day DAOH was lower in patients with in-hospital inotrope use, no renin-angiotensin system inhibitors prescription at discharge, New York Heart Association III-IV class at discharge, and correlated inversely with length of stay and age. CONCLUSION: A clinical and biohumoral profile consistent with chronic advanced heart failure and end-organ damage identifies acute heart failure patients discharged home from cardiology units, who are at highest risk of early death and/or readmission. These findings have practical implications for tailoring specific follow-up.

[The Italian Network for Heart Failure five years after the publication of the Italian "Consensus conference on the management of heart failure"]. / La rete per io Scompenso Cardiaco in Italia cinque anni dopo la pubblicazione della Consensus Conference "Il percorso assistenziale del paziente con Scompenso Cardiaco": a che punto siamo?

In the year 2006 the Italian Association of Hospital Cardiologists (ANMCO) promoted a Consensus Conference among professional Scientific Societies in order to redefine the role and core responsibilities of each health professionals involved in heart failure management in a novel integrated network. Five years later, a questionnaire has been proposed to each Italian Regional President of the Association, in order to assess the implementation of the proposed management strategies in the different clinical scenarios of the Italian Regions. Although the Document utilization is not homogeneous through Italy, it is still considered a valuable tool of work.

[The relationship between the heart and the kidney in acute heart failure: doubts of the cardiologist and the nephrologist's point of view]. / Cuore e rene nello scompenso cardiaco acuto: i dubbi del cardiologo e il punto di vista del nefrologo.

The pathophysiological interactions that link the heart and kidney in heart failure are multiple and complex. This issue constitutes one of the most vexing and difficult challenges facing cardiologists. In the setting of acute decompensated heart failure, worsening renal function has traditionally been directly associated with poor clinical prognosis and complicates treatment. In the last years, many reports suggest that worsening renal failure may represent the final common pathway of several mechanistically distinct processes, with different prognostic implications. In the clinical scenario, the clinical significance of transient worsening of renal function may be different as compared with irreversible or progressive renal failure. In addition, it can represent a relatively normal response to treatment-induced physiological derangements such as a reduction in renal perfusion and/or intravascular volume. We here focus on these highlights, with special reference to the diagnostic criteria of renal dysfunction and the management of fluid overload. Two expert nephrologists were asked to answer a few important clinical questions: how should renal dysfunction be recognized and monitored? Are there therapies to counteract it and when, and more importantly, for whom should be applied? Their answers serve as touchstones for cardiologists to provide better individualized care for their patients with acute heart failure. Only a multidisciplinary and collaborative management of cardio-renal interactions will help to mitigate the difficult day-to-day clinical practice and improve our understanding of this condition through a concerted and constructive approach.

Effects of Candesartan on Left Ventricular Function, Aldosterone and BNP in Chronic Heart Failure.

PURPOSE: Heart failure (HF) is characterized by activation of neurohormonal systems such as aldosterone and natriuretic peptides. In the absence of published data, CandHeart trial was designed to assess the effects on left ventricular (LV) function, aldosterone and brain natriuretic peptide (BNP) of candesartan in patients with HF and preserved (LVEF ≥ 40%) or depressed (LVEF <40%) LV systolic function. METHODS: A total of 514 patients with stable symptomatic NYHA II-IV HF and any left ventricular ejection fraction (LVEF)were randomized to candesartan (target dose 32 mg once daily) as add-on therapy or standard medical therapy alone. Standardized echocardiographic exams were performed locally under central quality control, whereas biomarkers were assayed in a core laboratory. RESULTS: The majority of patients (73.3%) were NYHA II and on ACE inhibitors (91.8%) and beta-blockers (85.4%). Mean age was 66 ± 11 years. Mean LVEF was 36.2 ± 9.7% and 24.9% of patients had LVEF ≥ 40%. LVEF increased significantly more in the candesartan group (p = 0.09 at 12 weeks and p = 0.01 at 48 weeks) and left ventricular end-diastolic diameter decreased in candesartan group (p = 0.05 at 12 weeks). Candesartan significantly reduced aldosterone at 48 weeks (p = 0.009). BNP was reduced similarly over time in both study groups (p = 0.35 and p = 0.98 at 12 and 48 weeks, respectively). There were 6.6% of discontinuations of candesartan for adverse events. CONCLUSIONS: In CandHeart, the addition of candesartan to standard medical treatment did not reduce circulating BNP more than standard therapy (primary endpoint), but it significantly improved LV function and produced a marked decrease in aldosterone levels at study end.

[Data from the IN-HF Outcome registry]. / I dati del registro IN-HF outcome.

The IN-HF Outcome registry enrolled 1855 patients admitted for acute heart failure and 3755 outpatients with chronic heart failure seen at 64 cardiology units of the Italian Network-Heart Failure. We assessed gender-related differences in clinical characteristics, management, and short- and long-term mortality and morbidity outcomes. Women were older, more often hypertensive and with a higher prevalence of heart failure with preserved systolic function. Aggressive management was less frequent in women who underwent less often diagnostic and therapeutic procedures. We found no gender-related differences in either acute or long-term mortality nor in hospital readmissions.

[Role of outpatient heart failure clinics and primary care physicians in the tailored follow-up of heart failure patients]. / La gestione integrata fra ambulatorio scompenso e cure primarie per la personalizzazione del follow-up nel paziente con scompenso cardiaco.

Continuity of care is pivotal to appropriately manage patients affected by heart failure (HF). HF is a chronic disease with frequent exacerbations that requires long-term care at different complexity levels. The lack of adequate communication between hospital cardiologists and primary care physicians (PCPs) is the main pitfall in continuity of care for HF patients. To overcome this problem, all dedicated outpatient HF clinics should organize together with PCPs in the community educational and auditing initiatives, based on locally derived performance measures to assess the appropriateness and effectiveness of integrated care pathways. The primary task of PCPs is to follow up stable HF patients and focus assessment on patient empowerment, adjustment of drug therapy, assessment of clinical stability and the early identification of worsening signs and symptoms. The progress of information technology should help in achieving adequate communication between hospital professionals and PCPs; outpatient clinical records should in any case comply with qualitative standards of discharge summaries for all patients taken in charge by PCPs. Systematic assessment of shared care between hospital cardiologists and PCPs will be a main objective of the outpatient HF clinic network in the near future.

Prognostic value of osteoprotegerin in chronic heart failure: The GISSI-HF trial.

BACKGROUND: Circulating levels of osteoprotegerin (OPG), a member of the tumor necrosis factor receptor superfamily, is predictive of death and hospitalization for heart failure after acute coronary syndrome. The association between OPG and outcome in patients with chronic heart failure (CHF) is unknown. METHODS: Plasma OPG levels at baseline were assessed in 1,229 patients with CHF recruited from 51 clinical centers and included in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Heart Failure (GISSI-HF) trial. Patients were randomized to n-3 polyunsaturated fatty acids (1 g/d) or rosuvastatin (10 mg/d) versus placebo. Osteoprotegerin was analyzed by enzyme-linked immunosorbent assay. The association between OPG and outcome was assessed by Cox proportional hazards regression models. RESULTS: During a median follow-up time of 3.9 years, 332 patients died; and 791 patients died or were hospitalized because of cardiovascular causes. By univariate analysis, baseline OPG levels were strongly associated with the incidence of death (hazard ratio {HR} [95% CI] 1.53 [1.40-1.67] per 1-SD increase in log OPG). After adjustment for conventional risk markers, OPG remained a significant predictor of death (HR [95% CI] 1.20 [1.06-1.35], P < .001). Similar findings were observed for the composite end point (HR [95% CI] 1.34 [1.07-1.69], P = .012). CONCLUSION: In patients with CHF, OPG is associated with the incidence of death independently of conventional cardiovascular risk factors.

[Heart failure in primary care in Italy: analysis of management and needs by general practitioners]. / L'insufficienza cardiaca cronica sul territorio in Italia: analisi delle modalità di gestione clinica e dei bisogni dei medici di medicina generale.

BACKGROUND: Heart failure (HF) is a major clinical problem and a challenge for healthcare systems. Primary care physicians (PCPs) play an important role in the clinical management of HF patients. The aim of the present investigation was to evaluate the behaviors and problems of Italian PCPs in managing patients with HF. METHODS: Clinical behaviors and perceived obstacles were evaluated through the administration of a modified version of the Euro-HF questionnaire to a nationwide sample of 385 PCPs. RESULTS: Out of 389 042 persons entitled to receive their medical assistance, all PCPs declared to care 9263 patients with HF (prevalence of HF 2.4%, 24 HF patients/PCP). HF was diagnosed either by symptoms only (14% of cases), or by analysis of symptoms plus signs (57%), by combining the evidence of cardiac dysfunction by echocardiography to the assessment of symptoms and signs (12%) or by adding consultation by a cardiologist to the clinical assessment in the PCP office (17%). Forty-two percent of the PCPs participating in the survey had a free access to echocardiography whereas measurement of natriuretic peptide serum levels was freely available to 14% of PCPs. Pharmacological therapy for HF prescribed by the PCPs included in this survey included: diuretics (91%), inhibitors of the renin-angiotensin system (87%), digitalis (34%), beta-blockers (33%), aldosterone antagonists (23%). Drugs considered to potentially leading to major side effects were: digitalis (51%), beta-blockers (48%) and diuretics (47%), much less angiotensin-converting enzyme-inhibitors (17%) and aldosterone antagonists (14%). Consultation with a cardiologist for starting beta-blocker treatment was judged mandatory by 57% of PCPs. Management of HF patients was considered sufficient by 70% of PCPs. Improvement in the access to echocardiography, laboratory data and consultation with a specialist were the priorities indicated by PCPs for optimizing the management of HF patients. CONCLUSIONS: PCPs have a suboptimal approach to the diagnostic evaluation of HF patients and to implementation and management of beta-blocker therapy. These behaviors derive from a difficult access to echocardiography, laboratory parameters and consultation with a cardiologist.

[Left ventricular geometric patterns and cardiac function in patients with chronic renal failure undergoing hemodialysis]. / Pattern geometrici e funzione cardiaca in soggetti con insufficienza renale cronica in fase dialitica.

UNLABELLED: The aim of this study was to estimate the impact and prevalence of left ventricular geometric alterations and systolic and diastolic dysfunction in hemodialysis patients, as well as the relationship with cardiac troponin as a marker of myocardial damage. METHODS: 31 patients (pts), 19 males and 12 females, age 58.1+/-16.4 (26 on hemodialysis, 5 on peritoneal dialysis) and 31 healthy normal controls were enrolled. Echocardiography measurements were carried out according to the American Society of Echocardiography recommendations. Left ventricular mass was calculated, according to the Devereux formula and indexed to height and weight 2.7. Doppler echocardiography was performed to study diastolic function by measurements of isovolumetric relaxation period (IVRT), E wave deceleretion time (DTE) and E/A ratio. Cardiac troponin was measured by a third generation electro-chemiluminescence immunoassay. Statistical analysis was performed using the t-test for between-group comparisons and the Pearson and Spearman's tests to investigate correlations; p values of <0.05 were considered statistically significant. RESULTS: Eccentric hypertrophy was the most frequent pattern (n=17; 55%), followed by normal cardiac geometry (n=7; 23%), and concentric hypertrophy (n=5; 16%). Only 6% of pts (n=2) showed concentric remodelling. Systolic dysfunction was present in terms of endocardial parameters in 3 pts (9%) (fractional shortening <25%, EF<50%), but in terms of midwall myocardial shortening in 51% (n=16). Diastolic dysfunction was present in 87% (n=27) with a pattern of impaired relaxation (in 5 without left ventricular hypertrophy). E/A was negatively correlated with age (r=-0.41, p=0.02); DTE was positively correlated with posterior wall thickness (r=0.36, p=0.05) and interventricular septum thickness (r=0.45, p=0.01); cardiac troponin was positively correlated with age (r=0.50, p=0.00), left ventricular mass (r=0.41, p=0.02), posterior wall thickness (r=0.41; p=0.02) and interventricular septum thickness (r=0.39, p=0.03) but not with diastolic dysfunction parameters. No significant difference was found in terms of duration of dialysis between patients with normal left ventricular geometry and those with left ventricular hypertrophy, but a significant difference in age was found (p=0.03). Pts with diastolic dysfunction had more frequent hypotensive episodes during dialysis (p<0.01). CONCLUSION: Impaired geometry and cardiac function is frequently observed in pts undergoing hemodialysis. Diastolic dysfunction is associated to a geometric pattern of left ventricular hypertrophy, although it can be an isolated initial manifestation of myocardial damage. Depressed midwall myocardial shortening can discriminate left ventricular dysfunction better than traditional endocardial systolic indexes.

[Echocardiography in the diagnostic and prognostic evaluation of thromboembolic pulmonary hypertension]. / L'ecocardiografia nella valutazione diagnostic e prognostica della ipertensione polmonare tromboembolica.

Pulmonary arterial hypertension frequently develops after a thromboembolic pulmonary event. The difference in degree of pulmonary artery pressure depends mainly on the size and location of the pulmonary embolus and presence of pre-existing cardiopulmonary diseases. Right ventricle (RV) afterloading from an acute obstruction of the pulmonary vasculature causes an increase of RV volume and dysfunction of right heart cavities, the varying levels of severity of which explain the multiple clinical expression of pulmonary embolism (PE). While the diagnostic approach, therapeutic management and prognostic evaluation are now well defined, the natural progression of PE is still not completely understood. In particular, insufficient data exist on the rate, timing and modalities of development of chronic thromboembolic pulmonary hypertension (CTPH). The aim of this review is to evaluate the role of echocardiography in detecting patients with CTPH, and in assessing hemodynamic consequences on RV and related prognostic implications.

[The diastolic function: an echocardiographic study and its clinical meaning]. / La funzione diastolica: studio ecocardiografico e significato clinico.

Many patients with manifestations and/or symptoms of heart failure show a normal or only slight depressed systolic function of the left ventricle. The origin of these symptoms is attributed to anomalies of the diastolic function and the echocardiography has became an important technique for a non-invasive investigation of such anomalies. The valuation of the diastolic function, mainly in patients with a left ventricle dysfunction, is usually performed by means of the analysis of the transmitral flow with pulsed Doppler, integrating as necessary the basal information with actions of preload variations. However, in many cases it is necessary to use other procedures of study to better characterise the diastolic function in each patient by means of the analysis of venous pulmonary flow, the valuation of propagation velocity of mitral flow with Color M-Mode, or the valuation of diastolic velocities of myocardium with Doppler tissue imaging. The integrated analysis of these various methods of exam, moreover, allows to enhance the diagnostic accuracy in the evaluation of the filling pressure, which is a fundamental parameter to stratify the risk of short/medium term events, being equal the left ventricle dysfunction.

Diagnostic utility of echocardiography in patients with suspected pulmonary embolism.

The aim of this study was to investigate the clinical utility of echocardiography in the diagnosis of pulmonary embolism (PE). For this, we enrolled 162 patients with suspected PE in a prospective study. We evaluated the sensitivity and specificity of right ventricular dilatation, the Doppler evidence of pulmonary hypertension, and their possible associations. We also calculated the number of lung-scan angiography procedures avoided and the number of patients unnecessarily treated when echocardiography was included in the diagnostic work-up. The sensitivity and specificity of echocardiography ranged between 29 and 52% and between 96% and 87%, respectively. Adding echocardiography to the diagnostic strategy for PE would avoid about 12 to 28% of lung-scan angiography procedures, but would cause inappropriate treatment of 4 to 14% of all treated patients. The clinical utility of echocardiography in the diagnosis of PE is limited. The reduction in the number of standard diagnostic procedures obtained through its use would be counterbalanced by an excess of patients inappropriately treated.

[Prevalence of structural abnormalities of the atrial septum and their association with recent ischemic stroke or transient ischemic attack: echocardiographic evaluation in 18631 patients]. / Prevalenza di anomalie del setto interatriale e loro associazione con recenti episodi di stroke/attacco ischemico transitorio: valutazione ecocardiografica in 18631 pazienti.

BACKGROUND: Ischemic stroke is one of the most frequent causes of morbidity and mortality in industrialized countries. In more than 40% of cases the cause of the ischemic event is not recognized, especially in young patients in whom, moreover, the presence of a structural abnormality of atrial septal aneurysm (ASA) and patent foramen ovale (PFO) is more frequently reported. The prevalence of this two minor atrial septal defects is strongly related to the study population (unselected patients and patients with recent ischemic stroke/transient ischemic attack-TIA) and to the diagnostic tool employed (transthoracic echocardiography--TTE or transesophageal echocardiography--TEE). METHODS: We retrospectively evaluated the prevalence of ASA in 16,836 patients who underwent TTE from January 1, 1994 to June 30, 2002. During this time period we also evaluated the prevalence of ASA, PFO and their association in 1795 patients in whom a TEE was performed. The patients who underwent TEE were divided into two groups: group A included 430 patients with recent stroke/TIA or suspect cardioembolic event, and group B included 1365 patients as controls. RESULTS: An ASA was detected in 1.6% of the whole study population; 0.7% of the patients underwent TTE and 10.2% of the patients underwent TEE. In group A the prevalence of ASA was 24%, in group B 4.7% (p < 0.001). A PFO was identified in 9.9% of patients in whom a TEE was performed; the rate was 24% in group A and 5.3% in group B (p < 0.001). In a subgroup of 65 patients, < 60 years (mean age 45 +/- 8 years), with cryptogenic or unexplained stroke/TIA a TEE examination identified the presence of ASA, PFO and their association in a rate of 20, 15 and 34%, respectively. CONCLUSIONS: Our data show, in a large study population, a prevalence of ASA and PFO not negligible. The association of this two atrial septal abnormalities in patients with stroke/TIA, especially those classified as cryptogenic, suggests to study in depth these minor atrial septal defects and in particular: 1) to standardize ASA definition; 2) to identify the etiopathogenetic mechanisms leading to embolic events; 3) to define the best pharmacological treatment.

[Diagnosis of heart failure in general medicine: role of cerebral natriuretic peptide. Results of a pilot study of a population sample from Calabria]. / La diagnosi di scompenso cardiaco in medicina generale: ruolo del peptide natriuretico cerebrale. Risultati di uno studio pilota su di un campione di popolazione della Calabria.

BACKGROUND: The aim of this study was to evaluate the usefulness of brain natriuretic peptide (BNP) in diagnosing congestive heart failure (CHF), in an unselected population. METHODS: Eighty-three patients (47 men, 36 women, mean age 70 +/- 10 years) were referred to our hospital ambulatory from their general practitioners, with a diagnosis of CHF. RESULTS: Clinical-instrumental evaluation confirmed diagnosis in 45 patients (54%) (group A), and excluded it in the remaining 38 (46%) (group B). There were no differences between groups regarding age, weight, height, heart rate, blood pressure. Statistically significant differences between groups were found regarding ejection fraction (44 +/- 10% group A vs 60 +/- 7% group B, p < 0.01), and BNP blood concentration (162 +/- 226 pg/ml group A vs 73 +/- 23 pg/ml group B, p < 0.01). Forty-two patients in group A (93%) and 25 in group B (65%) had a BNP value > 20 pg/ml (p < 0.05). Using this cut-off value, sensitivity was 93%, specificity 34%, negative predictive value 81% and positive predictive value 62%. Forty-two patients in group A (93%) and 14 in group B (36%) had an "abnormal" electrocardiogram (p < 0.01). The presence of electrocardiographic abnormalities showed a sensitivity for the diagnosis of CHF of 93%, specificity of 63%, negative predictive value of 89% and positive predictive value of 77%. CONCLUSIONS: In our population BNP dosage confirms the high negative predictive value reported in the literature and may be useful to exclude diagnosis of CHF in patients with suspect signs and symptoms.