Cardiovascular disease patients and predictors of length of stay of residential of cardiac rehabilitation. A specific rehabilitation is mandatory in very old patients?

As more adults are living into old age, they are predisposed to cardiovascular disease (CVD) and the demand for cardiac rehabilitation is increasing. We aimed to verify predictors of length of stay (LOS) in young (Y) vs older (O) vs very old (VO) CVD patients, admitted to residential cardiac rehabilitation. Patients' demographic and clinical characteristics at admission, as well as Barthel index (BI), Cumulative Illness Rating Scale (CIRS), comorbidity severity/complexity, NYHA classification, left ventricular ejection fraction (LVEF), physical activity level were compared in Y (≤65 years) vs O (between >65 and <76 years) vs VO patients (with an age of ≥76 years) against LOS. In 5,070 consecutively CVD patients were included; they were 1392 Y (38%) 1944 O (35%) 1334 VO patients (27%) and LOS duration was 16±7, 19±9 and 22±10 days, respectively (p<0.0001). In Y, LOS was linked to BI (p=0.000) and to LVEF (p=0.000) at multivariable analysis with area under ROC curve of 0.82, whereas in O, LOS was associated to gender (p=0.013) CIRS severity (p=0.000), BI (p=0.000), LVEF (p=0.000), and in those VO to gender (p=0.004), BI (p=0.000) and medical infusion (p=0.000) at multivariable with ROC curve of 0.83 and 0.74, respectively. In very old patients, a prolonged LOS is related to extra-cardiac conditions. Therefore, we promote a specific cardiac rehabilitation for these patients.

Advances in image reconstruction software in nuclear cardiology: Is all that glitters gold?

The cornerstone results of nuclear cardiology in the last 25 years were obtained with the Filtered Back Projection as the preferred reconstruction method for tomographic studies. Recently, evolution of the OSEM iterative reconstruction algorithms was implemented by different vendors. The value and limitations of the new methods are briefly addressed.

Comparative analysis of iterative reconstruction algorithms with resolution recovery and time of flight modeling for 18F-FDG cardiac PET: A multi-center phantom study.

BACKGROUND: The purpose of this study was to evaluate the image quality in cardiac 18F-FDG PET using the time of flight (TOF) and/or point spread function (PSF) modeling in the iterative reconstruction (IR). METHODS: Three scanners and an anthropomorphic cardiac phantom with an insert simulating a transmural defect (TD) were used. Two sets of scans (with/without TD) were acquired, and four reconstruction schemes were considered: (1) IR; (2) IR + PSF, (3) IR + TOF, and (4) IR + TOF + PSF. LV wall thickness (FWHM), contrast between LV wall and inner chamber (C IC), and TD contrast in LV wall (C TD) were evaluated. RESULTS: Tests of the reconstruction protocols showed a decrease in FWHM from IR (13 mm) to IR + PSF (11 mm); an increase in the C IC from IR (65%) to IR + PSF (71%) and from IR + TOF (72%) to IR + TOF + PSF (77%); and an increase in the C TD from IR + PSF (72%) to IR + TOF (75%) and to IR + TOF + PSF (77%). Tests of the scanner/software combinations showed a decrease in FWHM from Gemini_TF (13 mm) to Biograph_mCT (12 mm) and to Discovery_690 (11 mm); an increase in the C IC from Gemini_TF (65%) to Biograph_mCT (73%) and to Discovery_690 (75%); and an increase in the C TD from Gemini_TF/Biograph_mCT (72%) to Discovery_690 (77%). CONCLUSION: The introduction of TOF and PSF increases image quality in cardiac 18F-FDG PET. The scanner/software combinations exhibit different performances, which should be taken into consideration when making cross comparisons.

Differences in polar-map patterns using the novel technologies for myocardial perfusion imaging.

BACKGROUND: New technologies are available in MPI. Our aim was to evaluate their impact on the uniformity of normal myocardial uptake in the polar-map representation, over different count statistics, with and without the attenuation (AC) and scatter corrections (SC). METHODS: A phantom study was performed using 5 Anger gamma cameras with filtered back projection or iterative reconstruction with resolution recovery (IRR), with or without SCAC; a D530c, with or without AC; and a D-SPECT. Count statistics ranged up to a quarter of the reference for the conventional gamma cameras and up to one half for the advanced scanners. Using polar maps, the segmental uptakes and their uncertainties, the 'global uniformity' of polar maps expressed as the coefficient of variation (COV) among the segmental uptakes and the anterior/inferior (ANT/INF) ratio were calculated. RESULTS: Both segmental uptakes and their uncertainties did not depend on the count statistics in the range studied. An increase in the segmental uptakes was found from IRR to IRR + SCAC (78.0% ± 13.5% vs 86.1% ± 9.4%; P < .0001). COV was lower for D-SPECT (10.1% ± 0.5%) and after SCAC for both conventional (9.9% ± 3.0%) and advanced systems (8.9% ± 1.7%). The ANT/INF ratio was above 1 for IRR (1.12 ± 0.07) and fell slightly below 1 for IRR + SCAC (0.97 ± 0.05). CONCLUSIONS: To compare data from the analysis of polar maps across different systems will require the adoption of specific normality databases, developed for each system and reconstruction method employed.

High dosage of a fixed combination oxycodone/naloxone prolonged release: efficacy and tolerability in patients with chronic cancer pain.

PURPOSE: Opioids are associated with side effects in the treatment of moderate-to-severe chronic cancer pain. Oral combination of opioid agonist-antagonist oxycodone-naloxone (OXN-PR) attenuates gastrointestinal side effects; however, evidence on high-dose OXN-PR treatment is scant. This study evaluates the efficacy and tolerability of high-dose OXN-PR in chronic cancer pain. PATIENTS AND METHODS: This was a multicenter, prospective 60-day observation on consecutive cancer patients with uncontrolled moderate-severe chronic pain or intolerant to other analgesics, who were switched at entry visit (T0) to OXN-PR ≥80 mg daily. Patients were reassessed 14, 30, 45, and 60 days later (T60). Primary endpoint of the study was analgesic response rate (decrease ≥30% of pain intensity from baseline, measured on a 0-10 numerical rating scale, NRS) after 30 days on OXN-PR. Additional endpoints assessed at every visit were the impact of pain on quality of life (QoL), breakthrough cancer pain (BTCP) episodes, opioid dosage escalation index, bowel dysfunction, safety, and other side effects. RESULTS: One hundred nineteen patients were included (age 64 ± 12, metastatic disease in 91.6%); 101 of them (84.9%) completed the 60-day observation. At T0, the majority had severe pain (NRS ≥7 in 79.8%; neuropathic features in 83.2%). Response rate at 30-day visit was 79.8% (n = 95). OXN-PR resulted in a significant reduction in pain over time (T0: 7.4 ± 1.3; T60: 3.3 ± 1.8; p < 0.001), and the number of daily (BTCP) declined (3.9 ± 2.2 vs. 2.0 ± 0.6, p < 0.001). Daily dosage of OXN-PR slightly increased (T0: 81.3 ± 6.0; T60: 93.6 ± 34.0; p < 0.001). The impact of pain on QoL abated (p < 0.0001), and bowel function improved overtime (p < 0.001). After the switch to OXN-PR, the number of patients complaining for side effects decreased overall (p < 0.0001); laxatives and antiemetic use also declined significantly. CONCLUSIONS: OXN-PR was highly effective and well tolerated even at high doses in cancer patients with chronic pain. The agonist-antagonist combination rapidly alleviated pain and its impact on life style, reducing the number of BTCP and improving opioid side effects.

Integrated care of chronic degenerative non-communicable diseases and rehabilitation: the odd couple?

Chronic degenerative non-communicable diseases affecting different organs and systems are considered by the World Health Organization (WHO) as the emergent epidemic in the third millennium...

Uncontrolled risk factors and worsening perfusion pattern on SPECT myocardial perfusion imaging in medically treated patients with stable chronic ischaemic heart disease.

PURPOSE: Few data exist on the correlation between the effectiveness of risk factor control and the evolution of myocardial perfusion over time in patients with stable ischaemic heart disease. The aim of the study was to evaluate the changes in stress-rest myocardial perfusion in medically treated patients with stable chronic ischaemic heart disease and the relationship with risk factor control. METHODS: The study cohort included 174 consecutive patients (age 60 ± 9 years, 68 % men) undergoing stress-rest myocardial perfusion imaging (MPI) (study 1), who also underwent repeat evaluation (study 2) and who were clinically stable on medical therapy. Summed stress, rest and difference scores were calculated. According to the evolution of perfusion pattern from study 1 to study 2, patients were classified as improved, stable or worsened. RESULTS: Study 2 was performed on average 2.7 years after study 1. Of the 174 patients, 47 (26.9 %), 53 (30.8 %) and 74 (42.5 %) were classified as stable, improved and worsened, respectively. A significant trend was observed between the number of risk factors at the time of study 1 and worsening of myocardial perfusion (24 % of patients with zero or one risk factor showed worsening, 31 % with two, and 59 % with three or more; p = 0.03). Moreover, patients with worsened perfusion had a higher number of poorly controlled risk factors. CONCLUSION: Despite medical therapy and clinical stability, myocardial perfusion worsened in 42.5 % of patients. The risk profile was reclassified in half of the patients. Worsening occurred more frequently in patients with three or more risk factors at the time of study 1 and in those with poorly controlled risk factors at the time of study 2; in this subset of patients, even if clinically stable, reassessment after 2 years could be considered.

Critical appraisal of appropriateness in nuclear cardiology.

Radionuclide myocardial perfusion imaging (MPI) is a large component of the healthcare spending both in developed and developing countries. MPI is also responsible for a significant increase in the exposition of patients and health care operators to ionizing radiations for medical purposes. Thus, health-care systems and pertinent scientific societies were involved in developing criteria to contain the non-appropriate use by implementing Appropriate Use Criteria and Clinical Indications Guidelines. The present manuscript will review the concept and limitations of such an approach.

Comparative analysis of cadmium-zincum-telluride cameras dedicated to myocardial perfusion SPECT: A phantom study.

BACKGROUND: This investigation used image data generated by an anthropomorphic phantom with a cardiac insert for a comparison between two solid state cameras: D-SPECT and D530c. METHODS: For each camera, two sets (with and without a simulated transmural defect (TD)) of scans were acquired starting from the in vivo standard count statistics in the left ventricle (LV). Other two acquisitions corresponding to 150% and 50% of the reference count statistics were acquired. Five performance indices related to spatial resolution, contrast, and contrast-to-noise ratio (CNR) were analyzed. RESULTS: D-SPECT showed a lower LV wall thickness and an inferior sharpness than D530c. No significant differences were found in terms of contrast between LV wall and the inner cavity, TD contrast or CNR. No significant differences were observed in CNR when moving from the reference level of count statistics down to 50% or up to 150% of the counts acquired on the LV. CONCLUSIONS: Our results show that D-SPECT and D530c have different performances. The lack of differences in the image performance indices along the range of count statistics explored, indicates that there is the possibility for a further reduction in the injected activity and/or the acquisition time, for both systems.

1-23I-MIBG thyroid uptake: Implications for MIBG imaging of the heart.

BACKGROUND: 123I-MIBG has been widely used in patients with heart failure and neurological disorders. The patients are pre-treated with Lugol's oral solution or potassium perchlorate to prevent thyroid uptake of unlabeled 123I to limit the thyroid radiation exposure. However, despite the inhibition of the iodide pump, the thyroid is frequently visualized. The aim of this study was to study the pattern of thyroid uptake. METHODS: We reviewed the 123I-MIBG images of 57 patients studied in three different centers in Italy for cardiac (n = 42) or neurological (n = 15) indications. They were imaged at 15 minutes and 4 hours after injection and in all patients, the thyroid was included in the imaging field of view. In 2 of the 3 centers, the patients were pre-treated with Lugol's oral solution and/or potassium perchlorate (group 1) but in the third center, they were not (group 2). The following imaging parameters were evaluated: heart-to-mediastinum ratio (H/M), thyroid-to-mediastinum ratio (T/M) at 4 hours, and tracer wash out from the heart (HWO) and from the thyroid (TWO). RESULTS: In the cardiac patients, the HWO was 22.98 ± 7.16% and TWO was 11.4 ± 11.86% (P < .0001). The TWO was 12.2 ± 13.1% in group 1 and 10.05 ± 8.97% in group 2 (P = NS). In the neurological patients the HWO was 26 ± 8.1% and the TWO was 20.32 ± 6.41 (P < .05). The difference in TWO was statistically significant (P < .01) between cardiac and neurological patients, whereas the HWO was not. The 4-hour H/M was 1.49 ± 0.23 in cardiac patients vs 1.4 ± 0.39 in neurological patients (P = NS). The 4-hour T/M was 1.33 ± 0.3 in cardiac patients vs 1.15 ± 0.13 in neurological patients (P < 0.05). CONCLUSION: The thyroid visualization in MIBG imaging is likely an expression of thyroid sympathetic innervation. The differences in TWO and T/M ratio in cardiac and neurological patients probably express differences in thyroid dopaminergic receptors. Thus, pre-treatment with potassium perchlorate or Lugol's solution may not be justified in patients undergoing 123I-MIBG imaging in whom the risk of side effects due to pre-treatment could be higher than the risk due to thyroid radiation exposure.

Comparative analysis of iterative reconstruction algorithms with resolution recovery for cardiac SPECT studies. A multi-center phantom study.

BACKGROUND: This investigation used image data generated by a physical phantom over a wide range of count statistics to evaluate the effectiveness of several of the newer commercially available SPECT reconstruction iterative algorithms (IRR) in improving perfusion defect contrast and spatial resolution, while controlling image noise. METHODS: A cardiac phantom was imaged using four different gamma cameras over a wide range of counts statistics (from 6 to 0.8 Mcounts). Images were reconstructed with FBP, OSEM, and the IRR available on site. IRR were applied without corrections (IRR NC), with attenuation correction (IRR AC), scatter correction (IRR SC), and attenuation + scatter corrections (IRR SCAC). Four image performance indices related to spatial resolution, contrast, and image noise were analyzed. RESULTS: IRR NC always determined significant improvements in all indices in comparison to FBP or OSEM. Improvements were emphasized with IRR SC and IRR SCAC. Count reduction from 6 to 1.5 Mcounts did not impair the performances of any of the considered indices. CONCLUSIONS: This is the first study comparing the relative performance of different, commercially available, IRR software, over a wide range of count statistics; the additional effect of scatter and attenuation corrections, alone or in combination, was also evaluated. Our results confirm that IRR algorithms produce substantial benefits with respect to conventional FBP or OSEM reconstruction methods, as assessed through different figures of merit, in particular when SC and/or SCAC are also included.

Efficacy of the switch to modified-release prednisone in rheumatoid arthritis patients treated with standard glucocorticoids.

OBJECTIVES: In rheumatoid arthritis (RA), low-dose glucocorticoids (GCs) demonstrate disease-modifying potential when added to DMARDs. Modified-release (MR) prednisone taken at bedtime (released 2am) is more effective than immediate-release (IR) GC taken in the morning. METHODS: In an open-label observational study, 950 RA outpatients (mean age 57 ± 13 years; 75% females) treated with GCs and DMARDs (83.7% methotrexate, 10.5% leflunomide; 15.8% biologics) were switched from IR-prednisone or 6-methyl (6M)-prednisolone to low-dose MR-prednisone and followed for 4 months. Morning stiffness duration (MS), pain intensity (numerical rating scale [NRS], 0-10), patient and physician global assessment (GA, 0-10 scale) and disease activity score (DAS28) were assessed at baseline, 2 and 4 months. RESULTS: 513 patients were switched to MR-prednisone from IR-prednisone (9.4±5.4 mg) and 437 from 6M-prednisolone (6.7±3.7 mg). Among 920 patients (96.8%) completing 4-months' MR-prednisone treatment, MS decreased from 58±37 min at T1 to 32±24 min at endpoint (p<0.001); NRS pain intensity reduced from 5.4±1.8 to 3.5±1.4 (p<0.001), and patient and physician GA scores improved from 5.4±1.7 to 3.5±1.4 and 5.1±1.7 to 3.3±1.4, respectively (p<0.001). DAS28 score decreased from 4.2±1.4 to 3.3±1.2 (p<0.001). Mean daily MR-prednisone dosage decreased from 8.2mg to 6.7mg between baseline and endpoint and significantly higher improvements in MS, NRS pain and GA scores were seen in patients switched from 6M-prednisolone versus IR-prednisone. MR-prednisone was well tolerated. CONCLUSIONS: Switching GC-treated RA patients to low-dose MR-prednisone significantly improved outcomes over 4 months.

Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve replacement (TAVR): a multicenter retrospective study.

BACKGROUND: The aim of this study was to evaluate cardiac rehabilitation (CR)-derived predictors of outcome in patients discharged from rehabilitation after transcatheter aortic valve replacement (TAVR). METHODS: We retrospectively analyzed data from 232 TAVR patients (aged 82±6 years, 55% females) discharged following an average 3-week residential CR program in the period January 2009 to December 2017. Comorbidities (cumulative illness rated state-comorbidity index, CIRS-CI), echocardiography on admission, disability (Barthel Index [BI]) and functional capacity (6-min walk distance, 6MWD) at discharge, and maximal training session intensity expressed in METs/min were collected. The endpoint was all-cause mortality. RESULTS: Seventy-four (32%) deaths occurred at 3-year follow-up. At discharge, non-survivors had a higher comorbidity rate (CIRS-CI 5.2±2.3 vs. 4.1±1.9, P=0.000), higher disability level (BI 80.4±24 vs. 88.8±17, P=0.000), and worse renal function (creatinine 1.6±0.9 vs. 1.2±0.4 mg/dL, P=0.000). They were also more often on diuretics (73% vs. 53.2%, P=0.003) and beta-blocker therapy (73% vs. 57.6%, P=0.042) and had a markedly reduced functional capacity (6MWD 221±100m vs. 265±105m, P=0.001). At multivariate Cox proportional hazards regression analysis, independent predictors of survival at follow-up were lower comorbidity rate, a better-preserved renal function, lower use of diuretics, and a higher 6MWD at discharge (Harrell's C = 0.707). CONCLUSIONS: Patients attending residential CR after TAVR are very old with significant comorbidity. The overall 3-year mortality rate after CR discharge is high. Our findings suggest the need for individually tailored follow-up care in patients discharged from CR after TAVR to address their residual exercise capacity, comorbidities, and renal function impairment.

Prognostic value of 6-min walk test compared to cardiopulmonary exercise test in patients with severe heart failure.

AIMS: The 6-min walk test (6MWT) and cardiopulmonary exercise test (CPET) are both predictive in heart failure (HFrEF). Although 6MWT substitutes for CPET in HFrEF patients, as submaximal testing may be preferable, its prognostic superiority still needs to be verified, particularly in regard to beta blockers (BBs). We aimed to compare the prognostic role of CPET and 6MWT and investigate whether BB therapy influences the predictive value. METHODS: This is a single-center, retrospective study. Advanced HFrEF patients were followed up for 3 years: events were cardiovascular death or urgent heart transplantation. We analyzed the predictive capacity of CPET and 6MWT in patients, and subdivided according to use of BBs. RESULTS: In a group of 251 HFrEF patients, we found a correlation between meters and peak VO2 (r2 = 0.94). Over the 3-year follow-up, 74 events were recorded. Both CPET and 6MWT variables were correlated with outcome at univariate analysis (meter and VE/VCO2 slope, peak VO2, VO2 at ventilatory anaerobic threshold, percentage predicted of peak VO2), but only percentage predicted of peak VO2 (pppVO2) was an independent predictor. In 103 HFrEF patients on BBs (23 nonsurvivors), neither pppVO2 nor meter were predictive, while in 148 patients not treated with BB (51 with events) pppVO2 was selected as an independent prognostic parameter (P = 0.001). CONCLUSIONS: 6MWT is a valid alternative to CPET, although the percentage of predicted of peak VO2 emerged as the strongest predictor. Nonetheless, our results suggest that both functional derived parameters are not predictive among those patients treated with BBs. Further studies are necessary to confirm these findings.

Cardiopulmonary exercise testing in patients with asymptomatic left ventricular dysfunction: lack of prognostic predictive power of ventilatory variables.

AIMS: The indication for cardiopulmonary exercise testing (CPET) in predictive evaluation has been extended beyond chronic heart failure (HF) patients to include asymptomatic left ventricular dysfunction (ALVD) patients, but its prognostic value is still unclear. We aimed to verify if CPET can predict outcome in ALVD and to identify which of the CPET parameters predictive in chronic HF are also effective in ALVD patients. METHODS AND RESULTS: We screened ALVD (LVEF ≤ 40% without HF symptoms) and HF patients for cardiac death, and compared peak oxygen consumption (pVO2), exertional oscillatory ventilation (EOV), and ventilatory response (VE/VCO2 slope) between survivors and non-survivors. Asymptomatic left ventricular dysfunction and HF patients formed the study population (585 ALVD and 695 HF). Both groups had similar male prevalence (98% vs. 98%; P = 0.345) but ALVD patients were younger (52 ± 10 vs. 60 ± 10 years, P = 0.004). Cardiac death was observed in 142 patients (5% of ALVD, 15% of HF). Exertional oscillatory ventilation occurred in 4% of ALVD, whereas VE/VCO2 slope was significantly lower (30 ± 7 vs. 35 ± 4) and pVO2 higher (16 ± 4 vs. 14 ± 3 mL/kg/min) than in chronic HF patients. Asymptomatic left ventricular dysfunction non-survivors had a significantly greater EOV incidence (13% vs. 3%, P = 0.003), lower pVO2 (13 ± 4 vs. 16 ± 3 mL/kg/min P = 0.000) and higher VE/VCO2 slope (33 ± 7 vs. 31 ± 5, P = 0.032). No ventilatory parameter had prognostic value at multivariable analysis in ALVD patients. CONCLUSIONS: Cardiopulmonary exercise testing can predict events in ALVD patients, but the risk stratification relies on different parameters than in HF patients. Further analysis in a multi-centre trial is required to better quantify the predictive impact of CPET risk parameters in ALVD patients.

Functional capacity assessment and Minimal Clinically Important Difference in post-acute cardiac patients: the role of Short Physical Performance Battery.

BACKGROUND: The Short Physical Performance Battery (SPPB) test is a well-established tool to assess physical performance, and to identify frail patients. Assessment of the SPPB in a specific population of elder patients in cardiac rehabilitation phase after a cardiac event is missing. AIM: The aim of this study was to correlate SPPB and the cardiac rehabilitation outcome in a group of elder patients after a cardiac event and to identify the Minimal Clinically Important Difference (MCID) of the SPPB. METHODS: Consecutive (n = 392) patients aged ≥75 years, in the rehabilitation phase after cardiac surgery (70.1%), congestive heart failure (7.4%), or acute coronary syndrome (22.5%), were enrolled. SPPB was performed twice: on admission and discharge. The MCID was assessed with the 'anchor method', and the Patient Global Impression of Change was employed as the anchor. RESULTS: On admission, SPPB classified 56, 117, 116, and 94 patients as severe, moderate, mild, or minimal/no limitations, respectively. Patients with the lower SPPB had the longer length of stay, and the higher complications rate. At receiver operating characteristic analysis, an SPPB improvement >1 was identified as the MCID (area-under-curve 0.77, 95% CI 0.67-0.85). Overall, 285 patients (74.2%) had a 'clinically significant' improvement in SPPB, with a rate of improvement higher in patients with severe/moderate limitations (83.0%) and lower in those with mild (78.9%) or minimal/no limitations (53.6%). CONCLUSION: A lower SPPB score is associated with a higher complications rate in the post-acute phase. An improvement >1 point of SPPB was identified as the MCID; this reference value could serve as the goal for rehabilitation interventions.