Secondary prevention advices after cardiovascular index event: From drug prescription to risk factors control in real world practice.

The present study aims at evaluating the achievement of blood pressure, lipid and blood glucose targets, healthy lifestyle changes and appropriate drug prescription/adherence in patients attending secondary prevention/CR ambulatory visit after index cardiovascular event in a time period ranging 1 to 5 year. At ambulatory visit, a predetermined set of data collection was used, including demographic data, cardiovascular risk factors and lifestyle habits, type and time of index event, current symptoms, physical sign, biochemistry and current medical treatment (including type and dosage). Cardiovascular risk profile (smoking habits, physical activity and body weight), secondary prevention goals (LDL-cholesterol, blood pressure, resting heart rate, glycated haemoglobin level) and the use of recommended drugs were also evaluated and categorized. Study population consisted of 800 patients [644 men (84.5%), aged 69±10.9 years)]. Cardiovascular index events were coronary artery bypass graft (CABG) (20%) ST segment elevation myocardial infarction (STEMI) (28%), non-ST segment elevation myocardial infarction (NSTEMI) (21%) and stable angina (13%) by unstable angina (13%) and stroke (5%). About 30% of patients was symptomatic (angina or dyspnoea) at the time of ambulatory visit. Major comorbidities were hypertension (73%), dyslipidaemia (64%) and diabetes (40%). More than 80% of patients achieved target levels for blood pressure. Patients that have participated to cardiac rehabilitation programmes after cardiovascular index event showed best achievement in blood pressure target (83.8% vs 76.8%, p=0.02). LDL-cholesterol target (<70 mg/dl) was achieved in about 2/3 of patients; HbA1c target (<7%) was achieved in 56.4% of diabetic population. About 75% of study cohort was treated with RAAS inhibitors, 85% with beta-blockers, 92% with statins and 87% with acetylsalicylic acid. All drugs were increasingly adopted from index event. Implementing secondary prevention guidelines into the 'real world' clinical practice in "late" interval from 1 to 5 years after a cardiovascular event improved risk factors control and appropriate drug prescription. Whether these improvements translated into prognostic advantages remains to be elucidated.

Iron deficiency from the standpoint of cardiac rehabilitation: novel therapeutic opportunities.

Anemia is one of the most frequent comorbidities found in patients with coronary artery disease and chronic heart failure (CHF) who are being followed in cardiac rehabilitation facilities. The more frequent type of anemia is caused by iron deficiency (IDA, iron-deficiency anemia): this review summarizes the state of the art of this topic. First of all, the mechanisms of IDA will be analyzed. Subsequently, a description of the main conditions where IDA can unfavorably affect the clinical course, and of its more frequent complications, will be presented (percutaneous interventions, heart surgery, CHF). Special attention will be paid in the description of anemia in the setting of CHF. To this regard, in recent years a relevant amount of research has been carried out, to determine whether treating anemia (either by directly stimulating erythropoiesis or by correcting iron deficiency by oral or intravenous route) is of any clinical and prognostic relevance in patients with CHF. The results of this research will, therefore, be summarized and critically discussed. Finally, we will outline the promising role of cardiac rehabilitation facilities and of its network of experts in the diagnosis, prognostic stratification, and treatment of anemia and iron deficiency.

Serum uric acid and outcomes in patients with chronic heart failure through the whole spectrum of ejection fraction phenotypes: Analysis of the ESC-EORP Heart Failure Long-Term (HF LT) Registry.

BACKGROUND: Retrospective analyses of clinical trials indicate that elevated serum uric acid (sUA) predicts poor outcome in heart failure (HF). Uric acid can contribute to inflammation and microvascular dysfunction, which may differently affect different left ventricular ejection fraction (LVEF) phenotypes. However, role of sUA across LVEF phenotypes is unknown. OBJECTIVES: We investigated sUA association with outcome in a prospective cohort of HF patients stratified according to LVEF. METHODS: Through the Heart Failure Long-Term Registry of the European Society of Cardiology (ESC-EORP-HF-LT), 4,438 outpatients were identified and classified into: reduced (<40% HFrEF), mid-range (40-49% HFmrEF), and preserved (≥50% HFpEF) LVEF. Endpoints were the composite of cardiovascular death/HF hospitalization, and individual components. RESULTS: Median sUA was 6.72 (IQ:5.48-8.20) mg/dl in HFrEF, 6.41 (5.02-7.77) in HFmrEF, and 6.30 (5.20-7.70) in HFpEF. At a median 372-day follow-up, the composite endpoint occurred in 648 (13.1%) patients, with 176 (3.6%) deaths and 538 (10.9%) HF hospitalizations. Compared with lowest sUA quartile (Q), Q-III and Q-IV were significantly associated with the composite endpoint (adjusted HR 1.68: 95% CI 1.11-2.54; 2.46: 95% CI 1.66-3.64, respectively). By univariable analyses, HFrEF and HFmrEF patients in Q-III and Q-IV, and HFpEF patients in Q-IV, showed increased risk for the composite endpoint (P<0.05 for all); after model-adjustment, significant association of sUA with outcome persisted among HFrEF in Q-IV, and HFpEF in Q-III-IV. CONCLUSIONS: In a large, contemporary-treated cohort of HF outpatients, sUA is an independent prognosticator of adverse outcome, which can be appreciated in HErEF and HFpEF patients.

Topically applied heparins for the treatment of vascular disorders : a comprehensive review.

Effective treatment of peripheral vascular disorders is important not only for resolution of local symptoms but also for preventing the development of systemic conditions such as deep vein thrombosis. Topical heparins are widely used in Europe for the prevention and treatment of local symptoms associated with peripheral vascular disorders. This comprehensive review of the literature evaluated the efficacy and safety of topically applied heparins for the treatment of vascular disorders. A total of 1055 patients participated in a total of 20 studies that compared topical heparin formulations with placebo, no treatment, subcutaneous heparin or with each other in the treatment of superficial thrombophlebitis or venous insufficiency. Heparin gel 1000 IU/g (Lioton) 1000 gel, Menaven) 1000 gel) was more effective than placebo in reducing the signs and symptoms of superficial thrombophlebitis. Liposomal heparin gel 2400 IU/g (LipoHep Forte) was as effective as subcutaneous low-molecular-weight heparin at relieving local symptoms of superficial venous thrombosis. In head-to-head studies comparing different topical heparin formulations, all preparations appeared effective but heparin gel 1000 IU/g was superior to a heparinoid mucopolysaccharide cream (Hirudoid) in patients with vascular disorders in terms of resolving spontaneous pain, induced pain, oedema and heaviness in the limb. Another study demonstrated the superiority of heparin gel 1000 IU/g compared with a gel formulation containing heparin 100 IU/g, aescinate and essential phospholipids (Essaven), for symptom resolution. All treatments were generally well tolerated, with a relatively low incidence of local skin events. In summary, topical heparin preparations may be useful for relieving the signs and symptoms of vascular disorders while improving microcirculation. There is some evidence to suggest that heparin gel 1000 IU/g may be more effective than other topical preparations in treating these conditions, possibly because of the relatively high heparin levels in this formulation. This remains to be tested in well controlled, adequately powered clinical trials.

Regression or reduction in progression of atherosclerosis, and avoidance of coronary events, with lovastatin in patients with or at high risk of cardiovascular disease: a review.

HMG-CoA reductase inhibitors (statins) are the drugs of first choice for treating hypercholesterolaemia in order to prevent or slow the progression of coronary heart disease (CHD). Statins generally reduce the risk of CHD morbidity or mortality by about 30%. Lovastatin is effective in lowering plasma total cholesterol and low-density lipoprotein cholesterol levels, and is widely prescribed for both the primary and secondary prevention of CHD. In the major AFCAPS/TexCAPS primary prevention study of 6605 middle-aged or elderly men and women without symptomatic cardiovascular disease and with only moderately elevated serum lipids, treatment with lovastatin 20-40 mg once daily for a mean of 5.2 years significantly (p < 0.001) reduced the incidence of a first acute major cardiac event by 37% compared with placebo. In the smaller ACAPS study of 919 men and women who were asymptomatic for cardiovascular disease, but with evidence of early atherosclerosis, treatment with lovastatin for 3 years significantly (p = 0.001) slowed or reversed atherosclerosis compared with placebo, as measured by changes in the intimal-medial thickness of carotid arteries on B-mode ultrasound. Three randomised, controlled, secondary prevention trials have demonstrated that in patients with coronary artery disease, treatment with lovastatin 20-80 mg/day alone or in combination with colestipol for 2-2.5 years reduced the severity of stenosis and/or slowed or reversed the progression of atherosclerosis, as assessed by angiography. In the FATS study, the severity of stenosis after 2.5 years in recipients of lovastatin plus colestipol was reduced by 2.8% compared with placebo, while the frequency of lesion progression was halved and the frequency of lesion regression was tripled. Treatment with lovastatin for 2.2 years in the MARS study significantly reduced the mean percent diameter stenosis compared with placebo (p = 0.005) in patients with more severe stenosis, and also significantly (p = 0.002) reduced the mean global change score (indicating less progression). In the CCAIT study, lovastatin therapy for 2 years significantly improved coronary change scores (p < 0.01) and significantly reduced the incidence of new lesions (p = 0.001) compared with placebo. Across the primary and secondary prevention studies, lovastatin was shown to be similarly effective in women, the elderly, smokers and in subjects with hypertension, hypercholesterolaemia or type 2 diabetes mellitus. Therefore, the available data demonstrate that lovastatin provides significant lipid-modifying efficacy, slows progression or causes regression of atherosclerosis, and protects against acute cardiac events, in both those with and those without symptomatic CHD.

[Italian cardiologists and tobacco smoking. A survey on the prevalence and knowledge of smoking and strategies for smoking cessation in a cohort of Italian cardiologists]. / Cardiologi italiani e fumo di tabacco. Survey su prevalenza e conoscenza del tabagismo e delle strategie antifumo di una coorte di cardiologi italiani.

BACKGROUND: Tobacco use is the single most preventable cause of death. Its cessation is the most cost-effective strategy for reducing long-term cardiovascular morbidity and mortality. Although both healthcare professionals and the general population are aware of the detrimental effects of smoking on health, more than 25% of Italians are current smokers. Recent surveys showed that almost 50% of smoker patients relapse to smoke after having been discharged for acute coronary syndrome. Physicians who smoke may be a barrier for effective cessation interventions. Thus, it is important to assess cardiologists' attitude toward smoking habits and the implementation of smoking cessation programs. METHODS: The survey "Italian cardiologists and smoking habits" has been held in 2013 during the 44° National Congress of the Italian Association of Hospital Cardiologists (ANMCO) to assess cardiologists' smoking status, their level of knowledge about smoking cessation interventions and their involvement in the management of smoking cessation. Out of more than 1200 cardiologists attending the ANMCO congress, 610 subjects (aged 51 ± 11 years) answered an anonymous 35-item questionnaire; they were asked to declare their smoking status (9.5% current smokers). RESULTS: Among doctors who attended the survey, 58% correctly indicated smoking as an addiction and 45% regularly advised their patients to stop smoking. The majority of cardiologists (93%) reported a positive attitude toward smoking cessation strategies, 62% of them thought that cardiologists themselves should treat smoking dependence, though specific tools (70%) and education for the management of smoking cessation are lacking (66%). Two thirds of the entire sample of ANMCO cardiologists declared their willingness to participate in specialized educational programs. CONCLUSIONS: More than a half of Italian cardiologists are aware that smoking is an addiction. Although they feel themselves yet inadequate toward this approach, they are favorable to implement their own knowledge and skills toward smoking cessation.

[Appropriateness of diagnostic tests in cardiovascular prevention: what can we skip?]. / Appropriatezza delle procedure diagnostiche in prevenzione cardiovascolare: di che cosa possiamo fare a meno?

In recent years, a huge increase in the use of cardiac procedures, both invasive and non-invasive, was observed. Diagnostic tests, mainly non-invasive tests, are often prescribed inappropriately, in most cases replacing the clinical evaluation. The rate of inappropriate tests in cardiology is largely variable, depending on regional issues and different medical approach. When the test entails radiation exposure, the biological risk for both the patient and the environment must be taken into account. For this reason, the test that results in less biological risk should always be preferred as a first step.Moreover, it has not been clearly demonstrated that some diagnostic tests help to improve the outcome, that is to prevent cardiovascular events. As many as one sixth of the patients who undergo stress imaging are not taking proper medication, and very frequently no change in therapy is made after the test, regardless of the outcome. Since the appropriateness of diagnostic evaluation requests is mandatory, we focused on the diagnostic tests usually performed in primary and secondary prevention that carry no contribution to the clinical management of patients. This review addresses the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models.

Prevalence and prognostic value of elevated urinary albumin excretion in patients with chronic heart failure: data from the GISSI-Heart Failure trial.

BACKGROUND: Increased urinary excretion of albumin is an early sign of kidney damage and a risk factor for progressive cardiovascular and renal diseases and heart failure. There is, however, only limited information on the prevalence and prognostic role of urinary albumin excretion in patients with established chronic heart failure. METHODS AND RESULTS: A total of 2131 patients enrolled in 76 sites participating in the GISSI-Heart Failure trial provided a first morning spot sample of urine at any of the clinical visits scheduled in the trial to calculate the urinary albumin-to-creatinine ratio. The relation between log-transformed urinary albumin-to-creatinine ratio and all-cause mortality (428 deaths, time from urine collection to event or censoring) was evaluated with Cox multivariable models adjusted for all significant risk factors at the time of urine collection, in the study population, and in patients without diabetes or hypertension. Almost 75% of the patients had normal urinary albumin excretion, but 19.9% had microalbuminuria (30 to 299 mg/g creatinine) and 5.4% had overt albuminuria (>or=300 mg/g). There was a progressive, significant increase in the adjusted rate of mortality in the study population (hazard ratio, 1.12; 95% CI, 1.05 to 1.18 per 1-U increase of log(urinary albumin-to-creatinine ratio), P=0.0002) and in the subgroup of patients without diabetes or hypertension. Randomized treatments (n-3 polyunsaturated fatty acids or rosuvastatin) had no major impact on albumin excretion. CONCLUSIONS: Independently of diabetes, hypertension, or renal function, elevated albumin excretion is a powerful prognostic marker in patients with chronic heart failure.