Metabolic syndrome in patients with intermittent claudication referred to vascular rehabilitation.

AIM: The prevalence of the metabolic syndrome, a clustering of cardiovascular risk factors whose underlying pathophysiology is related to insulin resistance, was estimated in patients with intermittent claudication referred to a short-course intensive rehabilitation program focused on physical training. Improvements in walking distance at the end of the program were also compared among patients with and without the syndrome. METHODS: The metabolic syndrome was documented among 34 (39%) out of 87 enrolled patients, without significant differences between those with and without the syndrome concerning sex (males 91% vs 92% respectively, P=0.816), age (64+/-8 vs 65+/-7 years, P=0.54), coronary heart disease (44% vs 32%, P=0.365), localization of peripheral arterial disease, and impairment of walking capacity as evaluated by constant treadmill test (initial claudication distance (ICD) 156+/-93 vs 176+/-126 m, P=0.428; absolute claudication distance (ACD) 429+/-324 vs 409+/-269 m, P=0.756). RESULTS: At the end of the program, both ICD and ACD significantly improved without any of significant differences between the two groups (ICD +152% vs +174% respectively, P=0.518; ACD +112% vs +177%, P=0.053). CONCLUSIONS: Metabolic syndrome is frequent among patients with intermittent claudication and is not associated with poor response to physical training. Our data highlight the need for considering vascular rehabilitation in these patients in order to both improve walking capacity and minimize cardiovascular morbidity and mortality.

Economic evaluation of a short-course intensive rehabilitation program in patients with intermittent claudication.

AIM: The aim of this study was to provide cost-description and cost-effectiveness of a short-course intensive in-hospital rehabilitation program in patients with intermittent claudication. METHODS: Costs per case treated were calculated according to a local standard protocol including diagnostic evaluation of peripheral arterial disease and other related cardiovascular conditions, physical training, and secondary prevention. Three additional less structured scenarios were also evaluated. RESULTS: All 107 enrolled patients (males 91%, mean age 65+/-8 years) completed the program (4-week duration; twice a day walking exercise) and showed significant increases in walking performance, as evaluated by constant treadmill-test. At admission, the mean values of initial claudication distance (ICD) and absolute claudication distance (ACD) were 150+/-111 and 432+/-327 m, respectively. At the end of the program, 12 (11%) patients completed the treadmill test without pain, while 31 (29%) completed the test without stopping due to maximal pain. Among the remaining 64 (60%) patients, the ICD and ACD increased by 137% and 112%, respectively. The cost per case treated ranged from Euro 1733.2 (standard protocol) to Euro 918.9 (physical training only). By adding the cost of hospitalization and indirect costs, the same costs ranged from Euro 4626.2 to Euro 3811.9. The average cost to walk one additional meter without pain as a result of the rehabilitation program was Euro 57.5, while the cost to walk one additional meter before stopping was Euro 27. As showed by sensitivity analysis, the maintenance of the expected level of treatment success was crucial for program's cost-effectiveness. CONCLUSION: From the societal viewpoint, short-course intensive rehabilitation may be cost-effective in patients with stable intermittent claudication and could be considered in decision models evaluating different therapeutic options.

[Stratification of arrhythmia risk in infarction: reflexions in the light of large trials]. / Stratificazione del rischio aritmico nell'infartuato: riflessioni alla luce dei grandi trial.

The identification of patients at higher risk of life-threatening ventricular arrhythmias after myocardial infarction still represents a clinically relevant problem, particularly after results of recent studies which support the efficacy of implantable cardioverter defibrillator (ICD) in reducing total mortality in patients with a previous myocardial infarction and left ventricular dysfunction, with and without additional risk markers. However, owing to the high cost of ICD therapy, an effective arrhythmic risk stratification may be desirable. The low diagnostic accuracy reported by various studies using single risk stratifiers (either invasive and non invasive) suggested a combined use of multiple parameters in order to improve the predictive power of the risk stratification algorithms. This approach, that takes into account the multifactorial genesis of malignant ventricular arrhythmias, has been demonstrated to be able to identify subgroups of patients at very high arrhythmic risk. In particular, a two-level algorithm based upon the selection of candidates to electrophysiologic study among patients with abnormal non-invasive testing, showed itself as a particularly effective tool for identification of such patients. In this paper the Authors summarize most recent results on the risk stratification protocols and the use of ICDs and provide an operative algorithm that keeps into account either aggressive and moderate approaches to patients surviving a myocardial infarction.

Clinical validation of an anxiety and depression screening test for intensive in-hospital rehabilitation.

Routine hospital psychological care must necessarily make use of a clinically reliable screening instrument for the identification of the patients to be referred for a clinical interview with a psychologist. This study compared two tests for the evaluation of anxiety and depression that are widely used in the hospital setting: the Hospital Anxiety and Depression Scale (HADS) and Form A-D, consisting of the State-Trait Anxiety Inventory (STAI-X1) for the evaluation of anxiety, and the Depression Questionnaire (DQ) for measuring depression. The aim of the study was to identify which of these instruments is the most suitable for screening a population admitted at in-hospital intensive rehabilitation using the clinical interview-based psychological evaluation as the gold standard. Both of the tests showed a concordance with the clinical opinion expressed by the psychologist, whose judgement was guided by the use of the validation study evaluation form. The analyses confirmed the good correlation of the two instruments in measuring anxiety and depression. The sensitivity of the STAI-X1 (52%) was less than that of HADS section A (72%), but its specificity (99%) was greater than that observed with the application of the HADS Anxiety subscale (84%). Analysis of the ROC curves showed that the STAI-X1 percentages of sensitivity and specificity tended to balance at higher level with a cut-off point equal to the 80th percentile. The results of the analysis of the DQ demonstrated equivalence with the results obtained using HADS section D, with a cut-off point of the 90th percentile. On the basis of these results, and given that both the STAI-X1 and the DQ have a broadly based Italian normative population, we feel that they can be recommended for psychological screening of patients in an in-hospital intensive rehabilitation.