The future of telemedicine for the management of heart failure patients: a Consensus Document of the Italian Association of Hospital Cardiologists (A.N.M.C.O), the Italian Society of Cardiology (S.I.C.) and the Italian Society for Telemedicine and eHealth (Digital S.I.T.).

Telemedicine applied to heart failure patients is a tool for recording and providing remote transmission, storage and interpretation of cardiovascular parameters and/or useful diagnostic images to allow for intensive home monitoring of patients with advanced heart failure, or during the vulnerable post-acute phase, to improve patient's prognosis and quality of life. Recently, several meta-analyses have shown that telemedicine-supported care pathways are not only effective but also economically advantageous. Benefits seem to be substantial, with a 30-35% reduction in mortality and 15-20% decrease in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management since all modern devices can transmit technical and diagnostic data. However, telemedicine may provide benefits to heart failure patients only as part of a shared and integrated multi-disciplinary and multi-professional 'chronic care model'. Moreover, the future development of remote telemonitoring programs in Italy will require the primary use of products certified as medical devices, validated organizational solutions as well as legislative and administrative adoption of new care methods and the widespread growth of clinical care competence to remotely manage the complexity of chronicity. Through this consensus document, Italian Cardiology reaffirms its willingness to contribute promoting a new phase of qualitative assessment, standardization of processes and testing of telemedicine-based care models in heart failure. By recognizing the relevance of telemedicine for the care of non-hospitalized patients with heart failure, its strategic importance for the design of innovative models of care, and the many challenges and opportunities it raises, ANMCO and SIC through this document report a consensus on the main directions for its widespread and sustainable clinical implementation.

ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care.

Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics. The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals. The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment. In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.

ANMCO Position Paper: hospital discharge planning: recommendations and standards.

The hospital discharge is often poorly standardized and affected by discontinuity and fragmentation of care, putting patients at high risk of both post-discharge adverse events and early readmission. The present ANMCO document reviews the modifiable components of the hospital discharge process related to adverse events or re-hospitalizations and suggests the optimal methods for redesigning the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that the hospital discharge: • is not an isolated event, but a process that has to be planned as soon as possible after the admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions, as equal partners; • is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process; • must be organized by an operator who is responsible for the coordination of all phases of the hospital patient journey, involving afterward the general practitioner and transferring to them the information and responsibility at discharge; • is the result of an integrated multidisciplinary team approach; • appropriately uses the transitional and intermediate care services; • is carried out in an organized system of care and continuum of services; and • programs the passage of information to after-discharge services.

Improvement of myocardial performance (Tei) index closely reflects intrinsic improvement of cardiac function: assessment in revascularized hibernating myocardium.

BACKGROUND: Myocardial performance index (MPI), or Tei index, is an indicator of systolic and diastolic myocardial function. MPI increases in case of cardiac dysfunction; however, whether reversal of left ventricular dysfunction is also reflected by concomitant improvement (i.e., decrease) of MPI is unknown. METHODS: Fifty-two patients with chronic ischemic cardiomyopathy and viable myocardium by dobutamine stress echocardiography were studied by echocardiography before and more than 4 months after cardiac revascularization. Patients were in optimal medical therapy, which remained unchanged following revascularization. RESULTS: At baseline, ejection fraction (EF: 32 ± 6%) and wall motion score index (WMSI: 2.37 ± 0.32) were impaired, and MPI averaged 0.71 ± 0.19. Revascularization markedly improved EF (44 ± 10%, P < 0.0001) and WMSI (1.77 ± 0.44, P < 0.0001). MPI also improved (0.59 ± 0.26, P < 0.0001), and its decrease was significantly correlated with the improvement in EF (r =-0.68, P < 0.0001) and to the extent of viable myocardium (r =-0.45, P = 0.0007). Responders to revascularization (≥5% increase in EF at follow-up, n = 40% and 77%) achieved a significant improvement in MPI at follow-up in contrast with nonresponders (-23 ± 25% vs. 0.02 ± 0.18%, P = 0.001). Improvement in MPI was largely driven by a significant reduction in isovolumic contraction time (P < 0.001) with consequent prolongation of the ejection phase. CONCLUSION: In patients with chronic ischemic cardiomyopathy, MPI improves along with recovery of function, reflecting the intrinsic improvement of viable segments induced by revascularization.

Effect of revascularizing viable myocardium on left ventricular diastolic function in patients with ischaemic cardiomyopathy.

AIMS: In patients with ischaemic left ventricular (LV) dysfunction and viable myocardium, revascularization improves systolic function. Diastolic dysfunction is also present in such patients; however, whether revascularization improves diastolic function also is largely unknown. METHODS: Twenty-six patients with chronic ischaemic cardiomyopathy [ejection fraction (EF) 32 +/- 6%, wall motion score index (WMSI) 2.45 +/- 0.33] and viable myocardium (low-dose dobutamine echocardiography) were examined at baseline and > or =4 months after revascularization. Diastolic function was assessed by transmitral pulsed-wave Doppler and tissue Doppler imaging (TDI) at the mitral annulus. RESULTS: At baseline, 62% of patients showed non-restrictive filling (non-RF) pattern, and 38% restrictive filling (RF) pattern. After revascularization, along with improvement in systolic function (EF 43 +/- 10%, WMSI 1.78 +/- 0.47, P = 0.0002 for both), diastolic filling improved in most patients, with only three patients still exhibiting RF pattern (P = 0.016); furthermore, E' velocity increased (32 +/- 42%, P = 0.0028) and E/E' decreased (-19 +/- 31%, P = 0.0378) compared with baseline. Left ventricular filling pressure also decreased, from 17.5 +/- 6.8 to 13.1 +/- 6.5 mmHg (P = 0.005). Improvement of diastolic function by TDI was related to the extent of viability at baseline (P = 0.0098) and to LV reverse remodelling after revascularization (P = 0.0092). CONCLUSION: In patients with ischaemic cardiomyopathy, LV diastolic filling may largely improve after revascularization. Improvement of diastolic dysfunction is related to the amount of viable tissue and it may represent an additional advantage of revascularizing dyssinergic but viable myocardium.

Superior Prognostic Value of Right Ventricular Free Wall Compared to Global Longitudinal Strain in Patients With Heart Failure.

BACKGROUND: Global right ventricular (RV) longitudinal strain (RVGLS) and free wall RV longitudinal strain (RVFWS) have both been advocated as sensitive tools to evaluate RV function and predict prognosis in patients with heart failure and reduced ejection fraction (HFrEF). However, because the interventricular septum is an integral part of the left ventricle (LV) also, RVGLS might be influenced by LV dysfunction. Thus, we compared the prognostic performance of either RV strain parameter in HFrEF patients, also taking into account the degree of LV systolic dysfunction. METHODS: In 288 prospectively enrolled outpatients with stable HFrEF, RVGLS and RVFWS were assessed by speckle-tracking and LV systolic function by global longitudinal strain and LV ejection fraction. Patients were followed up for 30.2 ± 23.0 months; the primary endpoint was all-cause death/heart failure-related hospitalization. Prognostic performance was assessed by C-statistic and net reclassification improvement. RESULTS: There were 95 events during follow-up. By univariable analysis, both RVGLS (hazard ratio × 1 SD, 1.60; 95% CI, 1.29-1.99; P < .0001) and RVFWS (hazard ratio × 1 SD, 1.82; 95% CI, 1.45-2.29; P < .0001) were associated with outcome, and both remained significant after correction for EMPHASIS risk score, New York Heart Association class, natriuretic peptides, and therapy. However, after further correction for LV systolic function parameters, only RVFWS remained significantly associated with outcome (P < .01). A basic prediction model was improved by adding RVFWS (net reclassification improvement 0.390; P < .05), but not RVGLS. CONCLUSIONS: Although both RVGLS and RVFWS have prognostic value, RVFWS better predicts outcome in HFrEF patients, mainly because it is less influenced by LV longitudinal dysfunction.

[ANMCO Position paper: From acute to chronic disease: the needs of complex cardiac patients]. / Position paper ANMCO: Bisogni assistenziali del malato cardiopatico complesso: dalla fase acuta alla fase cronica.

Managing a patient suffering from a chronic disease requires a multidisciplinary team that can take care of them beyond the simple coordination of various specialties. In this context, a central role in the treatment of chronic heart disease is the continuity of care that should promote organic integration among different hospital departments, hospital and community. This position paper of the Italian Association of Hospital Cardiologists (ANMCO) aims at defining the general principles to inspire care for complex cardiac patients at different phases of the disease. A multidisciplinary integrated holistic approach uses analytical tools able to understand the elements that characterize complexity and therefore suggest appropriate management strategies: (i) care pathways aimed at optimizing treatments; (ii) care pathways in intensive care and ward in a multidisciplinary perspective; (iii) integration of social and health needs; (iv) nursing role in the context of continuity of outpatient, community and home care; (v) promotion of educational interventions.

[ANMCO/FADOI/SIAARTI/SIC/SIMG/SIMI/SIMEU consensus document: The clinical care pathway of acute heart failure patients from symptom onset to discharge from the emergency department]. / Documento di consenso ANMCO/FADOI/SIAARTI/SIC/SIMG/SIMI/SIMEU: Il percorso clinico-diagnostico e terapeutico del paziente con scompenso cardiaco acuto dal domicilio alla dimissione dal Pronto Soccorso/ Dipartimento di Emergenza-Accettazione.

Acute heart failure (AHF) represents a relevant burden for emergency departments worldwide. AHF patients have markedly worse long-term outcomes than patients with other acute cardiac diseases (e.g. acute coronary syndromes); mortality or readmissions rates at 3 months approximate 33%, whereas 1-year mortality from index discharge ranges from 25% to 50%.The multiplicity of healthcare professionals acting across the care pathway of AHF patients represents a critical factor, which generates the need for integrating the different expertise and competence of general practitioners, emergency physicians, cardiologists, internists, and intensive care physicians to focus on care goals able to improve clinical outcomes.This consensus document results from the cooperation of the scientific societies representing the different healthcare professionals involved in the care of AHF patients and describes shared strategies and pathways aimed at ensuring both high quality care and better outcomes. The document describes the patient journey from symptom onset to the clinical suspicion of AHF and home management or referral to emergency care and transportation to the hospital, through the clinical diagnostic pathway in the emergency department, acute treatment, risk stratification and discharge from the emergency department to ordinary wards or home. The document analyzes the potential role of a cardiology fast-track and Observation Units and the transition to outpatient care by general practitioners and specialist heart failure clinics.The increasing care burden and complex problems generated by AHF are unlikely to be solved without an integrated multidisciplinary approach. Efficient networking among emergency departments, intensive care units, ordinary wards and primary care settings is crucial to achieve better outcomes. Thanks to the joint effort of qualified scientific societies, this document aims to achieve this goal through an integrated, shared and applicable pathway that will contribute to a homogeneous care management of AHF patients across the country.

Left Atrial Reservoir Function and Outcome in Heart Failure With Reduced Ejection Fraction.

Background Left atrial (LA) volume is a marker of cardiac remodeling and prognosis in heart failure (HF) with reduced ejection fraction (EF), but LA function is rarely measured or characterized. We investigated determinants and prognostic impact of LA reservoir function in patients with HF with reduced EF. Methods and Results In 405 patients with stable HF with reduced EF (EF, ≤40%) in sinus rhythm, we assessed LA reservoir function by both LA total EF (by phasic volume changes) and peak atrial longitudinal strain (PALS; by speckle tracking echocardiography); LA functional index was also calculated. During follow-up (median, 30 months; Q1-Q3, 13-52), 139 patients (34%) reached the composite end point (all-cause death/HF hospitalization). Median PALS was 15.5% (interquartile range, 11.2-20.6). By univariable analysis, all LA function parameters significantly predicted outcome ( P <0.01 for all), with PALS showing the highest predictive accuracy (area under the curve, 0.75; sensitivity, 73%; specificity, 70%). Impaired PALS was associated with greater left ventricular and LA volumes, worse left ventricular EF, left ventricular global longitudinal strain, right ventricular systolic function, and more severe diastolic dysfunction. After multivariable adjustment (including LA volume and left ventricular global longitudinal strain), PALS, but not LA total EF or LA functional index, remained significantly associated with outcome (hazard ratio per 1-SD decrease, 1.38; 95% CI, 1.05-1.84; P=0.030). Adding PALS to a base model, including age, sex, LA volume, EF, E/E' ratio, and global longitudinal strain, provided incremental predictive value (continuous net reclassification improvement, 0.449; P=0.0009). Conclusions In HF with reduced EF, assessment of LA reservoir function by PALS allows powerful prognostication, independently of LA volume and left ventricular longitudinal contraction.

Prognostic Value of Right Ventricular Dysfunction in Heart Failure With Reduced Ejection Fraction: Superiority of Longitudinal Strain Over Tricuspid Annular Plane Systolic Excursion.

BACKGROUND: In heart failure (HF) with reduced ejection fraction, right ventricular (RV) impairment, as defined by reduced tricuspid annular plane systolic excursion, is a predictor of poor outcome. However, peak longitudinal strain of RV free wall (RVFWS) has been recently proposed as a more accurate and sensitive tool to evaluate RV function. Accordingly, we investigated whether RVFWS could help refine prognosis of patients with HF with reduced ejection fraction in whom tricuspid annular plane systolic excursion is still preserved. METHODS AND RESULTS: A total of 200 patients with HF with reduced ejection fraction (age, 66±11 years; ejection fraction, 30±7%) with preserved tricuspid annular plane systolic excursion (>16 mm) underwent RV function assessment using speckle-tracking echocardiography to measure peak RVFWS. After a median follow-up period of 28 months, 62 (31%) patients reached the primary composite end point of all-cause death/HF rehospitalization. Median RVFWS was -19.3% (interquartile range, -23.3% to -15.0%). By lasso-penalized Cox-hazard model, RVFWS was an independent predictor of outcome, along with Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure-HF score, Echo-HF score, and severe mitral regurgitation. The best cutoff value of RVFWS for prediction of outcome was -15.3% (area under the curve, 0.68; P<0.001; sensitivity, 50%; specificity, 80%). In 50 patients (25%), RVFWS was impaired (ie, ≥-15.3%); event rate (per 100 patients per year) was greater in them than in patients with RVFWS <-15.3% (29.5% [95% confidence interval, 20.4-42.7] versus 9.4% [95% confidence interval, 6.7-13.1]; P<0.001). RVFWS yielded a significant net reclassification improvement (0.584 at 3 years; P<0.001), with 68% of nonevents correctly reclassified. CONCLUSIONS: In patients with HF with reduced ejection fraction with preserved tricuspid annular plane systolic excursion, RV free-wall strain provides incremental prognostic information and improved risk stratification.

Non-cardiac factors for prediction of response to cardiac resynchronization therapy: The value of baseline, and of serial changes, in red cell distribution width.

BACKGROUND: Increased red blood cell distribution width (RDW) has been associated with poor outcome after cardiac resynchronization therapy (CRT). However, whether baseline RDW, and its serial changes after CRT implant, have incremental prognostic value is unknown. METHODS AND RESULTS: In 148 consecutive patients (age, 68±9years; 122 men) undergoing CRT, RDW was assessed before and 3months after implant. Patients were categorized according to baseline RDW (≤14.5% vs >14.5%); and as "stable", "decreased", "increased", relative to post-implant changes. Primary end-point was a composite of death/HF hospitalization during follow-up (median 21months). A reduction in left ventricular (LV) end-systolic volume by ≥15% at 6-month identified LV reverse remodeling. By multivariable logistic regression analysis "increased" (OR:0.22, 95%CI: 0.07-0.69, P=0.010) and "stable-high" RDW at follow-up (OR: 0.39, 95%CI: 0.17-0.89, P=0.027) showed a lower likelihood to develop LV reverse remodeling, while baseline RDW was no longer predictive of LV remodeling. During follow-up, there were 57 events. Baseline RDW>14.5% (HR: 2.24, 95%CI: 1.05-4.77, P=0.036), "increased" (HR: 2.55, 95% CI: 1.09-5.97, P=0.030) and "stable-high" RDW (HR: 2.95, 95% CI: 1.45-5.99, P=0.003) independently predicted outcome after adjusting for functional improvement after CRT, radial dyssynchrony, BNP, creatinine clearance, and left atrial volume index. However, integrated discrimination improvement and net reclassification improvement were not statistically significant when both baseline RDW and its changes were added to a base predictive model. CONCLUSION: Increased and stable-high values of RDW were independently associated with both LV reverse remodeling and outcome after CRT; however, RDW did not show any incremental predictive value.

Fibrosis assessment by integrated backscatter and its relationship with longitudinal deformation and diastolic function in heart failure with preserved ejection fraction.

Myocardial reflectivity, as assessed by calibrated integrated backscatter (cIB) analysis, is a non-invasive surrogate for the amount of left ventricular (LV) fibrosis. The aim of this study was to assess the myocardial reflectivity pattern in patients with heart failure and preserved ejection fraction (HFpEF), and to evaluate its relationship with longitudinal systolic deformation of LV by 2D-speckle tracking echocardiography, and degree of diastolic dysfunction. Transthoracic echocardiography, myocardial Doppler-derived systolic (Sm) and early diastolic velocity (E'), global longitudinal strain (GLS), and tissue characterization by cIB, were obtained in 86 subjects, 46 with HFpEF, and 40 controls. GLS was significantly impaired in HFpEF patients (-15.4 ± 3.5 % vs -21.5 ± 2.9 % in controls; P < 0.0001). Increased myocardial reflectivity, as evidenced by less negative values of cIB, was also found in HFpEF compared to controls (-21.2 ± 4.4 dB vs -25.3 ± 3.9 dB, P < 0.0001). In HFpEF patients, myocardial reflectivity was positively related to GLS (r = 0.68, P < 0.0001), E/E' ratio (r = 0.38, P = 0.009), and Tau (r = 0.43, P = 0.002), and inversely related to E' velocity (r = -0.46, P = 0.0012). These associations remained significant after adjustment for age, preload and afterload indices. Patients with HFpEF show changes of LV structure consistent with enhanced fibrosis-as evidenced by increased myocardial reflectivity- which parallel the degree of diastolic dysfunction, and of longitudinal systolic dysfunction.

Incremental Value of Gait Speed in Predicting Prognosis of Older Adults With Heart Failure: Insights From the IMAGE-HF Study.

OBJECTIVES: The aim of this study was to assess the relationship between gait speed and the risk for death and/or hospital admission in older patients with heart failure (HF). BACKGROUND: Gait speed is a reliable single marker of frailty in older people and can predict falls, disability, hospital admissions, and mortality. METHODS: In total, 331 community-living patients ≥70 years of age (mean age 78 ± 6 years, 43% women, mean ejection fraction 35 ± 11%, mean New York Heart Association functional class 2.7 ± 0.6) in stable condition and receiving optimized therapy for chronic HF were prospectively enrolled and followed for 1 year. Gait speed was measured at the usual pace over 4 m, and cutoffs were defined by tertiles: ≤0.65, 0.66 to 0.99, and ≥1.0 m/s. RESULTS: There was a significant association between gait speed tertiles and 1-year mortality: 38.3%, 21.9%, and 9.1% (p < 0.001), respectively. On multivariate analysis, gait speed was associated with a lower risk for all-cause death (hazard ratio: 0.62; 95% confidence interval: 0.43 to 0.88) independently of age, ejection fraction <20%, systolic blood pressure, anemia, and absence of beta-blocker therapy. Gait speed was also associated with a lower risk for hospitalization for HF and all-cause hospitalization. When gait speed was added to the multiparametric Cardiac and Comorbid Conditions Heart Failure risk score, it improved the accuracy of risk stratification for all-cause death (net reclassification improvement 0.49; 95% confidence interval: 0.26 to 0.73, p < 0.001) and HF admissions (net reclassification improvement 0.37; 95% confidence interval: 0.15 to 0.58; p < 0.001). CONCLUSIONS: Gait speed is independently associated with death, hospitalization for HF, and all-cause hospitalization and improves risk stratification in older patients with HF evaluated using the Cardiac and Comorbid Conditions Heart Failure score. Assessment of frailty using gait speed is simple and should be part of the clinical evaluation process.

[ANMCO/SIC/SIT Consensus document: The future of telemedicine in heart failure]. / Documento di consenso ANMCO/SIC/SIT: Il futuro della telemedicina nello scompenso cardiaco.

Telemedicine applied to heart failure patients is a tool for recording, remote transmission, storage and interpretation of cardiocirculatory parameters and/or diagnostic images, useful, as emphasized by the latest guidelines, to allow for intensive home monitoring in patients with advanced heart failure or during the vulnerable post-acute phase to improve the prognosis and quality of life for patients.Recently, several meta-analyses have shown that the patterns of care supported by telemedicine are not only effective, but also economically advantageous. The benefit is unquestionable with a 30-35% reduction in mortality and a 15-20% reduction in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management as all modern devices can transmit technical and diagnostic data. However, telemedicine can bring benefits to the patient with heart failure only if it is part of a shared and integrated, multidisciplinary and multiprofessional "Chronic Care Model". Moreover, the future development of remote telemonitoring programs in our country goes through the primary use of products certified as medical device, field validation of organizational solutions proposed, a legislative and administrative adaptation to new care methods and the widespread growth of competence in clinical care to remotely manage the complexity of chronicity.With this consensus document the Italian Cardiology reaffirms its willingness to contribute to the government of the tumultuous and fragmented technological development, proposing a new phase of qualitative assessment, standardization of processes and testing the application of telemedicine to heart failure.

Atrial fibrillation, cognitive impairment, frailty and disability in older heart failure patients.

BACKGROUND: Aim of the study was to prospectively assess the relation between atrial fibrillation, cognitive impairment, frailty and disability in older patients with chronic heart failure . METHODS: Three hundred thirty-one ambulatory community-living patients aged 70 years and older (mean 78 ±â€Š6; range 70-93; 43% women) in stable conditions and optimized therapy were enrolled in seven heart failure cardiology clinics. Cognitive impairment was defined by a corrected Mini Mental State Examination score less than 24. Gait speed was used as marker of frailty and measured on a 4 m distance at usual pace. RESULTS: Ninety-eight patients (30%) were on atrial fibrillation at enrolment and 20 (6%) had a history of paroxysmal/persistent atrial fibrillation. Patients with atrial fibrillation were more frequently women with severe valvular disease, preserved left ventricular ejection fraction and less frequently on beta-blockers. At multivariable analyses, atrial fibrillation emerged as independently related to cognitive impairment [odds ratio (OR) 1.909 (1.072-3.397); P = 0.028], as well as to reduced gait speed [OR 4.366 (2.104-9.060); P < 0.001]. Furthermore, atrial fibrillation was significantly associated with disability in either basic or instrumental activities of daily living. No differences were found in mortality and morbidity. CONCLUSION: Among patients with chronic heart failure, those with atrial fibrillation present a high prevalence of frailty, cognitive impairment and disability. The hypothetical mechanisms by which atrial fibrillation and heart failure may affect these conditions are multiple and further studies are warranted. However, screening for these variables in clinical practice is simple and inexpensive and may allow better strategies for intervention in this high-risk population.

[ANMCO/SIC Consensus document: The heart failure network: organization of outpatient care]. / Documento di consenso ANMCO/SIC. La rete cardiologica per la cura del malato con scompenso cardiaco: organizzazione dell'assistenza ambulatoriale.

Changing demographics and an increasing burden of multiple chronic comorbidities in western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of-hospital phases of HF. The needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for hospitalized HF and those followed up at HF clinics.The Working Group on Heart Failure of the Italian Association of Hospital Cardiologists (ANMCO) has drafted a consensus document for the organization of a national HF care network. The aims of this document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among healthcare professionals. In this document, HF clinics are classified into three groups: 1) community HF clinics, devoted to the management of stable patients in strict liaison with primary care, regular re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, 2) hospital HF clinics, that target both new-onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for medicine units and community clinics; 3) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. These different types of HF clinics are integrated in a dedicated network for the management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multiprofessional providers to ensure continuity of care. This consensus document is expected to promote a more efficient organization of HF care, in particular for elderly patients and in transition phases from acute to chronic HF, by networking outpatient cardiology offer and primary care.

[ANMCO Position paper: Hospital discharge planning]. / Position paper ANMCO: Gestione della dimissione ospedaliera.

Hospital discharge is often poorly standardized and is characterized by discontinuity and fragmentation of care, putting patients at high risk of post-discharge adverse events and early readmission. The present ANMCO position paper reviews the modifiable components of the hospital discharge process related to adverse events or rehospitalizations and suggests the optimal methods for redesign the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that hospital discharge:- is not an isolated event, but a process that has to be planned immediately after admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions as equal partners;- is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process;- must be organized by an operator who is responsible for the coordination of all phases of the hospital patient pathway, involving afterwards the physician and transferring to them the information and responsibility;- is the result of an integrated multidisciplinary team approach;- uses appropriately the transitional and intermediate care services;- is carried out in an organized system of care and continuum of services;- programs the passage of information to after-discharge services.

Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure.

AIMS: Residual pulmonary congestion at discharge is associated with poor prognosis in heart failure (HF), but its quantification through physical examination is challenging. Ultrasound imaging of lung comets (B-lines) could improve congestion evaluation. The aim of this study was to assess the short-term prognostic value of B-lines after discharge from HF hospitalisation compared with other indices of haemodynamic congestion (BNP, E/e', and inferior vena cava diameter) or clinical status (NYHA class). METHODS AND RESULTS: Sixty consecutive HF inpatients underwent clinical examination, echocardiography, and lung ultrasound at discharge, independently of, and in addition to routine management by the attending physicians. The median B-line count was 8.5 (5-34). Three-month event-free survival for the primary endpoint (all-cause death or HF hospitalisation) was 27 ± 10% in patients with ≥30 B-lines and 88 ± 5% in those with <30 B-lines (P < 0.0001). In a multivariable model, ≥30 B-lines significantly predicted the combined endpoint (hazard ratio 5.66, 95% confidence interval 1.74-18.39, P = 0.04), along with NYHA ≥III and inferior vena cava diameter, while other indirect measures of congestion (BNP and E/e' ≥15) were not retained in the model; furthermore ≥30 B-lines independently also predicted the secondary outcomes (HF hospitalisation and death). Importantly, B-line addition to NYHA class and BNP was associated with improved risk classification (integrated discrimination improvement 15%, P = 0.02; continuous net reclassification improvement 65%, P = 0.03). CONCLUSION: Residual pulmonary congestion at discharge, as assessed by a B-line count ≥30, is a strong predictor of outcome. Lung ultrasonography may represent a useful tool to identify and monitor congestion and optimize therapy during and/or after hospitalisation for HF, which should be further validated in multicentre studies.

Plasma lipophilic antioxidants and malondialdehyde in congestive heart failure patients: relationship to disease severity.

Plasma levels of malondialdehyde (MDA), vitamin A, and of antioxidant micronutrients including vitamin E, lutein, zeaxanthin, beta-cryptoxanthin, lycopene, and alpha- and beta-carotene were measured in 30 patients with class II and III congestive heart failure (CHF) according to the New York Heart Association (NYHA) classification and in 55 controls. Ejection fraction was evaluated by echocardiography in all patients as a measure of the emptying capacity of the heart. Plasma levels of all measured compounds were significantly lower and MDA significantly higher in patients compared to controls (p <.001). Class II NYHA patients showed significantly lower MDA levels and significantly higher levels of vitamin A, vitamin E, lutein, and lycopene than class III patients. Ejection fraction was inversely correlated with MDA levels and directly correlated with vitamin A, vitamin E, lutein, and lycopene levels in patients. The present study supports the concept that an increased consumption of vitamin-rich fruits and vegetables might help in achieving cardiovascular health.

[Clinical features and diagnostic evaluation of heart failure in the elderly]. / Manifestazioni cliniche e valutazione diagnostica dello scompenso cardiaco nell'anziano.

The diagnosis of heart failure in the elderly frequently represents a clinical challenge. Atypical symptoms and signs and confounding comorbid conditions are common situations in old patients with heart failure and may obscure the clinical picture, complicating the diagnostic evaluation. Furthermore in the elderly, especially in female gender with a long-lasting history of hypertension, heart failure commonly may ensue as a consequence of a predominating impairment of the diastolic function with normal or near-normal preserved systolic function. Echocardiography represents the gold standard for the confirmation of the clinical suspicion of heart failure and may provide detailed information about left and right ventricular dimensions and function, atrial dimensions, valvular function and pericardium. For this reason it is recommended as part of initial diagnostic evaluation in almost all cases of heart failure. However, the low diagnostic accuracy of the clinical picture in elderly patients with suspected heart failure, as suggested by the international guidelines, requires the corroboration of the clinical suspicion with the help of "first-line" traditional investigations like ECG and chest X-ray. Recently natriuretic peptides (B-type natriuretic peptide [BNP] and NT-proBNP) have emerged as an attracting "tool" to support the clinical signs in patients with suspected heart failure. In this review we discuss about the opportunity that BNP and NT-proBNP would be relevant in the diagnostic process of elderly patients with suspected heart failure.