Healthy lifestyle interventions to combat noncommunicable disease-a novel nonhierarchical connectivity model for key stakeholders: a policy statement from the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine.

Noncommunicable diseases (NCDs) have become the primary health concern for most countries around the world. Currently, more than 36 million people worldwide die from NCDs each year, accounting for 63% of annual global deaths; most are preventable. The global financial burden of NCDs is staggering, with an estimated 2010 global cost of $6.3 trillion (US dollars) that is projected to increase to $13 trillion by 2030. A number of NCDs share one or more common predisposing risk factors, all related to lifestyle to some degree: (1) cigarette smoking, (2) hypertension, (3) hyperglycemia, (4) dyslipidemia, (5) obesity, (6) physical inactivity, and (7) poor nutrition. In large part, prevention, control, or even reversal of the aforementioned modifiable risk factors are realized through leading a healthy lifestyle (HL). The challenge is how to initiate the global change, not toward increasing documentation of the scope of the problem but toward true action-creating, implementing, and sustaining HL initiatives that will result in positive, measurable changes in the previously defined poor health metrics. To achieve this task, a paradigm shift in how we approach NCD prevention and treatment is required. The goal of this American Heart Association/European Society of Cardiology/European Association for Cardiovascular Prevention and Rehabilitation/American College of Preventive Medicine policy statement is to define key stakeholders and highlight their connectivity with respect to HL initiatives. This policy encourages integrated action by all stakeholders to create the needed paradigm shift and achieve broad adoption of HL behaviors on a global scale.

Renal function and peak exercise oxygen consumption in chronic heart failure with reduced left ventricular ejection fraction.

BACKGROUND: Chronic kidney disease is associated with sympathetic activation and muscle abnormalities, which may contribute to decreased exercise capacity. We investigated the correlation of renal function with peak exercise oxygen consumption (V̇O2) in heart failure (HF) patients. METHODS AND RESULTS: We recruited 2,938 systolic HF patients who underwent clinical, laboratory, echocardiographic and cardiopulmonary exercise testing. The patients were stratified according to estimated glomerular filtration rate (eGFR). Mean follow-up was 3.7 years. The primary outcome was a composite of cardiovascular death and urgent heart transplantation at 3 years. On multivariable regression, eGFR was predictor of peakV̇O2(P<0.0001). Other predictors were age, sex, body mass index, HF etiology, NYHA class, atrial fibrillation, resting heart rate, B-type natriuretic peptide, hemoglobin, and treatment. After adjusting for significant covariates, the hazard ratio for primary outcome associated with peakV̇O2<12 ml·kg(-1)·min(-1)was 1.75 (95% confidence interval (CI): 1.06-2.91; P=0.0292) in patients with eGFR ≥60, 1.77 (0.87-3.61; P=0.1141) in those with eGFR of 45-59, and 2.72 (1.01-7.37; P=0.0489) in those with eGFR <45 ml·min(-1)·1.73 m(-2). The area under the receiver-operating characteristic curve for peakV̇O2<12 ml·kg(-1)·min(-1)was 0.63 (95% CI: 0.54-0.71), 0.67 (0.56-0.78), and 0.57 (0.47-0.69), respectively. Testing for interaction was not significant. CONCLUSIONS: Renal dysfunction is correlated with peakV̇O2. A peakV̇O2cutoff of 12 ml·kg(-1)·min(-1)offers limited prognostic information in HF patients with more severely impaired renal function.

Fibrosis markers and CRIM1 increase in chronic heart failure of increasing severity.

BACKGROUND: Fibrosis suppressors/activators in chronic heart failure (CHF) is a topic of investigation. AIM: To quantify serum levels of fibrosis regulators in CHF. METHODS: ELISA tests were used to quantify fibrosis regulators, procollagen type-(PIP)I, (PIP)III, collagen-I, III, BMP1,2,3,7, SDF1α, CXCR4, fibulin 1,2,3, BMPER, CRIM1 and BAMBI in 66 CHF (NYHA class I, n = 9; II, n = 34; III n = 23), and in 14 controls. RESULTS: In CHF, TGFßR2, PIPIII, SDF1α and CRIM1 were increased. PIPIII correlated with CRIM1. CONCLUSIONS: The BMPs inhibitor CRIM1 is increased and correlates with higher levels of serum PIPIII showing an imbalance in favor of pro-fibrotic mechanisms in CHF.

[Left ventricular assist device: which emotional impact on the patient?]. / Assistenza ventricolare meccanica: quale impatto emozionale sul paziente?

BACKGROUND: Advanced heart failure is a challenging disease; the implantable Left Ventricular Assist Device (L-VAD) is becoming a good chance for relieving symptoms and prolong survival in most CHF patients. The emotional impact of L-VAD implantation is thought to be high but, at present, published data are scant about that. Aim of this study was to evaluate the modifications of perceived quality of life (QoL) in a group of patients recently treated with L-VAD implantation, admitted to a residential cardiac rehabilitation program, and to compare the results to those obtained in patients awaiting heart transplantation and recently transplanted. MATERIAL AND METHOD: We enrolled 66 patients (pts) with a recent implant of L-VAD, 51 with refractory heart failure awaiting heart transplantation (HT) and 55 recently treated with HT. On day two after admission, all patients underwent a complete psychometric assessment consisting in the compilation of: Minnesota Living with Heart Failure Questionnaire (MLHFQ). Beck Anxiety Inventory (BAI). Beck Depression Inventory-II (BDI-II). RESULTS: L-VAD recipients had significantly higher scores at MLHFQ. Both the total score and the 2 subscales scores (respectively physical and emotional disturbances) were statistically significant when compared with post-transplant patients. Posttransplant pts had the lowest scores regarding anxiety symptoms, while the bearers of device had the highest ones. The same results were obtained for depression scores (BDI-II), both in total score and in the subscales (somatic symptoms and affective symptoms). CONCLUSIONS: With an opening scoring, this study showed the development of more relevant psychological troubles in patients treated with L-VAD when compared to those awaiting for heart transplantation and those transplanted.

EaRly-start ExerciSe training afTer acute hemodynAmic decompensation in patients with chRonic hearT failure (RE-START). A multicenter, randomized, controlled trial on short-term feasibility and impact on functional capacity, symptoms and neurohumoral activation .

RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an early-start AET program on functional capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient-reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP > 1000 pg/mI at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine > 2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6-min WT at day 1, 6, 12 and 30 and echocardiogram, patient-reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.

Flow-mediated dilation normalization predicts outcome in chronic heart failure patients.

BACKGROUND: Reduced flow-mediated dilation (FMD) is a known prognostic marker in heart failure (HF), but may be influenced by the brachial artery (BA) diameter. Aiming to adjust for this influence, we normalized FMD (nFMD) by the peak shear rate (PSR) and tested its prognostic power in HF patients. METHODS AND RESULTS: BA diameter, FMD, difference in hyperemic versus rest brachial flow velocity (FVD), PSR (FVD/BA), and nFMD (FMD/PSR × 1000) were assessed in 71 HF patients. At follow-up (mean 512 days), 19 HF (27%) reached the combined endpoint (4 heart transplantations [HTs], 1 left ventricle assist device implantation [LVAD], and 14 cardiac deaths [CDs]). With multivariate Cox regression analysis, New York Heart Association functional class ≥III (hazard ratio [HR] 9.36, 95% confidence interval [CI] 2.11-41.4; P = .003), digoxin use (HR 6.36, 95% CI 2.18-18.6; P = .0010), FMD (HR 0.703, 95% CI 0.547-0.904; P = .006), PSR (HR 1.01, 95% CI 1.005-1.022; P = .001), FVD (HR 1.04, 95% CI 1.00-1.06; P = .02), and nFMD (HR 0.535, 95% CI 0.39-0.74; P = .0001) were predictors of unfavorable outcome. Receiver operating characteristic curve for nFMD showed that patients with nFMD >5 seconds had significantly better event-free survival than patients with nFMD ≤5 seconds (log-rank test: P < .0001). CONCLUSIONS: nFMD is a strong independent predictor of CD, HT, and LVAD in HF with left ventricular ejection fraction <40%. Patients with nFMD >5 seconds have a better prognosis than those with lower values.

Aerobic training and angiogenesis activation in patients with stable chronic heart failure: a preliminary report.

The pathophysiology of chronic heart failure (CHF) involves multiple hystologic and molecular alterations. To determine the effects of physical training on circulating endothelial progenitor cells (EPCs), angiogenesis (angiogenin, angiopoietin-1 and -2, VEGF, Tie-2, SDF-1α) and inflammation (IL-6, CRP), we compared data obtained from 11 CHF pts before and after 3 months aerobic exercise training, to those from 10 non trained CHF pts (CHF-C group, age 64 + 2 years, NYHA 2). At the end of the study, EPCs count and AP-2 serum levels significantly increased in the CHF-TR group. These preliminary data suggest a significant effect of even a short program of physical training on angiogenic activation and endothelial dysfunction.

Reduced exercise capacity in early-stage amyotrophic lateral sclerosis: Role of skeletal muscle.

Our objective was to correlate skeletal muscle mass (SM) with cardiopulmonary exercise testing (CPET) descriptors of exercise capacity in patients with amyotrophic lateral sclerosis (ALS) and compare ALS CPET data with those of patients with mitochondrial myopathy (MM) and normal subjects (N). Twenty-four early-stage ALS patients (63±11 years) underwent bioelectrical impedance analysis of body composition, resting spirometry, and ramp CPET. Six MM and six N were used as controls (56 ± 7 and 63 ± 4 years, respectively). Results showed that ALS SM index was similar to that of N (9.0±2.1 kg/m(2) vs. 10.4±1.9 kg/m(2), respectively; p = n.s.), whereas peak VO(2)/kg SM was significantly lower (41.5 ± 11.6 ml/kg/min vs. 57.8 ± 7.5 ml/kg/min, respectively; p < 0.01). However, the heart rate/VO(2) slope did not differ between ALS and N, being significantly higher in MM than in both ALS and N (6.1 ± 1.4 beats/ml/kg/min vs. 4.2 ± 1.1 beats/ml/kg/min vs. 3.8 ± 2.0 beats/ml/kg/min, respectively; both p < 0.01), excluding a marked skeletal muscle metabolic impairment in ALS. Neither cardiovascular nor ventilatory dysfunction was detected in ALS. Early-stage ALS patients show a SM similar to N, but with a reduced peak VO(2)/kg SM. Such a reduced peripheral O(2) utilization is consistent with deconditioning as the main cause of impaired exercise capacity in this population.

[Standards and outcome measures in cardiovascular rehabilitation. Position paper GICR/IACPR]. / Requisiti e indicatori in cardiologia riabilitativa: documento di consenso del GICR/IACPR.

Despite major improvements in diagnostics and interventional therapies, cardiovascular diseases remain a major health care and socio-economic problem in Italy. Costs and resources required are increasing in close correlation to both the improved quality of care and to the population ageing. There is an overwhelming evidence of the efficacy of cardiac rehabilitation (CR) in terms of reduction in morbidity and mortality after acute cardiac events. CR services are by definition multi-factorial and comprehensive. Furthermore, systematic analysis and monitoring of the process of delivery and outcomes is of paramount importance. The aim of this position paper promoted by the Italian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR) is to provide specific recommendations to assist CR staff in the design, evaluation and development of their care delivery organization. The position paper should also assist health care providers, insurers, policy makers and consumers in the recognition of the quality of care requirements, standards and outcome measure, quality and performance indicators, and professional competence involved in such organization and programs. The position paper i) include comprehensive CR definition and indications, ii) describes priority criteria based on the clinical risk for admission to both inpatient or outpatient CR, and iii) defines components and technological, structural and organizing requirements for inpatient or outpatient CR services, with specific indicators and standards, performance measures and required professional skills. A specific chapter is dedicated to the requirements for highly specialized CR services for patients with more advanced cardiovascular diseases.

Stepwise increase of angiopoietin-2 serum levels is related to haemodynamic and functional impairment in stable chronic heart failure.

BACKGROUND: A reciprocal link between inflammation, oxidative/nitrosative stress, and endothelial dysfunction has been postulated in chronic heart failure (CHF). The endothelial repair mechanisms involved remain to be determined. Our aim was to investigate whether there are detectable signs of ongoing angiogenesis in serum of CHF patients and to evaluate the correlation with indexes of haemodynamic and functional impairment. METHODS AND RESULTS: Enzyme-linked immunosorbent assay tests were used to quantify angiogenin, angiopoietin-1, angiopoietin-2, vascular endothelial growth factor, Tie-2, and brain natriuretic peptide in serum of 87 patients with CHF of increasing severity according to New York Heart Association (NYHA; class I, n = 8; II, n = 45; and III, n = 34) and in 14 healthy subjects matched for age and sex. Angiogenin, angiopoietin-2, and Tie-2 were significantly increased in CHF of increasing severity (Kruskal-Wallis: p = 0.0004, p < 0.0001, and p = 0.017, respectively). Angiopoietin-2 was inversely correlated with the 6-min walking test (r = -0.65, p < 0.0001), peak oxygen consumption (VO(2max); r = -0.57, p = 0.0002), and deceleration time (r = -0.61, p < 0.0001). Multiple regression analysis showed that angiopoietin-2 was mainly associated with VO(2max) (p = 0.018). The angiopoietin-2 area under the receiver operating characteristic curve for CHF diagnosis was 0.94 (95% CI 0.88-0.99; p < 0.001). CONCLUSIONS: These data demonstrate that angiopoietin-2 and selected serum markers of angiogenesis progressively increase with haemodynamic and functional decline in CHF.

Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation.

Cardiac patients after an acute event and/or with chronic heart disease deserve special attention to restore their quality of life and to maintain or improve functional capacity. They require counselling to avoid recurrence through a combination of adherence to a medication plan and adoption of a healthy lifestyle. These secondary prevention targets are included in the overall goal of cardiac rehabilitation (CR). Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients. The CR approach is delivered in tandem with a flexible follow-up strategy and easy access to a specialized team. To promote implementation of cardiac prevention and rehabilitation, the CR Section of the EACPR (European Association of Cardiovascular Prevention and Rehabilitation) has recently completed a Position Paper, entitled 'Secondary prevention through cardiac rehabilitation: A condition-oriented approach'. Components of multidisciplinary CR for seven clinical presentations have been addressed. Components include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, weight control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. Cardiac rehabilitation services are by definition multi-factorial and comprehensive, with physical activity counselling and exercise training as central components in all rehabilitation and preventive interventions. Many of the risk factor improvements occurring in CR can be mediated through exercise training programmes. This call-for-action paper presents the key components of a CR programme: physical activity counselling and exercise training. It summarizes current evidence-based best practice for the wide range of patient presentations of interest to the general cardiology community.

[Analysis of the vital exhaustion construct in a female population during cardiac rehabilitation]. / Analisi del costrutto di vital exhaustion in una popolazione femminile durante riabilitazione cardiologica.

BACKGROUND: Vital Exhaustion (VE) is a psychological construct that has been shown to be predictive for cardiac morbidity and mortality. There are not sufficient data which clarify whether the female population express this construct differentely comparing to males. This study aims to analyze the construct of Vital Exhaustion in a population of women admitted to a cardiac rehabilitation program. MATERIAL AND METHOD: The selected sample consisted of 854 women with an average age of 58 years (SD +/- 10.2). All patients were at their first hospitalization for a cardiac rehabilitation program. The tool used to analyze the construct of Vital Exhaustion was the B scale of the Cognitive Behavioural Assessment Hospital form (CBA-H). The study also analyzed the answers to the D scale of the CBA-H concerning aspects of lifestyle and behavioral habits. RESULTS: The percentage of women with considerable value of Vital Exhaustion was very high (67.7%). Moreover, the group of women with higher Vital Exhaustion showed more dysfunctional habits (smoking, poor physical activity, incorrect diet) and more referred psychological problems as well as job and/or family distress and insomnia. 207 women (24.2%) of the sample belonged to economically active population; 136 (69%) of these women presented a high value of VE and 61 (31%) a low one. Among the employed women, 24% of the group with high VE value reported to be unsatisfied, while the same condition lowered at 9.6% in the group with low VE value (p = .004); moreover, 41.7% versus 18.5% (p = .000) described their working life as a source of tension. CONCLUSIONS: Considering a sample of female cardiac patients, this study shows that the construct of Vital Exhaustion is particularly present. It also appears that the construct of Vital Exhaustion can be interpreted as an indicator of lifestyle problems in women, helping health-professionals in selecting efficient educational and/or psychological interventions.

Cardiovascular prevention and rehabilitation for patients with ventricular assist device from exercise therapy to long-term therapy. Part I: Exercise therapy.

In the present context of an aging population, limited donor heart availability, improved reliability of mechanical cardiac support and improved patient outcomes, ventricular assist device (VAD) options to support end-stage heart failure patients are rapidly expanding. In addition, both the smaller size and lighter weight of the pumps now produced and early evidence that these third generation devices may be associated with lower risk of infection and right ventricular failure will probably lead to greater physician and patient acceptability. This is the first of a two-part review on the role of cardiovascular prevention and rehabilitation in patients with VAD. In this first part, we will discuss the role of exercise therapy in VAD patients, while the second will focus on long-term management. One of the prerequisites for use of a VAD--whether permanent (as destination therapy) or semi-permanent (as an alternative to heart transplantation)--is that exercise capacity, although not normal, must be adequate for daily life activities. An intensive multidisciplinary rehabilitation program has the potential to increase exercise performance and improve the quality of life of VAD patients. Both early progressive mobilization and exercise training may improve the overall condition of VAD patients, and favorably impact their clinical course.

Cardiovascular prevention and rehabilitation for patients with ventricular assist device from exercise therapy to long-term therapy. Part II: long-term therapy.

Over the years left ventricular assist devices (VADs) have become more durable and reliable, smaller, simpler, easier to implant and more comfortable. The extensive experience now acquired shows successful hospital discharge with VAD use. We are entering an era in which long-term mechanical circulatory support will play an increasing role in the approach to end-stage heart failure (HF); at the same time, the extension of VADs into destination therapy has revealed the limitations of our understanding of these populations. This second paper on cardiovascular prevention and rehabilitation for patients with left VADs will deal with the management of patients outside the highly specialized HF centers and surgical setting, with particular focus on postoperative patient management. Outpatient management of VAD patients is time-intensive, and a multidisciplinary approach is ideal in long-term care. Although the new devices have definite advantages over the older pumps, some challenges still remain, i.e. infection, stroke, device thrombosis, gastrointestinal bleeding, recurrent HF symptomatology with or without multisystem organ failure, and occurrence of ventricular arrhythmias.

Cardiac deatH prevention by aUtomated defibrillatoRs in ChurcHes: rationale and design of the CHURCH trial.

Early defibrillation programs by the use of automated external defibrillators (AEDs) located in high-attendance public places may improve survival and neurologic outcome of patients undergoing sudden cardiac arrest (SCA). We planned a prospective cohort study to assess the effectiveness of a public-access defibrillation program based on positioning of AEDs in churches and training of lay volunteers in Basic Life Support Defibrillation during a single-day 5-hour training session. The CHURCH project aims to promote a widespread diffusion of AEDs, to train a large number of lay volunteers in Basic Life Support Defibrillation, and to increase population awareness on the opportunities for sudden death prevention. The rationale of the study rests on a survey commissioned by the Diocese of Milan that found a high prevalence of elderly subjects (44.5% were >60 years old) attending holy services in the morning hours, when sudden death incidence peaks. The catchment areas of the 12 parishes included in the trial as of June 2008 include a population of 140,000. The projected incidence of AED-treatable SCA, based on the presence of trained volunteers in the churches during day hours, at the CHURCH participating sites was estimated at 8 episodes per year. To estimate an overall 30% mortality reduction from SCA after AED placement at the study sites with respect to conventional SCA management by the Emergency Medical Service, 25 SCA episodes will have to be treated during the 4-year study period. The CHURCH project might be of interest and applicable in every country where high-attendance worship places are present.

Age-related prolongation of phase I of VO2 on-kinetics in healthy humans.

Data are lacking regarding age-related modifications of phase I (PhI) of pulmonary Vo(2) on-kinetics during moderate-intensity exercise. We studied three groups (aged 20-30, 40-50, and 60-70 years) of 10 normal subjects, who underwent one incremental and four below-gas exchange threshold constant-power cardiopulmonary exercise tests. Data from constant-power tests were time-aligned and averaged, and the PhI-phase II transition (PhI-IItr) determined when a sharp decrease from baseline of respiratory exchange ratio occurred. The Vo(2) phase II time constant (tau) was obtained by an exponential fitting starting 1) from PhI-IItr ("experimental" fitting strategy) and 2) after 20 s from exercise onset ("fixed-duration" fitting strategy). Assuming estimated arterial-venous O(2) concentration difference not to change with respect to resting value, cardiac output (CO) values at rest and PhI-IItr were obtained according to Fick's principle. Average pulmonary flow acceleration (AFA) during PhI was calculated as the ratio between CO increase during PhI and PhI duration. PhI duration was related to age (r = 0.74, P < 0.0001), increasing from 21 +/- 3 s to 27 +/- 3 s to 32 +/- 4 s in the 20-30, 40-50, and 60-70 age groups, respectively, and to AFA (r = -0.60, P < 0.001), but not to CO increase during PhI. With respect to the experimental fitting strategy, the fixed-duration strategy overestimated Vo(2) phase II tau the more the higher the subject's age, with a lower goodness of fit in the 60-70 group (SE 0.035 vs. 0.056, P < 0.01). In conclusion, PhI duration is related to age in healthy male humans and is linked to CO acceleration-rather than to increase-during PhI. A significant overestimation of phase II tau thus may occur in healthy elderly subjects and patients with a pathologically induced longer PhI duration when fitting data where the PhI-PhIItr was not experimentally determined but assumed to be a set value (i.e., 20 s).

Exercise haemodynamic variables rather than ventilatory efficiency indexes contribute to risk assessment in chronic heart failure patients treated with carvedilol.

AIMS: To evaluate the prognostic significance of traditional cardiopulmonary exercise testing (CPET) parameters in chronic heart failure (CHF) patients treated with beta-blockers. METHODS AND RESULTS: A total of 631 CHF patients were followed for cardiovascular death over 3.8 +/- 1.4 years; among them 79 (13%) died. All prognostic CPET parameters were related to outcome at univariate analysis, with haemodynamic-derived parameters [peak systolic blood pressure (SBP), peak circulatory power (CP) = peak oxygen consumption (pVO2) x peak SBP] and exertional oscillatory ventilation (EOV) reaching the highest chi2 (46.5, 40.9, and 22.6, respectively, all with P < 0.0001). Exertional oscillatory ventilation, although associated with high mortality rate (43 vs. 11%, P < 0.001), was detected in 42 (7%) patients. In non-EOV, again both peak SBP and peak CP reached the highest chi2 (30.6, and 21.6, respectively, all with P < 0.0001). Regarding CPET parameters, at multivariable analysis, peak SBP was the strongest risk index both in total and non-EOV populations, with 11% risk reduction every 5 mmHg increase. CONCLUSION: All traditional CPET risk parameters were informative in beta-blockers CHF patients, but peak SBP, peak CP, and EOV were the most predictive. In this low-risk population, EOV, although underrepresented, considerably enhanced risk stratification, although other ventilatory efficiency indexes provided less impressive predictive content. In large majority of non-EOV patients, peak SBP improved risk evaluation beyond other CPET parameters.

[Patient's emotional reactions in cardiac rehabilitation: analysis and perspectives]. / Le reazioni emozionali del paziente in riabilitazione cardiologica: analisi temporale e prospettive.

SUBJECT: Evaluation and treatment of psychological diseases are often included in cardiology rehabilitation programs. The aim of this study was to analyze the emotional reactions in a very consistent sample of cardiac patients, hospitalized for a rehabilitation program. MATERIALS AND METHODS: The sample consisted of 5417 patients, 4563 males and 854 females, with a mean age of 57.36 +/- 9.15 (range 18-83). They were admitted in the period between 1995 and 2005 and completed the Cognitive Behavioral Assessment, Hospital form (CBA-H). RESULTS: Significant level of state- anxiety was shown by 27.8% of the subjects, 22.1% reported health-related fears and 10% depressive symptoms. Women show higher scores in all of the three scales, and patients over 65 years scored higher in the depression scale. It is interesting to note that the mean scores in the three scales showed a progressive and significant decrease over the years. CONCLUSIONS: These data confirm that an accurate psychological screening can be extremely useful to support the Psychologist working in cardiac rehabilitation as it helps to plan more specifically the interventions, focusing on the objective patients' educational and psychological needs.

Oxidative stress induces myeloperoxidase expression in endocardial endothelial cells from patients with chronic heart failure.

Increased oxidative stress has been implicated in the pathogenesis of a number of cardiovascular diseases. Recent findings suggest that myeloperoxidase (MPO) may play a key role in the initiation and maintenance of chronic heart failure (CHF) by contributing to the depletion of the intracellular reservoir of nitric oxide (NO). NO consumption through MPO activity may lead to protein chlorination or nitration, leading to tissue damage. Primary cultures of human endocardial endothelial cells (EEC) obtained at heart transplantation of patients with CHF and human umbilical vein endothelial cells (HUVEC) were subjected to oxidative stress by incubation with hydrogen peroxide at non lethal (60 microM) dose for different exposure times (3 and 6 h). Treated and control cells were tested by immunohistochemistry and RT-PCR for MPO and 3-chlorotyrosine expression. Both endothelial cell types expressed myeloperoxidase following oxidative stress, with higher levels in EEC. Moreover, 3-chlorotyrosine accumulation in treated cells alone indicated the presence of MPO-derived hypochlorous acid. Immunohistochemistry on sections from post-infarcted heart confirmed in vivo the endothelial positivity to MPO, 3-chlorotyrosine and, to a minor extent, nitrotyrosine. Immunohistochemical observations were confirmed by detection of MPO mRNA in both stimulated EEC and HUVEC cells. This study demonstrates for the first time that EEC can express MPO after oxidative stress, both in vitro and in vivo, followed by accumulation of 3-chlorotyrosine, an end product of oxidative stress. Deregulation of endothelial functions may contribute to the development of a number of cardiovascular diseases, including CHF. The results also highlight the notion that endothelium is not only a target but also a key player in oxidative-driven cardiovascular stress.

Isolation and characterization of Oct-4+/HLA-G+ mesenchymal stem cells from human umbilical cord matrix: differentiation potential and detection of new markers.

The presence of multipotent cells in several adult and embryo-related tissues opened new paths for their use in regenerative medicine. Extraembryonic tissues such as umbilical cord are considered a promising source of stem cells, potentially useful in therapy. The characterization of cells from the umbilical cord matrix (Wharton's Jelly) and amniotic membrane revealed the presence of a population of mesenchymal-like cells, sharing a set of core-markers expressed by "mesenchymal stem cells". Several reports enlightened the differentiation capabilities of these cells, even if at times the lack of an extensive characterization of surface markers and immune co-stimulators expression revealed hidden pitfalls when in vivo transplantation was performed. The present work describes a novel isolation protocol for obtaining mesenchymal stem cells from the umbilical cord matrix. These cells are clonogenic, retain long telomeres, can undergo several population doublings in vitro, and can be differentiated in mature mesenchymal tissues as bone and adipose. We describe for the first time that these cells, besides expressing all of the core-markers for mesenchymal stem cells, feature also the expression, at both protein and mRNA level, of tolerogenic molecules and markers of all the three main lineages, potentially important for both their differentiative potential as well as immunological features.