Prevalence and 1-year prognosis of transient heart failure following coronary revascularization.

The occurrence of heart failure during the whole pre-discharge course of coronary revascularization, as far as its influence on subsequent prognosis, is poorly understood. The present study examined the effect of transient heart failure (THF) developing in the acute and rehabilitative phase on survival after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI). Patients in the Italian survey on cardiac rehabilitation and secondary prevention after cardiac revascularization (ICAROS) were analyzed for THF, the latter being defined either as signs and symptoms consistent with decompensation or cardiogenic shock. ICAROS was a prospective, multicenter registry of 1,262 consecutive patients discharged from 62 cardiac rehabilitation (CR) facilities, providing data on risk factors, lifestyle habits, drug treatments, and major cardiovascular events (MACE) during a 1-year follow-up. Records were linked to the official website of the Italian Association of Cardiovascular Prevention and Rehabilitation (GICR-IACPR). The overall prevalence of pre-discharge THF was 7.6%, with 69.8% of cases in acute wards, 22.9% during CR, and 7.3% in both settings. THF affected more frequently patients with chronic cardiac condition (42.7 vs. 30.6%; p < 0.05), age ≥75 years (33.3 vs. 23.1%; p < 0.005), COPD (19.8 vs. 12.3%; p < 0.05), and chronic kidney disease (17.7 vs. 7%; p < 0.001). After discharge, THF patients showed good maintenance rates of RAAS modulators (90.6%) and beta-blockers (83.3%), while statin therapy significantly decreased from 81.3 to 64.6% (p < 0.05). The pursuit of secondary prevention targets, as far as self-reported drug adherence, was not different among groups. Patients with THF had increased 1-year mortality (8.3 vs. 1.6%, p < 0.001). Moreover, THF independently predicted adverse outcome with OR for recurrent events (mainly further episodes of decompensation) of 2.4 (CI 1.4-4.3). Patients who experienced THF after coronary revascularization had increased post-discharge mortality and cardiovascular events. Hemodynamic instability, rather than recurrent myocardial ischemia, seems to be linked with worse prognosis.

Effective secondary prevention through cardiac rehabilitation after coronary revascularization and predictors of poor adherence to lifestyle modification and medication. Results of the ICAROS Survey.

BACKGROUND AND AIM: Secondary prevention is a priority after coronary revascularization. We investigate the impact of a cardiac rehabilitation (CR) program on lifestyle, risk factors and medication modifications and analyze predictors of poor behavioral changes and events in patients after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS: Multicenter (n=62), prospective, longitudinal survey in post-CABG or -PCI consecutive patients after a comprehensive CR program. Cardiac risk factors, lifestyle habits, medication and 1 year cardiovascular events were collected. Logistic regression analyzed the association between risk factors, events and predictors of non-adherence to treatment and lifestyle. RESULTS: At 1 year, of the 1262 patients (66 ± 10 years, CABG 69%, PCI 31%), 94% were taking antiplatelet agents (vs. 91.8% at CR admission and 91.7% at CR discharge, p=ns), 87% statins (vs. 67.5%, p<.0001, and 86.3%, p=ns), 80.7% beta-blockers (vs. 67.4%, p<.0001, and 88.8%, p=ns), and 81.1% ACE inhibitors (vs. 57.5% p<.0001, and 77.7%, p=ns). 89.9% of the patients showed good adherence to treatment, 72% adhered to diet and 51% to exercise recommendations; 74% of smokers stopped smoking. Younger age was predictive of smoking resumption (OR 8.9, CI 3.5-22.8). Pre-event sedentary lifestyle (OR 3.3, CI 1.3-8.7) was predictive of poor diet. Older patients with comorbidity (OR 3.1; CI, 1.8-5.2) tended to persist in sedentary lifestyle and discontinue therapy and diet recommendations. Age, diabetes, smoking and PCI indication were predictors of recurrent CV events which occurred in 142 patients. CONCLUSION: Participation in CR results in excellent treatment after revascularization, as well as a good lifestyle and medication adherence at 1 year and provides further confirmation of the benefit of secondary prevention. Several clinical characteristics may predict poor behavioral changes.

[ICAROS (Italian survey on CardiAc RehabilitatiOn and Secondary prevention after cardiac revascularization): temporary report of the first prospective, longitudinal registry of the cardiac rehabilitation network GICR/IACPR]. / ICAROS (Italian survey on CardiAc RehabilitatiOn and Secondary prevention after cardiac revascularization): primo bilancio di una grande esperienza scientifica del network riabilitativo GICR/IACPR.

The Italian survey on CardiAc RehabilitatiOn and Secondary prevention after cardiac revascularization (ICAROS) was a multicenter, prospective, longitudinal survey carried out by the Italian Association on Cardiovascular Prevention and Rehabilitation (GICR/IACPR) in patients on completion of a CR program after coronary artery by pass grafting (CABG) and percutaneous coronary intervention (PCI). The aim was to evaluate in the short and medium-term: i) the cardioprotective drug prescription, modification and adherence; ii) the achievement and maintenance of recommended lifestyle targets and risk factor control and their association with cardiovascular events; iii) the predictors of non-adherence to therapy and lifestyle recommendations. The ICAROS results offers a portrait of the "real world" of clinical practice concerning patients after CABG and PCI, and stresses the need to improve secondary prevention care after the index event: many patients after revascularization leave the acute wards without an optimal prescription of preventive medication but the prescription of cardiopreventive drugs and risk factors control is excellent after completion of a CR program. Following CR, the maintenance of evidence-based drugs and lifestyle adherence at one year is fairly good as far as the target goals of secondary prevention are concerned, but to investigate the influence of CR on long-term outcome longer-term studies are required. Last, but not least, ICAROS shows that some characteristics (PCI as index event, living alone, poor eating habits or smoking in young age, and old age, in particular with comorbidities) may identify patients with poor behavioral modification in the medium-term follow-up and in these patients further support may be warranted. In conclusion, participation in CR results in excellent treatment after revascularization, as well as a good lifestyle and medication adherence at 1 year and provides further confirmation of the the benefit of secondary prevention.

Preoperative cardiac evaluation and perioperative cardiac therapy in patients undergoing open surgery for abdominal aortic aneurysms: effects on cardiovascular outcome.

BACKGROUND: Cardiovascular complications, such as death, myocardial infarction, or heart failure, are the leading causes of morbidity and mortality in adult patients undergoing major noncardiac surgery. OBJECTIVE: To evaluate the effects of an accurate preoperative cardiac evaluation, together with optimized perioperative drug therapy, in reducing cardiovascular events in patients undergoing open aortic surgery for abdominal aneurysm. METHODS: Between January 2000 and December 2008, we considered all consecutive patients undergoing elective abdominal aortic open surgery at the Vascular Surgery Unit of the University of Study-Spedali Civili (Italy). Since January 2003, we have used an intensive cardiac preoperative evaluation: patients with at least one cardiac risk factor received a preoperative cardiac evaluation; all non-invasive and invasive tests were performed preoperatively when indicated by the consultant cardiologist, that also optimized the pharmacological perioperative therapy. The outcome of the 418 patients undergoing surgery between 2003 and 2008 was compared with those of the 204 patients in the previous triennium 2000 to 2002, when only patients with positive history for cardiac disease received a standard preoperative cardiological clinical or instrumental evaluation. RESULTS: Patients enrolled in the 2003 to 2008 interval were slightly older and with a higher prevalence of comorbidities compared with those observed in the previous triennium; furthermore, the number of noninvasive tests performed before surgery increased significantly. Nevertheless, the number of major cardiac perioperative complications decreased over time: particularly, in-hospital mortality rate was 0.9% in the latter period, compared with 3.4% in the years 2000 to 2002. Also, the long-term mortality was significantly reduced in patients operated on between 2003 and 2008 compared with those operated on in the previous triennium. CONCLUSION: These data suggest a significant benefit of an intensive cardiac preoperative evaluation in reducing the incidence of perioperative and postoperative cardiac morbidity and mortality.

Gender differences in cardiac rehabilitation programs from the Italian survey on cardiac rehabilitation (ISYDE-2008).

PURPOSE: In recent years epidemiological and clinical evidence has shown gender disparities in several aspects of cardiovascular disease. Aim of this study was to identify gender differences in the clinical profile and management of patients admitted to cardiac rehabilitation (CR) programs. POPULATION: Patients enrolled in the ISYDE-2008 survey were considered. RESULTS: The ISYDE-2008 survey enrolled 2281 patients; 604 (26.5%) were women. Compared to men, women were older (mean age 70.8 ± 11.5 versus men's 65.6 ± 11.5 years), had less traditional risk factors (low cardiovascular risk profile in 45.3% of women and 38.0% of men, p=0.003), were more frequently admitted after valvular surgery and heart failure, but less for post-acute myocardial infarction and post-by-pass procedure. Women were more frequently admitted to an in-hospital rehabilitation program. Women showed a more complicated acute and rehabilitative course, with 63.2% of them having at least one complication during acute-phase, compared to 52.5% of men, and 48.3% during rehabilitation, compared to 35.0% of men (p<0.0001). During rehabilitation, women underwent exercise tests less frequently, except for the 6-minute walking test. At discharge, women received ACE-inhibitors/ARBs, ß-blockers, statins, omega-3 fatty acids, antiplatelet agents less frequently, but more frequently digoxin, amiodarone, diuretics, oral anticoagulants, insulin and anti-depressive drugs. The duration of the rehabilitation program was longer for women. Mortality was very low in the entire population. CONCLUSIONS: Women are less frequently admitted to CR than men. They are older and show a greater cardiovascular burden. Women are more likely to be enrolled in CR after valvular surgery and heart failure than men.

Late postoperative atrial fibrillation after cardiac surgery: a national survey within the cardiac rehabilitation setting.

AIMS: The aims of this study were to determine the incidence and clinical predictors of new-onset and recurrent late postoperative atrial fibrillation (POPAF) in a large cohort of patients who underwent cardiac rehabilitation programs (CRPs) after discharge from surgery units, and the association between late POPAF and cardiovascular morbidity and mortality in the medium term. METHODS: The ISYDE and ICAROS registries were two multicenter, prospective studies carried out by the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR-GICR), providing clinical information on consecutive patients completing CRP in 165 facilities. Patients following cardiac surgery were considered, with the exclusion of those with persistent POPAF at discharge from the surgery units. A total of 2256 patients following cardiac surgery were enrolled (isolated coronary surgery 62.9%, valve interventions 16%, combined surgery 21.1%). RESULTS: The mean age of patients was 67 ± 10 years, and the observation period 13 ± 20 days. During CRP, POPAF occurred in 241 (10.7%) patients, with 4.4% new-onset and 6.3% recurrent cases, respectively. In the logistic regression model, valve surgery (P < 0.05), a history of early POPAF (P < 0.001), and the presence of postoperative ventricular arrhythmias (P < 0.05) independently predicted the occurrence of late POPAF. Lack of prescription of cardioprotective drugs was not associated with late POPAF. Late POPAF increased the 1-year risk of cardiovascular events after CRP, mainly episodes of decompensated heart failure. CONCLUSION: A high level of suspicion for late POPAF, after discharge from surgery units, should be maintained due to the risk of occurrence, the low antiarrhythmic effect of common cardioprotective drugs and the impact on cardiovascular prognosis.

[After ACC/AHA and ESC Guidelines: Pre-operative cardiological evaluation in non-cardiac surgery: certainties, controversial areas and opportunities for a team approach]. / Dopo le Linee Guida ACC/AHA ed ESC: La valutazione cardiologica preoperatoria nella chirugia non cardiaca: le certezze, le aree controverse e le opportunità di una gestione in team.

A standardized and evidence-based approach to the cardiological management of patients undergoing noncardiac surgery has been recently defined by Task Forces of the American Heart Association (AHA), American College of Cardiology (ACC) and the European Society of Cardiology (ESC) that published their guidelines in 2007 and 2009, respectively. Both the recommendations moved from risk indices to a practical, stepwise approach of the patient, which integrates clinical risk factors and test results with the estimated stress of the planned surgical procedure. In the present paper the main topics of the guidelines are discussed, and moreover, emphasis is placed on four controversial issues such as the use of prophylactic coronary revascularization in patients with myocardial ischemia, the perioperative management of patients with congestive heart failure, the routine use of betablockers and statins, and, finally, the management of antiplatelet therapies in patients with coronary stents. In addition to promoting an improvement of immediate perioperative care, the preoperative cardiological evaluation should be a challenge for identifying subjects with enhanced risk of cardiovascular events, who should be treated and monitored during a long-term follow-up.

Cardiac rehabilitation in very old patients: data from the Italian Survey on Cardiac Rehabilitation-2008 (ISYDE-2008)--official report of the Italian Association for Cardiovascular Prevention, Rehabilitation, and Epidemiology.

BACKGROUND: Using data from the Italian SurveY on carDiac rEhabilitation-2008 (ISYDE-2008), this study provides insight into the level of implementation of cardiac rehabilitation (CR) in very old cardiac patients. METHODS: Data from 165 CR units were collected online from January 28 to February 10, 2008. RESULTS: The study cohort consisted of 2,281 patients (66.9 ± 11.8 years): 1,714 (62.4 ± 9.6 years, 78% male) aged<75 years and 567 aged ≥ 75 years (80.8 ± 4.5 years, 59% male). Compared with adults, a higher percentage of older patients were referred to CR programs after cardiac surgery or acute heart failure and showed more acute phase complications and comorbidity. Older patients were less likely discharged to home, more likely transferred to nursing homes, or discharged with social networks activation. Older patients had higher death rate during CR programs (odds ratio = 4.6; 95% confidence interval = 1.6-12.9; p = .004). CONCLUSION: The ISYDE-2008 survey provided a detailed snapshot of CR in very old cardiac patients.

Six-minute walking test after cardiac surgery: instructions for an appropriate use.

The 6-min walking test is a practical, simple, inexpensive test, which does not require any exercise equipment or advanced training. The test has been proposed both as a functional status indicator and as an outcome measure in various categories of patients (postmyocardial infarction, heart failure, postcardiac surgery) admitted to rehabilitation programs. The purpose of this study is to review the literature regarding the usefulness of 6-min walking test for the evaluation of patients entering a cardiac rehabilitation program early after cardiac/thoracic surgery. The test is feasible and safe, even in elderly and frail patients, shortly after admission to an in-hospital rehabilitation program. The results of the test is influenced by many demographic and psychological variables, such as age, sex (with women showing lower functional capacity), comorbidity (particularly diabetes mellitus, arthritis, and other musculoskeletal diseases), disability, self-reported physical functioning, and general health perceptions; contrasting data correlate walked distance with left ventricular ejection fraction. Practical suggestions for test execution and results interpretation in this specific clinical setting are given according to current evidence.

Physical and emotional symptom burden of patients with end-stage heart failure: what to measure, how and why.

OBJECTIVE: Much of our understanding about symptom burden near the end of life is based on studies of cancer patients. The aim of this study was to explore physical and emotional symptom experience among end-stage chronic heart failure patients, looking for those symptoms mostly related to their global health status. METHODS: Forty-six patients with end-stage heart failure compiled the following: Edmonton Symptom Assessment Scale (ESAS) and Kansas City Cardiomyopathy Questionnaire (KCCQ). RESULTS: End-stage heart failure patients have many complaints and poor global health status. The most distressing symptoms reported were general discomfort and tiredness followed by anorexia and dyspnea. The KCCQ summary scores were highly correlated with ESAS (r = -0.78; P = 0.0001). Among the domains explored by the KCCQ, social functioning and self-efficacy showed the lowest correlation coefficients with ESAS (r = -0.50; P = 0.001 and r = -0.31; P = 0.003, respectively); concerning the physical limitation domain, the symptom score and the quality-of-life domain, the correlation coefficients were as follows: r = -0.71 (P = 0.0001), r = -0.75 (P = 0.0001) and r = -0.74 (P = 0.0001), respectively. In the multiple regression analysis of ESAS and KCCQ scores, general discomfort, depression and anxiety were the symptoms that mostly related with the results in the domains explored by the KCCQ. No independent predictor was found among symptoms and quality of life. CONCLUSION: General discomfort together with depression and anxiety were the symptoms that were mostly related with the physical limitation domain of global health status, but did not influence the social functioning and the self-efficacy domains. When ESAS is used together with KCCQ, comprehensive and quantitative information on a patient's physical, emotional and social distress is provided.

[The Italian SurveY on carDiac rEhabilitation 2008 (ISYDE 2008): study presentation]. / II progetto ISYDE 2008 (Italian SurveY on carDiac rEhabilitation): strutture, rete, organizzazione e programmi di cardiologia riabilitativa in Italia.

In this paper, the Italian Society of Cardiac Rehabilitation and Prevention (GICR) presents the third survey on the status of cardiac rehabilitation (CR) in Italy. The Italian SurveY on carDiac rEhabilitation 2008 (ISYDE 2008) is a multicenter, observational study aimed at identifying the number and characteristics of Italian CR facilities, both in terms of health operators and interventions. Clinical records of all patients consecutively discharged within the whole network--composed of up to 200 CR units--from January 28 to February 10, 2008 will also be reviewed for diagnosis of admission, comorbidities, rehabilitation programs, and drug therapy, in order to obtain a snapshot of current implementation strategies in daily clinical practice. The survey will adopt a web-based methodology for data provision and transmission. Preliminary results of the survey are expected in the late summer 2008.

The Italian Survey on Cardiac Rehabilitation-2008 (ISYDE-2008). Part 3. National availability and organization of cardiac rehabilitation facilities. Official report of the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR-GICR).

From January 28th to February 10th 2008, the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR-GICR) conducted the ISYDE-2008 study, the primary aim of which was to take a detailed snapshot of cardiac rehabilitation (CR) provision in Italy--in terms of number and distribution of facilities, staffing levels, organization and setting--and compare the actual CR provision with the recommendations of national guidelines for CR and secondary prevention. The secondary aim was to describe the patient population currently being referred to CR and the components of the programs offered. Out of 190 cardiac rehabilitation centers existing in Italy in 2008, 165 (87%) took part in the study. On a national basis, there is one CR unit every 299,977 inhabitants: in northern Italy there is one CR unit every 263,578 inhabitants, while in central and southern Italy there is one every 384,034 and 434,170 inhabitants, respectively. The majority of CR units are located in public hospitals (59%), the remainder in privately owned health care organizations (41%). Fifty-nine percent are located in hospitals providing both acute and rehabilitation care, 32% are in specifically dedicated rehabilitation structures, while 8% operate in the context of residential long term care for chronic conditions. Almost three-quarters of CR units currently operating are linked to dedicated cardiology divisions (74%), 5% are linked to physical medicine and rehabilitation divisions, 2% to internal medicine, and 19% to cardiac surgery and other divisions. Inhospital care is provided by 62.4% of the centers; outpatient care is provided on a day-hospital basis by 10.9% of facilities and on an ambulatory basis by 20%. The CR units are led in 86% of cases by a cardiologist and in only 14% of cases by specialists in internal medicine, geriatrics, physical medicine and rehabilitation, pneumology or other disciplines. In terms of staffing, each cardiac rehabilitation unit has 4.0 +/- 2.7 dedicated physicians (range 1-16, mode 2), 10.1 +/- 8.0 nurses, 3.3 +/- 2.5 physiotherapists (range 0-20; 16% of services have no physiotherapist in the rehabilitation team), 1.5 +/- 0.8 psychologists, and a dietitian (present in 62% of CR units). Phase II CR programs are available in 67.9% of cases in residential (inpatient) and in 30.9% of cases in outpatient (day-hospital and ambulatory) settings. Phase III programs are offered by 56.4% of the centers in ambulatory outpatient regime, and on an at home basis by 4.8% with telecare supervision, 7.3% without. Long term secondary prevention follow up programs are provided by 42.4% of CR services.

Blunted erythropoietin production and defective iron supply for erythropoiesis as major causes of anaemia in patients with chronic heart failure.

AIMS: Anaemia is often observed in patients with chronic heart failure (CHF), and it may be associated with a worse prognosis. Aim of this study was to identify the individual mechanisms of anaemia in CHF patients. METHODS AND RESULTS: One hundred and forty-eight consecutive patients with haemoglobin concentration <13 g/dL (if males) or <12 g/dL (if females) were enrolled. Factors responsible for anaemia were investigated by evaluating endogenous erythropoietin (Epo) production, serum cytokines levels, body iron status, and iron supply for erythropoiesis. Most patients (57%) presented anaemia of chronic disease and among them, 92% showed evidence of a defective endogenous Epo production. This was indicated by an observed/predicted log(serum Epo) ratio less than 0.8 and/or a defective iron supply for erythropoiesis diagnosed by low transferrin saturation and/or increased value of soluble transferrin receptor. According to regression analysis sex, renal failure, and serum Epo were correlated with anaemia. CONCLUSION: According to our study, about half of anaemic CHF patients showed anaemia of chronic disease with blunted endogenous Epo production and/or a defective iron supply for erythropoiesis. Determination of the individual mechanisms of anaemia in CHF could justify a rational therapeutic approach to anaemia.

Distance walked in the 6-minute test soon after cardiac surgery: toward an efficient use in the individual patient.

STUDY OBJECTIVES: To describe the results of the 6-min walking test performed on admission to an intensive rehabilitation program after cardiac surgery and to develop, through an algorithm based on a few clinical indicators, reference tables in order to apply distance walked values more efficiently in the individual patient at his/her entry into a cardiac rehabilitation program. SETTING: Intensive cardiac rehabilitation units. PATIENTS AND INTERVENTION: A total of 2,555 consecutive patients admitted between January 2001 and December 2002 to the Cardiac Rehabilitation Department of the S. Maugeri Foundation early after cardiac surgery performed a 6-min walking test within the fourth day of hospital admission. RESULTS: The mean walked distance was 296 +/- 111 m (+/- SD). At multiple regression analysis, age, sex, and comorbidity were independent predictors of walking test performance. The left ventricular ejection fraction only influenced the walked distance in men. Starting from these variables, we propose an algorithm and specific reference tables. CONCLUSIONS: Reference values for gender-, age-, comorbidity-, and systolic function-related test performance in patients after cardiac surgery at the beginning of the rehabilitative phase are provided. Once a new patient has been categorized through simple parameters, the actual distance walked could be compared with the matched reference value, thus making the interpretation of the result more efficient. The walked distance might be used to define different levels of disability and to personalize therapeutic exercise prescriptions.

[Distance covered in walking test after heart surgery in patients over 70 years of age: outcome indicator for the assessment of quality of care in intensive rehabilitation]. / La distanza percorsa al test del cammino dopo chirurgia cardiaca in pazienti ultrasettantenni: un indicatore di risultato per la valutazione della qualità delle cure in riabilitazione intensiva.

UNLABELLED: For quality-of-care assessment of rehabilitation programs after cardiac surgery, measures of functional recovery have been proposed as outcome indicators. Aim of this study was to evaluate the feasibility, the safety and the informative content of the 6-min walking test (6 WT) performed in elderly patients soon after admission in an intensive rehabilitation program after cardiac surgery. METHODS: Population consists of 115 consecutive over-70 patients admitted to an in-hospital rehabilitation program after cardiac surgery. Within 7 days of admission, in 107 patients (93%) clinical conditions allowed the execution of a 6 WT, on ECG telemetry monitoring. Resting and exertional heart rate, score of fatigue (Borg Scale 1 divided by 20), symptoms, ECG alterations and arrhythmias were recorded. Other considered variables were: comorbidity (Charlson index), length of stay and complications occurring during the whole surgical and rehabilitation in-hospitalisation stay, disability (nursing needs: Maslow and nursing chart), functional status at discharge, left ventricular ejection fraction, number of exercise treatment sessions, self-perceived health-status at admission and at discharge (EuroQoL questionnaire). RESULTS: The mean walked distance was 194 +/- 93 m. No complication neither ECG alteration occurred during the 6 WT; only isolated premature ventricular beats were recorded in 26 pts. Heart rate increased from 86 +/- 13 at rest to 95 +/- 17 bpm at the end of the 6 WT (p < .0001). The perceived fatigue score was 12.9 +/- 1.2 Borg. Complications, length of stay, nursing needs, self-perceived health-status and functional capacity at discharge differed between patients who performed the 6 WT within 4 days compared with those who did it later, and between patients who walked < or = 120 m (lower quartile) compared with those who walked more. CONCLUSIONS: In elderly patients after cardiac surgery the 6 WT performed within the first week of admission in rehabilitation unit is feasible and safe. Simple cut-offs like timing of the 6 WT and walking performance identify more severe patients with lower susceptibility to recovery.

[Health care quality in terminal cardiac decompensation: a "multidisciplinary" reflexion]. / Qualità dell'assistenza nello scompenso cardiaco terminale: una riflessione "multidisciplinare".

Although improved, the prognosis of chronic heart failure is still malignant, the survival rate being similar to that of cancer. Due to the relevant epidemiology of this disease, the terminal care of heart failure has a significant impact, searching for the best quality of cure and care.