Effects of the COVID-19 pandemic on the formation of fellows in training in cardiology.

CoronaVIrus Disease-19 (COVID-19) had a huge impact on human health and economy. However, to this date, the effects of the pandemic on the training of young cardiologists are only partially known. To assess the consequences of the pandemic on the education of the cardiologists in training, we performed a 23-item national survey that has been delivered to 1443 Italian cardiologists in training, registered in the database of the Italian Society of Cardiology (SIC). Six hundred and thirty-three cardiologists in training participated in the survey. Ninety-five percent of the respondents affirmed that the training programme has been somewhat stopped or greatly jeopardized by the pandemic. For 61% of the fellows in training (FITs), the pandemic had a negative effect on their education. Moreover, 59% of the respondents believe that they would not be able to fill the gap gained during that period over the rest of their training. A negative impact on the psycho-physical well being has been reported by 86% of the FITs. The COVID-19 pandemic had an unparalleled impact on the education, formation and mental state of the cardiologists in training. Regulatory agencies, universities and politicians should make a great effort in the organization and reorganization of the teaching programs of the cardiologists of tomorrow.

Long-term follow-up analysis of a highly characterized arrhythmogenic cardiomyopathy cohort with classical and non-classical phenotypes-a real-world assessment of a novel prediction model: does the subtype really matter.

AIMS: To provide long-term outcome data on arrhythmogenic cardiomyopathy (ACM) patients with non-classical forms [left dominant ACM (LD-ACM) and biventricular ACM (Bi-ACM)] and an external validation of a recently proposed algorithm for ventricular arrhythmia (VA) prediction in ACM patients. METHODS AND RESULTS: Demographic, clinical, and outcome data were retrieved from all ACM patients encountered at our institution. Patients were classified according to disease phenotype (R-ACM; Bi-ACM; LD-ACM). Overall and by phenotype long-term survival were calculated; the novel Cadrin-Tourigny et al. algorithm was used to calculate the a priori predicted VA risk, and it was compared with the observed outcome to test its reliability. One hundred and one patients were enrolled; three subgroups were defined (R-ACM, n = 68; Bi-ACM, n = 14; LD-ACM, n = 19). Over a median of 5.41 (2.59-8.37) years, the non-classical form cohort experienced higher rates of VAs than the classical form [5-year freedom from VAs: 0.58 (0.43-0.78) vs. 0.76 (0.66-0.89), P = 0.04]. The Cadrin-Tourigny et al. predictive model adequately described the overall cohort risk [mean observed-predicted risk difference (O-PRD): +6.7 (-4.3, +17.7) %, P = 0.19]; strafing by subgroup, excellent goodness-of-fit was demonstrated for the R-ACM subgroup (mean O-PRD, P = 0.99), while in the Bi-ACM and LD-ACM ones the real observed risk appeared to be underestimated [mean O-PRD: -20.0 (-1.1, -38.9) %, P < 0.0001; -22.6 (-7.8, -37.5) %, P < 0.0001, respectively]. CONCLUSION: Non-classical ACM forms appear more prone to VAs than classical forms. The novel prediction model effectively predicted arrhythmic risk in the classical R-ACM cohort, but seemed to underestimate it in non-classical forms.

A case-mix classification system for explaining healthcare costs using administrative data in Italy.

BACKGROUND: The Italian National Health Service (NHS) provides universal coverage to all citizens, granting primary and hospital care with a copayment system for outpatient and drug services. Financing of Local Health Trusts (LHTs) is based on a capitation system adjusted only for age, gender and area of residence. We applied a risk-adjustment system (Johns Hopkins Adjusted Clinical Groups System, ACG® System) in order to explain health care costs using routinely collected administrative data in the Veneto Region (North-eastern Italy). METHODS: All residents in the Veneto Region were included in the study. The ACG system was applied to classify the regional population based on the following information sources for the year 2015: Hospital Discharges, Emergency Room visits, Chronic disease registry for copayment exemptions, ambulatory visits, medications, the Home care database, and drug prescriptions. Simple linear regressions were used to contrast an age-gender model to models incorporating more comprehensive risk measures aimed at predicting health care costs. RESULTS: A simple age-gender model explained only 8% of the variance of 2015 total costs. Adding diagnoses-related variables provided a 23% increase, while pharmacy based variables provided an additional 17% increase in explained variance. The adjusted R-squared of the comprehensive model was 6 times that of the simple age-gender model. CONCLUSIONS: ACG System provides substantial improvement in predicting health care costs when compared to simple age-gender adjustments. Aging itself is not the main determinant of the increase of health care costs, which is better explained by the accumulation of chronic conditions and the resulting multimorbidity.

Sudden cardiac death in athletes: what is the role of screening?

PURPOSE OF REVIEW: To briefly review the field of sudden cardiac death (SCD) in the athlete and the impact of preparticipation screening on identification of at-risk cardiovascular disorders and mortality reduction. RECENT FINDINGS: Competitive sports activity is associated with an increase in the risk of SCD in susceptible adolescents and young adults with clinically silent cardiovascular disorders. Screening including 12-lead electrocardiogram (ECG) has been demonstrated to allow identification of athletes affected by malignant heart muscle diseases at a presymptomatic stage and lead to substantial reduction of the risk of SCD during sports. The use of modern criteria for interpretation of the ECG in the athlete significantly improves the screening accuracy by reducing the false-positive rate (increased specificity), with the important requisite of maintaining the ability for detection of life-threatening heart diseases (preserved sensitivity). Screening including ECG has a more favourable cost-benefit ratio than that based on history and physical examination alone, with cost estimates per year of life saved below the threshold to consider a health intervention as cost-effective. Screening with exercise testing middle-aged/senior athletes engaged in leisure sports activity is likely to be cost-effective in older patients with coronary risk factors, while it is not justified in low-risk subgroups. SUMMARY: Preparticipation screening is a life-saving and cost-effective strategy in young athletes in whom SCD is mostly caused by ECG-detectable heart muscle diseases.

Risk of sports: do we need a pre-participation screening for competitive and leisure athletes?

Sudden cardiac arrest is most often the first clinical manifestation of an underlying cardiovascular disease and usually occurs in previously asymptomatic athletes. The risk benefit ratio of physical exercise differs between young competitive athletes and middle-age/senior individuals engaged in leisure-time sports activity. Competitive sports are associated with an increase in the risk of sudden cardiovascular death (SCD) in susceptible adolescents and young adults with underlying cardiovascular disorders. In middle-age/older individuals, physical activity can be regarded as a 'two-edged sword': vigorous exertion increases the incidence of acute coronary events in those who did not exercise regularly, whereas habitual physical activity reduces the overall risk of myocardial infarction and SCD. Although cardiovascular pre-participation evaluation offers the potential to identify athletes with life-threatening cardiovascular abnormalities before onset of symptoms and may reduce their risk of SCD, there is a significant debate among cardiologists about efficacy, impact of false-positive results and cost-effectiveness of routine screening. This review presents an appraisal of the available data and criticisms concerning screening programmes aimed to prevent SCD of either young competitive athletes or older individuals engaged in leisure-time sports activity.

AECVP and SCVP 2009 recommendations for training in cardiovascular pathology.

Cardiovascular disease is of continuing importance as the result of a growing burden of risk factors in both developing and developed countries and the increasing number of elderly people worldwide. The recruitment and training of a new generation of Cardiovascular Pathologists is crucial to sustaining clinical excellence and to advancing our knowledge of cardiovascular disease. These pathologists will also have a key role in undergraduate and postgraduate training. In 2005 a task force of the Society for Cardiovascular Pathology published a document on the role of Cardiovascular Pathology as subspecialty of Anatomical Pathology (Pathological Anatomy). The 2005 report emphasized the need for a core curriculum and structured learning for residents and fellows in Cardiovascular Pathology. This new consensus statement on training is the result of collaboration between Cardiovascular Pathology Societies based in Europe and North America. It includes a detailed curriculum and describes three levels of expertise that can be developed.

Quantitative assessment of endomyocardial biopsy in arrhythmogenic right ventricular cardiomyopathy/dysplasia: an in vitro validation of diagnostic criteria.

AIMS: To provide a standardized endomyocardial biopsy (EMB) protocol and diagnostic quantitative parameters for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). The Task Force criteria for the in vivo diagnosis of ARVC/D include tissue characterization by EMB as a major criterion. METHODS AND RESULTS: EMBs were simulated in vitro with a Cordis bioptome in explanted hearts from six groups: diffuse (n = 10) and segmental (n = 10) ARVC/D, dilated cardiomyopathy (DC) (n = 10), controls (n = 10), adipositas cordis (n = 10), elderly >80 years (n = 10). Sampling sites were the RV inferior-subtricuspid, antero-apical, and mid-outflow tract (RVOT), the septum, and the left ventricle (LV). Histomorphometry was performed to evaluate the amount of myocardium and fibrous and fatty tissues. Myocyte diameters and abnormalities were also assessed. By selecting a 95% specificity, the ARVC/D diagnostic cut-offs on cumulative RV EMB samples are myocardium <59%, fibrosis >31% and fat >22% (80, 50, and 50% sensitivity, respectively). By excluding elderly and obese people groups a lower cut-off for fat was found (>9%). A high variability between different RV sampling sites was observed; the antero-apical was the most informative region although fat at this level is non-specific. No useful diagnostic cut-off for fatty tissue was identified at the antero-apical and RVOT area. No significant difference was found for any tissue parameter either in septal or in LV EMB. Increased RV myocyte diameters and cytological changes were detected in ARVC/D and DC. CONCLUSION: The residual myocardium is the main diagnostic morphometric parameter in ARVC/D, whereas fat at the apex is non-specific. Sensitivity and specificity vary according to the RV region. Target sampling of the triangle of dysplasia is required, although only a single region is often informative, emphasizing the usefulness of imaging-guided EMB. There is no diagnostic value of either septal or LV EMB. Cardiomyopathic changes of the myocytes also appear important for establishing a pathological diagnosis.