Cost-effectiveness of outpatient adherence to recommendations for monitoring of patients hospitalized for heart failure.

AIMS: A set of indicators to assess the quality of care for patients hospitalized for heart failure was developed by an expert working group of the Italian Health Ministry. Because a better performance profile measured using these indicators does not necessarily translate to better outcomes, a study to validate these indicators through their relationship with measurable clinical outcomes and healthcare costs supported by the Italian National Health System was carried out. METHODS AND RESULTS: Residents of four Italian regions (Lombardy, Marche, Lazio, and Sicily) who were newly hospitalized for heart failure (irrespective of stage and New York Heart Association class) during 2014-2015 entered in the cohort and followed up until 2019. Adherence to evidence-based recommendations [i.e. renin-angiotensin-aldosterone system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and echocardiograms (ECCs)] experienced during the first year after index discharge was assessed. Composite clinical outcomes (cardiovascular hospital admissions and all-cause mortality) and healthcare costs (hospitalizations, drugs, and outpatient services) were assessed during the follow-up. The restricted mean survival time at 5 years (denoted as the number of months free from clinical outcomes), the hazard of clinical outcomes (according to the Cox model), and average annual healthcare cost (expressed in euros per person-year) were compared between adherent and non-adherent patients. A non-parametric bootstrap method based on 1000 resamples was used to account for uncertainty in cost-effectiveness estimates. A total of 41 406 patients were included in this study (46.3% males, mean age 76.9 ± 9.4 years). Adherence to RAS inhibitors, beta-blockers, MRAs, and ECCs were 64%, 57%, 62%, and 20% among the cohort members, respectively. Compared with non-adherent patients, those who adhered to ECCs, RAS inhibitors, beta-blockers, and MRAs experienced (i) a delay in the composite outcome of 1.6, 1.9, 1.6, and 0.6 months and reduced risks of 9% (95% confidence interval, 2-14%), 11% (7-14%), 8% (5-11%), and 4% (-1-8%), respectively; and (ii) lower (€262, €92, and €571 per year for RAS inhibitors, beta-blockers, and MRAs, respectively) and higher costs (€511 per year for ECC). Adherence to RAS inhibitors, beta-blockers, and MRAs showed a delay in the composite outcome and a saving of costs in 98%, 84%, and 93% of the 1000 bootstrap replications, respectively. CONCLUSIONS: Strict monitoring of patients with heart failure through regular clinical examinations and drug therapies should be considered the cornerstone of national guidelines and audits.

Flexible Approaches Based on Multistate Models and Microsimulation to Perform Real-World Cost-Effectiveness Analyses: An Application to Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors.

OBJECTIVES: This study aims to show the application of flexible statistical methods in real-world cost-effectiveness analyses applied in the cardiovascular field, focusing specifically on the use of proprotein convertase subtilisin-kexin type 9 inhibitors for hyperlipidemia. METHODS: The proposed method allowed us to use an electronic health database to emulate a target trial for cost-effectiveness analysis using multistate modeling and microsimulation. We formally established the study design and provided precise definitions of the causal measures of interest while also outlining the assumptions necessary for accurately estimating these measures using the available data. Additionally, we thoroughly considered goodness-of-fit assessments and sensitivity analyses of the decision model, which are crucial to capture the complexity of individuals' healthcare pathway and to enhance the validity of this type of health economic models. RESULTS: In the disease model, the Markov assumption was found to be inadequate, and a "time-reset" timescale was implemented together with the use of a time-dependent variable to incorporate past hospitalization history. Furthermore, the microsimulation decision model demonstrated a satisfying goodness of fit, as evidenced by the consistent results obtained in the short-term horizon compared with a nonmodel-based approach. Notably, proprotein convertase subtilisin-kexin type 9 inhibitors revealed their favorable cost-effectiveness only in the long-term follow-up, with a minimum willingness to pay of 39 000 Euro/life years gained. CONCLUSIONS: The approach demonstrated its significant utility in several ways. Unlike nonmodel-based or alternative model-based methods, it enabled to (1) investigate long-term cost-effectiveness comprehensively, (2) use an appropriate disease model that aligns with the specific problem under study, and (3) conduct subgroup-specific cost-effectiveness analyses to gain more targeted insights.

Incidence, Characteristics, and Management of Patients with Recurrent Myocardial Infarctions: Insights from the EYESHOT POST-MI.

Background: It is unknown whether patients who survived two or multiple episodes of myocardial infarction (MI) present different clinical characteristics and management than patients at their first MI. Methods: The EYESHOT post-MI was a prospective, observational, nationwide study aimed to evaluate the management of patients presenting to cardiologists 1 to 3 years from the last MI event. In 3 months of enrolment, 165 Italian cardiology centers included 1633 consecutive post-MI patients. In the present analysis, we stratified the study cohort according to the number of prior MI episodes (i.e., 1, 2 or ≥3). Results: Among the 1618 patients enrolled with complete data on MI history, 1335 (82.5%) were at their first MI episode, 209 (12.9%) had a history of 2 MIs, and the remaining 74 (4.6%) had ≥ 3 prior MIs. Patients with a history of multiple MIs were increasingly older and presented a significantly higher rate of risk factors compared to those at their first MI. During the year prior to enrolment, patients with 2 or ≥3 MI episodes more frequently underwent coronary angiography compared to the other group (p < 0.0001). In addition, several lifesaving and antianginal drugs were more frequently prescribed in patients presenting with a history of multiple MIs compared to those at their first MI. Conclusions: Our data suggest that patients with multiple MIs managed by cardiologists in routine clinical practice present an incremental clinical risk, more frequently undergo coronary angiography, and are more intensively managed with pharmacological therapies compared to patients at their first MI episode.

[ANMCO Position paper: Reorganization of cardiology in the era of the COVID-19 pandemic]. / Position paper ANMCO: Riorganizzazione della cardiologia in epoca di pandemia COVID-19.

The COVID-19 pandemic represents an unprecedented event that has brought deep changes in hospital facilities with reshaping of the health system organization, revealing inadequacies of current hospital and local health systems. When the COVID-19 emergency will end, further evaluation of the national health system, new organization of acute wards, and a further evolution of the entire health system will be needed to improve care during the chronic phase of disease. Therefore, new standards for healthcare personnel, more efficient organization of hospital facilities for patients with acute illnesses, improvement of technological approaches, and better integration between hospital and territorial services should be pursued. With experience derived from the COVID-19 pandemic, new models, paradigms, interventional approaches, values and priorities should be suggested and implemented.

Risk stratification and secondary prevention post-myocardial infarction: insights from the EYESHOT Post-MI study.

AIMS: Clinical management of patients more than 1 year after acute myocardial infarction (MI) is challenging. Patient risk stratification may help to establish therapeutic priorities. We aimed to describe the comprehensive risk profile and management of patients with prior MI. METHODS: We analyzed data from the EYESHOT Post-MI study, which evaluated the management of patients 1-3 years after MI. The risk profile of participants was defined according to the qualifying high-risk features of the PEGASUS-TIMI 54 trial (history of diabetes, history of recurrent MI, angiographic evidence of multivessel coronary disease, chronic kidney disease with estimated glomerular filtration rate <60 ml/min, age ≥65 years). Patients were classified into five subgroups according to the presence of zero, one, two, three, or more than three features. RESULTS: Of the 1633 patients in the EYESHOT Post-MI study, 1008 could be stratified according to PEGASUS-TIMI 54 high-risk features. About 22% of patients had no high-risk features, whereas 25% showed at least three features. The prevalence of patients with specific clinical severity indicators was progressively higher with the increasing number of high-risk features. Dual antiplatelet therapy and oral anticoagulation were more frequently used in patients with an increasing number of high-risk features (P for trend <0.0001). Lipid-lowering therapies were less frequently prescribed in patients with a higher number of features (P for trend 0.006 for statins; P for trend 0.007 for ezetimibe). CONCLUSION: Higher-risk post-MI patients, identified by PEGASUS-TIMI 54 high-risk features, showed an increased prevalence of major clinical severity indicators. Secondary prevention therapies were not adequately implemented in higher-risk patients.

Sex-related differences in chronic heart failure: a community-based study.

AIMS: To evaluate sex-related differences among real-life outpatients with chronic heart failure across the ejection fraction spectrum and to evaluate whether these differences might impact therapy and outcomes. METHODS: A total of 2528 heart failure patients were examined between 2009 and 2015 [mean age 76, 42% females; 59% with heart failure with preserved ejection fraction (HFpEF), 17% with heart failure with mid-range ejection fraction (HFmrEF) and 24% with heart failure with reduced ejection fraction (HFrEF)]. Females showed a higher prevalence of HFpEF than males. RESULTS: Females were older, less obese and with less ischaemic heart disease. They have renal failure and anaemia more frequently than males. There were no differences in terms of heart failure therapy in the HFrEF group, but a lower prescription rate of angiotensin-converting enzyme-I/AT1 blockers in HFmrEF and HFpEF and a higher prescription of mineralocorticoid receptor antagonists in the female group with HFpEF were observed. Crude rate mortality and composite outcome (death/heart failure progression) run similarly across sexes regardless of the ejection fraction categories. After adjustment, risk of mortality was significantly lower in females than males in the HFmrEF and HFpEF groups, whereas similar risk was confirmed across sexes in the HFrEF group. Considering prognostic risk factors, noncardiac comorbidities emerged in the HFpEF group. CONCLUSION: In a community-based heart failure cohort, females were differently distributed within heart failure phenotypes and they presented some different characteristics across ejection fraction categories. Although in an unadjusted model there was no significant difference for adverse outcomes, in an adjusted model females showed a lower risk of mortality in HFpEF and HFmrEF. Concerning sex-related prognostic risk factors, noncardiac comorbidities significantly affected adverse prognosis in females with HFpEF.

ANMCO POSITION PAPER: The role of cardiology in the management of the health needs in the post-Covid-19 era.

At the end of 2019 a new Coronavirus appeared in China and, from there, it spread to the rest of the world. On 24th May, 2020, the confirmed cases in the world were more than 5 million and the deaths almost 350.000. At the end of May, Italy reported more than 27.000 cases among healthcare professionals and 163 deaths among physicians. The National Health Systems from almost all over the world, including Italy's, were unprepared for this pandemic, and this generated important consequences of organizational nature. All elective and urgent specialized activities were completely reorganized, and many hospital units were partially or completely converted to the care of the COVID-19 patients. A significant reduction in hospital admissions for acute heart disease were recorded during the SARS-CoV-2 pandemic and, in order to gradually resume hospital activities, the Italian National Phase 2 Plan for the partial recovery of activities, must necessarily be associated with a Phase 2 Health Plan. In regards to the cardiac outpatient activities we need to identify short term goals, i.e. reschedule the suspended outpatient activities, revise the waiting lists, review the 'timings' of the bookings. This will reduce the number of available examinations compared to the pre-Covid-19 era. The GP's collaboration could represent an important resource, a structured telephone follow-up plan is advisable with the nursing staff's involvement. It is equally important to set medium-long term goals, the pandemic could be an appropriate moment for making a virtue of necessity. It is time to reason on prescriptive appropriateness, telemedicine implementation intended as integration to the traditional management. It is time to restructure the cardiological units related to the issue of structural adjustment to the needs for functional isolation. Moreover, the creation of 'grey zones' with multidisciplinary management according to the intensity of care levels seems to be necessary as well as the identification of Covid dedicated cardiologies. Finally, the pandemic could represent the opportunity for a permanent renovation of the cardiological and territorial medicine activities.

[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.

Prevalence and pharmacologic management of familial hypercholesterolemia in an unselected contemporary cohort of patients with stable coronary artery disease.

INTRODUCTION: Familial hypercholesterolemia (FH) is an inherited disorder characterized by elevated plasma levels of low-density lipoprotein cholesterol (LDL-C) associated with premature cardiovascular disease. METHODS: Using the data from the START (STable Coronary Artery Diseases RegisTry) study, a nationwide, prospective survey on patients with stable coronary artery disease (CAD), we described prevalence and lipid lowering strategies commonly employed in these patients. The study population was divided into "definite/probable FH," defined as a Dutch Lipid Clinic Network (DLCN) score ≥6, "possible FH" with DLCN 3-5, and "unlikely FH" in presence of a DLCN <3. RESULTS: Among the 4030 patients with the DLCN score available, 132 (3.3%) were classified as FH (2.3% with definite/probable and 1.0% with possible FH) and 3898 (96.7%) had unlikely FH. Patients with both definite/probable and possible FH were younger compared to patients not presenting FH. Mean on-treatment LDL-C levels were 107.8 ± 41.5, 84.4 ± 40.9, and 85.8 ± 32.3 (P < 0.0001) and a target of ≤70 mg/dL was reached in 10.9%, 30.0%, and 22.0% (P < 0.0001) of patents with definite/probable, possible FH, and unlikely FH, respectively. Statin therapy was prescribed in 85 (92.4%) patients with definite/probable FH, in 38 (95.0%) with possible FH, and in 3621 (92.9%) with unlikely FH (P = 0.86). The association of statin and ezetimibe, in absence of other lipid-lowering therapy, was more frequently used in patients with definite/probable FH compared to patients without FH (31.5% vs 17.5% vs 9.5%; P < 0.0001). CONCLUSIONS: In this large cohort of consecutive patients with stable CAD, FH was highly prevalent and generally undertreated with lipid lowering therapies.

[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.

Sex Profile and Risk Assessment With Cardiopulmonary Exercise Testing in Heart Failure: Propensity Score Matching for Sex Selection Bias.

BACKGROUND: In heart failure (HF), women show better survival despite a comparatively low peak oxygen consumption (V˙o2): this raises doubt about the accuracy of risk assessment by cardiopulmonary exercise testing (CPET) in women. Accordingly, we aimed to check (1) whether the predictive role of well-known CPET risk indexes, ie, peak V˙o2 and ventilatory response (V˙e/V˙co2 slope), is sex independent and (2) if sex-related characteristics that impact outcome in HF should be considered as associations that may confound the effect of sex on survival. METHODS: The study population consisted of 2985 patients with HF, 498 (17%) of whom were women, from the multicentre Metabolic Exercise Test Data Combined with Cardiac and Kidney Indexes (MECKI): the end point was cardiovascular death within a 3-year period. RESULTS: During the follow-up, 305 (12%) men and 39 (8%) women (P = 0.005) died, and female sex was linked to better survival on univariate analysis (P = 0.008) and independent of peak V˙o2 and V˙e/V˙co2 slope on multivariate analysis. According to propensity score matching for female sex to exclude a sex selection bias and sample discrepancy, 498 men were selected: the standardized percentage bias ranged from 20.8 (P < 0.0001) to 3.3 (P = 0.667). After clinical profile harmonizing, female sex was predictive of HF at univariate analysis. CONCLUSIONS: The low peak V˙o2 and female association with better outcome in HF might be counterfeit: the female prognostic advantage is lost when sex-specific differences are correctly taken into account with propensity score matching, suggesting that for an effective and efficient HF model, adjustment must be made for sex-related characteristics.

[Remarks on polyparametric assessment of sudden death risk for primary prevention ICD implantation in patients with left ventricular dysfunction of ischemic and non ischemic etiology. Italian Association of Hospital Cardiologists (ANMCO) Experts Position Paper]. / Considerazioni su una valutazione poliparametrica nella stratificazione del rischio di morte improvvisa per l'indicazione all'impianto di cardioverter-defibrillatore in prevenzione primaria, nella disfunzione ventricolare sinistra di origine ischemica e non ischemica. Position paper dell'Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO).

It is generally recognized that current guidelines, based on ejection fraction criteria, do not allow appropriate selection of patients for implantable cardioverter-defibrillator (ICD) therapy in the primary prevention of sudden death, thus hindering the optimal use of ICD in patients with left ventricular dysfunction of ischemic and nonischemic etiology. Ejection fraction alone has limitations in both sensitivity and specificity. Assessment of the risk for sudden death using a combination of multiple tests (ejection fraction associated with one or more different arrhythmic risk markers) could partially compensate for these limitations. In this position paper, the potential usefulness of a polyparametric assessment using some of the most investigated risk markers of sudden death is discussed, including late gadolinium enhancement cardiac magnetic resonance, programmed ventricular stimulation, T-wave alternans, autonomic tone, biomarkers, and genetic testing.

Rationale for cardiopulmonary exercise test in the assessment of surgical risk.

Although in the past years a reduced mortality in peri-operative care has been observed, cardiovascular mortality and morbidity still is a major burden in patients undergoing noncardiac surgery and its evaluation is still a difficult task. An accurate risk stratification can improve quality of peri-operative care and may improve survival, while reducing healthcare costs. In clinical practice, we make our assessment of a patient's cardiac status based on history, examination and investigations, together with risks related to the surgical procedure, to generate an 'individualized cardiac risk assessment'. At the present, risk stratification with clinical risk score and cardiac testing have been shown to be suboptimal in identifying high-risk patients. Surgery, like exercise, increases oxygen consumption. Indeed, one of the key elements in determining risk assessment is exercise intolerance, but future research in this field is needed to clarify this statement. Cardiopulmonary exercise testing (CPET) provides a global assessment of functional capacity involving and integrating the physiological measurement during incremental exercise. The pattern of CPET's variables identifies the abnormal exercise capacity, often providing an objective evaluation of cause and, moreover, predicting outcomes in both apparently healthy and chronic disease populations. An anaerobic threshold VO2 above 11 ml/kg per min seems to identify individuals with a very low surgical risk even if undergoing major surgery. This review is focused on tools of risk assessment in patients undergoing noncardiac surgery and on the physiological basis for CPET in detecting patients 'at risk'.

[Current perspectives in telemonitoring and devices in chronic heart failure patients: lights and shadows]. / Prospettive della telemedicina e del monitoraggio mediante dispositivi nel paziente con scompenso cardiaco cronico: luci e ombre.

The complexity of an integrated approach, mandatory for chronic diseases such as heart failure, might be simplified by the availability of new technologies for remote data transmission at relatively low costs. Home telemonitoring for complex patients opens new perspectives for the safe discharge of chronically severe patients and intensive surveillance for unstable subjects, and shows potential benefits on patients' quality of life and cost containment. Systematic reviews and meta-analyses document a 30-35% decrease in mortality and a 15-20% reduction in hospital admissions. Critical issues remain the presence of health facilities and professionals both in hospital and in the community adequately prepared for patient management through the telemonitoring tool, the selection of patients who may benefit most from it, and financial reimbursement of remote monitoring. The main indication to telemonitoring is the patient at high risk of short-term hemodynamic deterioration, but psychosocial issues should also be considered. New perspectives for tailored management of heart failure patients come from the recent availability of implantable devices able to record hemodynamic parameters. Current evidence is, however, insufficient to affirm their reliability, efficacy, cost-effectiveness, and management changes that may derive from their use.

Usefulness of frailty profile for targeting older heart failure patients in disease management programs: a cost-effectiveness, pilot study.

BACKGROUND: Disease management programs (DMP) improve outcomes in patients with heart failure. Because older heart failure patients represent a heterogeneous population, the aim of this study was to determine which patients benefit mostly from a DMP, by means of their frailty profile. SETTING: Heart failure outpatient clinic. METHODS: Consecutive (n = 173) patients aged more than 70 years were randomized to a multidisciplinary DMP (n = 86) or usual care (n = 87). A modified frailty score (range 1-6) was used as an index of global functional impairment. RESULTS: Mild to moderate frailty (frailty score = 2-3) was associated with significant improvements in outcomes (death and/or heart failure admission, heart failure admissions and all-cause admissions) in DMP patients vs. usual care. Even in more frail patients (frailty score = 4-6) a significant reduction in heart failure admissions was observed. By contrast, nonfrail patients (frailty score = 1) did not derive significant benefit. In the cost-effectiveness analysis, the mean savings per patient, stratified according to their frailty score, were -1003.31 euro for frailty score 1 (95% confidence interval -3717.00-1709.00), 1104.72 euro for frailty score 2 (-280.6-2491.00), 2635.42 euro for frailty score 3 (352.60-4917.00, P = 0.025) and 419.53 euro for frailty score 4-6 (-1909.00-2749.00). Intervention was therefore significantly cost saving in moderately frail, but not in nonfrail or severely frail patients. Thus, DMP was dominant (i.e. both less costly and more effective than usual care) in moderately frail patients. At sensitivity analysis, DMP remained dominant even to changes in cost of intervention and hospitalizations. CONCLUSION: This suggests that an intensive, hospital-based DMP appears to be more effective in older patients with mild-to-moderate levels of frailty. Thus, a multidimensional assessment of frailty seems to be a useful tool for appropriate selection of model of care.

Relative survival in dilated cardiomyopathy: a stratification study of long-term outcome to evaluate life insurance cover.

OBJECTIVES: The aim of this study was to compare mortality of dilated cardiomyopathy (DCM) patients with the mortality in the background Italian population, taking into account demographic characteristics and clinical stratification of long-term outcome, ie, "reverse remodelling" within the first 2 years of follow-up. BACKGROUND: DCM is a myocardial disease, characterized by left and/or right ventricular dilation and dysfunction and poor outcome. Evidence-based treatment with ACE inhibitors, beta-blockers and, in the last decade, implantable cardioverter defibrillators have been demonstrated to improve significantly heart failure symptoms and prognosis. At present, DCM patients are unlikely to be accepted for life insurance. METHODS: A cohort of 577 DCM patients consecutively enrolled from 1988 to 2004 in the Heart Muscle Disease Registry of Trieste, Italy, was matched by sex, age and registry data entry with the mortality data of the Italian population. Relative survival has been estimated by means of Kaplan-Meier technique, and mortality ratios (MR) with corresponding 95% confidence intervals have been computed. RESULTS: DCM patients who showed a significant reverse remodelling within the first 2 years of treatment showed comparable survival with respect to the control population, and therefore could be taken into consideration for life insurance coverage, at least for a short or medium-term of years. CONCLUSIONS: The data illustrate that survival probability strongly depend on the individual treatment and evolution of the disease and could be easily measured within the first 2 years of follow-up. If this information is collected at the time of evaluation of an applicant for life cover, the insurance company could possibly improve its risk stratification.

[Screening for asymptomatic left ventricular systolic dysfunction in high-risk patients. Preliminary experience with a program based on the use of ECG and natriuretic peptide]. / Lo screening della disfunzione sistolica ventricolare sinistra asintomatica nei pazienti ad alto rischio cardiovascolare. esperienza pilota di un programma basato sull'utilizzo dell'ECG e dei peptidi natriuretici.

BACKGROUND: Patients with asymptomatic left ventricular systolic dysfunction (ALVSD) have an increased risk of heart failure (HF) and a worse life expectancy. Since valuable therapies may prevent such dismal evolution, screening programs for ALVSD have recently been advocated to detect as early as possible such ominous condition. Echocardiography represents the gold standard for the assessment of ALVSD but its indiscriminate use in screening programs is impractical. Clinical multivariate risk assessment associated with ECG and serum brain natriuretic peptide (BNP) may be a feasible strategy to screen ALVSD. We prospectively sought to investigate the feasibility and effectiveness of a screening program for ALVSD based on ECG and BNP used in a hierarchical sequence in patients at high risk for HF. METHODS: Patients > or =55 years old with > or =2 risk factors for HF or > or =70 years old with > or =1 risk factor for HF entered the study performing sequentially ECG, BNP and echocardiographic evaluation. ALVSD was defined as a left ventricular ejection fraction < or =50%. RESULTS: Thirty-three of 122 enrolled patients (27%) had ALVSD. They were older, presented more frequently a history of chemotherapy exposure, had often bundle branch block and higher BNP levels. No patient without any major abnormalities (atrial fibrillation, left ventricular hypertrophy, STT alterations of ischemic/strain origin, pathologic Q wave, bundle branch block) on ECG (n=31, 24.4%) had ALVSD. Among the 91 patients with abnormal ECG, ALVSD was observed in 33 (36%). The area under the receiver operating characteristic curve to detect ALVSD by BNP was 0.86 (confidence interval 0.79-0.94, p<0.0001) and BNP values of > or =43 pg/ml showed a sensitivity and a specificity of 94% and 57%, respectively. The proposed screening program was able to identify 95% (31/33) of patients with ALVSD saving 53% of echocardiographic examinations with a substantial reduction of the costs to diagnose ALVSD. CONCLUSIONS: Our prospective investigation confirms that ECG and BNP may be useful in detecting ALVSD in high-risk patients. A cost-effective screening program based on such simple and low-cost diagnostic tests might be employed for the prevention of HF in primary and secondary prevention programs in high-risk patients.