Positive affect as a predictor of non-pharmacological adherence in older Chronic Heart Failure (CHF) patients undergoing cardiac rehabilitation.

In Chronic Heart Failure (CHF) patients, psychological and cognitive variables and their association with treatment adherence have been extensively reported in the literature, but few are the investigations in older people. The present study aimed to evaluate the psychological, cognitive, and adherence to treatment profile of older (>65 years) CHF patients, the interrelation between these variables, and identify possible independent predictors of self-reported treatment adherence. CHF inpatients undergoing cardiac rehabilitation were assessed for: anxiety, depression, cognitive impairment, positive and negative affect, and self-reported adherence (adherence antecedents, pharmacological adherence, and non-pharmacological adherence). 100 CHF inpatients (mean age: 74.9 ± 7.1 years) were recruited. 16% of patients showed anxiety and 24.5% depressive symptoms; 4% presented cognitive decline. Cognitive functioning negatively correlated to depression, anxiety, and negative affect (p < 0.01). The adherence antecedents (disease acceptance, adaptation, knowledge, and socio-familiar support) negatively correlated to anxiety (p < 0.05), depression (p < 0.001), and negative affect (p < 0.05), while they positively correlated to positive affect (p < 0.01). Pharmacological adherence negatively correlated to anxiety and negative affect (p < 0.05). Conversely, non-pharmacological adherence and positive affect positively correlated (p < 0.05). Furthermore, depression and anxiety negatively predicted adherence antecedents (ß = -0.162, p = 0.037) and pharmacological adherence (ß = -0.171, p = 0.036), respectively. Finally, positive affect was found as an independent predictor of non-pharmacological adherence (ß = 0.133, p = 0.004). In cardiac rehabilitation, a specific psychological assessment focused on anxiety, depression, and affect can provide useful information to manage CHF older patients' care related to treatment adherence. In particular, positive affect should be targeted in future interventions to foster patients' non-pharmacological adherence.

[Implementation of the ICD-ICF model in rehabilitation medicine: report of a clinical case in rehabilitative cardiology]. / Implementazione del modello ICD-ICF in medicina riabilitativa: presentazione di un caso clinico in cardiologia riabilitativa.

SUMMARY: This patient entered a Cardiac Rehabilitation Program after coronary artery bypass graft. Concomitant diseases and the degree of disability have been coded according to International Classification of Functioning (ICF). Rehabilitation multidisciplinary program has been started (physician, nurses, physiotherapist and nutritionist); atrial fibrillation, anaemia, pleural effusion, surgical wounds inflammation were treated. Educational program allowed a better knowledge of the diseases the patient is bearing; low functional capability diagnosed at admittance improved thanks to the coordinated intervention of professionals involved. Coding diseases and disabilities at admission ensured a detailed identification of patient's issues and allowed the identification and the proposal for a targeted rehabilitation program. The improvement of medical ICF codes b280, b810 and b820, of physiotherapeutic codes b235, d450, d4551 and d455 and of nursing codes b280, b810 and b820 depends on the marked reduction of disability level.

Exercise-based cardiac rehabilitation in cardiac resynchronization therapy recipients: A primer for practicing clinicians.

Cardiac resynchronization therapy (CRT) is a therapeutic option of increasing importance for chronic heart failure (CHF) and criteria for implantation now concern a large amount of patient populations. As a consequence, subjects with ongoing CRT (or immediately after CRT implantation) are more often referred to Cardiac Rehabilitation (CR) programmes, and it has been recently estimated that about one third of CHF patients attending CR in Italy currently have this kind of device. The presence of CRT represents a modulating factor for exercise prescription and monitoring, since CRT patients may be considered per se as a target group for CR. Exercise therapy (ET) increases benefits from CRT on functional capacity, and recent evidence suggests an adjuvant role of ET in improving cardiovascular prognosis also. Both aerobic endurance and resistance training activities may involve CHF patients with CRT, while the potential role of aerobic interval training needs more studies and evidence. Prescription of an ET program should be associated with information regarding device programming and possible limiting factors associated with pacing therapy, tailoring of the basic principles of ET (in terms of type of exercise, intensity and program duration) in this patient group is mandatory.

Predicting short-term mortality in advanced decompensated heart failure - role of the updated acute decompensated heart failure/N-terminal pro-B-type natriuretic Peptide risk score.

BACKGROUND: The first few months after admission are the most vulnerable period in patients with acute decompensated heart failure (ADHF). METHODS AND RESULTS: We assessed the association of the updated ADHF/N-terminal pro-B-type natriuretic peptide (NT-proBNP) risk score with 90-day and in-hospital mortality in 701 patients admitted with advanced ADHF, defined as severe symptoms of worsening HF, severely depressed left ventricular ejection fraction, and the need for i.v. diuretic and/or inotropic drugs. A total of 15.7% of the patients died within 90 days of admission and 5.2% underwent ventricular assist device (VAD) implantation or urgent heart transplantation (UHT). The C-statistic of the ADHF/NT-proBNP risk score for 90-day mortality was 0.810 (95% CI: 0.769-0.852). Predicted and observed mortality rates were in close agreement. When the composite outcome of death/VAD/UHT at 90 days was considered, the C-statistic decreased to 0.741. During hospitalization, 7.6% of the patients died. The C-statistic for in-hospital mortality was 0.815 (95% CI: 0.761-0.868) and Hosmer-Lemeshow χ(2)=3.71 (P=0.716). The updated ADHF/NT-proBNP risk score outperformed the Acute Decompensated Heart Failure National Registry, the Organized Program to Initiate Lifesaving Treatment in Patients Hospitalized for Heart Failure, and the American Heart Association Get with the Guidelines Program predictive models. CONCLUSIONS: Updated ADHF/NT-proBNP risk score is a valuable tool for predicting short-term mortality in severe ADHF, outperforming existing inpatient predictive models.

Prospective Use of Microvolt T-Wave Alternans Testing to Guide Primary Prevention Implantable Cardioverter Defibrillator Therapy.

BACKGROUND: We hypothesized that a negative microvolt T-wave alternans (MTWA) test would identify patients unlikely to benefit from primary prevention implantable cardioverter defibrillator (ICD) therapy in a prospective cohort. METHODS AND RESULTS: Data were pooled from 8 centers where MTWA testing was performed specifically for the purpose of guiding primary prevention ICD implantation. Cohorts were included if the ratio of ICDs implanted in patients who were MTWA "non-negative" to patients who were MTWA negative was >2:1, indicating that MTWA testing had a significant impact on the decision to implant an ICD. The pooled cohort included 651 patients: 371 MTWA non-negative and 280 MTWA negative. Among non-negative patients, 62% underwent ICD implantation whereas only 13% of MTWA-negative patients received an ICD (P<0.01). Despite a substantially lower prevalence of ICDs, long-term survival (6.9 years) was significantly better among MTWA-negative patients (68.2% non-negative vs. 87.1% negative, P=0.026). CONCLUSIONS: MTWA-negative patients had significantly better survival than MTWA non-negative patients, the majority of whom had ICDs. Despite a very low prevalence of ICDs, long-term survival among patients with left ventricular ejection fraction ≤40% and a negative MTWA test was better than in the ICD arm of any study to date that has demonstrated a benefit of ICDs. This provides further evidence that MTWA-negative patients are unlikely to benefit from primary prevention ICD therapy.

Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve replacement (TAVR): a multicenter retrospective study.

BACKGROUND: The aim of this study was to evaluate cardiac rehabilitation (CR)-derived predictors of outcome in patients discharged from rehabilitation after transcatheter aortic valve replacement (TAVR). METHODS: We retrospectively analyzed data from 232 TAVR patients (aged 82±6 years, 55% females) discharged following an average 3-week residential CR program in the period January 2009 to December 2017. Comorbidities (cumulative illness rated state-comorbidity index, CIRS-CI), echocardiography on admission, disability (Barthel Index [BI]) and functional capacity (6-min walk distance, 6MWD) at discharge, and maximal training session intensity expressed in METs/min were collected. The endpoint was all-cause mortality. RESULTS: Seventy-four (32%) deaths occurred at 3-year follow-up. At discharge, non-survivors had a higher comorbidity rate (CIRS-CI 5.2±2.3 vs. 4.1±1.9, P=0.000), higher disability level (BI 80.4±24 vs. 88.8±17, P=0.000), and worse renal function (creatinine 1.6±0.9 vs. 1.2±0.4 mg/dL, P=0.000). They were also more often on diuretics (73% vs. 53.2%, P=0.003) and beta-blocker therapy (73% vs. 57.6%, P=0.042) and had a markedly reduced functional capacity (6MWD 221±100m vs. 265±105m, P=0.001). At multivariate Cox proportional hazards regression analysis, independent predictors of survival at follow-up were lower comorbidity rate, a better-preserved renal function, lower use of diuretics, and a higher 6MWD at discharge (Harrell's C = 0.707). CONCLUSIONS: Patients attending residential CR after TAVR are very old with significant comorbidity. The overall 3-year mortality rate after CR discharge is high. Our findings suggest the need for individually tailored follow-up care in patients discharged from CR after TAVR to address their residual exercise capacity, comorbidities, and renal function impairment.

The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review.

Background: The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs). Methods: An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs. Findings: After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%). Discussion: CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.

Delphi consensus recommendations on how to provide cardiovascular rehabilitation in the COVID-19 era.

This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from -5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 'for' and 10 'against' respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.

Proportion of patients needing an implantable cardioverter defibrillator on the basis of current guidelines: impact on healthcare resources in Italy and the USA. Data from the ALPHA study registry.

AIMS: Implantable cardioverter defibrillators (ICD) improve survival in selected patients with left ventricular dysfunction or heart failure (HF). The objective is to estimate the number of ICD candidates and to assess the potential impact on public health expenditure in Italy and the USA. METHODS AND RESULTS: Data from 3513 consecutive patients (ALPHA study registry) were screened. A model based on international guidelines inclusion criteria and epidemiological data was used to estimate the number of eligible patients. A comparison with current ICD implant rate was done to estimate the necessary incremental rate to treat eligible patients within 5 years. Up to 54% of HF patients are estimated to be eligible for ICD implantation. An implantation policy based on guidelines would significantly increase the ICD number to 2671 implants per million inhabitants in Italy and to 4261 in the USA. An annual increment of prophylactic ICD implants of 20% in the USA and 68% in Italy would be necessary to treat all indicated patients in a 5-year timeframe. CONCLUSION: Implantable cardioverter defibrillator implantation policy based on current evidence may have significant impact on public health expenditure. Effective risk stratification may be useful in order to maximize benefit of ICD therapy and its cost-effectiveness in primary prevention.

Psychomotor speed as a predictor of functional status in older chronic heart failure (CHF) patients attending cardiac rehabilitation.

BACKGROUND: The association among psychological, neuropsychological dysfunctions and functional/clinical variables in Chronic Heart Failure (CHF) has been extensively addressed in literature. However, only a few studies investigated those associations in the older population. PURPOSE: To evaluate the psychological/neuropsychological profile of older CHF patients, to explore the interrelation with clinical/functional variables and to identify potential independent predictors of patients' functional status. METHODS: This study was conducted with a multi-center observational design. The following assessments were performed: anxiety (Hospital Anxiety and Depression Scale, HADS), depression (Geriatric Depression Scale, GDS), cognitive impairment (Addenbrooke's Cognitive Examination Revised, ACE-R), executive functions (Frontal Assessment Battery, FAB), constructive abilities (Clock Drawing Test, CDT), psychomotor speed and alternated attention (Trail Making Test, TMT-A/B), functional status (6-minute walking test, 6MWT) and clinical variables (New York Heart Association, NYHA; Brain Natriuretic Peptide, BNP; left ventricular ejection fraction, LVEF; left ventricular end diastolic diameter, LVEDD; left ventricular end diastolic volume, LVEDV; tricuspid annular plane systolic excursion, TAPSE). RESULTS: 100 CHF patients (mean age: 74.9±7.1 years; mean LVEF: 36.1±13.4) were included in the study. Anxious and depressive symptoms were observed in 16% and 24,5% of patients, respectively. Age was related to TMT-A and CDT (r = 0.49, p<0.001 and r = -0.32, p = 0.001, respectively), Log-BNP was related to ACE-R-Fluency subtest, (r = -0.22, p = 0.034), and 6MWT was related to ACE-R-Memory subtest and TMT-A (r = 0.24, p = 0.031 and r = -0.32, p = 0.005, respectively). Both anxiety and depression symptoms were related to ACE-R-Total score (r = -0.25, p = 0.013 and r = -0.32, p = 0.002, respectively) and depressive symptoms were related to CDT (r = -0.23, p = 0.024). At multiple regression analysis, Log-BNP and TMT-A were significant and independent predictors of functional status: worse findings on Log-BNP and TMT-A were associated with shorter distance walked at the 6MWT. CONCLUSIONS: Psychological and neuropsychological screening, along with the assessment of psychomotor speed (TMT-A), may provide useful information for older CHF patients undergoing cardiac rehabilitation.

Right ventricular pressure changes during induced ventricular tachycardias predict clinical symptoms of cerebral hypoperfusion: implications for a reduction of unnecessary, painful ICD shocks.

BACKGROUND: ICD shocks occurring in conscious patients (as in the case of well-tolerated arrhythmias, electromagnetic interference, or oversensing) have a deleterious impact on the quality of life. We evaluated if a hemodynamic parameter, calculated from the right ventricular pressure (RVP) or systemic arterial pressure (AP) signals, could predict early clinical symptoms of cerebral hypoperfusion during induced ventricular tachycardias (VTs). METHODS AND RESULTS: We analyzed 42 tolerated (no symptoms) and 30 untolerated (syncope or severe symptoms within 30 seconds from the onset) VTs, induced during electrophysiological study. The cycle length (CL) and the hemodynamic data (mean AP and RVP, arterial pulse pressure and RV pulse pressure, and maximum AP and RVP dP/dT) were automatically sampled in two VT epochs: the "detection" window, from beat 24 to 32, and the "preintervention" window, immediately before the first therapeutic attempt. Although the CL and all the hemodynamic parameters (expressed as % change versus pre-VT values) were significantly lower in untolerated versus tolerated VTs both at detection and preintervention (with the exception of the mean RVP which progressively increased in both groups), ROC analysis demonstrated that only the preintervention RV pulse pressure showed no overlap between groups, providing 100% sensitivity and positive predictive value. CONCLUSIONS: The reduction of the RV pulse pressure is a better predictor of early cerebral symptoms than CL or other hemodynamic indexes during induced VTs. Since long-term RVP monitoring is feasible, this parameter could be incorporated into ICDs decisional path, in the perspective of reducing unnecessary, painful shocks.

Predictors of mortality and hospitalization for cardiac causes in patients with heart failure and nonischemic heart disease: a subanalysis of the ALPHA study.

BACKGROUND: Several studies have searched for predictors of clinical outcome in patients with heart failure (HF). However, since they were collected in clinical trials, most data were subject to selection biases and do not specifically apply to patients with nonischemic heart disease. This study examined the impact of several variables on combined all-cause mortality and hospitalization for cardiac causes, in consecutive ambulatory patients with HF included in the ALPHA registry. METHODS AND RESULTS: This analysis included 446 patients with HF and nonischemic heart disease, in New York Heart Association functional class II or III, and a left ventricular (LV) ejection fraction below 40%. In 126 patients (73%) the disease was idiopathic dilated cardiomyopathy, in 72 (16%) hypertensive, in nine (2%) valvular, and in 39 (9%) of other etiologies. The median age was 61 years (range 51-69 years) and 349 (78%) patients were men. Over a median follow-up of 31 months (range 23-40), 82 patients (18%) died or were hospitalized for cardiac causes. In a proportional hazard (Cox) regression model, maximal oxygen consumption (HR 0.9, P = 0.001), LV end-diastolic diameter (HR 1.07, P < 0.001), resting systolic blood pressure (HR 0.97, P < 0.005), and hemoglobin (HR 0.86, P < 0.05) were independent predictors of the combined study endpoint. CONCLUSIONS: In an unselected population of patients with HF and nonischemic heart disease, a reduced exercise capacity, large LV end-diastolic diameter, low systolic blood pressure, and hemoglobin were correlated with long-term all-cause mortality or hospitalization for cardiac causes. These observations may help stratifying and tailoring the treatment of patients with HF and nonischemic heart disease.

Atrial fibrillation in heart failure patients: prevalence in daily practice and effect on the severity of symptoms. Data from the ALPHA study registry.

BACKGROUND: Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials. AIMS: To assess the prevalence and clinical correlates of AF among HF patients in everyday clinical practice from HF patients screened for the T-wave ALternans in Patients with Heart fAilure (ALPHA) study; to investigate the correlation between AF and functional status. METHODS AND RESULTS: Consecutive patients (N=3513) seen at nine Heart Failure Clinics were studied; 21.4% were in AF. AF prevalence was greater with increasing age (OR 1.04/year, p<0.001) in non-ischaemic cardiomyopathy (OR 2.34, p<0.001) and with increasing NYHA class (p<0.0001). Multiple logistic regression predictors of AF were age >70 years (OR 2.35), NYHA class II III or IV vs class I (OR 1.8, 4.4 and 3.1) and non-ischaemic cardiomyopathy (OR 3.2). A logistic model indicated that AF was associated with a 2.5 OR of being in NYHA class III-IV vs I-II while accounting for age, gender, left ventricular ejection fraction (LVEF), and aetiology of HF. CONCLUSIONS: The prevalence of AF in HF patients exceeds 20%, and increases with age and functional class. The presence of AF leads to a more severe NYHA class, indicating that AF contributes to the severity of heart failure.

Altered fasting glycemia in cardiac patients during in-hospital rehabilitation: impact on short and long-term follow-up.

BACKGROUND AND AIMS: Hospitalized patients after acute cardiovascular events have poorer prognosis if glucose regulation is diagnosed as abnormal. We compared the short and long-term outcome of patients with newly diagnosed altered fasting glycemia (AFG) to that of known diabetic patients and patients with normal glucose regulation (NGR) after admission to cardiac rehabilitation. METHODS: We retrospectively analyzed 2490 consecutive patients. Three groups were identified: known diabetes mellitus (n = 540, 22%), fasting glycemia above 110 mg/dl (AFG, n = 269, 11%), and fasting glycemia 110 mg/dl or less (NGR, n = 1681, 67%). Clinical variables, complications, and all-cause mortality were evaluated. RESULTS: At follow-up (median 3.1 ±â€Š2.4 years), after adjustment for age, sex, BMI, left ventricular ejection fraction, history of coronary artery disease, AFG had a significantly longer hospital stay versus NGR (21 ±â€Š8 versus 20 ±â€Š8 days; P = 0.019) and higher risk of paroxysmal atrial fibrillation (P = 0.041), pleural/pericardial effusions (P < 0.001), skin complications (P = 0.033), other events (P = 0.001), and blood tests (urea: P = 0.007; white blood cells: P = 0.002; neutrophils: P < 0.001; creatinine: P = 0.022). All-cause mortality was significantly higher in diabetes mellitus versus NGR (odds ratio 1.61, 95% confidence interval 1.17-2.21); a nonsignificant trend was observed in AFG versus NGR (odds ratio 1.23, 95% confidence interval 0.77-1.98). CONCLUSIONS: A high AFG prevalence in cardiac patients admitted to rehabilitation was observed. AFG patients were more vulnerable than NGR patients, had higher complication rates independently of covariates, and required longer hospital stay. AFG was not a significant predictor of all-cause mortality at 3 years, whereas DM was.

Relationship among body mass index, NT-proBNP, and mortality in decompensated chronic heart failure.

BACKGROUND: Obesity has been suggested to confer a survival benefit in acute heart failure. The concentrations of NT-proBNP may be reduced in patients with high body mass index (BMI). OBJECTIVES: To investigate the relationship among BMI, NT-proBNP, and mortality risk in decompensated chronic heart failure (DCHF). METHODS: This was a retrospective study. We studied 1001 patients with DCHF. Hazard ratios (HR) were calculated with Cox regression analysis. RESULTS: During the 1-year follow-up, 295 patients died. Compared with normal-weight patients, the unadjusted HR for death were 1.02 (95% CIs 0.79-1.33; p = 0.862) for patients with a BMI of 25.0-29.9 kg/m2 and 0.83 (95% CIs 0.61-1.12; p = 0.213) for patients with a BMI ≥ 30 kg/m2. NT-proBNP remained independently associated with mortality across the BMI categories. There was no statistically significant interaction between BMI and NT-proBNP levels for risk prediction. CONCLUSIONS: Obesity was not associated with mortality risk. NT-proBNP remained an independent prognostic factor across the BMI categories.

Mixed cranial nerve neuroma revealing itself as baroreflex failure.

We report here the first case of baroreflex failure due to a mixed cranial nerve neuroma in which the clinical manifestations (recurrent severe hypertensive crisis, hypotension) due to baroreflex arc impairment preceded the clinical diagnosis of brain tumour and neurosurgery by a few months. Given the clinical suspicion of baroreflex failure, even in the absence of iatrogenic clues, we propose that the patient's study should include neuroradiologic evaluation of the ponto-cerebellar angulus.

Incremental utility of prognostic variables at discharge for risk prediction in hospitalized patients with acutely decompensated chronic heart failure.

OBJECTIVES: To assess the incremental prognostic utility of discharge serum creatinine (SCr), systolic blood pressure (SBP), and NT-proBNP and sodium concentrations in hospitalized patients with acutely decompensated chronic heart failure. BACKGROUND: Whether key prognostic variables at discharge provide incremental prognostic information beyond that provided by a model based on admission variables (referent) remains incompletely defined. METHODS: The primary outcome was a composite of death, urgent heart transplantation, or ventricular assist device implantation at 1 year. The gain in predictive performance was assessed using C index, Bayesian Information Criterion, and Net Reclassification Improvement. RESULTS: The best fit was obtained when discharge NT-proBNP was added to the referent model. No interaction between admission and discharge NT-proBNP was found. Discharge SCr, SBP, and sodium did not improve goodness-of-fit. CONCLUSIONS: Admission and discharge NT-proBNP provide complementary and independent prognostic information; as such, they should be taken into account concurrently.

Non-invasive sudden death risk stratification.

Most sudden cardiac deaths are caused by fatal ventricular arrhythmias (ventricular tachycardia [VT] and fibrillation) in patients with and without known structural heart diseases. Given the large number of patients potentially at risk for developing ventricular arrhythmias, any strategy for treating them prophylactically requires efficient and effective risk stratification. Both non-invasive and invasive testing may be used for prognostic evaluation of patients with heart diseases. The optimal way to use them in the risk stratification for sudden cardiac death will depend in part on the goals of screening. At present risk markers perform better at identifying low-risk patients who may not need an implantable cardioverter-defibrillator (ICD), because all tests have a high negative predictive accuracy. In our opinion an electrophysiological test should not be performed and an ICD should not be implanted in post-myocardial infarction patients with moderate left ventricular dysfunction (left ventricular ejection fraction 30-40%) with a preserved autonomic balance and without non-sustained VT. In MADIT II-like patients electrophysiological testing does not seem necessary and an ICD could not be implanted only in patients with a negative T-wave alternans test. Most of the data available refer to patients with ischemic cardiomyopathy but the preliminary data on T-wave alternans suggest its usefulness in patients with non-ischemic cardiomyopathy too, although a large definitive study has not yet been completed in this important population.

T wave alternans is a predictor of death in patients with congestive heart failure.

Few data are available about the prognostic role of T wave alternans in patients with congestive heart failure. To assess the ability of T wave alternans, used alone or in combination with other risk markers, to predict cardiac death in decompensated patients, we enrolled 46 patients, mean age 59+/-9, males 89%, ischemic etiology 61%, NYHA class III 35%, left ventricular ejection fraction 29+/-7%. After 1.6 years follow-up, seven patients died from cardiac death (16%), non-sudden in six (86%) and sudden in one (14%). T wave alternans was positive in 24 (52%), negative in 13 (28%), indeterminate in nine patients (20%). T wave alternans was positive in all patients with events (100%) but only in 16 of 37 patients without (41%) (P=0.02). Other predictors of cardiac death were O(2) consumption at the peak of exercise (P=0.03), standard deviation of all NN intervals (P=0.05) and Wedge pressure (P=0.03). When receiver operator characteristics curves were calculated, the highest area (0.73) was found for O(2) consumption at the peak of exercise considering the single variables and for O(2) consumption at the peak of exercise plus T wave alternans (0.79) for combination of them; the comparison of the two receiver operator characteristics curves did not reach statistical difference (P=0.5). In conclusion, this is the first study reporting that T wave alternans can predict cardiac death, with a marginal additional prognostic power when used in combination with measurement of O(2) consumption at the peak of exercise.