Eicosapentaenoic Acid: between Cardiovascular Benefits and the Risk of Atrial Fibrillation.

In recent years, scientific research has increasingly focused on the cardiovascular benefits of omega-3 polyunsaturated fatty acids (n-3 PUFAs) supplements. The most promising results emerged from the new trials on a high-dose eicosapentaenoic acid (EPA)-only approach, instead of the previously prescribed therapy with EPA + docosahexaenoic acid (DHA). The evidence of the reduction of cardiovascular events in patients at high cardiovascular risk with EPA is intriguing. However, physicians have expressed concern about the potential high risk of atrial fibrillation (AF) occurrence due to such an approach. This study aims to investigate the current evidence on the cardiovascular benefits of EPA and its association with atrial arrhythmogenesis. Current guidelines consider EPA (as IPE) treatment for selected patients but with no specific indication regarding AF risk evaluation. We propose a flowchart that could be a starting point for the future development of an algorithm to help clinicians to prescribe EPA safely and effectively, especially in patients at high risk of incipient AF.

The cardiopulmonary exercise test in the prognostic evaluation of patients with heart failure and cardiomyopathies: the long history of making a one-size-fits-all suit.

Cardiopulmonary exercise test (CPET) has become pivotal in the functional evaluation of patients with chronic heart failure (HF), supplying a holistic evaluation both in terms of exercise impairment degree and possible underlying mechanisms. Conversely, there is growing interest in investigating possible multiparametric approaches in order to improve the overall HF risk stratification. In such a context, in 2013, a group of 13 Italian centres skilled in HF management and CPET analysis built the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score, based on the dynamic assessment of HF patients and on some other instrumental and laboratory parameters. Subsequently, the MECKI score, initially developed on a cohort of 2716 HF patients, has been extensively validated as well as challenged with the other multiparametric scores, achieving optimal results. Meanwhile, the MECKI score research group has grown over time, involving up to now a total of 27 centres with an available database accounting for nearly 8000 HF patients. This exciting joint effort from multiple HF Italian centres allowed to investigate different HF research field in order to deepen the mechanisms underlying HF, to improve the ability to identify patients at the highest risk as well as to analyse particular HF categories. Most recently, some of the participants of the MECKI score group started to join the forces in investigating a possible additive role of CPET assessment in the cardiomyopathy setting too. The present study tells the ten-year history of the MECKI score presenting the most important results achieved as well as those projects in the pipeline, this exciting journey being far to be concluded.

The importance of re-evaluating the risk score in heart failure patients: An analysis from the Metabolic Exercise Cardiac Kidney Indexes (MECKI) score database.

BACKGROUND: The role of risk scores in heart failure (HF) management has been highlighted by international guidelines. In contrast with HF, which is intrinsically a dynamic and unstable syndrome, all its prognostic studies have been based on a single evaluation. We investigated whether time-related changes of a well-recognized risk score, the MECKI score, added prognostic value. MECKI score is based on peak VO2, VE/VCO2 slope, Na+, LVEF, MDRD and Hb. METHODS: A multi-centre retrospective study was conducted involving 660 patients who performed MECKI re-evaluation at least 6 months apart. Based on the difference between II and I evaluation of MECKI values (MECKI II - MECKI I = ∆ MECKI) the study population was divided in 2 groups: those presenting a score reduction (∆ MECKI <0, i.e. clinical improvement), vs. patients presenting an increase (∆ MECKI >0, clinical deterioration). RESULTS: The prognostic value of MECKI score is confirmed also when re-assessed during follow-up. The group with improved MECKI (366 patients) showed a better prognosis compared to patients with worsened MECKI (294 patients) (p < 0.0001). At 1st evaluation, the two groups differentiated by LVEF, VE/VCO2 slope and blood Na+ concentration, while at 2nd evaluation they differentiated in all 6 parameters considered in the score. The patients who improved MECKI score, improved in all components of the score but hemoglobin, while patients who worsened the score, worsened all parameters. CONCLUSIONS: This study shows that re-assessment of MECKI score identifies HF subjects at higher risk and that score improvement or deterioration regards several MECKI score generating parameters confirming the holistic background of HF.

[Heart failure and iron deficiency]. / Scompenso cardiaco e carenza marziale.

Heart failure with reduced ejection fraction (HFrEF) is a clinical reality with an incidence of >10% in the population over 65 years of age, expected to increase in the coming years. Alongside the well-known pharmacological options (e.g. angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, neprilysin inhibitors, beta-blockers, aldosterone antagonists), which have significantly improved the clinical and prognostic outcomes of HFrEF patients, we now have a new therapeutic target: iron deficiency, defined as a ferritin concentration <100 µg/l or between 100-300 µg/l in the presence of a transferrin saturation <20%. Iron plays a major role in the transport of oxygen as a component of hemoglobin, as an oxygen reservoir, and as a component of myoglobin, as well as in the formation of energy, as a constituent of respiratory chain enzymes. Iron deficiency can therefore lead to anemia, changes in cognitive performance, behavior, emotions, reduced exercise capacity and myocardial structural and functional changes. Several clinical studies have shown that intravenous iron carboxymaltose supplementation can improve anemia, NYHA class, quality of life and exercise capacity of HFrEF patients. There are no randomized studies of adequate sample size that positively correlate iron supplementation with the higher endpoints of mortality and morbidity both in chronic and acute heart failure. Several studies are ongoing to answer these questions in the next few years.

Effects of cardiac contractility modulation by non-excitatory electrical stimulation on exercise capacity and quality of life: an individual patient's data meta-analysis of randomized controlled trials.

BACKGROUND: Although cardiac contractility modulation (CCM) has emerged as a promising device treatment for heart failure (HF), the effect of CCM on functional capacity and quality of life has not been the subject of an individual patient data meta-analysis to determine its effect on measures of functional capacity and life quality. This meta-analysis is aimed at systematically reviewing the latest available randomized evidence on the effectiveness of CCM on functional capacity and quality of life indexes in patients with HF. METHODS: The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched in May 2013 to identify eligible randomized controlled trials comparing CCM with sham treatment or usual care. Primary outcomes of interest were peak oxygen consumption, 6-minute walk test distance and quality of life measured by Minnesota Living With Heart Failure Questionnaire. There was no sufficient information to address safety. Mean difference and 95% confidence intervals (C.I.s) were calculated for continuous data using a fixed-effects model. RESULTS: Three studies enrolling 641 participants were identified and included. Pooled analysis showed that, compared to control, CCM significantly improved peak oxygen consumption (mean difference +0.71, 95% C.I. 0.20 to 1.21 mL/kg/min, p=0.006), 6-minute walk test distance (mean difference +13.92, 95% C.I. -0.08 to 27.91 m, p=0.05) and quality of life measured by Minnesota Living With Heart Failure Questionnaire (mean difference -7.17, 95% C.I. -10.38 to -3.96, p<0.0001). CONCLUSIONS: Meta-analysis of individual patient data from randomized trials suggests that CCM has significant if somewhat modest benefits in improving measures of functional capacity and quality of life.

Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey.

BACKGROUND: Cardiac rehabilitation (CR) programmes support patients to achieve professionally recommended cardiovascular prevention targets and thus good clinical status and improved quality of life and prognosis. Information on CR service delivery in Europe is sketchy. DESIGN: Postal survey of national CR-related organizations in European countries. METHODS: The European Cardiac Rehabilitation Inventory Survey assessed topics including national guidelines, legislation and funding mechanisms, phases of CR provided and characteristic of included patients. RESULTS: Responses were available for 28 of 39 (72%) countries; 61% had national CR associations; 57% national professional guidelines. Most countries (86%) had phase I (acute inhospital) CR, but with differing service availability. Only 29% reported provision to more than 80% patients. Phase II was also available, but 15 countries reported provision levels below 30%. Almost half (46%) had national legislation regarding phase II CR; three-quarters had government funding. Phase III was less supported: although available in most countries, 11 could not provide estimates of numbers participating. Thirteen reported that all costs were met by patients. CONCLUSION: Fewer than half of eligible cardiovascular patients benefit from CR in most European countries. Deficits include absent or inadequate legislation, funding, professional guidelines and information systems in many countries. Priorities for improvement include promoting national laws and guidelines specific for CR and increasing both CR programme participation rates and CR infrastructure. The European Association of Cardiovascular Prevention and Rehabilitation can have an important coordinating role in sharing expertise among national CR-related agencies. Ultimately, such cooperation can accelerate CR delivery to the benefit of cardiac patients across Europe.

Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation.

Increasing awareness of the importance of cardiovascular prevention is not yet matched by the resources and actions within health care systems. Recent publication of the European Commission's European Heart Health Charter in 2008 prompts a review of the role of cardiac rehabilitation (CR) to cardiovascular health outcomes. Secondary prevention through exercise-based CR is the intervention with the best scientific evidence to contribute to decrease morbidity and mortality in coronary artery disease, in particular after myocardial infarction but also incorporating cardiac interventions and chronic stable heart failure. The present position paper aims to provide the practical recommendations on the core components and goals of CR intervention in different cardiovascular conditions, to assist in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of CR. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, national or individual centre level, need to consider where and how structured programmes of CR can be delivered to all patients eligible. Thus a novel, disease-oriented document has been generated, where all components of CR for cardiovascular conditions have been revised, presenting both well-established and controversial aspects. A general table applicable to all cardiovascular conditions and specific tables for each clinical disease have been created and commented.

Reproducibility of internal atrial defibrillation threshold in paroxysmal and persistent atrial fibrillation.

BACKGROUND: Several pharmacological or technical factors may affect atrial defibrillation threshold (ADFT) for internal cardioversion (ICV) in the treatment of atrial fibrillation (AF). METHODS: We evaluated the reproducibility of ADFT in lone paroxysmal (electrically induced AF, 10 pts, 51+/-4 years) or persistent AF (15 pts, 64+/-7 years). The AF pattern (F-F interval) was characterised before each ICV attempt. A first step-up synchronised ICV test (ICV1, biphasic shock waveform 6 ms/6 ms) with increasing energy levels from 0.2 to 20 J was performed by a dual-lead defibrillation system (right atrium-coronary sinus configuration) connected to an external cardioverter defibrillator. After 30 min of stable sinus rhythm, a new sustained AF was induced (>20 min duration) and ICV protocol was repeated (ICV2). The AF cycle length was recorded for 30 s from the lateral wall of right atrium in basal condition and before each cardioversion attempt. RESULTS: The mean values of AF cycle length before a successful shock were similar in both AF populations (paroxysmal AF: pre-ICV1 175+/-21 ms vs pre-ICV2 181+/-20 ms (p=NS); persistent AF pre-ICV1 194+/-25 ms vs pre-ICV2 202+/-15 ms (p=NS)). No significant differences were observed between the two successful ICV tests concerning intensity, energy and impedance levels. The value of ADFT energy was reproducible in paroxysmal AF population (SD differences 1.2, coefficient of variability 9.6%). In persistent AF group only the impedance was reproducible (SD differences 2.6 Omega, coefficient of variability 4.5%), but not the energy requirements (SD differences 9.6, coefficient of variability 44.3%). CONCLUSIONS: ADFT is reproducible in paroxysmal AF patients, while a high coefficient of variability is present in persistent AF, possibly related to different patterns of re-entrant circuits in the reinduced AF. This observation is important in order to evaluate factors influencing ICV-ADFT correctly in AF patients.