LDL-cholesterol target levels achievement in high-risk patients: An (un)expected gender bias.

BACKGROUND AND AIMS: Lowering low-density lipoprotein cholesterol (LDL-C) is the cornerstone of cardiovascular disease prevention. Collection of epidemiological data is crucial for monitoring healthcare appropriateness. This analysis aimed to evaluate the proportion of high-risk patients who achieved guidelines recommended LDL-C goal, and explore the predictors of therapeutic failure, with a focus on the role of gender. METHODS AND RESULTS: Health administrative and laboratory data from seven Local Health Districts in Tuscany were collected for residents aged ≥45 years with a history of major adverse cardiac or cerebrovascular event (MACCE) and/or type 2 diabetes mellitus (T2DM) from January 1, 2019, to January 1, 2021. The study aimed to assess the number of patients with optimal levels of LDL-C (<55 mg/dl for patients with MACCE and <70 mg/dl for patients with T2DM without MACCE). A cohort of 174 200 individuals (55% males) was analyzed and it was found that 11.6% of them achieved the target LDL-C levels. Female gender was identified as an independent predictor of LDL-C target underattainment in patients with MACCE with or without T2DM, after adjusting for age, cardiovascular risk factors, comorbidities, and district area (adjusted-IRR 0.58 ± 0.01; p < 0.001). This result was consistent in subjects without lipid-lowering therapies (adjusted-IRR 0.56 ± 0.01; p < 0.001). CONCLUSION: In an unselected cohort of high-risk individuals, females have a significantly lower probability of reaching LDL-C recommended targets. These results emphasize the need for action to implement education for clinicians and patients and to establish clinical care pathways for high-risk patients, with a special focus on women.

[Chronic diseases and risk of symptomatic COVID-19: results of a case-population study on a sample of patients in the Local Health Unit 'Toscana Centro' (Tuscany Region, Central Italy)]. / Malattie croniche e rischio di ammalarsi di COVID-19 sintomatica: risultati di uno studio case-population su un campione di casi in AUSL Toscana Centro.

BACKGROUND: the COVID-19 pandemic represents a challenge for health systems around the world, with just under 10,000 cases in Tuscany Region (Central Italy) and about 4,500 in the Local Health Unit (LHU) 'Toscana Centro', updated on 11 May 2020. The risk factors reported are several, including age, being male, and some chronic diseases such as hypertension, diabetes, respiratory and cardiovascular diseases. However, the relative importance of chronic diseases is still to be explored. OBJECTIVES: to evaluate the role of chronic diseases on the risk to develop clinically evident (at least mild symptomatic) forms of SARS-CoV-2 infection in the population of the LHU Toscana Centro. DESIGN: case-population study. SETTING AND PARTICIPANTS: 'case' is a subject with SARS-CoV-2 positive swab with at least mild clinical status, who lives in the LHU Toscana Centro area; 'controls' are all people residing in the LHU Toscana Centro area at 1 January 2020. People aged under 30 and patients living in nursing care homes are excluded from the analysis. MAIN OUTCOME MEASURES: the analysis assesses the effect of gender, age, neoplasm, and the main chronic diseases on the onset of an infection with at least mild symptoms by calculating odds ratios (OR) by multivariate logistic regression models (to produce adjusted OR by potential confounders). RESULTS: among the 1,840 cases, compared to the general population, the presence of males and over-60-year-old people is greater. Almost all the considered chronic diseases are more frequent among the cases, compared to the general population. A chronic patient has a 68% greater risk to be positive with at least mild symptoms. Many of the considered diseases show an effect on the risk of getting COVID-19 in a symptomatic form, which remains even adjusting by other comorbidities. The main ones include heart failure, psychiatric disorders, Parkinson's disease, and rheumatic diseases. CONCLUSIONS: these results confirm evidence already shown in other studies on COVID-19 patients and add information on the chronic diseases attributable risk in the population, referred to the symptomatic forms and adjusted by age, gender or the possible copresence of more diseases. These risk estimates should guide prevention interventions by health services in order to protect the chronic patients affected by the pathologies most at risk.

Opposite trends in hospitalization and mortality after implementation of a chronic care model-based regional program for the management of patients with heart failure in primary care.

BACKGROUND: The chronic care model (CCM) is an established framework for the management of patients with chronic illness at the individual and population level. Its application has been previously shown to improve clinical outcome in several conditions, but the prognostic impact of CCM-based programs for the management of patients with chronic heart failure (HF) in primary care is still to be elucidated. METHODS: We assessed the prognostic impact of a primary-care, CCM-based project applied in Tuscany, Italy, in 1761 patients with chronic HF enrolled in a retrospective matched cohort study. The project was based on predefined working teams including general practitioners and nurses, proactively scheduled regular follow-up visitations for each patient, counseling for therapy adherence and lifestyle modifications, appropriate diagnostic and therapeutic pathways according to international guidelines, and a key supporting role of the nurses, who were responsible for the practical coordination of the follow-up. A matched group of 3522 HF subjects assisted by general practitioners not involved in the project was considered as control group. The endpoints of this study were HF hospitalization and all-cause mortality. RESULTS: Over a 4-year follow-up period, HF hospitalization rate was higher in the CCM group than the controls (12.1 vs 10.3 events/100 patient-years; incidence rate ratio 1.15[1.05-1.27], p = 0.0030). Mortality was lower in the CCM group than the controls (10.8 vs 12.6 events/100 patient-years; incidence rate ratio 0.82[0.75-0.91], p < 0.0001). In multivariable analysis, the CCM status was associated with a 34% higher risk of HF hospitalization and 18% lower risk of death (p < 0.0001 for both). The effect on HF hospitalization was mostly driven by a 50% higher rate of planned HF hospitalization. CONCLUSIONS: Implementation of a CCM-based program for the management of HF patients in primary care led to reduced mortality and increased HF hospitalization. These findings support the hypothesis that the beneficial effects of CCM on survival might be extended to patients with chronic HF followed in primary care, but also support the need for further strategies aimed at improving the management of these patients in terms of hospitalizations.

Changes in diabetes care introduced by a Chronic Care Model-based programme in Tuscany: a 4-year cohort study.

Background: In 2010, Tuscany (Italy) implemented a Chronic Care Model (CCM)-based programme for the management of chronic diseases. The study's objective was to evaluate its impact on the care of patients with type 2 diabetes. Methods: A population-based cohort study was performed on patients with diabetes, identified by an administrative data algorithm, exposed to a CCM-based programme versus patients not exposed (8486 patients in each group). The groups were matched using a propensity score approach and observed from 2011 to 2014. The outcomes measured were: mortality rate and hazard ratio (HR), hospitalisation incidence rate (IR) (all causes and diabetes-related diseases) and incidence rate ratio (IRR), and Guideline Composite Indicator (GCI) as proxy of adherence to guidelines (IR and IRR). Stratified Cox regression analysis and conditional fixed effect Poisson regression analyses were performed to compute HR and IRR. Results: A significant improvement was observed for GCI (IRR 1.58; 95% CI 1.53­1.62) and for cardiovascular long-term complications (IRR 1.11; 95% CI 1.04­1.18). A protective effect was observed for neurological long-term complications (IRR 0.85; 95% CI 0.76­0.95), acute cardio-cerebrovascular long-term complications­stroke and ST segment elevation myocardial infarction­(IRR 0.81; 95% CI 0.71­0.92) and mortality (HR 0.88; 95% CI 0.81­0.96). Conclusion: The implementation of a CCM-based programme was followed by better management and benefits for the health status of patients. The increase in hospitalisations for cardiovascular long-term complications could engender cost-efficacy issues, but a better integrated care (GPs and specialists) and a more appropriate specialist outpatient services organisation could avoid a part of these, while still maintaining the benefits seen.

Gender differences in statin prescription rates, adequacy of dosing, and association of statin therapy with outcome after heart failure hospitalization: a retrospective analysis in a community setting.

PURPOSE: The existence of gender differences in the management of statin therapy among patients with chronic heart failure (HF) is still poorly investigated. We aimed at exploring the effect of gender on statin prescription rates and adequacy of dosing and on the association between statin therapy and all-cause 1-year mortality, after HF hospitalization in a community setting. METHODS: Statin prescription rates, adequacy of dosing (estimated as a PDD/DDD ratio >0.80), and 1-year mortality were retrospectively assessed in 2088 consecutive patients discharged from 5 local community hospitals with a definite diagnosis of HF after a mean length of stay of 7.6 days. The effect of gender was explored using multivariable logistic and Cox analyses adjusting to confounders. RESULTS: Women showed a lower statin prescription rate (25.7 vs 35.3%, P < 0.0001) and a lower prevalence of adequate statin dose (32.6 vs 42.3%, P < 0.0001) than men. Female gender was independently associated with a 24% lower probability of statin prescription and a 48% higher probability of inadequate statin dose. Statin prescription and adequacy of dosing were associated with 35 and 44% decreases in the risk of 1-year mortality, respectively, irrespective of gender. A nested case/control analysis confirmed that adequate statin dose was associated with 48% lower 1-year mortality, again without interaction with gender. CONCLUSIONS: In patients with chronic HF, female gender is independently associated with lower statin prescription rates and higher probability of inadequate dose. Statin therapy in these subjects is associated with improved 1-year survival in both men and women. This prognostic benefit is not affected by gender.

[Trends in occurrence, treatment, and outcomes of acute myocardial infarction in Tuscany Region (Central Italy), 1997-2010]. / Trend temporali di occorrenza, trattamento ed esiti dell'infarto miocardico acuto in Toscana, 1997-2010.

OBJECTIVES: to describe trends in attack rate, treatment, and outcomes of acute myocardial infarction (AMI) in Tuscany Region (Central Italy). DESIGN: population-based epidemiological study using the Tuscany Acute Myocardial Infarction Registry. SETTING AND PARTICIPANTS: cases have been identified by record linkage between the hospital discharge database and the mortality registry, and divided into hospitalised AMI (1997-2012) and out-of-hospital coronary deaths (1997-2010). Details on hospitalised cases based on the presence/absence of ST-segment elevation (STEMI / NSTEMI) can be detected for the period 2001-2012. MAIN OUTCOMEMEASURES: distribution by calendar time, gender, and type of event of absolute frequencies, age-standardised attack rates (per 100,000; standard Tuscany population, 2001) and percentages (standard: total hospitalised cases in 2011) of invasive cardiac procedures and 28-day case fatality in hospitalised cases. RESULTS: a reduction in both out-of-hospital coronary deaths and STEMI hospitalisations (attack rates, respectively, - 2.3% and -3.9% in males, -3.3% and -4.1% in females) and an increase in NSTEMI hospitalisations (+13.1% in males and +13.3% in females) were shown. The use of invasive cardiac procedures (PCI, coronary angiography) in hospitalised cases shows a considerable increase over time both in STEMI and in NSTEMI. The proportion, however, always remains lower in the whole period after the age of 70 and in women. The short term prognosis in hospitalised AMI cases shows an improvement over time, which, however, disappears when stratified by type of AMI. This trend is mainly related to the different weight that STEMI and NSTEMI have on incidence over time (increase in attack rates for NSTEMI and reduction for STEMI, with worst prognosis). CONCLUSIONS: results confirm the important changes in epidemiology, clinical presentation, and treatment of acute coronary disease in Tuscany, previously identified in the international literature. Differences in coronary reperfusion treatment of hospitalised cases still persist by age and gender. Additional efforts are needed to ensure equity in access to the best treatment for AMI.

Association of left ventricular longitudinal and circumferential systolic dysfunction with diastolic function in hypertension: a nonlinear analysis focused on the interplay with left ventricular geometry.

BACKGROUND: The relationships of left ventricular (LV) longitudinal and circumferential systolic dysfunction with diastolic performance in hypertensive patients have never been compared. METHODS AND RESULTS: In 532 asymptomatic hypertensive patients, circumferential function was assessed with the use of midwall fractional shortening (mFS) and stress-corrected mFS (SCmFS), whereas longitudinal function was assessed with the use of left atrioventricular plane displacement (AVPD) and systolic mitral annulus velocity (s'). Early diastolic annular velocity (e') and the E/e' ratio were measured. Global longitudinal and circumferential strain were determined in a subset of 210 patients. e' was linearly related to all systolic indexes (AVPD: R = 0.40; s': R = 0.39; mFS: R = 0.16; SCmFS: R = 0.17; all P < .0001), but the correlations were stronger with longitudinal indexes than with circumferential ones (P < .0001). E/e' was nonlinearly related to AVPD (R = -0.49; P < .0001) and s' (R = -0.34; P < .0001) and showed no relationship with mFS and SCmFS. Longitudinal indexes were superior to circumferential ones in predicting e' <8 cm/s, E/e' <8, and E/e' ≥13. The effect of LV geometry on LV diastolic function was evident among patients with preserved systolic longitudinal function, but was blunted among patients with impaired longitudinal function. In multivariable analyses, only longitudinal indexes remained associated with e' and E/e'. Analyses using strains provided similar results. CONCLUSIONS: In asymptomatic hypertensive subjects, LV diastolic performance is independently associated with longitudinal systolic dysfunction, but not with circumferential systolic dysfunction. Subtle longitudinal systolic impairment plays a role in mediating the effect of LV geometry on diastolic performance. These findings may support the need of critically revising the concept of isolated diastolic dysfunction in these patients.

Clinical outcome, valve dysfunction, and progressive aortic dilation in a pediatric population with isolated bicuspid aortic valve.

The aim of this study was to explore the medium-term clinical outcome and the risk of progression of aortic valve disease and aortic dilation in pediatric patients with isolated bicuspid aortic valve (BAV). 179 pediatric patients with isolated BAV were prospectively followed from January 1995 to December 2010. Patients with severe valve dysfunction at baseline were excluded. Clinical outcome included cardiac death, infective endocarditis, aortic complications, cardiac surgery and percutaneous valvuloplasty. Echocardiographic endpoints were: progression of aortic stenosis (AS) or regurgitation (AR) and progressive aortic enlargement at different levels of the aortic root, evaluated as z-score. The median age at diagnosis was 7.8 [2.7-12.0] years. After a median followup of 5.4 [2.3-9.2] years, all patients were alive. The clinical endpoint occurred in 4 (2.2 %) patients (0.41 events per 100 patient-years). A progression of AS and AR was observed in 9 (5.0 %) and 29 (16.2 %) patients, respectively. The z-scores at the end of follow-up were not significantly different from baseline at the annulus, Valsalva sinuses and sinotubular junction, whereas a slight increase was observed at the level of the ascending aorta (1.9 vs 1.5, p = 0.046). Significant progressive aortic dilation occurred in a minority of patients (10.6, 5.6, 9.5, and 19.0 % respectively). The clinical outcome in pediatric patients with isolated BAV is favourable and the progression of aortic valve dysfunction and aortic dilation is relatively slow. These findings may be taken into account to better guide risk assessment and clinical follow-up in these patients.

The diagnostic utility of transthoracic echocardiography for the diagnosis of infective endocarditis in the real world of the Italian Registry on Infective Endocarditis.

BACKGROUND: The choice of the imaging modality (transthoracic [TTE] vs. transesophageal echocardiography [TEE]) for the diagnosis of infective endocarditis (IE) depends on different variables. Aim of the present study is to provide updated data on the diagnostic sensitivity and the clinical usefulness of TTE vs. TEE from the Italian Registry on IE (RIEI). METHODS: The RIEI has enrolled consecutive cases of IE in every participating centre, evaluating diagnostic and therapeutic data from a real world practice perspective. RESULTS: From July 2007 to October 2010, 658 consecutive cases with definite IE according to Duke criteria have been enrolled in the RIEI (483 males). The following diagnostic echocardiographic exams were performed: 616 TTE (94%) and 476 TEE (72%). A positive TTE was recorded in 399 cases (65%), an uncertain TTE in 108 cases (17%), and a negative TTE in 109 cases (18%). For TEE, a positive study was reported in 451 cases (95%), uncertain in 13 cases (2.7%), and negative in 12 cases (2.5%) (P < 0.001). This difference is not evident in patients with tricuspid valve IE or i.v. drug addiction, and in Streptococcus bovis or Streptococcus viridans IE. TTE was significantly more performed before the admission and earlier than TEE during admission (P = 0.000). TTE was mainly responsible for the initial diagnosis in 59%. TEE contributed to changing the therapeutic approach in 42%. CONCLUSIONS: In the real world, TTE is performed earlier and more commonly, and it is the major echocardiographic tool for the initial diagnosis. TEE confirms its superior diagnostic sensitivity in most cases, although it is relatively underused.

Prevalence and long-term predictors of left ventricular hypertrophy, late hypertension, and hypertensive response to exercise after successful aortic coarctation repair.

Controversial data exist about the long-term results of aortic coarctation (AC) repair. This study explored the prevalence and predictors of left ventricular (LV) hypertrophy, late hypertension, and hypertensive response to exercise in 48 subjects (age, 15.1 ± 9.7 years) currently followed in the authors' tertiary care hospital after successful AC repair. Data on medical history, clinical examination, rest and exercise echocardiography, and ambulatory blood pressure monitoring were collected. The time from AC repair to follow-up evaluation was 12.9 ± 9.2 years. The prevalence of LV hypertrophy ranged from 23 to 38 %, based on the criteria used to identify LV hypertrophy, and that of concentric geometry was 17 %. One sixth of the patients without residual hypertension experienced late-onset hypertension. One fourth of those who remained normotensive without medication showed a hypertensive response to exercise. Age at AC repair was the strongest independent predictor of LV hypertrophy, defined using indexation either for body surface area (odds ratio [OR], 1.03; p = 0.0090) or for height(2.7) (OR 1.02; p = 0.029), and it was the only predictor of late hypertension (OR 1.06; p = 0.0023) and hypertensive response to exercise (OR 1.09; p = 0.029). The risk of LV hypertrophy was 25 % for repair at the age of 3.4 years but rose to 50 and 75 % for repair at the ages of 5.9 and 8.4 years, respectively. Similar increases were found for the risk of late-onset hypertension and hypertensive response to exercise. A considerable risk of LV hypertrophy, late hypertension, and hypertensive response to exercise exists after successful AC repair. Older age at intervention is the most important predictor of these complications.

[Mortality aftermyocardial infarction: when the health local organization network has a role in interpreting themarkers of theNational Agency for RegionalHealth Services]. / Mortalità dopo infarto miocardico: quanto la rete locale di organizzazione dell'assistenza conta nell'interpretazione di indicatori dell'Agenzia nazionale per i servizi sanitari regionali.

The Italian National Outcome Programme has assessed the performance of Italian hospitals regarding several clinical performance indicators, including 30-daymortality after admission for acute myocardial infarction. Risk adjustment was obtained using demographic and comorbidity data based on the hospital discharge databases in the index admission, as well as in those of the previous two years. Noticeably, the ICD-9-CM 410.7* classification coding for NSTEMI (Non-ST elevation myocardial infarction)myocardial infarction, i.e. the less severe form, was not used, due to known variability in its use. We found that hospital-specific adjusted relative risk of death versus the national mean, as computed by the programme, is negatively associated with the proportion of NSTEMI infarctions at each Tuscan and Florentine hospital, coherently with the hypothesis of a selection by the emergency network, which addresses STEMI (ST elevation myocardial infarction) patients to hospitals offering haemodynamic laboratory with reperfusive services. Individual level clinical data of 3,200 patients in the AMI-Florence study in the period April 2008-March 2010 found that ICD-9-CM410.7* is underused. The analysis based on hospital discharge diagnoses (410.7* vs. other 410* codes) cannot explain differences in mortality among Florentine hospitals, as opposed to the use of a classification of myocardial infarction type (STEMI vs. NSTEMI) based on clinical data collected in AMI-Florence.

Dilated cardiomyopathy and inclusion body myositis.

Inclusion body myositis (IBM) is the most common inflammatory myopathy after 50 years of age. In contrast to polymyositis and dermatomyositis, in which cardiac involvement is relatively common, current evidences indicate that IBM is not associated with cardiac disease. We report the case of a patient with biopsy-proven IBM who developed heart failure and major ventricular arrhythmias secondary to dilated cardiomyopathy few months after the clinical onset of IBM, and in whom no pathophysiologic causes explaining cardiac enlargement and dysfunction were found by laboratory and instrumental investigations. The hypothesis of a pathophysiologic association between the two conditions is discussed.

[The graduate school of medicine and palliative care: good news, but it's still not enough.] / La Scuola di specializzazione in medicina e cure palliative: una bella notizia, ma non è ancora abbastanza.

The recent establishment of palliative care and medicine as a medical specialty to be taught in postgraduate courses starting from the 2021/2022 academic year in Italy is certainly good news. Some doubts arise, anyway, if the academic programs will be limited to the postgraduate area instead of involving every university in the undergraduate courses. The risk is to maintain the reductionism of future physicians receiving a kind of education centered on the biomedical paradigm only. Since at least thirty years we know that there should not be a definite time marking a clear break between previous active treatments for the disease and subsequent palliative ones. Mainly in very old people affected by multiple chronic disorders a simultaneous presence of both forms of treatment should be scheduled, with increasing weight of palliation as the disease progresses and the probability of responding to active treatments becomes less and less. Unfortunately the reality of assistance in the last thirty days of life of patients suffering from cancer and/or chronic heart or lung diseases is increasingly centered on hospital settings, while the proportion of patients who are referred for hospice/palliative care in the last month of life is marginal, especially for non-cancer patients. We are going on with a health system that responds to the needs of the chronicities with the structures and pathways that are suitable for acute care: a completely different model would be needed. For over ten years palliative care in Italy has a specific regulatory reference such as that of law 38/2010, reaffirmed by the most recent law 219/2017: yet, although training is expressly provided for in these laws, we are still far from having made it, except for some sporadic cases. Now it seems that we are about to accomplish such provisions, even if starting from the roof instead of the foundations; as palliative care means multiprofessional and multidisciplinary teams a specific training program dedicated also to nurses, psychologists and physiotherapists is mandatory.

The role of N-terminal PRO-brain natriuretic peptide and echocardiography for screening asymptomatic left ventricular dysfunction in a population at high risk for heart failure. The PROBE-HF study.

BACKGROUND: Screening for asymptomatic left ventricular dysfunction (ALVD) in subjects at risk for heart failure (HF) can affect clinical management. The aim of the present study is to examine the role of NT-pro BNP in the diagnosis of ALVD in subjects with hypertension and diabetes from primary care. METHODS AND RESULTS: A total of 1012 subjects with hypertension and/or diabetes and no symptoms or signs of HF were assessed by B-type natriuretic peptide (NT-proBNP) assay and echocardiography. Diastolic dysfunction was present in 368/1012 subjects (36.4%): 327 (32.4%) with mild diastolic dysfunction and 41 (4%) with a moderate-to-severe diastolic dysfunction. Systolic dysfunction was present in 11/1012 (1.1%). NT-proBNP levels were 170 +/- 206 and 859 +/- 661 pg/mL, respectively, in diastolic and systolic dysfunction and 92 +/- 169 in normal subjects (P < .0001). Pooling moderate-to-severe diastolic with systolic dysfunction, a total of 52 subjects (5.1 %) were obtained: best cutoff value of NT-proBNP was 125 pg/mL (males <67 years: sensitivity [Sens] 87.5%, specificity [Spec] 92.7%, negative predictive value [NPV] 99.5%, positive predictive value [PPV] 33.3%; females <67 years: Sens 100%, Spec 84.1%, NPV 100%, PPV 33.3%; males >or=67 years: Sens 100%, Spec 77.1%, NPV 100%, PPV 32.5%; females >or=67 years: Sens 100%, Spec 59.9%, NPV 100%, PPV 23%). CONCLUSIONS: The prevalence of ALVD in subjects at risk for HF is 5.1%. Because of its excellent NPV, NT-proBNP can be used by general practitioners to rule out ALVD in hypertensive or diabetic patients.

Chronic Care Model for the Management of Patients with Heart Failure in Primary Care.

We recently investigated the prognostic impact of a Chronic Care Model (CCM)-based healthcare program applied in primary care in Tuscany Region mainly run by multidisciplinary teams composed of general practitioners (GPs) and nurses. The project included proactively planned follow-up visits for each patient, individualized counselling to optimize lifestyle modifications and adherence to appropriate diagnostic and therapeutic pathways. 1761 patients with Chronic heart failure (CHF) directly enrolled by the GPs were matched with 3522 CHF controls not involved in the project. Over a 4-year follow-up in the CCM group a higher CHF hospitalization rate was found (12.1 vs 10.3 events/100 patient-years; incidence rate ratio [IRR] 1.15, p=0.0030), whereas mortality was lower (10.8 vs 12.6 events/100 patient-years; IRR 0.82, p<0.0001). The CCM status was independently associated with a 34% increase in the risk of CHF hospitalization and a 18% reduction in the risk of death (p<0.0001 for both). The CCM status was associated with a 50% increase in the rate of planned Heart failure (HF) hospitalizations whereas the rate of 1-month CHF readmissions showed no differences. Such a divergent trend could be explained by the direct involvement of GPs in the CCM program, leading them to a better awareness of patients' clinical status, and then to a more frequent use of clinical pathways and facilities, including hospitalization. It is reasonable to argue that not all hospitalizations must necessarily be considered as a poor outcome, as they often provide additional opportunities to improve therapies, optimize patient education, or define follow-up strategies. The evidence of a divergent trend between mortality and hospitalization in our population might support the clinical importance of a multidisciplinary approach for the management of patients with HF.

Diagnosis-related differences in the quality of end-of-life care: A comparison between cancer and non-cancer patients.

BACKGROUND: Cancer, chronic heart failure (CHF), and chronic obstructive pulmonary disease (COPD) in the advanced stages have similar symptom burdens and survival rates. Despite these similarities, the majority of the attention directed to improving the quality of end-of-life (EOL) care has focused on cancer. AIM: To assess the extent to which the quality of EOL care received by cancer, CHF, and COPD patients in the last month of life is diagnosis-sensitive. METHODS: This is a retrospective observational study based on administrative data. The study population includes all Tuscany region residents aged 18 years or older who died with a clinical history of cancer, CHF, or COPD. Decedents were categorized into two mutually exclusive diagnosis categories: cancer (CA) and cardiopulmonary failure (CPF). Several EOL care quality outcome measures were adopted. Multivariable generalized linear model for each outcome were performed. RESULTS: The sample included 30,217 decedents. CPF patients were about 1.5 times more likely than cancer patients to die in an acute care hospital (RR 1.59, 95% C.I.: 1.54-1.63). CPF patients were more likely to be hospitalized or admitted to the emergency department (RR 1.09, 95% C.I.: 1.07-1.10; RR 1.15, 95% C.I.: 1.13-1.18, respectively) and less likely to use hospice services (RR 0.08, 95% C.I.: 0.07-0.09) than cancer patients in the last month of life. CPF patients had a four- and two-fold higher risk of intensive care unit admission or of undergoing life-sustaining treatments, respectively, than cancer patients (RR 3.71, 95% C.I.: 3.40-4.04; RR 2.43, 95% C.I.: 2.27-2.60, respectively). CONCLUSION: The study has highlighted the presence of significant differences in the quality of EOL care received in the last month of life by COPD and CHF compared with cancer patients. Further studies are needed to better elucidate the extent and the avoidability of these diagnosis-related differences in the quality of EOL care.

Prognostic comparison between creatinine-based glomerular filtration rate formulas for the prediction of 10-year outcome in patients with non-ST elevation acute coronary syndrome treated by percutaneous coronary intervention.

BACKGROUND:: Estimated glomerular filtration rate (eGFR) is a predictor of outcome among patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), but which estimation formula provides the best long-term risk stratification in this setting is still unclear. We compared the prognostic performance of four creatinine-based formulas for the prediction of 10-year outcome in a NSTE-ACS population treated by percutaneous coronary intervention. METHODS:: In 222 NSTE-ACS patients submitted to percutaneous coronary intervention, eGFR was calculated using four formulas: Cockcroft-Gault, re-expressed modification of diet in renal disease (MDRD), chronic kidney disease epidemiology collaboration (CKD-Epi), and Mayo-quadratic. Predefined endpoints were all-cause death and a composite of cardiovascular death, non-fatal reinfarction, clinically driven repeat revascularisation, and heart failure hospitalisation. RESULTS:: The different eGFR values showed poor agreement, with prevalences of renal dysfunction ranging from 14% to 35%. Over a median follow-up of 10.2 years, eGFR calculated by the CKD-Epi and Mayo-quadratic formulas independently predicted outcome, with an increase in the risk of death and events by up to 17% and 11%, respectively, for each decrement of 10 ml/min/1.73 m2. The Cockcroft-Gault and MDRD equations showed a borderline association with mortality and did not predict events. When compared in terms of goodness of fit, discrimination and calibration, the Mayo-quadratic outperformed the other formulas for the prediction of death and the CKD-Epi showed the best performance for the prediction of events (net reclassification improvement values 0.33-0.35). CONCLUSIONS:: eGFR is an independent predictor of long-term outcome in patients with NSTE-ACS treated by percutaneous coronary intervention. The Mayo-quadratic and CKD-Epi equations might be superior to classic eGFR formulas for risk stratification in these patients.

Prospective Validation of the Decalogue, a Set of Doctor-Patient Communication Recommendations to Improve Patient Illness Experience and Mood States within a Hospital Cardiologic Ambulatory Setting.

Strategies to improve doctor-patient communication may have a beneficial impact on patient's illness experience and mood, with potential favorable clinical effects. We prospectively tested the psychometric and clinical validity of the Decalogue, a tool utilizing 10 communication recommendations for patients and physicians. The Decalogue was administered to 100 consecutive patients referred for a cardiologic consultation, whereas 49 patients served as controls. The POMS-2 questionnaire was used to measure the total mood disturbance at the end of the consultation. Structural equation modeling showed high internal consistency (Cronbach alpha 0.93), good test-retest reproducibility, and high validity of the psychometric construct (all > 0.80), suggesting a positive effect on patients' illness experience. The total mood disturbance was lower in the patients exposed to the Decalogue as compared to the controls (1.4 ± 12.1 versus 14.8 ± 27.6, p = 0.0010). In an additional questionnaire, patients in the Decalogue group showed a trend towards a better understanding of their state of health (p = 0.07). In a cardiologic ambulatory setting, the Decalogue shows good validity and reliability as a tool to improve patients' illness experience and could have a favorable impact on mood states. These effects might potentially improve patient engagement in care and adherence to therapy, as well as clinical outcome.