Occurrence of neuropathies in patients with severe heart failure before and after heart transplantation.

Neuropathies may affect heart reinnervation and functional outcome after heart transplantation (HT). In this study, neurological evaluations, standard nerve conduction studies, and electromyography were performed in 32 HT candidates without a previous history of neuromuscular disorder. Ten patients underwent HT and were revaluated 3 months later. We found that before HT 10 (31.3%) patients had sensorimotor polyneuropathy (18.8%) or sensory polyneuropathy (12.5%). After HT, the percentage of patients with a neuromuscular disorder increased to 70%, most of them showing new or worsening neuropathies or neuromyopathies. The most sensitive abnormality that indicated neuromuscular involvement after HT was a reduction of the compound muscle action potential (CMAP) of the deep peroneal nerve. In conclusion, neuromuscular disorders are common in HT candidates, and they further increase in occurrence after HT. A reduction of the deep peroneal nerve CMAP amplitude after HT may help to identify patients who need a more detailed neurophysiological evaluation. The diagnosis of neuromuscular disorders before and after HT may contribute to the development of more accurate therapeutic and rehabilitative strategies for these patients.

Physiopathology and Diagnosis of Congestive Heart Failure: Consolidated Certainties and New Perspectives.

Volume overload and fluid congestion are a fundamental issue in the assessment and management of patients with heart failure (HF). Recent studies have found that in acute decompensated heart failure (ADHF), right and left-sided pressures generally start to increase before any notable weight changes take place preceding an admission. ADHF may be a problem of volume redistribution among different vascular compartments instead of, or in addition to, fluid shift from the interstitial compartment. Thus, identifying heterogeneity of volume overload would allow guidance of tailored therapy. A comprehensive evaluation of congestive HF needs to take into account myriad parameters, including physical examination, echocardiographic values, and biomarker serum changes. Furthermore, potentially useful diagnostic tools include bioimpedance to measure intercompartmental fluid shifts, and evaluation of ultrasound lung comets to detect extravascular lung water.

[Iron deficiency in heart failure: beyond the anemia.] / Iron deficiency nello scompenso cardiaco: oltre l'anemia.

Iron deficiency in heart failure is a frequent condition and may be a prerequisite for the development of anemia but not necessarily the two conditions coexist. Iron deficiency in itself independently of the presence of anemia, determines a series of alterations of the cellular processes of our body related to the production of energy in the form of ATP, cell proliferation and DNA synthesis. The causes of iron deficiency are several and among the various, the inflammatory state present in chronic heart failure, combined with the absorption deficit seems to play a predominant role. This review aims to cover all the main aspects related to iron deficiency in patients with heart failure starting from aetiology up to the therapeutic implications. In particular, the different causes and the pathophysiological mechanisms that underlie the iron deficiency will be examined, describing what are the consequences on the alterations on the biochemical processes in terms of absorption, transport and use of iron by target cells with particular regard to muscle cells and Erythropoietic line. The meaning, the role and the importance in clinical practice of the different laboratory tests that dose the iron (Ferritin, Serum Iron, Transferrin and Transferrin saturation or TSAT) that allow to identify the presence of absolute or relative iron deficiency will also be underlined. Literature data related to the consequences of iron deficiency and to the alterations concerning its transport on the symptoms and functional capacity of patients with heart failure will be reported as well as their impact on prognosis. A second part of the paper will address the main aspects related to iron therapy. We will discuss the administration of iron per os with regard to the different drugs, to the processes of absorption and to the use of different pharmaceutical formulations with their associated side effects. The scientific evidences on parenteral formulations and in particular on the use of Fe-carboxymaltose will be reported. Finally, we will discuss the role of erythropoietin in the context of heart failure.

[The heart failure management in Sicily: cognitive analysis of clinical features.] / La gestione dello scompenso cardiaco in Sicilia: analisi conoscitiva degli aspetti clinici e organizzativi.

INTRODUCTION: Heart failure (HF) is a main issue of modern healthcare system. Patient affected are continuously growing in number and age; therefore, an integrated management between different parts of healthcare system is crucial to optimize outcome and sustainability. So far, little is known about clinical pathways of HF patients in Sicily. METHODS: On initiative of the Regional HF Group of the Italian Association of Hospital Cardiologists (ANMCO), we decided to census all the Cardiology Unit of Sicily. A simple questionnaire elaborated by the group and exploring clinical and organizational matters of HF was sent to the Units. The answer arrived on a voluntary basis. RESULTS: 41/46 Units sent back the filled questionnaire. Five typologies of units were represented, based on complexity [1. Outpatient units; 2. Units without Intensive Care Unit (ICU); 3. Units with ICU; 4. Units with ICU and Cath Lab; 5. Units with ICU, Cath lab and Cardiac Surgery). A dedicated HF unit is present only in half centers, but it is formally recognized solely in 22% of Units. These Units have scarce dedicated staff and activity is predominantly based on personal initiative. Diagnostic and therapeutic tools are used appropriately in most of them, even though congestion is judged mainly through physical exam and echocardiography. Differently from the indications of the guidelines, post discharge titration of therapy lacks in almost 30% of centers. DISCUSSION AND CONCLUSIONS: In Sicily, HF is managed on a plan mainly based on personal initiative. The quality is sufficiently good but a more appropriate and structured organization in particular of the follow-up seems a necessary and improvable requirement in view of quality measurers and economic sustainability of health care.

[Clinical use of a new class of anticoagulant drugs: the direct thrombin inhibitors]. / L'impiego clinico di una nuova classe di farmaci anticoagulanti: gli inibitori diretti della trombina.

The coagulation cascade, and particularly thrombin, plays a very important role in arterial and venous thrombosis. Thereby, it is clear that thrombin inactivation is an optimal strategy for thrombotic disease prevention and treatment. The direct thrombin inhibitors are a new class of anticoagulant drugs directly binding thrombin and blocking its interaction with fibrinogen. The group of direct thrombin inhibitors includes recombinant hirudin (lepirudin and desirudin), bivalirudin, melagatran and its oral precursor, ximelagatran, argotraban and dabigatran. These drugs have several advantages compared to other anticoagulant drugs, and the particular pharmacokinetic properties of some of them could be very important for future management of thromboembolic prophylaxis. The efficacy and safety of these new drugs are evaluated in several clinical trials; however today only few clinical indications are available for the majority of them.