Additive prognostic value of cardiopulmonary exercise testing in elderly patients with heart failure.

To date, the role of CPET (cardiopulmonary exercise testing) for risk stratification in elderly patients with HF (heart failure) with depressed or preserved ventricular function has not been evaluated. In the present study, we analysed whether CPET is useful in predicting outcome in this population. A total of 220 NYHA (New York Heart Association) class I-III patients with HF > or =70 years of age [median age, 75 years; 23% had NYHA class III; and 59% had preserved ventricular systolic function (left ventricular ejection fraction > or =40%)] performed maximal CPET (peak expiratory exchange ratio >1.00). Median peak oxygen uptake was 11.9 ml.kg(-1) of body weight.min(-1), median VE/VCO(2) slope (slope of the minute ventilation/carbon dioxide production ratio) was 33.2 and 45% had an EVR (enhanced ventilatory response) to exercise (VE/VCO(2) slope > or =34). During 19 months of follow-up, 94 patients (43%) met the combined end point of death and hospital admission for worsening HF, arrhythmias or acute coronary syndromes. By Cox multivariable analysis, a creatinine clearance of <50 ml/min {HR (hazard ratio), 1.657 [95% CI (confidence interval), 1.055-2.602]} and EVR [HR, 1.965 (95% CI, 1.195-3.231)] were the best predictors of outcome, while ventricular function had no influence on prognosis. In conclusion, in elderly patients with HF, a steeper VE/VCO(2) slope provides additional information for risk stratification across the spectrum of ventricular function and identifies a high-risk population, commonly not considered in exercise testing guidelines.

Multiparametric risk stratification in patients with mild to moderate chronic heart failure.

BACKGROUND: Whether brain natriuretic peptide (BNP) combined with cardiopulmonary exercise test (CPx) and echocardiographic findings improves prognostic stratification in mild-to-moderate systolic heart failure (HF) is unclear. METHODS AND RESULTS: A total of 244 consecutive stable outpatients, median age of 71 (62-76) years, with New York Heart Association (NYHA) Class I-III HF and left ventricular ejection fraction (LVEF) < 45% underwent BNP measurement, Doppler echocardiography, and a maximal CPx. Median BNP was 166 (70-403) pg/mL, median LVEF 35% (28%-40%). A restrictive filling pattern (RFP) was present in 44 patients (18%). At CPx, peak oxygen uptake was 12 (9.7, 14.4) mL/kg/min and an enhanced ventilatory response to exercise (EVR, slope of the ventilation to CO2 production ratio, > or = 35) was found in 90 patients (37%) During 18 (9-37) follow-up months, 80 patients died or were admitted for worsening HF (33%). In addition to simple bedside clinical variables (NYHA Class III, creatinine clearance, hemoglobin), BNP levels were predictive of outcome (HR 1.35 [1.12-1.63]). However, both RFP (HR 3.36 [2.09-5.41]) and a steeper minute ventilation-carbon dioxide output slope (HR 1.50 [1.19-1.88]) outperformed BNP as prognostic markers. Patients with both RFP and EVR had a 7.30 (95% CI 4.02-13.25) HR for death or HF-admission versus subjects with neither predictor. CONCLUSIONS: This study highlights the importance of a multiparametric approach for optimal risk stratification in the elderly with mild-to-moderate HF. Patients at high risk should undergo closer follow-up and be carefully evaluated for different therapeutic options, including nonpharmacologic treatment.

Prognostic implications of intraventricular conduction defects in patients undergoing stress echocardiography for suspected coronary artery disease.

PURPOSE: To investigate the prognostic implications of conduction defects in subjects without proven coronary artery disease who had been referred for stress echocardiography. METHODS: The study sample consisted of 1230 patients (574 men and 656 women; mean [+/- SD] age, 63 +/- 10 years) who underwent stress echocardiography with dipyridamole (n = 780) or dobutamine (n = 450) to evaluate suspected coronary artery disease. A summary wall motion score (on a 1 to 4 scale) was calculated. Patients were followed for a mean of 41 +/- 27 months; mortality was the only endpoint. RESULTS: Four hundred and twenty patients (34%) had intraventricular conduction defects on a resting electrocardiogram (173 with complete left bundle branch block, 98 with isolated right bundle branch block, 43 with right bundle branch block with left anterior hemiblock, and 106 with left anterior hemiblock). Ischemia at stress echo (new or worsening of preexisting wall motion abnormality) was found in 250 patients (20%). There were 56 deaths during follow-up; 138 patients underwent revascularization and were censored. Multivariate predictors of mortality were resting wall motion score index (hazard ratio [HR] = 6.0 per unit increase; 95% confidence interval [CI]: 2.3 to 16; P <0.0001), ischemia at stress echo (HR = 3.9; 95% CI: 2.2 to 6.7; P <0.0001), age >65 years (HR = 3.2; 95% CI: 1.7 to 5.9; P <0.0001), hypertension (HR = 1.8; 95% CI: 1.1 to 3.2; P = 0.03), and right bundle branch block with left anterior hemiblock (HR = 3.7; 95% CI: 1.8 to 7.5; P <0.0001). The other three forms of intraventricular conduction defects (left bundle branch block, isolated complete right bundle branch block, and left anterior hemiblock) were not associated with mortality in multivariate analyses, or among the 980 patients who did not have ischemia. CONCLUSION: Right bundle branch block with left anterior hemiblock is an independent predictor of mortality in patients with suspected coronary artery disease undergoing stress echocardiography, whereas isolated right bundle branch block is associated with outcomes similar to those observed in patients with no conduction defects.

Clinical, exercise electrocardiographic, and pharmacologic stress echocardiographic findings for risk stratification of hypertensive patients with chest pain.

Exercise electrocardiography (ECG) is of limited usefulness in hypertensive patients, whereas pharmacologic stress echocardiography can provide diagnostic and prognostic information. The aim of this study was to compare the prognostic value of clinical data, exercise ECG, and pharmacologic stress echocardiography in hypertensive patients with chest pain and to identify the best strategy for their risk stratification. Three hundred sixty-seven hypertensive patients (189 men, age 61 +/- 9 years) with chest pain of unknown origin underwent exercise ECG and pharmacologic stress echocardiography (237 with dipyridamole and 130 with dobutamine) and were followed up for 31 +/- 24 months. Positive exercise ECG (ST-segment shift of > or =1 mm at 80 ms after the J point) and stress echocardiography (new wall motion abnormalities) were found in 130 (35%) and 86 (23%) patients, respectively. During follow-up, there were 13 deaths and 16 myocardial infarctions. Additionally, 43 patients underwent coronary revascularization and were censored accordingly. Of 12 clinical, electrocardiographic, and echocardiographic variables analyzed, a positive result of stress echocardiography was the only multivariate predictor of either death (hazard ratio [HR] 4.7, 95% confidence interval [CI] 1.5 to 14.5, p = 0.007) or hard events (death, myocardial infarction) (HR 4.1, 95% CI 1.8 to 9.3, p = 0.0009). Using an interactive stepwise procedure, stress echocardiography provided additional prognostic information to clinical evaluation and exercise ECG. However, the negative predictive value of the 2 tests was similarly (p = NS) high in assessing 4-year event-free survival. In conclusion, a negative exercise electrocardiographic test identifies low-risk hypertensive patients with chest pain and should be the first-line approach for risk stratification. In contrast, positive exercise ECG is unable to distinguish between patients with different levels of risk. In this case, stress echocardiography provides strong and incremental prognostic power over clinical and exercise electrocardiographic data.

Prediction of mortality in patients with right bundle branch block referred for pharmacologic stress echocardiography.

Right bundle branch block (RBBB) is independently associated with all-cause mortality in patients referred for noninvasive evaluation of coronary artery disease. However, further stratification of risk in these patients has not been specifically addressed. The aim of this study was to risk stratify patients with RBBB who were referred for stress echocardiography. The study population was comprised of 343 patients (267 men; age 66 +/- 9 years) with RBBB who underwent pharmacologic stress echocardiography (231 dipyridamole, 112 dobutamine) for evaluation of suspected or known coronary artery disease. Overall mortality was the only end point. Stress echocardiography was positive for ischemia in 109 patients (32%). During follow-up (38 +/- 32 months), 36 deaths occurred. Seventy-three patients underwent revascularization and were censored. Ischemia at stress echocardiography (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.5 to 5.5, p=0.002), left anterior fascicular block (LAFB) (HR 2.8, 95% CI 1.4 to 5.6, p = 0.002), age >65 years (HR 2.1, 95% CI 1.0 to 4.3, p=0.047), and wall motion score index at rest (HR 2.5, 95% CI 1.0 to 6.5, p=0.057) were multivariate predictors of mortality. On the basis of stress echocardiographic result and presence and/or absence of LAFB, 3 levels of risk were identified: (1) low-risk, in cases of no ischemia and no LAFB (49% of the entire study population); (2) intermediate-risk, in cases of ischemia or LAFB only; and (3) high-risk, in cases of ischemia and LAFB. Clinical data, electrocardiography at rest, and stress echocardiographic results can provide effective stratification of risk in patients with RBBB.

[Electrical cardioversion for atrial fibrillation: advantages of the transthoracic biphasic method]. / Cardioversione elettrica della fibrillazione atriale: vantaggio della cardioversione transtoracica ad onda bifasica.

BACKGROUND: The purpose of this study was to evaluate efficacy and safety of biphasic shock for atrial fibrillation cardioversion to sinus rhythm. A second endpoint was to evaluate myocardial damage by means of cardiac troponin I dosage. METHODS: We studied 164 patients, with drug-resistant atrial fibrillation (208 episodes). Group A patients underwent biphasic shock normalized with respect to weight: 50 J (weight < 60 kg), 70 J (weight 61-84 kg) and 100 J (weight > 84 kg; the second and third shocks were 2 and 3 times higher than the first. Group B underwent sequential monophasic shock of 200, 300 and 360 J. Troponin I was evaluated at baseline, and 6, 12 and 24 hours after cardioversion. RESULTS: Total efficacy was 92% for biphasic shock and 89% for monophasic shock. First-shock efficacy with biphasic waveform (57.3%) was significantly greater than with first monophasic waveform (21.5%) (p = 0.000). Cardiac troponin I increased from 0.4 +/- 1.1 to 0.8 +/- 2.2 compared to a normal value of 2 ng/ml. CONCLUSIONS: For transthoracic cardioversion of atrial fibrillation, biphasic shock has a greater efficacy requiring less energy compared to monophasic shock. Normal mean values of cardiac troponin I proved the absence of myocardial damage.

Managing complex therapies outside hospitals. An analysis of GPs practices of how to support medication at home.

Support systems for the management of prescriptions are commonplace in hospitals, whilst they are rarely found in general practice. This exploratory study draws on a qualitative survey conducted with focus groups to investigate the information needs of General Practitioners (GPs) in regard to the therapeutic management of complex patients, the purpose being to identify possible areas of application. The question addressed is whether the systems existing in hospitals can be usefully adapted and used by GPs or if a different approach needs to be adopted to design other tools. The analysis shows that the information needs of GPs relative to medication management are significantly different from those of their hospital colleagues because the former are not directly responsible for the administration but instead operate within a care network on which they cannot exercise direct control. This study suggests that support systems for therapy management should be designed on the assumption that it derives from cooperative work by a heterogeneous network of actors, and therefore with functionalities intended to satisfy the coordination needs of all the actors involved in the process.

[Italian nursing survey of cardiological intensive care units]. / Censimento infermieristico delle unità di terapia intensiva cardiologica in Italia.

BACKGROUND: The recent evolution of nursing management of cardiovascular disease has led to significant changes in specific healthcare processes. The aim of this study is to present the first nursing survey of Italian intensive cardiac care units (ICCUs). METHODS: In March and April 2007, a questionnaire investigating the main problems concerning ICCU organization, specifically addressed to nursing care, has been mailed to all the operative Italian ICCUs. The questionnaire investigated staff characteristics, education and training, daily work organization, risk management strategies, and nursing research. RESULTS: For a more detailed analysis, the ICCUs were divided into three levels (standard, medium and high) based on their technological equipment, and in particular mechanical ventilatory assistance and intra-aortic balloon pumping availability. A high proportion of ICCUs (347/385, 90%) answered to the questionnaire and an analysis of the responses revealed no significant differences between the three main geographical areas of Italy (North, Center, South). CONCLUSIONS: Despite some organizational and staffing problems, the survey confirmed the high level of routine nursing care, the strong tendency towards the integration of different professional competencies among the staff, and the high degree of standardization.

Prognostic value of brain natriuretic peptide and enhanced ventilatory response to exercise in patients with chronic heart failure.

Whether brain natriuretic peptide (BNP), combined with a cardiopulmonary exercise test (CPx) parameters or echocardiography improves prognostic stratification in mild-to-moderate systolic heart failure (HF) is currently unclear. In 156 consecutive stable outpatients with mild to moderate HF and left ventricular ejection fraction (LVEF) <40%, we assessed the impact of BNP assay, Doppler echocardiography and CPx on survival. Median BNP plasma levels were 207 [90-520] pg/mL. Mean LVEF was 33 +/- 7%. Left bundle branch block (LBBB) was present in 52 patients (33%) and a restrictive filling pattern in 35 (22%). The slope of the relation between minute ventilation and carbon dioxide production (VE/VCO(2) slope) averaged 35 +/- 8; an enhanced ventilatory response (EVR) to exercise (VE/VCO(2) slope >35) was found in 67 patients (43%). During 759 +/- 346 days of follow-up, 24 patients died. By multivariate analysis, the strongest independent predictors of all-cause death among clinical, echocardiographic variables and BNP were LBBB and beta-blocker treatment. When CPx variables were added, the best predictors of mortality were LBBB, beta-blockade and VE/VCO(2) slope. This study highlights the value of a sequential approach, based on clinical, laboratory and functional data to identify high-risk HF patients. BNP assay might constitute a simple alternative tool for patients with an inability or with clinical contraindications to exercise, advanced physical deconditioning and unreliable CPx results. However, whenever feasible, CPx with assessment of EVR is recommended for a more accurate prediction of prognosis.

Transthoracic Doppler echocardiography for the assessment of left atrial appendage size and blood flow velocity: a multicentre study.

OBJECTIVE: The aim of this study was to evaluate the reliability of transthoracic Doppler echocardiography (TTE) in the assessment of left atrial appendage (LAA) size and function. METHODS: We considered 86 consecutive patients [56 male, 30 female; mean age 64 +/- 13 years, sinus rhythm 36 patients (42%); atrial flutter/fibrillation 50 patients (58%)] referred for transoesophageal echocardiography (TEE) and TTE. Maximum LAA transverse diameters and LAA peak flow velocities were calculated by two-dimensional and pulsed-wave Doppler analysis at TEE and TTE. RESULTS: LAA systolic transverse diameters were detectable in 78 patients (91%) by TTE and showed a significant correlation with TEE (r = 0.77, P < 0.0001). LAA peak flow velocities were measurable by TTE in 72 patients (84%) and were comparable with TEE (50.4 +/- 23 vs 47.3 +/- 23.2 cm/s, r = 0.67, P < 0.0001). A peak blood flow velocity of <25 cm/s at TTE was the best indicator of very low (<20 cm/s) LAA flow velocity as detected by TEE (sensitivity 93%, specificity 87%, area under the curve 0.94, P < 0.0001). Conversely, a peak blood flow velocity of >56 cm/s at TTE indicated a very high (> 40 cm/s) LAA flow velocity as detected by TEE (sensitivity 50%, specificity 96%, area under the curve 0.87; P < 0.0001). CONCLUSIONS: Reliable LAA size and blood flow velocities can be obtained by TTE in consecutive, unselected patients. TTE identifies patients with low and high blood flow velocities in the LAA, providing helpful information for the definition of individual embolic risk.

Restrictive mitral inflow pattern is a strong independent predictor of lack of viable myocardium after a first acute myocardial infarction.

In patients with acute myocardial infarction (AMI) a restrictive mitral inflow pattern successfully predicts clinical outcome. The impact of myocardial viability on the mitral inflow velocities, however, is unknown. One hundred and forty-one patients with a first AMI underwent two-dimensional, Doppler and dobutamine stress echocardiography (DSE). Patients were classified into two groups based on Doppler measurement of left ventricular filling: a restrictive group (18 patients), and a non-restrictive group (123 patients). In the non-restrictive group, myocardial viability at DSE was found in 56 patients, while in the restrictive group only three patients showed contractile reserve (46% vs. 16%, p<0.03). The multivariate logistic regression analysis demonstrated that restrictive mitral inflow pattern was a strong independent predictor of lack of viable myocardium (OR=12.45, p<0.001).

Brain natriuretic peptide plasma level is a reliable indicator of advanced diastolic dysfunction in patients with chronic heart failure.

The aim of the study was to determine the value of brain natriuretic peptide for the identification of diastolic dysfunction status in congestive heart failure. We studied 204 patients with stable heart failure. Brain natriuretic peptide plasma levels were correlated with echocardiographic parameters of diastolic dysfunction. Diastolic dysfunction was classified as mild (abnormal echocardiographic relaxation pattern) and severe (pseudo-normal or restrictive pattern). A significant correlation between brain natriuretic peptide levels and the other parameters was detected. Brain natriuretic peptide dosage, then, seems to be a reliable tool for the assessment of diastolic dysfunction status in patients with congestive heart failure.

The cardiopulmonary exercise test is safe and reliable in elderly patients with chronic heart failure.

AIM: To assess safety and feasibility of cardiopulmonary exercise test (CPX) in elderly patients with chronic heart failure (CHF) and left ventricular dysfunction. METHODS AND RESULTS: We analysed 395 cardiopulmonary exercise tests (CPXs) performed in 227 clinically stable patients with CHF [mean age 76 years, males 70%, mean New York Heart Association (NYHA) class 2.2 +/- 0.5] and impaired left ventricular function (mean ejection fraction 43 +/- 12%). Ninety-eight out of 395 CPXs (25%) were performed in patients older than 80 years. A standard bicycle exercise ramp protocol was used, with increments of 10 W/min. An expiratory exchange ratio (RER) >or= 1.05 at the peak of CPX was considered as the index of maximal exercise. Average workload was 65 +/- 23 W. No adverse reactions were observed, although one test was stopped for non-sustained ventricular tachycardia. The main reasons for stopping were exhaustion (50%), dyspnoea (30%), maximal predicted heart rate (17%), orthopaedic problems (2.5%) and significant ST segment depression (0.5%). In the overall cohort, 80% of patients achieved an RER >or= 1.05 and, in 56% of them, the RER was >or= 1.15. The anaerobic threshold (AT) was detectable in 80% of CPXs, and mean oxygen consumption (VO2) at AT was 9 +/- 6 ml/kg per min, whereas mean peak VO2 was 11 +/- 3 ml/kg per min. In the cohort of patients aged > 80 years, 71% reached an RER >or= 1.05 and 47% reached an RER >or= 1.15. In these older patients, AT was detectable in 68% of CPXs performed, and the mean peak VO2 was 10 +/- 3 ml/kg per min. CONCLUSIONS: In elderly patients with CHF, the CPX is safe, feasible and able to provide basic information for individual risk assessment. These findings potentially extend the indications of CPX, which is currently applied to selected middle-aged patients with CHF, to the elderly population.

Reliability of cardiac dimensions and valvular regurgitation assessment by sonographers using hand-carried ultrasound devices.

AIM: We sought to assess the reliability of some basic echocardiographic data obtained by trained sonographers using a hand-held ultrasound device. METHODS: One hundred and twelve consecutive patients (mean age 61, 64 males) referred for in-hospital or ambulatory routine echocardiography were considered. All patients underwent two-dimensional and colour Doppler examination performed by a trained sonographer equipped with a hand-held ultrasound device and by a certified cardiologist equipped with a standard platform, in random order. Indexed left ventricular end-diastolic and end-systolic transverse diameters, aortic root, end-systolic left atrium transverse diameter, end-diastolic interventricular septum and posterior wall thickness were calculated by two-dimensional left parasternal long-axis view in blind conditions. Mitral and aortic valve regurgitation were investigated by colour-Doppler imaging on parasternal and apical views and compared using a 0 to 4 semi-quantitative score. RESULTS: Overall feasibility was high for both settings (sonographers: 93%; cardiologists: 95%; P not significant). Excellent concordance of end-diastolic diameter (kappa 0.75), left atrium (kappa 0.76) and interventricular septum thickness (kappa 0.77) results was found. Good concordance was observed for end-systolic diameter (kappa 0.66), aortic root (kappa 0.64) and posterior wall thickness (kappa 0.67) results. A high linear correlation between the couples of results was present for all parameters. A good agreement of the mitral (kappa 0.66) and aortic (kappa 0.84) regurgitation scores was also found, with a low prevalence of discordant results (mitral regurgitation: 22%, aortic regurgitation: 9%) and no > or =2-point discrepancies. CONCLUSION: In a general population referred for Doppler echocardiography, basic cardiac linear dimensions and valvular regurgitation severity assessment by trained sonographers using hand-held ultrasound devices appear accurate and reliable for routine clinical use.

Rapid brain natriuretic peptide test and Doppler echocardiography for early diagnosis of mild heart failure.

BACKGROUND: The early identification of patients at risk for the development of clinical heart failure (HF) is a new challenge in an effort to improve outcomes. METHODS: We prospectively evaluated whether the combination of brain natriuretic peptide (BNP) measurements (Triage BNP test, Biosite Diagnostics) and echocardiography would effectively stratify patients with new symptoms in a cost-effective HF program aimed at early diagnosis of mild HF. A total of 252 patients were referred by 100 general practitioners. RESULTS: Among the study population, the median BNP value was 78 ng/L (range, 5-1491 ng/L). BNP concentrations were lower among patients without heart disease [median 15 ng/L (range, 5-167 ng/L); n = 96] than among patients with confirmed HF [median, 165 ng/L (22-1491 ng/L); n = 157; Mann-Whitney U-test, 12.3; P <0.001]. Patients were grouped into diastolic dysfunction [BNP, 195 (223) ng/L], systolic dysfunction [BNP, 290 (394) ng/L], and both systolic and diastolic dysfunction [BNP, 776 (506) ng/L]. In this model, a cutoff value of 50 ng/L BNP increases the diagnostic accuracy in predicting mild HF, avoiding 41 echocardiograms per 100 patients studied, with a net saving of 14% of total costs. CONCLUSIONS: Blood BNP concentrations, in a cost effective targeted screening, can play an important role in diagnosing mild HF and stratifying patients into risk groups of cardiac dysfunction.

[Mitral valve prolapse]. / Il prolasso valvolare mitralico.

Mitral valve prolapse (MVP) is still a clinical challenging problem. In this report, we review the main characteristics of this entity. Epidemiology of MVP, which relies on the diagnostic criteria adopted, and the incidence of complications, both arrhythmic and structural, are influenced by the characteristics of the population studied, which may lead to bias in data interpretation. Even the definition of MVP may differ according to the cardiologist's or cardiac surgeon's point of view. Usually, cardiologists define MVP as the protrusion of all or part of the mitral leaflets into the left atrium, independent of maintenance of coaptation. Therefore, using this definition, mitral regurgitation is considered as a complication rather than a diagnostic criterion. Arrhythmias, either supraventricular or ventricular, are other possible complications, mostly not life-threatening and associated with myxomatous degeneration of the valve. Diagnosis of MVP is based on echocardiography, which provides detailed anatomic and functional evaluation of the affected valve. Leaflet thickness and motion as well as presence and severity of mitral regurgitation can be assessed, with important diagnostic and prognostic implications. Echocardiographic evaluation of the mitral valve requires a systematic approach in order to define the leaflet/scallop involved and the mechanisms of mitral regurgitation. To this aim, three-dimensional reconstruction may add further insights into objective rendering of mitral valve pathology. Finally, surgical timing in mitral regurgitation due to MVP is an evolving issue and the likelihood of surgical repair is a crucial factor in the optimal timing of surgical intervention, especially in asymptomatic patients with severe mitral regurgitation.

Early diagnosis of congestive heart failure: clinical utility of B-type natriuretic peptide testing associated with Doppler echocardiography.

OBJECTIVE: B-type natriuretic peptide (BNP) has emerged as an important diagnostic serum marker of congestive heart failure (CHF). The aim of this study was to evaluate whether BNP measurement associated with echocardiography could effectively stratify patients with new symptoms as part of a cost-effective heart failure programme based on cooperation between hospital cardiologists and primary care physicians. METHODS: Patients were referred to the cardiology clinic by general practitioners in case of clinical suspect of CHF. All patients underwent clinical examination, transthoracic echocardiography and plasma determination of BNP. Systolic dysfunction was defined as a left ventricular ejection fraction < 45%; diastolic dysfunction was defined as a preserved systolic function with signs of diastolic impairment. RESULTS: Three hundred and fifty-seven subjects were examined (50% males, mean age 73 years). BNP concentration was 469 +/- 505 pg/ml in the 240 patients diagnosed with CHF, compared with 43 +/- 105 pg/ml in the 117 patients without CHF (P = 0.001). CHF patients were grouped into those with diastolic dysfunction (n = 110; BNP 373 +/- 335 pg/ml), systolic dysfunction (n = 108; BNP 550 +/- 602 pg/ml), and both systolic and diastolic dysfunction (n = 22; BNP 919 +/- 604 pg/ml). At receiver operating characteristic analysis, the optimal BNP cut-off level for diagnosing CHF was 80 pg/ml (sensitivity 84%, specificity 91%). According to cost analysis, this cut-off level might provide a cost saving of 31% without affecting diagnostic accuracy. CONCLUSIONS: In patients referred by general practitioners for suspected CHF, plasma BNP levels might help to stratify subjects into different groups of cardiac dysfunction.

Cost of strategies after myocardial infarction (COSTAMI): a multicentre, international, randomized trial for cost-effective discharge after uncomplicated myocardial infarction.

AIMS: Risk stratification after uncomplicated acute myocardial infarction is mostly applied by either symptom-limited post discharge exercise electrocardiography or pre-discharge submaximal exercise test. Aim of the present study was to determine if early pharmacological stress echocardiography and discharge within 24 hours of the test in cases without induced myocardial ischemia leads to lower costs and similar clinical outcome during 1 year follow up when compared to clinical evaluation and exercise electrocardiography after discharge. METHODS AND RESULTS: Four-hundred fifty-eight patients from 10 participating centers with a recent uncomplicated myocardial infarction were randomized to pharmacological stress echocardiography on day 3-5 followed by early discharge in the case of negative test result (early discharge strategy) (n=233) or clinical evaluation with hospital discharge on day 7-9 and symptom-limited post-discharge exercise electrocardiography at 2-4 weeks after myocardial infarction (usual care strategy) (n=225). At 1 year follow up there were 63 events (4 deaths, 9 non fatal reinfarctions, 50 chest pains requiring hospitalization) in patients randomized to early discharge, and 69 events (6 deaths, 13 reinfarctions, 50 chest pains requiring hospitalization) in usual care (p=ns). Total median individual costs calculated on the basis of hospitalizations, investigations and interventions during 1 year follow up were 3561 for early discharge strategy vs 3850 for usual care strategy (p<0.05). CONCLUSIONS: Early pharmacological stress echocardiography followed by early discharge in case of negative test result gives similar clinical outcome and lower costs after uncomplicated myocardial infarction than clinical evaluation and delayed post-discharge symptom-limited exercise electrocardiography.