Evidence of Carotid Atherosclerosis Vulnerability Regression in Real Life From Magnetic Resonance Imaging: Results of the MAGNETIC Prospective Study.

Background Atherosclerosis vulnerability regression has been evidenced mostly in randomized clinical trials with intensive lipid-lowering therapy. We aimed to demonstrate vulnerability regression in real life, with a comprehensive quantitative method, in patients with asymptomatic mild to moderate carotid atherosclerosis on a secondary prevention program. Methods and Results We conducted a single-center prospective observational study (MAGNETIC [Magnetic Resonance Imaging as a Gold Standard for Noninvasive Evaluation of Atherosclerotic Involvement of Carotid Arteries]): 260 patients enrolled at a cardiac rehabilitation center were followed for 3 years with serial magnetic resonance imaging. Per section cutoffs (95th/5th percentiles) were derived from a sample of 20 consecutive magnetic resonance imaging scans: (1) lipid-rich necrotic core: 26% of vessel wall area; (2) intraplaque hemorrhage: 12% of vessel wall area; and (3) fibrous cap: (a) minimum thickness: 0.06 mm, (b) mean thickness: 0.4 mm, (c) projection length: 11 mm. Patients with baseline magnetic resonance imaging of adequate quality (n=247) were classified as high (n=63, 26%), intermediate (n=65, 26%), or low risk (n=119, 48%), if vulnerability criteria were fulfilled in ≥2 contiguous sections, in 1 or multiple noncontiguous sections, or in any section, respectively. Among high-risk patients, a conversion to any lower-risk status was found in 11 (17%; P=0.614) at 6 months, in 16 (25%; P=0.197) at 1 year, and in 19 (30%; P=0.009) at 3 years. Among patients showing any degree of carotid plaque vulnerability, 21 (16%; P=0.014) were diagnosed at low risk at 3 years. Conclusions This study demonstrates with a quantitative approach that vulnerability regression is common in real life. A secondary prevention program can promote vulnerability regression in asymptomatic patients in the mid to long term.

Cardiac Magnetic Resonance in Stable Coronary Artery Disease: Added Prognostic Value to Conventional Risk Profiling.

AIMS: Cardiovascular magnetic resonance (CMR) permits a comprehensive evaluation of stable coronary artery disease (CAD). We sought to assess whether, in a large contemporaneous population receiving optimal medical therapy, CMR independently predicts prognosis beyond conventional cardiovascular risk factors (RF). METHODS: We performed a single centre, observational prospective study that enrolled 465 CAD patients (80% males; 63±11 years), optimally treated with ACE-inhibitors/ARB, aspirin, and statins (76-85%). Assessments included conventional evaluation (clinical history, atherosclerosis RF, electrocardiography, and echocardiography) and a comprehensive CMR with LV dimensions/function, late gadolinium enhancement (LGE), and stress perfusion CMR (SPCMR). RESULTS: During a median follow-up of 62 months (IQR 23-74) there were 50 deaths and 92 major adverse cardiovascular events (MACE). CMR variables improved multivariate model prediction power of mortality and MACE over traditional RF alone (F-test p<0.05 and p<0.001, respectively). LGE was an independent prognostic factor of mortality (hazard ratio [95% CI]: 3.4 [1.3-8.8]); moreover, LGE (3.3 [1.7-6.3]) and SPCMR (2.1 [1.4-3.2]) were the best predictors of MACE. CONCLUSION: LGE is an independent noninvasive marker of mortality in the long term in patients with stable CAD and optimized medical therapy. Furthermore, LGE and SPCMR independently predict MACE beyond conventional risk stratification.

EaRly-start ExerciSe training afTer acute hemodynAmic decompensation in patients with chRonic hearT failure (RE-START). A multicenter, randomized, controlled trial on short-term feasibility and impact on functional capacity, symptoms and neurohumoral activation .

RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an early-start AET program on functional capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient-reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP > 1000 pg/mI at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine > 2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6-min WT at day 1, 6, 12 and 30 and echocardiogram, patient-reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.

Psychological needs and mental health in women aged > or = 65 years after cardiac surgery: an exploratory study.

BACKGROUND: Recent developments in cardiac care have led to an increase survival even among elderly cardiac patients. Previous studies showed that women have worse health related outcomes compared with men. The main aims of this study are to assess psychological needs and factors promoting mental health among women aged > or = 65 years following heart surgery. METHODS: 74 consecutive women aged > or = 65 years and referred to a cardiac rehabilitation unit in Northern Italy after heart surgery were enrolled in this exploratory study. Psychological questionnaires exploring cognitive functioning, psychological needs, anxiety, depression, physical and mental health status, self-esteem were administered by a psychologist to each patient using a face-to-face interview. RESULTS: The main areas of psychological needs reported by patients were relational and emotional support, assistance and treatment, information about diagnosis and future conditions and information concerning economic-insurance issues. Multivariate linear regression analysis showed that factors significantly associated with patients' mental health were anxiety (p = 0.01) and locus of control (p = 0.01). CONCLUSIONS: In order to improve older cardiac women's mental health after cardiac surgery is important to offer tailored rehabilitative interventions able to meet their specific needs such as the management of anxiety symptoms and loss of control, the need to regain the family role, the need of more information concerning the diagnosis and prognosis and emotional support.

An elderly-centered, personalized, physiotherapy program early after cardiac surgery.

BACKGROUND: Early post-surgery in-hospital rehabilitation in elderly patients should be aimed at accelerating the recovery of the highest level of functional autonomy and reducing the hospital stay. DESIGN: We designed a personalized physiotherapy program tailored to the frailty level of over-70-year-old patients soon after cardiac surgery. The aims of this study were (a) to validate our frailty-based approach for functional stratification of the patients, and (b) to assess the effect of the individualized program on independence and mobility, and compare it with our usual program. METHODS: We followed 224 consecutive patients aged 70-87 years, who followed either the personalized (n= 150) or usual (n= 74) program. All patients underwent a comprehensive physical functioning evaluation at the baseline and at the end of hospitalization. RESULTS: The frailty-based stratification was successful in identifying those patients at higher risk of falls, with heavy nursing needs, greater dependency, and poorer heath status perception. On discharge, both groups had significantly improved on all measures of independence and mobility, but most of these changes (nursing needs, mobility, balance, and muscle strength) were significantly greater (P < 0.05) in the intervention group. These patients also had a significantly shorter length of stay (17.5 ± 8 vs. 21 ± 4 days, P = 0.0002), and 91% of them could be discharged in a state of substantial independence. CONCLUSION: An elderly-centered stratification based on functional frailty is useful to identify patients with more dependency and greater needs. A consequent personalized physiotherapy program designed to enhance independent mobility soon after cardiac surgery is safe and well accepted, and is more effective then usual physiotherapy.

Levels of circulating pro-angiogenic cells predict cardiovascular outcomes in patients with chronic heart failure.

BACKGROUND: Circulating pro-angiogenic cells (PACs) contribute to vascular and myocardial regeneration. A low level of PACs is associated with worse outcome in patients with coronary heart disease. However, little is known about PACs in heart failure (HF). METHODS AND RESULTS: Blood was sampled at baseline in 111 patients with HF, 67 from 5 Italian Centers and 44 from Frankfurt, Germany. In cultured mononuclear cells from peripheral blood, PACs were counted as double-stained by tetramethylindocarbocyanine-labeled acetylated LDL and fluorescein-5-isothiocyanate-labeled lectin. Mean age of the patients was 62 years, 12 were females, 66 had ischemic etiology, 26 were in New York Heart Association Class >II. Cutoffs for PACs were assessed by receiver operating characteristic curves, to identify the optimal cutoffs for PAC level in predicting outcomes. Mean level of PACs was 35+/-29 (mean+/-SD) cells/mm(2), 2- to 3-fold lower than in age-matched healthy volunteers, but unrelated to severity of HF, age, or sex. Over 2.5 years, 12 cardiovascular deaths and 47 first hospitalizations for cardiovascular reasons were recorded. After adjustment for demographic and clinical variables, elevated creatinine and natriuretic peptides, and PACs

Nitroprusside in decompensated heart failure: what should a clinician really know?

Sodium nitroprusside is an older intravenous vasodilator appropriate for acute hospital treatment of patients with congestive heart failure. It is a balanced arterial and venous vasodilator with a very short half-life, facilitating rapid titration. In general, it improves hemodynamic and clinical status by reducing systemic vascular resistance, left ventricular filling pressure, and increasing cardiac output. This review summarizes recently published literature and recent data regarding the use of this intravenous vasodilator in decompensated heart failure patients.

Physical and emotional symptom burden of patients with end-stage heart failure: what to measure, how and why.

OBJECTIVE: Much of our understanding about symptom burden near the end of life is based on studies of cancer patients. The aim of this study was to explore physical and emotional symptom experience among end-stage chronic heart failure patients, looking for those symptoms mostly related to their global health status. METHODS: Forty-six patients with end-stage heart failure compiled the following: Edmonton Symptom Assessment Scale (ESAS) and Kansas City Cardiomyopathy Questionnaire (KCCQ). RESULTS: End-stage heart failure patients have many complaints and poor global health status. The most distressing symptoms reported were general discomfort and tiredness followed by anorexia and dyspnea. The KCCQ summary scores were highly correlated with ESAS (r = -0.78; P = 0.0001). Among the domains explored by the KCCQ, social functioning and self-efficacy showed the lowest correlation coefficients with ESAS (r = -0.50; P = 0.001 and r = -0.31; P = 0.003, respectively); concerning the physical limitation domain, the symptom score and the quality-of-life domain, the correlation coefficients were as follows: r = -0.71 (P = 0.0001), r = -0.75 (P = 0.0001) and r = -0.74 (P = 0.0001), respectively. In the multiple regression analysis of ESAS and KCCQ scores, general discomfort, depression and anxiety were the symptoms that mostly related with the results in the domains explored by the KCCQ. No independent predictor was found among symptoms and quality of life. CONCLUSION: General discomfort together with depression and anxiety were the symptoms that were mostly related with the physical limitation domain of global health status, but did not influence the social functioning and the self-efficacy domains. When ESAS is used together with KCCQ, comprehensive and quantitative information on a patient's physical, emotional and social distress is provided.

Adequate energy-protein intake is not enough to improve nutritional and metabolic status in muscle-depleted patients with chronic heart failure.

BACKGROUND: An adequate energy-protein intake (EPI) when combined with amino acid supplementation may have a positive impact on nutritional and metabolic status in patients with chronic heart failure (CHF). METHODS AND RESULTS: Thirty eight stable CHF patients (27 males, 73.5+/-4 years; BMI 22.5+/-1.4 kg/m2), with severe depletion of muscle mass and were randomised to oral supplements of essential amino acids 8 g/day (EAA group; n=21) or no supplements (controls; n=17). All patients had adequate EPI (energy> or =30 kcal/kg; proteins >1.1 g/kg). At baseline and 2-months after randomisation, the patients underwent metabolic (plasma lactate, pyruvate concentration; serum insulin level; estimate of insulin resistance by HOMA index), nutritional (measure of nitrogen balance), and functional (exercise test, walking test) evaluations. Body weight increased by >1 kg in 80% of supplemented patients (mean 2.96 kg) and in 30% of controls (mean 2.3 kg) (interaction <0.05). Changes in arm muscle area, nitrogen balance, and HOMA index were similar between the two treatment groups. Plasma lactate and pyruvate levels increased in controls (p<0.01 for both) but decreased in the supplemented group (p<0.01 and 0.02 respectively). EAA supplemented patients but not controls improved both exercise output and peak oxygen consumption and walking test. CONCLUSIONS: Adequate EPI when combined with essential amino acid supplementation may improve nutritional and metabolic status in most muscle-depleted CHF patients.

[Metabolic frailty in malnourished heart failure patients]. / Precarietà metabolica nei pazienti con scompenso cardiaco cronico e malnutrizione.

UNLABELLED: Muscular wasting (MW) and cardiac cachexia (CC) are often present in patients with chronic heart failure (HF). AIM: To identify whether MW and CC are due to malnutrition or impairment of protein metabolism in HF patients. MATERIAL AND METHOD: In 78 clinically stable HF patients (NYHA class II-III), aged from 32 to 89 years, we measured anthropometrical parameters and nutritional habits. In the identified 35 malnourished patients, we also measured: insulin resistance, gluconeogenetic amino acids blood concentration and nitrogen balance. RESULTS: Seventy-five patients had eating-related symptoms. However we found significant nutritional impairment in 35 patients only. In addition, these 35 patients had: 1) significant increase of blood Alanine independently from both presence of insulin resistance or food intake reduction and 2) positive nitrogen balance. CONCLUSION: Food intake is not impaired in CHF patients. In spite of normal food intake, 35 of 78 patients had nutritional impairment with reduced anthropometric parameters and increased blood Alanine. These findings show alteration of proteins metabolism with proteolysis. We believe that specific physical training with nutritional supplement can be an additional therapy able to prevent protein disarrangement in CHF patients.

[Elderly patient-centered rehabilitation after cardiac surgery]. / Percorso riabilitativo individualizzato dedicato al paziente ultrasettantenne cardioperato.

The rate of over-70 year post-surgery patients referred to the Cardiac Rehabilitation Units is increasing. Strategies designed to encourage and facilitate participation in rehabilitation programs in the elderly should be developed. Aim of this paper is to present our elderly-centered program, specifically designed on patient's needs and frailty, and its short- and medium-term results in 160 consecutive over-70 year patients, admitted in our Cardiac Rehabilitation Unit soon after cardiac surgery. The program was safe, well accepted by the patients, and effective in improving objective and subjective functional status.

The complex symptom burden of the aged heart failure population.

PURPOSE OF REVIEW: The primary remit of terminal care in heart failure is to relieve suffering, which begins with a routine and standardized assessment of symptoms using validated instruments. The scope of this review is to explore symptom burden and control, and to examine some instruments used to assess and monitor heart failure patients' distress. RECENT FINDINGS: Elderly heart failure patients have many complaints and poor global health status. Symptoms are both of cardiac and noncardiac origin, attributable to the high frequency of comorbidities, side effects of medication and the psychosocial consequences of a chronic progressive illness. SUMMARY: Continuity of care, familiarity with the patient and the quality of inter-personal relationships between patients, relatives, nurses and physicians are essential to obtain high-quality end-of-life care. Validated instruments to measure symptom burden may be useful tools to quantify patients' distress and to evaluate the efficacy of care.

Does atrial fibrillation in elderly patients with chronic heart failure limit the efficacy of carvedilol? Suggestions from an observational study.

BACKGROUND: No clinical investigation provided any information about a possible influence of atrial fibrillation on the response to beta-blocker therapy in elderly patients with chronic heart failure (CHF). The aim of this study was to observe carvedilol effects in a cohort of patients > 70 years of age with CHF due to left ventricular dysfunction and with chronic atrial fibrillation. METHODS: An observational, 12-month prospective clinical and echocardiographic study was carried out on 240 patients > 70 years of age with heart failure due to systolic dysfunction, 64 of whom with atrial fibrillation. RESULTS: After 1 year of beta-blocker treatment, patients with atrial fibrillation and those in sinus rhythm showed similar benefits, in terms of symptomatic improvement (deltaNYHA -0.44 if atrial fibrillation vs -0.57 if sinus rhythm, p = NS), reduction of events (death + hospitalizations -38 vs -15%), recovery of cardiac function (left ventricular ejection fraction delta +8.8 vs +9.4%, p = NS; left ventricular end-diastolic volume delta -17.2 vs -12.5 ml, p = NS), and reduction in mitral regurgitation (delta -042 vs -0.57, p = NS). No difference was found between the two study groups regarding left ventricular end-diastolic volume reduction (12% in atrial fibrillation patients and 18% in sinus rhythm patients, p = NS) and prevalence of the "reverse remodeling" phenomenon (22 and 21%, respectively, p = NS). CONCLUSIONS: In CHF patients > 70 years of age, beta-adrenergic blockade was shown to be equally effective in improving symptoms and left ventricular geometry and function in patients with atrial fibrillation or in sinus rhythm, without any adjunctive sign of long-term clinical deterioration.