ABSTRACT
BACKGROUND: Troponin changes over time have been suggested to allow for an early diagnosis of cardiac injury ensuing cancer chemotherapy; cancer patients with troponin elevation may benefit of therapy with enalapril. It is unknown whether a preventive treatment with enalapril may further increase the benefit. METHODS: The International CardioOncology Society-one trial (ICOS-ONE) was a controlled, open-label trial conducted in 21 Italian hospitals. Patients were randomly assigned to two strategies: enalapril in all patients started before chemotherapy (CT; 'prevention' arm), and enalapril started only in patients with an increase in troponin during or after CT ('troponin-triggered' arm). Troponin was assayed locally in 2596 blood samples, before and after each anthracycline-containing CT cycle and at each study visit; electrocardiogram and echocardiogram were done at baseline, and at 1, 3, 6 and 12-month follow-up. Primary outcome was the incidence of troponin elevation above the threshold. FINDINGS: Of the 273 patients, 88% were women, mean age 51 ± 12 years. The majority (76%) had breast cancer, 3% had a history of hypertension and 4% were diabetic. Epirubicin and doxorubicin were most commonly prescribed, with median cumulative doses of 360 [270-360] and 240 [240-240] mg/m2, respectively. The incidence of troponin elevation was 23% in the prevention and 26% in the troponin-triggered group (p = 0.50). Three patients (1.1%) -two in the prevention, one in the troponin-triggered group-developed cardiotoxicity, defined as 10% point reduction of LV ejection fraction, with values lower than 50%. INTERPRETATION: Low cumulative doses of anthracyclines in adult patients with low cardiovascular risk can raise troponins, without differences between the two strategies of giving enalapril. Considering a benefit of enalapril in the prevention of LV dysfunction, a troponin-triggered strategy may be more convenient.
Subject(s)
Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Antineoplastic Agents/adverse effects , Enalapril/therapeutic use , Troponin C/blood , Ventricular Dysfunction, Left/prevention & control , Adult , Aged , Anthracyclines/adverse effects , Cardiotoxicity/blood , Cardiotoxicity/prevention & control , Female , Humans , Male , Middle Aged , Neoplasms/drug therapy , Ventricular Dysfunction, Left/blood , Ventricular Dysfunction, Left/chemically inducedABSTRACT
The hospital discharge is often poorly standardized and affected by discontinuity and fragmentation of care, putting patients at high risk of both post-discharge adverse events and early readmission. The present ANMCO document reviews the modifiable components of the hospital discharge process related to adverse events or re-hospitalizations and suggests the optimal methods for redesigning the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that the hospital discharge: ⢠is not an isolated event, but a process that has to be planned as soon as possible after the admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions, as equal partners; ⢠is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process; ⢠must be organized by an operator who is responsible for the coordination of all phases of the hospital patient journey, involving afterward the general practitioner and transferring to them the information and responsibility at discharge; ⢠is the result of an integrated multidisciplinary team approach; ⢠appropriately uses the transitional and intermediate care services; ⢠is carried out in an organized system of care and continuum of services; and ⢠programs the passage of information to after-discharge services.
ABSTRACT
Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyse the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education, and legal aspects.
ABSTRACT
Hospital discharge is often poorly standardized and is characterized by discontinuity and fragmentation of care, putting patients at high risk of post-discharge adverse events and early readmission. The present ANMCO position paper reviews the modifiable components of the hospital discharge process related to adverse events or rehospitalizations and suggests the optimal methods for redesign the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that hospital discharge:- is not an isolated event, but a process that has to be planned immediately after admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions as equal partners;- is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process;- must be organized by an operator who is responsible for the coordination of all phases of the hospital patient pathway, involving afterwards the physician and transferring to them the information and responsibility;- is the result of an integrated multidisciplinary team approach;- uses appropriately the transitional and intermediate care services;- is carried out in an organized system of care and continuum of services;- programs the passage of information to after-discharge services.
Subject(s)
Patient Discharge/standards , Aftercare/standards , Algorithms , Humans , Patient Discharge Summaries/standardsABSTRACT
Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyze the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education and legal aspects.
Subject(s)
Cardiology , Emergency Treatment , Myocardial Infarction/diagnosis , Myocardial Infarction/therapy , Telemedicine , Cardiology/legislation & jurisprudence , Cardiology/trends , Electrocardiography , Emergency Medical Services/methods , Emergency Treatment/trends , Humans , Italy , Myocardial Infarction/physiopathology , Telemedicine/legislation & jurisprudence , Telemedicine/trends , Time Factors , Treatment OutcomeABSTRACT
Malignant pericardial effusion (MPE) is a serious complication of several cancers. The most commonly involved solid tumors are lung and breast cancer. MPE can give rise to the clinical picture of cardiac tamponade, a life threatening condition that needs immediate drainage. While simple pericardiocentesis allows resolution of the symptoms, MPE frequently relapses unless further procedures are performed. Prolonged drainage, talcage with antineoplastic agents, or surgical creation of a pleuro-pericardial window are the most commonly suggested ones. They all result in MPE resolution and high rates of long-term control. Patients suitable for further systemic treatments can have a good prognosis irrespective of the pericardial site of disease. We prospectively enrolled patients with cardiac tamponade treated with prolonged drainage associated with Bleomycin administration. Twenty-two consecutive patients with MPE and associated signs of hemodynamical compromise underwent prolonged drainage and subsequent Bleomycin administration. After injection of 100âmg lidocaine hydrochloride, 10âmg Bleomycin was injected into the pericardial space. The catheter was clumped for 48âh and then reopened. Removal was performed when the drainage volume was <25 mL daily. Twelve patients (54%) achieved complete response and 9 (41%) a partial response. Only 1 (5%) had a treatment failure and underwent a successful surgical procedure. Acute toxicity was of a low degree and occurred in 7 patients (32%). It consisted mainly in thoracic pain and supraventricular arrhythmia. The 1-year pericardial effusion progression-free survival rate was 74.0% (95% confidence interval [CI]: 51.0-97.3). At a median follow-up of 75 months, a pericardial progression was detected in 4 patients (18%). One- and two-year overall survival rates were 33.9% (95% CI: 13.6-54.2) and 14.5% (95% CI: 0.0-29.5), respectively, with lung cancer patients having a shorter survival than breast cancer patients. The worst prognosis, however, was shown in patients not suitable for systemic treatments, irrespective of the site of the primary tumor.Prolonged drainage and intrapericardial Bleomycin is a safe and effective treatment, which should be considered as first choice at least in patients suitable for active systemic treatment.
Subject(s)
Bleomycin , Breast Neoplasms , Cardiac Tamponade , Drainage , Lung Neoplasms , Pericardial Effusion , Pericardium , Postoperative Complications , Adult , Aged , Antineoplastic Agents/administration & dosage , Antineoplastic Agents/adverse effects , Bleomycin/administration & dosage , Bleomycin/adverse effects , Breast Neoplasms/complications , Breast Neoplasms/mortality , Breast Neoplasms/pathology , Cardiac Tamponade/drug therapy , Cardiac Tamponade/etiology , Cardiac Tamponade/surgery , Drainage/adverse effects , Drainage/methods , Drug Administration Routes , Female , Humans , Italy/epidemiology , Lung Neoplasms/complications , Lung Neoplasms/mortality , Lung Neoplasms/pathology , Male , Middle Aged , Outcome Assessment, Health Care , Pericardial Effusion/etiology , Pericardial Effusion/surgery , Pericardium/drug effects , Pericardium/pathology , Pericardium/surgery , Postoperative Complications/etiology , Postoperative Complications/prevention & control , Retrospective Studies , Secondary Prevention/methods , Survival Analysis , TimeABSTRACT
BACKGROUND: Whether cyclosporine A (CsA) has beneficial effects in reperfused myocardial infarction (MI) is debated. OBJECTIVES: This study investigated whether CsA improved ST-segment resolution in a randomized, multicenter phase II study. METHODS: The authors randomly assigned 410 patients from 31 cardiac care units, age 63 ± 12 years, with large ST-segment elevation MI within 6 h of symptom onset, Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 to 1 in the infarct-related artery, and committed to primary percutaneous coronary intervention, to 2.5 mg/kg intravenous CsA (n = 207) or control (n = 203) groups. The primary endpoint was incidence of ≥70% ST-segment resolution 60 min after TIMI flow grade 3. Secondary endpoints included high-sensitivity cardiac troponin T (hs-cTnT) on day 4, left ventricular (LV) remodeling, and clinical events at 6-month follow-up. RESULTS: Time from symptom onset to first antegrade flow was 180 ± 67 min; a median of 5 electrocardiography leads showed ST-segment deviation (quartile [Q]1 to Q3: 4 to 6); 49.8% of MIs were anterior. ST-segment resolution ≥70% was found in 52.0% of CsA patients and 49.0% of controls (p = 0.55). Median hs-cTnT on day 4 was 2,160 (Q1 to Q3: 1,087 to 3,274) ng/l in CsA and 2,068 (1,117 to 3,690) ng/l in controls (p = 0.85). The 2 groups did not differ in LV ejection fraction on day 4 and at 6 months. Infarct site did not influence CsA efficacy. There were no acute allergic reactions or nonsignificant excesses of 6-month mortality (5.7% CsA vs. 3.2% controls, p = 0.17) or cardiogenic shock (2.4% CsA vs. 1.5% controls, p = 0.33). CONCLUSIONS: In the CYCLE (CYCLosporinE A in Reperfused Acute Myocardial Infarction) trial, a single intravenous CsA bolus just before primary percutaneous coronary intervention had no effect on ST-segment resolution or hs-cTnT, and did not improve clinical outcomes or LV remodeling up to 6 months. (CYCLosporinE A in Reperfused Acute Myocardial Infarction [CYCLE]; NCT01650662; EudraCT number 2011-002876-18).
Subject(s)
Cyclosporine/administration & dosage , Electrocardiography , Myocardial Infarction/therapy , Myocardial Reperfusion/methods , Ventricular Function, Left/physiology , Ventricular Remodeling/drug effects , Coronary Angiography , Dose-Response Relationship, Drug , Echocardiography , Female , Follow-Up Studies , Humans , Immunosuppressive Agents/administration & dosage , Injections, Intravenous , Male , Middle Aged , Myocardial Infarction/diagnosis , Myocardial Infarction/physiopathology , Prospective Studies , Treatment OutcomeABSTRACT
This study evaluates per-procedure, collective and per capita effective dose to the population by interventional cardiology (IC) procedures performed during 2002-11 at the main hospital of Aosta Valley Region that can be considered as representative of the health-care level I countries, as defined by the UNSCEAR, based on its socio-demographic characteristics. IC procedures investigated were often multiple procedures in patients older than 60 y. The median extreme dose-area product values of 300 and 22 908 cGycm(2) were found for standard pacemaker implantation and coronary angioplasty, respectively, while the relative mean per-procedure effective dose ranged from 0.7 to 47 mSv. A 3-fold increase in frequency has been observed together with a correlated increase in the delivered per capita dose (0.05-0.27 mSv y(-1)) and the collective dose (5.8-35 man Sv y(-1)). Doses increased particularly from 2008 onwards mainly because of the introduction of coronary angioplasty procedures in the authors' institution. IC practice contributed remarkably in terms of effective dose to the population, delivering â¼10% of the total dose by medical ionising radiation examination categories.
Subject(s)
Angioplasty, Balloon, Coronary , Cardiology/methods , Cardiovascular Diseases/therapy , Coronary Angiography/methods , Radiography, Interventional/methods , Aged , Aged, 80 and over , Cardiovascular Diseases/diagnostic imaging , Female , Humans , Male , Middle Aged , Radiation Dosage , Radiation, IonizingABSTRACT
Health technology management consists of several decision processes including the acquisition of new technology. The purchasing of a new device requires the selection of one among several products taking into account different criteria. When the technology is characterized by large amount of parameters the choice becomes problematical and a support tool is needed. In 2003 Sloane et al. published a study in which they demonstrated the potentialities of the Analytic Hierarchy Process (AHP) to support the selection of a biomedical instrumentation. The work presented here describes the application of AHP to support the quality assessment for the selection of pacemakers and implantable defibrillators and shows that the method is indeed very appropriate for that task.
Subject(s)
Algorithms , Decision Support Systems, Management , Decision Support Techniques , Equipment and Supplies/classification , Purchasing, Hospital/methods , Technology Assessment, Biomedical/methods , Italy , Purchasing, Hospital/organization & administration , Technology Assessment, Biomedical/organization & administrationABSTRACT
A unidirectional clinical pathway for acute myocardial infarction from out-of-hospital setting to the coronary care unit and catheterization laboratory could lead to mortality reduction. The ongoing "Progetto Torino Network. Gestione globale dell'infarto miocardico acuto prime ore dal territorio all'ospedale" is based on this statement and described in the three-structural, diagnostic-therapeutical, multimedial issues. This project represents the historical evolution of our involvement in out-of-hospital cardiac emergency management.