Iron deficiency from the standpoint of cardiac rehabilitation: novel therapeutic opportunities.

Anemia is one of the most frequent comorbidities found in patients with coronary artery disease and chronic heart failure (CHF) who are being followed in cardiac rehabilitation facilities. The more frequent type of anemia is caused by iron deficiency (IDA, iron-deficiency anemia): this review summarizes the state of the art of this topic. First of all, the mechanisms of IDA will be analyzed. Subsequently, a description of the main conditions where IDA can unfavorably affect the clinical course, and of its more frequent complications, will be presented (percutaneous interventions, heart surgery, CHF). Special attention will be paid in the description of anemia in the setting of CHF. To this regard, in recent years a relevant amount of research has been carried out, to determine whether treating anemia (either by directly stimulating erythropoiesis or by correcting iron deficiency by oral or intravenous route) is of any clinical and prognostic relevance in patients with CHF. The results of this research will, therefore, be summarized and critically discussed. Finally, we will outline the promising role of cardiac rehabilitation facilities and of its network of experts in the diagnosis, prognostic stratification, and treatment of anemia and iron deficiency.

Longitudinal profile of NT-proBNP levels in ischemic heart failure patients undergoing surgical ventricular reconstruction: The Biomarker Plus study.

BACKGROUND: Plasma concentrations of natriuretic peptides have been shown to predict prognosis in heart failure (HF) patients with left ventricle (LV) dysfunction. It is still unclear if measurements after cardiac surgery are associated with any effect on the outcome. We aimed to prospectively investigate the longitudinal profile of serial evaluations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in ischemic HF patients undergoing Surgical Ventricular Reconstruction (SVR) and how NT-proBNP levels at different time-points are associated with the outcome. METHODS: One hundred and forty-three patients (122 men, 64 ±â€¯9 years old) with post-infarction LV remodeling referred to our Center for SVR had an assessment of NT-proBNP levels before surgery and 6, 12 and 18 months after surgery. The analysis was performed using the logarithm of the biomarker and joint modeling of serial measurements through mixed models together with Cox regression to analyze time to event data. RESULTS: The average level of the biomarker decreased by about 50% during the first year after the operation. Time-varying NT-proBNP levels were associated with the hazard of: 1% increase in NT-proBNP during the follow-up was associated with 1.5% increase of the risk of the composite event (95% CI: 1.0%, 2.6%) and with 4.2% increase of the risk of death (95% CI: 2.2%, 8.2%). CONCLUSIONS: Serial profiles (either in increasing or in decreasing) at different time points are associated with a modulation of the risk of adverse events and, therefore, are important indicators for monitoring the evolution of the disease, even after cardiac surgery.

Patterns and determinants of functional and absolute iron deficiency in patients undergoing cardiac rehabilitation following heart surgery.

Background Anaemia and iron deficiency are frequent following major surgery. The present study aims to identify the iron deficiency patterns in cardiac surgery patients at their admission to a cardiac rehabilitation programme, and to determine which perioperative risk factor(s) may be associated with functional and absolute iron deficiency. Design This was a retrospective study on prospectively collected data. Methods The patient population included 339 patients. Functional iron deficiency was defined in the presence of transferrin saturation <20% and serum ferritin ≥100 µg/l. Absolute iron deficiency was defined in the presence of serum ferritin values <100 µg/l. Results Functional iron deficiency was found in 62.9% of patients and absolute iron deficiency in 10% of the patients. At a multivariable analysis, absolute iron deficiency was significantly ( p = 0.001) associated with mechanical prosthesis mitral valve replacement (odds ratio 5.4, 95% confidence interval 1.9-15) and tissue valve aortic valve replacement (odds ratio 4.5, 95% confidence interval 1.9-11). In mitral valve surgery, mitral repair carried a significant ( p = 0.013) lower risk of absolute iron deficiency (4.4%) than mitral valve replacement with tissue valves (8.3%) or mechanical prostheses (22.5%). Postoperative outcome did not differ between patients with functional iron deficiency and patients without iron deficiency; patients with absolute iron deficiency had a significantly ( p = 0.017) longer postoperative hospital stay (median 11 days) than patients without iron deficiency (median nine days) or with functional iron deficiency (median eight days). Conclusions Absolute iron deficiency following cardiac surgery is more frequent in heart valve surgery and is associated with a prolonged hospital stay. Routine screening for iron deficiency at admission in the cardiac rehabilitation unit is suggested.

Myocardial Revascularization for Patients With Diabetes: Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention?

Patients affected by diabetes usually have extensive coronary artery disease. Coronary revascularization has a prominent role in the treatment of coronary artery disease in the expanding diabetic population. However, diabetic patients undergoing coronary artery bypass grafting or percutaneous coronary intervention experience worse outcomes than nondiabetic patients. Several studies comparing coronary artery bypass grafting vs percutaneous coronary intervention in subgroups of diabetic patients demonstrated a survival advantage and fewer repeat revascularization procedures with an initial surgical strategy. This review summarizes the current state of evidence comparing the effectiveness and safety of coronary artery bypass grafting and percutaneous coronary intervention in diabetic patients.

[The Italian Survey on Cardiac Rehabilitation - 2013 (ISYDE.13-Directory): national availability and organization of cardiac rehabilitation facilities]. / Italian Survey on Cardiac Rehabilitation (ISYDE.13-Directory): report su strutture, organizzazione e programmi di cardiologia riabilitativa in Italia.

BACKGROUND: The Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (GICR-IACPR) and the Italian Society of Cardiologists of Accredited Hospitals (SICOA) developed the ISYDE.13 survey with the purpose to take a detailed snapshot of number, distribution, facilities, staffing levels, organization, and program details of cardiac rehabilitation (CR) units in Italy. METHODS: The study was carried out using a web-based questionnaire running on the GICR-IACPR website for 4 weeks from September 2 to 29, 2013. RESULTS: Out of 221 CR centers existing in Italy (+14% vs 2008), 191 (86%) participated in the survey. On a national basis, there is a CR unit every 268 852 inhabitants. The majority of CR units are located in public hospitals (57.1%), the remaining 42.9% in private hospitals; 130 CR centers (68%) provide inpatients care and account for 3527 beds (5.9 per 100 000 inhabitants): of these 374 are day-hospital beds and 408 are sub-intensive beds. Forty-one of the Italian in-hospital CR centers offer also outpatient programs and 61 centers (32%) offer only outpatient CR programs; 131 of the CR units (68.6%) are linked to dedicated cardiology divisions and in 77% of cases the head is a cardiologist. Home-based programs are offered by 9 centers (4.7%) and CR programs with telecare supervision by 16 (8.4%). Long-term secondary prevention follow-up programs are provided by 94 of CR services (49.2%). During one week of activity, the 191 centers completed 1335 inpatient CR programs and 971 outpatient CR programs. According to these data, it may be assumed that in Italy approximately 100 000 patients are referred annually to CR programs. CONCLUSIONS: ISYDE.13 showed an incremental trend of CR provision in Italy, particularly in outpatient programs. However, at present, the national network of CR units covers only one third of the potential requirements defined by current secondary prevention recommendations.

Incidence and clinical presentation of myocardial ischemia in patients with chronic CAD in Italy: the ISPICA survey study.

AIM: This survey study was performed to provide an overall picture on the incidence of symptoms, with or without typical angina, in the real-life clinical practice and to identify clinical factors associated with atypical presentations in an unselected population of consecutive outpatients with chronic coronary artery disease (CAD). METHODS: Thirty-six cardiology units located in different geographic areas of Italy enrolled a total of 1475 outpatients (73.6% men and 26.3% women; mean age 71 ±â€Š10 and 67 ±â€Š9 years in men and women, respectively) with a documented diagnosis of chronic CAD. Each patient underwent a medical history, with a detailed investigation as to the presence of typical angina or ischemic equivalents defined as sensation of chest pressure, or arm, neck, or jaw pain. RESULTS: At admission, symptoms suggesting ischemic episodes were reported by 24.4% of patients. After an in-depth medical history collection by the specialist, the prevalence of combined typical or atypical myocardial ischemic episodes was ascertained in 39.3% of the overall population.Typical angina was reported by 13.6% of men and 22.7% of women (P < 0.0001), whereas ischemic equivalents were present in 7.3 and 12.9% of male and female patients, respectively (P < 0.001). Previous coronary artery bypass grafting (CABG; P < 0.001) and fewer medical visits by cardiologists (P = 0.02) were independent predictors of atypical presentations. CONCLUSION: The ISPICA study shows that in an Italian population of real-world patients with chronic CAD, ischemic episodes, with both typical and atypical presentation, are still present in nearly 50% of patients, despite optimal medical therapy, and that atypical presentations of angina are linked to fewer visits by specialists and previous CABG. These findings would suggest to encourage patients with chronic CAD and general practitioners to consider more frequent cardiology specialist visits and to take into account the possibility of atypical presentations, particularly in patients with previous CABG.

Clinical characteristics and course of patients with diabetes entering cardiac rehabilitation.

BACKGROUND: Using data from the Italian SurveY on carDiac rEhabilitation (ISYDE-2008), this study provides insight into the level of implementation of Cardiac Rehabilitation (CR) in patients with diabetes. METHODS: Data from 165 CR units were collected online from January 28th to February 10th, 2008. RESULTS: The study cohort consisted of 2281 patients (66.9 ± 12 yrs); 475 (69.7 ± 10 yrs, 74% male) patients with diabetes and 1806 (66.2 ± 12 yrs, 72% male) non-diabetic patients. Compared to non-diabetic patients, patients with diabetes were older and showed more comorbidity [myocardial infarction (32% vs. 19%, p < 0.0001), peripheral artery disease (10% vs. 5%, p < 0.0001), chronic obstructive pulmonary disease (20% vs. 11%, p < 0.0001), chronic kidney disease (20% vs. 6%, p < 0.0001), and cognitive impairment (5% vs. 2%, p = 0.0009), respectively], and complications during CR [re-infarction (3% vs. 1%, p = 0.04), acute renal failure (9% vs. 4%, p < 0.0001), sternal revision (3% vs. 1%, p = 0.01), inotropic support/mechanical assistance (7% vs. 4%, p = 0.01), respectively]; a more complex clinical course and interventions with less functional evaluation and a different pattern of drug therapy at hospital discharge. Notably, in 51 (3%) and in 104 (6%) of the non-diabetic cohort, insulin and hypoglycemic agents were prescribed, respectively, at hospital discharge from CR suggesting a careful evaluation of the glycemic metabolism during CR program, independent of the diagnosis at the admission. Mortality was similar among diabetic compared to non-diabetic patients (1% vs. 0.5%, p = 0.23). CONCLUSIONS: This survey provided a detailed overview of the clinical characteristics, complexity and more severe clinical course of diabetic patients admitted to CR.

ISMAR-study presentation: in-hospital epidemiology and clinical management of respiratory and cardiac comorbidities in cardiac and respiratory disease units.

BACKGROUND: Cardiovascular and respiratory diseases are leading causes of morbidity and their co-occurrence has important implications in mortality and other outcomes. Even the most recent guidelines do not reliably address clinical, prognostic, and therapeutic concerns due to the overlap of respiratory and cardiac diseases. STUDY OBJECTIVES AND DESIGN: In order to evaluate in the reality of clinical practice the epidemiology and the reciprocal impact of cardio-pulmonary comorbidity on the clinical management, diagnostic workup and treatment, 1,500 cardiac and 1,500 respiratory inpatients, admitted in acute and rehabilitation units, will be enrolled in a multicenter, nationwide, prospective observational study. For this purpose, each center will enroll at least 50 consecutive patients. At discharge, data analysis will be aimed at the definition of cardiac and pulmonary inpatient comorbidity prevalence, demographic characteristics, length of hospital stay, and risk factors, taking into account also procedures, pharmacological and non-pharmacological treatment, and follow up in patients with cardio-respiratory comorbidity. CONCLUSIONS: The purely observational design of the study aims to give new relevant information on the assessment and management of overlapping patients in real life clinical practice, and new insight for improvement and implementation of current guidelines on the management of individual diseases.

Cardiac rehabilitation in chronic heart failure: data from the Italian SurveY on carDiac rEhabilitation (ISYDE-2008).

BACKGROUND: Using data from the Italian SurveY on carDiac rEhabilitation (ISYDE-2008), this study provides insight into the level of implementation of cardiac rehabilitation in patients with chronic heart failure (CHF). METHODS: Data from 165 Italian cardiac rehabilitation units were collected online from 28 January to 10 February 2008. RESULTS: The study cohort consisted of 2281 patients (66.9 ±â€Š11.8 years): 285 (71.3 ±â€Š12.2 years, 66% male) CHF patients and 1996 (66.3 ±â€Š11.6 years, 74% male) non-CHF patients. Compared with non-CHF, CHF patients were older, showed more comorbidity, had lower left ventricular (LV) ejection fraction and reduced access to functional evaluation, underwent more complications during cardiac rehabilitation, and had longer length of in-hospital stay. CHF patients were also more likely to be transferred to ICU (9 versus 3%, P < 0.0001), and less likely to be discharged home (85 versus 92%, respectively, P < 0.0001). Also, discharge prescriptions were significantly different from those of non-CHF patients. Finally, CHF patients had higher mortality during cardiac rehabilitation (1.7 versus 0.5%, P = 0.01). After adjusting for age, ejection fraction, comorbidity, previous interventions and complications during cardiac rehabilitation, multivariate logistic analysis showed that not performing any of the physical performance tests [odds ratio (OR) = 7.0, 95% confidence interval (CI), 1.9-25.8, P = 0.003], acute respiratory failure (OR = 2.3, 95% CI, 1.3-4.1, P = 0.002), acute kidney insufficiency or worsening of chronic kidney disease (OR = 2.9, 95% CI, 1.5-5.6, P = 0.001) and worsening of cognitive impairment (OR = 3.7, 95% CI, 2.0-6.7, P < 0.001) were significant predictors of death in CHF patients. CONCLUSION: The ISYDE-2008 survey provided a detailed snapshot of cardiac rehabilitation in CHF patients, and confirmed the complexity and the more severe clinical course of these patients during cardiac rehabilitation.

Prevalence and 1-year prognosis of transient heart failure following coronary revascularization.

The occurrence of heart failure during the whole pre-discharge course of coronary revascularization, as far as its influence on subsequent prognosis, is poorly understood. The present study examined the effect of transient heart failure (THF) developing in the acute and rehabilitative phase on survival after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI). Patients in the Italian survey on cardiac rehabilitation and secondary prevention after cardiac revascularization (ICAROS) were analyzed for THF, the latter being defined either as signs and symptoms consistent with decompensation or cardiogenic shock. ICAROS was a prospective, multicenter registry of 1,262 consecutive patients discharged from 62 cardiac rehabilitation (CR) facilities, providing data on risk factors, lifestyle habits, drug treatments, and major cardiovascular events (MACE) during a 1-year follow-up. Records were linked to the official website of the Italian Association of Cardiovascular Prevention and Rehabilitation (GICR-IACPR). The overall prevalence of pre-discharge THF was 7.6%, with 69.8% of cases in acute wards, 22.9% during CR, and 7.3% in both settings. THF affected more frequently patients with chronic cardiac condition (42.7 vs. 30.6%; p < 0.05), age ≥75 years (33.3 vs. 23.1%; p < 0.005), COPD (19.8 vs. 12.3%; p < 0.05), and chronic kidney disease (17.7 vs. 7%; p < 0.001). After discharge, THF patients showed good maintenance rates of RAAS modulators (90.6%) and beta-blockers (83.3%), while statin therapy significantly decreased from 81.3 to 64.6% (p < 0.05). The pursuit of secondary prevention targets, as far as self-reported drug adherence, was not different among groups. Patients with THF had increased 1-year mortality (8.3 vs. 1.6%, p < 0.001). Moreover, THF independently predicted adverse outcome with OR for recurrent events (mainly further episodes of decompensation) of 2.4 (CI 1.4-4.3). Patients who experienced THF after coronary revascularization had increased post-discharge mortality and cardiovascular events. Hemodynamic instability, rather than recurrent myocardial ischemia, seems to be linked with worse prognosis.

Effective secondary prevention through cardiac rehabilitation after coronary revascularization and predictors of poor adherence to lifestyle modification and medication. Results of the ICAROS Survey.

BACKGROUND AND AIM: Secondary prevention is a priority after coronary revascularization. We investigate the impact of a cardiac rehabilitation (CR) program on lifestyle, risk factors and medication modifications and analyze predictors of poor behavioral changes and events in patients after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS: Multicenter (n=62), prospective, longitudinal survey in post-CABG or -PCI consecutive patients after a comprehensive CR program. Cardiac risk factors, lifestyle habits, medication and 1 year cardiovascular events were collected. Logistic regression analyzed the association between risk factors, events and predictors of non-adherence to treatment and lifestyle. RESULTS: At 1 year, of the 1262 patients (66 ± 10 years, CABG 69%, PCI 31%), 94% were taking antiplatelet agents (vs. 91.8% at CR admission and 91.7% at CR discharge, p=ns), 87% statins (vs. 67.5%, p<.0001, and 86.3%, p=ns), 80.7% beta-blockers (vs. 67.4%, p<.0001, and 88.8%, p=ns), and 81.1% ACE inhibitors (vs. 57.5% p<.0001, and 77.7%, p=ns). 89.9% of the patients showed good adherence to treatment, 72% adhered to diet and 51% to exercise recommendations; 74% of smokers stopped smoking. Younger age was predictive of smoking resumption (OR 8.9, CI 3.5-22.8). Pre-event sedentary lifestyle (OR 3.3, CI 1.3-8.7) was predictive of poor diet. Older patients with comorbidity (OR 3.1; CI, 1.8-5.2) tended to persist in sedentary lifestyle and discontinue therapy and diet recommendations. Age, diabetes, smoking and PCI indication were predictors of recurrent CV events which occurred in 142 patients. CONCLUSION: Participation in CR results in excellent treatment after revascularization, as well as a good lifestyle and medication adherence at 1 year and provides further confirmation of the benefit of secondary prevention. Several clinical characteristics may predict poor behavioral changes.

[ICAROS (Italian survey on CardiAc RehabilitatiOn and Secondary prevention after cardiac revascularization): temporary report of the first prospective, longitudinal registry of the cardiac rehabilitation network GICR/IACPR]. / ICAROS (Italian survey on CardiAc RehabilitatiOn and Secondary prevention after cardiac revascularization): primo bilancio di una grande esperienza scientifica del network riabilitativo GICR/IACPR.

The Italian survey on CardiAc RehabilitatiOn and Secondary prevention after cardiac revascularization (ICAROS) was a multicenter, prospective, longitudinal survey carried out by the Italian Association on Cardiovascular Prevention and Rehabilitation (GICR/IACPR) in patients on completion of a CR program after coronary artery by pass grafting (CABG) and percutaneous coronary intervention (PCI). The aim was to evaluate in the short and medium-term: i) the cardioprotective drug prescription, modification and adherence; ii) the achievement and maintenance of recommended lifestyle targets and risk factor control and their association with cardiovascular events; iii) the predictors of non-adherence to therapy and lifestyle recommendations. The ICAROS results offers a portrait of the "real world" of clinical practice concerning patients after CABG and PCI, and stresses the need to improve secondary prevention care after the index event: many patients after revascularization leave the acute wards without an optimal prescription of preventive medication but the prescription of cardiopreventive drugs and risk factors control is excellent after completion of a CR program. Following CR, the maintenance of evidence-based drugs and lifestyle adherence at one year is fairly good as far as the target goals of secondary prevention are concerned, but to investigate the influence of CR on long-term outcome longer-term studies are required. Last, but not least, ICAROS shows that some characteristics (PCI as index event, living alone, poor eating habits or smoking in young age, and old age, in particular with comorbidities) may identify patients with poor behavioral modification in the medium-term follow-up and in these patients further support may be warranted. In conclusion, participation in CR results in excellent treatment after revascularization, as well as a good lifestyle and medication adherence at 1 year and provides further confirmation of the the benefit of secondary prevention.

Gender differences in cardiac rehabilitation programs from the Italian survey on cardiac rehabilitation (ISYDE-2008).

PURPOSE: In recent years epidemiological and clinical evidence has shown gender disparities in several aspects of cardiovascular disease. Aim of this study was to identify gender differences in the clinical profile and management of patients admitted to cardiac rehabilitation (CR) programs. POPULATION: Patients enrolled in the ISYDE-2008 survey were considered. RESULTS: The ISYDE-2008 survey enrolled 2281 patients; 604 (26.5%) were women. Compared to men, women were older (mean age 70.8 ± 11.5 versus men's 65.6 ± 11.5 years), had less traditional risk factors (low cardiovascular risk profile in 45.3% of women and 38.0% of men, p=0.003), were more frequently admitted after valvular surgery and heart failure, but less for post-acute myocardial infarction and post-by-pass procedure. Women were more frequently admitted to an in-hospital rehabilitation program. Women showed a more complicated acute and rehabilitative course, with 63.2% of them having at least one complication during acute-phase, compared to 52.5% of men, and 48.3% during rehabilitation, compared to 35.0% of men (p<0.0001). During rehabilitation, women underwent exercise tests less frequently, except for the 6-minute walking test. At discharge, women received ACE-inhibitors/ARBs, ß-blockers, statins, omega-3 fatty acids, antiplatelet agents less frequently, but more frequently digoxin, amiodarone, diuretics, oral anticoagulants, insulin and anti-depressive drugs. The duration of the rehabilitation program was longer for women. Mortality was very low in the entire population. CONCLUSIONS: Women are less frequently admitted to CR than men. They are older and show a greater cardiovascular burden. Women are more likely to be enrolled in CR after valvular surgery and heart failure than men.

[Standards and outcome measures in cardiovascular rehabilitation. Position paper GICR/IACPR]. / Requisiti e indicatori in cardiologia riabilitativa: documento di consenso del GICR/IACPR.

Despite major improvements in diagnostics and interventional therapies, cardiovascular diseases remain a major health care and socio-economic problem in Italy. Costs and resources required are increasing in close correlation to both the improved quality of care and to the population ageing. There is an overwhelming evidence of the efficacy of cardiac rehabilitation (CR) in terms of reduction in morbidity and mortality after acute cardiac events. CR services are by definition multi-factorial and comprehensive. Furthermore, systematic analysis and monitoring of the process of delivery and outcomes is of paramount importance. The aim of this position paper promoted by the Italian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR) is to provide specific recommendations to assist CR staff in the design, evaluation and development of their care delivery organization. The position paper should also assist health care providers, insurers, policy makers and consumers in the recognition of the quality of care requirements, standards and outcome measure, quality and performance indicators, and professional competence involved in such organization and programs. The position paper i) include comprehensive CR definition and indications, ii) describes priority criteria based on the clinical risk for admission to both inpatient or outpatient CR, and iii) defines components and technological, structural and organizing requirements for inpatient or outpatient CR services, with specific indicators and standards, performance measures and required professional skills. A specific chapter is dedicated to the requirements for highly specialized CR services for patients with more advanced cardiovascular diseases.

Postoperative anemia and exercise tolerance after cardiac operations in patients without transfusion: what hemoglobin level is acceptable?

BACKGROUND: Restrictive transfusion strategies have been suggested for cardiac surgical patients, leading to various degrees of postoperative anemia. This study investigates the exercise tolerance during rehabilitation of cardiac surgical patients who did not receive transfusions, with respect to their level of postoperative anemia. METHODS: This observational study started in January 2010 and ended in May 2010 in 2 rehabilitation hospitals and 2 large-volume cardiac surgical hospitals. The study population was 172 patients who did not receive transfusions during cardiac surgical operations with cardiopulmonary bypass and subsequently followed a rehabilitation program in 1 of the 2 rehabilitation hospitals. No patient received a transfusion during the rehabilitation hospital stay. Exercise tolerance was measured using the 6-minute walk test at admission and discharge from the rehabilitation hospital. The level of anemia at admission to the rehabilitation hospital was tested as an independent predictor of exercise tolerance within a model inclusive of other possible confounders. RESULTS: Patients with values of hemoglobin less than 10 g/dL at admission to the rehabilitation institute had a significantly (p=0.007) worse performance on the 6-minute walk test than patients with higher values (258±106 vs 306±101 meters). This functional gap was completely recovered during a normal rehabilitation period. Other independent factors affecting exercise tolerance were age, sex, and albumin concentration. CONCLUSIONS: Postoperative anemia with hemoglobin levels of 8 to 10 g/dL is well tolerated in patients who have not received a transfusion and induces only a transient impairment of exercise tolerance.

Late postoperative atrial fibrillation after cardiac surgery: a national survey within the cardiac rehabilitation setting.

AIMS: The aims of this study were to determine the incidence and clinical predictors of new-onset and recurrent late postoperative atrial fibrillation (POPAF) in a large cohort of patients who underwent cardiac rehabilitation programs (CRPs) after discharge from surgery units, and the association between late POPAF and cardiovascular morbidity and mortality in the medium term. METHODS: The ISYDE and ICAROS registries were two multicenter, prospective studies carried out by the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR-GICR), providing clinical information on consecutive patients completing CRP in 165 facilities. Patients following cardiac surgery were considered, with the exclusion of those with persistent POPAF at discharge from the surgery units. A total of 2256 patients following cardiac surgery were enrolled (isolated coronary surgery 62.9%, valve interventions 16%, combined surgery 21.1%). RESULTS: The mean age of patients was 67 ± 10 years, and the observation period 13 ± 20 days. During CRP, POPAF occurred in 241 (10.7%) patients, with 4.4% new-onset and 6.3% recurrent cases, respectively. In the logistic regression model, valve surgery (P < 0.05), a history of early POPAF (P < 0.001), and the presence of postoperative ventricular arrhythmias (P < 0.05) independently predicted the occurrence of late POPAF. Lack of prescription of cardioprotective drugs was not associated with late POPAF. Late POPAF increased the 1-year risk of cardiovascular events after CRP, mainly episodes of decompensated heart failure. CONCLUSION: A high level of suspicion for late POPAF, after discharge from surgery units, should be maintained due to the risk of occurrence, the low antiarrhythmic effect of common cardioprotective drugs and the impact on cardiovascular prognosis.

Cardiac rehabilitation in very old patients: data from the Italian Survey on Cardiac Rehabilitation-2008 (ISYDE-2008)--official report of the Italian Association for Cardiovascular Prevention, Rehabilitation, and Epidemiology.

BACKGROUND: Using data from the Italian SurveY on carDiac rEhabilitation-2008 (ISYDE-2008), this study provides insight into the level of implementation of cardiac rehabilitation (CR) in very old cardiac patients. METHODS: Data from 165 CR units were collected online from January 28 to February 10, 2008. RESULTS: The study cohort consisted of 2,281 patients (66.9 ± 11.8 years): 1,714 (62.4 ± 9.6 years, 78% male) aged<75 years and 567 aged ≥ 75 years (80.8 ± 4.5 years, 59% male). Compared with adults, a higher percentage of older patients were referred to CR programs after cardiac surgery or acute heart failure and showed more acute phase complications and comorbidity. Older patients were less likely discharged to home, more likely transferred to nursing homes, or discharged with social networks activation. Older patients had higher death rate during CR programs (odds ratio = 4.6; 95% confidence interval = 1.6-12.9; p = .004). CONCLUSION: The ISYDE-2008 survey provided a detailed snapshot of CR in very old cardiac patients.