EWHETA (Eat Well for a HEalthy Third Age) Project: novel foods to improve the nutrition in the elderly people.

Cardiovascular diseases (CVD) are the leading cause of mortality. However, by treating modifiable cardiovascular risk factors and following a healthy diet as the Mediterranean diet, we have opportunity to prevent CVD. In the EWHETA (Eat Well for a HEalthy Third Age) Project, our goal has been to develop novel foods ("Mediterranean Lasagne", MLs) in versions all nutritionally complete and well balanced in terms of calories, whole carbohydrates, fibers, source of vegetable proteins, and vegetable fats. MLs can be easy prepared at home (inexpensively) and used as fresh food or can be pre-prepared and used in residences for elderly people or in health care residencies. The project has saw the alliance between nutritionists and food and sensor scientists and the active involvement of older people in tasting the novel foods to achieve the final tasty versions of the MLs. We think that the nutritional components of these novel foods and its well-accepted taste, insert in a healthy diet and life style (fundamental aspects at every age), and could contribute to improve diet in the elderly people and prevent malnutrition.

REHAL®, a telemedicine platform for home cardiac rehabilitation.

AIM: The new REHAL® platform manages home-based cardiac rehabilitation programs without most of the drawbacks of an earlier E-Remedy EC proposal. The proposal is based on the awareness that safe home rehabilitation is only possible in the post-hospital phase when the patient no longer needs direct control by medical staff and has become accustomed to the technological set-up. METHODS: The platform is composed of a web-based database and client software (Ergomonitor), which allows health staff to manage the sessions without a real-time connection and legal liability. Ergomonitor permits the complete management of a bike (training session settings, web transmission and data recording) by a serial connection to a PC. Patients own their data and may approve the access of health personnel to evaluate the results and introduce longitudinal ambulatory information together with updated physical activity protocols. The health service does not bear the cost of the technological set-up. Ergomonitor acquires and records heart rate, loads, pedalling speed and other parameters of interest (i.e., arterial pressure) and forwards data to a remote database. Health personnel can modify time by time the scheduled exercise settings, analyse the results of each session and compare session by session. RESULTS: The platform is actually used in hospital, gymnasium and home context. More than 1000 subjects have been enrolled in the protocol, with a very good appreciation. CONCLUSION: The first experience of REHAL® (six months, more than 1000 enrolled patients) highlights the positive aspects of the solution: the patients are very satisfied with the continuity of the rehabilitation programme and the clinicians are very satisfied they can follow their patient population longitudinally and with a personalized protocol.

Low ankle-brachial index predicts an adverse 1-year outcome after acute coronary and cerebrovascular events.

BACKGROUND: Low ankle-brachial Index (ABI) identifies patients with symptomatic and asymptomatic peripheral arterial disease. The aim of this study was to correlate ABI value (normal or low) with 1-year clinical outcome in patients hospitalized for acute coronary syndromes or cerebrovascular diseases (CVD). METHODS: ABI was measured in consecutive patients hospitalized because of acute myocardial infarction, unstable angina, stroke or transient ischemic attack (TIA). An ABI lower than or equal to 0.90 was considered abnormal. The primary outcome of the study was the composite of non-fatal acute myocardial infarction, non-fatal ischemic stroke, and death from any cause during the year following the index event. RESULTS: An abnormal ABI was found in 27.2% of 1003 patients with acute coronary syndromes, and in 33.5% of 755 patients with acute CVD. After a median follow-up of 372 days, the frequency of the primary outcome was 10.8% (57/526) in patients with abnormal ABI and 5.9% (73/1232) in patients with normal ABI [odds ratio (OR) 1.96; 95% CI 1.36-2.81]. Death was more common in patients with abnormal ABI (OR 2.05; 95% CI 1.31-3.22). Cardiovascular mortality accounted for 81.7% of overall mortality. ABI was predictive of adverse outcome after adjustment for vascular risk factors in the logistic regression analysis (OR 1.93; 95% CI 1.24-3.01). The predictive value of ABI was mainly accounted for by patients hospitalized for acute coronary syndromes (adverse outcome: 12.8% in patients with abnormal ABI and 5.9% in patients with normal ABI, OR 2.35; 95% CI 1.47-3.76). CONCLUSIONS: An abnormal ABI can be found in one-third of patients hospitalized for acute coronary or cerebrovascular events and is a predictor of an adverse 1-year outcome.

[Role of echocardiography in the different stages of natural history of heart failure]. / Il ruolo dell'ecocardiogramma nelle diverse fasi della storia naturale dello scompenso cardiaco.

The prognostic value of echocardiographic findings in patients with heart failure is well known. In contrast, few studies have addressed the changing significance of echocardiographic findings during the natural history of heart failure. Ejection fraction is useful for stratifying the cardiac risk in the early phase of the disease, but a further risk stratification among patients with ejection fraction < 30%, < 25%, or < 20% has not been observed. On the other hand, the identification of a "restrictive" left ventricular filling pattern allows to select patients with poor prognosis among those with advanced heart failure. In patients with mild to moderate heart failure, the prognostic risk should be assessed by ejection fraction and left ventricular filling pattern integrated with other echocardiographic findings such as pulmonary venous flow pattern, right ventricular function, and transmitral flow pattern changes after exercise. In conclusion, the prognostic significance of echocardiographic findings varies during the natural history of heart failure, and therefore may differ in the way it influences the management and therapeutic approach.

[Neurologic events after heart surgery: the need for a more thorough preoperative assessment]. / Eventi neurologici post-cardiochirurgia: la necessità di una valutazione pre-operatoria più approfondita.

The occurrence of neurologic complications after cardiac surgery varies widely and has increased during the last years for several reasons: older age of patients, higher prevalence aortic valve replacement, and more careful diagnosis of cerebral ischemia. Recent studies showed that embolic mechanism is involved in most patients, and two main clinical outcomes are detectable: type I outcome, consisting of TIA and ischemic stroke, and type II outcome, consisting of cognitive defects and seizures. The overall prevalence of neurologic complications after cardiac surgery is nearly 16% and suggests the need of systematic preoperative evaluation of patients for identifying those with high risk and the individualization of the surgical strategy. The preoperative work-up should include two-dimensional echocardiography, transesophageal echocardiography (for detecting patients with ascending aortic lesion who need alternative surgical strategies, i.e. different site of cross clamping, cannulation, and proximal anastomosis of the venous graft), Doppler ultrasound of carotid arteries (for identifying those candidates to combined surgery), and psychobehavioural evaluation (for selecting patients with cognitive deterioration who could be treat by off-pump surgery). In conclusion, a preoperative stratification of the neurologic risk, and a more careful postoperative monitoring should be mandatory for preventing and adequately treating neurologic complications of cardiac surgery.

[Interactions between physical training and pharmacologic treatment in the prevention of ventricular remodelling in patients with left ventricular dysfunction]. / Interazione tra training fisico e terapia farmacologica nella prevenzione del rimodellamento ventriculare nel paziente con disfunzione ventricolare sinistra.

Exercise training is a recommended treatment for chronic heart failure. So far, randomized clinical trials showed that exercise training can improve peak oxygen consumption and reduce neurohormonal and adrenergic activation, nevertheless, the effect on left ventricular remodeling is still controversial. The present study reviewed the randomized clinical trials that investigated the effects of exercise training on left ventricular remodeling. After a first study that showed a worsening of left ventricular function, the following studies showed a neutral effect, and finally, the ELVD-CHF study showed both a reduction in left ventricular dilation and an improvement of ejection fraction. These different results could be explained by the pharmacological treatment before exercise training: in the first study patients did not assume ACE-inhibitors, in the following studies most patients assumed ACE-inhibitors and, finally, in ELVD-CHF, patients assumed ACE-inhibitors and about one fifth of them were on beta-blockers too. In conclusion, exercise training may improve peak oxygen consumption and reduce neurohormonal and adrenergic activation in patients with chronic heart failure. Further studies are necessary to assess if exercise training, associated with ACE-inhibitors and beta-blockers, can reverse or prevent left ventricular remodeling.

Cardiologic complications of subarachnoid hemorrhage.

Cardiac complications are frequent in patients with subarachnoid hemorrhage (SAH). They include ECG abnormalities, cardiac arrhythmias, myocardial damage, and neurogenic pulmonary edema. The pathophysiology of these abnormalities is related to an imbalance of the autonomic cardiovascular control and to increased circulating and local myocardial tissue catecholamines. Cardiac involvement is more common in patients with severe neurological deficits and it may increase the morbidity associated with SAH because of the occurrence of life-threatening arrhythmias or pulmonary edema. Monitoring of cardiac events in patients with SAH might result in a better understanding of their clinical outcome, as well as providing a basis for specific treatment capable of preventing myocardial necrosis and cardiac arrhythmias.

[Complicated atherosclerosis of the ascending aorta as a cause of recurrent cerebral embolisms in young adulthood]. / Aterosclerosi complicata dell'aorta ascendente come causa di embolie cerebrali recidivanti in età giovanile.

The authors report the case of a young woman (47 yrs old) who underwent cardiac evaluation for recurrent unexplained cerebral transient ischemic attacks. In the search for a source of embolization, a transesophageal echocardiography was performed and this revealed an atherosclerotic complex plaque of the ascending aorta as the sole potential source of cerebral embolism, while the remaining aortic wall was normal. The atheroma showed a calcific portion inserted on the aortic wall and a mobile hypoechogenic portion protruding into the aortic lumen. Furthermore, we found increased levels of cholesterol, fibrinogen and plasmatic homocysteine after methionine loading. Atherosclerotic lesions of the aortic arch are a rare cause of embolism in young patients with stroke, but they can lead to important complications such as thrombosis and embolism, similar to atherosclerotic lesions in elderly patients. The mechanisms that predispose for atherosclerosis of the aorta in young patients are still unknown. It was recently reported that not only hypercholesterolemia but also elevated levels of fibrinogen and homocysteine are independent risk factors for cerebrovascular disease. It is possible that these factors may be important predictors of atherosclerosis of the thoracic aorta in young patients, but more clinical data are still necessary. This case report confirms the importance of performing a TEE study and examining the cholesterol, fibrinogen and homocysteine plasmatic concentrations in all of young patients with unexplained stroke or transient ischemic attacks.

Prophylaxis of thromboembolic events in congestive heart failure.

In patients with heart failure the incidence of thromboembolism is 0.9-5.5%/year (mean 1.9%/year), but no randomized studies are available to support the indication for anticoagulant therapy in those patients. Atrial fibrillation and previous thromboembolic events seem to be the major risk factors, whereas the effect of ventricular dysfunction has not been independently evaluated; nonetheless several studies suggest that thromboembolism is more likely among those patients with lower ejection fraction and lower peak exercise oxygen consumption. Anticoagulant therapy seems to be indicated also in patients with left ventricular aneurysm with mobile and protruding thrombi. Several studies of patients with dilated cardiomyopathy show that the incidence of thromboembolism ranges from 1.6 to 4.5%/year in patients not treated with anticoagulants, while it is virtually absent in anticoagulated patients. The clinical opportunity of long-term anticoagulant treatment in heart failure patients should be weighted not only on the clinical markers of thromboembolic risk, but also on the relative risk/benefit ratio of the single patient.

[Prognostic significance of normal exertion myocardial scintigraphy in asymptomatic subjects with abnormal ergometric test]. / Significato prognostico della scintigrafia miocardica da sforzo negativa in soggetti asintomatici con positività del test ergometrico.

AIM OF THE STUDY: ST-segment depression on exercise stress test (EST) is an independent predictor of future cardiac events. Nevertheless, in apparently healthy subjects without angina the occurrence of false positive results is frequent. Thallium myocardial imaging (TMI) may improve diagnostic and prognostic accuracy of EST. The aim of the present study was to assess the role of a normal exercise TMI for excluding a coronary artery disease in subjects with asymptomatic abnormal EST. METHODS: Subjects referred for TMI from 1/1980 to 5/1991 with an abnormal EST and without history of ischemic, congenital, or valvular heart disease or abnormal resting ECG were included into the study. 137 subjects (98 men, 39 women), mean age 53 +/- 8 yrs (range 37-74 yrs) were enrolled and followed-up for 6.4 yrs (range 3-13 yrs). Clinical indications for EST were: atypical chest pain in 56 (41%) cases, check-up in 52 (38%) cases, sport activity in 29 (19%) cases. All subjects had a maximal symptom-limited EST. Abnormal EST was defined by a horizontal or downsloping > or = 1 mm or upsloping > or = 1.5 mm ST-segment depression at 0.08 sec. from J-point, in at least 2 leads. EST was discontinued for fatigue in 129 (94%) cases, for ST-segment depression > or = 3 mm in 8 (6%) cases. None had chest pain during EST. All subjects selected for the study had normal TMI. Criteria for normal TMI were homogeneous Thallium uptake on postexercise images and a normal washout in the delayed images by qualitative analysis. Planar images were obtained in 118 (86%) cases, and tomographic SPECT images in 19 (14%). RESULTS: During the follow-up period no subject died for cardiac causes and only 9 subjects (1%/yr) had non fatal cardiac events: 4 (0.45%/yr) had a non fatal myocardial infarction (one subject had coronary angiography for postinfarction angina and subsequent 3 coronary bypass graft for multivessels disease), 2 subjects (0.2%/yr) became symptomatic for unstable angina (both had coronary angiography and subsequent PTCA for critical left main coronary artery stenosis) and 3 (0.34%/yr) developed stable angina (one had coronary angiography and subsequent bypass graft for a critical stenosis of left main coronary artery). Four further subjects died for non cardiac events. Comparing clinical data and TE results of subjects with and without coronary events, we found that some parameters were related to a higher incidence of cardiac events: hypertension (78% vs 31% respectively in subjects with and without cardiac events, p < 0.01), hypercholesterolemia (33% vs 4.7%, p < 0.01); > or = 2 conventional coronary risk factors (56% vs 17%, p < 0.02); and a slow regression of abnormal ST-segment depression during recovery (2.8 +/- 2 vs 1.5 +/- 1 min, p < 0.01). CONCLUSIONS: In conclusion, in subjects without typical chest pain and with abnormal asymptomatic EST, a normal exercise TMI identifies subjects with very low risk of future cardiac events (1%/yr). Our data suggest that subjects with abnormal asymptomatic EST should be routinely submitted to exercise TMI.

Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy.

BACKGROUND AND PURPOSE: Patients with symptomatic carotid stenosis who are candidates for carotid endarterectomy are at high short- and long-term risk of coronary events. To stratify patients at different risk of coronary events we investigated the usefulness of a noninvasive preoperative cardiological workup. METHODS: We studied 172 consecutive patients admitted to the Neurosurgical Department for symptomatic high-grade (70% to 99%) carotid stenosis (age, 42 to 74 years; mean, 57.8 years). Patients without history of coronary artery disease (CAD) and able to exercise were submitted to exercise electrocardiographic testing (EET) and, if abnormal, to exercise thallium myocardial imaging (TMI). Patients were classified into four groups: group 1, patients without CAD: no history of CAD, normal EET, or normal TMI in the presence of indeterminant EET (n = 93, 54%); group 2, patients with silent CAD: no history of CAD and concordant abnormal EET and TMI (n = 28, 16%); group 3, patients unable to exercise: no history of CAD and inability to perform adequate EET because of previous stroke or claudication (n = 29, 17%); and group 4, patients with known CAD: history of angina or myocardial infarction (MI) (n = 22; 13%). RESULTS: The four groups were comparable in regard to age, sex, and computed tomographic scan of the brain. The prevalence of stroke was higher in patients unable to exercise; hypercholesterolemia was more frequent in patients with known CAD. During the perioperative period (< or = 30 days after carotid endarterectomy), coronary events occurred in 3 patients (2%): fatal MI in 2 patients in group 4 and 1 patient in group 3. One hundred percent of patients were followed up for 6.2 years. Coronary events occurred in 23 of the 168 patients discharged from the hospital (13.7%); these were fatal in 11 (6.5%): 3 patients of group 1 (3%; sudden death in 2, fatal MI in 1), 8 patients of group 2 (29%; fatal MI in 5, unstable angina in 3), 8 patients of group 3 (28%; fatal MI in 4, nonfatal MI in 4), and 4 patients of group 4 (18%; fatal MI in 2, sudden death in 1, unstable angina in 1). Kaplan-Meier estimated curves of survival free from fatal and nonfatal coronary events were 97%, 51%, 49%, and 59%, respectively (P < .001, group 1 versus groups 2 and 3; P < .01, group 1 versus group 4). CONCLUSIONS: Among patients undergoing carotid endarterectomy, coronary events occurred twice as often as cerebral recurrences. A preoperative noninvasive cardiac investigation, including EET, can adequately identify groups of patients with diverse short- and long-term prognoses. In addition to patients with known CAD, those with silent CAD or who are unable to exercise represent, without the need of further investigation, groups at high risk of coronary events in long-term follow-up.