The Fenice project to evaluate and improve the quality of healthcare in high-dependency care units: results after the first year.

High-Dependency care Units (HDUs) have been introduced worldwide as intermediate wards between Intensive Care Units (ICUs) and general wards. Performing a comparative assessment of the quality of care in HDU is challenging because there are no uniform standards and heterogeneity among centers is wide. The Fenice network promoted a prospective cohort study to assess the quality of care provided by HDUs in Italy. This work aims at describing the structural characteristics and admitted patients of Italian HDUs. All Italian HDUs affiliated to emergency departments were eligible to participate in the study. Participating centers reported detailed structural information and prospectively collected data on all admitted adult patients. Patients' data are presented overall and analyzed to evaluate the heterogeneity across the participating centers. A total of 12 HDUs participated in the study and enrolled 3670 patients. Patients were aged 68 years on average, had multiple comorbidities and were on major chronic therapies. Several admitted patients had at least one organ failure (39%). Mortality in HDU was 8.4%, raising to 16.6% in hospital. While most patients were transferred to general wards, a small proportion required ICU transfer (3.9%) and a large group was discharged directly home from the HDU (31%). The expertise of HDUs in managing complex and fragile patients is supported by both the available equipment and the characteristics of admitted patients. The limited proportion of patients transferred to ICUs supports the hypothesis of preventing of ICU admissions. The heterogeneity of HDU admissions requires further research to define meaningful patients' outcomes to be used by quality-of-care assessment programs.

Multiple Myeloma Patients Undergoing Carfilzomib: Development and Validation of a Risk Score for Cardiovascular Adverse Events Prediction.

Cardiovascular adverse events (CVAEs) are linked to Carfilzomib (CFZ) therapy in multiple myeloma (MM); however, no validated protocols on cardiovascular risk assessment are available. In this prospective study, the effectiveness of the European Myeloma Network protocol (EMN) in cardiovascular risk assessment was investigated, identifying major predictors of CVAEs. From January 2015 to March 2020, 116 MM patients who had indication for CFZ therapy underwent a baseline evaluation (including blood pressure measurements, echocardiography and arterial stiffness estimation) and were prospectively followed. The median age was 64.53 ± 8.42 years old, 56% male. Five baseline independent predictors of CVAEs were identified: office systolic blood pressure, 24-h blood pressure variability, left ventricular hypertrophy, pulse wave velocity value and global longitudinal strain. The resulting 'CVAEs risk score' distinguished a low- and a high-risk group, obtaining a negative predicting value for the high-risk group of 90%. 52 patients (44.9%) experienced one or more CVAEs: 17 (14.7%) had major and 45 (38.7%) had hypertension-related events. In conclusion, CVAEs are frequent and a specific management protocol is crucial. The EMN protocol and the risk score proved to be useful to estimate the baseline risk for CVAEs during CFZ therapy, allowing the identification of higher-risk patients.

Lung ultrasound for the early diagnosis of COVID-19 pneumonia: an international multicenter study.

PURPOSE: To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient's symptoms and clinical history. METHODS: This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed. RESULTS: We studied 1462 patients, classified in mild (n = 400), severe (n = 727), and mixed (n = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23-91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients with objective respiratory failure (99.3%). The HighLUS showed a specificity of 88.8% (CI 85.55-91.65%) that was higher in the mild phenotype (94.4%; CI 90.0-97.0%). At multivariate analysis, the HighLUS was a strong independent predictor of RT-PCR positivity (odds ratio 4.2, confidence interval 2.6-6.7, p < 0.0001). CONCLUSION: Combining LUS patterns of probability with clinical phenotypes at presentation can rapidly identify those patients with or without COVID-19 pneumonia at bedside. This approach could support and expedite patients' management during a pandemic surge.

Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis.

OBJECTIVES: The prevalence of hypertensive emergencies and urgencies and of acute hypertension-mediated organ damage (aHMOD) in emergency departments is unknown. Moreover, the predictive value of symptoms, blood pressure (BP) levels and cardiovascular risk factors to suspect the presence of aHMOD is still unclear. The aim of this study was to investigate the prevalence of hypertensive emergencies and hypertensive urgencies in emergency departments and of the relative frequency of subtypes of aHMOD, as well as to assess the clinical variables associated with aHMOD. METHODS: We conducted a systematic literature search on PubMed, OVID, and Web of Science from their inception to 22 August 2019. Two independent investigators extracted study-level data for a random-effects meta-analysis. RESULTS: Eight studies were analysed, including 1970 hypertensive emergencies and 4983 hypertensive urgencies. The prevalence of hypertensive emergencies and hypertensive urgencies was 0.3 and 0.9%, respectively [odds ratio for hypertensive urgencies vs. hypertensive emergencies 2.5 (1.4-4.3)]. Pulmonary oedema/heart failure was the most frequent subtype of aHMOD (32%), followed by ischemic stroke (29%), acute coronary syndrome (18%), haemorrhagic stroke (11%), acute aortic syndrome (2%) and hypertensive encephalopathy (2%). No clinically meaningful difference was found for BP levels at presentations. Hypertensive urgency patients were younger than hypertensive emergency patients by 5.4 years and more often complained of nonspecific symptoms and/or headache, whereas specific symptoms were more frequent among hypertensive emergency patients. CONCLUSION: Hypertensive emergencies and hypertensive urgencies are a frequent cause of access to emergency departments, with hypertensive urgencies being significantly more common. BP levels alone do not reliably predict the presence of aHMOD, which should be suspected according to the presenting signs and symptoms.

Echocardiography in Pandemic: Front-Line Perspective, Expanding Role of Ultrasound, and Ethics of Resource Allocation.

The grave clinical context of the coronavirus disease 2019 (COVID-19) pandemic must be understood. Italy is immersed in the COVID-19 pandemic. Most of the world will soon follow. The United States currently has the most documented cases of COVID-19 of any nation. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated acute cardiomyopathy is common in critical care patients and is associated with a high mortality rate. Patients with COVID-19 frequently require mechanical support for adequate oxygenation. A severe shortfall of ventilators is predicted. Of equal concern is the projected shortage of trained professionals required to care for patients on mechanical ventilation. Ultrasonography is proving to be a valuable tool for identifying the pulmonary manifestations and progression of COVID-19. Lung ultrasound also facilitates successful weaning from mechanical ventilation. Ultrasonography of the lung, pleura, and diaphragm are easily mastered by experienced echocardiographers. Echocardiography has an established role for optimal fluid management and recognition of cardiac disease, including SARS-CoV-2-associated acute cardiomyopathy. Cardiologists, anesthesiologists, sonographers, and all providers should be prepared to commit their full spectrum of skills to mitigate the consequences of the pandemic. We should also be prepared to collaborate and cross-train to expand professional services as necessary. During a declared health care crisis, providers must be familiar with the ethical principles, organizational structure, practical application, and gravity of limited resource allocation.

Prevalence of Hypokalemia and Primary Aldosteronism in 5100 Patients Referred to a Tertiary Hypertension Unit.

Primary aldosteronism (PA) was considered a rare disorder almost always associated with hypokalemia. The widespread screening of patients with hypertension unveiled an increased prevalence of PA with normokalemic hypertension the prevailing phenotype. Many studies have reported the prevalence of hypokalemia in patients with PA; conversely, the prevalence of PA in patients with hypokalemia is unknown. In this retrospective observational study, we define the prevalence of hypokalemia in referred patients with hypertension and the prevalence of PA in patients with hypokalemia and hypertension. Hypokalemia was present in 15.8% of 5100 patients with hypertension, whereas 76.9% were normokalemic, and 7.3% hyperkalemic. The prevalence of PA in patients with hypokalemia was 28.1% and increased with decreasing potassium concentrations up to 88.5% of patients with spontaneous hypokalemia and potassium concentrations <2.5 mmol/L. A multivariate regression analysis demonstrated the association of hypokalemia with the occurrence of cardiovascular events independent of PA diagnosis. An association of PA with the occurrence of cardiovascular events and target organ damage independent of hypokalemia was also demonstrated. In conclusion, our results confirm that PA is a frequent cause of secondary hypertension in patients with hypokalemia, and the presence of hypertension and spontaneous hypokalemia are strong indications for PA diagnosis. Finally, we show that PA and hypokalemia are associated with an increased risk of cardiovascular events.

Effectiveness of Renal Denervation in Resistant Hypertension: A Meta-Analysis of 11 Controlled Studies.

INTRODUCTION: Early uncontrolled studies reported large blood pressure reductions in subjects with resistant hypertension treated with renal denervation, however these results were not confirmed in several of the latest publications. AIM: The aim of the current study was to evaluate the effectiveness of RDN in controlled studies comparing RDN to either a sham procedure or to medical therapy. METHOD: Only controlled studies were included in the analysis. Both the unadjusted and control-adjusted BP changes were calculated. RESULTS: We identified 11 publications of which only 3 were double-blinded RCTs with a sham control, while 8 were open label studies where the control group was treated with medical therapy. Only 2 studies assessed adherence to medical therapy with robust methodologies. Office BP reduction (- 18/8 mmHg) significantly overestimated ABPM change (- 9/- 5 mmHg), with high heterogeneity between the included studies. When the treatment effect was adjusted for the BP change in the control group, BP changes became non significant (ABPM: - 1.8 for systolic BP [95% CI - 4.5 to 0.9] and - 0.6 for diastolic BP [95% CI - 2.3 to 1.2]). These results were confirmed when only the sham-controlled studies were analysed. CONCLUSIONS: In spite of promising results in early reports, renal denervation fails to show superiority to a sham procedure or to medical therapy in recently published controlled studies. Lack of a sham control in most publications and heterogeneity in assessment of treatment adherence may account for part the variability reported in the studies. Renal denervation fails to show superiority to a sham procedure or to medical therapy in recently published controlled studies.

Mechanism of Progressive Heart Failure and Significance of Pulmonary Hypertension in Obstructive Hypertrophic Cardiomyopathy.

BACKGROUND: There are limited data on the prevalence, pathophysiology, and management implications of pulmonary hypertension in patients with obstructive hypertrophic cardiomyopathy and advanced heart failure. METHODS AND RESULTS: To assess the clinical significance of measured cardiopulmonary hemodynamics in hypertrophic cardiomyopathy patients with heart failure, we retrospectively assessed right heart catheterization data in 162 consecutive patients with outflow tract gradients (median [interquartile range], 90 mm Hg [70-110 mm Hg]), 59±11 years old, and 49% men, predominately New York Heart Association class III/IV status. Pulmonary hypertension (mean pulmonary artery pressure, ≥25 mm Hg) was present in 82 patients (51%), including 29 (18%) regarded as moderate-severe (mean pulmonary artery pressure, ≥35 mm Hg) and 28 (34%) also had increased pulmonary vascular resistance >3.0 WU. The pulmonary artery wedge pressure was ≤15 mm Hg in 54%, indicating that left atrial hypertension was absent in a majority of patients. Notably, 9 patients (11%) met hemodynamic criteria for precapillary pulmonary hypertension (mean pulmonary artery pressure, ≥25 mm Hg; pulmonary vascular resistance, >3.0 WU; pulmonary artery wedge pressure, ≤15 mm Hg). Over a median follow-up of 327 days (90-743 days) after surgical myectomy (or alcohol septal ablation), 92% and 95% of patients with or without preoperative pulmonary hypertension, respectively, were asymptomatic or mildly symptomatic. One postoperative death occurred in a 59-year-old woman with acute respiratory failure and mean pulmonary artery pressure of 65 mm Hg. CONCLUSIONS: Pulmonary hypertension was common in obstructive hypertrophic cardiomyopathy patients with advanced heart failure. Although possibly a contributor to preoperative heart failure, pulmonary hypertension did not significantly influence clinical and surgical outcome. Notably, a novel patient subgroup was identified with resting invasive hemodynamics consistent with pulmonary vascular disease.

Procedural Reassessment of Radiofrequency Renal Denervation in Resistant Hypertensive Patients.

INTRODUCTION: Recent anatomical and clinical studies have led to the hypothesis that in several cases of failure of response to renal denervation (RDN), the procedure has not been technically correct. AIM: To perform procedural reassessment in patients with true resistant hypertension who underwent RDN. METHODS: We retrospectively reassessed the procedural technique of RDN in 10 true resistant hypertensive patients, comparing the sites of renal ablations with the knowledge of animal and human post mortem evidences. Procedural ablation technique was assessed in terms of number of ablations for each renal artery and site of ablation (quadrant and distance from renal ostium) by using the radiologic images of each RDN and the number of radiofrequency ablation attempts documented in the reports of each denervation session. RESULTS: 10 patients were studied, 9 denervated with Simplicity monoelectrode catheter, 1 with multielectrode balloon technique. Responders to the procedure underwent more ablations and particularly at least a quadrant ablation in one of the kidney arteries, >2 ablations in Dorsal plus Ventral quadrants and in 67% of then >10 ablations were done in superior inferior and ventral quadrants. CONCLUSION: This study confirms the importance of a well knowledge of renal artery anatomy and underlines the relevance of the choice of ablation sites in order to obtain a successful RDN procedure.

Evaluation of a short home blood pressure measurement in an outpatient population of hypertensives.

Current guidelines suggest the use of home blood pressure monitoring (HBPM) as a method complementary to ambulatory blood pressure monitoring (ABPM) for the identification of arterial hypertension. A cross-sectional study was conducted to evaluate the accuracy of a short HBPM schedule compared with ABPM, and to evaluate to what extent HBPM can replace ABPM. A total of 310 patients who performed ABPM in our hypertension clinic were enrolled between November 2011 and June 2015. They performed a 4-day HBPM schedule, with two readings in the morning and two readings at night. Results showed a moderate correlation between HBPM and ABPM (r = 0.59 for systolic blood pressure (SBP) and r = 0.72 for diastolic blood pressure (DBP)) and moderate diagnostic agreement (area under curve: 0.791 for SBP and 0.857 for DBP). No significant difference was found between first-day average and those of days 2-4. Diagnostic agreement between the two techniques was moderate, supporting the notion that HBPM cannot replace ABPM in the general population. However, we identified two HBPM thresholds, 123/75 and 144/87 mm Hg, through which subjects who may not require further ABPM can be identified.

Adherence to antihypertensive therapy and therapeutic dosage of antihypertensive drugs.

Adherence to antihypertensive therapy is critical to achieving adequate blood pressure control. About half of hypertensive patients do not take their drugs as directed and the physicians often underestimate this issue. Non-adherence has important public health economic implications (numbers of visits, diagnostic procedures, prescribed drugs) and, moreover, it results in increased morbidity and mortality rates. Poor adherence can have several patients and therapy related causes. Currently, multiple different direct and indirect methods to measure therapeutic adherence are available, but, in clinical practice, there is no cost-effective and simple one. Therapeutic drug monitoring (TDM), characterized by drug (or metabolites) concentration measurement in body fluids (blood or urine), is a cost-effective direct method to assess therapeutic adherence. Despite some limitations, TDM may decrease health costs, by reducing the number of visits and by identifying those patients who would undergo unnecessary invasive procedures. Moreover, TDM can be a new alternative method to identify patients with true resistant hypertension, improving the achievement of blood pressure control In this minor revision, we would assess poor therapeutic adherence in hypertensive population, analyzing the different direct and direct available methods, with emphasis on TDM.

Echocardiographic aortic root dilatation in hypertensive patients: a systematic review and meta-analysis.

OBJECTIVE: The risk of thoracic aortic dissection is strictly related to the diameter of the ascending aorta. Arterial hypertension represents a major risk factor for the development of aortic dissection and is thought to be directly involved in the pathogenesis of aortic aneurysms. Recent studies have suggested a high prevalence of aortic root enlargement in the hypertensive population, but evidence of a direct link between blood pressure values and size of the aortic root has been inconclusive so far. The aim of the current study was to evaluate prevalence of aortic root dilatation (ARD) in the hypertensive population and to assess the correlates of this condition. METHODS: Medical literature was reviewed to identify articles assessing prevalence of echocardiographic ARD in hypertensive patients. RESULTS: A total of eight studies including 10 791 hypertensive patients were considered. Prevalence of ARD in the pooled population was 9.1% with a marked difference between men and women (12.7 vs. 4.5%; odds ratio 3.15; 95% confidence interval 2.68-3.71). Hypertensive patients with ARD and those with normal aortic root size had similar office blood pressure values, but the former were older and had a significantly higher left-ventricular mass (0.52 SDs, 95% confidence interval 0.41-0.63). CONCLUSION: ARD is a common phenotype in hypertensive patients, with men showing a markedly higher susceptibility, but office blood pressure values do not appear to be directly associated with aortic root diameter.

Effectiveness of blood pressure educational and evaluation program for the improvement of measurement accuracy among nurses.

AIM: To assess the procedure for measuring blood pressure (BP) among hospital nurses and to assess if a training program would improve technique and accuracy. METHODS: 160 nurses from Molinette Hospital were included in the study. The program was based upon theoretical and practical lessons. It was one day long and it was held by trained nurses and physicians who have practice in the Hypertension Unit. An evaluation of nurses' measuring technique and accuracy was performed before and after the program, by using a 9-item checklist. Moreover we calculated the differences between measured and effective BP values before and after the training program. RESULTS: At baseline evaluation, we observed inadequate performance on some points of clinical BP measurement technique, specifically: only 10% of nurses inspected the arm diameter before placing the cuff, 4% measured BP in both arms, 80% placed the head of the stethoscope under the cuff, 43% did not remove all clothing that covered the location of cuff placement, did not have the patient seat comfortably with his legs uncrossed and with his back and arms supported. After the training we found a significant improvement in the technique for all items. We didn't observe any significant difference of measurement knowledge between nurses working in different settings such as medical or surgical departments. CONCLUSIONS: Periodical education in BP measurement may be required, and this may significantly improve the technique and consequently the accuracy.

Silent cerebrovascular damage and its early correlates in essential hypertensive patients.

This study tested the association between cognitive functions, cerebrovascular damage, and cerebrovascular reactivity in 71 essential young hypertensives (age matched) and 22 normotensives (age matched). They underwent ambulatory blood pressure monitoring, neurocognitive tests, cerebral magnetic resonance, and transcranial Doppler. Twenty-three percent of patients showed more than 10 white matter lesions and 8% showed none. No control subjects showed more than 10 white matter lesions and 90% of normal controls showed no lesions. Patients with more than 10 white matter alterations had longer hypertensive story and showed significant lower nocturnal blood pressure fall. Pulsatility index was correlated with the number of white matter lesions.

Arterial stiffness: from physiology to clinical implications.

Current European guidelines for the management of arterial hypertension introduce the assessment of arterial stiffness by pulse wave velocity (PWV) as an index of hypertension-related cardiovascular target organ damage. An increase in arterial stiffness is related to haemodynamic modifications at the level of the aorta, leading to a rise in cardiac afterload, a reduction in coronary perfusion and an overstretch of the aortic walls. An increasing number of studies have demonstrated the accuracy of PWV as an independent predictor of cardiovascular events and cardiovascular mortality in patients with different co-morbidities and cardiovascular risk. Many strategies have demonstrated their efficacy in preventing arterial stiffening; therapy of arterial hypertension is the mainstay in the management of patients with increased PWV and altered pulse wave reflection. Literature has clearly shown the specific efficacy of drugs interfering with the renin-angiotensin-aldosterone system and calcium-channel blockers in the control of central haemodynamics, particularly when compared with ß-blockers (ß-adrenoceptor antagonists). The same action has not yet been demonstrated on PWV. Further studies are needed to assess the real relative efficacy of different drug classes on the management of arterial stiffness and the clinical and prognostic relevance of these therapies.