[Comparison between telephone and outpatient nursing management in patients with chronic heart failure in a large territorial area in Piedmont, Italy]. / Confronto tra gestione infermieristica telefonica ed ambulatoriale integrata dei pazienti affetti da scompenso cardiaco cronico in un vasto territorio piemontese.

BACKGROUND: In the last years, the increasing incidence and prevalence, the deterioration of quality of life, the high mortality and the elevated costs related to chronic heart failure represent one of the most important problems of public health care. Multidisciplinary management systems based on specialized nurses teams improve the outcome and reduce the costs of care of these patients. The aim of this study was to analyze the use for 1 year, in an urban or suburban population, of two different nurse-based management systems in addition to usual care for outpatients with congestive heart failure. METHODS: We enrolled 102 patients: group A (n = 49) was followed up with a phone-nurse-based system and group B (n = 53) was followed up with a nurse ambulatory system. RESULTS: An improvement in NYHA class was observed in both groups (group A: NYHA class I-II 31 to 38 patients, NYHA class III-IV 18 to 7 patients, p = 0.03; group B: NYHA class I-II 37 to 43 patients, NYHA class III-IV 16 to 6 patients, p = 0.03). An improvement was also observed in the Minnesota Living with Heart Failure Questionnaire (group A: 25 +/- 10 to 15 +/- 9; p <0.01; group B: 29 +/- 13 to 20 +/- 10; p <0.01), and in ejection fraction (group A: from 31 +/- 9 to 37 +/- 12%; p <0.01; group B: from 30 +/- 9 to 35 +/- 13%; p = 0.02). No significant differences were found between the two groups in mortality, hospital readmission, emergency room and day-hospital admissions. CONCLUSIONS: Our results confirm the effectiveness of a monitoring management and educational system for heart failure patients. A phone-nurse-based system requires minor staff and has a better flexibility than a nurse ambulatory system; the latter, however, leads to a professional and human complete interaction as well as enables rapid intervention of the cardiologist in case of instability.

[Management of heart failure in Piedmont Region]. / La gestione ambulatoriale dello scompenso cardiaco cronico nella Regione Piemonte.

BACKGROUND: Congestive heart failure (CHF) represents an emerging problem in industrialized countries: it continues to be diagnosed at high rates and has an decreased survival time, raising new problems, such as the need of an adequate medical service organization and resource expenditure. Aim of this analysis was a quantitative evaluation of diagnostic and therapeutic resource use for CHF in outpatient departments in Piedmont, Italy. METHODS: We performed a cross-sectional observational study, based on a two-month data collection in 12 outpatient departments dedicated to congestive heart failure. Information was obtained on each patient using a specific anonymous data collection form. RESULTS: We obtained and analyzed for the study 547forms. Mean patient age was 66.1 years, mean ejection fraction was 36.6%. Coronary artery disease accounted for 34.6% of congestive heart failure cases, followed by idiopathic etiology (26.4%). Main comorbidities were diabetes (22.3%) and chronic obstructive pulmonary disease (17.7%). Sixty-nine% of patients received a medical treatment with angiotensin-converting enzyme (ACE) inhibitors, 72.6% with beta-blockers, 48.8% with aldosterone antagonists. As far as diagnostic resource use during a six-month period preceeding observation, 46.8% of patients underwent echocardiographic examination, 9.9% Holter ECG, 6.0% coronary angiography. Therapy was more often increased in patients who underwent an instrumental evaluation during the preceeding six-month period. CONCLUSIONS: Data suggests that in Piedmont outpatients with chronic heart failure receive a high drug prescription level and a small number of instrumental evaluations, as suggested in main international guidelines.

Primary angioplasty and routine utilization of thrombus aspiration devices: feasibility and results in a consecutive series of 486 patients.

BACKGROUND: Primary percutaneous transluminal coronary angioplasty (PTCA) is the treatment of choice for acute ST-segment elevation myocardial infarction (STEMI) in high-volume centres with experienced operators, but is often limited by a suboptimal microvascular perfusion due to distal embolization and impaired myocardial perfusion. The present study investigates whether routine use of thrombus aspiration (TA) devices is feasible in daily practice, along with its safety and effectiveness. METHODS: This study is based on a series of 486 consecutive STEMI patients treated at our single institution by the same three operators (from 2001 to 2005). They underwent primary PTCA with or without TA according to these angiographic features: infarct related artery (IRA) diameter>or=3 mm; thrombotic occlusion or angiographic evidence of thrombus; absence of severe proximal tortuosity or calcification. We evaluate the efficacy of TA in terms of procedural success, coronary thrombolysis in myocardial infarction (TIMI) flow, myocardial blush grade (MBG), resolution>or=50% of ST segment elevation, and clinical events during hospital stay and at 6-month follow-up. RESULTS: A total of 486 primary PTCAs were performed, 217 (44.6%) with TA as a first device using RESCUE (n=65), EXPORT (n=140) and DIVER-CE (n=12) catheters. In 141 (65%) cases, macroscopic material was aspirated. The patients submitted to TA were more often males (84.7% versus 71.7%, P<0.05) and younger (age: 61.02+/-11.91 versus 64.47+/-10.59 years, P<0.01) than patients treated with traditional PTCA and the IRA was more frequently occluded at angiography (basal TIMI 0: 70.5% versus 47.9%). Application of the TA did not increase the complexity of the procedure (door-to-balloon times, minutes of fluoroscopy and amount of dye). TA alone was effective to restore TIMI 3 flow in 187 cases (86.2%) as a first device and in three other cases (1.4%) after predilatation with balloon. Direct stenting without predilatation was possible in 144 cases (66.4%) after TA. TA was not effective in 27 cases (12.4%) and this subgroup had both angiographic and clinical unfavourable results in comparison with the effective TA group (final TIMI 1 in 11.1% versus 0.5%, P<0.015; final MBG 1 in 55.5% versus 9.5%, P<0.001; lack of ST segment resolution>or=50% in 44.4% versus 7.9%, P<0.001; in-hospital mortality 14.8% versus 2.6%, P<0.05 and mortality at 6 months 18.5% versus 3.1%, P<0.05). In the whole TA population, final TIMI 3 flow was achieved in 203 cases (93.5%), final MBG 3 in 145 cases (66.8%) and ST segment resolution>or=50% in 185 cases (85.2%), in-hospital mortality was 4.1% and cumulative mortality at 6-month follow-up was 5.5%. CONCLUSIONS: In our case series, 486 consecutive unselected patients with STEMI were treated in a primary PTCA high-volume centre using TA devices. Our study demonstrates that, in STEMI patients treated with primary PTCA, a routine strategy with TA before angioplasty guided by angiographic selection criteria is feasible in almost 50% of cases, is safe and effective, does not increase procedural time and offers good results in terms of tissue perfusion, both epicardial (TIMI flow) and myocardial (MBG, ST regression). When successfully performed, TA identifies a population with favourable in-hospital and 6-month outcome.

[Outpatient medical and nurse management program in patients with chronic heart failure in a large territorial area in Piedmont. Four years of follow-up]. / Scompenso cardiaco: gestione medico- infermieristica in un'area piemontese caratterizzata da estrema dispersione territoriale. Risultati a quattro anni.

BACKGROUND: Chronic heart failure is the leading cause of hospitalization and readmissions. In the last years many strategies based on the interaction of multi-competence programs have been evaluated to improve its management. METHODS: We evaluated the feasibility of an outpatient management program for patients with chronic hearth failure jointly treated by hospital, territorial cardiologists, nurses and primary physicians in a large area of Piedmont. Between January 2001 and January 2005, 122 consecutive patients (26.2% female, mean age 66 +/- 11 years) with chronic heart failure were enrolled in the study. Etiology was: coronary heart disease 40.2%, dilated cardiomyopathy 18%, hypertension 18%, unknown 14%, valvular heart disease 4.9%, other 4.9%. Cardiologists were expected to assess etiology, to perform instrumental examinations and titration of beta-blockers; nurses to reinforce patient education to monitor adherence to pharmacological and dietary therapy. Patients were subsequently followed by primary physicians. The endpoints were to compare: 1) hospitalization and emergency department admissions in the 12 months before the first evaluation and every year after referral; 2) Minnesota questionnaire, NYHA functional class, pharmacological therapies at the referral time and at the end of follow-up. RESULTS: One hundred and fifteen patients were followed for 47 +/- 1.5 months (5.6% drop out). Thirty-four patients died (29.5%), 11 non-cardiac causes, 14 congestive heart failure, 6 sudden cardiac death, 3 cardiac transplantation. Ejection fraction improved from 31 +/- 10 to 36 +/- 12%. Emergency department admissions and hospitalizations decreased from 54 and 56 respectively in the year before the first evaluation to 14 and 21 per year (p < 0.001). NYHA classes I-II improved from 65.5 to 87.7% and NYHA classes III-IV were reduced from 34.5 to 12.3%. The Minnesota score decreased from 25 to 21.9. Patients treated with ACE-inhibitors + angiotensin II receptor blocker therapy increased from 91 to 96%, beta-blockers from 35.2 to 69%, potassium sparing drugs increased from 54 to 64%. CONCLUSIONS: Our study showed that a medical and nurse outpatient management program for patients with chronic heart failure, also in a large urban and country area, decrease number of hospitalizations and improve functional class and adherence to medical therapy. These results kept constant over time in the subsequent 4 years.

[Heart rupture in acute myocardial infarction: multicenter observational study of the coronary unit of Piedmont]. / Rottura di cuore nell'infarto miocardico acuto: studio multicentrico osservazionale delle unità coronariche piemontesi.

BACKGROUND: The aim of this study was to prospectively evaluate the incidence of cardiac rupture during myocardial infarction (MI) as well as the predictive value of the main cardiac rupture risk factors. METHODS: The study was carried out in 17 coronary care units (CCU) between January and December 1999 in the Piedmont region (Italy). RESULTS: The incidence of cardiac rupture was 1.4% of the total number of MI (n = 3041). Data from 13 out of 17 CCU showed the following causes of death during MI: 66% heart failure, 16% cardiac rupture, 7% arrhythmias, 11% others. Twenty-seven percent out of 44 cardiac ruptures had prior angina, 9% prior MI; 24% of patients were diabetic; 38% had anterior wall MI; 62% infero-postero-lateral MI; 86% showed ST-segment elevation, and 79.5% developed Q waves. Thrombolysis was administered in 39% of cases. Forty-three percent cardiac ruptures occurred within 24 hours. Electromechanical dissociation was present in 73% of cases, syncope and hypotension in 43%, bradycardia in 30%. An echocardiogram was performed in 89% of cases in the suspicion of cardiac rupture but only 45% showed severe pericardial effusion. One patient was referred to surgery but he died in the postoperative period. Autoptical diagnosis was made in 32% of cases. All patients died. The analysis of some qualitative variables (gender, thrombolysis, MI localization, ST-segment/non-ST-segment elevation) in 8 out of 17 CCU, between the cardiac rupture group (n = 22) and the MI group (n = 1330) showed a significant result only for the female gender. CONCLUSIONS: Cardiac rupture is the second cause of death during MI after heart failure; there is a higher incidence of cardiac rupture in infero-postero-lateral MI, after the first 24 hours particularly in the female gender; there is a low global incidence (1.4%).