[Appropriateness of the request for preoperative cardiological evaluation in non-cardiac surgery: 8-year experience in a high-volume cardiological center]. / Appropriatezza della richiesta di consulenza cardiologica preoperatoria nella chirurgia non cardiaca: esperienza di 8 anni di un centro cardiologico ad alto volume di attività.

BACKGROUND: In the last decades the population undergoing non-cardiac surgery has become more numerous and complex. Cardiovascular perioperative complications represent at least one third of the perioperative deaths. Despite the pivotal role of the cardiologist in the perioperative management, current guidelines are often hardly useful in different settings of clinical practice. Local clinical protocols contribute to fill these gaps, to define the role of each specialist in the perioperative context and to achieve the best medical outcome. METHODS: This single-center retrospective study analyzes the background of 33 463 preoperatory cardiologic visits, the adherence to scientific evidence in our institute and the impact of the implementation of a shared clinical protocol (CP) in terms of reduction of inappropriate requests of cardiological evaluations. RESULTS: Among all the patients, the mean age was 59 ± 18 years, 52.8% were male. Hypertension was the most prevalent disease followed by diabetes, chronic coronary syndrome and atrial fibrillation. The "low-risk surgery" category was the most represented (56.2%) and the vast majority of patients (70.1%) was totally free from predictors of perioperative cardiovascular events. After the introduction of the CP, the number of inappropriate evaluations decreased by 32%, mainly in the low-risk category. However, despite the overall reduction, almost two thirds of the evaluations were still deemed inappropriate according to the CP, mostly (82.9%) in the low-risk category and to a lesser degree (55%) in the moderate/high-risk category. CONCLUSIONS: The inappropriate use of the resources resulted in disappointing organizational performance, poor assistance quality and a huge number of inappropriate preoperatory evaluations. The implementation of a CP, developed on the basis of the local needs, is a useful tool to enhance the organizational standards for the cardiological evaluation of patients undergoing non-cardiac surgery. Regular verifications, a widespread knowledge of the guidelines and a more efficient system of management and surveillance may improve the appropriateness of these evaluations.

Preoperative assessment of cardiovascular risk in patients undergoing noncardiac surgery: the Orion study.

In patients undergoing noncardiac surgery risk indices can estimate patients' perioperative risk of major cardiovascular complications. The indexes currently in use were derived from observational studies that are now outdated with respect to the current clinical context. We undertook a prospective, observational, cohort study to derive, validate, and compare a new risk index with established risk indices. We evaluated 7335 patients (mean age 63±13 years) who underwent noncardiac surgery. Based on prospective data analysis of 4600 patients (derivation cohort) we developed an Updated Cardiac Risk Score (UCRS), and validated the risk score on 2735 patients (validation cohort). Four variables (i.e. the UCRS) were significantly associated with the risk of a major perioperative cardiovascular events: high-risk surgery, preoperative estimate glomerular filtration rate <30 ml/min/1.73 m2, age ≥75 years, and history of heart failure. Based on the UCRS we created risk classes 1,2,3 and 4 and their corresponding 30-day risk of a major cardiovascular complication was 0.8% [95% confidence interval (CI) 0.5-1.7], 2.5 (95% CI 1.6-5.6), 8.7 (95% CI 5.2-18.9) and 27.2 (95% CI 11.8-50.3), respectively. No significant differences were found between the derivation and validation cohorts. Receiver operating characteristic (ROC) curves demonstrate a high predictive performance of the new index, with greater power to discriminate between the various classes of risk than the indexes currently used. The high predictive performance and simplicity of the UCRS make it suitable for wide-scale use in preoperative cardiac risk assessment of patients undergoing noncardiac surgery.

Treatment of heart failure in the elderly: Which drugs are essential and which should be avoided.

With improved health care and with population aging, heart failure (HF) has become a common disease among the elderly and is one of the principal causes of mortality in elderly age. But the pharmacological management of HF in the elderly has still not yet been defined, as the clinical context is complicated by comorbidities, and differs from that of younger adults. In general, elderly patients with HF should be treated according to current guideline recommendations, for which ACE-I, beta-blockers and anti-aldosterones constitute the cornerstone of therapy. Interesting prospects are opening up with the use of new drugs such as neprilysin inhibitors, which appear to reproduce in the elderly the positive effects observed in the young adult population, and ivabradine, which may substitute the traditional use (now probably obsolete) of digitalis. Currently, however, treatment of HF in elderly patients is characterized by insufficient drug titration and by a habitual underuse of the recommended therapies - this is partly due to prescription inertia and in part to the negative effect of polypharmacotherapy on patient adherence. Even if HF therapy is similar in older and younger patients, the presence in older patients of more comorbidities, and frailty, functional status, and socio-environmental factors related to aging require a multidisciplinary approach to care and, above all, an additional assessment aimed at personalizing the treatment.

Prevalence and management of familial hypercholesterolemia in patients with coronary artery disease: The heredity survey.

BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is a genetic disorder characterized by high levels of low density lipoprotein cholesterol (LDL-C) predisposing to premature cardiovascular disease. Its prevalence varies and has been estimated around 1 in 200-500. The Heredity survey evaluated the prevalence of potential FH and the therapeutic approaches among patients with established coronary artery disease (CAD) or peripheral artery disease (PAD) in which it is less well documented. METHODS: Data were collected in patients admitted to programs of rehabilitation and secondary prevention in Italy. Potential FH was estimated using Dutch Lipid Clinic Network (DLCN) criteria. Potential FH was defined as having a total score≥6. RESULTS: Among the 1438 consecutive patients evaluated, the prevalence of potential FH was 3.7%. The prevalence was inversely related to age, with a putative prevalence of 1:10 in those with <55yrs of age (male) and <60yrs (female). Definite FH (DLCN score>8) had the highest percentages of patients after an ACS (75% vs 52.5% in the whole study population). At discharge, most patients were on high intensity statin therapy, but despite this, potential FH group still had a higher percentage of patients with LDL-C levels not at target and having a distance from the target higher than 50%. CONCLUSIONS: Among patients with established coronary heart disease, the prevalence of potential FH is higher than in the general population; the results suggest that a correct identification of potential FH, especially in younger patients, may help to better manage their high cardiovascular risk.

New assessment for advanced age: Italian study protocol on the assessment of surgical risk in the over-75-year age-group.

The role of age in the risk stratification of patients candidate for non-cardiac surgery is still today an unresolved issue. European guidelines, in contrast to American guidelines, do not attribute to age an independent role in increasing the risk, and the indices for assessment of perioperative cardiovascular risk are based on studies that were carried out on middle-aged subgroups of the population without specific attention to the elderly patient. While the indices of geriatric assessment have still not yet gained a standardized role in the risk stratification of patients candidate to non-cardiac surgery, their need is becoming increasingly urgent considering the epidemiological impact of elderly patients with multi-comorbidities who more and more in the future will undergo such interventions. The European guidelines themselves identify an "evidence gap" concerning frailty which requires a deeper evaluation. The aim of the multicenter observational study VALUTA-75 is to verify if the indices of risk stratification routinely used by the cardiologist integrated with those of physical and cognitive performance of specific geriatric pertinence can improve the ability to predict perioperative cardiovascular and non cardiovascular events, with the scope of improving the therapeutic process.

The Difficult Evolution of Intensive Cardiac Care Units: An Overview of the BLITZ-3 Registry and Other Italian Surveys.

Coronary care units, initially developed to treat acute myocardial infarction, have moved to the care of a broader population of acute cardiac patients and are currently defined as Intensive Cardiac Care Units (ICCUs). However, very limited data are available on such evolution. Since 2008, in Italy, several surveys have been designed to assess ICCUs' activities. The largest and most comprehensive of these, the BLITZ-3 Registry, observed that patients admitted are mainly elderly males and suffer from several comorbidities. Direct admission to ICCUs through the Emergency Medical System was rather rare. Acute coronary syndromes (ACS) account for more than half of the discharge diagnoses. However, numbers of acute heart failure (AHF) admissions are substantial. Interestingly, age, resources availability, and networking have a strong influence on ICCUs' epidemiology and activities. In fact, while patients with ACS concentrate in ICCUs with interventional capabilities, older patients with AHF or non-ACS, non-AHF cardiac diseases prevail in peripheral ICCUs. In conclusion, although ACS is still the core business of ICCUs, aging, comorbidities, increasing numbers of non-ACS, technological improvements, and resources availability have had substantial effects on epidemiology and activities of ICCUs. The Italian surveys confirm these changes and call for a substantial update of ICCUs' organization and competences.

[The network for acute coronary syndromes in the metropolitan area of Cagliari (Italy): management of ST-elevation myocardial infarction, reperfusion time, and adherence to guidelines]. / La rete per l'emergenza coronarica nell'Area Vasta di Cagliari: gestione dell'infarto miocardico acuto con sopraslivellamento del tratto ST, analisi dei tempi di riperfusione e aderenza alle linee guida.

BACKGROUND: An integrated network for the management of acute ST-elevation myocardial infarction (STEMI) allows a pre-hospital diagnosis and facilitates the best strategy to provide the most effective reperfusion therapy. This study aims to assess the network impact on timing and mode of reperfusion in the metropolitan area of Cagliari. METHODS: From January 1, 2008 to December 31, 2010 all patients affected by STEMI with symptom onset <12h were enrolled. We evaluated modality of hospital access, reperfusion therapies, and time for avoidable delay. The first medical contact-to-balloon time (FMC-to-balloon) was compared between patients without ECG transmission (No-ECG group) and those with ECG transmission and direct transport to the cath-lab (Cath-Lab-ECG group) or the emergency room/intensive cardiac care unit (ER/ICCU-ECG group). RESULTS: Out of 622 patients enrolled, 324 (52.1%) arrived to hospital by emergency medical systems. In this group a pre-hospital diagnosis was made in 79.3% of cases (n = 257); among them, 138 patients (53.7%) had a direct access to cath-lab, 99 to ICCU (38.5%), and 20 (7.8%) to ER. In the whole study population an urgent coronary angiography was performed in 612 patients (98.4%) and a primary percutaneous coronary intervention (p-PCI) in 589 (96.2%). In the Cath-Lab-ECG group the FMC-to-balloon was 89 ± 29 min (median 87 min, interquartile range 72-100), significantly lower than in the ER/ICCU-ECG group [122 ± 39 min (115 min)] and the No-ECG group [150 ± 54 min (139 min)] (p<0.01). A FMC-to-balloon ≤90 min was achieved in 66.4% of Cath-Lab-ECG patients, 22.1% of ER/ICCU-ECG patients, and 8.3% of No-ECG patients (Cath-Lab-ECG vs ER/ICCU-ECG, p<0.01). CONCLUSIONS: Our results show that an integrated network provides a pre-hospital diagnosis in the majority of STEMI. However, only a direct transport to the cath-lab allows to achieve a FMC-to-balloon ≤90 min in a large proportion of patients. Out of this condition, adherence to guideline-recommended time of ≤90 min is significantly lower.

[Heart failure in Italian intensive cardiac care units: data from the BLITZ-3 survey]. / I pazienti con scompenso cardiaco nelle unità di terapia intensiva cardiologica italiane: i dati dello studio BLITZ-3.

BACKGROUND: Only limited information about clinical characteristics, diagnostic procedures and therapeutic options is available in patients admitted to an intensive cardiac care unit (ICCU) for heart failure. The aim of this study was to evaluate causes of admission, clinical characteristics, diagnostic and therapeutic options, and outcome of patients admitted for heart failure in the ICCU network. METHODS: The BLITZ-3 Registry prospectively included patients admitted by 332 Italian ICCUs. Data of the patients admitted with a principal diagnosis of heart failure are analyzed. RESULTS: From April 7 to 20, 2008, 6986 consecutive patients with acute cardiac conditions were admitted to ICCUs; 966 (14%) out of 6986 patients were admitted for acute heart failure. Heart failure was the second cause of admission after acute coronary syndromes (52%). Mean age of patients admitted for heart failure was 73 years, 42% were female, and diabetes accounted for 32% of heart failure patients. Most patients were admitted to the emergency department (62%), and were discharged by the cardiology ward (65%). Median length of stay in the ICCU was 4 days, and during the stay in ICCU 5% of the patients with heart failure died. Advanced age and elevated creatinine values were associated with a higher risk of death. Echocardiography was performed in 79% of heart failure patients, coronary angiography in 10%, assisted ventilation in 15%, ultrafiltration in 3%, and right catheterization in 1%. Diuretics were administered in 93% of patients admitted for acute heart failure, intravenous nitrates in 41%, inotropes in 22%, beta-blockers in 42%, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 66%. CONCLUSIONS: In a nationwide survey, acute heart failure accounted for 14% of hospital admissions in ICCUs. Patients admitted for heart failure are usually old, with frequent comorbidities. Diagnostic and therapeutic procedures are rarely used, with the exception of echocardiography.

Elderly patients with acute coronary syndromes admitted to Italian intensive cardiac care units: a Blitz-3 Registry sub-analysis.

BACKGROUND: Guideline-recommended therapies for acute coronary syndromes (ACS) derive from randomized trials in which elderly patients are underrepresented. Although numbers of this population are increasing, they are largely undertreated in the real world. OBJECTIVE: The study evaluates the impact of older age on care for patients with ACS admitted to the Italian Intensive Cardiac Care Units (ICCUs) network. METHODS: We analyzed data from the BLITZ-3 Registry in order to assess in-hospital care among unselected elderly patients (≥75 years). RESULTS: From 7-20 April 2008, 6986 consecutive patients with acute cardiac conditions were admitted to ICCUs and prospectively enrolled; 3636 (52%) had ACS and 38% of them were elderly. Elderly patients had a higher risk profile, their median length of stay in ICCU was longer [4 days, interquartile range (IQR): 3-6 vs. 3 days, IQR: 2-5; P < 0.0001] and guideline-recommended care was applied less often. At multivariable analysis, elderly patients were less likely to receive reperfusion [odds ratio (OR) = 0.53, 95% confidence interval (CI) = 0.42-0.67] for ST-elevation, or early coronary angiography (OR = 0.45, 95% CI = 0.37-0.56) for non-ST elevation ACS. Besides, unadjusted in-ICCU total mortality was higher for elderly patients with ST-elevation (11.8% elderly vs. 1.8% younger patients; P < 0.0001) or non-ST-elevation (3.9% elderly vs. 0.6% younger patients; P < 0.0001) ACS. CONCLUSION: In a nationwide survey, age impacts on care. The elderly with ACS have a higher risk profile but receive less guideline-recommended care than younger patients. Thus, further improvements in care of this population should be pursued.

The management of acute myocardial infarction in the cardiological intensive care units in Italy: the 'BLITZ 4 Qualità' campaign for performance measurement and quality improvement.

AIM: To assess and promote compliance of Italian cardiological intensive care units (CCUs) with evidence-based guidelines for the management of acute myocardial infarction (MI). METHODS AND RESULTS: The process of diagnosis and treatment of MI was prospectively evaluated in 163 CCUs by use of 30 indicators during two enrolment phases, each followed by a feedback of both local and general performance. Overall, 5854 patients with ST-segment elevation MI (STEMI) and 5852 with non-ST-segment elevation MI (NSTEMI) were consecutively enrolled. The target for each indicator was defined as compliance with the relevant recommendations in ≥90% of suitable patients and it was met for nine (30%) and 10 (33.3%) indicators in the first and second phases, respectively. Regardless of target, a significant improvement in compliance was observed in the second phase in 10 out of 30 indicators (33.3%). Use of pre-hospital ECG, expedite delivery of reperfusion therapy, dosage of antithrombotic drugs, and non-pharmacological implementation of secondary prevention were often off target. Similar in-hospital mortality was observed in phases I and II, both in patients with STEMI (4.0 vs. 4.2%, p=0.79) and NSTEMI (1.8 vs. 2.4%, p=0.11). Overall, 30-day mortality were 5.7% for patients with STEMI and 3.4% with NSTEMI. CONCLUSIONS: Performance indicators can accurately weigh the whole process of diagnosis and treatment of patients with MI and monitor the improvements in the quality of care. In our large population of consecutive patients, satisfactory 30-day outcomes were observed despite suboptimal adherence to guidelines for some indicators of recognised prognostic relevance.

[Distribution and appropriateness of hospital admissions, resource utilization in the Italian intensive cardiac care units. The BLITZ-3 study]. / Distribuzione e appropriatezza dei ricoveri ed utilizzo di risorse nelle unità di terapia intensiva cardiologica italiane. Lo studio BLITZ-3.

BACKGROUND: The BLITZ-3 study prospectively evaluated the epidemiology of hospital admissions, the patterns of care and the most important comorbidities in intensive cardiac care unit (ICCU) patients. METHODS: Distribution and level of appropriateness of hospital admissions in relation to type of ICCU were analyzed (type A, 32%, without cardiac cath lab or cardiac surgery; type B, 49%, with cath lab; type C, 19%, with both cath lab and cardiac surgery). The caseload was estimated on the basis of different levels of mortality risk during the ICCU stay: high (>5.1%), intermediate (0.7-5.1%), low (< or = 0.7%). RESULTS: A total of 6986 consecutive patients admitted to 332 ICCUs were enrolled. A median number of 19 patients (interquartile range 15-26) was admitted to each center during the 14 days of enrollment; 28% of the ICCUs admitted more than 25 patients, 48% between 15 and 25, and 24% less than 15. A higher number of type A ICCUs admitted less than 15 patients (p<0.0001), whereas a higher number of type C ICCUs admitted more than 25 patients (p<0.0001). Hospital admissions for ST-elevation myocardial infarction occurred more frequently in type B or C ICCUs (p<0.0001), whereas hospital admission for heart failure mostly occurred in type A ICCUs (p<0.0001). The number of patients not undergoing reperfusion (p<0.0001) or treated with thrombolytic therapy (p<0.0001) was higher in the type A ICCUs. Coronary revascularization with primary percutaneous coronary intervention was performed more frequently in type B and C ICCUs (p<0.0001). Similarly, patients hospitalized for acute coronary syndrome underwent coronary angiography (p<0.0001) and percutaneous coronary intervention more frequently in type B and C ICCUs (p<0.0001). Prevalence of low-risk rather than intermediate- or high-risk patients was higher in type A ICCUs (p<0.05), and prevalence of high- or intermediate-risk patients was higher in type C ICCUs (p<0.05). CONCLUSIONS: The results of the BLITZ-3 study should lead the Italian cardiological community to reflect upon the needed number of ICCUs, the role of Spoke centers for their integration in the interhospital network, and inappropriate hospital admissions for low-risk conditions.

[Italian nursing survey of cardiological intensive care units]. / Censimento infermieristico delle unità di terapia intensiva cardiologica in Italia.

BACKGROUND: The recent evolution of nursing management of cardiovascular disease has led to significant changes in specific healthcare processes. The aim of this study is to present the first nursing survey of Italian intensive cardiac care units (ICCUs). METHODS: In March and April 2007, a questionnaire investigating the main problems concerning ICCU organization, specifically addressed to nursing care, has been mailed to all the operative Italian ICCUs. The questionnaire investigated staff characteristics, education and training, daily work organization, risk management strategies, and nursing research. RESULTS: For a more detailed analysis, the ICCUs were divided into three levels (standard, medium and high) based on their technological equipment, and in particular mechanical ventilatory assistance and intra-aortic balloon pumping availability. A high proportion of ICCUs (347/385, 90%) answered to the questionnaire and an analysis of the responses revealed no significant differences between the three main geographical areas of Italy (North, Center, South). CONCLUSIONS: Despite some organizational and staffing problems, the survey confirmed the high level of routine nursing care, the strong tendency towards the integration of different professional competencies among the staff, and the high degree of standardization.

Epidemiology and patterns of care of patients admitted to Italian Intensive Cardiac Care units: the BLITZ-3 registry.

BACKGROUND: Intensive cardiac care units (ICCUs) have shifted from the observation of patients with myocardial infarction to the care of different acute cardiac diseases. However, few data on such an evolution are available. METHODS AND RESULTS: From 7 to 20 April 2008, 6986 consecutive patients admitted to 81% of Italian ICCUs were prospectively enrolled. Patients observed were mainly elderly men (median age 72 years) with several co-morbidities. Most of them were triaged to ICCU from the emergency room, but 15% of admissions were transfer-in from other hospitals. Several diagnostic and therapeutic procedures were applied (78% had echocardiography and 35% coronary angiography) during the ICCU stay [median length 4 days, interquartile range (IQR) 2-5]. The discharge diagnosis was ST-elevation acute coronary syndrome (ACS) in 21%, non-ST-elevation ACS in 31%, acute heart failure (AHF) in 14% and other acute non-ACS, non-AHF cardiac diseases in 34%. Of those with ST-elevation ACS, 60% received reperfusion (15% fibrinolysis and 45% primary percutaneous coronary intervention). The overall in-ICCU crude mortality was 3.3%. CONCLUSION: The BLITZ-3 survey provides a unique snapshot of current epidemiology and patterns of care of patients admitted to ICCUs. Although ACS still remains the most frequent admission diagnosis, the number of non-ACS patients is substantial. However, the correct standard of care for these non-ACS patients has to be defined.