Exercise haemodynamic variables rather than ventilatory efficiency indexes contribute to risk assessment in chronic heart failure patients treated with carvedilol.

AIMS: To evaluate the prognostic significance of traditional cardiopulmonary exercise testing (CPET) parameters in chronic heart failure (CHF) patients treated with beta-blockers. METHODS AND RESULTS: A total of 631 CHF patients were followed for cardiovascular death over 3.8 +/- 1.4 years; among them 79 (13%) died. All prognostic CPET parameters were related to outcome at univariate analysis, with haemodynamic-derived parameters [peak systolic blood pressure (SBP), peak circulatory power (CP) = peak oxygen consumption (pVO2) x peak SBP] and exertional oscillatory ventilation (EOV) reaching the highest chi2 (46.5, 40.9, and 22.6, respectively, all with P < 0.0001). Exertional oscillatory ventilation, although associated with high mortality rate (43 vs. 11%, P < 0.001), was detected in 42 (7%) patients. In non-EOV, again both peak SBP and peak CP reached the highest chi2 (30.6, and 21.6, respectively, all with P < 0.0001). Regarding CPET parameters, at multivariable analysis, peak SBP was the strongest risk index both in total and non-EOV populations, with 11% risk reduction every 5 mmHg increase. CONCLUSION: All traditional CPET risk parameters were informative in beta-blockers CHF patients, but peak SBP, peak CP, and EOV were the most predictive. In this low-risk population, EOV, although underrepresented, considerably enhanced risk stratification, although other ventilatory efficiency indexes provided less impressive predictive content. In large majority of non-EOV patients, peak SBP improved risk evaluation beyond other CPET parameters.

Flow mediated dilation in patient with Berlin Heart Incor left ventricle assist device.

Endothelial function measured with brachial ultrasound (BU) is a validated prognostic factor in heart failure patients. LVAD (left ventricle assist device) application is a promising surgical technique to treat refractory heart failure patients both as a bridge to heart transplantation or as destination therapy. Clinical recovery in such patients may be associated to normal endothelial function measured by BU but, as recently reported, only in pulsatile flow LVAD patients. The present paper report a case of normal endothelial function even in a axial LVAD patient.

Sleep and exertional periodic breathing in chronic heart failure: prognostic importance and interdependence.

BACKGROUND: Sleep and exertional periodic breathing are proverbial in chronic heart failure (CHF), and each alone indicates poor prognosis. Whether these conditions are associated and whether excess risk may be attributed to respiratory disorders in general, rather than specifically during sleep or exercise, is unknown. METHODS AND RESULTS: We studied 133 CHF patients with left ventricular ejection fraction (LVEF) < or =40%. During 1170+/-631 days of follow-up, 31 patients (23%) died. Nonsurvivors had higher New York Heart Association class, ventilatory response (ve/vco2 slope), and apnea-hypopnea index (AHI) and lower peak vo2 (all P<0.01); lower LVEF and prescription of beta-blockers, and shorter transmitral deceleration time (all P<0.05). Exertional oscillatory ventilation (EOV), established by cyclic fluctuations in minute ventilation that persisted for > or =60% of exercise duration with an amplitude > or =15% of the average resting value, was significantly more frequent in nonsurvivors (42% versus 15%, P<0.01). Multivariable analysis selected AHI (hazard ratio [HR] 5.66, 95% CI 2.3 to 19.9, P<0.01), peak vo2 (HR 0.93, 95% CI 0.90 to 0.97, P<0.01), and beta-blocker prescription (HR 0.34, 95% CI 0.13 to 0.87, P<0.05) as predictors of cardiac events. The best cutoff for AHI was >30/h. EOV was significantly related to AHI >30/h (chi2 14.6, P<0.01): 78% of EOV patients showed AHI >30/h. Multivariable analysis, including breathing disorders alone (EOV, AHI >30/h) or in combination (EOV plus AHI >30/h), selected combined disorders as the strongest predictor of events (HR 6.65, 95% CI 2.6 to 17.1, P<0.01). CONCLUSIONS: In CHF, EOV is significantly associated with AHI >30/h. Although each breathing disorder alone is linked to total mortality, their combination has a crucial prognostic burden.

Cardiac rehabilitation in the elderly: patient selection and outcomes.

In Western countries, the aging and improving survival of patients with coronary heart disease are responsible for an increasing number of older adults (65 years of age and older) who are eligible for cardiac rehabilitation. The elderly with coronary heart disease represent a special population with changes induced by aging and lifestyle, comorbidity, cognitive dysfunction, and high risk of disability. Although the elderly account for the majority of cardiac admissions and procedures, studies on cardiac rehabilitation have traditionally focused on younger patients. In aged experimental animals, there is evidence that exercise training is able to improve hemodynamic parameters and biologic markers. Moreover, in older patients, exercise improves functional capacity and reduces myocardial work, similar to that seen in younger patients. As for younger patients, cardiac rehabilitation requires a multidisciplinary approach, including comprehensive assessment, treatment of risk factors and comorbidity, and psychosocial assessment. Cardiac rehabilitation is safe and helpful for elderly coronary patients. Physicians must be encouraged to prescribe cardiac rehabilitation programs for the elderly following major coronary events and coronary revascularization procedures.

Contribution of peak respiratory exchange ratio to peak VO2 prognostic reliability in patients with chronic heart failure and severely reduced exercise capacity.

BACKGROUND: We evaluated the influence of peak respiratory exchange ratio (pRER), as an index of effort adequacy, on peak VO2 prognostic reliability in patients with chronic heart failure (CHF) and reduced exercise capacity, whose peak VO2 may be underestimated because of poor patient motivation. METHODS: A cardiopulmonary exercise test was performed in 570 patients with CHF (age 60 +/- 10 years, ejection fraction 26% +/- 7%, New York Heart Association class 2.2 +/- 0.6), 193 of whom had a peak VO2 that was >10 but 10 but or=1.15 had a 2-year survival rate of 52%, and this pRER value (but not >or=1, >or=1.05, or >or=1.10) was the only independent predictor of the composite end point (chi(2) = 4.73, P =.03). Conversely, in the group of patients with a peak VO2 10 but

Limited predictive value of cardiopulmonary exercise indices in patients with moderate chronic heart failure treated with carvedilol.

BACKGROUND: Peak oxygen consumption (VO2) is traditionally used for risk stratification in chronic heart failure (CHF); however, its predictive value is unknown with carvedilol treatment. Therefore, we sought to investigate the prognostic role of gas-exchange parameters obtained from symptom-limited cardiopulmonary exercise testing (CPX) in patients with CHF that is treated with carvedilol. METHODS: A total of 508 consecutive patients (443 men, mean age [+/- SD] 59 +/- 9 years) with a mean left ventricular ejection fraction (LVEF) of 25% +/- 7% underwent CPX. The peak VO2 was 13.9 +/- 3 mL/kg/min; the rate of increase of minute ventilation per unit of increase of carbon dioxide production (VE/VCO2 slope) was 32 +/- 2. Outcomes (cardiovascular death or urgent heart transplantation) were determined when all patients who survived had been observed for a minimum of 6 months. RESULTS: Patients were divided into groups according to treatment (carvedilol and non-carvedilol); 236 patients were treated with carvedilol (46%), at a mean dose of 25 +/-13 mg. The VE/CO2 slope, LVEF, peak VO2, and carvedilol treatment were revealed by means of multivariate analysis to be independent and additional predictors in the total population; VE/VCO2 slope, LVEF, and peak VO2 were revealed to be independent and additional predictors in the patients in the noncarvedilol group (all P <.001); and only peak VO2 was revealed to be an independent and additional predictor in the patients in the carvedilol group (P <.01). In the carvedilol group, mortality rates were 26%, 11%, 10%, and 4% (P <.05) in patients with peak VO2 < or =10 mL/kg/min, >10 to < or =14 mL/kg/min, >14 to 18 mL/kg/min, and > or =18 mL/kg/min, respectively. No difference in mortality rates according to peak VO2 or additional outcome indices were identified in the 212 patients with peak VO2 >10 mL/kg/min. CONCLUSIONS: Peak VO2 provides limited predictive information in patients with CHF that is treated with carvedilol, and no additional gas exchange parameter yields supplementary advice.

Ventilatory response to exercise improves risk stratification in patients with chronic heart failure and intermediate functional capacity.

BACKGROUND: Peak oxygen consumption (VO2) has an important prognostic role in chronic heart failure (CHF), but its discriminatory power is limited in patients with intermediate exercise capacity (peak VO2 between 10-18 mL/kg/min). Thus, supplementary exertional indexes are greatly needed. METHODS: Six hundred patients with CHF with left ventricular ejection fraction (LVEF) < or = 40% who performed a symptom-limited cardiopulmonary exercise testing were screened and followed up for 780 +/- 450 days. RESULTS: Eighty-seven patients had major cardiac events (77 cardiac deaths and 10 urgent heart transplantations). Multivariate analysis revealed the rate of increase of minute ventilation per unit of increase of carbon dioxide production (VE/VCO2 slope) (chi2, 79.3, P <.0001), LVEF (chi2, 24.6, P <.0001), and peak VO2 (chi2, 9.4, P <.0001) as independent and additional predictors of major cardiac events. VE/VCO2 slope was the strongest independent predictor of outcome (chi2, 20.9, P =.0001) in patients with intermediate peak VO2 (n = 403), and the best cutoff value was 35 (chi2, 25.8; relative risk = 3.2, 95% CI 2.0-5.1, P <.0001). Total mortality rate was 30% in patients with VE/VCO2 slope > or = 35 (n = 103, 26%) and 10% in those with VE/VCO2 slope <35 (n = 300, 74%) (P <.0001). Patients with VE/VCO2 slope > or = 35 had a similar total mortality rate to those with peak VO2 < or = 10 mL/kg/min (30% vs 37%, P not significant). CONCLUSIONS: A rational and pragmatic risk stratification process with symptom-limited cardiopulmonary exercise testing in CHF should include both peak VO2 and VE/VCO2 slope, the latter index effectively predicting outcome in almost one fourth of patients with intermediate exercise capacity.

Left atrium remodeling after acute myocardial infarction (results of the GISSI-3 Echo Substudy).

To evaluate the existence, timing, and determinants of post-infarction left atrial remodeling, we studied a subgroup of 514 patients from the Third Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico Echo Substudy who underwent 4 serial 2-dimensional echocardiograms up to 6 months after acute myocardial infarction. This study is the first to demonstrate, in a large series of patients, the existence of early and late left atrial remodeling after low-risk acute myocardial infarction and the relation of left atrial remodeling to left ventricular remodeling.

Cardiopulmonary exercise testing and prognosis in chronic heart failure: a prognosticating algorithm for the individual patient.

The identification of individuals who are at high risk of chronic heart failure (HF) is a medical art of growing concern. Cardiopulmonary exercise stress testing (CPX) has become an important clinical tool to predict outcome. The value of peak oxygen consumption rests in the fact that it integrates elements of cardiac adaptations, and skeletal muscle, pulmonary, and endothelial dysfunctions more than other traditional prognostic indicators of chronic HF. Recently, exercise-related ventilatory abnormalities have gained attention, stimulating scientific debate and an innovative perspective. This review, through a critical examination of previous experiences, will focus on the prognostic application of CPX, defining a proficient outline of treatment for the individual patient.

Oscillatory ventilation during exercise in patients with chronic heart failure: clinical correlates and prognostic implications.

STUDY OBJECTIVES: Although breathing disorders are often found in patients with chronic heart failure, exertional oscillatory ventilation (EOV) has been occasionally described. The aim of this study was to determine the prevalence, clinical characteristics, and outcome of patients with chronic heart failure and EOV. SETTING: Cardiology division at tertiary-care hospital. STUDY POPULATION: We studied 323 patients with chronic heart failure and left ventricular ejection fraction (LVEF) < or = 40%. MEASUREMENTS AND RESULTS: All patients performed a symptom-limited cardiopulmonary exercise test and were followed up for 22 +/- 11 months (mean +/- SD). EOV was defined as cyclic fluctuations in minute ventilation (E) at rest that persist during effort lasting > or = 60% of the exercise duration, with an amplitude > or = 15% of the average resting value. Patients with EOV (12%), as compared to those without, showed higher New York Heart Association (NYHA) class (p < 0.05) and lower LVEF (p < 0.0001) and peak oxygen consumption (O(2)) [p < 0.0001]. During the follow-up period, 53 patients died or underwent urgent cardiac transplantation; this group showed higher NYHA class (p < 0.05) and E/CO(2) slope (p < 0.0001) and lower LVEF (p < 0.0001), mitral Doppler early deceleration time (p < 0.01), and peak O(2) (p < 0.0001). EOV was more frequent in nonsurvivors than in survivors (28% vs 9%, p < 0.01). Multivariate analysis revealed peak O(2) (chi(2), 51.5; p < 0.0001), EOV (chi(2), 45.4; p < 0.0001), and LVEF (chi(2), 20.6; p < 0.0001) as independent predictors of major cardiac events. CONCLUSIONS: EOV is not unusual in patients with chronic heart failure, and is associated with worse clinical status, cardiac function, and exercise capacity. EOV is a powerful predictor of poor prognosis and, consequently, it may be considered a valuable guide in the management of patients with chronic heart failure and should suggest a more aggressive medical treatment policy when detected.

Ultrasound-guided compression repair of femoral pseudoaneurysms complicating cardiac catheterization.

BACKGROUND: Femoral pseudoaneurysms complicate cardiac catheterizations in up to 3.2% of cases. Ultrasound-guided compression repair (UGCR) is a known valid alternative therapy to surgical and percutaneous repair. We evaluated its safety and efficacy in a series of patients. METHODS: Patients with clinical findings suggesting pseudoaneurysm after cardiac catheterization, underwent echo-color and duplex studies. When a pseudoaneurysm was diagnosed, the patient underwent UGCR until closure or for 50 min. A groin compression bandage was applied after the procedure and patients were put on bed rest for 12-18 hours; a new ultrasound study was performed the day after the procedure: when the UGCR procedure failed, patients were referred to a vascular surgeon or interventional radiologist. When possible, a third ultrasound study was performed 1 month after the procedure. RESULTS: Between January 2001 and June 2003, 15 pseudoaneurysms were diagnosed and treated by means of UGCR. The UGCR procedure (UGCR followed by groin bandage) was successful in 13 cases (87%); 1 patient underwent surgical repair and 1 patient underwent percutaneous repair. No local or systemic complications were observed following UGCR. CONCLUSIONS: Pseudoaneurysm UGCR constitutes a safe and valid procedure; it is less invasive and easier to perform than percutaneous and surgical repair.

[Life style and adherence to the recommended treatments after cardiac transplantation]. / Stile di vita e aderenza ai trattamenti raccomandati dopo trapianto cardiaco.

BACKGROUND: All the previous studies showed an increase in survival after cardiac transplantation. Nevertheless, a certain number of patients persist, in the short- and long-term period, in leading an incorrect lifestyle. Owing to this high-risk behavioral profile clinical, psychological and social problems could arise. METHODS: We have analyzed the quality of life and adherence to the recommended treatments in 107 patients at least 6 months (range 6-132 months) after they had been submitted to heart transplant and returned to their preoperative social and family environments. RESULTS: Data analysis has shown, in these patients, the return to their previous high-risk lifestyle habits: 18.4% of them did not adhere to the suggested diet, 13.2% did not perform physical activity, and 36.7% of the smokers took up the habit again after the transplant. Perceptions of emotional distress were still there: anxiety in 10.3% of cases and depression in 13.1%. An unsatisfactory sexuality was reported by 27.1% and only 27% returned to their previous job. Their outlook towards their self-efficacy seems to be predictive of the quality of life as perceived by the patient after the heart transplant: the better their outlook towards their self-efficacy, the better the quality of life. CONCLUSIONS: These data show that following heart transplant, before implementing postoperative preparation and rehabilitation programs one must carefully study those problem areas that unfortunately still exist.

Prognostic value of time-related changes of cardiopulmonary exercise testing indices in stable chronic heart failure: a pragmatic and operative scheme.

BACKGROUND: Although peak oxygen consumption (VO2) is an objective measurement of functional capacity linked to survival, most clinicians use clinical history to monitor changes over time of functional disability. The aim was to verify the prognostic value of time-related changes (Delta) of symptom-limited cardiopulmonary exercise testing (CPX) indices in stable chronic heart failure (CHF). DESIGN AND METHODS: We studied 231 stable CHF patients (200 men) with left ventricular ejection fraction (LVEF) of 24 +/- 8% and peak VO2 of 14.3 +/- 8 ml/kg per min, who performed two symptom-limited CPX over time. RESULTS: The two incremental CPX were separated by a mean interval of 258 +/- 42 days; 59 (26%) suffered cardiovascular death or underwent urgent heart transplantation during the follow-up (1167 +/- 562 days). Peak VO2, LVEF (measured at second evaluation), Deltapeak VO2 and DeltaNYHA (New York Heart Association classification) were selected as independent predictors in the total population, and LVEF, Deltapeak VO2, and NYHA in patients with peak VO2 of 14 ml/kg per min or less (106 patients); no Delta parameter was selected in patients with preserved exercise tolerance. Survival analysis was performed taking into consideration the inter-test variability of peak VO2 (6%): true fall: more than 6% decrease, decline within the measurement variability; less than 6% decrease, improvement within the measurement variability; less than 6% increase and true rise; more than 6% increase: total mortality rate was 51, 23, 19 and 14% (P < 0.0001), respectively. CONCLUSIONS: Deltapeak VO2 is a useful outcome index; a combination of static (single) and time-related functional variables can enhance the prognostication process in stable CHF patients.

Blunted erythropoietin production and defective iron supply for erythropoiesis as major causes of anaemia in patients with chronic heart failure.

AIMS: Anaemia is often observed in patients with chronic heart failure (CHF), and it may be associated with a worse prognosis. Aim of this study was to identify the individual mechanisms of anaemia in CHF patients. METHODS AND RESULTS: One hundred and forty-eight consecutive patients with haemoglobin concentration <13 g/dL (if males) or <12 g/dL (if females) were enrolled. Factors responsible for anaemia were investigated by evaluating endogenous erythropoietin (Epo) production, serum cytokines levels, body iron status, and iron supply for erythropoiesis. Most patients (57%) presented anaemia of chronic disease and among them, 92% showed evidence of a defective endogenous Epo production. This was indicated by an observed/predicted log(serum Epo) ratio less than 0.8 and/or a defective iron supply for erythropoiesis diagnosed by low transferrin saturation and/or increased value of soluble transferrin receptor. According to regression analysis sex, renal failure, and serum Epo were correlated with anaemia. CONCLUSION: According to our study, about half of anaemic CHF patients showed anaemia of chronic disease with blunted endogenous Epo production and/or a defective iron supply for erythropoiesis. Determination of the individual mechanisms of anaemia in CHF could justify a rational therapeutic approach to anaemia.