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Technological innovation provides easily accessible tools capable of simplifying healthcare processes. Notably, digital technology application in the cardiology field can improve prognosis, reduce costs, and lead to an overall improvement in healthcare. The digitization of health data, with the use of electronic health records and of electronic health files in Italy, represents one of the fields of application of digital technologies in medicine. The 2023 States General of the Italian Association of Hospital Cardiologists (ANMCO) provided an opportunity to focus attention on the potential benefits and critical issues associated with the implementation of the aforementioned digital tools, artificial intelligence, and telecardiology. This document summarizes key aspects that emerged during the event. more...

Increasing evidence shows an association between high lipoprotein(a) [Lp(a)] levels and atherothrombotic diseases. Lp(a) trait is largely controlled by kringle-IV type 2 (KIV-2) size polymorphism in LPA gene, encoding for apo(a). Environmental factors are considered to determinate minor phenotypic variability in Lp(a) levels. In the present study, we investigated the possible gene-environment interaction between KIV-2 polymorphism and Mediterranean diet adherence or fish weekly intake in determining Lp(a) levels. We evaluated Lp(a), KIV-2 polymorphism, fish intake and Mediterranean diet adherence in 452 subjects [median age (range) 66 (46-80)years] from Montignoso Heart and Lung Project (MEHLP) population. In subjects with high KIV-2 repeats number, influence of Mediterranean diet adherence in reducing Lp(a) levels was observed (p = 0.049). No significant difference in subjects with low KIV-2 repeats according to diet was found. Moreover, in high-KIV-2-repeat subjects, we observed a trend towards influence of fish intake on reducing Lp(a) levels (p = 0.186). At multivariate linear regression analysis, high adherence to Mediterranean diet remains a significant and independent determinant of lower Lp(a) levels (β = - 64.97, standard error = 26.55, p = 0.015). In conclusion, this study showed that only subjects with high KIV-2 repeats can take advantage to lower Lp(a) levels from correct nutritional habits and, in particular, from Mediterranean diet. more...

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyze the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education and legal aspects. more...

The ECG signal can be derived from different sources. These include systems for surface ECG, Holter monitoring, ergometric stress tests and systems for telemetry and bedside monitoring of vital parameters, useful to rhythm and ST-segment analysis and ECG screening of cardiac electrical sudden death predictors. A precise ECG diagnosis is based upon a correct recording, elaboration and presentation of the signal. Several sources of artifacts and potential external causes may influence the quality of the original ECG waveforms. Other factors that may affect the quality of the information presented depends upon the technical solutions employed to improve the signal. The choice of the instrumentations and solutions used to offer a high quality ECG signal are therefore of paramount importance. Some requirements are reported in detail in scientific statements and recommendations. The aim of this consensus document is to offer a scientific reference for the choice of systems able to offer a high quality ECG signal acquisition, processing and presentation suitable for clinical use. more...

Purpose: To assess the clinical significance of serial troponin I levels (measured in the first 72 hours from admission) in 42 consecutive patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Echocardiography and electrocardiogram testings were serially performed in the time window., Materials and Methods: Troponin I was measured every 12 hours in the first 72 hours from intensive care unit (ICU) admission. Echocardiography and electrocardiogram testings were serially performed in the same time window to clinically interpret Tn I levels., Results: Patients with admission positive Tn I (38.1%) showed higher values of systolic pulmonary hypertension (P = .013) associated with significantly lower values of tricuspid annular plane excursion (P = .011). Twenty-five patients (25/42, 59.5%) exhibited positive peak Tn I and at second echocardiographic assessment exhibited significant lower tricuspid annular plane excursion values (P = .005). At stepwise regression analysis the following variables were an independent predictor for in-ICU mortality: Pco2 (OR 1.08, 95% CI 1.011-1.161, P = .023), systolic pulmonary arterial hypertension (OR 0.83, 95% CI 0.701-0.977, P = .002), log peak Tn I (OR 3.56, 95% CI 1.045-12.132, P = .042)., Conclusions: In moderate-to-severe ARDS, serial troponin I assessment together with echocardiography evaluation helped to identify a subgroup at higher risk for in-ICU death. Moreover, troponin release can be related to right ventricular dysfunction, thus highlighting the clinical role of echocardiography in ARDS patients., (Copyright © 2016 Elsevier Inc. All rights reserved.) more...

Telemedicine applied to heart failure patients is a tool for recording, remote transmission, storage and interpretation of cardiocirculatory parameters and/or diagnostic images, useful, as emphasized by the latest guidelines, to allow for intensive home monitoring in patients with advanced heart failure or during the vulnerable post-acute phase to improve the prognosis and quality of life for patients.Recently, several meta-analyses have shown that the patterns of care supported by telemedicine are not only effective, but also economically advantageous. The benefit is unquestionable with a 30-35% reduction in mortality and a 15-20% reduction in hospitalizations. Patients implanted with cardiac devices can also benefit from an integrated remote clinical management as all modern devices can transmit technical and diagnostic data. However, telemedicine can bring benefits to the patient with heart failure only if it is part of a shared and integrated, multidisciplinary and multiprofessional "Chronic Care Model". Moreover, the future development of remote telemonitoring programs in our country goes through the primary use of products certified as medical device, field validation of organizational solutions proposed, a legislative and administrative adaptation to new care methods and the widespread growth of competence in clinical care to remotely manage the complexity of chronicity.With this consensus document the Italian Cardiology reaffirms its willingness to contribute to the government of the tumultuous and fragmented technological development, proposing a new phase of qualitative assessment, standardization of processes and testing the application of telemedicine to heart failure. more...

Background: The relationship between troponin and atrial fibrillation (AF) without acute coronary syndrome is still unclear. We sought to investigate the presence of coronary atherosclerosis and adverse outcomes in patients with AF., Methods: Consecutive patients with recent-onset AF and without severe comorbidities were enrolled between 2004 and 2013. Patients with a troponin rise or with adverse outcomes were considered for coronary angiography and revascularization when "critical" stenosis (≥70%) was recognized. Propensity score matching was performed to adjust for baseline characteristics; after matching, no differences existed between the groups of patients with or without troponin rise. The primary end point was the composite of acute coronary syndrome, revascularization, and cardiac death at 1- and 12-month follow-ups., Results: Of 3627 patients enrolled, 3541 completed the study; 202 (6%) showed troponin rise; and 91 (3%), an adverse outcome. In the entire cohort, on multivariate analysis, the odds ratio for the occurrence of the primary end point of troponin rise was 14 (95% confidence interval [CI], 10-23; P<.001), and that of known coronary artery disease was 3 (CI, 2-5; P=.001). In the matching cohort, the odds ratio of troponin rise was 10 (CI, 4-22; P<.001), and that of TIMI score greater than 2 was 4 (CI, 2-9; P≤.001). In the entire cohort, patients with or without troponin rise achieved the primary end point in 38 (19%) and 43 (1%) patients, respectively (P<.001). Stroke occurred in 4 (2%) and 20 (1%), respectively (P=.018). Critical stenosis and revascularization account for 23 (12%) and 15 (1%), respectively (P<.001). In the matching cohort, results were confirmed, but incidence of stroke was comparable., Conclusions: Patients with recent-onset AF and troponin rise showed higher prevalence of coronary atherosclerosis and adverse cardiac events. Stroke per se did not succeed in justifying the high morbidity. Thus, beyond stroke, coronary atherosclerosis might have a pivotal role in poor outcomes., (Copyright © 2015 Elsevier Inc. All rights reserved.) more...

Introduction: Limited data are available on the natural history of high on treatment platelet reactivity (HPR) by arachidonic acid and ADP - markers of unfavorable prognosis in acute coronary syndrome patients -., Material and Methods: In a cohort of acute coronary syndrome male patients (n=101), we evaluated the time-course of HPR by ADP (platelet aggregation by 10μM ADP≥70%) and arachidonic acid (platelet aggregation by 1mmol arachidonic acid≥20%) measuring platelet function in the acute phase (T0), at 6months (T1) and 1year (T2)., Results: We identified persistent (HPR at T0,T1 and T2), acute non persistent (HPR only at T0), and late (HPR only at T1 or T2). Patients with persistent HPR by ADP were more frequently with higher values of BMI. Patients carrying CYP2C19*2 variant were more prevalent in the group of persistent HPR (33%). Significant higher values of immature platelet fraction and high immature platelet fraction at 6 and 12months and mean platelet volume were present in patients with late HPR. Immature platelet fraction was the only variable significantly associated with late HPR by ADP at multivariate analysis (OR=1.6 (1.08-2.3), p=0.016). Patients with persistent HPR by arachidonic acid were more frequently diabetics. Immature platelet fraction at 6months and high immature platelet fraction at 6 and 12months were the parameters associated with late HPR by AA (OR=1.4 (1.0-1.9), p=0.036; OR=1.5 (1.08-2.4), p=0.05; OR=4.9 (1.3-18.8), p=0.018, respectively)., Conclusions: About 25% of 101 patients has persistent HPR; they are more frequently diabetics, overweight or carriers of CYP2C19*2. The occurrence of an inflammatory state, indicated by the increase of immature platelet fraction, is associated with the occurrence of late HPR., (Copyright © 2015 Elsevier Ltd. All rights reserved.) more...

We evaluated the relationship between admission renal function (as assessed by estimated glomerular filtration rate (eGFR)), hyperglycemia, and acute insulin resistance, indicated by the homeostatic model assessment (HOMA) index, and their impact on long-term prognosis in 825 consecutive patients with ST-elevation myocardial infarction (STEMI) without previously known diabetes who underwent primary percutaneous coronary intervention (PCI). Admission eGFR showed a significant indirect correlation with admission glycemia (Spearman's ρ -0.23, P < 0.001) and insulin values (Spearman's ρ -0.11, P = 0.002). The incidence of patients with admission glycemia ≥140 mg/dl was significantly higher in patients with eGFR <60 ml/min/m(2) (P < 0.001) as well as the incidence of HOMA positivity (P = 0.002). According to our data, a relationship between renal function and glucose values and acute insulin resistance in the early phase of STEMI was detectable, since a significant, indirect correlation between eGFR, insulin values, and glycemia was observed. Patients with renal dysfunction (eGFR <60 ml/min/1.73 m(2)) exhibited higher glucose values and a higher incidence of acute insulin resistance (as assessed by HOMA index) than those with normal renal function (eGFR ≥60 ml/min/1.73 m(2)). The prognostic role of glucose values for 1-year mortality was confined to patients with eGFR ≥60 ml/min/m(2), who represent the large part of our population and are thought to be at lower risk. In these patients, an independent relationship between 1-year mortality and glucose values was detectable not only for admission glycemia but also for glucose values measured at discharge. more...

Background: Application of percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) is suboptimal in older frail individuals. This study was conducted to verify if background risk is a risk factor for underuse and diminished effectiveness of PCI in older patients., Methods: An observational cohort study was conducted using data from the Acute Myocardial Infarction in Florence 2 registry, including all ACS hospitalised in 1 year in the area of Florence, Italy. Patients aged 75+ years were selected, whose background risk was stratified with the Silver Code (SC), a validated tool predicting mortality based upon administrative data. Multivariable OR for PCI application and HR for 1-year mortality by PCI usage were calculated., Results: In 698 patients (358 women, mean age 83 years), of whom 176 had ST-segment elevation myocardial infarction (STEMI), for each point increase in SC score the odds for application of PCI decreased by 11%, whereas the hazard of 1-year mortality increased by 10%, adjusting for positive and negative predictors. PCI reduced 1-year mortality progressively more with increasing SC, with HR (95% CI) of 0.8 (0.19 to 1.21), 0.41 (0.18 to 0.45), 0.41 (0.23 to 0.74) and 0.26 (0.14 to 0.48) for SC of 0-3, 4-6, 7-10 and 11+., Conclusions: Application of PCI in older ACS patients decreased with increasing background risk. This therapeutic attitude could not be justified by decreasing effectiveness of PCI in more compromised patients: conversely, application of PCI was associated with a long-term survival advantage that increased progressively with background risk, as expressed by SC., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.) more...

One hundred and fifty-three authors, 45 Italian scientific societies, and two Italian patients' associations participated in drafting the Italian Stroke Organization document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of the Italian Stroke Organization document, the main trials on carotid endoarterectomy and stenting were critically reviewed in order to formulate recommendations for these procedures. Recommendations are presented here for the referral of patients to either carotid endarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.) more...

Objective: To investigate the short-term effect of air temperature on outdoor occupational injuries (out&#95;OI) in Central Italy, also by taking different geographical factors and employment sectors of workers into account., Methods: Out&#95;OI for all of Tuscany (Central Italy), from 2003 to 2010 (n=162,399), were provided by the National Institute of Insurance for Occupational Illness and Injury. Representative daily meteorological data of the geographical area under study were obtained from the European Reanalysis-interim climatological reanalysis archive. Relationships between short-term changes in air temperature and out&#95;OI were studied through Generalised Additive Models., Results: The exposure-response curves of out&#95;OI and short-term changes in air temperature generally showed significant out&#95;OI increases when cold conditions occurred. The air temperature breakpoint corresponded to the 10th centile (-0.8°C) of the air temperature time series used in this study: a 1°C decrease in temperature below the 10th centile corresponded to a 2.3% (CI 1.3% to 3.3%) increase of out&#95;OI throughout all of Tuscany. The cold effect was strongest in plain areas, especially when out&#95;OI occurred in vehicles other than cars. No relationships of injuries with temperature extremes were observed in workers who generally spend half or most of their time outdoors, such as construction, land and forestry workers. However, these latter outdoor workers showed significant linear associations of injuries with typical (far-from-extreme) temperatures., Conclusions: This large population-based study highlights the significant and independent effects of short-term air temperature changes (especially cold) in triggering out&#95;OI. These findings represent the first step towards developing a geographically differentiated, operative outdoor-temperature-occupational-health warning system aimed at preventing outdoor work injuries., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.) more...

We assessed the incidence and the prognostic role for early death of acute insulin resistance (by means of homeostatic model assessment [HOMA] index) in 1350 patients with acute coronary syndrome (ACS) consecutively admitted to our intensive cardiac care unit (ICCU). The incidence of HOMA positivity was 5% (68 of 1350), with the highest percentage of HOMA positivity among ST-segment elevation myocardial infarction (STEMI). Patients with HOMA positivity showed a higher body mass index (P = .003), lower values of admission and discharge left-ventricular ejection fraction (LVEF; P < .001 and P = .003, respectively), and higher levels of peak troponin I (Tn I; P < .001). The HOMA index was an independent predictor of early death (odds ratio 1.724, 95% confidence interval 1.252-2.375, P = .001). In patients with ACS and without previously known diabetes, acute insulin resistance (HOMA index) is associated with a larger myocardial damage (ie, higher values of peak Tn I and lower LVEF) and a greater inflammatory activation (indicated by correlation with leukocyte count). The HOMA positivity was an independent predictor of in-ICCU mortality., (© The Author(s) 2013.) more...

The aim of this study is to identify the most effective thermal predictor of heat-related very-elderly mortality in two cities located in different geographical contexts of central Italy. We tested the hypothesis that use of the state-of-the-art rational thermal indices, the Universal Thermal Climate Index (UTCI), might provide an improvement in predicting heat-related mortality with respect to other predictors. Data regarding very elderly people (≥ 75 years) who died in inland and coastal cities from 2006 to 2008 (May-October) and meteorological and air pollution were obtained from the regional mortality and environmental archives. Rational (UTCI) and direct thermal indices represented by a set of bivariate/multivariate apparent temperature indices were assessed. Correlation analyses and generalized additive models were applied. The Akaike weights were used for the best model selection. Direct multivariate indices showed the highest correlations with UTCI and were also selected as the best thermal predictors of heat-related mortality for both inland and coastal cities. Conversely, the UTCI was never identified as the best thermal predictor. The use of direct multivariate indices, which also account for the extra effect of wind speed and/or solar radiation, revealed the best fitting with all-cause, very-elderly mortality attributable to heat stress. more...

Erythema is the most familiar short-term symptom of human skin associated with overexposure to unperceivable ultraviolet radiation (UV). However, people are able to perceive the warm infrared component of the solar radiation by means of thermal (dis)comfort. This study investigated the potentiality of perceived outdoor heat stress as a valuable proxy for the unperceivable effect of UV-induced risk of erythema in a Mediterranean city. Meteorological data and UVB (280-320nm) measurements were obtained for the 2004-2012 period by a weather station located in the municipality of Florence. Continuous measurements of erythemally effective UV (UVEry) were performed by means of a broadband temperature-corrected radiometer with the spectral response close to the erythemal action spectrum. Hourly UVEry doses were expressed as Standard Erythemal Doses (SEDs). The newly developed Universal Thermal Climate Index (UTCI), that represents the state-of-the-art of outdoor thermal (dis)comfort evaluation, was also assessed. Descriptive analyses of the hourly distribution per month of the frequencies of days with heat stress and UVEry exceeding 2.0, 3.0, 4.5 and 6.0 SEDs were carried out based on the general skin-type characteristics. The association between UVEry and UTCI was analyzed by a two-way contingency table approach. The probability of UVEry exceeding specific SED thresholds when heat stress occurs was often significantly higher than the same probability when no heat stress is perceived. Furthermore, increased magnitudes of the ratios, ranging from the very sensitive to the minimally sensitive skin types, were also found. However, during several months, too many days occur without any signs of heat discomfort, even when people may be exposed to relevant doses of harmful UVEry for the skin of various phototypes. These findings underlie the need for public health authorities to provide differentiated advice per month in relation to potential UV skin damage in the city of Florence., (Copyright © 2013 Elsevier B.V. All rights reserved.) more...

Background: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, particularly in the elderly. AF is considered an independent predictor of mortality and risk factor for stroke. AF-related stroke is usually severe and associated with a high rate of mortality and disability. Despite its prevalence, AF is a poorly known disease and it is underestimated by the general population. The aim of the Censis survey was to analyze the levels of AF knowledge and information in the Italian population and the level of AF risk awareness by general practitioners and AF patients., Methods: The survey included structured interviews with a sample of 1000 Italian citizens aged ≥18 years, 300 general practitioners, and 1200 AF patients., Results: The analysis confirmed low levels of knowledge of AF. In particular, the results showed that only one third of Italians know AF that is however perceived as a severe disease. In this subgroup, the risk of stroke associated with AF is known by 65%, but it is also widespread the wrong concept that AF is associated with an increased risk of myocardial infarction. The lack of knowledge of AF and its complications by the Italian population is due to educational gaps of general practitioners. In particular, only 50% of the Italian general practitioners perceive the thromboembolic risk of paroxysmal AF as comparable to that of permanent AF. In addition, there is an underuse of the scores for thromboembolic and hemorrhagic risk stratification recommended by current guidelines and a frequent use of antiplatelet therapy rather than oral anticoagulant therapy. There is also a low level of knowledge and awareness of the disease among AF patients. However, the majority of AF patients are aware of the importance of antithrombotic prophylaxis for stroke prevention., Conclusions: This study demonstrates limited knowledge and awareness of AF in the general population and also among general practitioners and affected patients. more...

ST-segment and non-ST-segment elevation myocardial infarction (STEMI, NSTEMI) have opposite epidemiology, the latter being nowadays more common than the former. Consistently with these epidemiological trends, application of evidence-based clinical practice guidelines on the management of NSTEMI should be promoted. We compared clinical features, hospital management and prognosis of STEMI/NSTEMI in an unselected cohort of 1,496 prospectively enrolled patients (STEMI, 36.9 % and NSTEMI, 63.1 %), admitted in 1 year to one of the six hospitals in Florence health district (Italy). Vital status was assessed after 1 year. NSTEMI patients were older, more often female, and affected by cardiovascular and non-cardiovascular comorbidities. Percutaneous coronary intervention (PCI) was performed more often in STEMI (82 %) than in NSTEMI patients (48 %, p < 0.001). Aspirin, clopidogrel, statins, beta-blockers, and ACE-inhibitors were prescribed more frequently in STEMI. In-hospital mortality was significantly lower in NSTEMI than in STEMI (4.2 vs. 8.9 %, p < 0.001), even after adjusting for confounders in a multivariable logistic model (OR 0.27, 95 % CI 0.16-0.45). One-year mortality was similar in NSTEMI and STEMI patients in an unadjusted comparison (18.0 vs. 16.7 %, p = 0.51), but it was lower in NSTEMI patients in multivariable Cox analysis (HR 0.56, 95 % CI 0.42-0.75). PCI reduced the risk of 1-year mortality similarly in STEMI (HR 0.47, 95 % CI 0.28-0.79) and NSTEMI (HR 0.41, 95 % CI 0.28-0.60). PCI reduces mortality in both STEMI and NSTEMI, but it is underutilised in patients with NSTEMI. To improve overall prognosis of AMI, efforts should be made at improving the care of NSTEMI patients. more...

Background: Previous studies on nonagenarians have widely investigated functional and cognitive decline, falls, predictors of mortality, inflammation and aging genetics. However, some intriguing domains, such as body composition, daily energy expenditure, sleep quality and physical activity, as well as endothelial progenitor cells and "omics" fields, such as proteomics or metabolomics, have been poorly explored. In this preliminary paper we report design, methods and characteristics of participants in the Mugello Study, a survey of nonagenarians aimed at filling these gaps., Methods: 475 non selected nonagenarians, 130 men and 345 women, mean age 92.6 years ± SD 2.6, received a visit by a trained physician at their residence. Along with the assessment of social, functional and cognitive status, reported in this paper, participants also underwent instrumental examinations, including body impedance assessment and continuous direct calorimetry, and were administered a series of validated questionnaires. Further, 385 participants accepted to undergo blood withdrawal., Results: In 52 cases the visit was conducted in nursing homes. Among the 423 home-living participants, 91 lived alone and 77 were not looked after by any caregiver. Altogether, 154 participants over 475 were free from disabilities and 266 showed Mini Mental State Examination raw scores ≥ 21. Men showed less disability and cognitive impairment (p<0.001, for both)., Conclusions: As a whole, our findings are comparable to those reported in other surveys. Future studies, by using the Mugello Study database and biologic bank, that will be available to all researchers, will shed some more light on the aging process in nonagenarians., (© 2013. Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. All rights reserved.) more...

Background: Contemporary therapeutic options have led to substantial improvement in survival of patients with heart failure. However, limited evidence is available specifically on idiopathic dilated cardiomyopathy. We thus examined changes in prognosis of a large idiopathic dilated cardiomyopathy cohort systematically followed during the past 30 years., Methods and Results: From 1977 to 2011, 603 consecutive patients (age, 53±12 years; 73% men; left ventricular ejection fraction, 32±10%) fulfilling World Health Organization criteria for idiopathic dilated cardiomyopathy, including negative coronary angiography, were followed up for 8.8±6.3 years. Patients were subdivided in 4 enrollment periods on the basis of heart failure treatment eras: (1) 1977-1984 (n=66); (2) 1985-1990 (n=102); (3) 1991-2000 (n=197); (4) 2001-2011 (n=238). Rates of patients receiving angiotensin-converting enzyme inhibitors/angiotensin receptors blockers, β-blockers, and devices at final evaluation increased from 56%, 12%, 8% (period 1) to 97%, 86%, 17% (period 4), respectively (P<0.05). There was a trend toward enrollment of older patients with less severe left ventricular dilatation and dysfunction during the years. During follow-up, 271 patients (45%) reached a combined end point including death (heart failure related, n=142; sudden death, n=71; and noncardiac, n=22) or cardiac transplant (n=36). A more recent enrollment period represented the most powerful independent predictor of favorable outcome {period 2 versus 1 (hazard ratio [HR], 0.64; P=0.04), period 3 versus 1 (HR, 0.35; P<0.001), period 4 versus 1 (HR, 0.14; P<001)}. Each period was associated with a 42% risk reduction versus the previous one (HR, 0.58; 95% confidence interval, 0.50-0.67; P<0.001), reflecting marked decreases in heart failure-related mortality and sudden death (period 4 versus 1: HR, 0.10; P<001 and HR, 0.13; P<0.0001, respectively)., Conclusions: Evidence-based treatment has led to dramatic improvement in the prognosis of idiopathic dilated cardiomyopathy during the past 3 decades. The benefits of controlled randomized trials can be replicated in the real world, emphasizing the importance of tailored follow-up and long-term continuity of care. more...

Aim: Limited data are available on the safety and outcome of percutaneous coronary intervention (PCI) in elderly patients with ST elevation myocardial infarction (STEMI), as elderly patients are under-represented in randomized trials., Methods: We therefore aimed at assessing the trends in mortality rates (both at short-term and at 1-year follow up) in an unselected cohort of 404 STEMI patients aged ≥ 75 years all submitted to primary PCI and consecutively admitted to our Intensive Cardiac Care Unit from 2004 to 2010., Results: In the first period (2004-2006), 202 patients (202/661, 30.6%) were aged ≥ 75 years, whereas in the second period (2007-2010), 203 patients (203/607, 33.4%) were aged ≥ 75 years. In the second period, STEMI patients were older (P<0.001), more diabetic (P<0.001) and with a higher incidence of comorbidities (P<0.001). A significantly lower use of intra-aortic balloon pump was observed, together with a reduced rate of bleeding, whereas the incidence of worsening renal function significantly increased (P=0.011). No difference was observed in the length of stay and in mortality rate (both in-hospital and 1-year post-discharge) between the first and the second period., Conclusions: According to our data, patients aged ≥ 75 years are characterized by an increasing number of comorbidities (in particular, a higher incidence of diabetes). Over a 6-year period, despite a more advanced age, early mortality (and length of stay) remained unchanged (probably thanks to a significant reduction in bleeding events), and no difference was observed in 1-year post-discharge mortality in these patients., (© 2012 Japan Geriatrics Society.) more...

Reticulated platelets (RP) are newly-formed platelets with a greater mass, a residual amount of RNA and an increased prothrombotic potential. No studies investigating the association between RP and the risk of cardiovascular death in acute coronary syndrome (ACS) patients are available. In the frame of the AMI-Florence 2 study, we investigated RP in 229 (154 M/ 75 F) ACS patients (125 ST-elevation myocardial infarction [STEMI]; 104 Non-STEMI/Unstable Angina). RP were measured by using the Sysmex XE-2100 haematology analyzer and were expressed as the percentage of RP out of the total optical platelet count (immature platelet fraction; IPF) and as the percentage of RP highly fluorescent (H-IPF). At one-year follow-up, 22 out of 229 patients (9.6%) died from cardiovascular causes. Higher values of IPF (p=0.05) and H-IPF (p=0.006) were detected in dead compared to alive patients. A receiver operating characteristics curve analysis identified IPF ≥3.3% and H-IPF ≥0.9% as optimal cut-off values to predict cardiovascular death. At the multivariate model adjusted for the Global Registry of Acute Coronary Events (GRACE) risk score, the association between RP and cardiovascular death remained significant for both IPF [OR (95%CI) : 4.15 (1.24-13.91) p=0.02] and H-IPF [OR (95%CI): H-IPF 5.03 (1.38-18.38) p=0.01]. In conclusion, RP are independent predictors of cardiovascular death and may be useful in improving risk stratification for ACS patients. Future prospective studies to evaluate the role of RP in determining cardiovascular events are warranted. more...

Objective: It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at providing a contribution to this issue., Methods: Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%., Results: Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement (P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% (P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively (P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively (P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001)., Conclusions: Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.) more...

Aims: Long-term prognosis of ST segment elevation myocardial infarction (STEMI) in the era of primary percutaneous coronary intervention (pPCI) remains relatively poorly investigated in unselected patients. This study analyzed 8-year follow-up of STEMI patients enrolled in the Florence Acute Myocardial Infarction Registry, a population-based, observational study performed in Italy in 2000-2001., Methods: The prognostic effect of pPCI adjusted for clinical and demographic characteristics on a composite end-point of new myocardial infraction, urgent revascularization or death, and on all-cause mortality separately, was assessed in multivariable Cox analysis, calculating hazard ratios and 95% confidence intervals. This analysis is concerned with 875 STEMI patients (mean age 70.6 ± 12.9 years), treated with pPCI (459) or conservatively (416)., Results: After 8 years, 59% of patients had experienced the composite end-point and 49% had died. The multivariable analysis showed a significantly better prognosis in patients receiving pPCI (hazard ratio 0.72, P = 0.001), evident also in the 645 patients who were event-free after the first year of follow-up (hazard ratio 0.72, P = 0.010). Other independent prognostic factors were advanced age, Killip class greater than 1, some cardiovascular or noncardiovascular comorbidities, in-hospital cardiogenic shock, ejection fraction less than 30%, and treatment with aspirin and statin during hospitalization. The beneficial effect of pPCI observed both in cases younger (adjusted hazard ratio 0.65, P = 0.013) and older than 75 years (adjusted hazard ratio 0.65, P = 0.001) was also confirmed considering as outcome all-cause mortality only., Conclusions: In unselected STEMI patients, survival advantage from pPCI extends for a long term (8 years). This survival advantage is maintained at advanced ages, thus enforcing the importance of improving delivery of appropriate care to older STEMI patients. more...

Aims: To assess the impact of microalbuminuria on the development of acute kidney injury and to investigate its prognostic role at long term follow-up in 526 consecutive patients with ST elevation myocardial infarction without previously known diabetes., Methods: Microalbuminuria was measured using immunonephelemetry in the urine collected in the night., Results: Patients with microalbuminuria were older (p = 0.013). They showed higher values of peak glycemia (p = 0.017), peak Tn I (p < 0.001), NT-pro BNP (p = 0.020), ESR (p = 0.003), CRP (p = 0.020), and leukocyte count (p < 0.001). Lower eGFR was observed in patients with microalbuminuria both on admission and during ICCU stay (p = 0.048 and p = 0.003, respectively). A positive correlation was observed between CRP and microalbuminuria (Spearman's rho 0.114, p = 0.024). The composite end point was observed in 73 patients (18 patients died and 59 patients developed acute kidney injury). At multivariable regression analysis, microalbuminuria was an independent predictor of acute kidney injury. At follow-up [42.6 (25th-75th percentile, 17.5-56.8) months], Kaplan-Meier curve analysis showed that patients with microalbuminuria had a lower survival rate in respect to patients without microalbuminuria. Cox regression analysis documented that microalbuminuria was an independent predictor of long term mortality (HR: 1.089; 97% CI 1.036-1.145; p < 0.001)., Conclusions: In a large series of STEMI patients without previously known diabetes submitted to PCI, microalbuminuria, as a marker of endothelial permeability following higher systemic inflammatory activation and larger infarct lesions, is an independent predictor for the development acute kidney injury. Furthermore, microalbuminuria identifies a subset of patients at higher risk for long term mortality. more...

Whether hyponatremia (sodium <135 mEq/L) in the acute phase of ST-segment elevation myocardial infarction is just a marker of "more ill" patients or decreased sodium concentration is able to exert a direct adverse effect on the cardiovascular system is still unknown. The aim of this study was to assess the prognostic impact, in the short and long terms, of admission hyponatremia in 1,231 consecutive patients with ST-segment elevation myocardial infarctions all submitted to primary percutaneous coronary intervention. In this series, 286 patients (23.2%) had sodium values <135 mEq/L. Patients with hyponatremia were older (p = 0.018) and more frequently had diabetes (p = 0.040). Anterior myocardial infarction was more frequent in patients with hyponatremia, who showed a higher incidence of 3-vessel coronary artery disease and advanced Killip class. Higher mortality rates were observed in patients with hyponatremia during intensive cardiac care unit stay and at follow-up. On multivariate regression analysis, admission sodium concentration was not independently related to early death, nor did it show any relations with long-term mortality on Cox regression analysis. In conclusion, the main findings of the present investigation are as follows: (1) hyponatremia is a common finding, being associated mainly with older age, diabetes, and advanced Killip class; (2) patients with hyponatremia had higher rates of in-hospital and long-term mortality; and (3) hyponatremia, also when assessed by means of the propensity score model, was not independently associated with increased risk for death in the short and long terms. These data therefore strongly suggest that the presence of hyponatremia in the acute phase of ST-segment elevation myocardial infarction should be considered a marker of more ill patients., (Copyright © 2012 Elsevier Inc. All rights reserved.) more...

High ambient temperatures have been associated with increased mortality across the world. Several studies suggest that timely preventive measures may reduce heat-related excess mortality. The main aim of this study was to detect the temporal modification of heat-related mortality, in older adults (aged 65-74) and in elderly ≥75 years old, in the Florentine area by comparing previous (1999-2002) and subsequent (2004-2007) periods to the summer of 2003, when a regional Heat-Health Warning System (HHWS) was set up. Mortality data from 1999 to 2007 (May-September) were provided by the Mortality Registry of the Tuscany Region (n = 21,092). Weather data were used to assess daily apparent temperatures (AT). Case-crossover time-stratified designs and constrained segmented distributed lag models were applied. No significant heat-related mortality odds ratio (OR) variations were observed among the sub-periods. Nevertheless, a general OR decrease dating from 1999-2002 (OR 1.23; lack of HHWS) to 2004-2005 (OR 1.21; experimental HHWS running only for Florence) and to 2006-2007 (OR 1.12; official HHWS extended to the whole Florentine area) was observed when the maximum AT was considered. This modification was only evident in subjects ≥75 years old. The heat effect was higher and sustained for more days (until lag 9) during the period 1999-2002 than 2004-2007. The decrease of the excessive heat effect on mortality between periods with the absence and existence of a HHWS is also probably due to the mitigation of preventive measures and the implementation of a HHWS with specific interventions for safeguarding the health of the "frail elderly". more...

Background: Heart failure (HF) is one of the leading causes of hospitalization and medical expenditure, especially in elderly patients. Cooperation between specialists and general practitioners may improve outcomes. A 1-year hospital-territory disease management program was designed in collaboration with the Tuscany Region and the Ministry of Health involving specialists, general practitioners and nurses to investigate the impact of our model on healthcare organization and hospitalization rates in patients with HF., Methods: The program used a web-based clinical report form, and monitoring of patients from specialists and nurses was coordinated by the general practitioners. We enrolled 106 patients (78.3% male, mean age 74.6 years), with a mean left ventricular ejection fraction 49% and mean Charlson index 2.2., Results: A statistically significant reduction was observed in the number of hospitalizations and emergency calls compared with the previous year. HF severity did not substantially changed in 69.8% of patients, whereas it improved in 17.0% and worsened in 13.2% (NYHA class)., Conclusions: Our preliminary data suggest that cooperation between hospitals and medical systems in the territory by means of a web-based clinical report may result in better management of healthcare interventions in the territory with subsequent reduction of hospitalizations. An extension of this model is now ongoing for collecting data from different areas, both within and outside Tuscany. more...

Hypertension is well established as a risk factor for the development of atherosclerosis. Data on the impact of hypertension in patients with ST elevation myocardial infarction are so far inconsistent, and are mainly related to studies performed in the thrombolytic era. We assessed the impact of hypertension over the short and long term in 560 patients with ST elevation myocardial infarction (STEMI) and without previously known diabetes, all of whom were submitted to mechanical revascularization and consecutively admitted to our Intensive Cardiac Care Unit. Hypertensive patients were older (p < 0.001), more frequently male (0.005), and they showed a reduced eGFR (p < 0.001). Smoking was more frequent in nonhypertensive patients (p < 0.001), while the incidence of three-vessel coronary artery disease was higher in hypertensive patients (p = 0.003). No difference in the in-hospital mortality rates for the two subgroups was detected. At follow-up (median 32.5 months, 25th-75th percentile 16.9-47.3 months), Kaplan-Meier survival analysis detected no differences in mortality between hypertensive and nonhypertensive patients (log rank χ(2) 0.38, p = 0.538). According to our data, obtained from a large series of consecutive STEMI patients without previously known diabetes, all of whom were submitted to primary PCI, a history of hypertension does not affect mortality over either the short or the long term. Moreover, hypertensive patients showed an altered glucose response to stress, as indicated by higher admission glucose values, poorer in-hospital glucose control, and a higher incidence of acute insulin resistance (as indicated by the HOMA index). Hypertensive patients therefore appear to warrant careful metabolic management during their hospital courses. more...

Since the mid '90s, the concept of evidence-based medicine has grown exponentially, contributing to the advancement of personalized medicine, which considers the "female gender" as an extremely important area of customization, but orphan of targeted research. Strong evidence do exists demonstrating gender differences in bleeding risk associated with antithrombotic treatment, mostly related to lower values of body mass, organ size and renal function in women than men. Across clinical studies, the search for the specific risk of bleeding in the female vs male gender has gained attention only recently; therefore, data from different studies and relatively limited meta-analyses should be assessed carefully. As for antiplatelet therapy for primary prevention, the risk of major bleeding events, such as cerebral hemorrhage, is lower for women than for men. Conversely, in acute situations in which antithrombotic drugs are given in association, the risk of bleeding is greater for women, in particular for combination therapies with heparin or low molecular weight heparin or thrombolytic agents. Numerous studies in the literature evaluated the incidence of minor and major bleeding during oral anticoagulant therapy in relation to gender, but the results are not entirely consistent and appear to vary over the years. In summary, there are some aspects of guidance in the complex spectrum of the bleeding risk related to antithrombotic treatment, with indications of a lower bleeding risk in women than men related to long-term preventive single antithrombotic drug treatments. In addition, hormonal effects and use of outprescribed drugs may also play a significant role in modulating hemostasis. more...

Background: The intraaortic balloon pump (IABP) is the most commonly used mechanical circulatory support for patients with acute coronary syndromes and cardiogenic shock. Nevertheless, IABP-related complications are still frequent and associated with a poor prognosis., Hypothesis: To prospectively assess the incidence and predictors of complications in patients treated with IABP., Methods: A total of 481 patients treated with IABP were prospectively enrolled in our registry (the Florence Registry). At multivariable logistic regression analysis the following variables were independent predictors for complications (when adjusted for age >75 years, eGFR and time length of IABP support): use of inotropes (OR 2.450, P < 0.017), nadir platelet count (1000/µL step; OR 0.990, P < 0.001), admission lactate (OR 1.175, P = 0.003). Nadir platelet count showed a negative correlation with length of time of IABP implantation (r-0.31; P < 0.001). A nadir platelet count cutoff value of less than 120,000 was identified using a receiver operating characteristic (ROC) curve for the development of complications (area under the curve [AUC] 0.70; P < 0.001)., Results: Complications were observed in the 13.1%, among whom 33 of 63 showed major bleeding. The incidence of complications was higher in patients aged >75 years (P = 0.015) and in those who had an IABP implanted for more than 24 hours (P = 0.001). Patients with complications showed an in Intensive Cardiac Care Unit (ICCU) mortality higher than patients who did not (44.4% vs 17.2%, P < 0.001)., Conclusions: In consecutive patients treated with IABP support, the degree of hemodynamic impairment and the decrease in platelet count were independent predictors of complications, whose development was associated with higher in-ICCU mortality., (© 2011 Wiley Periodicals, Inc.) more...

Background: Abdominal aortic aneurysm (AAA) has a multifactorial etiology and the relevance of genetic factors is getting increasing interest, in particular those related to the destructive remodeling of extracellular matrix., Methods: We performed a candidate gene association study of polymorphisms in genes coding matrix metalloproteinases (MMPs), tissue inhibitors of MMPs (TIMPs), and elastin (ELN) in AAA. DNA samples from 423 AAA patients and 423 controls were genotyped for 12 polymorphisms in 10 genes: MMP1 (-1607G/GG), MMP2 (-735C/T; -1306C/T; -1575 G/A), MMP3 (5A/6A), MMP9 (-1562C/T), MMP10 (A180G), MMP-12 (-82A/G), MMP-13 (-77A/G), TIMP1 (C434T), TIMP3 (-1296T/C), and ELN (G1355A)., Results: Genotype distribution was significantly different between patients and controls for the following polymorphisms: -1306C/T MMP2; 5A/6A MMP3; -77A/G MMP-13; G1355A ELN; and C434T TIMP1. In a multivariable logistic regression analysis adjusted for traditional cardiovascular risk factors and chronic obstructive pulmonary disease, -1306C/T MMP2 (odds ratios [OR] = 0.55 [95% confidence interval, CI .34-.85], P < .007) and G1355A ELN (OR = 0.64 ([95% CI .41-.99], P = .046) polymorphisms resulted in independent protective factors for abdominal aortic aneurysm (AAA), whereas 5A/6A MMP3 (OR = 1.82 [95% CI 1.04-3.12], P = .034) and -77 A/G MMP-13 (OR = 2.14 [95% CI 1.18-3.86], P = .012) polymorphisms resulted in independent risk factors for AAA. In a multivariable logistic regression analysis adjusted for traditional cardiovascular factors and chronic obstructive pulmonary disease, the prevalence of the contemporary presence of three or four genetic risk conditions was a strong and independent determinant of AAA disease (OR = 2.96, 95% CI 1.67-5.24, P < .0001). For those polymorphisms independently associated with AAA in this study (-1306C/T MMP2, 5A/6A MMP3, -77A/G MMP-13, and G1355A ELN polymorphisms), we performed a meta-analysis of the available data (this paper and literature data). We found a significant association with an increased risk of AAA for MMP3 (AAA patients n = 1258, controls n = 1406: OR = 1.48 [95% CI = 1.23-1.78], I(2) = 0%) and MMP-13 (AAA patients n = 800, controls n = 843: OR = 1.37 [95% CI = 1.04-1.82], I(2) = 25%) polymorphisms and a trend that did not reach the statistical significance, toward a decreased risk of AAA for MMP2 (AAA patients n = 1090, controls n = 1077: OR = 0.83 [95% CI = .60-1.15], I(2) =7 1%) and ELN (AAA patients n = 904, controls n = 1069: OR = 0.79 [95% CI = .53-1.18], I(2) = 72%) polymorphisms., Conclusions: These findings suggest that polymorphisms in MMP2, MMP3, MMP-13, and ELN genes may independently contribute to the pathogenesis of AAA., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.) more...

Background: Tako-tsubo (stress) cardiomyopathy (TTC) is a recently described acute cardiac syndrome that mimics ST-segment elevation myocardial infarction. The TTC Tuscany Registry is an observational prospective multicenter registry established to define the prevalence, epidemiology and prognosis of TTC in the Tuscany area., Methods: From January 1 to December 31, 2009, 105 consecutive patients hospitalized in the 14 Cardiology Units of the Tuscany Region with a diagnosis of TTC, were enrolled in the registry. TTC diagnosis was made using the Mayo Clinic modified criteria. Clinical, instrumental, laboratory and 6-month follow-up data were collected. Results. TTC represented 1.2% of all myocardial infarctions in the Tuscany Region during 2009, and it was diagnosed in 0.6% of the angiographic exams performed during the same year. The data collected showed that TTC affects mainly the female gender (91%) in the post-menopausal period (70 ± 11 years), though 5% of patients were ≤50 years old. An antecedent stressful event was frequently detected (74%). The main clinical presentation was chest pain (86%), associated with ST-segment elevation (59%). Mean left ventricular ejection fraction on admission was 40 ± 9%, and was associated with apical (37%), midapical (49%) or midventricular (5%) wall motion abnormalities. Left ventricular ejection fraction recovered to 51 ± 9% in 7 ± 9 days. Heart failure was the most common complication in the acute phase (14%), and 4 patients presented with cardiogenic shock. No patient died during the index hospitalization. At 6-month follow-up, no patient had TTC recurrence, 9 patients were rehospitalized (7 for noncardiac disease) and 2 patients died of noncardiac causes., Conclusions: Our data, which represent the largest prospective series of patients with a diagnosis of TTC, show that the prevalence of TTC in Tuscany is similar that described in other national and international studies. Moreover, the data highlight that TTC may occur also in male patients and in patients aged <50 years. The mid-term prognosis is good, but the risk of acute complications related to heart failure cannot be neglected. more...

Background: Back pain is a significant problem due to the high healthcare utilization, rising costs of care and low effectiveness of many current treatments., Aim: Aim of this study was to determine the effects of a community-based Adapted Physical Activity (APA) program focused on chronic, non-specific back pain., Design: Open-label intervention study., Setting: Community., Population: All patients admitted to Empoli Rehabilitation Department for non-specific back pain for at least three months, were considered for APA. Exclusion criteria were: "red flags", difficulty/disability in basic daily living activities, severe/acute medical conditions, acute pain, psychiatric disease or cognitive impairment, severe visuoauditory deficit. Overall, 650 persons were enrolled., Methods: The APA program, including strength and flexibility training and exercises for improving posture was delivered for 12 months, with 1-hour group classes three times per week., Results: Overall 261 (40.2%) subjects completed the 12-month APA program and were compared to the 310 (47.7%) who were screened but failed to initiate or complete the study. There were no significant differences in baseline demographic and clinical characteristics between groups. Patients who followed the APA program reported significantly improved health status and significant back pain improvement, compared with those who did not adhere to the program. In the logistic regression analysis adjusted for age and gender, a distance from home to gymnasium greater than the median for the study population (2.6 km) was the only baseline characteristic significantly associated with an increased risk of non-adherence (OR 1.44, 95%CI 1.01-2.13; P=0.04)., Conclusion: This study suggests that a community-based APA program can improve back pain and health status in persons with chronic, non-specific low back pain. CLINICA REHABILITATION IMPACT: These findings highlight the potential for new approaches to manage chronic disease and disability by facilitating a healthy lifestyle and promoting physical activity through implementation of community-based exercise programs. more...

Objective: The aim of this study was to evaluate the adherence to recommendations for secondary prevention of cardiovascular diseases in patients with acute coronary syndromes (ACS)., Methods and Results: Physical examination, a careful medical interview with assessment for lifestyle habits, adherence to pharmacological therapy and blood analyses were performed in 130 patients at the time of the acute event and after 6 months of follow-up. At follow-up examination, 7 patients persisted to smoke (5.4%), 41 (31.5%) continued to have high blood pressure, 34 (26.1%) had high levels of total cholesterol, 38 (29.2%) high levels of triglycerides, 64 (49.2%) high levels of LDL-cholesterol and 46 (35.4%) low levels of HDL-cholesterol. Despite all treatments no significant change occurred. A high percentage of patients (47%) reported a lower daily consumption of fruit and vegetables with respect to the recommended daily portions, nearly the whole population (92.3%) did not reach the recommended portions of legumes per week recommended, and a consistent percentage of patients (81.5%) did not consume fish twice a week, as recommended., Conclusion: These findings demonstrate the difficulty of modifying the lifestyle habits in patients with ACS. more...

Objective: Cost-effectiveness of heart surgery for elderly patients is still poorly defined. We evaluated outcome, quality of life (QoL), cost, and cost-effectiveness of octogenarians undergoing cardiac surgery., Methods: One thousand six hundred forty octogenarians undergoing various cardiac surgical procedures were prospectively studied between January 1998 and January 2009 and compared with similar patients aged 70 to 79 years. Several questionnaires were used to assess QoL. Six hundred age- and sex- matched healthy octogenarians and three hundred forty patients older than 80 years with medically treated valvular or coronary artery disease were healthy and unoperated control groups, respectively. In-hospital costs were obtained from the hospital's financial accounting department and cost-effectiveness was estimated and expressed as cost/QoL-adjusted life year (QALY) and cost-effectiveness ratio., Results: Significant improvements occurred in elderly patients in Role Physical (P < .001), Bodily Pain (P < .001), General Health (P = .004), Social Functioning (P < .001), and Role Emotional (P < .001), whereas Physical Functioning, Vitality, and Mental Health did not change (difference not signficant). Total direct costs were $5293 higher in the octogenarian group. Cost-effectiveness was $1391/QALY for elderly surgical patients, $516/QALY for younger cardiac surgical patients (P < .001 vs elderly), $897/QALY for untreated control group, and $641/QALY for healthy control group (P < .001 vs elderly surgical patients). The cost-effectiveness ratio for octogenarians was $94,426., Conclusions: Our findings confirm that cardiac surgery in elderly patients remains controversial from a cost-effectiveness standpoint, making econometric analysis an important component for any future evaluation of novel cardiovascular therapies. Our findings need to be confirmed by additional multicenter studies., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.) more...

The present investigation, performed in 1,122 consecutive STEMI patients treated with primary coronary intervention, was aimed at evaluating: (1) the prevalence of prior anemia and its prognostic significance in the short term; and (2) the prevalence of new anemia and its impact in the short term. The prevalence of prior anemia was 27.4%. Patients with a prior anemia were older and exhibited a higher incidence of chronic diseases and comorbidities. They showed a higher intra-hospital mortality rate (p < 0.001), a higher incidence of PCI failure (p < 0.001) and major bleedings (p < 0.001). Prior anemia was an independent predictor for intra-hospital mortality (OR 2.12; 95% CI 1.21-3.70, p = 0.009). Patients with a new anemia account for 46.8% of our series, and showed a higher early mortality rate and incidence of major bleedings in respect to those who maintained normal Hb values (p < 0.05 and <0.05, respectively). our data strengthens the prognostic role of Hb values in STEMI patients submitted to primary PCI, since the presence of prior anemia identified a subset of patients, characterized by advanced age, higher comorbidities and serious coronary artery disease, at higher risk for intra ICCU mortality and complications. Moreover, the development of anemia during an ICCU stay is common, and is associated with a higher mortality rate and incidence of complications in respect to patients who maintain normal Hb values. more...

Antiplatelets, antihypertensives, and statins might reduce the severity of the event or improve outcome in patients who, despite prior medical treatment, have a stroke. We evaluated, in patients who had an ischemic stroke, the effect, on stroke severity and outcome, of prior treatment with antiplatelets, antihypertensives, and statins, used either alone or in a three-drug combination. Stroke in Italy and Related Impact on Outcome (SIRIO) was a prospective, nationwide, multicenter, hospital-based, observational study that included patients aged.18 years with acute ischemic stroke. We studied 2,529 acute ischemic stroke patients from the SIRIO population: 887 were antiplatelet users, 1,497 antihypertensive users, 231 statin users, and 138 three-drug combination users prior to the index event. The adjusted logistic regression analysis showed an association between prior treatment with statins and good functional outcome at discharge, while prior treatment with antiplatelets, antihypertensives or the three-drug combination did not influence severity or outcome. The absolute probability of a good functional outcome was 46.3% (95% CI: 40.3%-53.2%) in statin users and 36.7% (95% CI: 34.7%-38.7%) in non-users of statins; the absolute risk difference was 9.6% (95% CI: 2.9%-16.4%; p=0.004). Prior treatment with antiplatelets, antihypertensives, or the three-drug combination did not influence stroke severity or outcome, while prior treatment with statins did not influence stroke severity but was associated with a better functional outcome. more...

On March 15th 2010, Italy adopted the Law no. 38 "Disposizioni per garantire l'accesso alle cure palliative e alla terapia del dolore" (Provisions aimed at ensuring access to palliative care and pain therapy). The aim of pain therapy is to enable patients with chronic diseases to achieve pain control. Palliative care, as defined by the World Health Organization, aims at "improving the quality of life of patients and families, who face the problems associated with incurable diseases, through prevention and relief from suffering, achieved through an early identification and treatment of pain by pharmacological medication and other physical, psychosocial and spiritual techniques". The main issues addressed by the law concern the monitoring of pain (the doctors will have to record on the clinical report form every level of pain intensity suffered by the patient, the appropriate therapy administered, and the pain relief achieved. This report must be kept accurately in all settings: hospital, day hospital and in outpatients). The law also suggests the establishment of two kinds of regional networks. One network (including Hospices) ensures the administration of palliative care to terminally ill patients; the other, including clinics and centers of pain therapy, provides assistance to patients with chronic pain. These networks involve general practitioners, hospital specialists and pain therapy specialists in order to ensure the best patient care. Simplification of the prescription of opiate drugs is also included in the law. In the prescription of opiates, the National Health Service medical staff can use the normal prescription form, and opiates will reimbursed by the NHS, like all other drugs. In addition, the technical papers provide precise indications of the appropriate modality of administration. The law allocates (art. 12, paragraph 2) 100 million euros per year and € 2,450,000 in the biennium 2010-2011 to implement experimental regional projects: "hospital-territory without pain". The Ministry of Health has established a deadline within which this law must be implemented at the regional level, and further establishes a specific National Observatory, an annual report on the use of drugs in the treatment of pain, and other provisions. The levels of spending by region will also be monitored in compliance with this law; university courses and masters are required to update professionals involved in pain treatment. In July 2010, in Florence, during the interdisciplinary IMPACT 2010 summit, Institutions and Scientific Societies met to define the concrete implementation of Law No. 38, in terms of the arrangements to ensure access to palliative care and pain management. Subsequently, last November, a new meeting was held bringing together medical directors from public hospitals; further meetings are planned with Regional Health Authorities to reaffirm the importance of this law and to implement it. The most important molecules in the opioids are traditionally divided into two groups: weak and strong. Among the strong analgesics are morphine, methadone, buprenorphine, fentanyl, oxycodone, hydromorphone. Among the weak are codeine and tramadol, or opiates administered at low doses, such as oxycodone combined with acetaminophen. IMPACT's aim is also to stimulate scientific association to consider with attention and continuous medical education on the appropriates of diagnosis and administration of these medications according to data flow sheets approved in Italy. Regarding the headaches, it should be noted that the law 38 cited above includes all forms of pain, and headaches should be integrated into the care networks. In this context, several multi-disciplinary professionals within the centers (hub and spoke) or territory (GPs, specialists from neurologists and other professionals involved) should be integrated to offer the best response to the needs of the citizen. The diagnosis and treatment of various forms of headache have to be integrated into the path of pain, both National and Regional, in line with the rest of the organization. more...

Background: Stress-induced or tako-tsubo cardiomyopathy (TTC) is a rare acute cardiac syndrome characterized by transient left ventricular (LV) dysfunction of uncertain cause and outcome. This study sought to assess the long-term outcome of patients with TTC., Methods: One-hundred sixteen consecutive patients were prospectively included in the study and observed at long-term follow-up. Primary end points were death, TTC recurrence, and hospitalization from any cause., Results: Mean initial LV ejection fraction (LVEF) at admission was 36% ± 9%. Two patients died of refractory heart failure during hospitalization. Of the patients who were discharged alive all except one showed complete LV functional recovery. At follow-up (2.0 ± 1.3 years), only 64 (55%) patients were asymptomatic. Rehospitalization rate was high (25%), with chest pain (n = 6) and dyspnea (n = 5) as the most common causes. Only two patients had a recurrence of TTC. Eleven patients died (seven from cardiovascular cause). There was no significant difference in mortality (12% vs 7%; P = .284) and in the other clinical events between patients with and without severe LV dysfunction at presentation (LVEF ≤ 35%). Mortality observed in patients with TTC was compared with age and sex-specific mortality of the general population using the standardized mortality ratio (SMR) method. The SMR was 3.40 (95% CI, 1.83-6.34) in the TTC population. The only independent predictor of death at Cox analysis was Charlson comorbidity index (hazard ratio, 1.786; P = .0001), but the degree of initial LV dysfunction was not an independent predictor of death., Conclusions: The recurrence of TTC is rare, but recurrences of chest pain or dyspnea are common in patients with TTC and frequently lead to hospital readmission. Long-term mortality is higher as compared with the control general population and at least in part related to patients' comorbidities. Initial LV dysfunction severity does not seem to impact long-term event rates. more...

Background and Purpose: Results on the effect of weather on stroke occurrences are still confusing and controversial. The aim of this study was to retrospectively investigate in Tuscany (central Italy) the weather-related stroke events through the use of an innovative source of weather data (Reanalysis) together with an original statistical approach to quantify the prompt/delayed health effects of both cold and heat exposures., Methods: Daily stroke hospitalizations and meteorologic data from the Reanalysis 2 Achieve were obtained for the period 1997 to 2007. Generalized linear and additive models and an innovative modeling approach, the constrained segmented distributed lag model, were applied., Results: Both daily averages and day-to-day changes of air temperature and geopotential height (a measure that approximates the mean surface pressure) were selected as independent predictors of all stroke occurrences. In particular, a 5°C temperature decrease was associated with 16.5% increase of primary intracerebral hemorrhage of people ≥65 years of age. A general short-term cold effect on hospitalizations limited to 1 week after exposure was observed and, for the first time, a clear harvesting effect (deficit of hospitalization) for cold-related primary intracerebral hemorrhage was described. Day-to-day changes of meteorologic parameters disclosed characteristic U- and J-shaped relationships with stroke occurrences., Conclusions: Thanks to the intrinsic characteristic of Reanalysis, these results might simply be implemented in an operative forecast system regarding weather-related stroke events with the aim to develop preventive health plans. more...

Background: In patients with acute coronary syndromes, an increase in hemorrhagic complications has been observed, and bleeding is now the most frequent noncardiac complication in these patients. Clinical trials and registries have used different scales to classify the severity of bleeding; so far, none of them has been developed for ST-segment elevation myocardial infarction (STEMI) patients in the era of primary percutaneous coronary intervention., Methods: We analyzed data from our Intensive Cardiac Care Florence STEMI Registry, comprising 991 STEMI patients consecutively admitted to our intensive cardiac care unit after mechanical revascularization, to assess the clinical impact of both Thrombolysis In Myocardial Infarction (TIMI) and Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) classifications in identifying patients with major bleeding at higher risk for in-hospital mortality., Results: Major bleeding events occurred in 8.9% of patients (88/991) in the TIMI classification and in 17.2% of patients (170/991) in the ACUITY classification. Among patients with major bleeding classified according to ACUITY, 82 patients did not meet the TIMI criteria for major bleeding. These patients represent the so-called gray zone, where no transfusion was performed and only 1 patient died., Conclusions: In STEMI patients who undergo primary percutaneous coronary intervention and receive dual antiplatelet therapy, TIMI is more capable than ACUITY in identifying patients with major bleeding at higher risk for early mortality. The presence of renal failure represents an independent predictor for major bleeding., (© 2011 Wiley Periodicals, Inc.) more...

Background: Recent evidence has documented a relation between elevated transaminases and atherosclerosis, independent of classic risk factors, including the metabolic syndrome. No data are thus far available on the prognostic role of transaminases in acute myocardial infarction., Material/methods: We assessed whether admission transaminases (alanine aminotransferase--ALT and aspartate aminotransferase--AST) hold a prognostic role for in-intensive Cardiac Care Unit (ICCU) mortality and complications (acute pulmonary edema and/or arrhythmias) in 1000 consecutive patients with ST-elevation myocardial infarction submitted to mechanical revascularization., Results: ALT and AST were independent predictors for in-ICCU mortality and for in-ICCU complications (when adjusted for age, left ventricular ejection fraction and sex) in the overall population, in diabetic patients but not in non-diabetic ones. ALT showed a significant correlation with NT-pro-BNP, Tn I, uric acid and leukocyte count in the overall population and in non-diabetic STEMI patients. AST showed a significant correlation with Tn I, uric acid and leukocyte count in the overall population and in non-diabetic patients. In diabetic patients, ALT and AST were significantly correlated only with peak Tn I., Conclusions: In 1000 consecutive STEMI patients submitted to mechanical revascularization, admission ALT and AST were independent predictors for in-ICCU mortality and complications in non-diabetic patients, being strictly related to infarct size (as indicated by peak Tn I), the degree of inflammatory activation (as inferred by leukocytes) and prognostic markers (NT-pro-BNP and uric acid). In diabetic STEMI patients, only ALT results were an independent predictor for in-hospital mortality and complications, being associated with peak Tn I. more...

Objective: To develop a scoring system for predicting in-hospital mortality among ST-elevation myocardial infarction (STEMI) patients submitted to percutaneous intervention (PCI) on intensive cardiac care unit admission by using early and readily available clinical, angiographic and laboratory data., Design: Prospective monocentric observational study in which we used discriminant analysis to develop a final scoring system, with prospective validation., Setting: Intensive cardiac care unit in Florence, a tertiary center., Population: Five hundred and fifty-eight unselected patients with STEMI (group A) consecutively admitted from 1 January 2004 to 31 December 2006. A control group (group B) comprising 183 STEMI patients admitted from 1 January 2007 to 30 September 2007., Main Outcomes and Measures: In-hospital death., Results: In group A the discriminant variables were admission Killip class, admission lactic acid, admission ejection fraction, admission troponin I (TnI), admission hemoglobin (Hb), ST-segment reduction post-PCI, systolic blood pressure on admission and chronic renal failure. We elaborated a scoring system, the Florence admission STEMI risk score, which shows an agreement of 95.7% between the observed and the estimated outcome on a statistical basis in the survival and death subgroups. We applied this score to group B (C statistics = 0.986)., Conclusion: The Florence admission STEMI risk score incorporates anamnestic (chronic renal failure), laboratory (lactic acid, TnI and Hb), procedural and post-procedural data (ST-segment reduction post-PCI, Killip class) as well as data strictly related to infarct size (ejection fraction, TnI). This scoring system is likely to be a simple and practical tool at the bedside for risk evaluation in patients with STEMI submitted to primary PCI. more...

Objectives: Previous investigations on microalbuminuria in acute myocardial infarction have been performed in heterogeneous populations of hypetensive/nonhypertensive, diabetic/nondiabetic patients, submitted to either thrombolysis or mechanical revascularization or not revascularized. Therefore, the aim of our investigation was to assess, in 242 consecutive hypertensive patients with ST elevation myocardial infarction without previously known diabetes, all submitted to mechanical revascularization, whether microalbuminuria, in the early phase, has a prognostic role for in-hospital mortality or complications (acute pulmonary edema and arrhythmias)., Methods: The study population was divided into two groups according to microalbuminuria excretion: group A (microalbuminuria within the normal range); group B (microalbuminuria above the normal range)., Results: The incidence of microalbuminuria was 52.1% (126/242). No significant difference was detectable in the incidence of in-hospital mortality and complications between the two groups. Patients with microalbuminuria exhibit a larger infarct size as indicated by higher values of troponin I. Microalbuminuria was associated with higher values of glucose and a higher prevalence of insulin resistance., Conclusion: In ST elevation myocardial infarction hypertensive patients without previously known diabetes, all submitted to mechanical revascularization, microalbuminuria is a common finding but it does not yield prognostic information about in-hospital mortality or complications. Interestingly it was associated with acute glucose dysmetabolism (as inferred by hyperglycemia and the prevalence of insulin resistance), thus suggesting that it can be considered part of the acute metabolic response to the acute coronary event. more...

Background: Acute myocardial infarction is known as an acute metabolic stress, but clinicians currently have limited guidance regarding the evaluation and management of hyperglycemia after revascularization., Methods and Results: We assessed the prognostic role of three different ranges of in-hospital peak glycemia (<140, 140-180, and >180 mg/dl) in 252 acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to percutaneous coronary intervention consecutively admitted to our intensive cardiac care unit (ICCU). Patients with highest peak glycemia showed the highest intra-ICCU mortality (7/44, 15.9%), which was significantly higher with respect to the other two subgroups (P=0.001 and 0.034, respectively). At backward stepwise logistic regression analysis, peak glycemia (odds ratio: 3.14; 95% confidence interval: 1.01-9.74, P=0.047) was an independent predictor of intra-ICCU mortality., Conclusion: In acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to mechanical revascularization, the poorer in-hospital glucose control was associated with higher mortality; peak glycemia greater than 180 mg/dl was associated with the highest mortality, whereas patients with peak glycemia comprised between 140 and 180 mg/dl exhibited intermediate mortality rates. According to our data during hospitalization intensivists should achieve glucose control values less than 140 mg/dl, as peak glycemia resulted in the independent predictor of intra-ICCU mortality. more...

Background: The purpose of this study was to evaluate the effectiveness of a standardized preoperative cardiac assessment in reducing the rate of perioperative cardiac complications in patients undergoing aortic surgery, paying particular attention to the analysis of the factors affecting perioperative cardiac outcomes., Methods: Between January 2005 and August 2008, a total of 531 elective interventions for abdominal aortic aneurysms were performed at our institution. All patients underwent preoperative evaluation on an outpatient basis, which included a standardized cardiac assessment protocol to evaluate perioperative cardiac risk. A surgical (open or endovascular) intervention was performed in all patients and perioperative (<30 days) results in terms of overall and cardiac mortality and morbidity rates were recorded., Results: Preoperative electrocardiogram, transthoracic echocardiography, and cardiology consultation were performed in all patients. In 348 cases (65.5%), further evaluation of cardiac functional capacity with noninvasive stress testing was recommended. A positive noninvasive stress test was noted in 86 (24.7%) of 348 patients and coronary angiography was performed in 34 (39.5%) of 86 patients. Thirteen of these patients underwent successful coronary revascularization (11 percutaneous transluminal coronary angioplasty, two coronary artery bypass graft) before vascular surgery. Thirty-day overall rate and cardiac mortality rate were 1.1% and 0.6%, respectively, and 30-day overall and cardiac morbidity rates were 11.5% and 6.8%, respectively. Univariate analysis demonstrated that in patients aged >80 years, chronic renal failure, congestive heart failure, valvular heart disease, positive noninvasive stress testing, and open surgical treatment significantly affected 30-day cardiac morbidity; however, only valvular heart disease and positive noninvasive stress testing maintained their significance with multivariate analysis (p = 0.005; 95% CI, 1.6-14.4; and p = 0.02; 95% CI, 1.2-8.1, respectively). None of the examined factors significantly affected 30-day cardiac mortality., Conclusion: In our experience, the use of a routine preoperative cardiac assessment allowed us to obtain satisfactory perioperative results in patients undergoing abdominal aortic surgery. Very few patients, however, require cardiac revascularization before abdominal aortic surgery. Patients with positive stress test may benefit from an endovascular treatment if anatomically feasible., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.) more...