Therapeutics and Clinical Risk Management, Aug 1, 2007
Clinical trials have consistently shown the benefi ts of beta-blocker treatment in patients with ... more Clinical trials have consistently shown the benefi ts of beta-blocker treatment in patients with chronic heart failure (HF). As a result, bisoprolol, carvedilol, and metoprolol succinate are now indicated for the treatment of all patients with chronic HF who do not have major contraindications. Bisoprolol is the fi rst beta-blocker shown to improve survival in an outcome trial. In the Cardiac Insuffi ciency Bisoprolol Study II (CIBIS-II), all-cause mortality and sudden death were reduced in patients treated with bisoprolol compared with those on placebo (11.8% vs 17.3%; p < 0.0001 and 3.6% vs 6.3%, p < 0.002; respectively) regardless of age, NYHA functional class, and co-morbidities. Further studies have shown both the effi cacy of bisoprolol on secondary endpoints and patients subgroups as well its high cost effectiveness. More recently, CIBIS-III has shown similar effi cacy and safety of the initiation of HF treatment with either bisoprolol or enalapril, with a tendency to a survival advantage with bisoprolol. Nowadays, the role of bisoprolol, as well as that of carvedilol and metoprolol succinate, in HF treatment is fi rmly established and research is mainly focused on implementation of treatment and better dosing. This article will summarize evidence for the effi cacy of bisoprolol in the treatment of HF.
Objectives: Low-triiodothyronine syndrome (LT3S) is a condition characterized by decreased total ... more Objectives: Low-triiodothyronine syndrome (LT3S) is a condition characterized by decreased total serum T3 and free T3 (f T3) with normal levels of thyroxine (f T4) and thyrotropin (TSH). Experimental studies have shown that altered thyroid hormones (THs) metabolism modifies cardiovascular homeostasis.
European Journal of Heart Failure Supplements, 2008
Pts with mechanical complication were excluded. Relevant variables were registered on admission. ... more Pts with mechanical complication were excluded. Relevant variables were registered on admission. Results: Between 2001 and 2007 a total of 74 pts were included. Main age was 62±13 years. Restoration of coronary flow was obtained in 72% (TIMI 3 in 61%) of pts. One-year mortality was 55% and 7 pts (9%) underwent UHT. After adjustment by multivariate analysis (covariates: age, smoking, LV ejection fraction, multi-vessel disease, left main disease, time to revascularization, time to CS and postprocedural TIMI 3) Cox regression showed left main disease (OR 9.9; IC 95% 2.2-45.2, P<0.01) and postprocedural TIMI 3 (OR 2.9; IC 95% 1.2-7.0, P=0.01) to be the strongest predictors of survival at 1 year. Mortality or need for UHT was 38% if TIMI 3 was achieved, 92% with TIMI 2 and 90% with TIMI 0 or 1 flow (p<0.001 long rank) . Conclusions: In our sample of pts with CS complicating AMI revascularizated within 36 hours of AMI and 18 of shock onset, left main disease and post-procedural TIMI <3 flow were significantly associated with worse prognosis. These results have a high clinical relevance and suggest that in these pts the goal is not just to reperfuse the artery but to reach a final TIMI 3 flow.
European Journal of Heart Failure Supplements, 2007
... were SBP at discharge (p&amp;amp;lt;0.0001), change in body weight during the hospitalisa... more ... were SBP at discharge (p&amp;amp;lt;0.0001), change in body weight during the hospitalisation (p=0.003), persistence at discharge of a re-strictive pattern of LV filling at Doppler-echocardiography (p=0.014), worsening renal function during the hospitalisation (p=0.019), BUN val-ues at ...
The role of heart rate (HR) as an independent predictor of cardiovascular morbidity and mortality... more The role of heart rate (HR) as an independent predictor of cardiovascular morbidity and mortality remains controversial. Direct evidence supporting a causal association between HR and prognosis is still lacking even if such relation appears plausible and may be inferred from epidemiological studies and clinical trials with HR lowering agents. The introduction of If current blocking agents, namely ivabradine, has offered the novel and unique opportunity to directly and exclusively interfere with HR and, thus, to validate the presence of a causal relationship between HR and prognosis. The BEAUTIFUL trial has recently confirmed that HR is a powerful negative prognostic predictor in patients with coronary artery disease and left ventricular systolic dysfunction. Particularly, subjects with a resting HR >70 b/min showed an increased risk of major adverse cardiovascular events. In these patients, HR reduction with ivabradine was associated with a reduction in major cardiac ischemic eve...
Hospitalizations for acute heart failure are associated with high mortality and readmission rates... more Hospitalizations for acute heart failure are associated with high mortality and readmission rates. Ten to 20% of the patients have signs of low cardiac output and fluid overload. The administration of inotropic agents to correct these hemodynamic abnormalities may be indicated in these patients. However, the risk to benefit ratio of inotropic agents is high and an increase of untoward effects and mortality has been suggested by many retrospective analyses and meta-analyses. Limitations of inotropic therapy seem mainly related to their mechanisms of action based, in the case of the traditional agents, on an increase in intracellular cyclic AMP and calcium concentrations. Concomitant peripheral vasodilation, such as in the case of the novel agent levosimendan is another important limitation, above when patients are hypotensive and/or treated with vasodilators and high doses of diuretics. Myosin activators, histaroxime, sarcoplasmic reticulum ATPase activators and metabolic agents seem...
Hellenic journal of cardiology : HJC = Hellēnikē kardiologikē epitheōrēsē
Right ventricular (RV) systolic dysfunction is a strong prognostic predictor in chronic heart fai... more Right ventricular (RV) systolic dysfunction is a strong prognostic predictor in chronic heart failure (HF). However, assessment of RV function remains difficult. We investigated the prognostic value of different echocardiographic parameters for evaluating RV function in 60 patients with chronic HF and a low left ventricular ejection fraction (<40%) who were on optimal medical treatment. RV function was assessed using standard and tissue Doppler echocardiography. The following parameters were measured: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC), right myocardial performance index (MPI), tissue Doppler peak myocardial velocity (Sm) and longitudinal strain of the right ventricular wall in the basal and middle segments. During a mean follow-up of 32 ± 13 months, 6 patients died and 16 were hospitalised for HF. TAPSE, RVFAC, right MPI and Sm did not predict cardiovascular events. The only variable associated with either cardiac...
European Journal of Heart Failure Supplements, 2008
Acute heart failure (AHF) is associated to a high incidence of deaths and rehospitalisations. It ... more Acute heart failure (AHF) is associated to a high incidence of deaths and rehospitalisations. It is therefore important to identify patients at highest risk of events on the basis of simple clinical parameters measured during hospitalisation. Most of the studies performed to date are mainly based on data from surveys or multicenter trials, mostly collected only at the time of hospitalisation, often with relatively short follow-up duration and with few data regarding the role of medical treatment. The aim of this study was to analyse the prognostic significance of clinical, laboratory and Doppler-echo variables in consecutive patients admitted for AHF at our institute in whom data were collected both at the time of hospitalisation and at discharge. We studied 497 consecutive patients, aged 68±11 years, 72% males, 55% with coronary artery disease, 31% with diabetes. At entry and at discharge, s-creatinine was of 1.58±0.79 and 1.63±0.76 mg/dl (p=0.013 vs. entry), s-sodium was of 138.5±4 and 138.9±3.7 meq/lt (p=0.011 vs. entry), and s-Hb was of 12.9±1.9 and 12.6±1.6 gm/dl (p<0.001 vs. entry). Patients were followed for 387±327 days (median 320). During follow-up, 71 patients (14%) died for cardiac causes and 206 (41%) were rehospitalised for HF. At multivariable analysis, the only independent predictors of death were heart rate (HR), s-sodium and s-creatinine, all measured at the time of discharge (all p<0.001), age (p=0.001), detectable TnI levels during hospitalisation (p=0.021), and treatment with inotropic agents during the hospitalisation (p=0.001). Similarly, independent predictors of death or HF rehospitalisations were systolic blood pressure (p<0.0001), furosemide dose (p<0.0001), glomerular filtration rate (p=0.001), a restrictive LV filling pattern at Doppler-echocardiography (p=0.012), all measured at discharge, and a previous HF hospitalisation (p=0.03). Conclusions: Patients hospitalised for AHF are at high risk of major cardiovascular events. Marked changes of most clinical and laboratory variables occur during hospitalisation. Heart rate, SBP, renal function and persistent signs of congestion, all assessed at the time of discharge, are the most important prognostic variables.
We describe a case of a 54 years old man in whom an initial diagnosis of acute coronary syndrome ... more We describe a case of a 54 years old man in whom an initial diagnosis of acute coronary syndrome (ACS) revealed to be finally an acute aortic dissection. This case report stresses the importance to maintain a high grade of suspicion of aortic dissection as a possible alternative in presence of eletrocardiographic myocardial ischemic signs. In many medical centers where thrombolitic therapy, antiplatelets receptor blockers, heparin or percutaneous coronary angioplasty is the first line therapy for ACS the outcome may be catastrophic in situation such as aortic dissection.
... MARCO METRA, SAVINA NODARI, TANIA BORDONALI, SILVIA BUGATTI, BENEDETTAFONTANELLA, CARLO LOMBA... more ... MARCO METRA, SAVINA NODARI, TANIA BORDONALI, SILVIA BUGATTI, BENEDETTAFONTANELLA, CARLO LOMBARDI, ALBERTO SAPORETTI, GIULIA VERZURA, ROSSELLA ... related to mortality and morbidity in patients with chronic heart failure: results from Val-HeFT. ...
Journal of the American Society of Echocardiography, 2012
Background: The aim of this study was to investigate the effects of transcatheter aortic valve im... more Background: The aim of this study was to investigate the effects of transcatheter aortic valve implantation (TAVI) on left ventricular (LV) hypertrophy and diastolic function in patients with severe aortic valve stenosis (AVS). There are few and conflicting data on LV mass remodeling and LV diastolic function after TAVI.
Therapeutics and Clinical Risk Management, Aug 1, 2007
Clinical trials have consistently shown the benefi ts of beta-blocker treatment in patients with ... more Clinical trials have consistently shown the benefi ts of beta-blocker treatment in patients with chronic heart failure (HF). As a result, bisoprolol, carvedilol, and metoprolol succinate are now indicated for the treatment of all patients with chronic HF who do not have major contraindications. Bisoprolol is the fi rst beta-blocker shown to improve survival in an outcome trial. In the Cardiac Insuffi ciency Bisoprolol Study II (CIBIS-II), all-cause mortality and sudden death were reduced in patients treated with bisoprolol compared with those on placebo (11.8% vs 17.3%; p < 0.0001 and 3.6% vs 6.3%, p < 0.002; respectively) regardless of age, NYHA functional class, and co-morbidities. Further studies have shown both the effi cacy of bisoprolol on secondary endpoints and patients subgroups as well its high cost effectiveness. More recently, CIBIS-III has shown similar effi cacy and safety of the initiation of HF treatment with either bisoprolol or enalapril, with a tendency to a survival advantage with bisoprolol. Nowadays, the role of bisoprolol, as well as that of carvedilol and metoprolol succinate, in HF treatment is fi rmly established and research is mainly focused on implementation of treatment and better dosing. This article will summarize evidence for the effi cacy of bisoprolol in the treatment of HF.
Objectives: Low-triiodothyronine syndrome (LT3S) is a condition characterized by decreased total ... more Objectives: Low-triiodothyronine syndrome (LT3S) is a condition characterized by decreased total serum T3 and free T3 (f T3) with normal levels of thyroxine (f T4) and thyrotropin (TSH). Experimental studies have shown that altered thyroid hormones (THs) metabolism modifies cardiovascular homeostasis.
European Journal of Heart Failure Supplements, 2008
Pts with mechanical complication were excluded. Relevant variables were registered on admission. ... more Pts with mechanical complication were excluded. Relevant variables were registered on admission. Results: Between 2001 and 2007 a total of 74 pts were included. Main age was 62±13 years. Restoration of coronary flow was obtained in 72% (TIMI 3 in 61%) of pts. One-year mortality was 55% and 7 pts (9%) underwent UHT. After adjustment by multivariate analysis (covariates: age, smoking, LV ejection fraction, multi-vessel disease, left main disease, time to revascularization, time to CS and postprocedural TIMI 3) Cox regression showed left main disease (OR 9.9; IC 95% 2.2-45.2, P<0.01) and postprocedural TIMI 3 (OR 2.9; IC 95% 1.2-7.0, P=0.01) to be the strongest predictors of survival at 1 year. Mortality or need for UHT was 38% if TIMI 3 was achieved, 92% with TIMI 2 and 90% with TIMI 0 or 1 flow (p<0.001 long rank) . Conclusions: In our sample of pts with CS complicating AMI revascularizated within 36 hours of AMI and 18 of shock onset, left main disease and post-procedural TIMI <3 flow were significantly associated with worse prognosis. These results have a high clinical relevance and suggest that in these pts the goal is not just to reperfuse the artery but to reach a final TIMI 3 flow.
European Journal of Heart Failure Supplements, 2007
... were SBP at discharge (p&amp;amp;lt;0.0001), change in body weight during the hospitalisa... more ... were SBP at discharge (p&amp;amp;lt;0.0001), change in body weight during the hospitalisation (p=0.003), persistence at discharge of a re-strictive pattern of LV filling at Doppler-echocardiography (p=0.014), worsening renal function during the hospitalisation (p=0.019), BUN val-ues at ...
The role of heart rate (HR) as an independent predictor of cardiovascular morbidity and mortality... more The role of heart rate (HR) as an independent predictor of cardiovascular morbidity and mortality remains controversial. Direct evidence supporting a causal association between HR and prognosis is still lacking even if such relation appears plausible and may be inferred from epidemiological studies and clinical trials with HR lowering agents. The introduction of If current blocking agents, namely ivabradine, has offered the novel and unique opportunity to directly and exclusively interfere with HR and, thus, to validate the presence of a causal relationship between HR and prognosis. The BEAUTIFUL trial has recently confirmed that HR is a powerful negative prognostic predictor in patients with coronary artery disease and left ventricular systolic dysfunction. Particularly, subjects with a resting HR >70 b/min showed an increased risk of major adverse cardiovascular events. In these patients, HR reduction with ivabradine was associated with a reduction in major cardiac ischemic eve...
Hospitalizations for acute heart failure are associated with high mortality and readmission rates... more Hospitalizations for acute heart failure are associated with high mortality and readmission rates. Ten to 20% of the patients have signs of low cardiac output and fluid overload. The administration of inotropic agents to correct these hemodynamic abnormalities may be indicated in these patients. However, the risk to benefit ratio of inotropic agents is high and an increase of untoward effects and mortality has been suggested by many retrospective analyses and meta-analyses. Limitations of inotropic therapy seem mainly related to their mechanisms of action based, in the case of the traditional agents, on an increase in intracellular cyclic AMP and calcium concentrations. Concomitant peripheral vasodilation, such as in the case of the novel agent levosimendan is another important limitation, above when patients are hypotensive and/or treated with vasodilators and high doses of diuretics. Myosin activators, histaroxime, sarcoplasmic reticulum ATPase activators and metabolic agents seem...
Hellenic journal of cardiology : HJC = Hellēnikē kardiologikē epitheōrēsē
Right ventricular (RV) systolic dysfunction is a strong prognostic predictor in chronic heart fai... more Right ventricular (RV) systolic dysfunction is a strong prognostic predictor in chronic heart failure (HF). However, assessment of RV function remains difficult. We investigated the prognostic value of different echocardiographic parameters for evaluating RV function in 60 patients with chronic HF and a low left ventricular ejection fraction (<40%) who were on optimal medical treatment. RV function was assessed using standard and tissue Doppler echocardiography. The following parameters were measured: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC), right myocardial performance index (MPI), tissue Doppler peak myocardial velocity (Sm) and longitudinal strain of the right ventricular wall in the basal and middle segments. During a mean follow-up of 32 ± 13 months, 6 patients died and 16 were hospitalised for HF. TAPSE, RVFAC, right MPI and Sm did not predict cardiovascular events. The only variable associated with either cardiac...
European Journal of Heart Failure Supplements, 2008
Acute heart failure (AHF) is associated to a high incidence of deaths and rehospitalisations. It ... more Acute heart failure (AHF) is associated to a high incidence of deaths and rehospitalisations. It is therefore important to identify patients at highest risk of events on the basis of simple clinical parameters measured during hospitalisation. Most of the studies performed to date are mainly based on data from surveys or multicenter trials, mostly collected only at the time of hospitalisation, often with relatively short follow-up duration and with few data regarding the role of medical treatment. The aim of this study was to analyse the prognostic significance of clinical, laboratory and Doppler-echo variables in consecutive patients admitted for AHF at our institute in whom data were collected both at the time of hospitalisation and at discharge. We studied 497 consecutive patients, aged 68±11 years, 72% males, 55% with coronary artery disease, 31% with diabetes. At entry and at discharge, s-creatinine was of 1.58±0.79 and 1.63±0.76 mg/dl (p=0.013 vs. entry), s-sodium was of 138.5±4 and 138.9±3.7 meq/lt (p=0.011 vs. entry), and s-Hb was of 12.9±1.9 and 12.6±1.6 gm/dl (p<0.001 vs. entry). Patients were followed for 387±327 days (median 320). During follow-up, 71 patients (14%) died for cardiac causes and 206 (41%) were rehospitalised for HF. At multivariable analysis, the only independent predictors of death were heart rate (HR), s-sodium and s-creatinine, all measured at the time of discharge (all p<0.001), age (p=0.001), detectable TnI levels during hospitalisation (p=0.021), and treatment with inotropic agents during the hospitalisation (p=0.001). Similarly, independent predictors of death or HF rehospitalisations were systolic blood pressure (p<0.0001), furosemide dose (p<0.0001), glomerular filtration rate (p=0.001), a restrictive LV filling pattern at Doppler-echocardiography (p=0.012), all measured at discharge, and a previous HF hospitalisation (p=0.03). Conclusions: Patients hospitalised for AHF are at high risk of major cardiovascular events. Marked changes of most clinical and laboratory variables occur during hospitalisation. Heart rate, SBP, renal function and persistent signs of congestion, all assessed at the time of discharge, are the most important prognostic variables.
We describe a case of a 54 years old man in whom an initial diagnosis of acute coronary syndrome ... more We describe a case of a 54 years old man in whom an initial diagnosis of acute coronary syndrome (ACS) revealed to be finally an acute aortic dissection. This case report stresses the importance to maintain a high grade of suspicion of aortic dissection as a possible alternative in presence of eletrocardiographic myocardial ischemic signs. In many medical centers where thrombolitic therapy, antiplatelets receptor blockers, heparin or percutaneous coronary angioplasty is the first line therapy for ACS the outcome may be catastrophic in situation such as aortic dissection.
... MARCO METRA, SAVINA NODARI, TANIA BORDONALI, SILVIA BUGATTI, BENEDETTAFONTANELLA, CARLO LOMBA... more ... MARCO METRA, SAVINA NODARI, TANIA BORDONALI, SILVIA BUGATTI, BENEDETTAFONTANELLA, CARLO LOMBARDI, ALBERTO SAPORETTI, GIULIA VERZURA, ROSSELLA ... related to mortality and morbidity in patients with chronic heart failure: results from Val-HeFT. ...
Journal of the American Society of Echocardiography, 2012
Background: The aim of this study was to investigate the effects of transcatheter aortic valve im... more Background: The aim of this study was to investigate the effects of transcatheter aortic valve implantation (TAVI) on left ventricular (LV) hypertrophy and diastolic function in patients with severe aortic valve stenosis (AVS). There are few and conflicting data on LV mass remodeling and LV diastolic function after TAVI.
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