Atrial fibrillation (AF) is 1 of the most important healthcare issues and an important cause of healthcare expenditure. AF care requires specific arrhythmologic skills and complex treatment. ...Therefore, it is crucial to know its real affect on healthcare systems to allocate resources and detect areas for improving the standards of care. The present nationwide, retrospective, observational study involved 233 general practitioners. Each general practitioner completed an electronic questionnaire to provide information on the clinical profile, treatment strategies, and resources consumed to care for their patients with AF. Of the 295,906 patients screened, representative of the Italian population, 6,036 (2.04%) had AF: 20.2% paroxysmal, 24.3% persistent, and 55.5% permanent AF. AF occurred in 0.16% of patients aged 16 to 50 years, 9.0% of those aged 76 to 85 years, and 10.7% of those aged ≥85 years. AF was symptomatic despite therapy in 74.6% of patients and was associated with heart disease in 75%. Among the patients with AF, 24.8% had heart failure, 26.8% renal failure, 18% stroke/transient ischemic attack, and 29.3% had ≥3 co-morbidities. The rate control treatment strategy was pursued in 55%. Of the 6,036 patients with AF, 46% received anticoagulants. The success rate of catheter ablation of the AF substrate was 50%. In conclusion, in our study, the frequency of AF was 2 times greater than previously reported (approximately 0.90%), rate control was the most pursued treatment strategy, anticoagulants were still underused, and the success rate of AF ablation was lower than reported by referral centers.
Objectives. This study was performed to evaluate the effects of l-carnitine administration on long-term left ventricular dilation in patients with acute anterior myocardial infarction.
Background. ...Carnitine is a physiologic compound that performs an essential role in myocardial energy production at the mitochondrial level. Myocardial carnitine deprivation occurs during ischemia, acute myocardial infarction and cardiac failure. Experimental studies have suggested that exogenous carnitine administration during these events has a beneficial effect on function.
Methods. The l-Carnitine Ecocardiografia Digitalizzata Infarto Miocardico (CEDIM) trial was a randomized, double-blind, placebo-controlled, multicenter trial in which 472 patients with a first acute myocardial infarction and high quality two-dimensional echocardiograms received either placebo (239 patients) or l-carnitine (233 patients) within 24 h of onset of chest pain. Placebo or l-carnitine was given at a dose of 9 g/day intravenously for the first 5 days and then 6 g/day orally for the next 12 months. Left ventricular volumes and ejection fraction were evaluated on admission, at discharge from hospital and at 3, 6 and 12 months after acute myocardial infarction.
Results. A significant attenuation of left ventricular dilation in the first year after acute myocardial infarction was observed in patients treated with l-carnitine compared with those receiving placebo. The percent increase in both end-diastolic and endsystolic volumes from admission to 3-, 6- and 12-mouth evaluation was significantly reduced in the l-carnitine group. No significant differences were observed in left ventricular ejection fraction changes over time in the two groups. Although not designed to demonstrate differences in clinical end points, the combined incidence of death and congestive heart failure after discharge was 14 (6%) in the l-carnitine treatment group versus 23 (9.6%) in the placebo group (p = NS). Incidence of ischemic events during follow-up was similar in the two groups of patients.
Conclusions. l-Carnitine treatment initiated early after acute myocardial infarction and continued for 12 months can attenuate left ventricular dilation during the first year after an acute myocardial infarction, resulting in smaller left ventricular volumes at 3, 6 and 12 months after the emergent event.
A special computer network has been specifically designed and realized to connect 36 Italian cardiological institutions to a central core laboratory. This network, which has been created to run the ...CEDIM Multicenter Trial (effects of L-carnitine on left ventricular function in patients with myocardial infarction assessed by digital echocardiography), enables automatic verification, via computer, 24 hours a day, of patient eligibility criteria, randomization, transmission, and filing of real-time left ventricular echocardiographic examinations. All the investigators participating in the CEDIM trial underwent several training courses as well as dummy run procedures to achieve optimal performance of all the operational procedures required for the network to function smoothly and correctly. This paper describes the aims of this special network, its technical characteristics, and the investigator training and dummy run procedures.
Type 2 diabetes (T2D) patients are at increased risk for cardiovascular (CV) events. Most guidelines recommend treating low-density lipoprotein cholesterol (LDL-C) levels to ≤70 mg/dL (1.8 mM) for ...patients with T2D and established atherosclerotic CV disease, and some a more aggressive target of ≤55 mg/dL (1.4 mM). Our objective was to assess the degree to which these LDL-C targets are achieved in routine practice.
Using data from TECOS, an international pragmatic CV outcomes trial of sitagliptin vs placebo, we assessed lipid-lowering treatment among patients with T2D and CV disease, baseline lipid values, and the association between baseline LDL-C and 5-year risk for major adverse cardiac events (MACE; ie, CV death, nonfatal myocardial infarction, or nonfatal stroke).
Overall, 11,066 of 14,671 TECOS participants (75.4%) had LDL-C measured at baseline. Median age was 65 years, 72% were male, and median T2D duration was 10 years. Overall, 82.5% of patients were on statins; only 5.8% were on ezetimibe. At baseline, 14.3% had LDL-C ≤55 mg/dL, 18.4% between 55.1 and 70 mg/dL, 35% between 70.1 and 100 mg/dL, and 32.3% >100 mg/dL. Each 10 mg/dL higher LDL-C value was associated with a higher risk of MACE (HR 1.05, 95% CI 1.03–1.07) or CV death (HR 1.06, 95% CI 1.04–1.09).
Although most high-risk patients with T2D and CV disease were on lipid-lowering therapy, only 1:3 had LDL-C <70 mg/dL and 1:6 had LDL-C <55 mg/dL. Each 10 mg/dL higher LDL-C value was associated with a 5% and 6% higher 5-year incidence of MACE and CV death, respectively. (TECOS, NCT00790205).
Given the rapidity of the evolution of the epidemic (which could soon become a pandemic), pending confirmation from clinical research, some aspects that have been put in place, and others that ...deserve to be considered for the most prudent and judicious management are as follows: * Organization (or strengthening) of a national ICU Network * Definition and verification of pandemic emergency plans (with verification of organ care and support devices, personal protective equipment and appropriate trai ning as extensive as possible) * Establishment of appropriate Rapid Triage protocols on the territory and in front of Emergency Departments to identify patients with suspicion of COVID-19 at an early stage and insert them in dedicated logistical and clinical pathways which are separate from the other clinical conditions of non infected users * Accurate and extensive training with appropriate simulations on dressing and undressing procedures with Personal Protective Equipment (PPE) * Identification of the hospitals that should receive COVID-19 patients, or strict separation of the treatment areas (of any intensity level) dedicated to people with COVID-19, and their transit and transport routes, including areas for radiological diagnostics * Redefine the number of nurses with care skills in ICU in consideration of a working model with a patient - nurse ratio 1:1 and where possible 2:1 for procedures with a high workload. Organize shifts so that a nurse or an Health Carer Assistant (HCA) always remains "clean" outside the area where PPE is to be used and provide for the possibility of having free nurses on shift who can support or lighten the workload. * Increase of beds in intensive and sub-intensive tensive care unit, with priority recruitment of already experienced nurses, as the need to care for a large number of patients can suddenly arise and evolve very quickly so as not to allow training and integration of newly hired or inexperienced in intensive care. * Expect increased workloads due to high pronation needs, and PPE dressing and undressing procedures * Need to aggregate care interventions and anticipate any preventable/predictable situations to reduce the patient's bedside time and allow adequate interval times without PPE * Need to schedule shifts on COVID - 19 patients such that nurses do not wear PPE for more than 3 hours (4 hours maximum), and take appropriate measures to prevent pressure - related injuries related to PPE (protective hydrocolloids on contact points of filter masks) * Predict the need to extend shifts due to workload, but also cases of possible increase in illness among care staff * Strengthening of support operators for logistical needs linked to the decontamination and reconditioning of multi-use care and assistance equipment * Meticulous monitoring of daily and terminal environmental hygiene procedures, with particular attention to common and repeated contact surfaces such as keyboards, PCs, telephones, switches, door handles, and personal mobile phones * Need to consider the possibility of psychological support for intensive therapy teams facing up this situation due to the increase of work-related stress, the possibility of burn-out in relation to the lengthening of "health emergency" times, the feeling of isolation and anxiety of the operators (also related to the health of their meaningful) * Particular attention should be paid to refreshing the internal safety rules aimed at limiting the dispersion of contaminants containing SARS-Cov2 viruses, particularly for procedures at risk: - Tracheal intubation - Tracheostomy bedside - Tracheal suction (closed circuit) - Limit as much as possible the oxygenation and ventilation methods that can nebulize particles - Aerosol therapy (privilege the installation of the systems directly at the time of intubation of the patient) - Avoid accidental disconnection of the ventilator circuit - Use the "expiratory pause block" functions combined with the closure of the endotracheal tube in case of programmed opening of the circuit - Avoid the use of high diffusion droplet systems (High Flow Nasal Cannula, Noninvasive ventilation with face mask, CPAP by Boussignac system) - Privilege the use of the helmet as an interface for oxygen therapy or CPAP, placing a HEPA (high efficiency particulate air) filter on the expiratory line - Place a HEPA filter on the expiratory valves of the ventilators, on the side where the exhaled gas escapes into the atmosphere. - Place a HEPA filter on manual ventilation devices - Prefer the use of single-use fibroscopes * In case of MET activation for CPR maneuvers, inside hospitals, operators must consider the unknown patient as potentially infected, and use the PPE provided for Covid patients (equip emergency backpacks with complete dressing kits for at least 2 operators) * Immediate notification of any disruption of barriers caused by individual PPE or accidental exposure conditions * Prudential and temporary limitation of access to patient visits in all areas of the hospital, with absolute prohibition of entry to people with respiratory symptoms.
Data la rapidita dell'evolversi della epidemia (che potrebbe assumere a breve i caratteri di pandemia), in attesa di conferme da parte della ricerca clinica, alcuni aspetti che sono stati messi in ...atto e che meritano di essere presi in considerazione per una gestione il piú possibile prudente ed oculata sono i seguenti: * Organizzazione (o rafforzamento) della rete tra le Terapie Intensive a livello nazionale * Definizione e verifica di piani per emergenza pandemica (con verifica di dispositivi di cura e supporto d'organo, dispositivi di protezione individuale e adeguata formazione il piú estesa possibile) * Istituzione di adeguati protocolli di Triage rapido sul territorio e davanti ai Dipartimenti di Emergenza per individuare precocemente i pazienti con sospetto di COVID-19 ed indirizzare in percorsi logistici e clinici dedicati e separati rispetto alle altre condizioni cliniche degli utenti * Formazione capillare e puntuale con adeguate simulazioni sulle procedure di vestizione e svestizione con i dispositivi di Protezione Individuale (DPI) * Identificazione degli ospedali che dovranno accogliere i pazienti COVID-19, oppure, all'interno di questi, rigorosa separazione delle aree di cura (di qualsiasi livello di intensita) dedicate alle persone affette da COVID-19, e dei percorsi di transito e trasporto relativi, comprese le aree di diagnostica radiologica * Adeguamento del numero degli infermieri con competenze di assistenza in terapia intensiva in previsione di rapporti infermieri pazienti il piú possibile superiori ad 1:1. Il carico di lavoro e fortemente aumentato a causa del rallentamento fisiologico che indossare i DPI massimali comporta, oltre alla necessita di aumentare i livelli di attenzione per evitare eventuali contaminazioni e dispersione di virus SARS-Cov-2. Organizzare i turnidi lavoro in modo che un infermiere resti sempre "pulito" al di fuori dell'area in cui e previsto l'utilizzo dei DPI * Aumento dei posti letto in terapia intensiva e subintensiva, con reclutamento privi legiato di personale infermieristico gia esperto, in quanto le necessita di assistere numeri elevati di pazienti possono presentarsi improvvisamente ed assumere caratteri di rapidissima evolutivita che non consentono percorsi di formazione e inserimento di neoassunti o inesesperti nelle terapie intensive * Previsione di carichi di lavoro aumentati a causa di elevate necessita di pronazione, e delle procedure di vestizione e svestizione dei DPI * Necessita di clusterizzare gli interventi assistenziali ed anticipazione di eventuali situazioni prevenibili/prevedibili per ridurre il tempo di stazionamento al letto del paziente e permettere adeguati tempi di intervallo di recupero senza DPI * Necessita di programmare i turni sui pazienti COVID - 19 in modo che gli infermieri non indossino i DPI per piú 3 ore (4 al massimo), e adozione di adeguate misure di prevenzione di lesioni da pressione device correlate ai DPI (idrocolloidi protettivi su punti di contatto di maschere filtranti) * Previsione della necessita di prolungare i turni di lavoro a causa del carico di lavoro, ma anche dei casi di possibile aumento di malattia tra il personale di assistenza * Potenziamento degli operatori di supporto per le necessita logistiche legate alla decontaminazione e ricondizionamento dei materiali di cura ed assistenza non monouso * Meticolosa sorveglianza circa le procedure di igiene ambientale quotidiana e terminale, con particolare attenzione a superfici di contatto comune e ripetuto come tastiere, PC, telefoni, interruttori, maniglie delle porte, e telefoni cellulari personali * Necessita di tenere presente la possibilita di supporto psicologico per i gruppi delle terapie intensive che affrontano questa situazione a causa l'aumento di stress-lavoro correlato, possibilita di burn-out in relazione all'allungamento dei tempi di "emergenza sanitaria", di sensazione di isolamento ed ansia degli operatori (legata anche alla salute delle proprie persone significative) * Particolare attenzione al refreshing sulle regole di sicurezza interna volte al la limitazione della dispersione dei contaminanti contenenti virus SARS-Cov2, particolarmente nelle procedure a rischio: - Intubazione tracheale - Tracheostomia bedside - Aspirazione tracheale (circuito chiuso) - Limitare al massimo le metodiche di ossigenazione e ventilazione che possono nebulizzare particelle - Aerosol terapia (privilegiare l'installazione dei sistemi direttamente al momento dell'intubazione del paziente) - Evitare deconnessioni accidentali del circuito ventilatorio - Utilizzare le funzioni "blocco pausa espiratoria" abbinata alla chiusura del tubo endotracheale in caso di apertura programmata del circuito - Evitare l'utilizzo di sistemi ad alta diffusione di droplet (High Flow Nasal Cannula, Non invasive ventilation with face mask, CPAP di Boussignac) - Privilegiare l'utilizzo dell'elmetto come interfaccia per ossigeno terapia o CPAP, ponendo sulla linea espiratoria un filtro HEPA (high efficiency particulate air) - Posizionare un filtro HEPA sulle valvole espiratorie dei ventilatori, sul lato di fuoriuscita del gas espirato in ambiente - Posizionare un filtro HEPA sui dispositivi di ventilazione manuale - Privilegiare l'utilizzo di fibroscopi monouso * In caso di attivazione dei MET per manovre di rianimazione cardio polmonare, all'interno degli ospedali, gli operatori devono considerare il paziente sconosciuto come potenzialmente infetto, ed utilizzare i DPI previsti per i pazienti Covid (attrezzare gli zaini per l'urgenza con Kit completi di vestizione per almeno 2 operatori). * Segnalazione immediata ai superiori dell'eventuale interruzione di barriere date dai DPI individuali o da condizioni di esposizione accidentale * Limitazione prudenziale e temporanea dell'accesso alle visite dei pazienti in tutte le aree dell'ospedale, con assoluto divieto di ingresso a persone con sintomatologia respiratoria.
Background Several studies suggest transient ischemic attack (TIA) may be neuroprotective against ischemic stroke analogous to preinfarction angina's protection against acute myocardial infarction. ...However, this protective ischemic preconditioning-like effect may not be present in all ages, especially among the elderly. The purpose of this study was to determine the neuroprotective effect of TIAs (clinical equivalent of cerebral ischemic preconditioning) to neurologic damage after cerebral ischemic injury in patients over 65 years of age. Methods We reviewed the medical charts of patients with ischemic stroke for presence of TIAs within 72 hours before stroke onset. Stroke severity was evaluated by the National Institutes of Health Stroke Scale and disability by a modified Rankin scale. Results We evaluated 203 patients (≥65 years) with diagnosis of acute ischemic stroke and categorized them according to the presence (n = 42, 21%) or absence (n = 161, 79%) of TIAs within 72 hours of stroke onset. Patients were monitored until discharged from the hospital (length of hospital stay 14.5 ± 4.8 days). No significant differences in the National Institutes of Health Stroke Scale and modified Rankin scale scores were observed between those patients with TIAs and those without TIAs present before stroke onset at admission or discharge. Conclusion These results suggest that the neuroprotective mechanism of cerebral ischemic preconditioning may not be present or functional in the elderly.
The life span of human beings is partially influenced by genetic factors, but outcomes of aging are profoundly influenced by lifestyle and other environmental factors. Age-related modifications of ...the cardiovascular system are preserved by antiaging lifestyle interventions such as physical activity and caloric restriction. Accordingly, physical activity and low body mass index reduce mortality in older men with cardiovascular diseases. Several mechanisms have been proposed to explain the protective effect of lifestyle interventions against cardiovascular diseases in the elderly, including a reduction of vulnerability (i.e., the age-related reduction of endogenous mechanisms protective against pathologic insults). The age-related reduction of ischemic preconditioning, the most powerful endogenous protective mechanism against myocardial ischemia, is restored by both physical activity and caloric restriction. Thus, older persons can implement lifestyle practices that minimize their risk of death from cardiovascular diseases.
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