Background:The first few months after admission are the most vulnerable period in patients with acute decompensated heart failure (ADHF).Methods and Results:We assessed the association of the updated ...ADHF/N-terminal pro-B-type natriuretic peptide (NT-proBNP) risk score with 90-day and in-hospital mortality in 701 patients admitted with advanced ADHF, defined as severe symptoms of worsening HF, severely depressed left ventricular ejection fraction, and the need for i.v. diuretic and/or inotropic drugs. A total of 15.7% of the patients died within 90 days of admission and 5.2% underwent ventricular assist device (VAD) implantation or urgent heart transplantation (UHT). The C-statistic of the ADHF/NT-proBNP risk score for 90-day mortality was 0.810 (95% CI: 0.769–0.852). Predicted and observed mortality rates were in close agreement. When the composite outcome of death/VAD/UHT at 90 days was considered, the C-statistic decreased to 0.741. During hospitalization, 7.6% of the patients died. The C-statistic for in-hospital mortality was 0.815 (95% CI: 0.761–0.868) and Hosmer-Lemeshow χ2=3.71 (P=0.716). The updated ADHF/NT-proBNP risk score outperformed the Acute Decompensated Heart Failure National Registry, the Organized Program to Initiate Lifesaving Treatment in Patients Hospitalized for Heart Failure, and the American Heart Association Get with the Guidelines Program predictive models.Conclusions:Updated ADHF/NT-proBNP risk score is a valuable tool for predicting short-term mortality in severe ADHF, outperforming existing inpatient predictive models. (Circ J 2015; 79: 1076–1083)
Abstract Background Although the prognostic value of right ventricular dysfunction in chronic heart failure (HF) has been studied extensively, it remains insufficiently characterized in the setting ...of acute decompensated HF (ADHF). We sought to assess whether measurement of tricuspid annular plane systolic excursion (TAPSE) or TAPSE-to–estimated pulmonary arterial systolic pressure (ePASP) ratio allows improvement of risk prediction in ADHF. Methods Four hundred ninety-nine patients with ADHF were studied. Cox regression analyses were used to analyze the association of TAPSE and TAPSE-to-ePASP ratio with 1-year mortality and logistic regression analyses to analyze the association of the 2 variables of interest with adverse in-hospital outcome (AiHO) (in-hospital death plus worsening HF). Results During the 365-day follow-up, 143 patients (28.7%) died. At univariable analysis, both TAPSE ( P = 0.026) and TAPSE-to-ePASP ratio ( P < 0.0001) were significantly associated with 1-year mortality. At multivariable Cox analysis, age ( P = 0.0270), ischemic heart disease ( P = 0.020), systolic blood pressure ( P = 0.006), log N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels ( P < 0.0001), serum sodium levels ( P = 0.001), and hemoglobin levels ( P = 0.001) at admission were independently associated with 1-year mortality. Adjusting for these covariates, neither TAPSE ( P = 0.314) nor TAPSE-to-ePASP ratio ( P = 0.237) remained independently associated with 1-year mortality. Eighty-three patients (16.6%) had an AiHO. At multivariable logistic regression analysis, the TAPSE-to-ePASP ratio was independently associated with an AiHO ( P = 0.024). The association of TAPSE alone or ePASP alone was not statistically significant. Conclusions Our data strongly suggest that early assessment of TAPSE or TAPSE-to-ePASP ratio does not improve prediction of 1-year mortality over other key risk markers in ADHF. Nonetheless, the TAPSE-to-ePASP ratio did appear to be independently associated with AiHO.
RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an earlystart AET program on functional ...capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient- reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP >1000 pg/ml at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine >2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6- minWT at day 1, 6, 12 and 30 and echocardiogram, patient- reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.
RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an early-start AET program on functional ...capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient-reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP > 1000 pg/mI at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine > 2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6-min WT at day 1, 6, 12 and 30 and echocardiogram, patient-reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.
RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an early-start AET program on functional ...capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient-reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP > 1000 pg/mI at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine > 2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6-min WT at day 1, 6, 12 and 30 and echocardiogram, patient-reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.
Sudden cardiac death (SDC) is responsible for approximately 60-70% of deaths in New York Heart Association (NYHA) class II congestive heart failure (CHF) patients. Recently, microvolt-level T wave ...alternans has been proposed as a new noninvasive tool to identify CHF patients at risk for SCD and ventricular tachycardia/fibrillation (VT/VF).
To determine the prognostic value of MTWA in NYHA class II patients.
Among 181 consecutive CHF patients with ischemic and nonischemic cardiomyopathy, 73 patients in NYHA class II with left ventricular ejection fraction <45% were selected and prospectively investigated. MTWA was determined during bicycle exercise testing. The study end point was defined as SCD, documented sustained VT/VF and appropriate implantable cardioverter defibrillator (ICD) shock.
MTWA was positive in 30 (41%) patients, negative in 26(36%) patients and indeterminate in 17 (23%) patients. During an average follow-up of 17.1+/-7.4 months, seven patients had an arrhythmic event in the MTWA positive group, whereas one and no events occurred in the indeterminate and negative group, respectively. From Kaplan-Meier univariate analysis and multivariate Cox analysis, MTWA was a significant arrhythmic risk stratifier (p=0.01 and p=0.03, respectively). Sensitivity, specificity, negative and positive predictive values of MTWA were 100%, 53%, 100% and 24%, respectively.
Our data suggest that MTWA is a promising predictor of arrhythmic events in NYHA class II CHF patients.
Sudden cardiac death (SDC) is responsible for approximately 60–70% of deaths in New York Heart Association (NYHA) class II congestive heart failure (CHF) patients. Recently, microvolt-level
T wave ...alternans has been proposed as a new noninvasive tool to identify CHF patients at risk for SCD and ventricular tachycardia/fibrillation (VT/VF).
To determine the prognostic value of MTWA in NYHA class II patients.
Among 181 consecutive CHF patients with ischemic and nonischemic cardiomyopathy, 73 patients in NYHA class II with left ventricular ejection fraction <45% were selected and prospectively investigated. MTWA was determined during bicycle exercise testing. The study end point was defined as SCD, documented sustained VT/VF and appropriate implantable cardioverter defibrillator (ICD) shock.
MTWA was positive in 30 (41%) patients, negative in 26(36%) patients and indeterminate in 17 (23%) patients. During an average follow-up of 17.1±7.4 months, seven patients had an arrhythmic event in the MTWA positive group, whereas one and no events occurred in the indeterminate and negative group, respectively. From Kaplan–Meier univariate analysis and multivariate Cox analysis, MTWA was a significant arrhythmic risk stratifier (
p=0.01 and
p=0.03, respectively).
Sensitivity, specificity, negative and positive predictive values of MTWA were 100%, 53%, 100% and 24%, respectively.
Our data suggest that MTWA is a promising predictor of arrhythmic events in NYHA class II CHF patients.
Availability of a telematic system of electrocardiogram (ECG) transmission may improve the management of ST-elevation myocardial infarction (STEMI), by reducing time to treatment. The aim of this ...study was to show the effectiveness of telephone transmission of ECG in improving quality of care for patients with acute STEMI.
Since January 1, 2003, we activated a management program of STEMI in healthcare district of Varese, located in the North-West of Lombardy (Italy), comprising one fourth-level hospital, equipped with a cath lab on call 24/24 h for primary angioplasty since 1993 and cardiac surgery, and 2 community hospitals, placed in a mountain area approximately 30 km far from Varese. The emergency medical system (EMS) transport was activated 24/24 h and has 15 basic life support (BLS) ambulances with trained nurse staff and 2 mobile units with medical staff, all of them equipped with semiautomatic defibrillator Lifepack 12, enabling a GSM telephone transmission of a 12-lead ECG, coupled with 3-lead continuous rhythm recording and clinical data, if necessary. The ECGs were transmitted to a core unit placed in the coronary care unit (CCU) of the Hospital di Circolo of Varese, directly connected with the EMS core unit.
From January 2003 to August 2005, a total of 2063 ECGs were transmitted, 538 of them (26%) recorded by EMS ambulances. Of 144 ECGs (7%) showing a persistent ST-elevation suggesting an acute STEMI (group A), 112 subjects underwent reperfusion: 73 were treated with angioplasty and 39 by lysis alone. By comparing data of group A with a group of 256 patients (180 reperfused) with acute STEMI, admitted to our hospital in the same period without ECG teletransmission (group B), we observed no statistical difference in mortality and reperfusion rates but a significative reduction in the pre-hospital and in-hospital times in group A patients treated by primary angioplasty and thrombolysis.
Our study confirms previous results in that an early availability of a 12-lead ECG, transmitted from peripheral community hospitals and BLS ambulances, is able to reduce time to management of patients with an acute STEMI, thus improving quality of decision-making and treatment.
In Italy, rainfall is the primary trigger of landslides that frequently cause fatalities and large economic damage. Using a variety of information sources, we have compiled a catalogue listing 753 ...rainfall events that have resulted in landslides in Italy. For each event in the catalogue, the exact or approximate location of the landslide and the time or period of initiation of the slope failure is known, together with information on the rainfall duration D, and the rainfall mean intensity I, that have resulted in the slope failure. The catalogue represents the single largest collection of information on rainfall-induced landslides in Italy, and was exploited to determine the minimum rainfall conditions necessary for landslide occurrence in Italy, and in the Abruzzo Region, central Italy. For the purpose, new national rainfall thresholds for Italy and new regional rainfall thresholds for the Abruzzo Region were established, using two independent statistical methods, including a Bayesian inference method and a new Frequentist approach. The two methods proved complementary, with the Bayesian method more suited to analyze small data sets, and the Frequentist method performing better when applied to large data sets. The new regional thresholds for the Abruzzo Region are lower than the new national thresholds for Italy, and lower than the regional thresholds proposed in the literature for the Piedmont and Lombardy Regions in northern Italy, and for the Campania Region in southern Italy. This is important, because it shows that landslides in Italy can be triggered by less severe rainfall conditions than previously recognized. The Frequentist method experimented in this work allows for the definition of multiple minimum rainfall thresholds, each based on a different exceedance probability level. This makes the thresholds suited for the design of probabilistic schemes for the prediction of rainfall-induced landslides. A scheme based on four probabilistic thresholds is proposed. The four thresholds separate five fields, each characterized by different rainfall intensity-duration conditions, and corresponding different probability of possible landslide occurrence. The scheme can be implemented in landslide warning systems that operate on rainfall thresholds, and on precipitation measurements or forecasts.
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