Alessandra Pratesi

Adiponectin in outpatients with coronary artery disease: Independent predictors and relationship with heart failure

BACKGROUND AND AIMS Chronic heart failure (HF) is characterised by a neurohormonal dysfunction associated with chronic inflammation. A role of metabolic derangement in the pathophysiology of HF has been recently reported. Adiponectin, an adipose-tissue-derived cytokine, seems to play an important role in cardiac dysfunction. We investigated the variation of circulating adiponectin in patients with coronary artery disease (CAD), with or without HF, in order to identify its independent predictors. METHODS AND RESULTS A total of 107 outpatients with CAD were enrolled in the study and divided into three groups: CAD without left ventricular systolic dysfunction (group 1); CAD with left ventricular dysfunction without HF symptoms (group 2) and CAD with overt HF (group 3). Plasma adiponectin was determined by enzyme-linked immunosorbent assay. Adiponectin concentrations increased progressively from group 1 (7.6 ± 3.6 ng ml⁻¹) to group 2 (9.1 ± 6.7 ng ml⁻¹) and group 3 (13.7 ± 7.6 ng ml⁻¹), with the difference reaching statistical significance in group 3 versus 1 and 2 (p < 0.001). A multivariable model of analysis demonstrated that the best predictors of plasma adiponectin were body mass index, N-terminal pro-brain natriuretic peptide and high-density lipoprotein cholesterol. However, even after adjusting for all three independent predictors, the increase of adiponectin in group 3 still remained statistically significant (p = 0.015). CONCLUSION Our data confirm the rise of adiponectin in overt HF. The levels of circulating adipokine seem to be mainly predicted by the metabolic profile of patients and by biohumoral indicators, rather than by clinical and echocardiographic indexes of HF severity.

Adiponectin, diabetes and ischemic heart failure: a challenging relationship

BackgroundSeveral peptides, named adipokines, are produced by the adipose tissue. Among those, adiponectin (AD) is the most abundant. AD promotes peripheral insulin sensitivity, inhibits liver gluconeogenesis and displays anti-atherogenic and anti-inflammatory properties. Lower levels of AD are related to a higher risk of myocardial infarction and a worse prognosis in patients with coronary artery disease. However, despite a favorable clinical profile, AD increases in relation to worsening heart failure (HF); in this context, higher adiponectinemia is reliably related to poor prognosis. There is still little knowledge about how certain metabolic conditions, such as diabetes mellitus, modulate the relationship between AD and HF.We evaluated the level of adiponectin in patients with ischemic HF, with and without type 2 diabetes, to elucidate whether the metabolic syndrome was able to influence the relationship between AD and HF.ResultsWe demonstrated that AD rises in patients with advanced HF, but to a lesser extent in diabetics than in non-diabetics. Diabetic patients with reduced systolic performance orchestrated a slower rise of AD which began only in face of overt HF. The different behavior of AD in the presence of diabetes was not entirely explained by differences in body mass index. In addition, NT-proBNP, the second strongest predictor of AD, did not differ significantly between diabetic and non-diabetic patients. These data indicate that some other mechanisms are involved in the regulation of AD in patients with type 2 diabetes and coronary artery disease.ConclusionsAD rises across chronic heart failure stages but this phenomenon is less evident in type 2 diabetic patients. In the presence of diabetes, the progressive increase of AD in relation to the severity of LV dysfunction is hampered and becomes evident only in overt HF.

Cardiac Rehabilitation in Very Old Adults: Effect of Baseline Functional Capacity on Treatment Effectiveness

To assess the effect of cardiac rehabilitation (CR) and identify predictors of changes in functional capacity with CR in a consecutive series of older adults with a recent cardiac event.

Prognostic value of adiponectin in coronary artery disease: Role of diabetes and left ventricular systolic dysfunction.

OBJECTIVES Adiponectin (AD) promotes insulin sensitivity and has anti-atherogenic properties. However, the role of AD on clinical outcomes in coronary artery disease (CAD) is controversial. We analyzed whether AD was an independent predictor of all-cause mortality and hospitalization in patients with CAD. METHOD We prospectively enrolled 138 patients with stable CAD, with or without type 2 diabetes and with or without left ventricular dysfunction. A telephone follow-up was conducted to register long term outcomes. Sensitivity/specificity ratio for AD was investigated with ROC analysis and the independent role of AD on outcome was evaluated with Cox regression model of analysis. The survival rate was represented by Kaplan Meyer curves. RESULTS Of 138 patients, 61 had type 2 diabetes and 71 left ventricular systolic dysfunction (EF<40%). Median time of follow-up was 1384days; mortality rate was 18.8% (26 deaths) and hospitalization rate was 47.1% (65 events). Mean concentration of AD was 9.87±7.53ng/ml; the analysis of the ROC curve identified an AD cut-off level of 13.2ng/ml (AUC 0.779; p<0.0001). Patients with AD >13.2ng/ml had a significantly higher risk of death (HR=6.50; 95% CI: 2.40-17.70), but not of cardiovascular hospitalization (HR=0.87; 95% CI: 0.31-2.44). AD predictivity remained significant also in patients with type 2 diabetes and with left ventricular systolic dysfunction. CONCLUSION In stable CAD, an AD value of >13.2ng/ml independently predicts a 6-fold increased risk of all-cause mortality.

Cardiovascular prevention and rehabilitation in the elderly: evidence for cardiac rehabilitation after myocardial infarction or chronic heart failure.

Cardiac rehabilitation in the elderly today often represents a utopia. The international scientific literature takes little into account this type of prescription for old people, although they represent a large and growing proportion of cardiac patients, with acute coronary syndrome or heart failure, which we have to manage in everyday life. Furthermore, interventions of health education, clinical follow up, rehospitalisation prevention and prescription of tailored exercise, are sometimes more necessary in this kind of patients, given the presence of multimorbidity, functional dependence, frailty, sarcopenia, social neglect. Most of the data on the feasibility, safety and efficacy of cardiac rehabilitation are favourable, but they are few and apparently not strong enough to convince the medical community. Therefore is necessary to join efforts to identify the geriatric patients peculiarities and plan a suitable program of cardiac rehabilitation, which takes into account the multi-dimensionality and complexity of typical problems of the elderly, for which the classical cardiac outcomes can be limited.

Sudden cardiac arrest in a 73-year-old woman caused by systemic capillary leak syndrome.

A 73-year-old woman was referred to the Geriatric Intensive Care Unit of our University Hospital, on February 2015, for post-anoxic coma after cardiac arrest. The patient was reported to be in good health until a few days before the event. She exercised regularly. A year before, she was admitted to the emergency department (ED) for, allegedly, ‘‘dehydration during influenza’’. The night before the event, she experienced vomiting and diarrhea, and progressive weakness with myalgia involving the upper and lower limbs. The next morning, she underwent a pre-syncopal episode of short duration. She called the local emergency service, but, during transfer to the hospital, she suddenly underwent pulseless electrical activity (time to ROSC 18 min). At arrival in the ED, the first blood test demonstrated hypokalemia (2.8 mmol/L), associated with modest neutrophilic leukocytosis and moderate hemoconcentration. She was apyretic (procalcitonin 0.12 lg/mL). A total-body CT scan showed only an extravasation of fluids restricted to the right adductor muscles; there were no signs of infection. In the next few hours, the laboratory tests indicated marked hemoconcentration (hemoglobin 16.6 g/ dL), severe hypoproteinemia (total protein levels\2 g/dL), hypocholesterolemia (total cholesterol \50 mg/dL), renal insufficiency (creatinine 1.43 mg/dL), and high level of ferritin (3408 ng/mL). Rapidly, she developed anasarca with marked lower limb pitting edema, resulting in the development of a compartment syndrome and rhabdomyolysis that necessitated continuous renal replacement therapy (CRRT). The first few days of hospitalization were characterized by hemodynamic instability that required vasopressor and intravenous fluid therapy; she developed disseminated intravascular coagulation (DIC) due to a deficiency of liver-produced coagulation factors. Chest X-ray study, electrocardiogram, and echocardiogram excluded a primary cardiogenic cause of hypotension and peripheral edema. A throat swab was positive for influenza B virus; all other culture tests were negative. Plasma concentrations of IL-6 and IL-10 were markedly increased (78.3 and 86 pg/mL, respectively). The blood test also demonstrated the presence of monoclonal gammopathy (IgG lambda 1.87 g/L). The clinical picture was compatible with systemic capillary leak syndrome (SCLS), also known as Clarkson’s disease [1]. Less than 160 cases have been described since 1960 [1]. To our knowledge, this is the first case to be reported that arose with a sudden cardiac arrest, likely due to hypokalemia, with edema and severe hypotension emerging only later. SCLS is characterized by the reversible leakage of fluids and macromolecules into tissues, causing a wide spectrum of clinical pictures, from dehydration to hypovolemic shock. The disease is sporadic, most often manifesting in previously healthy, white adults [1]. Only one familial case has been reported in the literature. A minority of subjects have ‘‘chronic SCLS’’ characterized by recurrent peripheral edema [2]; however, the majority of patients undergo acute, often fatal, hypotensive episodes [1–3]. In our case, a year before, the subject was admitted to the ED for dehydration during an episode of common flu. On that occasion, a blood test demonstrated moderate hemoconcentration, which, along with disproportionate hypotension, should have raised a flag. & Francesca Tarantini francesca.tarantini@unifi.it

Electrophysiological correlates of word recognition memory process in patients with ischemic left ventricular dysfunction

OBJECTIVE The relationship between left ventricular ejection fraction (LVEF) and cognitive performance in patients with coronary artery disease without overt heart failure is still under debate. In this study we combine behavioral measures and event-related potentials (ERPs) to verify whether electrophysiological correlates of recognition memory (old/new effect) are modulated differently as a function of LVEF. METHODS Twenty-three male patients (12 without [LVEF>55%] and 11 with [LVEF<40%] left ventricular dysfunction), and a Mini Mental State Examination score >25 were enrolled. ERPs were recorded while participants performed an old/new visual word recognition task. RESULTS A late positive ERP component between 350 and 550ms was differentially modulated in the two groups: a clear old/new effect (enhanced mean amplitude for old respect to new items) was observed in patients without LVEF dysfunction; whereas patients with overt LVEF dysfunction did not show such effect. In contrast, no significant differences emerged for behavioral performance and neuropsychological evaluations. CONCLUSIONS These data suggest that ERPs may reveal functional brain abnormalities that are not observed at behavioral level. SIGNIFICANCE Detecting sub-clinical measures of cognitive decline may contribute to set appropriate treatments and to monitor asymptomatic or mildly symptomatic patients with LVEF dysfunction.

DAPT plus anticoagulant therapy: The difficult coexistence post-ACS in older patients with atrial fibrillation

Atrial fibrillation (AF) and coronary artery disease requiring percutaneous coronary intervention (PCI) and stenting often coexist in older patients. This poses the difficult problem of concurrent anticoagulant and double antiplatelet therapy (triple therapy). Current treatment guidelines do recommend triple therapy, especially in the course of acute coronary syndrome (ACS), with limitations due to an excessive risk of bleeding associated with this therapeutic regimen. This review summarizes randomized clinical trials and observational studies that compared triple therapy with a variety of different therapeutic options. Although the available evidence is not completely satisfactory and other studies are urgently needed, alternative regimens to triple therapy in AF patients undergoing PCI and stenting are promising, at least in terms of safety.

Risk Assessment in Cardiac and Noncardiac Surgery in Older Patients

Over the past 20 years, the number of older people undergoing surgery has increased exponentially, with projections suggesting that close to 50 % of the surgical activity in the USA will focus on the elderly population within the next few years [1]. This will unavoidably result in an increase prevalence of elderly patients evaluated preoperatively for different surgical indications [2], due to the increase in average length of life, improvement in surgical and anesthetic techniques, and significant reduction in intra- and perioperative mortality and morbidity [3, 4]. Despite these remarkable significant improvements, surgical risk, perioperative complications, mortality, and severe disability remain significantly higher in the elderly as compared to younger surgical candidates [5].

Pushing Age Limits Forward: How Should Acute Coronary Syndromes Be Treated in Centenarians? Discussion of Some Clinical Cases

Elderly adults with dementia hospitalized at the end of life are increasingly being admitted to the ICU, accounting for one in two EOL hospitalizations by the end of the last decade, reflecting the overall rise in demand for critical care services in this population. The rate of EOL hospitalizations in those admitted to ICU rose 36%, suggesting that a lower threshold for ICU admission is not likely to be a critical driver of rising ICU admissions. The unchanged rate of hospital mortality in individuals admitted to the ICU reaffirms that it can be misleading as a sole measure of EOL events. It is likely that the rapid rise of discharge to hospice of individuals with dementia hospitalized at the end of life and admitted to the ICU, accounting for the majority of EOL ICU hospitalizations by the end of last decade, reflects increasing occurrence of EOL discussions by clinicians with patients and, more likely, their proxies. Nevertheless, the timing of EOL discussions leading to a decision to pursue hospice care in individuals with dementia admitted to the ICU cannot be inferred from the administrative dataset, and their effect on reducing further possible burdensome care is unknown. Nevertheless, it is plausible to assume that important parts of these discussions take place after admission to the CU, given evolving trends of ICU admission. These findings may not be representative of other healthcare environments, and the current study lacks data about the severity of dementia in the examined population. In addition, dementia hospitalizations may have been underestimated because of the limited ability of clinicians to diagnose the disease and limited sensitivity of administrative data, although it is unlikely that the latter limitation explains the observed annual patterns of EOL hospitalizations within the dementia cohort. The findings of rising ICU use of individuals with dementia during EOL hospitalizations highlights the ongoing challenges facing clinicians to consistently align patients’ goals of care with subsequent potentially burdensome interventions in advance and to enhance allocation of critical care resources where they are likely to benefit patients with advancing cognitive decline.