Giuseppe Di Tano

How often we need to measure brain natriuretic peptide (BNP) blood levels in patients admitted to the hospital for acute severe heart failure? Role of serial measurements to improve short-term prognostic stratification.

BACKGROUND Brain natriuretic peptide (BNP) is increasingly used in the management of patients with heart failure (HF). It is still unclear how to use serial BNP measurement in HF. AIM To evaluate the usefulness of three consecutive measurements of BNP in patients (pts) hospitalized for acute HF. METHODS Clinical evaluation, BNP levels and echocardiography were assessed in 150 pts (67% males, age: 69+/-12 years; left ventricular ejection fraction: 34+/-14%) admitted for severe HF (NYHA class III-IV: 146/150). BNP measurements were obtained: at admission (basal, T0), at discharge (T1) and at first ambulatory control (T2), after optimization of medical therapy in those with discharge BNP level >250 pg/mL. End-points were death and hospital readmission during 6-month follow-up. RESULTS According to BNP levels 3 groups of patients were identified: Group 1 (62 pts, 41%), in whom discharge (T1) BNP was high and persisted elevated at T2 despite aggressive medical therapy; at 6-month follow-up 72% died or were hospitalized for HF. Group 2 (36 pts, 24%), in whom discharge (T1) BNP was high but decreased after medical therapy (T2); death and HF-readmission were observed in 8 pts (26%). Group 3 (52 pts, 35%), in whom discharge (T1) BNP levels were <250 pg/mL and persisted below this value at T2; death and HF-hospital readmission were observed in 6 pts (12%). Event rate differences among groups were statistically significant (p<0.001). At Cox-analysis discharge BNP cutoff of 250 pg/mL was the only parameter predictive of a worse outcome. CONCLUSION These data suggest that 3 BNP measurements, at admission, at discharge and few weeks later can allow to identify HF pts whom, despite a further potentiation of medical therapy, will present a worsening or even will die during short-term follow-up.

Evolution of renal function during and after an episode of cardiac decompensation: results from the Italian survey on acute heart failure.

Background Renal dysfunction is frequently associated with heart failure and strongly influences the outcome of heart failure patients. Although recommended pharmacological interventions for heart failure may contribute to the development of, or worsen renal dysfunction, their relations with renal function have not been fully explored in an unselected community population. Methods and aim We studied 1008 patients recruited in the Italian survey on acute heart failure to assess the prevalence, the prognostic role of renal function and the relations between the changes in renal function and the pharmacological interventions during hospitalization and at 6-month follow-up. Patients were categorized using the National Kidney Foundation cut-offs for degree of renal function measured by the glomerular filtration rate. Results Moderate-to-severe renal dysfunction was diagnosed in 59% of patients at hospital admission and 61% at discharge. These patients were older and had a higher prevalence of diabetes, anemia, history of hypertension, myocardial infarction and hospitalization for heart failure than those with normal or mildy impaired renal function. At admission the former were treated more frequently with diuretics, angiotensin converting enzyme-inhibitor (ACEi) or angiotensin receptor blockers (ARBs) than the latter. Diuretics were given at higher dose and for a longer time during the hospital stay while beta-blockers, digoxin, antialdosterone agents, ACEi and ARBs were given less frequently in patients who had moderate-to-severe renal dysfunction than those who did not. High-dose diuretic treatment, inability to start or maintain beta-blockers during hospital stay and the nonprescription of ACEi/ARBs at discharge emerged, by multivariate analysis, as predictors of death at 6-month follow-up (mortality rate = 14%), independent of the persistence of moderate-to-severe renal dysfunction over time, anemia, male sex and history of heart failure. Conclusions In acute heart failure, renal dysfunction is frequent and impacts prognosis. In this setting, the pharmacological interventions are significantly associated with changes in renal function and 6-month mortality.

The 30-day metric in acute heart failure revisited: data from IN-HF Outcome, an Italian nationwide cardiology registry.

Unplanned readmissions early after a discharge from acute heart failure hospitalization are common and have become a reimbursement benchmark and marker of hospital quality. However, the competing risk of short‐term post‐discharge mortality is substantial.

Improving the appropriateness of sudden arrhythmic death primary prevention by implantable cardioverter-defibrillator therapy in patients with low left ventricular ejection fraction. Point of view.

It is generally accepted that the current guidelines for the primary prevention of sudden arrhythmic death, which are based on ejection fraction, do not allow the optimal selection of patients with low left ventricular ejection fraction of ischemic and nonischemic etiology for implantation of a cardioverter-defibrillator. Ejection fraction alone is limited in both sensitivity and specificity. An analysis of the risk of sudden arrhythmic death with a combination of multiple tests (ejection fraction associated with one or more arrhythmic risk markers) could partially compensate for these limitations. We propose a polyparametric approach for defining the risk of sudden arrhythmic death using ejection fraction in combination with other clinical and arrhythmic risk markers (i.e. late gadolinium enhancement cardiac magnetic resonance, T-wave alternans, programmed ventricular stimulation, autonomic tone, and genetic testing) that have been validated in nonrandomized trials. In this article, we examine these approaches to identify three subsets of patients who cannot be comprehensively assessed by the current guidelines: patients with ejection fraction of 35% or less and a relatively low risk of sudden arrhythmic death despite the ejection fraction value; patients with ejection fraction of 35% or less and high competitive risk of death due to evolution of heart failure or noncardiac causes; and patients with ejection fraction between 35 and 45% with relatively high risk of sudden arrhythmic death despite the ejection fraction value.

Galectin-3 predicts left ventricular remodelling after anterior-wall myocardial infarction treated by primary percutaneous coronary intervention

Objectives Despite modern reperfusion therapies, left ventricular remodelling (LVR) occurs frequently after an ST-elevated myocardial infarction (STEMI) and represents a strong predictor of mortality and heart failure. Galectin-3 (Gal-3), a novel biomarker involved in inflammation, tissue repair and fibrogenesis, might be a valuable predictor of LVR. Methods We enrolled consecutively admitted patients with a first anterior STEMI and left anterior descending artery occlusion treated by primary percutaneous coronary intervention (pPCI). Gal-3, N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiography and cardiovascular events were evaluated 48 hours after admission, at 1 and 6 months. LVR was defined as a ≥15% increase in LV end-systolic volume. Results We recruited 103 patients (28% women, aged 64.6±12 years, LV ejection fraction 47±11%). Median baseline Gal-3 and NT-proBNP levels were 13.2 ng/mL (10.8–17.1 ng/mL) and 2132 pg/mL (1019–4860 pg/mL) respectively. During 6 months of follow-up, 4 patients dropped out, 7 died and 26 (28.3%) of the 92 survivors developed LVR (LVR+). LVR+ patients had higher Gal-3 levels at baseline, 1 and 6 months than LVR− (p<0.0001). By univariable logistic regression, age, female gender, higher baseline Gal-3 and NT-proBNP, smaller LV end-diastolic volume (LVEDV) were associated to an increased risk of LVR. By multivariable analysis, only LVEDV (OR 0.96, 95% CI 0.93 to 0.99/1 mL change) and Gal-3 levels (OR 1.22, 95% CI 1.06 to 1.42/1 ng/mL change) independently predicted LVR (C-statistics 0.84, 95% CI 0.75 to 0.93). Conclusion Gal-3 serum levels measured during hospitalisation could be clinically useful in predicting LVR among patients admitted with anterior STEMI treated by pPCI.

[ANMCO/SIMEU Consensus document: In-hospital management of patients presenting with chest pain].

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: 1) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; 2) the increasing percentage of hospitalizations of low-risk cases.It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

Clinical Presentation and Outcome in a Contemporary Cohort of Patients with Acute Myocarditis: The Multicenter Lombardy Registry

Background: There is controversy about the outcome of patients with acute myocarditis (AM), and data are lacking on how patients admitted with suspected AM are managed. We report characteristics, in-hospital management, and long-term outcome of patients with AM based on a retrospective multicenter registry from 19 Italian hospitals. Methods: A total of 684 patients with suspected AM and recent onset of symptoms (<30 days) were screened between May 2001 and February 2017. Patients >70 years of age and those >50 years of age without coronary angiography were excluded. The final study population comprised 443 patients (median age, 34 years; 19.4% female) with AM diagnosed by either endomyocardial biopsy or increased troponin plus edema and late gadolinium enhancement at cardiac magnetic resonance. Results: At presentation, 118 patients (26.6%) had left ventricular ejection fraction <50%, sustained ventricular arrhythmias, or a low cardiac output syndrome, whereas 325 (73.4%) had no such complications. Endomyocardial biopsy was performed in 56 of 443 (12.6%), and a baseline cardiac magnetic resonance was performed in 415 of 443 (93.7%). Cardiac mortality plus heart transplantation rates at 1 and 5 years were 3.0% and 4.1%. Cardiac mortality plus heart transplantation rates were 11.3% and 14.7% in patients with complicated presentation and 0% in uncomplicated cases (log-rank P<0.0001). Major AM-related cardiac events after the acute phase (postdischarge death and heart transplantation, sustained ventricular arrhythmias treated with electric shock or ablation, symptomatic heart failure needing device implantation) occurred in 2.8% at the 5-year follow-up, with a higher incidence in patients with complicated forms (10.8% versus 0% in uncomplicated AM; log-rank P<0.0001). &bgr;-Adrenoceptor blockers were the most frequently used medications both in complicated (61.9%) and in uncomplicated forms (53.8%; P=0.18). After a median time of 196 days, 200 patients had follow-up cardiac magnetic resonance, and 8 of 55 (14.5%) with complications at presentation had left ventricular ejection fraction <50% compared with 1 of 145 (0.7%) of those with uncomplicated presentation. Conclusions: In this contemporary study, overall serious adverse events after AM were lower than previously reported. However, patients with left ventricular ejection fraction <50%, ventricular arrhythmias, or low cardiac output syndrome at presentation were at higher risk compared with uncomplicated cases that had a benign prognosis and low risk of subsequent left ventricular systolic dysfunction.

ANMCO Position Paper: hospital discharge planning: recommendations and standards

Abstract The hospital discharge is often poorly standardized and affected by discontinuity and fragmentation of care, putting patients at high risk of both post-discharge adverse events and early readmission. The present ANMCO document reviews the modifiable components of the hospital discharge process related to adverse events or re-hospitalizations and suggests the optimal methods for redesigning the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that the hospital discharge: • is not an isolated event, but a process that has to be planned as soon as possible after the admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions, as equal partners; • is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process; • must be organized by an operator who is responsible for the coordination of all phases of the hospital patient journey, involving afterward the general practitioner and transferring to them the information and responsibility at discharge; • is the result of an integrated multidisciplinary team approach; • appropriately uses the transitional and intermediate care services; • is carried out in an organized system of care and continuum of services; and • programs the passage of information to after-discharge services.

ANMCO Position Paper: direct oral anticoagulants for stroke prevention in atrial fibrillation: clinical scenarios and future perspectives

Abstract It is now 4 years since the introduction of the new direct oral anticoagulants into clinical practice. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) has deemed necessary to update the previous position paper on the prevention of thrombo-embolic complications in patients with non-valvular atrial fibrillation, which was published in 2013. All available scientific evidence has been reviewed, focusing on data derived from both clinical trials and observational registries. In addition, all issues relevant to the practical clinical management of oral anticoagulation with the new direct inhibitors have been considered. Specific clinical pathways for optimal use of oral anticoagulation with the new directly acting agents are also developed and proposed for clinical implementation. Special attention is finally paid to the development of clinical algorithms for medium and long-term follow-up of patients treated with new oral direct anticoagulants.

ANMCO/SIC Consensus Document: Cardiology networks for outpatient heart failure care

Abstract Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics. The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals. The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment. In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.