Lorenzo Boncinelli

EHRA Expert Consensus Statement on the management of cardiovascular implantable electronic devices in patients nearing end of life or requesting withdrawal of therapy

The purpose of this Consensus Statement is to focus on implantable cardioverter-defibrillator (ICD) deactivation in patients with irreversible or terminal illness. This statement summarizes the opinions of the Task Force members, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS), based on ethical and legal principles, as well as their own clinical, scientific, and technical experience. It is directed to all healthcare professionals who treat patients with implanted ICDs, nearing end of life, in order to improve the patient dying process. This statement is not intended to recommend or promote device deactivation. Rather, the ultimate judgement regarding this procedure must be made by the patient (or in special conditions by his/her legal representative) after careful communication about the deactivations consequences, respecting his/her autonomy and clarifying that he/she has a legal and ethical right to refuse it. Obviously, the physician asked to deactivate the ICD and the industry representative asked to assist can conscientiously object to and refuse to perform device deactivation.

Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit Results From a Pilot, Randomized Trial

Background— Observational studies suggest that open visiting policies are preferred by most patients and visitors in intensive care units (ICUs), but no randomized trial has compared the safety and health outcomes of unrestrictive (UVP) and restrictive (RVP) visiting policies. The aim of this pilot, randomized trial was to compare the complications associated with UVP (single visitor with frequency and duration chosen by patient) and RVP (single visitor for 30 minutes twice a day). Methods and Results— Two-month sequences of the 2 visiting policies were randomly alternated for 2 years in a 6-bed ICU, with 226 patients enrolled (RVP/UVP, n=115/111). Environmental microbial contamination, septic and cardiovascular complications, emotional profile, and stress hormones response were systematically assessed. Patients admitted during the randomly scheduled periods of UVP received more frequent (3.2±0.2 versus 2.0±0.0 visits per day, mean±SEM) and longer (2.6±0.2 versus 1.0±0.0 h/d) visits (P<0.001 for both comparisons). Despite significantly higher environmental microbial contamination during the UVP periods, septic complications were similar in the 2 periods. The risk of cardiocirculatory complications was 2-fold (odds ratio 2.0; 95% CI, 1.1 to 3.5; P=0.03) in the RVP periods, which were also associated with a nonsignificantly higher mortality rate (5.2% versus 1.8%; P=0.28). The UVP was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. Conclusions— Despite greater environmental microbial contamination, liberalizing visiting hours in ICUs does not increase septic complications, whereas it might reduce cardiovascular complications, possibly through reduced anxiety and more favorable hormonal profile.

Cardiopulmonary resuscitation of older, inhospital patients : Immediate efficacy and long-term outcome

Objective To determine the independent effect of advancing age on prognosis after cardiopulmonary resuscitation (CPR). Design and Setting Retrospective analysis of clinical records of patients who received CPR in a geriatric department equipped with an intensive care unit. Patients A total of 245 patients (146 men, 99 women; mean age, 70 ± 11 yrs) received CPR. Of these, 221 had a cardiocirculatory arrest (CA) in the intensive care unit and 24 had a CA in the general ward of the department. Acute myocardial infarction was the most frequent admission diagnosis. Interventions CPR according to standard guidelines in all cases. Measurements and Main Results Immediate, short-term (hospital discharge), and long-term (median follow-up, 31.5 months; range, <1–124 months) survival. Older patients had a lower immediate survival (<70 yrs [72/137] 52.6% vs. ≥70 yrs [43/108] 39.4%;p < .05) and, less frequently, ventricular tachycardia/fibrillation (VT/VF) as a cause of CA. VT/VF bore the lowest immediate mortality rate (19/104; 18.3%) as compared with asystole/complete heart block (66/102; 64.7%) or pulseless electrical activity (40/49; 81.6%;p < .001). Acute myocardial infarction, acute heart failure, hypotension, and occurrence of CA in the intensive care unit were also univariate predictors of unfavorable, immediate prognosis. However, in a multiple logistic analysis model, the mechanism of CA (asystole/complete heart block or pulseless electrical activity vs. VT/VF), acute myocardial infarction, heart failure, and hypotension were independent predictors of unfavorable immediate prognosis, whereas advancing age was not. Similarly, after initially successful CPR, short-term survival was independently associated with acute myocardial infarction, hypotension before CA, initial rhythm at CA, and need for mechanical ventilatory support after CPR, but not with age. Long-term survival (42 patients; 17.2% of the original cohort; median survival, 32 months) was also independent of age, whereas it was negatively associated with heart failure. Conclusion Immediate, short- and long-term prognosis after inhospital CPR is independent of age, at least when possible confounders are simultaneously taken into account.

Renal, but not systemic, hemodynamic effects of dopamine are influenced by the severity of congestive heart failure*

Objective:To determine whether the short-term systemic and renal hemodynamic response to dopamine is influenced by clinical severity of congestive heart failure. Design:Effects of increasing doses of dopamine were assessed in patients consecutively admitted for acutely decompensated congestive heart failure. Setting:Intensive care unit. Patients:We enrolled 16 congestive heart failure patients stratified by clinical severity (New York Heart Association [NYHA] class III, n = 8; NYHA class IV, n = 8) and two additional NYHA class III patients as controls. Interventions:Measurements were carried out throughout five 20-min experimental periods: baseline, dopamine infusion at 2, 4, and 6 μg·kg−1·min−1, and recovery. Controls received a similar amount of saline. Measurements and Main Results:Systemic and renal hemodynamics were determined respectively by right cardiac catheterization and radioisotopes (iodine 131-labeled hippuran and iodine 125-labeled iothalamate clearance). The peak increase in heart rate and cardiac index occurred at a dopamine dose of 4–6 μg·kg−1·min−1. The dose-response relation was similar in NYHA classes III and IV. Improvement in effective renal plasma flow and glomerular filtration rate, peaking at 4 μg·kg−1·min−1, was more rapid and marked in NYHA class III than class IV patients, in whom the renal fraction of cardiac output failed to increase. The systemic and renal effects of dopamine were independent of age. No change occurred in controls. Conclusions:The dose of dopamine producing an optimal improvement of systemic and renal hemodynamics in congestive heart failure is higher than usually reported. A greater clinical severity of congestive heart failure impairs the renal effects of dopamine, probably through a selective loss in renal vasodilating capacity.

Atrial fibrillation is a possible marker of frailty in hospitalized patients: results of the GIFA Study

Background and aims: Atrial fibrillation (AF) is the most common arrhythmia in elderly people, who are particularly exposed to its most severe complications, such as stroke, worsening heart failure and dementia. Some studies demonstrate that AF is associated with increased mortality in home-dwelling subjects, but little is known about the clinical impact of the arrhythmia in hospitalized patients. We studied the clinical associations and effects of AF on the 23,174 hospitalized patients enrolled in the GIFA (Gruppo Italiano di Farmacoepidemiologia nell’Anziano) Study. Methods: Patients were divided into three groups according to the absence or presence of AF (sinus rhythm, non_AF; AF as main diagnosis, AF_main; AF as comorbid condition, AF_associated) and stratified into four age-groups (≤60, 61–70, 71–80 and >80 yrs). Results: AF_associated patients were older, more frequently disabled, and characterized by greater comorbidity and longer in-hospital length of stay. Urea nitrogen concentration was higher, and total cholesterol was lower in AF_associated patients, compared with the other two groups. Overall mortality was 6.0%. Mortality was higher in AF_associated patients (non_AF: 6.0% vs AF_associated: 7.1% vs AF_main: 0%, p<0.001). Conclusions: Our results suggest that, in hospitalized patients, AF as a comorbid condition is associated with worse metabolic profile and clinical outcomes, and thus, may represent a marker of frailty.

Does advanced age affect the immediate and long-term results of direct-current external cardioversion of atrial fibrillation?

OBJECTIVES: To determine whether advanced age affects the immediate and long‐term results of direct‐current external cardioversion (ECV) of atrial fibrillation (AF), the sustained arrhythmia most commonly encountered in older patients.

Immediate and long-term survival after intra-aortic balloon pumping : is advanced age an independent, unfavorable prognostic factor ?

OBJECTIVE: To determine whether advanced age is an independent prognostic factor that may increase the risk of complications and reduce the immediate and long‐term survival after treatment with intra‐aortic balloon pumping (IABP) for acute ischemic heart disease.

Age-related changes in the pharmacodynamics of intravenous glyceryl trinitrate

Comparable hemodynamic effects were obtained administering a much lower intravenous dose of glyceryl trinitrate (GTN) in elderly than in younger patients. The pharmacodynamics and kinetics of GTN were thus assessed in 2 groups of patients with acute my-ocardial infarction (group A: ≤ 65 years, 6 patients; group B: ≥ 75 years, 6 patients). The arterial and venous dose-concentration relationship and the associated hemodynamic changes at end-point (EP: 10% reduction in mean systemic arterial pressure) were similar in the 2 groups. However, in older subjects EP was reached at a lower GTN infusion rate (0.11 ± 0.04 vs 0.33 ± 0.11 μg·kg−1·min−1, mean ± S.D.; p < 0.001), and with lower arterial and venous drug concentrations (arterial [GTN]: 1.2 ± 0.1 vs 4.6 ± 1.2 ng·ml−1; p < 0.01; venous [GTN]: 0.09 ± 0.05 vs 0.35 ± 0.15 ng·ml−1; p < 0.05), whereas overall GTN kinetics appeared to be substantially independent of age. Thus, the enhanced efficacy of GTN in advanced age seems to stem mainly from pharmacodynamic changes, which may be the consequence of dampened baroreceptor reflexes, as suggested by a lower heart rate increase per unitary fall in systolic arterial pressure observed in group B (0.12 ± 0.07 vs 0.41 ± 0.29 b·min−1·mmHg−1; p < 0.05). (Aging 2: 59–64, 1990)

Vascular entrapment of a ruptured intra-aortic balloon: A case report of successful removal without surgery

Intra-aortic balloon pump entrapment is a rare complication that may necessitate major abdominal surgery that is potentially life threatening in the critically ill patients who require balloon counterpulsation. We report successful removal of a ruptured and entrapped intra-aortic balloon pump catheter after use of streptokinase solution to clear clots from the device. We suggest this procedure as a safer, nonsurgical method that may eliminate the need for abdominal surgery.

Severe hyponatremia due to hypopituitarism with adrenal insufficiency: A case report

Objective: Adrenal insufficiency due to hypopituitarism can lead to severe hyponatremia with potentially fatal consequences. Prompt diagnosis and adequate hormonal replacement therapy are essential to block an otherwise unfavorable course and to re-establish a healthy life. Unfortunately, this condition is often misdiagnosed. Design: Case report. Setting: Intensive Care Unit of a teaching hospital. Patient: A 76-yr-old man with refractory hypotension, acute myocardial infarction, and left ventricular dysfunction, secondary to severe chronic pan-hypopituitarism, associated with severe hyponatremia. Methods and main results: The patient underwent mechanical ventilation and continuous venous-venous hemodiafiltration, for severe respiratory and renal insufficiency. A hormonal replacement therapy with T4, hydrocortisone, and nandrolone was started and the patient was discharged to a rehabilitation facility after 31 days of hospitalization. Conclusions: Hypopituitarism with secondary adrenal insufficiency is often misdiagnosed at an early stage and a high degree of suspicion is necessary for early diagnosis. Determination of plasma cortisol level in patients with hyponatremia not explained by other causes should always be obtained.