Paolo Valoti

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.

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.

Improved exercise tolerance by cardiac rehabilitation after myocardial infarction in the elderly: results of a preliminary, controlled study.

Elderly patients are commonly excluded from cardiac rehabilitation after myocardial infarction (MI). The present controlled, non-randomized trial was undertaken as a preliminary study to compare some effects of cardiac rehabilitation between patients younger and older than 65 years without contraindications to physical exercise. Baseline total work capacity (TWC) was assessed by a maximal ergometric stress testing 4 weeks after MI. Patients were then prospectively enrolled into an 8-week ambulatory rehabilitation program (R- group: age ≤ 65 N=16; age >65 N=16). Those who refused or who could not participate in the program because of logistic difficulties served as controls (NR- group: age ≤ 65 N=16; age >65 N=14). In spite of non- randomized allocation, clinical characteristics did not differ between either treatment groups or age groups. TWC was re- assessed at 8 weeks from baseline evaluation in all patients. The number of completed training sessions in the R- group, and the proportion of sessions which were suspended for physiological or pathological (adverse events during exercise) causes were similar under and over 65 years. TWC increased (p<0.001 in the R- group, the improvement being similar in the two age cohorts (≤ 65: +55% vs >65: +65%, NS). A spontaneous enhancement of TWC (+37%, p<0.001 occurred among younger controls as well. Only older controls did not improve their TWC; moreover, their +16% change was significantly (p<0.05 less than the +65% increase obtained by the R- group of the same age. Though non- randomized allocation must be acknowledged as a major limitation of the present study, these results suggest that cardiac rehabilitation may be more cost- effective in those patients who are usually excluded because of their advanced age. (Aging Clin. Exp. Res. 6: 175–180, 1994)

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.

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.

Resistin level in coronary artery disease and heart failure: the central role of kidney function.

Objectives The aim of this study was to evaluate resistin levels in patients with coronary artery disease (CAD) with or without chronic heart failure, in order to define its independent predictor. Methods One hundred and seven 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 heart failure symptoms (group 2); CAD with overt heart failure (group 3). Plasma resistin was determined by ELISA. Results Resistin progressively increased from group 1 (10.7 ± 5.0 ng/ml) to groups 2 (11.8 ± 5.8 ng/ml) and 3 (17.0 ± 6.8 ng/ml), with the difference reaching statistical significance in group 3 versus groups 1 and 2 (P = 0.001). A multivariable model of analysis demonstrated that the best predictor of plasma resistin level was the estimated glomerular filtration rate (P < 0.001), indicating that reduction of kidney function was the main cause of the adipokine increase observed in patients with CAD and overt heart failure. Conclusions Our data confirm the rise of resistin plasma levels previously described in patients affected by chronic heart failure; however, in our study, this relationship seemed to be mediated mainly by the level of kidney function, and only partially by the severity of ventricular dysfunction.

Primary PCI in a patient with acute occlusion of native LAD beyond the LIMA graft anastomosis: first reported case, technical challenges and review of the literature

We present a case of a man with an anterior STEMI due to acute occlusion of the LAD, distally to the anastomosis with LIMA graft. We describe our treatment strategy with primary PCI and the difficulties we encountered: insufficient length of balloon and stent shafts and need for deep intubation of the graft with the guiding catheter. The procedure was complicated by graft dissection that was successfully treated with a DES. Afterwards we successfully stented the culprit lesion. We discuss technical possibilities for overcoming such difficulties and present brief review of literature on STEMI in patients with previous CABG.

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

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.