Roberto Tramarin

Left Atrial Appendage Dysfunction: A Cause of Thrombosis? Evidence by Transesophageal Echocardiography-Doppler Studies

The blood flow velocity patterns within the left atrial appendage were studied by transesophageal color flow imaging and pulsed Doppler in 84 patients. At the time of the study, 57 of the patients were in sinus rhythm, 25 were in atrial fibrillation, and two were in atrial flutter. The relationships between atrial rhythm, blood flow pattern and the presence/absence of spontaneous echocardiographic contrast or thrombus within the appendage were investigated. Transesophageal echocardiography allowed recording of blood flow velocities in 81 of the 84 patients studied. In 51 of the 55 patients in sinus rhythm the pulsed Doppler study showed a biphasic blood flow pattern, whereas a multiphasic pattern was found in the two patients with atrial flutter and in 14 patients with atrial fibrillation. In four patients with sinus rhythm and 10 patients with atrial fibrillation, no significant blood flow velocity could be detected. Thrombus or spontaneous echocardiographic contrast were found within the left atrial appendage in 20 patients, and in all these patients blood flow was either absent or significantly reduced. Our findings indicate that an absent or low blood flow velocity within the left atrial appendage represents a predisposing factor for thrombosis. Isolated left atrial appendage dysfunction has been documented in four patients during sinus rhythm, which may lead to thrombosis. This observation may offer an explanation for cardioembolic events that occur occasionally in patients without apparent heart disease and sinus rhythm.

Cardiac Rehabilitation in Very Old Patients: Data From the Italian Survey on Cardiac Rehabilitation-2008 (ISYDE-2008)—Official Report of the Italian Association for Cardiovascular Prevention, Rehabilitation, and Epidemiology

BACKGROUND Using data from the Italian SurveY on carDiac rEhabilitation-2008 (ISYDE-2008), this study provides insight into the level of implementation of cardiac rehabilitation (CR) in very old cardiac patients. METHODS Data from 165 CR units were collected online from January 28 to February 10, 2008. RESULTS The study cohort consisted of 2,281 patients (66.9 ± 11.8 years): 1,714 (62.4 ± 9.6 years, 78% male) aged<75 years and 567 aged ≥ 75 years (80.8 ± 4.5 years, 59% male). Compared with adults, a higher percentage of older patients were referred to CR programs after cardiac surgery or acute heart failure and showed more acute phase complications and comorbidity. Older patients were less likely discharged to home, more likely transferred to nursing homes, or discharged with social networks activation. Older patients had higher death rate during CR programs (odds ratio = 4.6; 95% confidence interval = 1.6-12.9; p = .004). CONCLUSION The ISYDE-2008 survey provided a detailed snapshot of CR in very old cardiac patients.

Late postoperative atrial fibrillation after cardiac surgery: A national survey within the cardiac rehabilitation setting

Aims The aims of this study were to determine the incidence and clinical predictors of new-onset and recurrent late postoperative atrial fibrillation (POPAF) in a large cohort of patients who underwent cardiac rehabilitation programs (CRPs) after discharge from surgery units, and the association between late POPAF and cardiovascular morbidity and mortality in the medium term. Methods The ISYDE and ICAROS registries were two multicenter, prospective studies carried out by the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR-GICR), providing clinical information on consecutive patients completing CRP in 165 facilities. Patients following cardiac surgery were considered, with the exclusion of those with persistent POPAF at discharge from the surgery units. A total of 2256 patients following cardiac surgery were enrolled (isolated coronary surgery 62.9%, valve interventions 16%, combined surgery 21.1%). Results The mean age of patients was 67 ± 10 years, and the observation period 13 ± 20 days. During CRP, POPAF occurred in 241 (10.7%) patients, with 4.4% new-onset and 6.3% recurrent cases, respectively. In the logistic regression model, valve surgery (P < 0.05), a history of early POPAF (P < 0.001), and the presence of postoperative ventricular arrhythmias (P < 0.05) independently predicted the occurrence of late POPAF. Lack of prescription of cardioprotective drugs was not associated with late POPAF. Late POPAF increased the 1-year risk of cardiovascular events after CRP, mainly episodes of decompensated heart failure. Conclusion A high level of suspicion for late POPAF, after discharge from surgery units, should be maintained due to the risk of occurrence, the low antiarrhythmic effect of common cardioprotective drugs and the impact on cardiovascular prognosis.

Incidence and Prognostic Significance of Symptomatic and Asymptomatic Exercise-Induced Ischemia in Patients with Recent Myocardial Infarction

To determine the incidence and the significance of anginal chest pain during abnormal exercise testing (S-T greater than or equal to 0.1 mV) in patients with recent myocardial infarction we reviewed a series of 353 patients who underwent maximal bicycle exercise stress 4-8 weeks following acute myocardial infarction. Of the 353 patients, 26 had ischemic ECG changes and chest pain (group A); 85 patients had ischemic ECG changes but no chest pain (group B). The two groups differ significantly only in the frequency of a history of typical angina pectoris more than 6 months prior to acute myocardial infarction (group A 42.3% vs. group B 15.2%, p less than 0.01). Typical chest pain is more frequent in anterior versus inferior myocardial infarction (50 vs. 14.4%, p less than 0.001). The patients were followed up for 28.8 +/- 8.7 months with clinical and exercise testing controls. The incidence of exertional angina during the follow-up was significantly more frequent in group A patients than in group B patients (80.7 vs. 24.7%, p less than 0.001). Unstable angina pectoris was more frequent in group A (34.6 vs. 11.8%, p less than 0.01). There was no statistically significant difference in mortality (group A 3.8% vs. group B 5.9%) and cardiac events (group A 3.8% vs. group B 5.9%) between the two groups. Thus, we concluded that the occurrence of anginal pain associated with S-T segment depression during exercise testing does not increase the prognostic risk.

Postoperative Anemia and Exercise Tolerance After Cardiac Operations in Patients Without Transfusion: What Hemoglobin Level Is Acceptable?

BACKGROUND Restrictive transfusion strategies have been suggested for cardiac surgical patients, leading to various degrees of postoperative anemia. This study investigates the exercise tolerance during rehabilitation of cardiac surgical patients who did not receive transfusions, with respect to their level of postoperative anemia. METHODS This observational study started in January 2010 and ended in May 2010 in 2 rehabilitation hospitals and 2 large-volume cardiac surgical hospitals. The study population was 172 patients who did not receive transfusions during cardiac surgical operations with cardiopulmonary bypass and subsequently followed a rehabilitation program in 1 of the 2 rehabilitation hospitals. No patient received a transfusion during the rehabilitation hospital stay. Exercise tolerance was measured using the 6-minute walk test at admission and discharge from the rehabilitation hospital. The level of anemia at admission to the rehabilitation hospital was tested as an independent predictor of exercise tolerance within a model inclusive of other possible confounders. RESULTS Patients with values of hemoglobin less than 10 g/dL at admission to the rehabilitation institute had a significantly (p=0.007) worse performance on the 6-minute walk test than patients with higher values (258±106 vs 306±101 meters). This functional gap was completely recovered during a normal rehabilitation period. Other independent factors affecting exercise tolerance were age, sex, and albumin concentration. CONCLUSIONS Postoperative anemia with hemoglobin levels of 8 to 10 g/dL is well tolerated in patients who have not received a transfusion and induces only a transient impairment of exercise tolerance.

Gender differences in cardiac rehabilitation programs from the Italian survey on cardiac rehabilitation (ISYDE-2008)

PURPOSE In recent years epidemiological and clinical evidence has shown gender disparities in several aspects of cardiovascular disease. Aim of this study was to identify gender differences in the clinical profile and management of patients admitted to cardiac rehabilitation (CR) programs. POPULATION Patients enrolled in the ISYDE-2008 survey were considered. RESULTS The ISYDE-2008 survey enrolled 2281 patients; 604 (26.5%) were women. Compared to men, women were older (mean age 70.8 ± 11.5 versus mens 65.6 ± 11.5 years), had less traditional risk factors (low cardiovascular risk profile in 45.3% of women and 38.0% of men, p=0.003), were more frequently admitted after valvular surgery and heart failure, but less for post-acute myocardial infarction and post-by-pass procedure. Women were more frequently admitted to an in-hospital rehabilitation program. Women showed a more complicated acute and rehabilitative course, with 63.2% of them having at least one complication during acute-phase, compared to 52.5% of men, and 48.3% during rehabilitation, compared to 35.0% of men (p<0.0001). During rehabilitation, women underwent exercise tests less frequently, except for the 6-minute walking test. At discharge, women received ACE-inhibitors/ARBs, β-blockers, statins, omega-3 fatty acids, antiplatelet agents less frequently, but more frequently digoxin, amiodarone, diuretics, oral anticoagulants, insulin and anti-depressive drugs. The duration of the rehabilitation program was longer for women. Mortality was very low in the entire population. CONCLUSIONS Women are less frequently admitted to CR than men. They are older and show a greater cardiovascular burden. Women are more likely to be enrolled in CR after valvular surgery and heart failure than men.

Cardiac rehabilitation in chronic heart failure: data from the Italian SurveY on carDiac rEhabilitation (ISYDE-2008).

Background Using data from the Italian SurveY on carDiac rEhabilitation (ISYDE-2008), this study provides insight into the level of implementation of cardiac rehabilitation in patients with chronic heart failure (CHF). Methods Data from 165 Italian cardiac rehabilitation units were collected online from 28 January to 10 February 2008. Results The study cohort consisted of 2281 patients (66.9 ± 11.8 years): 285 (71.3 ± 12.2 years, 66% male) CHF patients and 1996 (66.3 ± 11.6 years, 74% male) non-CHF patients. Compared with non-CHF, CHF patients were older, showed more comorbidity, had lower left ventricular (LV) ejection fraction and reduced access to functional evaluation, underwent more complications during cardiac rehabilitation, and had longer length of in-hospital stay. CHF patients were also more likely to be transferred to ICU (9 versus 3%, P < 0.0001), and less likely to be discharged home (85 versus 92%, respectively, P < 0.0001). Also, discharge prescriptions were significantly different from those of non-CHF patients. Finally, CHF patients had higher mortality during cardiac rehabilitation (1.7 versus 0.5%, P = 0.01). After adjusting for age, ejection fraction, comorbidity, previous interventions and complications during cardiac rehabilitation, multivariate logistic analysis showed that not performing any of the physical performance tests [odds ratio (OR) = 7.0, 95% confidence interval (CI), 1.9–25.8, P = 0.003], acute respiratory failure (OR = 2.3, 95% CI, 1.3–4.1, P = 0.002), acute kidney insufficiency or worsening of chronic kidney disease (OR = 2.9, 95% CI, 1.5–5.6, P = 0.001) and worsening of cognitive impairment (OR = 3.7, 95% CI, 2.0–6.7, P < 0.001) were significant predictors of death in CHF patients. Conclusion The ISYDE-2008 survey provided a detailed snapshot of cardiac rehabilitation in CHF patients, and confirmed the complexity and the more severe clinical course of these patients during cardiac rehabilitation.

Scar detection by contrast-enhanced magnetic resonance imaging in chronic coronary artery disease: a comparison with nuclear imaging and echocardiography.

We compared contrast-enhanced MRI (CeMRI) with the most widely used imaging techniques for myocardial infarct (MI) diagnosis, SPECT and Echo, in unselected patients with chronic coronary artery disease (CAD). Two blinded operators assessed scars on MRI, SPECT and Echo images using a 16-segments LV model. We studied 105 consecutive patients: 50 had Q-wave MI (Q-MI), 19 non Q-wave MI or rest angina (nonQ-MI/RA) and 36 effort angina (EA) history. CeMRI was positive, respectively, in 96%, 37%, and 6%, SPECT in 90%, 53%, and 44%, and Echo in 84%, 32%, and 28% of patients (within Q-MI: CeMRI vs. SPECT p < 0.03, vs. Echo p < 0.001; within EA CeMRI vs. SPECT and ECHO p < 0.001; all trends p < 0.001, pseudo r-square: 0.56-0.75 for CeMRI, 0.18-0.28 for SPECT and 0.23-0.37 for Echo). CeMRI and SPECT agreed in 83 patients (79%); negative SPECT with 1 +/- 0 segments subendocardial delayed enhancement (DE) was found in 4 (4%); negative CeMRI with 4 +/- 3 segments perfusion defects in 18 (17%), 16 of whom were obese or showed LBB or sub-occlusion of related coronary. CeMRI and Echo agreed in 78 patients (75%); negative Echo with 2 +/- 1 segments subendocardial DE was found in 13 (12%) and negative CeMRI with 11 +/- 7 segments kinetic abnormalities in 14 (13%), in 10 confirmed by Cine-MRI. In Q-MI, CeMRI detects DE more frequently than perfusion defects and, especially, kinetic abnormalities are found by SPECT and Echo, respectively. CeMRI identifies small areas of DE also in some patients with nonQ-MI or RA but usually not in patients with EA. This biologically plausible decreasing trend is shown by CeMRI more clearly than by SPECT and Echo. Disagreement between CeMRI and SPECT or Echo may be reduced, but perhaps not fully eluded, performing dobutamine Echo and SPECT after maximal epicardial coronary dilatation.

Short-term reproducibility of ergometric parameters in functional stress test after recent myocardial infarction

In order to assess the short-term reproducibility of the most important ergometric parameters, 108 males (mean age 50.3 +/- 7.8 years) underwent a functional stress test (FST) on average 35 days after myocardial infarction. The exercise test was repeated 3 days later in the same conditions. Patients were fasting and in pharmacological washout. The following parameters were analyzed: total work performed (TWP), VO2, heart rate (HR), systolic blood pressure (SBP), arrhythmias and S-T segment depression and elevation. TWP and VO2 values did not show any significant difference during the two tests under the various workloads. HR and SBP responses proved to be well reproducible in patients with HR and SBP not exceeding the mean values obtained from 222 normal subjects who underwent the same exercise test by more than +/- 1 SD; reproducibility was significantly lower in the other patients, particularly in patients with HR and SBP exceeding normal values by more than +/- 1 SD. Therefore, in this case, further FST are necessary to obtain more reliable parameters to decide on individual pharmacological and exercise prescriptions. Arrhythmias were reproducible up to 67% (p less than 0.01) regardless of Lowns class and the presence of S-T segment depression or elevation. S-T segment depression or elevation was reproducible up to 100%.

Does the return to work have a negative impact on the lifestyle of cardiovascular patients? Comments on the ICAROS results

Dear Editor,Although cardiovascular disease (CVD) is most prevalent in theelderly, it often affects patients in their productive years prior toretirement age (65–70 years) [1]. In this case, almost always,medical and rehabilitative support has the objective to promotethe return to work (RTW) [2]. Previous studies have focused onvariables that can affect a more rapid and satisfactory RTW, andthese studies concluded that the RTW after CVD is a complex andmultidimensional process that is more influenced by psychosocialfactors (e.g., depression, work strain, job satisfaction, and workplacejustice) than by the patients clinical status (e.g., left ventricularejection fraction) [3,4]. The RTW after a cardiovascular event is noteasy [5], and observational studies have reported that workers withCVD show increased rates of absenteeism and disability periodscompared with workers without CVD [6]. There is an abundance ofscientific literature demonstrating that lifestyle interventions inpatients with CAD can reduce the risk of new events, improve thesurvival and the quality of life [7,8]. Nevertheless, the influence ofwork on healthy lifestyle is relatively unknown and adverse jobconditions, characterized by high job strain, might increase thelikelihood of co-occurring health risk behaviors [9].Wethusanalyzed the data collected with the Italian survey on CardiacRehabilitation and Secondary prevention after cardiac revascular-ization (ICAROS) to verify patient adherence to a healthy lifestyle.ICAROS has already been described elsewhere [8,10].Inbrief,itisaprospective, longitudinal, multicenter registry with on-line datacollection that evaluates the achievement and maintenance ofrecommended lifestyle targets and risk control after completing acomprehensive inpatient or outpatient cardiac rehabilitation pro-gram aftercardiac revascularization. The lifestyle data collectionwasperformed by trained investigators at discharge from the CardiacRehabilitation program, as well as 6 months and 1 year later, using abrief questionnaire that analyzed smoking habits (smoking vs. nosmoking), diet (the consumption frequency of vegetables, fruit, fish,olive oil and cheese/butter was evaluated to obtain a Mediterraneandiet score, which was then categorized into good or bad diet), andphysical activity (never/rarely vs. ≥30 min/session of moderateintensity exercise per 3 times/week) [8,10]. The ethical committeefor each center approved the protocol, and informed consent wasobtained from each patient. To obtain a balanced sample for thisresearch,accordingtothecurrentincreasein meanretirementageinItaly, we extracted only working age patients (b70) from the ICAROSdatabase, and we divided them into two groups: workers and non-workers before CVD. Using these categories, we selected 789 of 1272patients; demographic and lifestyle profiles of the study populationsare reported in Table 1.Inoursample,thenumberofworkingpeopledecreasedovertime.Atthe moment of the index event workers were 51.5% of the studypopulation:6and12 monthsaftertheendofthesupervisedCRprogrampatient with a profitable work were 47 and 38.9%, respectively. Thus,9.6% of those that were working before CVD did not return to work6 months after discharge, and 17.3% of those that returned to work lefttheir jobs within the first 12 months after discharge.We performed 3 logistic regressions to assess the influence ofwork on smoking behavior, dietary habits and physical activity,controlling for the effects of time after discharge, other lifestylehabits, intervention type, age and sex (Table 2 ).The logistic regressionused to predict smoking behavior revealedthat the odds for smoking was 1.84 (95% CI = 1.13–2.99) timesgreater for workers compared with non-workers. Nevertheless, sex(male odds ratio (OR) = 2.75; 95% CI = 1.25–6.03) and, weakly, age(OR = 0.97; 95% CI = 0.94–0.99) also affected smoking behavior.The return to work did not have an effect on dietary habits andphysical activity. However, our data suggested that these lifestylebehaviors were linked. Indeed, bad dietary habits increased theprobability of smoking (OR = 1.81; 95% CI = 1.23–2.66), smokingbehavior decreased the probability of adopting a healthy diet(OR = 0.62; 95% CI = 0.39–1.00) and adopting a healthy dietincreased the probability of being physically active (≥3times/week), with an odds ratio of 1.98 (95% CI = 1.56–2.40).Our data highlighted three important aspects related to thereturn to work and lifestyle modification that, to the best of ourknowledge, were previously unexplored. First, a considerable groupof CVD patients returned to work but then, within the first yeardecided to retire; second, patients that returned to work had anincreased risk of not quitting. Finally patients with a defectivecontrol of one lifestyle risk factors are at higher risk for adoption ofan additional unhealthy lifestyle. Because the return to work for CVDpatients is psychologically stressful [4,6], it might be postulated thatsome patients decide to retire and that other patients resumesmoking after the RTW as a result of maladaptive coping strategies.In conclusion, this ancillary analysis of ICAROS highlights theimportance of considering in patients with CAD not only the RTWbut also their level of functioning once they are back at work [10].Inparticular, one question raised here is whether it is possible tobalance work life with a healthy lifestyle or if the RTW leads tosmoking and other unhealthy behaviors. From this perspective, wethink that our data open an interesting field of research and a newrole for cardiac rehabilitation.