OBJECTIVES: This study sought to 1) assess the short-, medium-and long-term prognostic power of peak oxygen consumption (VO2) in patients with heart failure; 2) verify the consistency of a nonmeasurable anaerobic threshold (AT) as a criterion of nonapplicability of peak VO2; 3) develop simple rules for the efficient use of peak VO2 in individualized prognostic stratification and clinical decision making. BACKGROUND: Peak VO2, when AT is identified, is among the indicators for heart transplant eligibility. However, in clinical practice the application of defined peak VO2 cutoff values to all patients could be inappropriate and misleading. METHODS: Six hundred fifty-three patients consecutively considered for eligibility for heart transplantation were followed up. Outcomes (cardiac death and urgent transplantation) were determined when all survivors had a minimum of 6 months of follow-up. RESULTS: Contraindication to the exercise test identified very high risk patients. The relatively small sample of women did not allow inferences to be drawn. In men, peak VO2 stratified into three levels (< or = 10, 10 to 18 and >18 ml/kg per min) identified groups at high, medium and low risk, respectively. The prognostic power of peak VO2 < or = 10 ml/kg per min was maintained even when the AT was not detected. In patients in New York Heart Association functional class III or IV, peak VO2 did not have prognostic power. In patients in functional class I or II, peak VO2 stratification was prognostically valuable, but less so at 6 than at 12 or 24 months. Age did not influence peak VO2 prognostic stratification. CONCLUSIONS: A contraindication to exercise testing should be considered a priority for listing patients for heart transplantation. Only in less symptomatic male patients does a peak VO2 < or = 10 ml/kg per min identify short-, medium- and long-term high risk groups. A peak VO2 >18 ml/kg per min implies good prognosis with medical therapy.

Anaerobic Threshold↗

PubMed1998

Administration of thrombolytic therapy to 17,944 patients with acute myocardial infarction: the GISSI-3 database.

BACKGROUND: There is growing interest in assessing therapy for acute myocardial infarction. Because thrombolysis was not a study therapy in the GISSI-3 trial, the decision about thrombolysis was left to the responsible physicians. We evaluated the data on thrombolytic therapy among patients with acute myocardial infarction enrolled in the GISSI-3 trial to study the relation between rate of prescription and the characteristics of patients and participating coronary care units. METHODS: Complete clinical data were available for 17,944 patients randomized between June 1991 and July 1993 from 200 coronary care units in Italy. Demographic and clinical information were obtained for each patient, and each coronary care unit was classified according to patient volume, level of technology, and wide geographic area in which it was located. A multivariate logistic regression was performed with administration of thrombolytic therapy as the dependent variable and previously defined clinical and structural variables as independent variables. RESULTS: The most important factor in administration of thrombolytic therapy was that less than 6 hours elapse from symptom onset to hospital admission (odds ratio [OR] 14.05; 95% confidence interval [CI] 12.3 to 16.0). Next were location of coronary care unit in southern Italy (OR 1.81; 95% CI 1.62 to 2.01), presence of ST elevation at entrance electrocardiogram ECG (OR 1.47; 95% CI 1.35 to 1.61), absence of previous myocardial infarction (OR 1.35; 95% CI 1.22 to 1.49), and presence of catheterization laboratory or cardiac surgery program or both in the same hospital (OR 1.24; 95% CI 1.14 to 1.35). Coronary care units with high or low patient volume did not show different rates of administration of thrombolytic agents. CONCLUSIONS: The GISSI-3 experience confirmed a high rate of prescription of thrombolytic therapy to patients admitted within 6 hours of symptom onset and those with ST-segment elevation on entrance electrocardiogram. It demonstrated that patients admitted to coronary care units with catheterization laboratories or cardiac programs or both have higher chances of receiving thrombolytic treatment than those admitted to hospitals without these capabilities.

Adult↗

PubMed1998

Myocardial revascularization through a mini-thoracotomy with thoracoscopic assistance.

OBJECTIVE: Left internal mammary artery harvesting through a mini-thoracotomy makes gaining the proximal portion of this vessel very difficult and exposes the patient to the risk of chest wall trauma due to excessive spreading of the ribs. The adoption of video thoracoscopic assistance can give several advantages to the procedure. METHODS: With the patient in a 30 degrees left-side-up thoracotomy position, a 8-12 cm anterior thoracotomy is performed in the left fourth or fifth intercostal space. Two thoracoscopic ports are inserted in the third and fourth left intercostal spaces in the midaxillary line. Complete mobilization of the left internal mammary artery is performed with a mixed surgical and thoracoscopic technique. RESULTS: Since July 1996, 12 patients underwent myocardial revascularization with the left internal mammary artery through a mini-thoracotomy, with the aid of video assisted thoracoscopy. There were no deaths or perioperative infarctions. Mean hospital stay was 4 days (3-6). In nine patients a postoperative angiographic study was performed: in all cases the length of the mammary artery pedicle was adequate; one patient underwent a successful angioplasty on a narrowed anastomosis on the left anterior descending artery. In another patient the left internal mammary artery had been grafted to a diagonal branch. In all other cases angiography showed good results. CONCLUSIONS: Thoracoscopic assistance helps achieving complete mobilization of the left internal mammary artery, maximizing its useful length, without an extended thoracotomy.

Endoscopy↗

PubMed1998

Clinical and epidemiological characteristics of juvenile myocardial infarction in Italy: the GISSI experience.

BACKGROUND: No clinical and epidemiological data are available about acute myocardial infarction (AMI) at a young age in large populations, due to the low prevalence of AMI in younger people. The aim of the present study is to analyze epidemiological and clinical characteristics of AMI among younger people in Italy, using the data bases of the three GISSI studies. METHODS: Analysis of epidemiological and clinical characteristics of AMI according to different age groups in the three GISSI studies that collected data from 1985 to 1993. RESULTS: In the GISSI-2 and GISSI-3 data bases, the prevalence of AMI at a young age (2 and 1.8% respectively; difference -0.2% with 95% CI from -0.4 to 0.3%), hospital mortality (2.3 and 1.9% respectively; difference -0.4% with 95% CI from -1.9 to 1.0%), and the rate of young female patients (8 and 7% respectively; difference -1% with 95% CI from -3.6 to 1.6%) are similar. In the GISSI-2 study, we observed that in comparison to elderly patients (> 70 years) young patients (< 40 years) are more frequently smokers (83.9 vs 21.0%; difference 62.9% with 95% CI from 58.5 to 67.3%) and have a higher rate of family history for CAD (42.1 vs 21.1%; difference 21.0% with 95% CI from 15.3 to 26.7%) and of hypercholesterolemia (28.3 vs 15.0%; difference 13.3% with 95% CI from 18.5 to 80.8%), but show a lower prevalence of hypertension (12.2 vs 44.3%; difference from -32.1% with 95% CI from -28.0 to -36.2%) and diabetes (2.9 vs 18.8%; difference -15.9% with 95% CI from -13.5 to -18.3%). AMI at a young age is generally the first event in ischemic heart disease; in comparison with older patients with previous AMI (6.4 vs 17.4%; difference -11.0% with 95% CI from -7.8 to -14.0%) and history of angina (23.2 vs 40.0%, difference -16.8% with 95% CI from -11.8 to -21.9%) this is less frequent. The rate of complications is lower in younger as opposed to older patients for both early (7.7 vs 31.2%; difference -23.5% with 95% CI from -20.0 to -26.9%) and late heart failure (2.9 vs 18.5%; difference -15.6% with 95% CI from -13.2 to -18.0%), as well as for angina (6.4 vs 10.5%; difference -4.1% with 95% CI from -1.1 to -7.1%), reinfarction (1.0 vs 3.3%; difference -2.3% with 95% Ci from -1.1 to -3.6%) and complete AV block (1.6 vs 6.6%; difference -5.0% with 95% CI from -3.3 to -6.7%). In young patients, we observed lower in-hospital (1.6 vs 21.1%; difference -19.5% with 95% CI to -21.6%) and six-month mortality (1.3 vs 8.1%; difference -6.8% with 95% CI from -5.0 to -8.5%). CONCLUSIONS: The incidence and mortality of AMI at a young age was steady during the period between 1988 and 1993. AMI at a young age is a clinical entity with specific characteristics that differ from those found in old patients. In addition, it has peculiar risk profile with a better short- and medium-term outcome.

Adult↗

PubMed1998

[Models of preoperative risk stratification in cardiac surgery: the prediction of mortality or of survival?].

BACKGROUND: The need to assess the quality of heart surgery outcomes stimulated the development of pre-surgical risk stratification models in order to predict outcome on the basis of patient characteristics. The aim of the study was to compare the predictive accuracy of hospital mortality according to the following three models: Parsonnet (NBI Score), Higgins (CCF Score) and Roques (French Score), in a setting totally independent from the one in which the models were derived. METHODS: For each of the 516 patients undergoing heart surgery at our institution between January 1992 and December 1993, we calculated the pre-surgical risk according to the three models. Then we compared the predicted mortality against the observed mortality by means of the Shannon accuracy index, the ROC curve analysis and the overestimation histogram. RESULTS: Overall observed mortality (1.5%) was similar to the predicted mortality by the NBI Score (1.5 +/- 2.1%, p = ns), the CCF Score (1.7 +/- 2.0%, p = ns) and the French Score (1.9 +/- 2.5%, p = ns). The predictive accuracy of global mortality is very high and equal with the three models, and it is very low in the 8 patients who died (NBI Score = 0.06 +/- 0.06; CCF Score = 0.125 +/- 0.067; French Score = 0.102 +/- 0.07, p = ns). The area under the ROC curve is identical in the 3 models. CONCLUSIONS: The predicted mortality obtained by the three models is not significantly different from the observed mortality and therefore, the global accuracy is similar and very high, while it is very low for patients who will die. The models for pre-surgical risk stratification are useful for comparing the results among different institutions or different surgeons, or for monitoring the results over time in the same institution, but they cannot be used to accurately predict the individual risk of hospital mortality.

Aged↗

PubMed1997

Amlodipine in chronic heart failure.

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Amlodipine↗

PubMed1997

Risk stratification for open heart operations: comparison of centers regardless of the influence of the surgical team.

BACKGROUND: Risk-adjusted mortality was previously used to compare institutions as a whole or surgeons. Because the same surgical team is working in two different hospitals, the aim of our study was to assess whether the institution can make a difference in surgical mortality. METHODS: Preoperative data of 554 patients in institution A and 500 in institution B were prospectively collected during the same period of time. All patients were operated on by the same surgeon with the same first assistant and anesthesiology staff in both institutions. Patient population was stratified according to Parsonnet's predictive model, in five risk groups, and mortality was adjusted by the direct standardization method. RESULTS: At institution A it was observed that in-hospital mortality was 2.3% (95% confidence interval, 1.3% to 4.0%), and in institution B 4.0% (95% confidence interval, 2.5% to 6.1%). The difference between the two mortality rates (1.7%; 95% confidence interval, -0.5% to 3.8%) is not statistically significant (p = 0.16), nor is the difference within each class. The standardized mortality ratio was 3.6% (95% confidence interval, 2.7% to 4.8%) and 5.8% (95% confidence interval, 4.6% to 7.2%), respectively. The difference of 2.2% (95% confidence interval, 0.5% to 3.8%) is statistically significant (p = 0.01). CONCLUSIONS: The institution can affect mortality of patients undergoing open heart operations, regardless of the influence of the surgical team.

Cardiac Surgical Procedures↗

PubMed1997

New diagnostic criteria for infective endocarditis. A study of sensitivity and specificity.

OBJECTIVE: The purpose of this study was to determine the sensitivity and specificity of new criteria proposed by Duke University for case definition of infective endocarditis as compared to the previously accepted Von Reyn criteria. PATIENTS: A total of 143 consecutive suspected cases of infective endocarditis in 137 febrile patients were included. Of these, 69 had infective endocarditis, pathologically proven in 28, but with only a clinical diagnosis in 41. In the remaining 74 cases, the diagnosis of infective endocarditis was rejected after a follow-up of at least 3 months. RESULTS: The sensitivity of Duke's criteria was significantly higher, both when patients with possible infective endocarditis were considered as true-positive (definition 1; 100% vs 69%, P < 0.001) and when possible cases were considered as rejected (definition 2; 76% vs 51%, P < 0.01). Specificity was very high with both criteria: 92% Von Reyn vs 88% Duke (ns) with definition 1 and 99% Von Reyn vs 97% Duke (ns) with definition 2. The overall accuracy of the Duke criteria in the entire population was significantly higher with both definitions (0.94 vs 0.81 definition 1, P < 0.001; 0.87 vs 0.75, P = 0.015 definition 2). CONCLUSION: Duke's criteria for defining infective endocarditis has been shown to be more sensitive than previously adopted criteria, while maintaining a high degree of specificity. Therefore, they must be accepted as a substitute for previous criteria.

Adolescent↗

PubMed1997

[Differences in pharmacologic treatment after acute myocardial infarction. The role of treatment effectiveness].

BACKGROUND: Despite growing interest concerning the prescription of different drugs in different clinical settings, no explanatory variables have been determined. The aim of this study was to verify if there are any differences in drug prescription at the time of hospital release following myocardial infarction and if any of these differences can be explained by scientific evidence concerning treatment efficacy. METHODS: All drugs prescribed to 430 patients discharged from three different cardiology departments after acute myocardial infarction were analyzed. Based on current scientific evidence, it has been, ascertained that aspirin, beta-blockers and ACE-inhibitors can be prescribed unless contraindicate whereas anticoagulants, nitrates and calcium antagonists should be prescribed only in specific clinical conditions. The odd ratio of prescription of each drug among the three cardiology departments was calculated and adjusted for any clinical and test result variables that can specifically affect drug prescription. RESULTS: Different clinical characteristics of the patients discharged from the three cardiology departments are the following: mean age ranges from 60 to 66 years (p < 0.001), the incidence of non-Q myocardial infarction ranges from 23 to 45% (p < 0.001), post infarction angina ranges from 6 to 15% (p = 0.016), left ventricular failure ranges from 6 to 13% (p = 0.003) and arrhythmia ranges from 5 to 18% (p = 0.007). The adjusted odd ratio for clinical and test results variables showed that prescriptions were similar for ACE-inhibitors (odd ratio 1.3; 95% confidence interval from 0.6 to 3.2), aspirin (OR 2.2; 95% confidence interval from 0.8 to 5.5), beta-blockers (OR 2.2, 95% confidence interval from 0.9 to 5.5) and oral anticoagulants (1.6; 95% confidence interval from 0.6 to 4.5). Instead, there is a statistically significant difference in the prescription of nitrates (OR 4.4; 95% confidence interval from 1.6 to 12.3) and of calcium antagonists (OR 5.4%, 95% confidence interval from 1.0 to 12.5). CONCLUSIONS: Evidence based drug efficacy after acute myocardial infarction seems to establish a uniform pattern of drug prescription in different cardiology departments.

Acute Disease↗

PubMed1997

[Assessment of the quality of health care: heart surgery].

In the process of health planning and of the evaluation of health care, there is growing interest in assessing the quality of medical care. Traditionally, quality indexes are divided into three groups: structure, process and outcome. The first two indexes can be measured more easily and quickly, but outcome indexes are more appropriate care indicators for both health planners and patients. The introduction of quality assessment means that physicians work in order to achieve the required standards even if it does not increase the real quality of care, that data are systematically biased in order to increase the quality score and, lastly, that physicians do not rely on case-mix statistical adjustment of results. All these problems have already been evaluated by the Health Department of New York State. Since 1989, outcome data of open-heart surgery have been monitored in all cardiac surgery centers in the state. It is still open to debate whether the decreased mortality in New York State is due to the quality assessment program, to the migration of sicker patients to nearby states, or to the refusal of heart surgeons to operate on high-risk patients. In Italy as well, new rules have been introduced into health legislation in order to assess the quality of health care. Even if methodological and legislative instruments to assess quality of care are still not completely reliable in terms of assessing the quality of care with simple and effective methods, this does not exclude the need to proceed in assessing the quality of health care.

Cardiac Surgical Procedures↗

PubMed1997

[Ergometric test and atropine: doubts about strategy].

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Atropine↗

PubMed1997

[In-hospital mortality of elderly patients with myocardial infarct. Difference between the sexes].

The number of women who become ill and die from acute myocardial infarction (AMI) increases steadily with age. It is not yet clearly defined whether and why women suffer from a higher in-hospital mortality rate after AMI. In this study we evaluated the importance of the female sex as a risk factor for in-hospital mortality in elderly patients suffering from AMI. A retrospective study was performed in 724 patients (429 males, 295 females) aged > or = 65 years (mean age 74.9 +/- 6.3 years) consecutively admitted to San Giovanni Battista Hospital in Turin during the period 1988-1991 with validated primary discharge diagnosis of AMI. In-hospital mortality was significantly higher in females (34.6%) compared to males (25.6%, p > 0.01). After multivariate analysis female sex was not independent predictive for in-hospital death. Multivariate analysis was therefore repeated in the various sections of the history of AMI (anamnestic variables, including age and sex: physical signs on admission, ECG findings, laboratory tests, clinical progress, including complications and treatment) in order to identify the factors responsible for the higher mortality rate in women. These were found to be low hemoglobin values (< 12 g/dl) on admission, development of cardiac failure disorders and rhythm disturbances during hospitalization, and differences in therapeutic procedures. In spite of the absence of an independent unfavourable effect of female sex, elderly women with AMI have a higher in-hospital mortality rate. A more precarious state of health on admission, a peculiar susceptibility to severe complications during hospital-stay and differences in therapeutic procedures appear to be the factors responsible for this increased mortality rate in women.

Age Factors↗

PubMed1996

Detection of human cytomegalovirus myocardial involvement by polymerase chain reaction during systemic infection and correlation with pp65 antigenemia and DNAemia in infected heart recipients.

The presence of human cytomegalovirus DNA was investigated in 103 unfixed endomyocardial biopsies, performed during the first 4 months in 17 heart transplant recipients by polymerase chain reaction. Results were correlated with human cytomegalovirus systemic infection, as detected by the test for the viral lower matrix phosphoprotein pp65 (antigenemia) and by polymerase chain reaction for viral DNA in blood leukocytes (DNAemia). Three patients out of 17 did not develop cytomegalovirus infection and 14 did: 5 had symptomatic disease treated with ganciclovir and 9 developed asymptomatic infection and were not treated. Viral DNA was detected in 24 out of 103 biopsies (23%) from 13 patients: 5 with symptomatic infection during the acute phase of disease (mean levels of pp65: 125+/-232 pp65 positive leukocytes/200,000 examined cells) and 8 patients with asymptomatic infection when the mean antigenemia was 5+/-15/200,000 (4 patients) or when DNAnemia was present in the blood (4 patients). No histological evidence of myocarditis was shown in viral DNA-positive biopsies. No difference in acute rejection was found in viral DNA-positive and DNA-negative biopsy specimens in symptomatic and asymptomatic infected patients. Our experience suggests that during systemic symptomatic and asymptomatic cytomegalovirus infection, polymerase chain reaction can detect a relatively frequent myocardial involvement, but this involvement is not associated with myocarditis or with a higher incidence of acute rejection. THe presence of viral DNA in myocardial biopsies can be a result of high viremia, but it also can be due to low level of viral DNA in circulating infected leukocytes. Polymerase chain reaction is the most sensitive method for cytomegalovirus DNA detection in biopsies, but its results need to be evaluated together with morphology-preserving methods and systemic markers of infection in order to make a correct diagnosis.

Animals↗