PubMed | CNR Institute of Neuroscience, University of Verona, Salvatore Maugeri Foundation, Stcamillo Forlanini Hospital and 18 more.
Type: | Journal: International journal of cardiology | Year: 2015
The Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score is a prognostic model to identify heart failure (HF) patients at risk for cardiovascular mortality (CVM) and urgent heart transplantation (uHT) based on 6 routine clinical parameters: hemoglobin, sodium, kidney function by the Modification of Diet in Renal Disease (MDRD) equation, left ventricle ejection fraction (LVEF), percentage of predicted peak oxygen consumption (VO2) and VE/VCO2 slope.MECKI score must be generalizable to be considered useful: therefore, its performance was validated in a new sequence of HF patients.Both the development (MECKI-D) and the validation (MECKI-V) cohorts were composed of consecutive HF patients with LVEF <40% able to perform a symptom-limited cardiopulmonary exercise testing. The CVM or uHT rates were analyzed at one, two and three years in both cohorts: all patients with a censoring time shorter than the scheduled follow-up were excluded, while those with events occurring after 1, 2 and 3 years were considered as censored.MECKI-D and MECKI-V consisted of 2009 and 992 patients, respectively. MECKI-V patients had a higher LVEF, higher peak VO2 and lower VE/VCO2 slope, higher prescription of beta-blockers and device therapy: after the 3-year follow-up, CVM or uHT occurred in 206 (18%) MECKI-D and 44 (13%) MECKI-V patients (p<0.000), respectively. MECKI-V AUC values at one, two and three years were 0.81 0.04, 0.76 0.04, and 0.80 0.03, respectively, not significantly different from MECKI-D.MECKI score preserves its predictive ability in a HF population at a lower risk.
PubMed | Institute of Milan, UOC Cardiologia Ospedale S. Spirito, ISMETT Mediterranean Institute for Transplantation and Advanced Specialized Therapies, G da Saliceto Hospital and 17 more.
Type: Journal Article | Journal: European journal of heart failure | Year: 2016
Obesity has been found to be protective in heart failure (HF), a finding leading to the concept of an obesity paradox. We hypothesized that a preserved cardiorespiratory fitness in obese HF patients may affect the relationship between survival and body mass index (BMI) and explain the obesity paradox in HF.A total of 4623 systolic HF patients (LVEF 31.59.5%, BMI 26.23.6kg/m(2) ) were recruited and prospectively followed in 24 Italian HF centres belonging to the MECKI Score Research Group. Besides full clinical examination, patients underwent maximal cardiopulmonary exercise test at study enrolment. Median follow-up was 1113 (553-1803) days. The study population was divided according to BMI (<25, 25-30, >30 to 35kg/m(2) ) and predicted peak oxygen consumption (peak VO2 , <50%, 50-80%, >80%). Study endpoints were all-cause and cardiovascular deaths including urgent cardiac transplant. All-cause and cardiovascular deaths occurred in 951 (28.6%, 57.4 per person-years) and 802 cases (17.4%, 48.4 per 1000 person-years), respectively. In the high BMI groups, several prognostic parameters presented better values [LVEF, peak VO2 , ventilation/carbon dioxide slope, renal function, and haemoglobin (P < 0.01)] compared with the lower BMI groups. Both BMI and peak VO2 were significant positive predictors of longer survival: both higher BMI and peak VO2 groups showed lower mortality (P < 0.001). At multivariable analysis and using a matching procedure (age, gender, LVEF, and peak VO2 ), the protective role of BMI disappeared.Exercise tolerance affects the relationship between BMI and survival. Cardiorespiratory fitness mitigates the obesity paradox observed in HF patients.
PubMed | University of Washington, G da Saliceto Hospital, St Camillo Forlanini Hospital, University of Verona and 14 more.
Type: Journal Article | Journal: The Canadian journal of cardiology | Year: 2016
In heart failure (HF), women show better survival despite a comparatively low peak oxygen consumption (Vo2): this raises doubt about the accuracy of risk assessment by cardiopulmonary exercise testing (CPET) in women. Accordingly, we aimed to check (1) whether the predictive role of well-known CPET risk indexes, ie, peak Vo2 and ventilatory response (Ve/Vco2 slope), is sex independent and (2) if sex-related characteristics that impact outcome in HF should be considered as associations that may confound the effect of sex on survival.The study population consisted of 2985 patients with HF, 498 (17%) of whom were women, from the multicentre Metabolic Exercise Test Data Combined with Cardiac and Kidney Indexes (MECKI): the end point was cardiovascular death within a 3-year period.During the follow-up, 305 (12%) men and 39 (8%) women (P= 0.005) died, and female sex was linked to better survival on univariate analysis (P= 0.008) and independent of peak Vo2 and Ve/Vco2 slope on multivariate analysis. According to propensity score matching for female sex to exclude a sex selection bias and sample discrepancy, 498 men were selected: the standardized percentage bias ranged from 20.8 (P < 0.0001) to 3.3 (P= 0.667). After clinical profile harmonizing, female sex was predictive of HF at univariate analysis.The low peak Vo2 and female association with better outcome in HF might be counterfeit: the female prognostic advantage is lost when sex-specific differences are correctly taken into account with propensity score matching, suggesting that for an effective and efficient HF model, adjustment must be made for sex-related characteristics.
PubMed | CNR Institute of Neuroscience, University of Verona, Institute of Diagnostic and Nuclear Development, G da Saliceto Hospital and 20 more.
Type: Comparative Study | Journal: European journal of preventive cardiology | Year: 2015
Oxygen uptake at the anaerobic threshold (VO2AT), a submaximal exercise-derived variable, independent of patients motivation, is a marker of outcome in heart failure (HF). However, previous evidence of VO2AT values paradoxically higher in HF patients with permanent atrial fibrillation (AF) than in those with sinus rhythm (SR) raised uncertainties.We tested the prognostic role of VO2AT in a large cohort of systolic HF patients, focusing on possible differences between SR and AF.Altogether 2976 HF patients (2578 with SR and 398 with AF) were prospectively followed. Besides a clinical examination, each patient underwent a maximal cardiopulmonary exercise test (CPET).The follow-up was analysed for up to 1500 days. Cardiovascular death or urgent cardiac transplantation occurred in 303 patients (250 (9.6%) patients with SR and 53 (13.3%) patients with AF, p=0.023). In the entire population, multivariate analysis including peak oxygen uptake (VO2) showed a prognostic capacity (C-index) similar to that obtained including VO2AT (0.76 vs 0.72). Also, left ventricular ejection fraction, ventilation vs carbon dioxide production slope, -blocker and digoxin therapy proved to be significant prognostic indexes. The receiver-operating characteristic (ROC) curves analysis showed that the best predictive VO2AT cut-off for the SR group was 11.7ml/kg/min, while it was 12.8ml/kg/min for the AF group.VO2AT, a submaximal CPET-derived parameter, is reliable for long-term cardiovascular mortality prognostication in stable systolic HF. However, different VO2AT cut-off values between SR and AF HF patients should be adopted.
PubMed | Centro Cardiovascolare, CNR Institute of Neuroscience, Institute of Diagnostic and Nuclear Development, Heart Failure Unit and 17 more.
Type: Journal Article | Journal: European journal of internal medicine | Year: 2015
Atrial fibrillation (AF) is common in heart failure (HF). It is unclear whether AF has an independent prognostic role in HF. The aim of the present study was to assess the prognostic role of AF in HF patients with reduced ejection fraction (EF).HF patients were followed in 17 centers for 3.15years (1.51-5.24). Study endpoints were the composite of cardiovascular (CV) death and heart transplant (HTX) and all-cause death. Data analysis was performed considering the entire population and a 1 to 1 match between sinus rhythm (SR) and AF patients. Match process was done for age5, gender, left ventricle EF5, peakVO23 (ml/min/kg) and recruiting center.A total of 3447 patients (SR=2882, AF=565) were included in the study. Considering the entire population, CV death and HTX occurred in 114 (20%) AF vs. 471 (16%) SR (p=0.026) and all-cause death in 130 (23%) AF vs. 554 (19.2%) SR patients (p=0.039). At univariable Cox analysis, AF was significantly related to prognosis. Applying a multivariable model based on all variables significant at univariable analysis (EF, peakVO2, ventilation/carbon dioxide relationship slope, sodium, kidney function, hemoglobin, beta-blockers and digoxin) AF was no longer associated with adverse outcomes. Matching procedure resulted in 338 couples. CV death and HTX occurred in 63 (18.6%) AF vs. 74 (21.9%) SR (p=0.293) and all-cause death in 71 (21%) AF vs. 80 (23.6%) SR (p=0.406), with no survival differences between groups.In systolic HF AF is a marker of disease severity but not an independent prognostic indicator.
Vitacca M.,Fondazione Salvatore Maugeri |
Barbano L.,Fondazione Salvatore Maugeri |
Vanoglio F.,Fondazione Salvatore Maugeri |
Luisa A.,Fondazione Salvatore Maugeri |
And 3 more authors.
American Journal of Physical Medicine and Rehabilitation | Year: 2016
Objective This study aims to determine whether a 6-month home physiotherapy program can improve outcomes in critical care survivors. Design Forty-eight consecutive patients were randomized. The treatment group underwent 2 sessions/day of breathing retraining and bronchial hygiene, physical activity (mobilization, sit-to-stand gait, limb strengthening), and exercise re-conditioning whereas controls underwent standard care. Maximum inspiratory/expiratory pressures (MIP/MEP), forced volumes, blood gases, dyspnea, respiratory rate, disability, peripheral force measurements, perceived health status (Euroquol-5D), patient adherence/satisfaction, safety, and costs were assessed. Results Outcomes of treatment versus controls: MIP 14 ± 17 vs. -0.2 ± 14 cm H2O, MEP 27 ± 27 vs. 6 ± 21 cm H2O both P < 0.03; in addition, quality of life (Euroquol-5D) (P = 0.04), FEV 1 (P = 0.03), dyspnea (P = 0.002), and respiratory rate (P = 0.009) were significantly improved for treated cardiorespiratory patients only. Eighty-three percent of the treated patients were decannulated versus 14% of controls (P = 0.01). Compliance was high (74 ± 25%) and there were no side effects. The majority (87.4%) expressed satisfaction with the program. Treatment cost was 459€/patient/month. Conclusions Carrying over regular bronchial hygiene techniques, physical activity, and exercise into the home after long critical care stays is safe and has a beneficial effect on respiratory muscles, decannulation, pulmonary function, and quality of life. © 2016 Wolters Kluwer Health, Inc.
Agostoni P.,Centro Cardiologico Monzino |
Agostoni P.,University of Milan |
Agostoni P.,University of Washington |
Swenson E.R.,University of Milan |
And 14 more authors.
Journal of Applied Physiology | Year: 2011
Background: high-altitude adaptation leads to progressive increase in arterial PaO2. In addition to increased ventilation, better arterial oxygenation may reflect improvements in lung gas exchange. Previous investigations reveal alterations at the alveolar-capillary barrier indicative of decreased resistance to gas exchange with prolonged hypoxia adaptation, but how quickly this occurs is unknown. Carbon monoxide lung diffusing capacity and its major determinants, hemoglobin, alveolar volume, pulmonary capillary blood volume, and alveolar-capillary membrane diffusion, have never been examined with early high-altitude adaptation. Methods and Results: lung diffusion was measured in 33 healthy lowlanders at sea level (Milan, Italy) and at Mount Everest South Base Camp (5,400 m) after a 9-day trek and 2-wk residence at 5,400 m. Measurements were adjusted for hemoglobin and inspired oxygen. Subjects with mountain sickness were excluded. After 2 wk at 5,400 m, hemoglobin oxygen saturation increased from 77.2 ± 6.0 to 85.3 ± 3.6%. Compared with sea level, there were increases in hemoglobin, lung diffusing capacity, membrane diffusion, and alveolar volume from 14.2 ± 1.2 to 17.2 ±1.8 g/dl (P < 0.01), from 23.6 ± 4.4 to 25.1 ± 5.3 ml·min-1·mmHg-1 (P < 0.0303), 63 ± 34 to 102 ± 65 ml·min-1·mmHg-1 (P < 0.01), and 5.6 ± 1.0 to 6.3 ± 1.1 liters (P < 0.01), respectively. Pulmonary capillary blood volume was unchanged. Membrane diffusion normalized for alveolar volume was 10.9 ± 5.2 at sea level rising to 16.0 ± 9.2 ml·min-1·mmHg -1·1-1 (P < 0.01) at 5,400 m. Conclusions: at high altitude, lung diffusing capacity improves with acclimatization due to increases of hemoglobin, alveolar volume, and membrane diffusion. Reduction in alveolar-capillary barrier resistance is possibly mediated by an increase of sympathetic tone and can develop in 3 wk. Copyright © 2011 the American Physiological Society.
Paolillo S.,University of Naples Federico II |
Paolillo S.,University of Milan |
Farina S.,University of Milan |
Bussotti M.,Cardiologia Riabilitativa |
And 6 more authors.
European Journal of Preventive Cardiology | Year: 2012
Patients affected by pulmonary arterial hypertension (PAH) show a reduced exercise tolerance with early occurrence of dyspnoea and fatigue. The origin of functional capacity limitation is multifactorial and several mechanisms have been proposed, including right heart failure, which leads to a limited increase in cardiac output during exercise, and hyperventilation with a reduced perfusion of properly ventilated alveoli. In addition, abnormalities in arterial blood gases are observed, with the occurrence of hypoxemia and hypocapnia, related to an abnormal ventilation/perfusion match, gas diffusion abnormalities, low mixed venous oxygen saturation and to the development of intra- and extra-pulmonary right-to-left shunts. At present, the 6-minute walking test is the most used method to assess exercise tolerance in PAH; it is also useful to monitor the response to therapy and provides prognostic information. However, the assessment of functional capacity by cardiopulmonary exercise test (CPET) seems to be more complete, because CPET allows for discrimination between the metabolic, cardiovascular and pulmonary components of exercise limitation. Moreover, CPET estimates the severity of disease and assesses patients' prognosis and response to therapy. In PAH, a typical CPET-response is observed, characterized by a severe reduction in peak VO2, work rate, O2 pulse and anaerobic threshold and by a marked increase in VE/VCO2 slope and in the dead space to tidal volume ratio. However, the use of CPET should be limited to experienced centres. This review will focus on resting lung function and exercise tolerance tests, showing that CPET can provide the physiological explanation of functional limitation in PAH. © 2011 The European Society of Cardiology.
PubMed | Coordinatore Dietista Unith Operativa Of Science Dellalimentazione E Dietetica Nuovo Ospedale S Agostino Estense Azienda Usl, Cardiologia Riabilitativa and University of Modena and Reggio Emilia
Type: Journal Article | Journal: Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace | Year: 2014
The aim of study was to test the usefulness of Moynihan questionnaire in the evaluation of knowledge on healthy diet of patients undergoing cardiology rehabilitation.We enrolled 51 patients (pts): 41 men and 10 women, mean age 67.97 +/-11.2 years. The case study included: 21 pts that underwent coronary bypass surgery, 16 pts replaced plastic tube, 14 pts had surgery for the other reasons. All pts underwent nutritional investigation by a dietitian. Anthropometric and biochemical parameters were detected and, by the end, the Moynihan questionnaire was administrated. Pts underwent nutritional coaching, and questionnaire and dietary assessment were rechecked after 3 months.At baseline, the mean Questionnaire score was 22.4 +/- 3.2 points, decreased to 20.6 +/-3.1 points after 3 months (p<0.05). A detailed analysis of the questions showed that the major informations gaps were related to consumption of fruits and vegetables, consumption of fat and salt. In addition pts have acquired more general knowledge about food composition.The Moynihan questionnaire is an useful instrument of evaluation of dietary knowledge even in selected patients population. In the present study involving patients after cardiac surgery the main difficulties were related to high age of pts, the low cultural level and, mainly, to the post-surgery stress. However, an increase of correct answers as well as an increased knowledge about food composition were detected after educational intervention performed by the dietitian.
PubMed | University of Washington, Centro Cardiologico Monzino, Cardiologia Riabilitativa and University of Milan
Type: Comparative Study | Journal: The American journal of cardiology | Year: 2014
The objective of this study was to evaluate inert gas rebreathing (IGR) reliability in cardiac output (CO) measurement compared with Fick method and thermodilution. IGR is a noninvasive method for CO measurement; CO by IGR is calculated as pulmonary blood flow plus intrapulmonary shunt. IGR may be ideal for follow-up of patients with pulmonary hypertension (PH), sparing the need of repeated invasive right-sided cardiac catheterization. Right-sided cardiac catheterization with CO measurement by thermodilution, Fick method, and IGR was performed in 125 patients with possible PH by echocardiography. Patients were grouped according to right-sided cardiac catheterization-measured mean pulmonary and wedge pressures: normal pulmonary arterial pressure (n = 20, mean pulmonary arterial pressure = 18 3 mm Hg, pulmonary capillary wedge pressure = 11 5 mm Hg), PH and normal pulmonary capillary wedge pressure (PH-NW, n = 37 mean pulmonary arterial pressure = 42 13 mm Hg, pulmonary capillary wedge pressure = 11 6 mm Hg), and PH and high pulmonary capillary wedge pressure (PH-HW, n = 68, mean pulmonary arterial pressure = 37 9 mm Hg, pulmonary capillary wedge pressure = 24 6 mm Hg). Thermodilution and Fick measurements were comparable. Fick and IGR agreement was observed in normal pulmonary arterial pressure (CO = 4.10 1.14 and 4.08 0.97 L/min, respectively), whereas IGR overestimated Fick in patients with PH-NW and those with PH-HW because of intrapulmonary shunting overestimation in hypoxemic patients. When patients with arterial oxygen saturation (SO2) 90% were excluded, IGR and Fick agreement improved in PH-NW (CO = 4.90 1.70 and 4.76 1.35 L/min, respectively) and PH-HW (CO = 4.05 1.04 and 4.10 1.17 L/min, respectively). In hypoxemic patients, we estimated pulmonary shunt as Fick - pulmonary blood flow and calculated shunt as: -0.2423 arterial SO2 + 21.373 L/min. In conclusion, IGR is reliable for CO measurement in patients with PH with arterial SO2 >90%. For patients with arterial SO2 90%, a new formula for shunt calculation is proposed.