Simona Sarzi Braga

Fondazione Salvatore Maugeri IRCCS, Ticinum, Lombardy, Italy

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Publications (33)145.4 Total impact

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    ABSTRACT: BACKGROUND: NT-proBNP has been associated with prognosis in acute decompensated heart failure (ADHF). Whether NT-proBNP provides additional prognostic information beyond that obtained from standard clinical variables is uncertain. We sought to assess whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) determination improves risk reclassification of patients with ADHF and to develop and validate a point-based NT-proBNP risk score. METHODS: This study included 824 patients with ADHF (453 in the derivation cohort, 371 in the validation cohort). We compared two multivariable models predicting 1-year all-cause mortality, including clinical variables and clinical variables plus NT-proBNP. We calculated the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI). Then, we developed and externally validated the NT-proBNP risk score. RESULTS: One-year mortalities for the derivation and validation cohorts were 28.3% and 23.4%, respectively. Multivariable predictors of mortality included chronic obstructive pulmonary disease, estimated glomerular filtration rate, sodium, hemoglobin, left ventricular ejection fraction, and moderate to severe tricuspid regurgitation. Adding NT-proBNP to the clinical variables only model significantly improved the NRI (0.129; p=0.0027) and the IDI (0.037; p=0.0005). In the derivation cohort, the NT-proBNP risk score had a C index of 0.839 (95% CI: 0.798-0.880) and the Hosmer-Lemeshow statistic was 1.23 (p=0.542), indicating good calibration. In the validation cohort, the risk score had a C index of 0.768 (95% CI: 0.711-0.817); the Hosmer-Lemeshow statistic was 2.76 (p=0.251), after recalibration. CONCLUSIONS: The NT-proBNP risk score provides clinicians with a contemporary, accurate, easy-to-use, and validated predictive tool. Further validation in other datasets is advisable.
    International journal of cardiology 02/2013; · 6.18 Impact Factor
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    ABSTRACT: Background The ADHF/NT-proBNP score is a validated risk scoring system that predicts mortality in hospitalized heart failure patients with a wide range of left ventricular ejection fractions (LVEF). We sought to assess discrimination and calibration of the score when applied to patients with advanced decompensated heart failure (AHF). Methods We studied 445 patients hospitalized for AHF, defined by the presence of severe symptoms of worsening HF at admission, severely depressed LVEF, and the need for intravenous diuretics and/or inotropes. The primary outcome was cumulative (in-hospital and postdischarge) and postdischarge 1-year mortality. Separate analyses were performed for patients aged ≤70 years. A Seattle Heart Failure Score (SHFS) was calculated for each patient discharged alive. Results During follow-up, 144 (32.4%) patients experienced death and 69 (15.5%) heart transplantation (HT) or ventricular assist device (VAD) implantation as a first event. After accounting for the competing events VAD and HT, the ADHF/NT-proBNP score’s C-statistic for cumulative mortality was 0.738 in the overall study cohort and 0.771 in patients aged ≤70 years. The C-statistic for postdischarge mortality was 0.741 and 0.751, respectively. Adding prior (≤6 months) hospitalizations for HF to the score increased the C-statistic for postdischarge mortality to 0.759 in the overall cohort and 0.774 in patients ≤70 years. Predicted and observed mortality rates by quartiles of score were highly correlated. The SHFS demonstrated adequate discrimination but underestimated risk. The ADHF/NT-proBNP risk calculator is available at: Conclusions Our data suggest that the ADHF/NT-proBNP score may efficiently predict mortality in patients hospitalized with AHF.
    The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 01/2013; · 3.54 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) after cardiac surgery is associated with increased mortality, morbidity, and expenditure. Controversial data exist on possible preventive effects of n-3 polyunsatured fatty acids (PUFAs) against postoperative AF. We investigated whether preoperative PUFA therapy is effective in reducing AF after cardiac surgery during the surgical hospitalization and/or the cardiac rehabilitation period. Over a 4-year period, 530 patients (363 men, 68.5%) with a mean age of 66.4 +/- 10.9 years, undergoing cardiac surgery were monitored for ''early AF'' and ''late AF'' defined as AF documented in the surgical department or during the rehabilitation program, respectively. The overall incidence of early AF in the whole study sample was 44.7%, whereas late AF occurred in 14.7% patients. Patients with AF had a longer length of hospital and rehabilitation stay (10.4 +/- 9.8 vs 9.5 +/- 9.2 days, P = .025 and 24.2 +/- 15.3 vs 21.1 +/- 8.3 days, P = .008, respectively). Early AF occurred in 31.0% of the patients with preoperative PUFAs compared with 47.3% of those without them (P = .006). Conversely, late AF was not influenced by preoperative PUFA regimen (11.9% vs 15.2%, P = .43). Preoperative PUFAs were independently associated with a 46% reduction in risk of early AF development (OR 0.54, 95% CI 0.31-0.92), after propensity score analysis. Preoperative PUFA therapy is associated with a decreased incidence of early AF after cardiac surgery but not late AF. Patients undergoing cardiac surgery may benefit from a preventive PUFA approach.
    Angiology 10/2010; 61(7):643-50. · 2.37 Impact Factor
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    ABSTRACT: Implantable cardioverter defibrillators (ICD) improve survival in selected patients with left ventricular dysfunction or heart failure (HF). The objective is to estimate the number of ICD candidates and to assess the potential impact on public health expenditure in Italy and the USA. Data from 3513 consecutive patients (ALPHA study registry) were screened. A model based on international guidelines inclusion criteria and epidemiological data was used to estimate the number of eligible patients. A comparison with current ICD implant rate was done to estimate the necessary incremental rate to treat eligible patients within 5 years. Up to 54% of HF patients are estimated to be eligible for ICD implantation. An implantation policy based on guidelines would significantly increase the ICD number to 2671 implants per million inhabitants in Italy and to 4261 in the USA. An annual increment of prophylactic ICD implants of 20% in the USA and 68% in Italy would be necessary to treat all indicated patients in a 5-year timeframe. Implantable cardioverter defibrillator implantation policy based on current evidence may have significant impact on public health expenditure. Effective risk stratification may be useful in order to maximize benefit of ICD therapy and its cost-effectiveness in primary prevention.
    Europace 08/2010; 12(8):1105-11. · 2.77 Impact Factor
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    ABSTRACT: The baroreflex control of circulation is always operating and modulates blood pressure and heart rate oscillations. Thus, the study of cardiovascular variability in humans is performed in a closed-loop model and the physiology of post-sinoaortic denervation is completely unknown in humans. We dissected for the first time the different components of systolic arterial pressure (SAP) and RR-interval spectra in a patient with 'baroreflex failure' (due to mixed cranial nerve neuroma) who represents a human model to investigate the cardiovascular regulation in an open-loop condition. Interactions among cardiovascular variability signals and respiratory influences were described using the multivariate parametric ARXAR model with the following findings: (1) rhythms unrelated to respiration were detected only at frequencies lower than classical low frequency (LF; Slow-LF, around 0.02 Hz) both in SAP an RR spectra, (2) small high-frequency (HF) modulation is present and related with respiration at rest and in tilt (but for SAP only) and (3) the Slow-LF fluctuations detected both in SAP and RR oscillate independently as the multivariate model shows no relationships between SAP and RR, and these oscillations are not phase related. Thus, we showed that in a patient with impaired baroreflex arc integrity the Slow-LF rhythms for RR have a central origin that dictates fluctuations on RR at the same rhythm but unrelated to the oscillation of SAP (which may be related with both peripheral activity and central rhythms). The synchronization in LF band is a hallmark of integrity of baroreflex arc whose impairment unmasks lower frequency rhythms in SAP and RR whose fluctuations oscillate independently.
    Journal of human hypertension 11/2009; 24(6):417-26. · 2.80 Impact Factor
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    ABSTRACT: T-wave alternans is a change, in the microvolt range, of T-wave amplitude on an ABABAB sequence. At present, various groups of patients have been evaluated, including those with myocardial infarction, congestive heart failure, implantable cardioverter-defibrillators and a clinical indication for programmed ventricular stimulation. In all clinical conditions analyzed, T-wave alternans analysis demonstrated a good diagnostic accuracy, suggesting a possible clinical use of the test in these settings.
    Giornale italiano di cardiologia (2006) 11/2008; 9(10 Suppl 1):33S-39S.
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    ABSTRACT: ICD shocks occurring in conscious patients (as in the case of well-tolerated arrhythmias, electromagnetic interference, or oversensing) have a deleterious impact on the quality of life. We evaluated if a hemodynamic parameter, calculated from the right ventricular pressure (RVP) or systemic arterial pressure (AP) signals, could predict early clinical symptoms of cerebral hypoperfusion during induced ventricular tachycardias (VTs). We analyzed 42 tolerated (no symptoms) and 30 untolerated (syncope or severe symptoms within 30 seconds from the onset) VTs, induced during electrophysiological study. The cycle length (CL) and the hemodynamic data (mean AP and RVP, arterial pulse pressure and RV pulse pressure, and maximum AP and RVP dP/dT) were automatically sampled in two VT epochs: the "detection" window, from beat 24 to 32, and the "preintervention" window, immediately before the first therapeutic attempt. Although the CL and all the hemodynamic parameters (expressed as % change versus pre-VT values) were significantly lower in untolerated versus tolerated VTs both at detection and preintervention (with the exception of the mean RVP which progressively increased in both groups), ROC analysis demonstrated that only the preintervention RV pulse pressure showed no overlap between groups, providing 100% sensitivity and positive predictive value. The reduction of the RV pulse pressure is a better predictor of early cerebral symptoms than CL or other hemodynamic indexes during induced VTs. Since long-term RVP monitoring is feasible, this parameter could be incorporated into ICDs decisional path, in the perspective of reducing unnecessary, painful shocks.
    Journal of Cardiovascular Electrophysiology 10/2008; 20(3):299-306. · 3.48 Impact Factor
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    ABSTRACT: B-type natriuretic peptide (BNP) levels are known to predict atrial fibrillation (AF) occurrence short-term after cardiac surgery, but no information is available on their predictive potential at a later time point. We evaluated whether BNP levels predict postcardiac surgery AF events occurring during rehabilitation program. AF impact on hospitalization length and rehabilitation program have also been evaluated. One hundred and forty-nine patients who underwent cardiac surgery were monitored for 'late' AF, defined as AF occurring during the rehabilitation period (20+/-5 days) in contrast to 'early' AF defined as AF documented in the surgical department soon after surgery. BNP was determined at rehabilitative hospital admission (10+/-5 days after surgery). Late AF was observed in 17% of patients. AF patients had higher BNP levels than event-free patients (459+/-209 vs. 401+/-449 pg/ml, P=0.01). Lower kaliemia values (P=0.048), early AF (P<0.001), and combined surgery (coronary artery by pass graft and valve replacement; P=0.016) were also associated with late AF. At multivariate analysis, BNP levels more than 322 pg/ml (P=0.02), and early AF (P=0.003) showed an independent association with late AF occurrence, which did not interfere with the physical training program but prolonged hospitalization (22+/-5 vs. 20+/-5 days, P=0.062) and telemetry monitoring (6+/-5 vs. 1+/-3 days, P<0.001). BNP levels measured at the beginning of the rehabilitation program are independent predictors of late AF after cardiac surgery. These results suggest a more aggressive therapeutical approach during the rehabilitation period in patients with elevated BNP levels who have already experienced AF in the surgical department.
    European Journal of Cardiovascular Prevention and Rehabilitation 08/2008; 15(4):460-6. · 2.63 Impact Factor
  • S. Sarzi Braga, R.F.E. Pedretti
    11/2007: pages 71 - 73; , ISBN: 9780470995013
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    ABSTRACT: The purpose of this study was to test the ability of cardiopulmonary exercise testing (CPET)-derived variables as sudden cardiac death (SCD) predictors. The CPET variables, such as peak oxygen uptake (VO2), ventilatory requirement to carbon dioxide (CO2) production (VE/VCO2) slope, and exercise oscillatory breathing (EOB), are strong predictors of overall mortality in chronic heart failure (CHF) patients. Even though up to 50% of CHF patients die from SCD, it is unknown whether any of these variables predicts SCD. One hundred fifty-six CHF patients (mean age: 60.9 +/- 9.4 years; mean ejection fraction: 34.9 +/- 10.6%) underwent CPET. Subjects were tracked for sudden versus pump-failure cardiac mortality over 27.8 +/- 25.2 months. Seventeen patients died from SCD, and 17 died from cardiac pump failure. Survivors showed significantly higher peak VO2 (16.8 +/- 4.5 ml x kg(-1) x min(-1)) and lower VE/VCO2 slope (32.8 +/- 6.4) and prevalence of EOB (20.3%), compared with subjects who experienced arrhythmic (13.5 +/- 3.2 ml x kg(-1) x min(-1); 41.5 +/- 11.4; 100%) or nonarrhythmic (14.1 +/- 4.7 ml x kg(-1) x min(-1); 38.1 +/- 7.3; 47.1%) deaths (p < 0.05). At Cox regression analysis, all variables were significant univariate predictors of both sudden and pump failure death (p < 0.01). Multivariate analysis, including left ventricular (LV) ejection fraction, LV end systolic volume, and LV mass selected EOB, was the strongest predictor of both overall mortality (chi-square: 38.7, p < 0.001) and SCD (chi-square: 44.7, p < 0.001), whereas VE/VCO2 slope was the strongest ventilatory predictor of pump failure death (chi-square: 11.8, p = 0.001). Exercise oscillatory breathing is an independent predictor of SCD in patients with CHF and might help as an additional marker for prioritization of antiarrhythmic strategies.
    Journal of the American College of Cardiology 07/2007; 50(4):299-308. · 14.09 Impact Factor
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    ABSTRACT: Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials. To assess the prevalence and clinical correlates of AF among HF patients in everyday clinical practice from HF patients screened for the T-wave ALternans in Patients with Heart fAilure (ALPHA) study; to investigate the correlation between AF and functional status. Consecutive patients (N=3513) seen at nine Heart Failure Clinics were studied; 21.4% were in AF. AF prevalence was greater with increasing age (OR 1.04/year, p<0.001) in non-ischaemic cardiomyopathy (OR 2.34, p<0.001) and with increasing NYHA class (p<0.0001). Multiple logistic regression predictors of AF were age >70 years (OR 2.35), NYHA class II III or IV vs class I (OR 1.8, 4.4 and 3.1) and non-ischaemic cardiomyopathy (OR 3.2). A logistic model indicated that AF was associated with a 2.5 OR of being in NYHA class III-IV vs I-II while accounting for age, gender, left ventricular ejection fraction (LVEF), and aetiology of HF. The prevalence of AF in HF patients exceeds 20%, and increases with age and functional class. The presence of AF leads to a more severe NYHA class, indicating that AF contributes to the severity of heart failure.
    European Journal of Heart Failure 05/2007; 9(5):502-9. · 5.25 Impact Factor
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    Internal and Emergency Medicine 04/2007; 2(1):29-32. · 2.35 Impact Factor
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    ABSTRACT: We report here the first case of baroreflex failure due to a mixed cranial nerve neuroma in which the clinical manifestations (recurrent severe hypertensive crisis, hypotension) due to baroreflex arc impairment preceded the clinical diagnosis of brain tumour and neurosurgery by a few months. Given the clinical suspicion of baroreflex failure, even in the absence of iatrogenic clues, we propose that the patient's study should include neuroradiologic evaluation of the ponto-cerebellar angulus.
    Autonomic Neuroscience 01/2007; 130(1-2):57-60. · 1.85 Impact Factor
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    ABSTRACT: Sudden cardiac death (SCD) accounts for approximately 400,000 deaths each year in the USA and remains a health problem of epidemic proportions. Most SCDs are caused by fatal ventricular arrhythmias, i.e., ventricular tachycardia (VT) and ventricular fibrillation (VF), in patients with and without known structural heart diseases [1, 2]. Identifying patients at risk for these arrhythmias remains a major challenge since < 2% of patients who have sudden cardiac arrest are resuscitated and survive hospital discharge. Given the large number of patients potentially at risk for developing ventricular arrhythmias, any strategy for treating them prophylactically requires efficient and effective risk stratification. A number of recently completed randomized clinical trials showed that an implantable cardioverter defibrillator (ICD) can prevent SCD in selected high-risk patients. These trials have used different methods for identifying patients at risk for SCD. The Multicenter Automatic Defibrillator Implantation Trial (MADIT) and the Multicenter Nonsustained Tachycardia Trial (MUSTT) identified patients with left ventricular (LV) dysfunction and nonsustained VT who had VT induced by programmed ventricular stimulation [3, 4]. These two studies demonstrated that implantation of an ICD can reduce the risk of death in this group of high-risk patients. In contrast, in the Coronary Artery By-pass Graft (CABG) Patch Trial, which identified a group of high-risk patients with LV dysfunction and an abnormal signal-averaged electrocardiogram who were undergoing elective CABG surgery, implantation of an ICD did not reduce all-cause mortality [5].
    12/2006: pages 179-189;
  • International Journal of Cardiology 05/2006; 109(1):118-20. · 6.18 Impact Factor
  • European Journal of Cardiovascular Prevention & Rehabilitation - EUR J CARDIOVASC PREV REHABIL. 01/2006; 13.
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    ABSTRACT: Low levels of EPA and DHA are independently associated with increased risk of death from coronary heart disease, especially with sudden cardiac death. In randomised secondary prevention trials, fish or fish oil have been demonstrated to reduce total and CHD mortality. RBC fatty acid composition reflects long-term intake of EPA and DHA. RBC EPA and DHA levels may be considered a new risk factor for death from CHD. This potential new risk factor, the Omega-3 Index, seems to be inversely associated with risk for CHD mortality. An Omega-3 Index of 8% or greater was associated with the greatest cardioprotection, whereas an index of 4% or less was associated with the least. Thus, the Omega-3 Index may represent a novel, physiologically relevant, easily modified, independent, and graded risk factor for death from CHD that could have significant clinical utility.
    12/2005: pages 399-407;
  • Roberto F E Pedretti, Simona Sarzi Braga
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    ABSTRACT: Most sudden cardiac deaths are caused by fatal ventricular arrhythmias (ventricular tachycardia [VT] and fibrillation) in patients with and without known structural heart diseases. Given the large number of patients potentially at risk for developing ventricular arrhythmias, any strategy for treating them prophylactically requires efficient and effective risk stratification. Both non-invasive and invasive testing may be used for prognostic evaluation of patients with heart diseases. The optimal way to use them in the risk stratification for sudden cardiac death will depend in part on the goals of screening. At present risk markers perform better at identifying low-risk patients who may not need an implantable cardioverter-defibrillator (ICD), because all tests have a high negative predictive accuracy. In our opinion an electrophysiological test should not be performed and an ICD should not be implanted in post-myocardial infarction patients with moderate left ventricular dysfunction (left ventricular ejection fraction 30-40%) with a preserved autonomic balance and without non-sustained VT. In MADIT II-like patients electrophysiological testing does not seem necessary and an ICD could not be implanted only in patients with a negative T-wave alternans test. Most of the data available refer to patients with ischemic cardiomyopathy but the preliminary data on T-wave alternans suggest its usefulness in patients with non-ischemic cardiomyopathy too, although a large definitive study has not yet been completed in this important population.
    Italian heart journal: official journal of the Italian Federation of Cardiology 04/2005; 6(3):180-9.
  • Simona Sarzi Braga, Raffaele Manni, Roberto F E Pedretti
    The Lancet 01/2005; 366(9483):426. · 39.06 Impact Factor
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    ABSTRACT: Few data are available about the prognostic role of T wave alternans in patients with congestive heart failure. To assess the ability of T wave alternans, used alone or in combination with other risk markers, to predict cardiac death in decompensated patients, we enrolled 46 patients, mean age 59+/-9, males 89%, ischemic etiology 61%, NYHA class III 35%, left ventricular ejection fraction 29+/-7%. After 1.6 years follow-up, seven patients died from cardiac death (16%), non-sudden in six (86%) and sudden in one (14%). T wave alternans was positive in 24 (52%), negative in 13 (28%), indeterminate in nine patients (20%). T wave alternans was positive in all patients with events (100%) but only in 16 of 37 patients without (41%) (P=0.02). Other predictors of cardiac death were O(2) consumption at the peak of exercise (P=0.03), standard deviation of all NN intervals (P=0.05) and Wedge pressure (P=0.03). When receiver operator characteristics curves were calculated, the highest area (0.73) was found for O(2) consumption at the peak of exercise considering the single variables and for O(2) consumption at the peak of exercise plus T wave alternans (0.79) for combination of them; the comparison of the two receiver operator characteristics curves did not reach statistical difference (P=0.5). In conclusion, this is the first study reporting that T wave alternans can predict cardiac death, with a marginal additional prognostic power when used in combination with measurement of O(2) consumption at the peak of exercise.
    International Journal of Cardiology 02/2004; 93(1):31-8. · 6.18 Impact Factor

Publication Stats

247 Citations
145.40 Total Impact Points


  • 2002–2009
    • Fondazione Salvatore Maugeri IRCCS
      • Divisione di Cardiologia 1
      Ticinum, Lombardy, Italy
  • 2008
    • Azienda ospedaliera di Busto Arsizio
      Ansizio, Lombardy, Italy
  • 1993–1995
    • Istituto di Cura e Cura a Carattere Scientifico Basilicata
      Rionero in Vulture, Basilicate, Italy