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ABSTRACT: No studies have compared the prognostic values of invasive (phenylephrine, Phe) and noninvasive (transfer function) assessments of baroreflex sensitivity (BRS).
Three hundred and one heart failure patients [age: 53 ± 8 years, New York Heart Association class II-III: 88%, left-ventricular ejection fraction (LVEF): 28 ± 8%] underwent an 8 min ECG and arterial pressure recording, followed by Phe administration.
Phe-BRS and transfer function BRS (TF-BRS) could be measured in 89 and 72% of cases, respectively. The correlation and the 5-95th percentiles of the difference between the two methods were 0.61 (P < 0.0001), and -7.6, +7.5 ms/mmHg, respectively. During a median of 36 months, 23% of the patients experienced a cardiac event. In the common dataset of 202 patients, both BRS measurements (<3 ms/mmHg) were significantly associated with the outcome (both P < 0.001), but Phe-BRS had a better discriminatory power (area under the curve (AUC): 0.74 vs. 0.66, P = 0.03). Patients with a missing BRS (due to high grade ectopic activity) had a higher event rate (Phe-BRS: 38 vs. 24%, P = 0.23; TF-BRS: 37 vs. 19%, P = 0.002). Using this information, a prognostic index was derived for each BRS method, increasing measurability to 94 and 98%, respectively. Both indexes significantly predicted the outcome after adjustment for clinical covariates [hazard ratio (95% CI): 1.9 (1.1-3.3), P = 0.03 for Phe index and 2.0 (1.1-3.7), P = 0.02 for transfer function index].
Although the measurability of TF-BRS in heart failure patients is impaired, prognostic information can be extended to almost all patients, with a predictive power similar to that of Phe-BRS. The two measurements, however, convey a certain amount of independent prognostic information. Hence, TF-BRS can be integrated with but not replace Phe-BRS.
Journal of hypertension 06/2011; 29(8):1546-52. · 4.02 Impact Factor
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Clinical Endocrinology 05/2011; 75(6):864-5. · 3.17 Impact Factor
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ABSTRACT: This study investigated the clinical correlates and prognostic value of depressed baroreceptor-heart rate reflex sensitivity (BRS) among patients with heart failure (HF), with and without beta-blockade.
Abnormalities in autonomic reflexes play an important role in the development and progression of HF. Few studies have assessed the effects of beta-blockers on BRS in HF.
The study population consisted of 103 stable HF patients, age (median [interquartile range]) 54 years (48 to 57 years), with New York Heart Association (NYHA) functional class > or =III in 22, and with a left ventricular ejection fraction (LVEF) of 30% (24% to 36%), treated with beta-blockers; and 144 untreated patients, age 55 years (48 to 60 years), with NYHA functional class > or =III in 47%, and an LVEF of 26% (21% to 30%). They underwent BRS testing (phenylephrine technique).
In both treated and untreated patients, a lower BRS was associated with a higher (> or =III) NYHA functional class (p = 0.0002 and p < 0.0001, respectively); a more severe (> or =2) mitral regurgitation (p = 0.007 and p = 0.0002), respectively; a lower LVEF (p = 0.0004 and p = 0.001, respectively), baseline RR interval (p = 0.0004 and p = 0.0002, respectively), and SDNN (p < 0.0001, p = 0.002, respectively); and a higher blood urea nitrogen (p = 0.004, p < 0.0001, respectively). Clinical variables explained only 43% of BRS variability among treated and 36% among untreated patients. During a median follow-up of 29 months, 17 of 103 patients and 55 of 144 patients, respectively, experienced a cardiac event. A depressed BRS (<3.0 ms/mm Hg) was significantly associated with the outcome, independently of known risk predictors and beta-blocker treatment (adjusted hazard ratio: 3.0 [95% confidence interval: 1.5 to 5.9], p = 0.001).
Baroreceptor-heart rate reflex sensitivity does not simply mirror the pathophysiological substrate of HF. A depressed BRS conveys independent prognostic information that is not affected by the modification of autonomic dysfunction brought about by beta-blockade.
Journal of the American College of Cardiology 01/2009; 53(2):193-9. · 14.16 Impact Factor
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Monica Ceresa,
Soccorso Capomolla,
GianDomenico Pinna,
Eleonora Aiolfi,
Maria Teresa La Rovere,
Oreste Febo,
Vincenzo Paganini,
Angelo Rossi,
Giampaolo Guazzotti, Angelo Caporotondi,
Roberto Maestri,
Franco Cobelli
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ABSTRACT: The prognosis of chronic heart failure (CHF) remains poor despite advances in medical management. Several different variables determine prognosis. Recently anemia has emerged as an independent prognostic variable in the evaluation of CHF. It is therefore important to analyze the role of anemia in patients with mild to severe CHF already well characterized by hemodynamic, echo-Doppler, and cardiopulmonary exercise testing.
We performed this study to evaluate, in a large general cohort of CHF patients, the frequency of anemia and its correlation with their clinical profile. We assessed the prognostic value of anemia in relation to other known prognostic variables.
Two-dimensional echocardiography, right heart catheterization, cardiopulmonary tests and laboratory examinations were performed in a population of 980 consecutive patients with CHF (53 +/- 9.4 years, 85% male, LVEF 25 +/- 8%; 45% with NYHA class III-IV). A hemoglobin (Hb) concentration less than 12 g/dl was used to define anemic patients. The primary end point was cardiac death or urgent heart transplantation.
Nineteen percent of patients were anemic. These patients had a lower body mass index (24 +/- 3 vs. 25 +/- 4 Kg/m2 p < 0.0004), a worse functional class (64% were in NYHA class III-IV vs 41% in the non-anemic group, p < 0.0001), poorer exercise capacity (12.4 vs. 14.8 ml/kg/min peak VO2, p < 0.0001) and increased right (7 +/- 5 vs. 5 +/- 4 mmHg, p < .0004) and left (21 +/- 9 vs. 19 +/- 10 p < 0.007) ventricular filling pressures. During a 3-year follow-up cardiac deaths occurred in 236 (24%) and 52 (5%) of patients received an urgent heart transplant. On univariate regression analysis anemia was significantly correlated with these "hard" cardiac events (39% of anemic patients vs 27% of non-anemic patients). By multivariate logistic regression analysis different prognostic models were identified using non-invasive, with or without peak VO2, or invasive parameters. The prognostic model including anemia (AUC(ROC): 0.720) showed similar accuracy in predicting cardiac events to other prognostic models with peak VO2 (AUC(ROC): 0.719) or invasive variables (AUC(ROC): 0.719).
The present study demonstrates that anemia in CHF patients is associated with prognosis, worse NYHA functional class, exercise capacity and hemodynamic profiles. The relationship between anemia and mortality is independent of other simple non-invasive prognostic factors. Prognostic models with more complex or invasive independent predictors did not increase the accuracy to predict cardiac mortality or the need for urgent transplantation.
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo 07/2005; 64(2):124-33.
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Soccorso Capomolla,
Monica Ceresa,
GianDomenico Pinna,
Roberto Maestri,
Maria Teresa La Rovere,
Oreste Febo,
Angelo Rossi,
Vincenzo Paganini, Angelo Caporotondi,
Giampaolo Guazzotti,
Marco Gnemmi,
Andrea Mortara,
Franco Cobelli
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ABSTRACT: Correct classification of chronic heart failure (CHF) patients by dual evidence of congestion and adequate perfusion is the primary clinical focus for management.
To evaluate the accuracy of echo-Doppler compared with clinical evaluation in determining the hemodynamic profile of patients with CHF; and to compare therapeutic changes based on hemodynamic or echo-Doppler findings.
Three hundred and sixty-six consecutive CHF patients (ejection fraction 25+/-7%) in sinus rhythm, undergoing evaluation for cardiac transplantation, underwent physical examination prior to right heart catheterization and echo-Doppler studies. Subsequently, patients were randomized to therapeutic optimization using either right heart catheterization or echo-Doppler data. The end-points were: identification of low cardiac output (cardiac index <2.2 l/min/m(2)); high pulmonary wedge pressure (PWP >18 mm Hg); high right atrial pressure (RAP >5 mm Hg) and analysis of therapeutic changes made in response to the right heart catheterization and echo-Doppler studies.
Echo-Doppler showed better accuracy in estimating abnormal hemodynamic indices than clinical variables (cardiac index <2.2 l/min/m(2): echo positive predictive accuracy (PPA) 98% vs. clinical PPA 52% p<0.00001; PWP >18 mm Hg: echo PPA 85% vs. clinical PPA 76% p=0.0011; RAP >5 mm Hg: echo PPA 82% vs. clinical PPA 57% p<0.00001). When applied to individual patients, the echo-Doppler assessment was more accurate than clinical evaluation in defining the different hemodynamic profiles: wet/cold (89% vs. 13%, p<0.0001); wet/warm (73% vs. 30%, p<0.0001); dry/cold (68% vs. 12%, p<0.0001); dry/warm (88% vs. 51%, p<0.0001). Therapeutic decision-making based on echo-Doppler findings was similar to that based on hemodynamics.
Echo-Doppler hemodynamic monitoring proved accurate in estimating hemodynamic profiles and influenced therapeutic management.
European Journal of Heart Failure 06/2005; 7(4):624-30. · 4.90 Impact Factor
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Soccorso Capomolla,
Monica Ceresa,
Agostina Civardi,
Angela Lupo,
Anna Ventura,
Milena Scabini,
Patrizia Leonelli,
Giulia Salvaneschi,
Alessandra Petocchi,
GianDomenico Pinna,
Marina Ferrari,
Oreste Febo, Angelo Caporotondi,
Giampaolo Guazzotti,
Maria Teresa La Rovere,
Marco Gnemmi,
Roberto Maestri,
Franco Cobelli
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ABSTRACT: Physical training has proven to be a valid and effective therapeutic tool capable of counteracting muscle changes that occur in chronic heart failure (CHF) patients. Nevertheless, few studies have analyzed the frequency of use of this therapy and the reasons for any reduced compliance and adherence to the prescription. The aim of this study was to quantify the frequency of the participation of CHF patients in a program of domiciliary physical training and to analyze the factors that can influence adherence to the program.
Three hundred and twenty-two consecutive CHF patients (ejection fraction 28 +/- 7%) in a stable condition with optimized medical therapy performed a cardiopulmonary test, including determination of peak oxygen consumption, at baseline and after 9 +/- 3 months. All the patients had participated in sessions of health education on the relationship between illness/physical activity. The prescription of physiotherapy was decided by the physician on the basis of each patient's clinical need assessed in the diagnostic-therapeutic management. The patient referred for physiotherapy entered a therapeutic strategy that included sessions of training on anaerobic threshold, self-management of the session, and formulation of a domiciliary physical training program. During the follow-up evaluation the patients were asked to complete a questionnaire, which investigated the relationship between several factors and the patient's adherence to the physical training program, which was objectively evaluated by the change in peak oxygen consumption recorded at the end of the training, taking into account the spontaneous variations found in the control group.
Two hundred and eighty-two of the patients (88%) satisfied the criteria for inclusion in the study. Only 61 (22%) of them were judged to have adhered to the recommended physical training. Type of employment (chi 2 = 7.08, p < 0.02), the state of retirement (chi 2 = 8.9, p < 0.01), ischemic etiology (chi 2 = 5.91, p < 0.01), compatibility with employment (chi 2 = 15.8, p < 0.0004), availability of suitable domestic conditions (chi 2 = 14.5, p < 0.0008), the structure of the training program (chi 2 = 22.33, p < 0.0001) and a learning phase in a gym (chi 2 = 71.33, p < 0.0001) were significantly correlated at univariate analysis with the performance of the physical training. Multivariate analysis identified the structure of the training program (odds ratio 9.6, 95% confidence interval 2.8-33) and a learning phase in a gym (odds ratio 49.6, 95% confidence interval 11-210.8) as independent factors (r2 = 0.48) determining adherence to the physical training program.
Adherence to unmonitored, recommended domiciliary physical training appears to be modest even in patients who have been in-patients in a cardiac rehabilitation center. Various factors seem to influence the adherence of the patient to this therapy, but structural factors, such as the organization and learning of the program, more strongly influenced the patient's subsequent compliance.
Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 11/2002; 3(11):1098-105.
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Soccorso Capomolla,
Oreste Febo,
Monica Ceresa, Angelo Caporotondi,
Giampaolo Guazzotti,
Maria La Rovere,
Marina Ferrari,
Francesca Lenta,
Sonia Baldin,
Chiara Vaccarini,
Marco Gnemmi,
GianDomenico Pinna,
Roberto Maestri,
Paola Abelli,
Sandro Verdirosi,
Franco Cobelli
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ABSTRACT: This study compared the effectiveness and cost/utility ratio between a heart failure (HF) management program delivered by day-hospital (DH) and usual care in chronic heart failure (CHF) outpatients.
Previous studies showed that about 50% of readmissions for CHF can be prevented by a multidisciplinary approach. However, the performance, effectiveness, and cost/utility ratio of a process of HF outpatient management related to evidence-based medicine have not been considered.
A total of 234 prospective patients discharged by a HF Unit were randomized to two management strategies: 122 patients to usual community care and 112 patients to a HF management program delivered by the DH. Management (rate of readmissions, therapeutic interventions), functional parameters (New York Heart Association [NYHA] functional class, left ventricular diameters, and ejection fraction, deceleration time of early diastolic mitral flow, peak oxygen uptake, and mitral regurgitation) and hard outcomes (cardiac death and urgent cardiac transplantation) were evaluated. The cost/utility ratios of the two strategies were compared.
After 12 +/- 3 months of follow-up, the individual rate access in DH was 5.5 +/- 3.8 days. The DH subjects were readmitted to the hospital less frequently than were the usual-care group patients (13 vs. 78, p < 0.00001). Patients allocated to usual-care management showed heterogeneous changes in NYHA functional class (13% improved and 16% worsened p = NS); In contrast, the DH group showed significant changes in NYHA functional class (23% improved and 11% worsened, p < 0.009). Hard cardiac events in the one-year follow-up occurred in 25/234 (10.6%) patients; cardiac death occurred in 21/122 (17.2%) of the community group and in 3/112 (2.7%) in the DH group (p < 0.0007). One DH patient underwent urgent transplantation. Comparison of the two managerial models by Cox regression analysis showed that DH management significantly protected against the appearance of hard events (relative risk [RR] 0.17; confidence interval [CI] 0.06 to 0.66). The cost/utility ratio of the two management strategies was similar (usual care $2,409 vs. DH $2,244). The incremental analysis revealed a cost savings of $1,068 for each quality-adjusted life year gained. The cost/utility ratio for the integration of DH management of CHF was $19,462 (CI $13,904 to $34,048).
A heart failure outpatient management program delivered by a DH can reduce mortality and morbidity of CHF patients. This management strategy is cost-effective and has an equitable value from a societal point of view.
Journal of the American College of Cardiology 10/2002; 40(7):1259-66. · 14.16 Impact Factor
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Soccorso Capomolla,
GianDomenico Pinna,
Maria Teresa La Rovere,
Roberto Maestri,
Monica Ceresa,
Marina Ferrari,
Oreste Febo, Angelo Caporotondi,
Giampaolo Guazzotti,
Francesca Lenta,
Sonia Baldin,
Andrea Mortara,
Franco Cobelli
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ABSTRACT: Background Telemonitoring care can be integrated into health care provision as a substitute for routine clinical follow-up. A telemonitoring service (TMS) integrated into the process of chronic heart failure (CHF) care has not so far been evaluated. Objectives We describe our comprehensive home TMS and evaluate its outcomes in comparison to the usual program of care after discharge from a Heart Failure Unit (HFU). Methods 133 patients discharged from a HFU, underwent risk cluster classification for cardiac events and were prospectively randomized to usual community care ( n =66) and to a management program delivered by the TMS ( n =67). Clinical outcome including re-hospitalization, cardiac death, and emergency room access, was compared in the two groups. Results Patients were clustered as at low ( n =51), moderate ( n =43) and high ( n =39) risk. The compliance to telemonitoring was 82%. The compliance to system follow-up was (81%). The mean individual access rate to the TMS was 4.6±3.3 calls. Active interventions were made following 54% of the accesses. After 10±6 months, 135 events had occurred: 103 in the usual care group and 32 in telemonitoring group ( P <0.001). Re-hospitalisation was 22 (TMS) vs 77 (usual care) ( P <0.009). Cluster risk classification intercepted patients' increased health care demands (low risk: 0.34±0.62; moderate risk 1±1.2; high risk 1.9±1.5 events) Conclusion A management program delivered by a TMS can reduce health care demands by CHF patients.
