[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Percutaneous coronary interventions (PCI) in patients with ischemic systolic left ventricular dysfunction (SLVD) are routinely performed although their impact on prognosis remains unclear. METHODS: We retrospectively evaluated 385 consecutive patients (76 % male, 66 +/- 9 years) with SLVD (left ventricular ejection fraction [LVEF] </=40 %) due to chronic coronary artery disease, who underwent PCI between 1999 and 2009, and explored clinical factors associated with higher risk of death or of a composite of death and hospitalization for acute decompensated heart failure (ADHF). RESULTS: The median follow-up was 28 months (inter-quartile range 14-46 months). Death and the composite outcome of death and hospitalization for ADHF occurred in 80 (21 %) and 109 (28 %) patients respectively (8.4 and 11.5 per 100 patient-years of follow-up). Insulin-dependent diabetes mellitus (IDDM), multivessel disease, LVEF < 35 %, symptoms of heart failure (HF) emerged both as independent predictors of death (adjusted hazard ratios [HR] 2.64; 1.92, 1.88 and 1.67 respectively) and composite outcome of death and hospitalization for ADHF (adjusted HR 2.22, 1.92, 1.79 and 1.94 respectively). Furthermore advanced age (HR = 1.03) emerged as independent predictors of death and having performed a stress test before PCI correlated with reduced number of deaths and ADHF hospitalizations (HR = 0.60). Of note, PCI significantly reduced the symptom of angina from 63.2 % at baseline to 16.3 % at the last follow up (p < 0.0001). CONCLUSIONS: IDDM, symptoms of HF, multivessel disease and LVEF < 35 % appear to be associated with worse outcome patients with ischemic SLVD undergoing PCI, and may be taken into account for optimal risk stratification. On the other hand, performing a stress testing before PCI seems to be associated with a more favorable outcome.
[Show abstract][Hide abstract] ABSTRACT: There is a paucity of data about mid-term outcome of
patients with advanced heart failure (HF) treated with left ventricular assist device (LVAD) in Europe, where donor shortage and their aging limit the availability and the probability of success of heart transplantation (HTx). The aim of this study is to compare Italian single-centre mid-term outcome in prospective patients treated with LVAD vs. HTx. We evaluated 213 consecutive patients with advanced HF who underwent continuous-flow LVAD implant or HTx from 1/2006 to 2/2012, with complete follow-up at 1 year (3/2013). We compared outcome in patients who received a LVAD (n = 49) with those who underwent HTx (n = 164) and in matched groups of 39 LVAD and 39 HTx patients. Patients that were treated with LVAD had a worse risk profile in comparison with HTx patients. Kaplan–Meier survival curves estimated a one-year survival of 75.5 % in LVAD vs. 82.3 % in HTx patients, a difference that was non-statistically significant [hazard ratio (HR) 1.46; 95 % confidence interval (CI) 0.74–2.86; p = 0.27 for LVAD vs. HTx]. After group matching 1-year survival was similar between LVAD (76.9 %) and HTx (79.5 %; HR 1.15; 95 % CI 0.44–2.98; p = 0.78). Concordant data was observed at 2-year follow-up. Patients treated with LVAD as bridge-to-transplant indication (n = 22) showed a non significant better outcome compared with HTx with a 95.5 and 90.9 % survival, at 1- and 2-year follow-up, respectively. Despite worse preoperative conditions, survival is not significantly lower after LVAD than after HTx at 2-year follow-up. Given the scarce number of donors for HTx, LVAD therapy represents a valid option, potentially affecting the current allocation strategy of heart donors also in Europe.
Heart and Vessels 03/2015; DOI:10.1007/s00380-015-0654-4 · 2.07 Impact Factor
[Show abstract][Hide abstract] 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.
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.
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.
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; 168(3). DOI:10.1016/j.ijcard.2013.01.005 · 4.04 Impact Factor
[Show abstract][Hide abstract] 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).
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.
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: http://www.fsm.it/fsm/file/NTproBNPscore.zip.
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; 33(4). DOI:10.1016/j.healun.2013.12.005 · 6.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The mid- and long-term outcome of revascularization procedures is still uncertain in patients with chronic left ventricular systolic dysfunction due to coronary artery disease. The identification of dysfunctional myocardial segments with residual viability that can improve after revascularization is pivotal for further patient management. Hibernating myocardium (chronically dysfunctional but still viable tissue) can be identified by positron emission tomography and cardiac magnetic resonance and its presence and extent can predict functional recovery after revascularization. Before beta-blockers were introduced as routine care for heart failure, surgical revascularization appeared to improve survival in these patients. Nowadays, novel medical treatments and devices such as cardiac resynchronization therapy and implantable cardioverter-defibrillators have improved prognosis of these patients and their use is supported by a number of clinical trials. A recently concluded randomized trial, the STICH (Surgical Treatment for Ischemic Heart Failure) trial, has assessed the prognostic benefit derived from revascularization added to optimal medical therapy in patients with ischemic left ventricular dysfunction. This is an overview of the pathophysiological mechanisms as well as the main clinical studies and meta-analyses that have addressed this issue in the past four decades. Furthermore, a brief proposal for a randomized trial to assess effect on prognosis of revascularization of hibernating myocardium will be presented.
Giornale italiano di cardiologia (2006) 02/2012; 13(2):102-9. DOI:10.1714/1021.11143