The influence of physical activity performed at 20-40 years of age on cardiovascular outcomes in medical patients aged 65-75

Summary Introduction Several studies show that physical activity can reduce the risk of cardiovascular disease, but the vast majority of these focus on the short- to intermediate-term benefits or refer to very specific populations. This observational study was conducted to determine whether physical activity performed during the third or fourth decade of life influences the occurrence of cardiovascular events in patients aged 65-75 years. Materials and methods We studied a cohort of 2191 unselected patients admitted to Internal Medicine Departments. Data were collected on the patients' medical history and their physical activity level when they were 20 to 40 years old. For the latter purpose, we used a specific questionnaire to assess the levels of physical activity related to the patients' job, daily life, leisure time, and sports. Results Almost half (44.2%) of the patients we evaluated reported moderate-intense physical activity when they were 20-40 years old. Around one third (35.8%) of the patients had experienced at least one major cardiovascular event, and there was a slight trend towards fewer cardiovascular events in patients with histories of physical activity (mean risk reduction: 4%, multivariate analysis). More evident benefits were observed in the subgroup of patients with diabetes, where cardiovascular outcomes were much better in patients who had been physically active than in those with sedentary life-styles (mean risk reduction: 24%). Conclusions Given its design, our study may have underestimated the cardiovascular benefits of physical activity. Nonetheless, our results suggest that moderate-intense exercise during young adulthood may have limited beneficial effects on cardiovascular disease in old age, except in specific high-risk populations (diabetic patients). More evident benefits are probably associated with regular physical activity throughout life

Clinical characteristics of very old patients hospitalized in internal medicine wards for heart failure: a sub-analysis of the FADOI-CONFINE Study Group

The incidence and prevalence of chronic heart failure are increasing worldwide, as is the number of very old patients (>85 years) affected by this disease. The aim of this sub-analysis of the multicenter, observational CONFINE study was to detect clinical and therapeutic peculiarities in patients with chronic heart failure aged >85 years. We recruited patients admitted with a diagnosis of chronic heart failure and present in the hospital in five index days, in 91 Units of Internal Medicine. The patients' clinical characteristics, functional and cognitive status, and the management of the heart failure were analyzed. A total of 1444 subjects were evaluated, of whom 329 (23.1%) were over 85 years old. Signs and symptoms of chronic heart failure were more common in very old patients, as were severe renal insufficiency, anemia, disability and cognitive impairment. The present survey found important age-related differences (concomitant diseases, cognitive status) among patients with chronic heart failure, as well as different therapeutic strategies and clinical outcome for patients over 85 years old. Since these patients are usually excluded from clinical trials and their management remains empirical, specific studies focused on the treatment of very old patients with chronic heart failure are needed

Statins and regression of organ damage

Atherosclerosis develops over the course of 50 years. It is a generally asymptomatic process that begins early in life in response to the stimuli of cardiovascular risk factors. The first step is a lipid retention, oxidation, and modification, which provokes chronic inflammation at susceptible sites in the walls of all major conduit arteries. Initial fatty streaks evolve into fibrous plaques, some of which develop into forms that are vulnerable to rupture, causing thrombosis or stenosis. Erosion of the surfaces of some plaques and rupture of a plaque’s calcific nodule into the artery lumen also may trigger thrombosis. It has been demonstrated that statins significantly affect the prognosis and outcome of patients either with or at risk of having cardiovascular atherosclerotic disease. Several studies suggested an extra-beneficial effect of statins, since they may affect the cardiovascular system beyond their effect on the lipid profile, through pleiotropic effects such as modulation of endothelial function, and reduction of inflammatory and immunological processes in the vascular bed. Thus, these drugs favorably alter atherosclerosis in term of plaque size, cellular composition, chemical composition, and biological activities

Depression and Internal Medicine

BACKGROUND Depression is 2-4 times more frequent in medically ill patients than in the general population, it significantly undermines the quality of life and makes prognosis worse in terms of morbidity and mortality. Nevertheless the majority of cases are not recognized or appropriately treated. A growing body of evidence suggests that mood disorders and many medical illnesses are linked in a bidirectional way by several biological mechanisms. Autonomic function changes, hyperactivity of the hypothalamic-pituitary-adrenal axis, increases in plasma cortisol, elevated levels of proinflammatory cytokines, increased platelet activation and hypercoagulability, all of them occur in patients with depression and all of them are causal factors in development and progression of atherothrombotic lesions or they are implicated in the pathogenesis of neoplasm and other illness such as chronic pain, chronic obstructive pulmonary disease, rheumatoid arthritis and so on. CONCLUSIONS Although antidepressant use has not been shown to reduce mortality rates in patients with medical illness, it alleviates depression, improves the quality of life and reduces morbidity. Clinicians should be aware of this association and should make an effort in detecting and treating not only biological illness but also mood disorders

Chronic obstructive pulmonary disease and cardiovascular co-morbidities

BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) is the fourth largest cause of death worldwide. However, most patients with COPD die from cardiovascular causes (CVD). COPD is an independent risk factor for CVD and a predictor of long-term mortality. There is a high prevalence of traditional risk factors in this patient group, including smoking, sedentary behaviour and low socio-economic class. COPD is now recognized to having both local lung and systemic effects. The mechanism of such systemic effects is not completely known, but it is supposed to be related to enhanced systemic inflammation and to oxidative stress, both implicated in the pathogenesis of atherosclerotic process. CONCLUSIONS COPD is frequently associated with congestive heart failure (CHF). It is also a confounding factor for the diagnosis of CHF. In fact, some studies demonstrate that about 20% of patients diagnosed with COPD had also or only CHF. Patients with CHF and associated COPD have less frequently β-blockers prescription than CHF patients without COPD. COPD is a heavy negative prognostic factor for CHF hospitalization and mortality. Pulmonary Embolism (PE) in patients with COPD is generally underdiagnosed, and this last disease is a risk factor for a complicated course of PE, with increased mortality

Aging, patient-bed management and overcrowding in the medical departments

BACKGROUND Hospital overcrowding (HO) profoundly affects the whole hospital system, reducing productivity and efficiency. The aging population and the increased prevalence of chronic-degenerative diseases, susceptible to acute exacerbations, make the elderly as frequent users of the emergency room (ER). There is a general agreement that the current disease-oriented and episodic model of care does not adequately cope with the complex needs of older patients. Hospital admission and discharge do not sufficiently link with primary care and other community resources, such as long-term care facilities and outpatient clinics. AIM OF THE STUDY To evaluate, using a simple dedicated software, the activity data of nine hospitals of Local Health Authority of Bologna (Italy) (ER accesses, hospital admissions, average length of stay – LOS) and the impact of a patient and bed management net in which managers, doctors and nurses share their operational skills to improve patient flow in medical and geriatric wards. RESULTS Data show that 24% ER accesses concern people > 75 years old; 51% admissions concern people > 75 years old; half of these admissions are from ER frequent users (FU = ≥ 3 ER accesses/ year). Only 15% admissions of younger people are from ER frequent users. Each of > 75 years old frequent users produces an average of 2 admissions/year. At the end of the first year of this experience, ER accesses and admissions rose more than 8%. In our model of bed-management (patient and bed management net-software matching hospital capacity with admission, escalation measures) LOS was shortened by an average 0.5-1 day to a range from 0,5 to 1 day. DISCUSSION HO is due to mismanagement of chronic diseases (CD). Further actions are needed in primary health care to avoid unscheduled hospital due to CD. Applications for admission to hospital should be administered in the real context of the needs, developing both measures to face the contingent situation (setting temporary additional beds in one of the highest step of escalation measures) and post-discharge case management for selected “high risk-FU” patient profiles. CONCLUSIONS Our experience shows that an organizational model with a simple software is effective only to manage patient flow for relative small variations. Biggest peak of admissions requires strong link with primary care and other community resources, by systemic administration of health, particularly in frail people, with not scheduled hospital readmissions, for which hospital-centred care is not ever the best choice. Further research in initial ER assessment of FU is needed, by an identification of the high risk patient’s profile and its appropriate setting allocation