Contraction and relaxation velocities of the normal left ventricle using pulsed-wave tissue Doppler echocardiography

We designed the present study (1) to investigate the velocities of longitudinal movement of the human left ventricle by pulsed-wave tissue Doppler (PWTD) imaging; (2) to test the hypothesis that a heterogeneous pattern of longitudinal systolic and diastolic velocities exists among individual left ventricular wall segments; (3) to establish the range of this heterogeneity, and (4) to correlate the function of individual segments with the known orientation of myocardial fibers. PWTD is a novel ultrasound method to quantify myocardial contraction and relaxation velocities. In 27 young normal subjects, PWTD peak values of longitudinal systolic and diastolic velocities were measured for 12 left ventricular segments visualized from the apical window. The PWTD sampling of each myocardial segment resulted in a triphasic velocity curve during each cardiac cycle: a systolic velocity wave (S) directed toward the transducer, and an early diastolic (E) and a late diastolic (A) velocity wave away from the transducer. A heterogeneous pattern of systolic and diastolic myocardial velocities was observed between individual wall segments as well as for the basal and midsegments of each myocardial wall. The difference between the highest and lowest values for S was 38.4% in the basal segments and 56.3% in the midwall segments. The difference between low and high velocities for E was 61.4% in the basal and 38.2% in the midsegments; for A the difference was 29.5% in the basal and 32.6% in the midsegments. In general, lower velocity values were found in the septum with higher basal to midwall difference. The lateral and posterior walls had higher, but more uniform, velocities. PWTD enables the quantitative assessment of regional systolic and diastolic myocardial velocities. Substantial heterogeneity of velocities exists within individual myocardial segments, and must be taken into account in any clinical application. The observed heterogeneity in longitudinal function is consistent with the known spatial distribution of myocardial fiber

Operations management in Local Healthcare Agencies: a patient-pathway oriented framework

Healthcare (HC) is one of the largest and most complex industries. In the last years Local Healthcare Agencies (LHAs) have been experienced high increase in expenditure. New methodological approaches allowing to optimize their efficiency and effectiveness are needed. Hospital departments are the most expensive services provided by LHAs. In this paper, a framework to model LHAs and evaluate the effects of some strategic decisions on LHAs performances is proposed. The analysis focuses on hospital units treating heart failure diseases since they are one of the main hospital admissions causes. The “dehospitalization” of heart failure care pathways is evaluated as a possible solution to the problem of reducing costs and improving quality of service such as the system capability to provide service without delays

The Cardiac Rehabilitation Psychodynamic Group Intervention (CR-PGI): an explorative study

Objective: An explorative study focusing on the process of a Cardiac Rehabilitation Psychodynamic Group Intervention (CR-PGI) addressed to myocardial infarction (MI) patients is discussed. The study aimed at analyzing whether the treatment based on CR-PGI serves as a communicational context within which MI patients are enabled to explore new interpretations of their post-infarction condition. Methods: The intervention, divided into 12 weekly one-hour group sessions, was addressed to MI patients recruited within a Public Hospital of southern Italy. Each session was audio-recorded and lexical correspondence analysis (LCA) was applied to the verbatim transcripts, in order to provide a map of the evolution of the communication exchange occurring over the 12 sessions. Results: The findings showed that the discourses associated to the first eight sessions differed from the discourses of the last four sessions. Two main transitions occurred. The first concerns the response to the infarction, first interpreted as a process of affective elaboration and afterwards as practical management of the functional aspects associated with the condition of MI patients. The second concerns the nature of the change and contrasts a lifestyle-oriented model with a social role approach, which refers to social, legal, and medical practices related to the acknowledgment of being an MI patient. Conclusion: The findings offer preliminary support to the capacity of CR-PGI to work as a context where new meanings for the biographical rupture of the MI can be explored. Consistently with the rationale of the model, the intervention seems to have promoted the emergence of new ways of feeling and understanding one’s condition

Multicenter APULIA HF study: Efficacy of a shared management protocol between hospital and territory of patients hospitalized for acute heart failure

Background. The aim of this study was to demonstrate the efficacy of a management model to reduce hospitalizations in patients recently admitted for acute decompensated heart failure. Methods. The management model was based on a close integration between hospital and territory health services. Clinical evaluation, ECG, echocardiographic findings, total body bioimpedance and brain natriuretic peptide serum levels were used to assess clinical stability of patients at discharge and during follow-up. A dedicated nurse (care manager) was involved in patient empowerment, telephone follow-up, check of adherence to therapy and clinical conditions, and management of scheduled evaluations. All hospitalizations occurring prior to or after enrolment in the municipalities involved in the study were considered, as well as the hospitalizations occurring among enrolled patients. Results. A total of 301 patients were enrolled, 226 of them from the Centers of the Puglia Region, Italy. An overall reduction of 6[%] in total hospitalizations with DRG 127 was observed; the reduction was most evident in the two centers with the smaller reference population (-16[%] and -26[%], respectively). In the group of patients enrolled, an overall reduction in hospital admissions was observed after comparing the period before and after enrolment. A significant increase in the prescription rate of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, beta-blockers and aldosterone antagonists was also observed. Finally, an overall reduction in the costs for patient management was demonstrated. Similar results were obtained in the two additional Centers of the Basilicata and Lazio Regions. Conclusions. An integrated management between hospital and territory allows optimization of the management of heart failure patients, with improvement of therapy and reduction in hospitalizations and management costs

Long-term outcomes of early-onset myocardial infarction with non-obstructive coronary artery disease (MINOCA)

Background: Acute myocardial infarction with non-obstructive coronary artery disease (MINOCA) is frequent in patients experiencing an early-onset MI, but data concerning its long-term prognosis are limited and conflicting. Methods: The Italian Genetic Study on Early-onset MI enrolled 2000 patients experiencing a first MI before the age of 45 years, and had a median follow-up of 19.9 years. The composite primary endpoint was cardiovascular (CV) death, non-fatal MI, and non-fatal stroke (MACE); the secondary endpoint was rehospitalisation for coronary revascularisation. Results: MINOCA occurred in 317 patients (15.9%) and, during the follow-up, there was no significant difference in MACE rates between them and the patients with obstructive coronary artery disease (MICAD: 27.8% vs 37.5%; adjusted hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.57–1.09;p = 0.15). The CV death rate was lower in the MINOCA group (4.2% vs 8.4%, HR 0.26, 95%CI 0.08–0.86;p = 0.03), whereas the rates of non-fatal reinfarction (17.3% vs 25.4%; HR 0.76, 95%CI 0.52–1.13;p = 0.18), non-fatal ischemic stroke (9.5% vs 3.7%; HR 1.79, 95%CI 0.87–3.70;p = 0.12), and all-cause mortality (14.1% vs 20.7%, HR 0.73, 95%CI 0.43–1.25;p = 0.26) were not significantly different in the two groups. The rate of rehospitalisation for coronary revascularisation was lower among the MINOCA patients (6.7% vs 27.7%; HR 0.27, 95% CI 0.15–0.47;p < 0.001). Conclusions: MINOCA is frequent and not benign in patients with early-onset MI. Although there is a lower likelihood of CV death,the long-term risk of MACE and overall mortality is not significantly different from that of MICAD patients

Long-term outcomes of early-onset myocardial infarction with non-obstructive coronary artery disease (MINOCA)

Background: Acute myocardial infarction with non-obstructive coronary artery disease (MINOCA) is frequent in patients experiencing an early-onset MI, but data concerning its long-term prognosis are limited and conflicting. Methods: The Italian Genetic Study on Early-onset MI enrolled 2000 patients experiencing a first MI before the age of 45 years, and had a median follow-up of 19.9 years. The composite primary endpoint was cardiovascular (CV) death, non-fatal MI, and non-fatal stroke (MACE); the secondary endpoint was rehospitalisation for coro-nary revascularisation. Results: MINOCA occurred in 317 patients (15.9%) and, during the follow-up, there was no significant difference in MACE rates between them and the patients with obstructive coronary artery disease (MICAD: 27.8% vs 37.5%; adjusted hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.57-1.09;p = 0.15). The CV death rate was lower in the MINOCA group (4.2% vs 8.4%, HR 0.26, 95%CI 0.08-0.86;p = 0.03), whereas the rates of non-fatal reinfarction (17.3% vs 25.4%; HR 0.76, 95%CI 0.52-1.13;p = 0.18), non-fatal ischemic stroke (9.5% vs 3.7%; HR 1.79, 95%CI 0.87-3.70;p = 0.12), and all-cause mortality (14.1% vs 20.7%, HR 0.73, 95%CI 0.43-1.25;p = 0.26) were not significantly different in the two groups. The rate of rehospitalisation for coronary revascular-isation was lower among the MINOCA patients (6.7% vs 27.7%; HR 0.27, 95% CI 0.15-0.47;p < 0.001). Conclusions: MINOCA is frequent and not benign in patients with early-onset MI. Although there is a lower likelihood of CV death,the long-term risk of MACE and overall mortality is not significantly different from that of MICAD patients

Antithrombotic strategies in the catheterization laboratory for patients with acute coronary syndromes undergoing percutaneous coronary interventions: Insights from the EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in Italian cardiac care units Registry

Aims: In the last decades, several new therapies have emerged for the treatment of acute coronary syndromes (ACS). We sought to describe real-world patterns of use of antithrombotic treatments in the catheterization laboratory for ACS patients undergoing percutaneous coronary interventions (PCI). Methods: EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in Italian cardiac care units was a nationwide, prospective registry aimed to evaluate antithrombotic strategies employed in ACS patients in Italy. Results: Over a 3-week period, a total of 2585 consecutive ACS patients have been enrolled in 203 cardiac care units across Italy. Among these patients, 1755 underwent PCI (923 with ST-elevation myocardial infarction and 832 with non-ST-elevation ACS). In the catheterization laboratory, unfractioned heparin was the most used antithrombotic drug in both ST-elevation myocardial infarction (64.7%) and non-ST-elevation ACS (77.5%) undergoing PCI and, as aspirin, bivalirudin and glycoprotein IIb/IIIa inhibitors (GPIs) more frequently employed before or during PCI compared with the postprocedural period. Any crossover of heparin therapy occurred in 36.0% of cases, whereas switching from one P2Y12 inhibitor to another occurred in 3.7% of patients. Multivariable analysis yielded several independent predictors of GPIs and of bivalirudin use in the catheterization laboratory, mainly related to clinical presentation, PCI complexity and presence of complications during the procedure. Conclusion: In our contemporary, nationwide, all-comers cohort of ACS patients undergoing PCI, antithrombotic therapies were commonly initiated before the catheterization laboratory. In the periprocedural period, the most frequently employed drugs were unfractioned heparin, leading to a high rate of crossover, followed by GPIs and bivalirudin, mainly used during complex PCI