Quality of life in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: tools and evidence

: Aortic stenosis is the most prevalent valvular heart disease requiring intervention, especially in the elderly population. Surgical aortic valve replacement and transcatheter aortic valve implantation (TAVI) are well established treatment options for symptomatic patients with severe aortic stenosis, as they provide a significant survival benefit. Aortic stenosis may have an important impact on patients' quality of life (QoL). However, advanced age, comorbidities and frailty may limit the beneficial effect of aortic stenosis interventions in terms of QoL. Current guidelines mention the importance of frailty and avoiding the futility of interventions, but lack specific indications about decision-making. Also, there are limited data on how to specifically assess QoL in aortic stenosis patients since the most used questionnaires are validated in different populations (i.e. heart failure). The aim of this review is to summarize all the available tools for QoL assessment in patients with aortic stenosis; to report current evidence on the impact of TAVI on QoL; and to discuss the role of frailty and comorbidities in this setting

Coronary microvascular dysfunction. An update

Several studies in the last years have shown that a dysfunction of coronary microcirculation may be responsible for abnormalities in coronary blood flow and some clinical pictures. Coronary microvascular dysfunction, in absence of other coronary artery abnormalities, can cause anginal symptoms, resulting in a condition named microvascular angina (MVA). MVA can occur in a chronic form, predominantly related to effort (stable MVA), more frequently referred as cardiac syndrome X, or in an acute form, most frequently ensuing at rest, which simulates an acute coronary syndrome (unstable MVA). The main abnormalities characterizing these two forms of MVA consist of an impaired vasodilation and an increased vasoconstriction of small resistive coronary arteries, respectively. The mechanisms responsible for stable MVA are still unclear, but seem to include, together with the known traditional cardiovascular risk factors, an abnormally increased cardiac adrenergic activity. The prognosis of stable MVA is good, but some patients have progressive worsening of symptoms. Clinical outcome of patients with unstable MVA is substantially unknown, as there are no specific studies about this population. Treatment of stable MVA includes traditional anti-ischemic drugs as first step; in case of persisting symptoms several other drugs have been proposed, including xanthine derivatives, ACE-inhibitors, statins and, in women, estrogens. Severe forms of intense constriction (or spasm) of small coronary arteries may cause transmural myocardial ischemia, as the microvascular form of variant angina and the tako-tsubo syndrome

Effect of shift work on endothelial function in young cardiology trainees

Background: Long-term shift work (SW) is associated with an increase in cardiovascular disease (CVD). Previous studies have shown that prolonged SW is associated with endothelial dysfunction, suggesting that this abnormality may contribute to the SW-related increase in cardiovascular risk. The immediate effect of SW on endothelial function in healthy subjects, however, is unknown. Design: We studied endothelial function and endothelium-independent function in 20 healthy specialty trainees in cardiology at our Institute, without any cardiovascular risk factor (27.3\ub11.9 years, nine males), at two different times: (1) after a working night (WN), and (2) after a restful night (RN). The two test sessions were performed in a random sequence. Methods: Endothelial function was assessed by measuring brachial artery dilation during post-ischaemic forearm hyperaemia (flow-mediated dilation, FMD). Endothelium-independent function in response to 25 \ub5g of sublingual glyceryl trinitrate (nitrate-mediated dilation, NMD) was also assessed. Results: FMD was 8.02 \ub1 1.4% and 8.56 \ub1 1.7% after WN and RN, respectively (p = 0.025), whereas NMD was 10.5 \ub1 2.1% and 10.4 \ub1 2.0% after WN and RN, respectively (p = 0.48). The difference in FMD between WN and RN was not influenced by the numbers of hours slept during WN (4 hours) and by the duration of involvement of specialty trainees in nocturnal work (12 months). Conclusions: Our study shows that in healthy medical residents, without any cardiovascular risk factor, FMD is slightly impaired after WN compared to RN. Disruption of physiological circadian neuro-humoral rhythm is likely to be responsible for this adverse vascular effect

LA DIMISSIONE: DAL DOCUMENTO DI CONSENSO ANMCO ALLA REALTA’. LA DIMISSIONE COME PROCESSO

La gestione della dimissione ospedaliera è uno dei primi passi verso il miglioramento della qualità della prestazione sanitaria erogata. La dimissione non deve essere vista non come un evento isolato, ma come un processo pianificato, attivato al momento del ricovero o anche prima nel caso di ricoveri programmati, che deve iniziare con un processo di valutazione personalizzato immediato e comunque entro le 24 h., condiviso col malato e/o col caregiver come partner eguali, guidato da un coordinatore ed in sinergia con un team multidisciplinare, col quale definire obiettivi finalizzati al recupero fisico, funzionale e all’indipendenza del paziente in un continuum di cure e servizi, esplicitandone poi la destinazione post-ospedaliera con l’organizzazione di servizi post-ricovero che assicurino una rapida, sicura ed agevole transizione dall’ospedale ad altro ambiente di assistenza

Prevalence and clinical correlates of early repolarization and J wave in a large cohort of subjects without overt heart disease

Background: Recent studies have suggested that early repolarization (ER) is associated with increased risk of ventricular tachyarrhythmias. Early repolarization in these studies, however, was defined as J-wave (terminal QRS slurring or notching) or J-point elevation rather than typical ST-segment elevation (STE). Prevalence and characteristics of these different findings in the general population are poorly known. In this study, we assessed prevalence and correlates of STE typical of ER and of J wave in a large population of noncardiac subjects. Methods: We prospectively collected electrocardiograms of 4176 consecutive subjects without heart disease at our hospital. Results: Early repolarization was found in 84 subjects (2.0%) and J wave in 663 (15.9%). Among ER subjects, a J wave was present in 60 (71.4%). Variables independently associated with both ER and J wave included young age, male sex, and lower heart rate. There was no increased history of symptoms (palpitations and syncope) possibly related to arrhythmias in STE or J-wave subjects. Conclusions: Typical ER pattern and J wave are common in noncardiac subjects, particularly in young people, and are not associated with symptoms potentially related to arrhythmias

prognostic role of heart rate variability in patients with ST-segment elevation acute myocardial infarction treated by primary angioplasty

The aim of our study was to assess the prognostic value of heart rate variability (HRV) in ST-segment elevation acute myocardial infarction (STEMI) patients treated by percutaneous transluminal coronary angioplasty (PTCA) and optimal medical therapy

Association of heart rate variability with arrhythmic events in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is associated with an increased risk of sudden cardiac death (SCD). Risk stratification of ARVC/D patients, however, remains an unresolved issue. In this study we investigated whether heart rate variability (HRV) can be helpful in identifying ARVC/D patients with increased risk of arrhythmic events. METHODS AND RESULts: We studied 30 consecutive patients (17 males; 45.4 \ub1 18 years) with ARVC/D, diagnosed according to guideline criteria; 15 patients (50%) had received an implantable cardioverter defibrillator (ICD) for primary SCD prevention. HRV was assessed on 24-h ECG Holter monitoring. The primary endpoint was the occurrence of major arrhythmic events (SCD, sustained ventricular tachycardia (VT), ICD therapy for sustained VT or ventricular fibrillation (VF)). During the follow-up period (19 \ub1 7 months), no deaths occurred, but 5 patients (17%) experienced arrhythmic events (4 VTs and 1 VF, all in the ICD group). All HRV parameters were significantly lower in patients with, compared with those without, arrhythmic events. Low-frequency amplitude was the most significant HRV variable associated with arrhythmic events in univariate Cox regression analysis (P=0.017), and was the only significant predictor of arrhythmic events in multivariable regression analysis (hazard ratio 0.88, P=0.047), together with unexplained syncope (hazard ratio 16.1, P=0.039). CONCLUSIONS: Our data show that among ARVC/D patients HRV analysis might be helpful in identifying those with increased risk of major arrhythmic event

Use of T-wave alternans in identifying patients with coronary artery disease

AimsMicrovolt T-wave alternans (MTWA) has been found to predict fatal events in patients with coronary artery disease (CAD). In a previous study, we found that MTWA values are higher in patients with CAD, compared with apparently healthy individuals. In this study, we assessed the relation between CAD and MTWA in patients with a diagnosis based on coronary angiography results.MethodsWe studied 98 consecutive patients undergoing coronary angiography for suspected CAD. All patients underwent a maximal exercise stress test (EST), and MTWA was measured in the precordial ECG leads. Patients were divided into three groups: 40 patients without any significant (>50%) stenosis (group 1); 47 patients with significant stenosis (group 2); and 11 patients with a previous percutaneous coronary intervention (PCI) who had no evidence of restenosis (group 3). EST was repeated after 1 month in 24 group 2 patients who underwent PCI and in 17 group 1 patients.ResultsMTWA was significantly higher in group 2 (58.724V) compared with group 1 (34.2 +/- 15 V, P<0.01) and group 3 (43.2 +/- 24V, P<0.05). An MTWA greater than 60V had 95% specificity and 82% positive predictive value for obstructive CAD. At 1-month follow-up, MTWA decreased significantly in patients treated with PCI (from 61.3 +/- 22 to 43.5 +/- 17V; P<0.001), but not in group 1 patients (from 50.5 +/- 22 to 44.3 +/- 19 V, P=0.19).ConclusionMTWA is increased in patients with obstructive CAD and is reduced by coronary revascularization. An assessment of MTWA can be helpful in identifying which patients with suspected CAD are likely to show obstructive CAD on angiography

Effect of remote ischemic preconditioning on platelet activation and reactivity induced by ablation for atrial fibrillation

Radiofrequency ablation of atrial fibrillation has been associated with some risk of thromboembolic events. Previous studies showed that preventive short episodes of forearm ischemia (remote ischemic preconditioning [IPC]) reduce exercise-induced platelet reactivity. In this study, we assessed whether remote IPC has any effect on platelet activation induced by radiofrequency ablation of atrial fibrillation