Red blood cell distribution width as a novel prognostic marker after myocardial revascularization or cardiac valve surgery

The red blood cell distribution width (RDW) measures the variability in the size of circulating erythrocytes. Previous studies suggested a powerful correlation between RDW obtained from a standard complete blood count and cardiovascular diseases in both primary and secondary cardiovascular prevention. The current study aimed to evaluate the prognostic role of RDW in patients undergoing cardiac rehabilitation after myocardial revascularization and/or cardiac valve surgery. The study included 1.031 patients with available RDW levels, prospectively followed for a mean of 4.5 +/- 3.5 years. The mean age was 68 +/- 12 years, the mean RDW was 14.7 +/- 1.8%; 492 patients (48%) underwent cardiac rehabilitation after myocardial revascularization, 371 (36%) after cardiac valve surgery, 102 (10%) after valve-plus-coronary artery by-pass graft surgery, 66 (6%) for other indications. Kaplan-Meier analysis and Cox hazard analysis were used to associate RDW with mortality. Kaplan-Meier analysis demonstrated worse survival curves free from overall (log-rank p<0.0001) and cardiovascular (log-rank p<0.0001) mortality in the highest RDW tertile. Cox analysis showed RDW levels correlated significantly with the probability of overall (HR 1.26; 95% CI 1.19-1.32; p<0.001) and cardiovascular (HR 1.31; 95% CI 1.23-1.40; p<0.001) mortality. After multiple adjustments for cardiovascular risk factors, hemoglobin, hematocrit, C-reactive protein, microalbuminuria, atrial fibrillation, glomerular filtration rate,left ventricular ejection fraction and number of exercise training sessions attended, the increased risk of overall (HR 1.10; 95% CI 1.01-1.27; p=0.039) and cardiovascular (HR 1.13; 95% CI 1.01-1.34; p=0.036)mortality with increasing RDW values remained significant. The RDW represents an independent predictor of overall and cardiovascular mortality in secondary cardiovascular prevention patients undergoing cardiac rehabilitation

Anxiety disorders and stressful events in Takotsubo syndrome

Background: Anxiety disorders are more common in Takotsubo syndrome (TS) than in acute coronary syndrome patients. The aim of this study was to investigate whether pre-existing anxiety disorders predispose to TS triggered by exclusively emotional stressful events.Methods: Triggering events were compared in 58 TS patients with and without pre-existing anxiety disorders; clinical, electrocardiographic and echocardiographic data were also collected.Results: Thirty-one (53%) patients had a previous history of anxiety disorders. The exclusively emotional stressful event-rate was higher in TS patients with pre-existing anxiety disorder (74% vs. 30%, p = 0.001), while TS caused by an undetermined trigger were significantly higher in patients without anxiety disorders (33% vs. 10%, p = 0.027). Moreover, in TS patients without a previous history of anxiety disorders, a trend of higher prevalence of physical events was found (16% vs. 37%, p = 0.07).Conclusions: In patients with pre-existing anxiety disorders, TS was predominantly triggered by exclusively emotional stressful events, thereby suggesting a possible relationship between anxiety and emotional cardiac frailty in TS patients

anxiety disorders and stressful events in takotsubo syndrome

Background: Anxiety disorders are more common in Takotsubo syndrome (TS) than in acute coronary syndrome patients. The aim of this study was to investigate whether pre-existing anxiety disorders predispose to TS triggered by exclusively emotional stressful events. Methods: Triggering events were compared in 58 TS patients with and without pre-existing anxiety disorders; clinical, electrocardiographic and echocardiographic data were also collected. Results: Thirty-one (53%) patients had a previous history of anxiety disorders. The exclusively emotional stressful event-rate was higher in TS patients with pre-existing anxiety disorder (74% vs. 30%, p = 0.001), while TS caused by an undetermined trigger were significantly higher in patients without anxiety disorders (33% vs. 10%, p = 0.027). Moreover, in TS patients without a previous history of anxiety disorders, a trend of higher prevalence of physical events was found (16% vs. 37%, p = 0.07). Conclusions: In patients with pre-existing anxiety disorders, TS was predominantly triggered by exclusively emotional stressful events, thereby suggesting a possible relationship between anxiety and emotional cardiac frailty in TS patients

Reintegro lavorativo del paziente cardiopatico e ruolo del test cardiopolmonare in laboratorio e durante attività lavorativa: esperienze di uno studio pilota.

Il 45% delle sindromi coronariche acute si verifica in età lavorativa, e spesso il reintegro all’attività è possibile nel 70% dei pazienti. Il test cardiopolmonare in laboratorio è lo strumento principale per la valutazione della capacità funzionale; l’utilizzo di un test cardiopolmonare portatile, derivato dall’utilizzo in Medicina Sportiva, potrebbe essere impiegato nella registrazione del consumo lavorativo. Lo studio ha in prima istanza valutato con una survey il reintegro lavorativo in Emilia-Romagna (156 pazienti dimessi da 12 mesi dall’Ospedale di Piacenza), evidenziando come circa solo il 70% dei pazienti non torni all’attività lavorativa; tali pazienti erano prevalentemente lavoratori con attività di tipo manuale e con frazione di eiezione ridotta. Successivamente sono stati arruolati 59 pazienti con recente sindrome coronarica acuta e lavoro di tipo manuale e sottoposti a test cardiopolmonare in laboratorio; l’utilizzo del test per la valutazione della capacità funzionale ha mostrato un significativo miglioramento del reintegro lavorativo a distanza di 12 mesi rispetto ai dati della survey e della letteratura (86%Vs 70% - p = 0.03). Per la terza parte dello studio sono stati arruolati 28 pazienti con recente sindrome coronarica acuta e lavoro ad alto dispendio energetico (METs > 3); sono stati a test cardiopolmonare in laboratorio e a test cardiopolmonare portatile durante attività lavorativa (onsite), con una registrazione di 60-80 minuti. Il test è stato eseguito senza complicanze in tutti i pazienti ed è riuscito a misurare in modo specifico il consumo individuale delle singole mansioni lavorative. I consumi sono stati in media elevati (consumo medio lavorativo V02/V02 max laboratorio 57% ± 12), con raggiungimento della soglia anerobica (R medio 0,98 ±1); il test ha permesso una individualizzazione delle mansioni che ha portato ad un reintegro lavorativo a distanza di 12 mesi del 96%, significativamente maggiore dei dati in letteratura e delle due parti precedenti dello studio (p<0.01

Predictive role of P-wave axis abnormalities in secondary cardiovascular prevention

Background Abnormal P-wave axis has been correlated with an increased risk of all-cause and cardiovascular mortality in a general population. We aimed to evaluate the prognostic role of abnormal P-wave axis in patients undergoing myocardial revascularisation or cardiac valve surgery. Methods We considered data of 810 patients with available P-wave axis measure from a prospective monocentric registry of patients undergoing cardiovascular rehabilitation. A total of 436 patients (54%) underwent myocardial revascularisation, 253 (31%) valve surgery, 71 (9%) combined valve and coronary artery bypass graft surgery and 50 (6%) cardiac surgery for other cardiovascular disease. Mean follow-up was 47 ± 27 months. Results Over the whole group, P-wave axis was 43.8° ± 27.5° and an abnormal P-wave axis was found in 94 patients (12%). The risk of overall (hazard ratio (HR) 2.5, 95% confidence interval (CI) 1.6-4.0, P < 0.001) and cardiovascular mortality (HR 2.9, 95% CI 1.5-5.8, P = 0.002) was significantly higher in patients with abnormal P-wave axis even after adjustment for age, other electrocardiographic variables (PR, QRS, QTc intervals), left ventricular ejection fraction and left atrial volume index. After dividing the population according to the type of disease, patients with abnormal P-wave axis and ischaemic heart disease had 3.9-fold higher risk of cardiovascular mortality (HR 3.9, 95% CI 1.3-12.1, P = 0.017), while a 2.2-fold higher risk of cardiovascular mortality (HR 3.6, 95% CI 1.3-10.1, P = 0.015) was found in those with cardiac valve disease. Conclusion An abnormal P-wave axis represents an independent predictor of both overall and cardiovascular mortality in patients undergoing myocardial revascularisation or cardiac valve surgery

Prognostic value of frontal QRS-T angle in patients undergoing myocardial revascularization or cardiac valve surgery

Background: An abnormal frontal QRS-T angle (fQRSTa) is associated with increased risk of death in primary and secondary cardiovascular prevention. The aim of this study was to evaluate the fQRSTa prognostic role in patients undergoing myocardial revascularization and/or cardiac valve surgery. Methods: We enrolled and prospectively followed for 48 ± 26 months 939 subjects with available QRS and T axis data; mean age was 68 ± 12 years, 449 patients (48%) underwent myocardial revascularization, 333 (35%) cardiac valve surgery, 94 (10%) valve plus bypass graft surgery and 63 (7%) cardiac surgery for other cardiovascular (CV) diseases. The ECG variables were collected at the end of the cardiac rehabilitation program and fQRSTa was considered normal if 120° borderline otherwise. Endpoints were overall and CV mortality. Results: The fQRSTa was normal in 333 patients (36%), borderline in 285 (30%) and abnormal in 321 (34%). Overall (p = 0.012) and cardiovascular (p = 0.007) mortality were significantly higher in patients with abnormal fQRSTa even after adjusting separately for gender, PR-, QTc- intervals, presence of right or left bundle branch block and left atrial volume index. The predictive value was confirmed in patients with stable coronary artery disease (SCAD), not in patients with acute coronary syndrome or valve disease. SCAD patients with abnormal both fQRSTa and QRS axis had higher risk of overall (hazard ratio = 2.9, p < 0.0001) and CV (hazard ratio = 4.4, p < 0.0001) mortality compared with SCAD patients with normal fQRSTa, even after multivariate adjustment for age, gender, ECG intervals, left-ventricle ejection fraction and mass index. Conclusions: In SCAD patients undergoing myocardial revascularization, abnormal fQRSTa is independent predictor of overall and CV mortality

In-hospital day-by-day systolic blood pressure variability during rehabilitation: a marker of adverse outcome in secondary prevention after myocardial revascularization

Objective: Although it is known that increased visit-to-visit or home day-by-day variability of blood pressure (BP), independently of its average value, results in an increased risk of cardiovascular events, the prognostic value of in-hospital day-by-day BP variability in secondary cardiovascular prevention has not yet been established. Methods: We studied 1440 consecutive cardiac patients during a cardiovascular rehabilitation program of about 12 days after coronary artery bypass graft (CABG) and/or valve surgery. We measured auscultatory BP at the patient bed in each rehabilitation day twice, in the morning and the afternoon. We correlated SBP variability assessed as standard deviation (SBP-SD) and coefficient of variation (SBP-CoV) of the daily measures with overall mortality, cardiovascular mortality and major adverse cardiocerebrovascular events (MACCEs) after a mean follow-up of 49 months by Cox hazard analysis. Results: In our patients (age 68 +/- 11years, 61% hypertensive patients) the ranges of SBP-SD tertiles were: 4.1-9.1, 9.2-11.5 and 11.6-24.5 mmHg. Fifty-five percent of the patients underwent CABG, 33% underwent valve surgery, 12% both CABG and valve surgery. In CABG patients, the highest SBP-SD tertile showed the highest overall mortality, cardiovascular mortality and MACCEs (P &lt; 0.01). Results remained significant after multivariate analysis adjusting for age, sex, mean SBP, BMI, hypertension, hyperlipidaemia, and diabetes. No association between SBP-SD and mortality or MACCEs was found in valve surgery patients. Conclusion: In-hospital day-by-day SBP variability predicts mortality and MACCEs in CABG patients, possibly representing a target during rehabilitation and treatment in secondary cardiovascular prevention

Serum uric acid level predicts adverse outcomes after myocardial revascularization or cardiac valve surgery

Background High levels of serum uric acid have been associated with adverse outcomes in cardiovascular diseases such as myocardial infarction and heart failure. The aim of the current study was to evaluate the prognostic role of serum uric acid levels in patients undergoing cardiac rehabilitation after myocardial revascularization and/or cardiac valve surgery. Design We performed an observational prospective cohort study. Methods The study included 1440 patients with available serum uric acid levels, prospectively followed for 50 ± 17 months. Mean age was 67 ± 11 years; 781 patients (54%) underwent myocardial revascularization, 474 (33%) cardiac valve surgery and 185 (13%) valve-plus-coronary artery by-pass graft surgery. The primary endpoints were overall and cardiovascular mortality while secondary end-points were combined major adverse cardiac and cerebrovascular events. Results Serum uric acid level mean values were 286 ± 95 µmol/l and elevated serum uric acid levels (≥360 µmol/l or 6 mg/dl) were found in 275 patients (19%). Overall mortality (hazard ratio = 2.1; 95% confidence interval: 1.5-3.0; p < 0.001), cardiovascular mortality (hazard ratio = 2.0; 95% confidence interval: 1.2-3.2; p = 0.004) and major adverse cardiac and cerebrovascular events rate (hazard ratio = 1.5; 95% confidence interval: 1.0-2.0; p = 0.019) were significantly higher in patients with elevated serum uric acid levels, even after adjustment for age, gender, arterial hypertension, diabetes, glomerular filtration rate, atrial fibrillation and medical therapy. Moreover, strong positive correlations between serum uric acid level and probability of overall mortality ( p < 0.001), cardiovascular mortality ( p < 0.001) and major adverse cardiac and cerebrovascular events ( p = 0.003) were found. Conclusions Serum uric acid levels predict mortality and adverse cardiovascular outcome in patients undergoing myocardial revascularization and/or cardiac valve surgery even after the adjustment for age, gender, arterial hypertension, diabetes, glomerular filtration rate and medical therapy

An Impairment in Resting and Exertional Breathing Pattern May Occur in Long-Covid Patients with Normal Spirometry and Unexplained Dyspnoea

Abstract Background. Long-term sequelae, called Long-COVID (LC), may occur after SARS-CoV-2 infection, being an unexplained dyspnoea the most common symptom. The breathing pattern (BP) analysis by means of the ratio of the inspiratory time (TI) during the tidal volume (VT) to the total breath duration (TI/TTOT) and by the VT/TI ratio could further elucidate the underlying mechanisms of the unexplained dyspnoea in LC patients. Therefore, we analysed TI/TTOT and VT/TI at rest and at max- imal exercise in LC patients with unexplained dyspnoea compared to a control group. Methods. In this cross-sectional study, we enrolled LC patients with normal spirometry, who were required to perform a cardio-pulmonary exercise test (CPET) for unexplained dyspnoea, lasting at least 3 months after SARS CoV-2 infection. As a control group, we recruited healthy age and sex- matched subjects (HS). All subjects performed spirometry and CPET according to standardized pro- cedures. Results. We found that 42 LC patients (23 females) had lower maximal exercise capacity both in terms of maximal O2 uptake (VO2peak) and workload, compared to 40 HS (22 females) (p&lt;0.05). LC patients also showed significantly higher values of TI/TTOT at rest and at peak and lower values in VT/TI at peak (p&lt;0.05). In LC patients, values of TI/TTOT at peak were significantly related to 30 ∆PETCO2, i.e. the end-tidal pressure of CO2 at peak minus the one at rest (p&lt;0.05). When LC patients were categorized by the TI/TTOT 0.38 cut-off value, patients with TI/TTOT &gt; 0.38 showed lower values in VO2peak and maximal workload and greater values in the ventilation/CO2 linear relationship slope than patients with TI/TTOT ≤ 0.38 (p&lt;0.05). Conclusions. Our findings show that LC patients with unexplained dyspnoea have resting and ex- ertional BP more prone to diaphragmatic fatigue and less effective than controls. Pulmonary reha- bilitation might be useful to revert this unpleasant conditio