Barriers to cardiac rehabilitation access of older heart failure patients and strategies for better implementation

In heart failure (HF), cardiac rehabilitation (CR) may reduce decompensations, hospitalization, and ultimately mortality in long term. Many studies over the past decade have demonstrated that aerobic exercise training is effective and safe in stable patients with HF. Exercise CR resulted in a clinically important improvement in the QOL. Several clinical and psychosocial factors are associated with decreased participation in CR programs of elderly HF patients, such as perception of exercise as tiring or painful, comorbidities, lack of physician encouragement, and opinion that CR will not improve their health status. Besides low functional capacity, and chronic deconditioning may also deter patients from participating in CR programs.  Recent data suggest that current smoking, a BMI ≥30 kg/m2, diabetes mellitus, and cognitive dysfunction are associated with failure to enroll in outpatient CR in older age group. Moreover the lack of availability of CR facilities or the absence of financial refunds for enrolment of CHF patients in cardiac rehabilitation programs can play a crucial role. Many of this factors are modifiable through patient education and self care strategy instruction, health providers sensibilization, and implementing economic measures in order to make CR affordable.  Riassunto Numerosi studi hanno dimostrato come la riabilitazione cardiovascolare (RC) con esercizio aerobico sia risultato efficace e sicuro nei pazienti con scompenso cardiaco (SC), nel ridurre ospedalizzazioni, mortalità ed indurre un miglioramento della qualità di vita. Tuttavia numerosi fattori clinici e psicosociali, come la bassa capacità funzionale, le comorbidità, la percezione dell’esercizio fisico come noioso o doloroso, sono associati a ridotta partecipazione a RC da parte di pazienti anziani con SC.  Inoltre dati recenti mostrano come l’abitudine tabagica, un BMI ≥30 kg/m2, il diabete mellito ed il deterioramento cognitivo siano associati con il mancato arruolamento di pazienti anziani in programmi di RC.  In aggiunta la mancanza di disponibilità di strutture per la RC o l'assenza di rimborsi finanziari per l'iscrizione dei pazienti con SC in programmi di riabilitazione cardiaca possono svolgere un ruolo cruciale. Molti di questi fattori risultano modificabili attraverso programmi di educazione sanitaria del paziente, sensibilizzazione del personale sanitario ed attraverso un’implementazione delle misure economiche al fine di rendere accessibile la RC

Cardiac rehabilitation is safe and effective also in the elderly, but don't forget about drugs!

In the setting of heart failure (HF) pharmacotherapy demonstrates a quantifiable improvement in exercise tolerance also in HF with preserved ejection fraction (HFpEF). For patients with HFpEF, often older, with higher prevalence of hypertension, diabetes mellitus, atrial fibrillation and other comorbidities, endpoints such as quality of life and functional capacity may be more clinically relevant. However several study show as the use of ACE-I and B-blocker were lesser than expected. Beta-blocker therapy is the keystone of pharmacotherapy of HF patients and exercise training is the essential core of rehabilitation programs, it is important to elucidate the relationship between these therapies. Exercise training improves the clinical status of HF, improving left ventricular ejection fraction and improving quality of life, but it is possible that b-blocker may attenuate exercise training adaptations. Despite this, possible adverse b-blocker effects are just presumed and not confirmed by published randomized clinical trials. Metanalysis suggests that b-blocker compared with placebo enhances improvements in cardiorespiratory performance in exercise training intervention. Despite these evidences, prescription of gold standard therapy and adherence are still suboptimal and should be a priority goal for all CR program.  Riassunto Nell’ambito dei pazienti con scompenso cardiaco (SC) la terapia farmacologica permette di ottenere un miglioramento della tolleranza all’esercizio fisico anche nei pazienti con frazione di eiezione conservata. Questi pazienti spesso più anziani, con una più elevata incidenza di ipertensione, diabete mellito, fibrillazione atriale e comorbidità, endpoints quali qualità della vita e capacità funzionale dovrebbero risultare più clinicamente rilevanti. Tuttavia molti studi mostrano come l’utilizzo di ACE-I e Beta-bloccanti sia minore di quanto ci si aspetterebbe. Va evidenziato comunque come la terapia beta-bloccante costituisca il cardine della terapia farmacologica dello SC e come l’esercizio fisico sia il cuore dei programmi di riabilitazione, pertanto è importante valutarne le possibili interazioni. L’esercizio fisico migliora lo stato clinico dei pazienti con SC, ma è possibile che la terapia con Beta-bloccanti possa attenuare questi vantaggi. Tale assunto tuttavia rimane solo presunto e non confermato dai risultati dei trial pubblicati. Infatti una metanalisi suggerisce che la terapia Beta-bloccante, confrontata con il placebo, migliori la performance cardiorespiratoria nel gruppo sottoposto ad esercizio fisico. Malgrado tali evidenze, la prescrizione di una terapia medica ottimale e l’aderenza alla stessa rimangono ancora non ottimali e dovrebbe rappresentare un obiettivo primario per tutti i programmi di riabilitazione.

Effects of omega-loop bypass on esophagogastric junction function

BACKGROUND: At present, no objective data are available on the effect of omega-loop gastric bypass (OGB) on gastroesophageal junction and reflux. OBJECTIVES: To evaluate the possible effects of OGB on esophageal motor function and a possible increase in gastroesophageal reflux. SETTING: University Hospital, Italy; Public Hospital, Italy. METHODS: Patients underwent clinical assessment for reflux symptoms, and endoscopy plus high-resolution impedance manometry (HRiM) and 24-hour pH-impedance monitoring (MII-pH) before and 1 year after OGB. A group of obese patients who underwent sleeve gastrectomy (SG) were included as the control population. RESULTS: Fifteen OGB patients were included in the study. After surgery, none of the patients reported de novo heartburn or regurgitation. At endoscopic follow-up 1 year after surgery, esophagitis was absent in all patients and no biliary gastritis or presence of bile was recorded. Manometric features and patterns did not vary significantly after surgery, whereas intragastric pressures (IGP) and gastroesophageal pressure gradient (GEPG) statistically diminished (from a median of 15 to 9.5, P<.01, and from 10.3 to 6.4, P<.01, respectively) after OGB. In contrast, SG induced a significant elevation in both parameters (from a median of 14.8 to 18.8, P<.01, and from 10.1 to 13.1, P<.01, respectively). A dramatic decrease in the number of reflux events (from a median of 41 to 7; P<.01) was observed after OGB, whereas in patients who underwent SG a significant increase in esophageal acid exposure and number of reflux episodes (from a median of 33 to 53; P<.01) was noted. CONCLUSIONS: In contrast to SG, OGB did not compromise the gastroesophageal junction function and did not increase gastroesophageal reflux, which was explained by the lack of increased IGP and in GEPG as assessed by HRiM

Atrial fibrillation management in older heart failure patients: a complex clinical problem

BackgroundAtrial fibrillation (AF) and heart failure (HF), two problems of growing prevalence as a consequence of the ageing population, are associated with high morbidity, mortality, and healthcare costs. AF and HF also share common risk factors and pathophysiologic processes such as hypertension, diabetes mellitus, ischemic heart disease, and valvular heart disease often occur together. Although elderly patients with both HF and AF are affected by worse symptoms and poorer prognosis, there is a paucity of data on appropriate management of these patients.MethodsPubMed was searched for studies on AF and older patients using the terms atrial fibrillation, elderly, heart failure, cognitive impairment, frailty, stroke, and anticoagulants.ResultsThe clinical picture of HF patients with AF is complex and heterogeneous with a higher prevalence of frailty, cognitive impairment, and disability. Because of the association of mental and physical impairment to non-administration of oral anticoagulants (OACs), screening for these simple variables in clinical practice may allow better strategies for intervention in this high-risk population. Since novel direct OACs (NOACs) have a more favorable risk-benefit profile, they may be preferable to vitamin K antagonists (VKAs) in many frail elderly patients, especially those at higher risk of falls. Moreover, NOACs are simple to administer and monitor and may be associated with better adherence and safety in patients with cognitive deficits and mobility impairments.ConclusionsLarge multicenter longitudinal studies are needed to examine the effects of VKAs and NOACs on long-term cognitive function and frailty; future studies should include geriatric conditions

Other Bariatric Procedures

Roux-en-Y Gastric Bypass on Vertical Banded Gastroplasty (RYGB-on-VBG) , is a technical change of the standard Roux-en-Y Gastric Bypass (RYGB) with the goal to obtain a gastric bypass where it was possible to make the traditional endoscopy and x-ray study of the excluded stomach, conceived in 2002 after a pilot study performed with a functional gastric bypass for the same objective. In the midterm the RYGB-on-VBG procedure reached similar outcomes as standard techniques of gastric bypass, both in terms of weight loss and incidence of surgical complications, and achieved the same good results when performed in other bariatric surgery centres proving therefore to be operator-independent, while enabled traditional diagnostic evaluation of the bypassed stomach and biliary tract. Progressively, outcomes of RYGB-on-VBG have been presented at international meetings and published , also when adopted as conversion after failures of gastric restrictive procedures. This paper reports the long term results of patients who underwent RYGB-on-VBG in a single centre, with up to 12 years clinical follow-up

Manometric pattern progression in esophageal achalasia in the era of high-resolution manometry

none9Esophageal manometry represents the gold standard technique for the diagnosis of esophageal achalasia because it can detect both the lack of lower esophageal sphincter (LES) relaxation and abnormal peristalsis. From the manometric standpoint, cases of achalasia can be segregated on the grounds of three clinically relevant patterns according to the Chicago Classification v3.0. It is currently unclear whether they represent distinct entities or are part of a disease continuum with the possibility of transition from a pattern to another one. The four cases described in the present report could provide further insights on this topic because the manometric pattern changed from type III to type II in all patients-without any invasive treatment. The cases described here support the hypothesis that the different manometric patterns of achalasia represent different stages in the evolution of the same disease, type III being the early stage, type II an intermediate stage, and type I probably the end stage of achalasia.mixedSalvador, Renato; Costantini, Mario; Tolone, Salvatore; Familiari, Pietro; Galliani, Ermenegildo; Germanà, Bastianello; Savarino, Edoardo; Merigliano, Stefano; Valmasoni, MicheleSalvador, Renato; Costantini, Mario; Tolone, Salvatore; Familiari, Pietro; Galliani, Ermenegildo; Germanà, Bastianello; Savarino, Edoardo; Merigliano, Stefano; Valmasoni, Michel

Effects of Pegvisomant on left ventricular mass in refractroy acromegalic patients: a 4 years follow-up observational study

Effects of Pegvisomant on left ventricular mass in refractroy acromegalic patients: a 4 years follow-up observational study Moroni Carlo et al.; Cuore e Grossi Vasi, Endocrinologia, “Sapienza” Università di Roma Objective: Since morpho-functional bi-ventricular impairment (i.e. left ventricular hypertrophy, LVH) is described in Acromegalic patients (pts), the effects of medical and surgical treatments have been previously examined. Pegvisomant (PegV) is a GH receptor antagonist, indicated for acromegalic pts with unsuccessful surgical, radiation, and/or medical treatments, with the goal of obtaining normal IGF-1 serum levels. Aim of this observational study is to evaluate the effect of PegV on left ventricular structure. Methods: We evaluated seven consecutive pts (4 males, mean age was 50.1SD 9.8 years), with active acromegaly, eligible to PegV treatment (mean disease duration before PegV: 8 years ± 3.2) by means of a 4 yy clinical and instrumental follow-up. Starting from 10 mg daily, PegV was titrated to reach the expected levels of IGF-1 for sex and age. All patients underwent to transthoracic echocardiogram (TTE) yearly from acromegaly diagnosis; in our study we considered the following TTE results: 2 years before starting PegV (T -2), at the enrolment for PegV therapy (T0) and, respectively, after two and four years of treatment (T2, T4). We compared left ventricular dimensions, geometry (LVEDD: left ventricle end-diastolic diameter; RWT: relative wall thickness) and mass (LVM and LVM index , expressed as g/h2.7). Students t test for paired data was used. Results: At six months therapy all pts normalized IGF-1 levels, which remained stable during the whole follow up. LVM and LVMi were significantly higher at T0 when compared with T-2 (before PegV: p< 0.05 for both) whereas significantly lower at T+2 (after 2 yy PegV therapy: p<0.05 vs T0 for both). The improvement trend was confirmed after 4 years PegV treatment (p<0.05 vs T0 and vs T+2 for both). Conclusions: In our study, successful PegV treatment (involving IGF-1 serum level normalization) seems to be effective in inducing a significant LV mass reduction, whereas previous treatments showed no effect (Fig.1). The observed LVM reduction after PevG treatment could play a role in improving the cardiovascular prognosis of hypertrophic acromegalic patients

Cardiac involvement in undifferentiated connective tissue disease at risk for systemic sclerosis (otherwise referred to as very early-early systemic sclerosis): a TDI study

Undifferentiated connective tissue disease at risk for systemic sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc, is a condition characterized by Raynaud's phenomenon with serum SSc marker autoantibodies and/or typical capillaroscopic findings and unsatisfying classification criteria for the disease. The aim of the present study was to assess the prevalence of right (RV) or left ventricular (LV) systolic and/or diastolic dysfunction by standard echocardiography and tissue Doppler imaging (TDI). Thirty patients with UCTD-risk-SSc (28 female, mean age 47 ± 13 years, range 21-70) and 30 age- and sex-matched controls underwent cardiac assessment by standard echocardiography and TDI. UCTD-risk-SSc patients and controls did not show any difference at standard echocardiography. Despite results falling within the respective normal ranges, TDI pointed out a mild impairment of LV and RV diastolic (E m 15 ± 4 vs. 19 ± 5, p = 0.0004; E/E m 6.1 ± 1.7 vs. 4.8 ± 1.2, p = 0.001; E t 14 ± 3 vs. 16 ± 2, p = 0.02; E t/A t 0.9 ± 0.4 vs. 1.3 ± 0.3, p = 0.002; E/E t 3.5 ± 1.2 vs. 4.2 ± 0.9, p = 0.02) and systolic function (S m 13 ± 3 vs. 15 ± 2 cm/s, p < 0.0003; S t 14 ± 2 vs. 16 ± 3 cm/s, p < 0.0001) and increased estimated pulmonary artery wedge pressure (9 ± 2 vs. 8 ± 1, p = 0.001) in UCTD-risk-SSc patients as compared to controls. Notably, a statistically significant difference also emerged in the prevalence of TDI detected E'/A't, (71% of UCTD-risk-SSc patients vs. 19% of controls; p < 0.0001). Our study shows that UCTD-risk-SSc patients show a previously unrecognized, mild biventricular systolic and diastolic dysfunction as compared to controls. The pathophysiologic meaning as well the predictive value of developing overt SSc await to be elucidated.Undifferentiated connective tissue disease at risk for systemic sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc, is a condition characterized by Raynaud's phenomenon with serum SSc marker autoantibodies and/or typical capillaroscopic findings and unsatisfying classification criteria for the disease. The aim of the present study was to assess the prevalence of right (RV) or left ventricular (LV) systolic and/or diastolic dysfunction by standard echocardiography and tissue Doppler imaging (TDI). Thirty patients with UCTD-risk-SSc (28 female, mean age 47 +/- 13 years, range 21-70) and 30 age- and sex-matched controls underwent cardiac assessment by standard echocardiography and TDI. UCTD-risk-SSc patients and controls did not show any difference at standard echocardiography. Despite results falling within the respective normal ranges, TDI pointed out a mild impairment of LV and RV diastolic (E-m 15 +/- 4 vs. 19 +/- 5, p = 0.0004; E/E-m 6.1 +/- 1.7 vs. 4.8 +/- 1.2, p = 0.001; E (t) 14 +/- 3 vs. 16 +/- 2, p = 0.02; E-t/A(t) 0.9 +/- 0.4 vs. 1.3 +/- 0.3, p = 0.002; E/E-t 3.5 +/- 1.2 vs. 4.2 +/- 0.9, p = 0.02) and systolic function (S-m 13 +/- 3 vs. 15 +/- 2 cm/s, p < 0.0003; S-t 14 +/- 2 vs. 16 +/- 3 cm/s, p < 0.0001) and increased estimated pulmonary artery wedge pressure (9 +/- 2 vs. 8 +/- 1, p = 0.001) in UCTD-risk-SSc patients as compared to controls. Notably, a statistically significant difference also emerged in the prevalence of TDI detected E'/A'(t), (71% of UCTD-risk-SSc patients vs. 19% of controls; p < 0.0001). Our study shows that UCTD-risk-SSc patients show a previously unrecognized, mild biventricular systolic and diastolic dysfunction as compared to controls. The pathophysiologic meaning as well the predictive value of developing overt SSc await to be elucidated