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The Italian survey on CardiAc RehabilitatiOn and Secondary prevention after cardiac revascularization (ICAROS) was a multicenter, prospective, longitudinal survey carried out by the Italian Association on Cardiovascular Prevention and Rehabilitation (GICR/IACPR) in patients on completion of a CR program after coronary artery by pass grafting (CABG) and percutaneous coronary intervention (PCI). The aim was to evaluate in the short and medium-term: i) the cardioprotective drug prescription, modification and adherence; ii) the achievement and maintenance of recommended lifestyle targets and risk factor control and their association with cardiovascular events; iii) the predictors of non-adherence to therapy and lifestyle recommendations. The ICAROS results offers a portrait of the "real world" of clinical practice concerning patients after CABG and PCI, and stresses the need to improve secondary prevention care after the index event: many patients after revascularization leave the acute wards without an optimal prescription of preventive medication but the prescription of cardiopreventive drugs and risk factors control is excellent after completion of a CR program. Following CR, the maintenance of evidence-based drugs and lifestyle adherence at one year is fairly good as far as the target goals of secondary prevention are concerned, but to investigate the influence of CR on long-term outcome longer-term studies are required. Last, but not least, ICAROS shows that some characteristics (PCI as index event, living alone, poor eating habits or smoking in young age, and old age, in particular with comorbidities) may identify patients with poor behavioral modification in the medium-term follow-up and in these patients further support may be warranted. In conclusion, participation in CR results in excellent treatment after revascularization, as well as a good lifestyle and medication adherence at 1 year and provides further confirmation of the the benefit of secondary prevention.

In the year 2006 the Italian Association of Hospital Cardiologists (ANMCO) promoted a Consensus Conference among professional Scientific Societies in order to redefine the role and core responsibilities of each health professionals involved in heart failure management in a novel integrated network. Five years later, a questionnaire has been proposed to each Italian Regional President of the Association, in order to assess the implementation of the proposed management strategies in the different clinical scenarios of the Italian Regions. Although the Document utilization is not homogeneous through Italy, it is still considered a valuable tool of work.

A standardized and evidence-based approach to the cardiological management of patients undergoing noncardiac surgery has been recently defined by Task Forces of the American Heart Association (AHA), American College of Cardiology (ACC) and the European Society of Cardiology (ESC) that published their guidelines in 2007 and 2009, respectively. Both the recommendations moved from risk indices to a practical, stepwise approach of the patient, which integrates clinical risk factors and test results with the estimated stress of the planned surgical procedure. In the present paper the main topics of the guidelines are discussed, and moreover, emphasis is placed on four controversial issues such as the use of prophylactic coronary revascularization in patients with myocardial ischemia, the perioperative management of patients with congestive heart failure, the routine use of betablockers and statins, and, finally, the management of antiplatelet therapies in patients with coronary stents. In addition to promoting an improvement of immediate perioperative care, the preoperative cardiological evaluation should be a challenge for identifying subjects with enhanced risk of cardiovascular events, who should be treated and monitored during a long-term follow-up.

From January 28th to February 10th 2008, the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (IACPR-GICR) conducted the ISYDE-2008 study, the primary aim of which was to take a detailed snapshot of cardiac rehabilitation (CR) provision in Italy--in terms of number and distribution of facilities, staffing levels, organization and setting--and compare the actual CR provision with the recommendations of national guidelines for CR and secondary prevention. The secondary aim was to describe the patient population currently being referred to CR and the components of the programs offered. Out of 190 cardiac rehabilitation centers existing in Italy in 2008, 165 (87%) took part in the study. On a national basis, there is one CR unit every 299,977 inhabitants: in northern Italy there is one CR unit every 263,578 inhabitants, while in central and southern Italy there is one every 384,034 and 434,170 inhabitants, respectively. The majority of CR units are located in public hospitals (59%), the remainder in privately owned health care organizations (41%). Fifty-nine percent are located in hospitals providing both acute and rehabilitation care, 32% are in specifically dedicated rehabilitation structures, while 8% operate in the context of residential long term care for chronic conditions. Almost three-quarters of CR units currently operating are linked to dedicated cardiology divisions (74%), 5% are linked to physical medicine and rehabilitation divisions, 2% to internal medicine, and 19% to cardiac surgery and other divisions. Inhospital care is provided by 62.4% of the centers; outpatient care is provided on a day-hospital basis by 10.9% of facilities and on an ambulatory basis by 20%. The CR units are led in 86% of cases by a cardiologist and in only 14% of cases by specialists in internal medicine, geriatrics, physical medicine and rehabilitation, pneumology or other disciplines. In terms of staffing, each cardiac rehabilitation unit has 4.0 +/- 2.7 dedicated physicians (range 1-16, mode 2), 10.1 +/- 8.0 nurses, 3.3 +/- 2.5 physiotherapists (range 0-20; 16% of services have no physiotherapist in the rehabilitation team), 1.5 +/- 0.8 psychologists, and a dietitian (present in 62% of CR units). Phase II CR programs are available in 67.9% of cases in residential (inpatient) and in 30.9% of cases in outpatient (day-hospital and ambulatory) settings. Phase III programs are offered by 56.4% of the centers in ambulatory outpatient regime, and on an at home basis by 4.8% with telecare supervision, 7.3% without. Long term secondary prevention follow up programs are provided by 42.4% of CR services.

The Italian Society of Cardiac Rehabilitation and Prevention (GICR) has developed the ISYDE-2008 survey with the purpose to take a detailed snapshot in terms of number, distribution, facilities, staffing levels, organization, and programme details of CR units in Italy and to compare actual provision with the recommendation of National GL for CR and secondary prevention. The study will be carried out with a web-based questionnaire running on the GICR website in 2 weeks from Jan. 28 to Feb. 10, 2008. The first part of the questionnaire is designed to collect information on the institutional organization of the CR unit, on its location and functional relationships within the hospital, on the number of beds for inpatient CR units and hours of activity for outpatient and home-based services, on the composition of the core and multidisciplinary teams, and finally on the components of CR programmes. In the second part of the survey, CR directors will be requested to report for each patient discharged during the 2 weeks of the study, indications for admission to CR, time of enrolment, comorbidity, complications, risk profile, diagnostic procedures, exercise and educational programme, discharge modalities, treatment at discharge and follow-up schedule. More than 2300 pts are expected to enter in the survey, whose results depicting the status of CR in Italy will be available within April 2008.

Unlabelled: For quality-of-care assessment of rehabilitation programs after cardiac surgery, measures of functional recovery have been proposed as outcome indicators. Aim of this study was to evaluate the feasibility, the safety and the informative content of the 6-min walking test (6 WT) performed in elderly patients soon after admission in an intensive rehabilitation program after cardiac surgery., Methods: Population consists of 115 consecutive over-70 patients admitted to an in-hospital rehabilitation program after cardiac surgery. Within 7 days of admission, in 107 patients (93%) clinical conditions allowed the execution of a 6 WT, on ECG telemetry monitoring. Resting and exertional heart rate, score of fatigue (Borg Scale 1 divided by 20), symptoms, ECG alterations and arrhythmias were recorded. Other considered variables were: comorbidity (Charlson index), length of stay and complications occurring during the whole surgical and rehabilitation in-hospitalisation stay, disability (nursing needs: Maslow and nursing chart), functional status at discharge, left ventricular ejection fraction, number of exercise treatment sessions, self-perceived health-status at admission and at discharge (EuroQoL questionnaire)., Results: The mean walked distance was 194 +/- 93 m. No complication neither ECG alteration occurred during the 6 WT; only isolated premature ventricular beats were recorded in 26 pts. Heart rate increased from 86 +/- 13 at rest to 95 +/- 17 bpm at the end of the 6 WT (p < .0001). The perceived fatigue score was 12.9 +/- 1.2 Borg. Complications, length of stay, nursing needs, self-perceived health-status and functional capacity at discharge differed between patients who performed the 6 WT within 4 days compared with those who did it later, and between patients who walked < or = 120 m (lower quartile) compared with those who walked more., Conclusions: In elderly patients after cardiac surgery the 6 WT performed within the first week of admission in rehabilitation unit is feasible and safe. Simple cut-offs like timing of the 6 WT and walking performance identify more severe patients with lower susceptibility to recovery.

Chronic heart failure shows an increasing prevalence and extremely high rate of both hospital admission and readmission. Thus, in recent years there has been a growing interest in the development of more effective strategies for disease management. The existing literature shows programs involving multidisciplinary teams, specialized clinics, that employ a systematic approach and provide continuity of care, frequently involving a specialized nurse dedicated to comprehensive management. These experiences reported a favourable effects on clinically relevant outcome, including readmission, quality of care and cost of care. A recent randomized trial conducted by Krumholtz and colleagues emphasises the importance of patient's education and support intervention, without medical management components. This model was effective in reducing readmissions and in-hospital costs. On the basis of these data, patients education and support should be considered a "non-pharmacological therapy" for heart failure patients.

Unlabelled: The recovery process in the elderly after cardiac surgery is influenced not only by clinical cardiac conditions, but also by comorbidity, cognitive decline and disability. We evaluated the relationship between clinical objective and self-perceived factors and their influence on functional recovery in 204 consecutive, over-70s pts who were admitted into an intensive hospital rehabilitation program following cardiac surgery. The variables taken into consideration were: comorbidity (Charlson index), length of hospital stay and complications in cardiac surgery and rehabilitation, disability (nursing needs score index), functional status (6-min walking test), left ventricular EF, number of training sessions, self-perceived health status (EuroQol questionnaire), emotional impairment (anxiety/depression, CBA-2.0/interview)., Results: Functional capacity: the distance walked was 198 +/- 103 m at admission and 287 +/- 121 m at discharge (p < 0.0001). Only the nursing needs score index resulted as a weak, independent predictor of the distance walked at admission (r2 = 0.14, p < 0.001, beta = 0-.21), which (beta = 0.49), together with complications during rehabilitation (beta = -0.15), self-perceived health status at discharge (beta = 0.15) and number of training sessions (beta = 0.20), was independently correlated with the distance walked at time of discharge (r2 = 050, p < 0.0001). Patients mood: anxiety correlated with depression. Emotional scores did not correlate with functional measures. Patients self-perceived health status: only the nursing needs score index was a weak, independent predictor of well-being at entry (r2 = 0.15, p < 0.0001, beta = -0.29), which, in turn, was the only predictor of perception at discharge (r2 = 0.33, p < 0.0001, beta = 0-.42)., Conclusions: In an intensive hospital rehabilitation program following cardiac surgery in patients over 70 a) there was no correlation between clinical and psychological variables; b) anxiety and depression were associated, but neither influenced the recovery process nor correlated to health status perception; c) functional impairment was strongly influenced by nursing needs which also affected the self-perceived health status; d) both functional and perception recovery were influenced by disability at time of admission and reacted positively after rehabilitation.