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We evaluated the 1-year clinical events, pharmacological management, and quality of life in a contemporary cohort of stable coronary artery disease (CAD) patients managed by cardiologists.

Background In cardiovascular prevention and rehabilitation, care activities are carried out by different professionals in coordination, each with their own specific competence. This GICR–IACPR position paper has analysed the interventions performed by the nurse, physiotherapist, dietician and psychologist in order to identify what constitutes minimal care, and it lists the activities that are fundamental and indispensable for each team member to perform in clinical practice.Results In analysing each type of intervention, the following dimensions were considered: the level of clinical care complexity, determined both by the disease and by environmental factors; the ‘area’ complexity, i.e. the specific level of competence required of the professional in each professional section; organisational factors, i.e. whether the care is performed in an inpatient or outpatient setting; duration of the rehabilitation intervention. The specific contents of minimal care have been identified for each professional area together with the specific goals, the assessment tools and the main essential interventions. For the assessments, only a few validated tools have been indicated, leaving the choice of which instrument to use to the individual professional based on experience and usual practice.Conclusion For the interventions, attention has been focused on conditions of major complexity requiring special care, taking into account the different care settings, the clinical conditions secondary to the disease event, and the distinct tasks of each area according to the operator's specific role. The final report performed by each professional has also been included.

Background Stable coronary artery disease (CAD) is a leading cause of mortality worldwide. Few studies document the complete sequence of investigation of the overall stable CAD population during outpatient visits or hospitalisation.Aim To obtain accurate and up-to-date information on current management of patients with stable CAD.Methods START (STable coronary Artery diseases RegisTry) was a prospective, observational, nationwide study aimed at evaluating the presentation, management, treatment and quality of life of stable CAD patients presenting to cardiologists during outpatient visits or discharged from cardiology wards.Results Over a 3-month period, 5070 consecutive patients were enrolled in 183 participating centres: 72% managed by a cardiologist during outpatient or day hospital visits and 28% discharged from cardiology wards. The vast majority of patients (87%) received a coronary angiography (86% of patients managed during outpatient visits and 90% during hospitalisation; p< 0.0001). Outpatients more frequently received optimal medical therapy (OMT; i.e. aspirin or thienopyridine, β-blockers and statins) compared to hospitalised patients (70.2% vs 67.1%; p= 0.03). A personalised diet was prescribed in 58% (60.5% in outpatients and 52.9% in those admitted to hospitals; p< 0.0001), physical activity programmes were suggested in 65% (69.4% and 54.3%; p< 0.0001) and smoking cessation was recommended in 71% of currently smoking patients (73.2% and 65.2%; p= 0.02).Conclusions In this large, contemporary registry, patients with stable CAD discharged from cardiology wards more commonly underwent diagnostic imaging procedures and less frequently received OMT or lifestyle modification programmes compared to patients manged by cardiologists during outpatient visits.

Vehicle’s powertrain performance and comfort are largely depending on the clutch control strategy for an Automated Manual Transmission (AMT). The aim of the clutch control strategy is to ensure the smooth running of clutch operational cases: a comfortable clutch launch (vehicle takes off smoothly without jerk), a fast upshift/downshift (gear ratio changes) and a fast clutch opening. In most industrial cases, regardless of clutch actuation technology, clutch control is managed by clutch pressure control. However, the clutch pressure control is a challenge regarding clutch non-linearities and time-varying parameters. In this paper, a parallel adaptive feedforward and bang-bang controller is proposed in order to control the clutch pressure with an electromechanical clutch actuator. In this system, a control issue comes from potential time-varying parameters but the main challenge comes from the hysteretic behavior of the system due to dry friction in the actuator assembly. An analytic model of the clutch and its electromechanical actuator including dry friction has been constructed and a prototype has been designed and integrated on a test bench. The parallel adaptive feedforward and bang-bang controller architecture and algorithms are developed. For three critical clutch operational cases, simulations and experiments have been run. Finally, in spite of time-varying parameters and a high hysteretic system behavior, simulation and experimental control results highlight that the controller allows a precise tracking of the pressure reference and a fast time response.

Background Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) frequently coexist but concurrent COPD + CHF has been little investigated.Design This multicentre survey (SUSPIRIUM) was designed to evaluate: the prevalence of COPD in stable CHF and CHF in stable COPD; diagnostic/therapeutic work-up for concurrent COPD + CHF; clinical profile of patients with COPD + CHF; predictors of COPD in CHF and CHF in COPD.Methods A 5-month-long cross-sectional prospective observational survey was conducted in 10 cardiac and 10 respiratory connected outpatient units.Results The prevalence of CHF in the 378 surveyed COPD patients was 11.9% (95% confidence interval 8.8–16.6) and the prevalence of COPD in 375 CHF patients was 31.5% (95% confidence interval 26.8–36.4). Diagnostic tests for suspected comorbidity were prescribed in 21.6% and 22.9% of COPD and CHF patients, respectively. Patients with coexisting CHF + COPD had a higher incidence of hypertension, physical inactivity and more frequently a GOLD score of 3 or greater. Compared to CHF only, CHF + COPD patients were significantly older, more frequently smokers, at worse respiratory risk and in a higher New York Heart Association class. Conversely, hypercholesterolaemia, a family history of ischaemic heart disease, fluid retention and comorbidities were more frequent in COPD + CHF than COPD-only patients. At multivariate analysis, a GOLD score of 3 or greater in CHF strongly predicted coexistent COPD (odds ratio 8.985, P< 0.0001) as did a history of other respiratory diseases (5.184, P< 0.0001). A history of ischaemic heart disease (4.868, P< 0.0001), atrial fibrillation (3.302, P< 0.0001) and sedentary lifestyle (2.814, P< 0.004) predicted coexistent CHF in COPD.Conclusion The high prevalence of COPD + CHF calls for integrated disease management between cardiologists and pulmonologists. SUSPIRIUM identifies which cardiac/pulmonary outpatients should be screened for the respective comorbidity.

Pulmonary hypertension, which is related to right ventricular (RV) failure, indicates a poor prognosis in heart failure (HF). Increased ventilatory response and exercise oscillatory ventilation (EOV) also have a negative impact. We hypothesized that the severity classification of HF and risk prediction could be improved by combining functional capacity with cardiopulmonary exercise testing (CPET) and RV-pulmonary circulation coupling, as evaluated by the tricuspid annular plane systolic excursion (TAPSE)-pulmonary artery systolic pressure (PASP) relationship.

Reduced pulmonary arterial compliance (Ca) is a marker of poor prognosis in idiopathic pulmonary arterial hypertension. We tested the hypothesis that pulmonary arterial Ca could be a predictor of outcome in patients with chronic heart failure (CHF).

Background Scant data exist on factors that may identify outcome in patients with severe left ventricular (LV) dysfunction early after coronary artery bypass graft surgery (CABG).Design This study was designed to determine the prognostic value of clinical, operative, and postoperative factors in patients with LV dysfunction early after CABG.Methods In 333 consecutive patients with ejection fraction ≤ 35% on admission to residential cardiac rehabilitation after isolated CABG, potential preoperative, perioperative, and postoperative predictors of outcome, including 6-month LV remodeling, were recorded and patients followed up for a median of 3 years. The study end points were cardiovascular (CV) mortality and the combination of CV mortality and nonfatal CV events requiring hospitalization.Results The 3-year CV mortality-free survival and survival free of nonfatal CV event rates were 87 and 73%, respectively. Independent predictors of CV mortality were history of congestive heart failure [hazard ratio, HR: 2.8; 95% Confidence Interval (CI): 1.51-5.21], low ejection fraction on admission to cardiac rehabilitation (HR: 0.9; 95% CI: 0.87-0.96), and early complications after CABG (HR: 2.5; 95% CI: 1.23-5.15). When the combined end points were considered, postoperative left atrial size (HR: 1.07; 95% CI: 1.01-1.11), New York Heart Association class III or IV (HR: 1.69; 95% CI: 1.04-2.74), and 6-month remodeling (HR: 2.12; 95% CI: 1.33-3.36) were independent predictors.Conclusion Simple preoperative and postoperative variables may help identify patients with LV dysfunction early after CABG who are still at risk of major CV events. In this setting, 6-month LV remodeling is a strong predictor of a poor prognosis. Eur J Cardiovasc Prev Rehabil15:441-447 © 2008 The European Society of Cardiology

Background Cardiac rehabilitation programmes are a proven treatment for individuals with recent myocardial infarction, resulting in reduced morbidity and mortality compared to usual care. Unfortunately, following completion of a cardiac rehabilitation programme, risk factors and lifestyle behaviours may deteriorate. The GlObal Secondary Prevention strategiEs to Limit event recurrence after myocardial infarction (GOSPEL) study investigates the benefits of a programme of continued educational and behavioural interventions to achieve optimal long-term secondary prevention goals. DesignThis will be a multicentre, randomized, controlled study carried out in 78 Italian cardiac rehabilitation centres.Methods After completion of an initial cardiac rehabilitation programme, patients with recent (<3 months) myocardial infarction were randomized to either a long-lasting (over 3 years) multifactorial continued educational and behavioural programme (intensive approach) or usual care (control) group. Intensive approach patients participated in extensive cardiac rehabilitation sessions, monthly from months 1 to 6, then every 6 months for 3 years. Each session consisted of aerobic exercise, comprehensive lifestyle and risk factor counselling, and clinical assessment Usual care patients returned to their family physicians’ care, and attended the reference centre only for the 6-month and then annual scheduled assessment. The efficacy of the two different strategies will be evaluated in terms of morbidity and mortality as primary endpoint.Results From January 2001 through December 2002, 3241 patients were enrolled. Results will be available in mid 2006.Conclusions The GOSPEL trial, the rationale and design of which we present here, was designed to test a new strategy of secondary prevention delivery and to raise standards of long-term secondary prevention in Italy. With a cohort of over 3200 patients, GOSPEL is the largest randomized, multifactorial lifestyle and risk factor intervention trial after myocardial infarction conducted so far.

OBJECTIVES

OBJECTIVES

This study sought to investigate the relative and incremental prognostic value of demographic, historical, clinical, echocardiographic and mitral Doppler variables in patients with left ventricular systolic dysfunction.

Objectives. The aim of this multicenter randomized study was to investigate whether long-term physical training would influence left ventricular remodeling after anterior myocardial infarction.

Objectives. We sought to assess whether in clinically stable patients with chronic heart failure (CHF) the prolongation (i.e., increase) of an initially short (≤125 ms) Doppler transmitral deceleration time (DT) of early filling obtained with long-term optimal oral therapy predicts a more favorable prognosis.

SummaryA study was carried out to evaluate the efficacy of two different doses of a new hypotonizing agent, cimetropium bromide, as a premedication for X-ray of the stomach and duodenum. Forty consecutive patients were allocated at random to two groups and treated intravenously in double-blind fashion with 5 mg or 10 mg cimetropium bromide. The drug was administered immediately after the first phase of an upper gastro-intestinal series had been completed. Duration of the drug-induced hypokinesia was recorded fluoroscopically. The hypotonizing effect was evaluated by measuring the diameters of the gastric antrum, duodenal bulb and loop on the pre-injection and post-injection radiographs. In both groups, the relaxant effect started promptly (within 1 minute of injection) and lasted for an average of 10 minutes, which was considered adequate for the study. There were no statistically significant differences between the two groups in relaxant activity. The treatments were scored arbitrarily as ‘excellent’ in 75% of the examinations after the 10 mg dose and in 60% after the 5 mg dose. The difference between the two groups was not significant. Side-effects were few, of mild entity and not dose-related.

Objectives. This study investigated whether exercise-induced myocardial ischemia influences left ventricular remodeling after anterior myocardial infarction.

This study investigated the value of sestamibi scintigraphy in assessing residual ischemia after anterior myocardial infarction.

Inter-observer agreement was tested in the interpretation by 8 radiologists of mammograms from 45 women (for a total of 180 films per radiologist). The radiologists were representative of the whole range of those involved in mammography in the town of Torino, with a number of films read per year ranging from 100 to 4000. Out of the 45, 9 women were affected by breast cancer (histologically proved), 25 had benign disease (diagnosed with fine-needle aspiration) and 11 had normal breasts. Weighted kappa values were in the range 0.27–0.82 (median 0.60) for parenchymal patterns; 0.33–0.67 (0.48) for diagnosis in five categories; and 0.22–0.57 (0.38) for indications for further diagnostic tests. These values are comparable with those reported from other investigations.

Objectives. The aim of this study was to investigate the correlations between Doppler-derlved transmitral flow velocity variables and pulmonary capillary wedge pressure in patients with severe left ventricular systolic dysfunction.