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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.

Aging is one of the strongest risk factors for cardiovascular events and even elderly patients with established disease are likely to derive benefits from secondary prevention programs. Unfortunately, few clinical trials have been specificately addressed to older population. However, since this population is rising and presents with intrinsic characteristics, it is worthwhile to consider the problems of the elderly with a sociological and ethical approach too and not only from a medical point of view.

n-3 Poliunsaturated Fatty Acids (PUFA) are essential; foods rich in n-3 are fat fish and some vegetal oil. PUFA are precursors of Eicosanoids, involved in the processes of inflammation, thrombosis and immunity. Firstly, observational studies measured reduction of cardiovascular disease (CVD) incidence with greater PUFA dietary intake. Experimental studies discovered antiahrrhytmic, antiatherogenic, antiaggregating and antiinflammatory properties. Retrospective analysis found lower incidence of sudden death (SD) in fish consumers. Randomized, prospective trials after myocardial infarction showed, in people either eating fish or receiving an n-3 PUFA supplement, a reduction of SD, explained by specific effect on membrane ion channels. The lack of results on atherothrombosis do not match with most experimental results, and should better be evaluated in absence of aspirin therapy. Low evidence supports use of n-3 PUFA in angina or revascularization procedures. Recent observations denote positive effect on endothelial function of large and resistance arteries. Actually evidence-based medicine suggest: improve of fish consumption for primary prevention of CVD; n-3 PUFA supplementation for hypertrigliceridemia and secondary prevention of SD after myocardial infarction, which is also cost-effectiveness.

Background: Since the large multicenter DIG trial has shown no effects of digitalis on the all-cause mortality of patients with chronic heart failure (HF), the broad prescription of this drug in patients with HF appears to be at the very least, questionable. The aims of this study were: to analyze prescription patterns of digitalis, from 1995 to 2000, in a large group of outpatients with HF; to analyze the independent predictors of digitalis prescription and to evaluate the impact of the results of the DIG trial on the prescription rate of this drug., Methods: From 1995 to 2000, 11 070 HF outpatients (mean age 64 +/- 12 years, ejection fraction 35 +/- 12%) were enrolled in a large Italian database., Results: Out of 11 070 patients, 7198 (65%) were treated with digitalis. At multivariate analysis, the following variables were independently associated with digitalis prescription; atrial fibrillation (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.9-3.8), ejection fraction < 30% (OR 1.7, 95% CI 1.5-1.9), NYHA class III-IV vs II-III (OR 1.3, 95% CI 1.2-1.5), admission for HF during the previous year (OR 1.4, 95% CI 1.2-1.5). After the publication of the DIG trial, there was a significant reduction in the rate of digitalis prescription: the percentage of patients taking digitalis fell from 68% in 1996-1997 to 61% in 1998-1999 (p < 0.001)., Conclusions: Over 60% of Italian outpatients with HF were treated with digitalis; as expected, patients with a low ejection fraction, atrial fibrillation and in a more advanced stage of HF are more likely to receive this drug. Finally, after the publication of the DIG trial, the rate of digitalis prescription significantly decreased.

Atrial fibrillation is the most frequent complication after cardiac surgery. Its onset leads to a threefold higher risk for stroke compared with patients in sinus rhythm and other adverse events such as thromboembolic events and heart failure. The direct consequence is an increased length of hospital stays with obvious economic implications. These reasons have led the attention of many investigators to point out the rule of possible predisposing factors and underlining mechanisms in order to establish an effective preventive treatment. The present paper is aimed to review the state-of-the-art knowledge about post-operative atrial fibrillation and its complex etiopathogenesis which is in turn responsible for the lack of consensus regarding routine prophylaxis.

In current clinical practice, oral anticoagulant therapy is one of the most widely employed treatments in order to prevent embolic events in cardiovascular diseases. This therapy is bound to become more and more employed because of increasing mean age of general population and related increase of clinical settings which may require anticoagulation. Nowadays, available drugs for oral anticoagulation are vitamin K antagonists which inhibit the coagulation factors depending upon this vitamin for their synthesis. In this review we will examine: --their mechanism of action and its clinical implications related with the initial phase of therapy and the likelihood of side effects as cutaneous necrosis; --their pharmacokinetics which explain most of drug interactions; --affecting therapy factors: age of patients, impaired absorption, genetic polymorphisms of cytochrome P450, drug resistance, coagulation factors defects, particular clinical situations, vitamin K dietary intake; --different properties of various anticoagulant drugs; --toxicity; --problems related to monitoring anticoagulation intensity. At last, we will present the new pharmacological perspectives offered by direct inhibitors of the coagulation factors.

Cardiac rehabilitation is accepted as an important component in the management of heart disease. Diabetes Mellitus is a chronic disease frequently associated to ischemic heart disease and both disease require continuing medical care, aggressive treatment of other risk factors, educational programs for self management of disease to prevent acute complication. The scientific community should offer standard of care for management of diabetic patients with coronary artery disease, and should design new strategies to promote prevention in this high risk patients. The need to define characteristics and peculiar problems of diabetics patients with ischemic heart disease encouraged the Board of the Italian Group of Cardiac Rehabilitation and Prevention (GICR) to set up a working group composed of cardiologists and diabetologists chosen on the basis of their proven specific experience. The document is subdivided in six parts. In the first section is described the cardiovascular risks in patients with diabetes and the importance of post-prandial hyperglycemia and glycemic variability. We analyse also the difference in prevalence of ischemic heart disease in Italian diabetic patients compared with other countries. In the second section we described clinical presentation of ischemic heart disease in diabetic patients such as acute myocardial infarction and unstable angina, and the revascularization procedures (balloon angioplasty and coronary bypass surgery). We analysed the differences between the procedures and the evidence-based results. In patients with myocardial infarction we analysed the evidence-based therapy and specific advantages of aspirin, beta-blockers and ace-inhibitor in diabetic patients. In this section we also posed particular attention to the clinical course of patients who underwent bypass grafting and to the impact of diabetes on short and long-term results and on main intervention-related complications including deep infections, mediastinitis, neurological problems, renal failure. In the third section we evaluated the factors responsible of atherosclerosis progression and their treatment, and we underlined that cardiac rehabilitation is less effective for patients with diabetes mellitus. Suggestions proposed in this paper about risk factors are in line with the recommendations of standards guidelines of American Diabetics Association. In patients with concomitant diabetes and ischemic heart disease we suggest blood pressure <130/80, LDL-cholesterol <100 mg/dl, triglycerides <150 mg/dl and daily physical activity. In the fourth section we analysed therapeutic regimens and management of diabetes. We posed particular attention on insulin therapy in acute phase of myocardial infarction and in recent coronary bypass grafting, and chronic use of oral antidiabetic drugs or insulin. In the fifth section we provided some recommendations on the organization of educational programs and physical activity in these patients. In the last section we provided some information on diagnosis of coronary artery disease in diabetes, aim of screening and in which patients is need to perform diagnostic tests. We described the available diagnostic tests with the differences in each method.

Numerous studies have documented that cardiovascular prevention in subjects at high risk has a large impact on the clinical outcomes. Data also show the efficacy of an early, intensive, well-structured, professionally expert, multidisciplinary intervention, making use of adequate behavioural and pharmacologic instruments, on the global risk. Such intervention is, however, available at present for very few healthcare users, while the majority, above all in primary prevention, receive a programme of low impact, with poor feedback between the hospital specialist and general practitioner (GP), and often limited to the simple prescription of treatment or to specialist check-ups and/or general advice on lifestyle. The project of implementation takes as its starting point this analysis and the premise that for an intervention of cardiovascular prevention to be effective, particularly in the long term, and really applicable to the broad population, it must be governed primarily by the GP--providing that s/he be adequately trained, utilize new and more dynamic caring modes, and be able to count concretely both on integration with the specialist and on the support of a multidisciplinary team for specific interventions. The paper presents the various stages of the project: from definition of the resources available (health district, GPs, hospital specialists) to the need for GP training, to the modes of operation: instruments for risk calculation, procedures followed, model of integration between GP and specialist, identification of the goals and indicators. This is a low cost project in terms of both the human and structural resources employed, utilizing what is already available in the healthcare system of our country. One of its most original aspects is the medical visit jointly conducted by the GP and hospital specialist, which realizes in concrete terms the integration of the skills: GPs can finally confront in the field the specialist of referral, acquire new skills, improve their daily mode of operating, while they will be gratified by a work more in line with their professional image, and become promoters of health. Finally, this project highlights the propositive and operative role assumed by cardiac rehabilitation and prevention, which, after developing over the years a specific know-how on the subject, now transmits these skills to other healthcare resources and creates a link with the local territory, so providing an appropriate response to the need to put into practice primary and secondary cardiovascular prevention.

In this review, specific aspects and implications of echocardiography in patients who had undergone recent cardiac surgery will be analysed. This imaging method, which is fully effective in clinical practice, actually possesses diagnostic characteristics, which during assessments of patients, are found to be noninvasive and easily repeatable. They are of great value amongst this particular group of patients for discovering any possible complications from the surgical procedures. Technical problems and methodology will be described regarding the specificity of the patient during the early days after cardiac surgery (for instance the difficulties of executing in certain post-operative conditions such as pain, injuries or worsening of acoustic window). Informative contribution and specific assessment in patients following myocardial revascularisation surgery, reconstructive or valvular replacement surgery, and left ventricle or thoracic aorta surgery will be analysed. The role of echocardiography in the identification and monitoring of the main complications related to the operation will also be described. The increasing diagnostic potential and assessment of the investigation is thanks to its systematic use which lasts for the intensive phase of cardiac rehabilitation, but assumes specific and adequate operator competence for optimum use in clinical examinations.

In 2001-2002 the Italian Working Group on Cardiac Rehabilitation (CR) developed the ISYDE project, a survey on CR in Italy. In 2001, the CR units were 144 (57% in the North of the country), 58% in general hospitals, 23% in private hospitals, 8% in rehabilitative hospital, and only 2% in university clinics. Patients admitted to CR were 60,819 (vs 37.049 in 1996, +64%); 86% of CR units treated > 100 pts/year (vs 66% in 1996; +32%). Patients were admitted to CR units after cardiosurgery in 55% of cases, after myocardial infarction in 22%, and for chronic heart failure in 9.6%, without significant differences respect to 1996. A special survey investigated the work-up performed in patients with recent myocardial infarction. The admission ranges from 11th to 20th day, the mean duration of the CR programs ranges from 21 to 34 days. Most of italian CR units have a definite program for risk stratification and secondary prevention. In particular, the programs of exercise training, educational interventions concerning diet, lifestyle, and smoking cessation, and psychological intervention are well designed, developed, and evaluated before discharge in most cases. In conclusion, although in recent years the number of CR units are increasing, and the quality of care may be well-established by serial evaluations scheduled before discharge and during the long-term follow-up, a further development is mandatory to face the needs of cardiac patients in the post-acute and chronic phase of a cardiac disease.

In the last few years the population referred to cardiac rehabilitation centers has changed profoundly: the number of survivors of acute cardiac events has increased and heart surgery is being proposed to ever greater numbers of elderly patients with frequent and greater comorbidities, which make the management of physical training programs more complex. Consequently, just as rehabilitation cardiologists have had to expand their field of analyses and professional skills and nurses have had to integrate their care protocols, physiotherapists too have had to adapt the management of motor rehabilitation programs to the various needs and problems of each patient in the different phases of recovery. The aim of this paper is to present and discuss the procedures followed in our center concerning both the mode and contents of a standard course of motor rehabilitation for patients without complications and those for patients with complications. The paper analyzes the various assessments, the training program, the instruments of control and verification of the results, and discusses the instruments of intervention in patients affected by complications such as respiratory disturbances, musculoskeletal impairment, complications arising from injury, neurological deficit and severe deconditioning. Finally, the role of the physiotherapist in the active, propositive management of a recovery program is discussed.

The growing number of recipients of artificial heart valves draws ever more frequent attention to the problem of anticoagulant therapy, not only in its daily management but also in the event of specific conditions such as pregnancy, extra-cardiac surgery and invasive cardiac procedures in which specific measures must be adopted. In each case it is necessary to take into account not only the characteristics of the individual prosthesis but also those of the individual patient, each time making an overall assessment of the specific thromboembolic risk without forgetting possible complications of hemorrhage. This review examines the various mechanisms underlying the thromboembolic risk and, in the light of the leading literature on the topic, seeks to identify the most appropriate behaviors to adopt in the management of each individual case.

According to the latest data available, in Italy a cardiac rehabilitation program is currently proposed to only 17% of patients after an acute myocardial infarction and to 76% of patients after a coronary artery bypass grafting. One possible explanation for this difference is an underestimation of the rehabilitating techniques and some doubts about its efficacy on the quality of life and on secondary prevention. Regarding secondary prevention, many research results and independent reviews are now available and they give us the opportunity to develop a sufficiently evidence-based analysis of cardiac rehabilitation program results. Great improvements in functional capacity and substantial changes in the way of life seem to have been demonstrated, with good-health oriented behaviors and improvements in the whole risk profile (less cigarette smoking, more sports activities, less stress, improvement in lipid profile). It has been well proven that with comprehensive rehabilitation programs, there is a relevant slow down in atherosclerosis progression. Rehabilitation programs also have favorable effects on the quality of life in patients with cardiac disorders, with fewer symptoms and more psychological and social well being. Three high-quality meta-analyses resulted in a significant reduction in total and cardiovascular mortality, mostly linked to sudden death and fatal reinfarction reduction, equal to the one obtained by currently recommended postinfarct treatments. Certainly, there are still difficulties to overcome before definitive conclusions can be reached, because of differences both in rehabilitation programs in the various studies and because of the results achieved in recent years through changes in the pharmacological approach to secondary prevention. The Global Secondary Prevention Strategies to Limit Event Recurrence After Myocardial Infarction (GOSPEL study) from the Italian Study Group on Cardiac Rehabilitation (GICR) has been designed to answer to some of these questions. One of its goals is to evaluate whether an intensive intervention of cardiac rehabilitation in the postinfarct patients is actually applicable and efficacious.

A well defined Italian sample from Trino Vercellese (Northern Italy) is analysed for 75 nuclear DNA RFLPs. It represents the only European sample [Matullo et al 1994] which is unmixed in a comparative study of eight populations from four continents [Bowcock et al 1991a; Lin et al 1994]. Genetic substructure of this sample has been investigated by allele sharing distances and no bias or higher homogeneity is shown. Genetic variability between populations was measured by the FST statistics (average FST was 0.138 +/- 0.086). Average heterozygosity for eight populations was 0.312 +/- 0.069. Genetic distances were evaluated between pairs of populations. Phylogenetic trees were reconstructed and principal component analysis performed. Particular attention has been given to the genetic relationship between our sample and the mixed-Caucasoid sample: 14 out of 75 markers show statistically significant frequency differences (P < 0.05), 5 of which are significant at a probability level < 1%: GH/Bg1II (Lower system), D7S1/HindIII, D17S71/MspI, EPB3/PstI, HLA-DQA. Hypotheses on admixed origin of Europeans has been discussed.

Trino Vercellese, a village of Piedmont (Italy), was selected with the aim at reconstructing the genetic history of a putative Celtic sample known to be settled in Italy with the name of Rigomagus since pre-roman times. The HLA-A, Cw, B, DR and DQ antigens of 101 unrelated individuals have been typed. The antigens characterizing this sample for their higher frequency are shown to be A3, A11, A32, B35, B39, Bw52, Cw4, DRw11, DRw13, DQw7. Gene frequencies are estimated by maximum likelihood and Hardy-Weinberg equilibrium was tested with no deviant genetic locus. Two-locus haplotype frequencies were also estimated and those with significant associations tabulated. "Extended" haplotypes were reconstructed: the three most frequent haplotypes (covering a total frequency of 11.5%) share the same Cw, B, DR and DQ alleles. Comparisons with other Italian and European samples are indicated to challenge archeological evidence of a pre-roman genetic stratification of the people living in our old Rigomagus.

We analysed a sample of 55 unrelated individuals from Trino Vercellese, a village in northern Italy. It represents the only European sample which is unmixed in a comparative study of eight populations from four continents [Bowcock et al 1991a; Lin et al 1994]. RFLP analysis was performed on 32 DNA markers, for a total of 37 independent alleles. Genetic variability between populations was measured by the FST statistics (average FST is 0.138). Average heterozygosity was calculated for each marker and for each population. Genetic distances were evaluated between pairs of populations. Phylogenetic trees were reconstructed and principal component analysis performed.

A maximal, symptom-limited exercise test was performed 4 weeks after an acute myocardial infarction in 108 subjects aged less than 40. All the patients were afterwards engaged in a 6 weeks supervised rehabilitation program. Following the rehabilitation, 99 patients underwent programmed controls for a mean period of 23.4 +/- 16 months. Anamnestic data, site of the infarction, early exercise test response, rehabilitation results were statistically evaluated. They were compared with the follow-up data to estimate their predictive value of late cardiac events. Only the exercise testing data were found to be of prognostic significance. In fact, 77.8% of patients with ischemic response to the test had new cardiac events in the follow-up period. The percentage of late cardiac events was 26.7% in patients with hypotensive response and 8.4% in patients with normal response. The ischemic response was found to be more frequent in patients with inferior myocardial infarction. The highest rate of new cardiac events (86%) occurred in patients with inferior infarction and ischemic response to the early exercise test. An early exercise test seems to be of value to assess the prognosis after a myocardial infarction in young men. An ischemic response is a reliable sign of a poor prognosis; on the other hand, a normal response to the test does not exclude the possibility of late cardiac events, which may occur in about 10% of these patients.

Five male patients, aged between 31 and 58 years, presented with anginal chest pain with nausea and sweating after the interruption of exercise. Prinzmetal variant angina was observed during the recovery phase of exercise tolerance testing. Coronary arteriography and selective left ventricular angiography were normal in all cases. Ergonovine, used in one case, induced coronary artery spasm. The angina was eased by Nifedipine in three patients and passed off with time in the other two patients. In one case attack occurred with amiodarone therapy and in another with glyceril trinitrate, after normal exercise tolerance tests. Vagotonia, all the more pronounced when sympathetic tonus is increased, and hyperventilation seem to be the causative factors of what probably results from coronary artery spasm. Nifedipine, a calcium-blocking agent would appear to be the treatment of choice.

Human histocompatibility (HLA) gene frequencies were studied in the Italian population. A random sample of healthy individuals born in several Italian regions and provinces was studied to estimate HLA-A, -B, -C and -DR gene frequencies using the maximum likelihood method. The goodness of fit to Hardy-Weinberg proportions was evaluated by the likelihood ratio statistics. Different Italian regions and provinces show significant differences in the HLA alleles, providing further evidence for the genetic heterogeneity in the Italian population. This heterogeneity is also displayed by a synthetic geographical representation which uses colour to map the most informative gene differences. Statistically significant gametic associations between HLA-A, -B, -C and -DR loci are reported. The difference between northern and southern Italy and between continental Italy and Sardegna is clearly shown also by their heterogeneous linkage disequilibria.

In order to assess the short-term reproducibility of the most important ergometric parameters, 108 males (mean age 50.3 +/- 7.8 years) underwent a functional stress test (FST) on average 35 days after myocardial infarction. The exercise test was repeated 3 days later in the same conditions. Patients were fasting and in pharmacological washout. The following parameters were analyzed: total work performed (TWP), VO2, heart rate (HR), systolic blood pressure (SBP), arrhythmias and S-T segment depression and elevation. TWP and VO2 values did not show any significant difference during the two tests under the various workloads. HR and SBP responses proved to be well reproducible in patients with HR and SBP not exceeding the mean values obtained from 222 normal subjects who underwent the same exercise test by more than +/- 1 SD; reproducibility was significantly lower in the other patients, particularly in patients with HR and SBP exceeding normal values by more than +/- 1 SD. Therefore, in this case, further FST are necessary to obtain more reliable parameters to decide on individual pharmacological and exercise prescriptions. Arrhythmias were reproducible up to 67% (p less than 0.01) regardless of Lown's class and the presence of S-T segment depression or elevation. S-T segment depression or elevation was reproducible up to 100%.

In order to assess the reliability of left ventricular ejection fraction as estimated by gated blood pool method, radionuclide angiography (LAO) and single plane (RAO) contrast cineangiocardiography were performed within 14 days in 60 patients with coronary artery disease. The mean value of radionuclide ejection fraction was found to be 55 +/- 16%; contrast cineangiographic ejection fraction was 57 +/- 15%; r = 0.92. In 23 patients with previous anterior myocardial infarction gated blood pool method was found to underestimate left ventricular ejection fraction when compared with contrast cineangiography. The observed underestimation was wide significant in 11 patients with previous anterior infarction, low (less than 50%) radioisotopic ejection fraction and septal akinesia and/or apical dyskinesia; radionuclide ejection fraction = 33 +/- 8%; contrast cineangiographic ejection fraction = 42 +/- 9%; r = 0,76. This study confirms that the values of left ventricular ejection fraction as estimated by gated blood pool method in coronary patients are quite reliable; moreover, the intrinsic variability of the data is low. This may be not true in patients with previous anterior myocardial infarction. The Authors discuss the possible causes of disagreement between radioisotopic and contrastographic ejection fraction in patients with previous anterior infarction and poor left ventricular function: physical problems of measuring ejection fraction by gated blood pool in dilated ventricles; possible mistakes in evaluating blood pool due to the low mobility of the blood mass nearest to the scintillation camera; inhability of contrast cineangiography in RAO to recognize the interventricular septum and evaluate its kinetic abnormalities; unreliability of the geometrical model of revolution elypsoid in calculating end-systolic volumes in ventricles with abnormal wall-kinesis.(ABSTRACT TRUNCATED AT 250 WORDS)