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Recognition of the treatment gap in patients with heart failure (HF) led to the development of a set of process-of-care measures to improve the quality of care. To assess the association of established and emerging process-of-care measures with 1-year postdischarge survival, 496 patients with acute decompensated HF were studied. After adjustment for established prognostic factors, the relative risk (RR) for mortality in patients eligible for treatment was as follows: 0.49 (P < .001) for discharge prescription of renin-angiotensin system inhibitors (RAS-Is), 0.59 (P = .015) for β-blockers, 0.44 (P < .001) for combination therapy (ie, a β-blocker and a RAS-I), 0.87 (P nonsignificant) for aldosterone antagonists, and 0.49 (P nonsignificant) for planned cardioverter-defibrillator implantation. After adjustment for propensity scores, the RR was 0.49 (P < .001) for RAS-Is, 0.67 (P = .04) for β-blockers, and 0.57 (P < .001) for combination therapy. The data suggest that performance measures for RAS-Is, β-blockers, and combination therapy are strongly associated with improved 1-year survival. [ABSTRACT FROM PUBLISHER]

Background: The effects of cardiac rehabilitation (CR) in old patients with heart failure (HF) and severe functional impairment (SFI) are not well established., Methods: We studied 1397 patients with HF and severe functional impairment, defined as a six-minute walking distance (6MWD) <300 m, admitted to inpatient CR. The patients were divided into three groups: Group A (young, ≤65 years), Group B (old-young, 66 to 75 years), and Group C (old-old, >75 years). The primary outcome was an increase in 6MWD to 300 m or more after CR. We used multivariable Cox modeling to determine the association of the primary outcome with three-year mortality after discharge from CR., Results: At admission to CR, 38.5 % of the patients in group A, 40.0 % in group B, and 46.3 % in group C (p = .029) were unable to walk unassisted. Of these patients, 29.5 %, 32.6 %, and 30.2 % (p = .835), respectively, regained the ability to walk independently. Overall, 370 (26.5 %) patients achieved the primary outcome, 49.1 % in group A, 32.2 % in group B, and 15.7 % in group C (p < .001). The adjusted HR of 3-year mortality for the patients who achieved the primary outcome was 0.53 (95 %CI 0.34-0.83; p = .005) in group A, 0.49 (95 %CI 0.33-0.74; p = .001) in group B, and 0.68 (95 %CI 0.47-0.98; p = .037) in group C., Conclusions: Our findings suggest that old-old patients with HF and severe functional impairment may benefit from CR and that functional improvement may predict improved survival., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024. Published by Elsevier B.V.)

Background: While the prognostic value of six-minute walking test (6MWT) in patients with heart failure (HF) and reduced ejection fraction has been firmly established, there are few or no data correlating the distance walked during 6MWT (6MWD) with mortality in patients with HF with preserved ejection fraction (HFpEF) METHODS: We studied 482 patients with HFpEF who had been admitted to inpatients cardiac rehabilitation. The primary outcome was 3-year all-cause mortality. The association between 6MWD and the primary outcome was assessed using multivariable models. Established risk markers were incorporated into the models., Results: 174 patients died during the 3-year follow-up. Taking the highest tertile of 6MWD (≥360 m) as reference, the adjusted hazard ratio (HR) of the primary outcome was 2.23 (95 % CI 1.31-3.78; p = .003) for the patients in the intermediate tertile (241-359 m) and 4.94 (95 % CI 2.90-8.39; p < .001) for those in the lowest tertile (≤240 m). The annual mortality rate was 25.0 % in the lowest tertile, 10.9 % in the intermediate tertile, and 5.3 % in the highest tertile. When the distance walked was normalized for age, sex, and body mass index and expressed as percent-of-predicted walking distance, the adjusted HR was 1.30 (95 % CI 0.76-2.22; p = .331) for the patients in the intermediate tertile (58.2 % to 77.6 %) and 3.52 (95 % CI 2.12-5.85; p < .001) for those in the lowest tertile (≤58.1 %)., Conclusions: Our findings suggest that measuring functional capacity by evaluating the distance that a patient can walk over a period of 6 min provides important prognostic information in HFpEF., Competing Interests: Declarations of competing interest The authors declare they have no conflict of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2024. Published by Elsevier B.V.)

Objective: To assess the prevalence of diffuse idiopathic skeletal hyperostosis and its relationship with vascular risk factors among patients with congestive heart failure., Design: Population-based cross-sectional study., Participants: A total of 584 consecutive patients admitted to a Rehabilitative Cardiology Unit., Methods: Chi-square Automatic Interaction Detector (CHAID) decision tree analysis was used to build a predictive model., Results: The mean age (standard deviation) of the study population was 68.1 years (standard deviation 12.3), and 77.7% of the subjects were men. The overall prevalence of diffuse idiopathic skeletal hyperostosis in the cohort was 49.8%. Logistic regression analysis showed that age was a predictor of diffuse idiopathic skeletal hyperostosis (odds ratio: 1.034; 95% confidence interval 1.021-1.047, p < 0.001), with increasing odds ratios for increasing age tertiles. The CHAID prediction model identified 2 age "buckets": < 69 and ≥ 69 years. Patients ≥ 69 years had a diffuse idiopathic skeletal hyperostosis prevalence of 60.1%, compared with 39.2% among those < 69 years. Notably, body mass index was a predictor of diffuse idiopathic skeletal hyperostosis in this younger subset of patients (p = 0.028), with 2 body mass index "buckets", ≤ 23.3 and > 23.3 kg/m2, the latter showing more than twice the prevalence of diffuse idiopathic skeletal hyperostosis (43.2% vs 20%)., Conclusion: Diffuse idiopathic skeletal hyperostosis is extremely frequent among patients with congestive heart failure, with age and body mass index being the strongest predictors.

Aims: Ventilation vs. carbon dioxide production (VE/VCO 2 ) is among the strongest cardiopulmonary exercise testing prognostic parameters in heart failure (HF). It is usually reported as an absolute value. The current definition of normal VE/VCO 2 slope values is inadequate, since it was built from small groups of subjects with a particularly limited number of women and elderly. We aimed to define VE/VCO 2 slope prediction formulas in a sizable population and to test whether the prognostic power of VE/VCO 2 slope in HF was different if expressed as a percentage of the predicted value or as an absolute value., Methods and Results: We calculated the linear regressions between age and VE/VCO 2 slope in 1136 healthy subjects (68% male, age 44.9 ± 14.5, range 13-83 years). We then applied age-adjusted and sex-adjusted formulas to predict VE/VCO 2 slope to HF patients included in the metabolic exercise test data combined with cardiac and kidney indexes score database, which counts 6112 patients (82% male, age 61.4 ± 12.8, left ventricular ejection fraction 33.2 ± 10.5%, peakVO 2 14.8 ± 4.9, mL/min/kg, VE/VCO 2 slope 32.7 ± 7.7) from 24 HF centres. Finally, we evaluated whether the use of absolute values vs. percentages of predicted VE/VCO 2 affected HF prognosis prediction (composite of cardiovascular mortality + urgent transplant or left ventricular assist device). We did so in the entire cardiac and kidney indexes score population and separately in HF patients with severe (peakVO 2 < 14 mL/min/kg, n = 2919, 61.1 events/1000 pts/year) or moderate (peakVO 2 ≥ 14 mL/min/kg, n = 3183, 19.9 events/1000 pts/year) HF. In the healthy population, we obtained the following equations: female, VE/VCO 2 = 0.052 × Age + 23.808 (r = 0.192); male, VE/VCO 2 = 0.095 × Age + 20.227 (r = 0.371) (P = 0.007). We applied these formulas to calculate the percentages of predicted VE/VCO 2 values. The 2-year survival prognostic power of VE/VCO 2 slope was strong, and it was similar if expressed as absolute value or as a percentage of predicted value (AUCs 0.686 and 0.690, respectively). In contrast, in severe HF patients, AUCs significantly differed between absolute values (0.637) and percentages of predicted values (0.650, P = 0.0026). Moreover, VE/VCO 2 slope expressed as a percentage of predicted value allowed to reclassify 6.6% of peakVO 2 < 14 mL/min/kg patients (net reclassification improvement = 0.066, P = 0.0015)., Conclusions: The percentage of predicted VE/VCO 2 slope value strengthens the prognostic power of VE/VCO 2 in severe HF patients, and it should be preferred over the absolute value for HF prognostication. Furthermore, the widespread use of VE/VCO 2 slope expressed as percentage of predicted value can improve our ability to identify HF patients at high risk, which is a goal of utmost clinical relevance., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Summary: In the last two decades, population aging has led to a substantial increase in the number of people living with moderate-to-severe disability and, consequently, an increased demand for rehabilitation care. It is estimated that, currently, 2.8 million people live with severe disability in Italy. Although greater access to rehabilitation care is required to meet the needs of disabled patients, the capacity to provide rehabilitation has not changed over the last years and fails to meet current rehabilitation needs. Efforts should be devoted for aligning the capacity to provide rehabilitation care to the increased demand for rehabilitation care., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by Aracne Editrice, Roma, Italy.)

Palliative care is recognized as an approach that improves quality of life of patients and families facing life-threatening illnesses. This is achieved through prevention, early identification, assessment and treatment of symptoms and other psycho-social, spiritual and economic issues. Palliative care is not dependent on prognosis and can be delivered as "simultaneous care", together with disease-modifying treatments and adequate symptom relief. Palliative care relies on coordination across settings of care and offers open communication to patients and caregivers. Recently, there is increasing interest in the potential role of palliative care in refractory, advanced heart failure treated with optimal, maximized therapy.Heart failure is a chronic progressive syndrome characterized by periods of stability interrupted by acute exacerbations, usually leading to reduced functional status. It accounts for approximately one-third of deaths in industrialized countries and is a common cause of hospitalization. Fifty percent of patients with advanced heart failure die within 1 year of diagnosis and 50% of the remainder within 5 years. The trajectory of heart failure is often unpredictable and approximately 30% to 50% of patients die suddenly. Patients with heart failure suffer from numerous symptoms, often resistant to conventional treatments, frequently under-recognized and under-treated. Symptom assessment and control improve quality of life in patients with advanced heart failure; this can be managed at best by collaboration between specialistic teams.Although heart failure is a life-shortening condition, therapeutic and technological advances (such as left ventricular assist devices, coronary revascularization, percutaneous valve implantation, and implantable cardioverter defibrillators) can help healthcare professionals in the management of patients with advanced heart failure, improving global condition and reducing the risk of sudden death. On the other hand, it has to be acknowledged that management of cardiovascular implanted electronic devices towards end of life requires awareness of legal, ethical, religious principles regarding potential withdrawal of life-sustaining therapies.Adequate communication with patients regarding adverse events, end of life, benefits vs burdens of therapies and interventions, treatment preferences, and decision-making should be an issue in early stages of disease. The process of advanced care planning should be clearly documented and regularly reviewed.Barriers to the provision of palliative care in heart failure include clinical issues (disease trajectory), prognostic uncertainty, failure in identification of patients who need palliative care and timing of referral to specialist services, but also misconceptions of patients, families and sanitary staff regarding the role of palliative care, organization problems, and finally educational and time issues.This document focuses on the need of further, coordinated research and work-out on: (i) identification of heart failure patients eligible for palliative care, in terms of clinical and social-psychological issues, (ii) identification of trigger events and timing of referral; (iii) identification of adequate performance indicators/scales for measurement, assessment and follow-up of symptoms and quality of life in end-stage heart failure, including patient-reported outcome measures; (iv) treatment, care and organization strategies and models for advanced/end-stage heart failure ("care management"); and (v) implementation of knowledge and education of healthcare professionals in the fields of communication, ethics, and advanced care planning in heart failure.

Aims: Risk stratification in heart failure (HF) is crucial for clinical and therapeutic management. A multiparametric approach is the best method to stratify prognosis. In 2012, the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score was proposed to assess the risk of cardiovascular mortality and urgent heart transplantation. The aim of the present study was to compare the prognostic accuracy of MECKI score to that of HF Survival Score (HFSS) and Seattle HF Model (SHFM) in a large, multicentre cohort of HF patients with reduced ejection fraction., Methods and Results: We collected data on 6112 HF patients and compared the prognostic accuracy of MECKI score, HFSS, and SHFM at 2- and 4-year follow-up for the combined endpoint of cardiovascular death, urgent cardiac transplantation, or ventricular assist device implantation. Patients were followed up for a median of 3.67 years, and 931 cardiovascular deaths, 160 urgent heart transplantations, and 12 ventricular assist device implantations were recorded. At 2-year follow-up, the prognostic accuracy of MECKI score was significantly superior [area under the curve (AUC) 0.781] to that of SHFM (AUC 0.739) and HFSS (AUC 0.723), and this relationship was also confirmed at 4 years (AUC 0.764, 0.725, and 0.720, respectively)., Conclusion: In this cohort, the prognostic accuracy of the MECKI score was superior to that of HFSS and SHFM at 2- and 4-year follow-up in HF patients in stable clinical condition. The MECKI score may be useful to improve resource allocation and patient outcome, but prospective evaluation is needed., (© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.)

Acute heart failure is a leading cause of hospitalization and death, and it is an increasing burden on health care systems. The correct risk stratification of patients could improve clinical outcome and resources allocation, avoiding the overtreatment of low-risk subjects or the early, inappropriate discharge of high-risk patients. Many clinical scores have been derived and validated for in-hospital and post-discharge survival; predictive models include demographic, clinical, hemodynamic and laboratory variables. Data sets are derived from public registries, clinical trials, and retrospective data. Most models show a good capacity to discriminate patients who reach major clinical end-points, with C-indices generally higher than 0.70, but their applicability in real-world populations has been seldom evaluated. No study has evaluated if the use of risk score-based stratification might improve patient outcome. Some variables (age, blood pressure, sodium concentration, renal function) recur in most scores and should always be considered when evaluating the risk of an individual patient hospitalized for acute heart failure. Future studies will evaluate the emerging role of plasma biomarkers.

Background: Chronic kidney disease is associated with sympathetic activation and muscle abnormalities, which may contribute to decreased exercise capacity. We investigated the correlation of renal function with peak exercise oxygen consumption (V̇O2) in heart failure (HF) patients. METHODS AND RESULTS: We recruited 2,938 systolic HF patients who underwent clinical, laboratory, echocardiographic and cardiopulmonary exercise testing. The patients were stratified according to estimated glomerular filtration rate (eGFR). Mean follow-up was 3.7 years. The primary outcome was a composite of cardiovascular death and urgent heart transplantation at 3 years. On multivariable regression, eGFR was predictor of peakV̇O2(P<0.0001). Other predictors were age, sex, body mass index, HF etiology, NYHA class, atrial fibrillation, resting heart rate, B-type natriuretic peptide, hemoglobin, and treatment. After adjusting for significant covariates, the hazard ratio for primary outcome associated with peakV̇O2<12 ml·kg(-1)·min(-1)was 1.75 (95% confidence interval (CI): 1.06-2.91; P=0.0292) in patients with eGFR ≥60, 1.77 (0.87-3.61; P=0.1141) in those with eGFR of 45-59, and 2.72 (1.01-7.37; P=0.0489) in those with eGFR <45 ml·min(-1)·1.73 m(-2). The area under the receiver-operating characteristic curve for peakV̇O2<12 ml·kg(-1)·min(-1)was 0.63 (95% CI: 0.54-0.71), 0.67 (0.56-0.78), and 0.57 (0.47-0.69), respectively. Testing for interaction was not significant., Conclusions: Renal dysfunction is correlated with peakV̇O2. A peakV̇O2cutoff of 12 ml·kg(-1)·min(-1)offers limited prognostic information in HF patients with more severely impaired renal function.

Background: In patients with chronic heart failure (HF) the Metabolic Exercise Cardiac Kidney Indexes (MECKI) score, is a predictor of cardiovascular death and urgent heart transplantation. We investigated the relationship between age, exercise tolerance and the prognostic value of the MECKI score., Methods and results: We analyzed data from 3,794 patients with chronic systolic HF. The primary endpoint was a composite of cardiovascular death and urgent heart transplantation. Older patients had higher prevalence of comorbidities and lower exercise performance compared with younger subjects (peak V̇O2, 925 vs. 1,351 L/min; P<0.0001; V̇E/V̇CO2slope, 33.2 vs. 28.3; P>0.0001). The rate of the primary endpoint was 19% in the highest age quartile and 14% in the lowest quartile. At multivariable analysis, the independent predictors of the primary endpoint were left ventricular ejection fraction (LVEF), eGFR, peak V̇O2, serum Na(+)and the use of β-blockers in patients aged ≥70 years, and LVEF, eGFR and peak V̇O2in younger subjects. The MECKI risk score increased across age subgroups, but on receiver operating characteristic curve analysis its prognostic power was similar in both patients aged ≥70 and <70 years., Conclusions: Older patients with HF are a high-risk population with lower exercise performance. The MECKI score increased according to age and maintained its prognostic value also in older patients.

Background: The acute decompensated heart failure/N-terminal pro-B-type natriuretic peptide (ADHF/NT-proBNP) score is a validated risk scoring system that predicts mortality in hospitalized heart failure patients with a wide range of left ventricular ejection fractions (LVEFs). We sought to assess discrimination and calibration of the score when applied to patients with advanced decompensated heart failure (AHF)., Methods: We studied 445 patients hospitalized for AHF, defined by the presence of severe symptoms of worsening HF at admission, severely depressed LVEF, and the need for intravenous diuretic and/or inotropic drugs. The primary outcome was cumulative (in-hospital and post-discharge) mortality and post-discharge 1-year mortality. Separate analyses were performed for patients aged ≤ 70 years. A Seattle Heart Failure Score (SHFS) was calculated for each patient discharged alive., Results: During follow-up, 144 patients (32.4%) died, and 69 (15.5%) underwent heart transplantation (HT) or ventricular assist device (VAD) implantation. After accounting for the competing events (VAD/HT), the ADHF/NT-proBNP score's C-statistic for cumulative mortality was 0.738 in the overall cohort and 0.771 in patients aged ≤ 70 years. The C-statistic for post-discharge mortality was 0.741 and 0.751, respectively. Adding prior (≤6 months) hospitalizations for HF to the score increased the C-statistic for post-discharge mortality to 0.759 in the overall cohort and to 0.774 in patients aged ≤ 70 years. Predicted and observed mortality rates by quartiles of score were highly correlated. The SHFS demonstrated adequate discrimination but underestimated the risk. The ADHF/NT-proBNP risk calculator is available at http://www.fsm.it/fsm/file/NTproBNPscore.zip., Conclusions: Our data suggest that the ADHF/NT-proBNP score may efficiently predict mortality in patients hospitalized with AHF., (Copyright © 2014 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

On the basis of the results of pathophysiological and controlled clinical studies, cardiac rehabilitation is now recognized as an effective therapeutic intervention in patients with chronic heart failure (CHF). Achieving clinical stability, optimizing medical therapy, education and counseling regarding lifestyle changes, implementing an exercise training programme, and ensuring an adequate follow-up are the core components of cardiac rehabilitation in CHF. Cardiologists, nurses, physiotherapists, psychologists, and dietitians, all aim at the achievement of such objectives. Education and counseling of patients with CHF are essential aspects of patient care as they can improve the clinical and functional outcome of such patients. In this setting, specially trained nurses may play a pivotal role. An organized plan of patient education and counseling should include explanation of the disease and dietary and exercise regimen recommendations; in addition, the patients should be taught the name of each drug and its purpose, dosage, frequency, and significant side effects.

In patients with chronic heart failure, myocardial contractile responsiveness to dobutamine is diminished as a result of beta-receptor desensitization due to chronic adrenergic activation. Changes in beta-receptor effector mechanisms are more marked in idiopathic dilated cardiomyopathy (IDCM) than in ischemic dilated cardiomyopathy. As the magnitude of the dobutamine effect is proportional to the severity of left ventricular systolic dysfunction, the heterogeneous cardiotonic effects of dobutamine in IDCM may represent different evolutive stages of a progressive disease process. On the basis of this pathophysiologic background, some studies were undertaken to investigate the prognostic and functional implications of dobutamine stress echocardiography (DSE) in IDCM. Prognostic studies consistently suggest that myocardial response to dobutamine is related to the clinical outcome. However, the limited number of patients and events in the individual studies are important limitations. Moreover, the impact of beta-blockers on the potential ability of DSE to predict the prognosis needs to be assessed. A few studies also suggest that changes in left ventricular systolic function parameters following dobutamine infusion are related to exercise tolerance, as assessed by peak exercise oxygen consumption and functional recovery of the failing myocardium. The data suggest that DSE is a promising method, which may improve the risk stratification process in patients with IDCM and provide further insights into the pathophysiologic mechanisms underlying progressive systolic pump dysfunction and exercise intolerance. Further studies are however needed to define the role of DSE in IDCM.