Biomedical subjects
Publications and source records attributed to Alfredo Zuppiroli.
It has been recently observed that statins might slow the progression of aortic stenosis or sclerosis. Preliminary reports suggested a similar positive effect in reducing the degeneration of aortic valve bioprostheses even though this hypothesis should be further proven and supported by new data. In this review the present evidences of the possible effects of statins in this field are discussed.
Progression of sclerosis and stenosis is substantially unpredictable in the individual patient: in some cases it is very slow, in others it is accelerated. In addition, different patterns of progression (linear and non-linear) are possible. It has been suggested that the aortic valve lesion can be considered a form within the spectrum of the same atherosclerotic disease. In this context it seemed reasonable to hypothesize that targeted medical therapy could retard the progression of the disease. In particular HMG-CoA reductase inhibitors (statins) and angiotensin-converting enzyme inhibitors have been tested. The first experimental and clinical studies are now available, even though they are not conclusive to date. Large, prospective, randomized trials are ideally needed, but they are quite difficult, if not even impossible, to realize in practice. The ASSIST study (Asymptomatic aortic Sclerosis/Stenosis: Influence of STatins) of the Italian Society of Cardiovascular Echography aims to create a large, prospective, observational investigation, involving many centers of echocardiography and thousands of patients, in order to provide from the real clinical world at least some of the answers to this unsolved question.
Mitral valve prolapse (MVP) is still a clinical challenging problem. In this report, we review the main characteristics of this entity. Epidemiology of MVP, which relies on the diagnostic criteria adopted, and the incidence of complications, both arrhythmic and structural, are influenced by the characteristics of the population studied, which may lead to bias in data interpretation. Even the definition of MVP may differ according to the cardiologist's or cardiac surgeon's point of view. Usually, cardiologists define MVP as the protrusion of all or part of the mitral leaflets into the left atrium, independent of maintenance of coaptation. Therefore, using this definition, mitral regurgitation is considered as a complication rather than a diagnostic criterion. Arrhythmias, either supraventricular or ventricular, are other possible complications, mostly not life-threatening and associated with myxomatous degeneration of the valve. Diagnosis of MVP is based on echocardiography, which provides detailed anatomic and functional evaluation of the affected valve. Leaflet thickness and motion as well as presence and severity of mitral regurgitation can be assessed, with important diagnostic and prognostic implications. Echocardiographic evaluation of the mitral valve requires a systematic approach in order to define the leaflet/scallop involved and the mechanisms of mitral regurgitation. To this aim, three-dimensional reconstruction may add further insights into objective rendering of mitral valve pathology. Finally, surgical timing in mitral regurgitation due to MVP is an evolving issue and the likelihood of surgical repair is a crucial factor in the optimal timing of surgical intervention, especially in asymptomatic patients with severe mitral regurgitation.
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To date, there is no proved medical therapy able to significantly reduce the degenerative process of biologic prosthetic aortic valves. It has recently been suggested that statins may reduce the progression of native aortic valve stenosis. We examined the effect of statin treatment on bioprosthetic aortic valve degeneration and found a beneficial effect of statins in slowing bioprosthetic degeneration.
The aim of cardiovascular preoperative evaluation in non-cardiac surgery is to assess the patient's current cardiovascular status, to detect unknown diseases, to make recommendations concerning the medical management of the patient in the peri- and postoperative period, to plan the surgical strategy or, in some cases, to postpone non-cardiac surgery until the cardiac condition is corrected or stabilized; rarely, cardiovascular evaluation may result in an absolute contraindication for non-cardiac surgery. The basic clinical evaluation obtained by history, physical examination and review of the ECG usually provides enough data to estimate the cardiac risk. Patient's risk factors (unstable coronary syndromes, congestive heart failure, life-threatening arrhythmias, severe valvular heart diseases) and the type and setting of surgery are to be considered together with the clinical evaluation. Additional non-invasive tests may be recommended to evaluate left ventricular function and the presence of myocardial ischemia only if expected data will eventually result in changing the surgical procedure or perioperative management. Echocardiography is particularly useful in patients with major risk factors whereas exercise stress test is able to assess the patient's functional capacity or to identify silent myocardial ischemia or significant arrhythmias. The overall goal of cardiac assessment should be a consideration of both the impending surgery and the long-term cardiac risk independent of the decision to go to surgery. It is almost never appropriate to recommend coronary bypass surgery or other invasive interventions such as coronary angioplasty in an attempt to reduce the risk of non-cardiac surgery when they would not otherwise be indicated.
BACKGROUND: In patients with heart failure, poor ejection fraction and estimated severe aortic stenosis because of a reduced aortic valve area (AVA) and low gradients, dobutamine echocardiography (DE) was proposed to distinguish afterload mismatch from primary left ventricular dysfunction. In this setting the feasibility and safety of DE and the outcome following management based on DE results were investigated. METHODS: Forty-eight patients (mean age 73 +/- 9 years; 79% males; AVA 0.7 +/- 0.2 cm2; mean aortic gradient 22 +/- 6 mmHg; ejection fraction 0.28 +/- 0.07; NYHA functional class 2.9 +/- 0.8) underwent DE and were followed up for 24 +/- 21 months. Aortic valve replacement (AVR) was offered to patients with left ventricular contractile reserve (ejection fraction increase > or = 30% at peak DE) and fixed aortic stenosis (AVA increase < or = 0.25 cm2). RESULTS: DE elicited a left ventricular contractile reserve in 38 patients (79%). Among these, fixed aortic stenosis was present in 28 patients, among whom 19 underwent AVR and 9 declined surgery. The 20 patients without contractile reserve or with relative stenosis (AVA increase > 0.25 cm2) were not considered eligible for surgery. During follow-up, 23 cardiovascular deaths occurred: 2/19 among operated patients, 7/9 among patients who declined surgery and 14/20 among non-eligible patients. Patients with AVR showed a significantly more favorable outcome and improved functional status as compared to the other two groups (NYHA class 1.2 +/- 0.4 vs 2.7 +/- 0.6 at baseline; p < 0.001). Conversely, non-surgical management was the strongest independent predictor of an adverse outcome (relative risk 3.6, 95% confidence interval 1.8-7.3; p < 0.0001). CONCLUSIONS: In patients with heart failure and estimated severe aortic stenosis, DE could identify a subgroup with a left ventricular contractile reserve and fixed aortic stenosis who gained great benefit from AVR. The clinical outcome of patients who were not operated upon was unfavorable.
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A survey on patterns of information and informed consent procedures during daily clinical practice has been performed by the Ethical Commission of ANMCO. A structured questionnaire (38 questions) was sent to the 653 cardiological units of the National Health Service in Italy. Four hundred and eighty (73.5%) were received. The following variables were considered to evaluate differences in the answers from the various cardiological units: geographical site, presence or absence of an in-patient department, a cath-lab, and of cardiac surgery facilities. Independent predictors of returning questionnaires were: geographical site (Northern Italy vs Central and Southern) and the presence of a cath-lab. Informed consent forms were provided in 53% of instances, while in 40% a free comment about the topic of informed consent was sent. Statistically significant differences in the answers were found about physicians' and nurses' role, ways of information, qualitative and quantitative risk estimates, other persons' role, models of consent forms and procedures of obtaining consent. Free comments and informed consent forms did not allow a statistical analysis. However, they still provided sufficient material to identify specific patterns of how cardiologists deal with the informed consent process. The distinction between the two phases of information and consent was rarely clear. Information or educational material was often mixed with consent forms. While some still showed a paternalistic approach, or else considered informed consent as a formal act, others demonstrated a deep understanding of the significance of the concept of informed consent. A widespread need of guidelines and standard patterns resulted.
BACKGROUND: We evaluated the appropriateness of the prescription of echocardiography, exercise testing, Holter monitoring and vascular sonography for ambulatory patients, performed during 4 weeks in 21 outpatient laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs noncardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 5614 prescriptions (patients: 3027 males, 2587 females; mean age 63 years, range 14-96 years). The indication to the test was of class I (appropriate) in 45.3%, of class II (doubtfully appropriate) in 34.8% and of class III (inappropriate) in 19.9% of the cases. The test was abnormal in 58.3% of class I exams vs 17% of class III exams (p < 0.05). The test was useful in 72.4% of class I exams vs 17.1% of class III exams (p < 0.05). The test was prescribed by a cardiologist in 1882 cases (33.5%). Cardiologist-prescribed exams were of class I in 57.3%, of class II in 32.4% and of class III in 10.3% of the cases vs 39.2, 36.1 and 24.7% of non-cardiologist-prescribed exams (p < 0.05). Cardiologist-prescribed exams were abnormal in 53.4% of the cases vs 39% of those of non-cardiologists' (odds ratio 1.76, 95% confidence interval 1.58-1.97; p < 0.05). Cardiologist-prescribed exams were useful in 64.7% of the cases vs 44.4% of those of non-cardiologists' (odds ratio 2.26, 95% confidence interval 2.02-2.53; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, less than half of the prescriptions for non-invasive diagnostic tests are appropriate: appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are more often appropriate, abnormal and useful.
BACKGROUND: We evaluated the appropriateness of indications to echocardiography for ambulatory patients performed during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 2848 prescriptions (patients: 1450 males, 1398 females; mean age 62 years, range 15-90 years). The indications to test were of class I (appropriate) in 43.6%, of class II (of doubtfully appropriateness) in 36.8% and of class III (inappropriate) in 19.6% of the cases. In 60.8% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 83.8% of class I, in 56.6% of class II and in 17.8% of class III exams (p < 0.05). The exam was considered useful in 51.1% of the cases. In particular, a useful result was found in 78.9% of class I, in 39% of class II and in 12.1% of class III exams (p < 0.05). Cardiologists prescribed 856/2848 tests (30%). Their indications were of class I in 58.8%, of class II in 29.8% and of class III in 11.4% of the cases vs 37, 39.9 and 23.1% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 74.3% of cardiologist- vs 55% of non-cardiologist-prescribed examinations (odds ratio 2.45, 95% confidence interval 2.04-2.92; p < 0.05); similarly, clinically useful information could be derived from 63.1% of cardiologist- vs 46% of non-cardiologist-prescribed examinations (odds ratio 2.07, 95% confidence interval 1.75-2.45; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, about half of the prescriptions for echocardiography can be considered inappropriate; appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.