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L Tavazzi

Publications and source records attributed to L Tavazzi.

At least 73 records · Page 4Linked to original sources
PubMed1998

Ten-year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto-1 study. The GISSI Investigators.

BACKGROUND: We conducted a 10-year follow-up of the 11 712 patients with acute myocardial infarction randomized in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto-1 study, the first large trial assessing thrombolytic therapy. METHODS AND RESULTS: Information on survival at 10 years was obtained for the 93% of all randomized patients through the census offices of their towns of residence. The difference in survival produced by streptokinase and sustained up to 1 year was still significant at 10 years (log-rank test, P=0.02), with the absolute benefit of 19 (95% CI 1 to 37) lives saved per 1000 patients treated. The time dependence of the extent of the benefit was confirmed, as the higher mortality rate reductions found in patients treated earlier were still present at 10 years. In the overall population, most of the benefit was obtained before hospital discharge (RR 0.81, 95% CI 0.72 to 0.90), since no difference in survival between thrombolyzed and control patients discharged alive was found at 10 years (RR 0.98, 95% CI 0.90 to 1.06). However, a slight albeit nonsignificant divergence of the survival curves of patients randomized within the first hour was observed [90 (95% CI 34 to 146) lives saved per 1000 at 10 years versus 72 (95% CI 37 to 107) lives saved at hospital discharge]. CONCLUSIONS: The benefits of a single intravenous infusion of 1.5 million units of streptokinase in prolonging survival of patients with acute myocardial infarction is sustained up to 10 years, with a still-evident trend in favor of the patients admitted earlier.

Age Factors↗
PubMed1998

Peak exercise oxygen consumption in chronic heart failure: toward efficient use in the individual patient.

OBJECTIVES: This study sought to 1) assess the short-, medium-and long-term prognostic power of peak oxygen consumption (VO2) in patients with heart failure; 2) verify the consistency of a nonmeasurable anaerobic threshold (AT) as a criterion of nonapplicability of peak VO2; 3) develop simple rules for the efficient use of peak VO2 in individualized prognostic stratification and clinical decision making. BACKGROUND: Peak VO2, when AT is identified, is among the indicators for heart transplant eligibility. However, in clinical practice the application of defined peak VO2 cutoff values to all patients could be inappropriate and misleading. METHODS: Six hundred fifty-three patients consecutively considered for eligibility for heart transplantation were followed up. Outcomes (cardiac death and urgent transplantation) were determined when all survivors had a minimum of 6 months of follow-up. RESULTS: Contraindication to the exercise test identified very high risk patients. The relatively small sample of women did not allow inferences to be drawn. In men, peak VO2 stratified into three levels (< or = 10, 10 to 18 and >18 ml/kg per min) identified groups at high, medium and low risk, respectively. The prognostic power of peak VO2 < or = 10 ml/kg per min was maintained even when the AT was not detected. In patients in New York Heart Association functional class III or IV, peak VO2 did not have prognostic power. In patients in functional class I or II, peak VO2 stratification was prognostically valuable, but less so at 6 than at 12 or 24 months. Age did not influence peak VO2 prognostic stratification. CONCLUSIONS: A contraindication to exercise testing should be considered a priority for listing patients for heart transplantation. Only in less symptomatic male patients does a peak VO2 < or = 10 ml/kg per min identify short-, medium- and long-term high risk groups. A peak VO2 >18 ml/kg per min implies good prognosis with medical therapy.

Anaerobic Threshold↗
PubMed1998

Assessing baroreflex sensitivity in post-myocardial infarction patients: comparison of spectral and phenylephrine techniques.

OBJECTIVES: This study sought to compare, in post-myocardial infarction patients, baroreflex sensitivity (BRS) measured by the phenylephrine method (Phe-BRS) with that estimated by the Robbe (Robbe-BRS) and Pagani (alpha-low frequency [LF] and alpha-high frequency [HF]) spectral techniques. BACKGROUND: BRS assessed by Phe-BRS has been shown to be of prognostic value in patients with a previous myocardial infarction, but the need for drug injection limits the use of this technique. Several noninvasive methods based on spectral analysis of systolic arterial pressure and heart period have been proposed, but their agreement with Phe-BRS has never been investigated in post-myocardial infarction patients. METHODS: The linear association and the agreement between each spectral measurement and Phe-BRS were assessed by correlation analysis and by computing the relative bias and the limits of agreement in 51 post-myocardial infarction patients. RESULTS: The correlation with Phe-BRS was r = 0.63 for Robbe-BRS, r = 0.62 for alpha-LF and r = 0.59 for alpha-HF. The relative bias was significant for alpha-LF (2.6 ms/mm Hg, p < 0.001) and alpha-HF (2.5 ms/mm Hg, p = 0.01) and not significant (-0.6 ms/mm Hg, p = 0.3) for Robbe-BRS. The normalized limits of agreement ranged from -98% to 95% for Robbe-BRS, from -67% to 126% for alpha-LF and from -108% to 143% for alpha-HF. When patients were classified according to left ventricular ejection fraction (LVEF, cutoff value 40%), the relative bias was higher in patients with a depressed LVEF, although statistical significance was high only for Robbe-BRS and was borderline for alpha-LF. The limits of agreement were similar in both groups of patients (p > 0.3). CONCLUSIONS: Despite a substantial linear association, the agreement between spectral measurements and Phe-BRS in post-myocardial infarction patients is weak because the difference can be as large as the BRS value being estimated. Phe-BRS is the measurement most associated with hemodynamic impairment. Because several factors within each method contribute to the overall difference, neither method can be defined as being better than the other in estimating baroreflex gain, nor can one be used as an alternative to the other. Ad hoc studies are needed to assess which method provides the most useful physiologic or pathophysiologic information or the most accurate prediction of prognosis.

Baroreflex↗
PubMed1998

Predictors of primary atrial fibrillation and concomitant clinical and hemodynamic changes in patients with chronic heart failure: a prospective study in 344 patients with baseline sinus rhythm.

OBJECTIVES: This study investigated the incidence, predisposing factors and significance of the onset of atrial fibrillation (AF) in patients with chronic congestive heart failure (CHF). BACKGROUND: The association between CHF and AF is well documented, but the factors that predispose to the onset of the arrhythmia and its impact remain controversial. Methods. We prospectively followed up 344 patients with CHF and sinus rhythm (SR). Over a period of 19 +/- 12 months (mean +/- SD), 28 patients developed atrial fibrillation (AF), which became chronic in 18. RESULTS: At baseline, no differences were found in any clinical and hemodynamic variables between patients who developed chronic AF and those who did not. Reversible AF occurring during follow-up and lower mitral flow velocity at atrial contraction as detected at the last evaluation in SR were independent predictors of the subsequent development of chronic AF. When AF occurred, New York Heart Association functional class worsened (from 2.4 +/- 0.5 to 2.9 +/- 0.6, p = 0.0001), peak exercise oxygen consumption declined (from 16 +/- 5 to 11 +/- 5 ml/kg per min, p = 0.002), cardiac index decreased (from 2.2 +/- 0.4 to 1.8 +/- 0.4, p = 0.0008), and mitral and tricuspid regurgitation increased (from grade 1.8 +/- 1.1 to grade 2.4 +/- 1.4, p = 0.0001 and from grade 1.0 +/- 1.2 to grade 1.8 +/- 1.2, p = 0.001, respectively). Systemic thromboembolism occurred in 3 of the 18 patients with AF. Nine of 18 patients died after AF, and the occurrence of AF was a predictor of major cardiac events. CONCLUSIONS: In patients with CHF, reversible AF and reduction of left atrial contribution to left ventricular filling predict the subsequent development of chronic AF. The onset of AF is associated with clinical and hemodynamic deterioration and may predispose to systemic thromboembolism and poorer prognosis.

Adult↗
PubMed1998

Epidemiology of post-infarction risk stratification strategies in a country with a low volume of revascularization procedures. GISSI-Prognosis Investigators.

AIMS: The aims of the GISSI Prognosis Registry were to describe the diagnostic strategies initiated in acute myocardial infarction patients by a representative sample of Italian cardiological centres, and to determine which clinical or hospital characteristics were associated with the initiation of invasive diagnostic or therapeutic procedures. METHODS AND RESULTS: Baseline characteristics, major in-hospital events and the indication and results of invasive and non-invasive procedures were collected on 1489 acute myocardial infarction patients discharged alive from 65 Italian cardiological centres over a period of 3 months. Twenty-five percent of centres had on site catheterization laboratories while the rest did not. Statistical significance was analysed by chi-square tests for categorical variables. A two-sample Student t-test was used to compare continuous variables. The adjusted analysis was performed utilizing multiple logistic regression models. The most performed procedures were standard, non-invasive: 57.8% of the patients underwent an exercise stress test, 70.8% ambulatory ECG monitoring and 95.6% two-dimensional echocardiography. Nuclear or echocardiographic imaging tests were performed in 40% of acute myocardial infarction survivors. Overall, coronary angiography was planned in 549 patients (36.9%). Variables independently associated with the indication for coronary angiography were residual ischaemia, younger age, contraindication to exercise stress testing, level of patients' education, higher volume of non-invasive diagnostic tests, and male sex. Overall, during a 6-month follow-up period, coronary angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass surgery were performed, respectively in 35%, 10% and 8% of the study population. CONCLUSIONS: The setting where cardiologists practise determines the patterns of care in acute myocardial infarction patients more than the characteristics of the patient. The absence of evidence-based guidelines on the more complex and expensive procedures favour empirical attitudes and practices. The confirmation in a prospective cohort of patients, which aims to represent the care of a whole country, suggests that more effort should be given to the implementation of controlled studies rather than periodical reformulation of guidelines not supported by hard data.

Aged↗
PubMed1998

Objectives of guidelines on heart failure.

The lack of standardized diagnostic and therapeutic approaches has been a major problem in the management of heart failure. The European Society of Cardiology (ESC) guidelines on the diagnosis of heart failure have been designed to provide basic minimum requirements for the diagnosis of heart failure and to provide guidance on more advanced aspects of diagnosis for cardiology specialists. In addition, the dissemination of the ESC heart failure treatment guidelines will be useful in the standardizing and optimizing of heart failure management.

Cardiac Output, Low↗
PubMed1998

The bicaval anastomosis technique for orthotopic heart transplantation yields better atrial function than the standard technique: an echocardiographic automatic boundary detection study.

BACKGROUND: Atrial function is an important determinant of cardiac performance. In patients who undergo operation by standard heart transplantation atrial enlargement, distortion of geometry and asynchronous contraction resulting from the donor/recipient atrial connections may affect atrial function. The bicaval anastomosis technique should be free from these limitations. METHODS: We used the echocardiographic automatic boundary detection technique to obtain on-line time/volume curves of right and left atria from patients who had undergone bicaval (n = 22) or standard (n = 27) heart transplantation and from 15 control subjects. Maximal, middiastolic, preatrial contraction, and minimal volumes of both atria were measured. Reservoir volume (defined as the difference between maximal and middiastolic atrial volumes); pump volume (defined as the difference between preatrial contraction and minimal atrial volumes); and conduit volume (defined as the difference between left ventricular stroke volume and the sum of reservoir and pump volumes) were derived for both atria. Atrial emptying fraction was calculated as the difference between maximal and minimal volumes divided by the maximal volume and expressed in percent and pump fraction as the pump volume divided by the sum of reservoir and pump volumes. Tricuspid and mitral regurgitation, evaluated by color-flow Doppler scanning, were considered significant when they were greater than grade 1. Atrial ejection force was calculated from mitral and tricuspid flow velocities at atrial contraction. RESULTS: In patients who had bicaval heart transplantation, both atria were smaller than in patients who underwent standard heart transplantation. With the bicaval technique right and left atrial emptying (right 45% +/- 9% vs 36% +/- 10%, p < .05; left 51% +/- 8% vs 39% +/- 8%, p < .001) and pump fractions (right 57% +/- 17% vs 19% +/- 13%, p < .001; left 45% +/- 28% vs 22% +/- 12%, p < .01) were greater than with the standard technique and similar to those in control subjects. Right atrial ejection force was significantly greater in bicaval (10.0 +/- 5.6 kdyne) than in standard heart transplantation (4.5 +/- 2.2 kdyne, p < .0001). Significant tricuspid or mitral regurgitation was rarely found in bicaval heart transplant recipients (3 and 1 of the 22 patients, respectively), although they were much more frequent after standard heart transplantation (13 and 8 of the 27 patients, respectively). CONCLUSIONS: Heart transplantation performed with the bicaval anastomosis technique determines smaller atrial volumes, yields better right and left atrial function and fewer atrioventricular valve regurgitation than the standard technique.

Anastomosis, Surgical↗
PubMed1998

[An analysis of the decision process in the pharmacological treatment of a patient with chronic heart failure by means of a therapy management information system: the experience of the Montescano Heart Failure Unit].

A computer-based system integrated into the hospital information system for the pharmacological management of the chronic heart-failure patients admitted to the heart-failure unit of Montescano is presented. The major aims of the system involved monitoring the patients' treatment history and the related therapeutic decision-making. The treatment history of the first 151 consecutive CHF patients admitted after the system implementation is examined. The prescribed drug doses at admission and at discharge are compared, as well as the differences in etiology and NYHA class between patients discharged with or without each drug. Several considerations can be drawn from this analysis. First of all, in heart failure patients the choice of drugs is limited and optimal treatment is a result of individualized dosages. Secondly, time and trials are necessary to obtain optimal treatment. Consequently, continuity of care and in- and out-hospital networks are advisable. Third, a computer-based system offers advantages not only for the pharmacological management itself, but also for improving the quality of care through continuous analysis of the decision-making process.

Cardiology Service, Hospital↗
PubMed1997

Arterial baroreflex modulation of heart rate in chronic heart failure: clinical and hemodynamic correlates and prognostic implications.

BACKGROUND: In chronic heart failure (CHF), arterial baroreflex regulation of cardiac function is impaired, leading to a reduction in the tonic restraining influence on the sympathetic nervous system. Because baroreflex sensitivity (BRS), as assessed by the phenylephrine technique, significantly contributes to postinfarction risk stratification, the aim of the present study was to evaluate whether in CHF patients a depressed BRS is associated with a worse clinical hemodynamic status and unfavorable outcome. METHODS AND RESULTS: BRS was assessed in 282 CHF patients in sinus rhythm receiving stable medical therapy (age, 52+/-9 years; New York Heart Association [NYHA] class, 2.4+/-0.6; left ventricular ejection fraction [LVEF], 23+/-6%). The BRS of the entire population averaged 3.9+/-4.0 ms/mm Hg (mean+/-SD) and was significantly related to LVEF and hemodynamic parameters (LVEF, P<.005; cardiac index and pulmonary wedge pressure, P<.001 by regression analysis). Patients in NYHA classes III or IV and those with severe mitral regurgitation had markedly depressed vagal reflexes. The association of BRS with survival was described after its categorization in three groups: below the lowest quartile (<1.3 ms/mm Hg), between the lowest quartile and the median (1.3 to 3 ms/mm Hg), and above the median (>3 ms/mm Hg). During a mean follow-up of 15+/-12 months, 78 primary events (cardiac death, nonfatal cardiac arrest, and status 1 priority transplantation) occurred (27.6%). BRS was significantly related to outcome (log rank, 9.1; P<.01), with a relative risk of 2.7 (95% confidence interval, 1.6 to 4.7) for patients with the major derangement in BRS (<1.3 ms/mm Hg). At multivariate analysis, BRS was an independent predictor of death after adjustment for noninvasive known risk factors but not when hemodynamic indexes were also considered. In CHF patients with severe mitral regurgitation, however, BRS remained a strong prognostic marker independent of hemodynamic function. CONCLUSIONS: In moderate to severe CHF, a depressed sensitivity of vagal reflexes parallels the deterioration of clinical and hemodynamic status and is significantly associated with poor survival. Particularly in patients with severe mitral regurgitation the baroreceptor modulation of heart rate provides prognostic information of incremental value to hemodynamic parameters.

Adult↗
PubMed1997

Attenuation of unfavorable remodeling by exercise training in postinfarction patients with left ventricular dysfunction: results of the Exercise in Left Ventricular Dysfunction (ELVD) trial.

BACKGROUND: Exercise is currently recommended for patients after myocardial infarction; however, the effects of regular exercise on the remodeling process remain to be defined. The aim of this multicenter, randomized study was to investigate whether a long-term physical training program influences left ventricular size and function in postinfarction patients with systolic dysfunction. METHODS AND RESULTS: Consecutive patients with <40% ejection fraction after a first Q-wave myocardial infarction were randomly assigned to a 6-month exercise training program (n=39) or control group (n=38). After 6 months, a significant increase in work capacity was observed only in the training group (from 4.462+/-1.095 to 5.752+/-1.749 kilopond-meters [Kp-m], P<.01), not in the control group (from 4.375+/-1.143 to 4.388+/-1.199 Kp-m), whereas left ventricular volumes had increased in the control group (end-diastolic volume, from 94+/-26 to 99+/-27 mL/m2, P<.01; end-systolic volume, from 62+/-20 to 67+/-23 mL/m2, P<.01) but not in the training group (end-diastolic volume, from 93+/-28 to 92+/-28 mL/m2, P=NS; end-systolic volume, from 61+/-22 to 57+/-23 mL/m2, P=NS). Conversely, ejection fraction had improved in the training group (from 34+/-5% to 38+/-8%, P<.01) but not in the control group (from 34+/-5% to 33+/-7%, P=NS). CONCLUSIONS: In postinfarction patients with systolic dysfunction, long-term exercise training may attenuate the unfavorable remodeling response and even improve ventricular function over time.

Adult↗