Metabolic disorders affecting the liver and heart: Therapeutic efficacy of miRNA-based therapies?

Liver and heart disease are major causes of death worldwide. It is known that metabolic alteration causing type 2 diabetes (T2D) and Nonalcoholic fatty liver (NAFLD) coupled with a derangement in lipid homeostasis, may exacerbate hepatic and cardiovascular diseases. Some pharmacological treatments can mitigate organ dysfunctions but the important side effects limit their efficacy leading often to deterioration of the tissues. It needs to develop new personalized treatment approaches and recent progresses of engineered RNA molecules are becoming increasingly viable as alternative treatments. This review outlines the current use of antisense oligonucleotides (ASOs), RNA interference (RNAi) and RNA genome editing as treatment for rare metabolic disorders. However, the potential for small non-coding RNAs to serve as therapeutic agents for liver and heart diseases is yet to be fully explored. Although miRNAs are recognized as biomarkers for many diseases, they are also capable of serving as drugs for medical intervention; several clinical trials are testing miRNAs as therapeutics for type 2 diabetes, nonalcoholic fatty liver as well as cardiac diseases. Recent advances in RNA-based therapeutics may potentially facilitate a novel application of miRNAs as agents and as druggable targets. In this work, we sought to summarize the advancement and advantages of miRNA selective therapy when compared to conventional drugs. In particular, we sought to emphasise druggable miRNAs, over ASOs or other RNA therapeutics or conventional drugs. Finally, we sought to address research questions related to efficacy, side-effects, and range of use of RNA therapeutics. Additionally, we covered hurdles and examined recent advances in the use of miRNA-based RNA therapy in metabolic disorders such as diabetes, liver, and heart diseases.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

Epigenetics in the primary and secondary prevention of cardiovascular disease: influence of exercise and nutrition

Increasing evidence links changes in epigenetic systems, such as DNA methylation, histone modification, and non-coding RNA expression, to the occurrence of cardiovascular disease (CVD). These epigenetic modifications can change genetic function under influence of exogenous stimuli and can be transferred to next generations, providing a potential mechanism for inheritance of behavioural intervention effects. The benefits of exercise and nutritional interventions in the primary and secondary prevention of CVD are well established, but the mechanisms are not completely understood. In this review, we describe the acute and chronic epigenetic effects of physical activity and dietary changes. We propose exercise and nutrition as potential triggers of epigenetic signals, promoting the reshaping of transcriptional programmes with effects on CVD phenotypes. Finally, we highlight recent developments in epigenetic therapeutics with implications for primary and secondary CVD prevention.

Worldwide differences of hospitalization for ST-segment elevation myocardial infarction during COVID-19: A systematic review and meta-analysis

Background

Discrepant data were reported about hospital admissions for ST-segment elevation myocardial infarction (STEMI) during COVID-19 pandemic. We reviewed studies reporting STEMI hospitalizations during COVID-19 pandemic, investigating whether differences in COVID-19 epidemiology or public health-related factors could explain discrepant findings in different countries.

Methods

Search through MedLine, Embase, Scopus, Web-of-Science, Cochrane Register of Controlled Trials, of studies comparing STEMI admissions during COVID-19 pandemic with a reference period, without language restrictions, as registered in PROSPERO International Prospective Register of Systematic Reviews. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. Data independently extracted by multiple investigators were pooled using a random-effects model. Health-related metrics were from publicly-available sources.

Results

We included 79 articles (111,557 STEMI cases, from 57 countries). During peak COVID-19 pandemic, overall incidence rate-ratio (IRR) of STEMI hospitalizations over reference period decreased (0.80; 95% CI 0.76–0.84; p < 0.05). Although wide variations and significant heterogeneity were detected among studies (I² = 89%; p < 0.0001), no significant differences were observed by report methodology (survey vs registry), or observation/reference period. However, large differences emerged at country level not explained by COVID-related epidemiological data, nor by public health strategies. Instead, IRRs for STEMI admissions were inversely related to hospital bed availability in each country (p < 0.05).

Conclusions

During COVID-19 pandemic hospitalization for STEMI significantly decreased, although to a smaller extent than initially reported. Large variability emerged across countries, unrelated to COVID-related epidemiology or social containment measures. Disparities in healthcare organization likely contributed, indicating that proper organization of emergency medicine should be preserved during pandemics.

Predictors of long-term survival in patients undergoing residential cardiac rehabilitation (rCR) after transcatheter aortic valve replacement (TAVR): a multicenter retrospective study

Purpose

To evaluate exercise-based rCR derived outcome predictors in patients referred after TAVR.

Methods

Data of 232 patients (aged 82±6 years, 45%males) admitted to an average 3-week rCR program after TAVR (walking, up to 30 minutes of cycling or treadmill session twice daily, respiratory and calisthenic training) from January 2009 to December 2017 and home discharged, were retrospectively collected at 10 rCR Divisions of Istituti Clinici Scientifici Maugeri. Comorbidity (cumulative illness rated state-comorbidity index) (CIRS-CI) score, echocardiography on admission, disability (Barthel Index) (BI) score at discharge, six minutes walking test distance (6MWT) on discharge and maximal training session intensity (MTSI expressed in METs per minutes) were collected. All-cause mortality was assessed up to 3 years after rCR discharge.

Results

During a 3-year follow-up, there were 74 (32%) deaths. At univariate analysis, at discharge non survivors compared to survivors had significantly higher comorbidity rate (CIRS-ICC 5.2±2.3 vs 4.1±1.9, p=0.000) and disability level (BI 80.4±24 vs 88.8±17, p=0.000). Moreover, they had worse renal function (creatinine 1.6±0.9mg/dl vs 1.2±0.4, p=0.000), were more often on diuretic therapy (73% vs 53.2%, p=0.003) and on beta-blocker therapy (73% vs 57,6%, p=0.042) and had a markedly reduced functional capacity (6MWTD 221±100m vs 265±105m, p=0.001). At multivariate logistic stepwise analysis a lower comorbidity (CIRS-ICC), a more preserved renal function (creatinine level), a reduced use of diuretic therapy and 6MWT at discharge confirmed their power as independent predictors of survival at follow up (Table, Harrel's C = 0.707)

Conclusions

Patients attending rCR after TAVR are very old with significant comorbidity; overall mortality at 3-year follow-up after CR discharge is substantial. Our results suggest the need to implement ad-hoc long-term care strategies based on residual exercise capacity, comorbidity score and renal function for tailoring follow-up in patients discharged from rCR after TAVR.

Funding Acknowledgement

Type of funding sources: None. Table 1

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Better adherence with out-of-hospital healthcare improved long-term prognosis of acute coronary syndromes: Evidence from an Italian real-world investigation

BACKGROUND

Patients who experience a hospital admission for acute coronary syndromes (ACS) exhibit poor prognosis over the years. The purposes of this study were to evaluate the real-world patterns of out-of-hospital practice in the management of ACS patients and to assess their impact on the risk of selected outcomes.

METHODS

The cohort of 87,530 residents in the Lombardy Region (Italy) who were newly hospitalised for ACS during 2011-2015 was followed until 2018. Exposure to medical treatment including use of selected drugs, diagnostic procedures and laboratory tests was recorded. The main outcome of interest was re-hospitalisation for cardiovascular (CV) outcomes. Proportional hazards models were fitted to estimate hazard ratio, and 95% confidence intervals (CI), for the exposure-outcome association. Analyses were stratified according to the ACS type.

RESULTS

The cumulative incidence of re-hospitalisation for CV disease was 33%, 42% and 38% at 5 years after index discharge among STEMI, NSTEMI and unstable angina patients. Within one year from index discharge, between 70% and 80% of patients had at least a prescription of statins, beta-blockers and renin-angiotensin-system blocking agents, underwent ECG and lipid profile examination, and had a cardiologic examination. One patient in five underwent cardiac rehabilitation. Compared with patients who did not adhere to healthcare recommendations, the risk of CV hospital readmission was reduced from 10% (95% CI: 4%-10%) to 23% (12%-32%) among patients who underwent lipid profile examinations and who experienced cardiac rehabilitation.

CONCLUSION

Close out-of-hospital healthcare must be considered the cornerstone for improving the long-term prognosis of ACS patients.

[The rehabilitation phase]

Preventive Cardiology and Cardiac Rehabilitation (CR) is the specialty of clinical cardiology dedicated to the care of post-acute and chronic heart disease patients. The goals are to improve quality of life and prognosis, clinical stability, optimization of pharmacological and non-pharmacologic therapy, management of comorbidities, treatment of disabilities, reinforcement of secondary prevention interventions and adherence to therapy. The global mandate of CR has changed over time. From the acute intervention, we moved on to the care in the medium and long-term period.Despite its clear benefits and guideline recommendations, CR is still not fully considered within the cardiovascular landscape. Furthermore, the importance of CR at the clinical level and of the "health" gain of CR is little known by the beneficiaries themselves, i.e. patients on one side and the health system on the other. The main criticism is the low referral rate of cardiac patients to CR programs. In Italy, in Europe and in the USA it appears to be <30%. The challenge for CR is to work on the changes induced by epidemiology and the healthcare system needs. CR inpatient wards must be increasingly available and organized to acquire complex patients, often elderly and frail, up to the development of sub-intensive rehabilitation therapy units; in Italy, it is also necessary to develop outpatient pathways for patients of moderate-low complexity, in order to increase the referral rate to CR. Finally, integrating CR programs with long-term follow-up pathways of cardiac patients is a very important task, fully entering in the areas of e-Health and m-Health.

3039Vulnerability of carotid atherosclerosis: relationship with plaque location, plaque eccentricity and vessel remodeling patterns. Insight from the the MAGNETIC observational study

Conclusions

Carotid atherosclerotic plaque vulnerability seems to be independently associated with longitudinal location, plaque eccentricity and vessel positive remodeling.

Acknowledgement/Funding

Bayer AG, Leverkusen, Germany

[Cardiac rehabilitation "3.0": from the acute to the chronic stage. A position paper from the Italian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR)]

Cardiac rehabilitation (CR) represents a cardiology subspecialty that is devoted to the care of cardiac patients, early and long term after an acute event. CR aims at improving both quality of life and prognosis through risk and prognostic stratification, clinical stabilization and optimization of therapy, management of comorbidities, treatment of disability, and the provision of sustained long-term preventive and rehabilitative services.The mission of CR has changed over time. From being centred on the acute phase, health care of cardiac patients is increasingly involving the long-term chronic phase. The aim of the present position paper is to provide the state of the art of CR in Italy, discussing strengths and weaknesses as well as future perspectives.

[Treatment adherence in cardiovascular prevention]

Treatment adherence is a key element for (i) improving prognosis in cardiovascular and/or high-risk patients, (ii) reducing the burden of morbidity and mortality associated with cardiovascular disease at a population level, and (iii) decreasing costs due to rehospitalizations.Promotion of adherence should embrace all pharmacological and non-pharmacological interventions in cardiovascular prevention, including lifestyle and behavioral changes. In this perspective, cardiac prevention and rehabilitation programs are the most appropriate and cost-effective setting for delivering structured and multi-component interventions on patient's adherence. In this expert opinion document authored by the Italian Association for Cardiovascular Prevention and Rehabilitation, a modern reappraisal of the adherence issue is provided, together with simple, practical, and feasible suggestions to achieve this goal in the real life as well.

Cardiac Prevention and Rehabilitation "3.0": From acute to chronic phase. Position Paper of the ltalian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR)

Cardiac rehabilitation (CR) is the subspecialty of clinical cardiology dedicated to the treatment of cardiac patients, early and in the long term after an acute event. The aim of CR is to improve both quality of life and prognosis through prognostic stratification, clinical stabilization and optimization of therapy (pharmacological and non), management of comorbidities, treatment of disability, as well as through the provision and reinforcement of secondary prevention interventions and maintenaince of adherence to treatment. The mission of CR has changed over time. Once centered on the acute phase, aimed primarily at short-term survival, the healthcare of cardiac patients now increasingly involves the chronic phase where the challenge is to guarantee continuity and quality of care in the medium and long-term. The aim of the present position paper is to provide the state-of-the-art of CR in Italy, discussing its trengths and weaknesses as well as future perspectives.

Beta-blockers after myocardial infarction: Are they useful to all patients? And how long should be the beta-blocker therapy?

Some observational studies raised questions about the need for β-blockers in all patients after a first heart attack. Surprisingly, in some clinical settings, a limited mortality reduction was found in those who received β-blockade.Some studies suggest that patients without heart failure may not need post-MI β-blockers. The lack of data from randomized controlled clinical trials has led to clinical uncertainty and conflicting recommendations. Therefore, there are multiple information to revaluate the value of β-blocker therapy after a heart attack in absence of heart failure or left ventricular dysfunction and the time for new trials of an old group of drugs has arrived.

Effects of an Outpatient Service Rehabilitation Programme in Patients Affected by Pulmonary Arterial Hypertension: An Observational Study

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare disease characterised by a severe impairment of functional status and quality of life (QoL). Use of rehabilitative programmes may help to improve outcomes. The aim of this pre/post test case series was to evaluate the impact of a training program, including sessions of aerobic and resistance exercise, inspiratory muscle reinforcement, slow breathing, relaxation, and psychological support, on functional outcomes.

METHODS

Fifteen patients affected by PAH, in World Health Organization (WHO) Functional Class (FC) II or III and in stable clinical condition, were included in a 4-week cardiorespiratory training programme conducted in outpatient service. Patients were tested during a routine control visit (T0), one month later at the beginning of the training programme (T1), and at study end (T2). Between T0 and T1, patients continued their normal activities and therapies. At each step, patients underwent respiratory and functional evaluation by spirometry, 6-minute walk test (6-MWT), maximal cardiopulmonary exercise testing (CPET), echocardiography, and levels of brain natriuretic peptide (BNP). QoL was also assessed at T1 and T2 using the Hospital Anxiety and Depression Scale and the EuroQoL-5D questionnaire. The primary endpoint was the effect of training on peak oxygen consumption (peak V̇O2).

RESULTS

There were no significant differences in BNP levels, or in any of the respiratory or echocardiographic parameters measured, between T0 and T1. Between T1 and T2, significant improvements were recorded in QoL (HADS-Anxiety mean change 3.5 ± 3.3 and HADS-Depression mean change 1.6 ± 2.0, all p < 0.01). Significant improvements were also observed in functional capacity with distance walked at 6-MWT increasing from 455 ± 115 to 487 ± 120 (+8%, p < 0.01), workload (WR) of CPET increased of 22% (from 73 ± 22 to 87 ± 21 watt, p < 0.001), peak V̇O2 increasing from 17.3 ± 4.2 to 19.9 ± 4.5 mL/kg/min (p < 0.001) and pulse O2 increasing from 7.8 ± 1.8 to 8.8 ± 2.4 mL/beat (p < 0.01). No adverse events or deterioration in clinical status were observed during the training sessions.

CONCLUSION

Cardiorespiratory training in a outpatient service is a suitable option for patients with PAH in WHO FC II/III thanks to improved exercise capacity and QoL, which may allow them to achieve better outcomes.

[Chronicity and aging in Cardiology: Geriatric Cardiology, Cardiac Rehabilitation or Care-Related Cardiogeriatric Rehabilitation? delle cure correlate?]

OBJECTIVES

The population of elderly adults is constantly increasing and age is a strong determinant of the development of chronic diseases, especially cardiovascular diseases; therefore old subjects represent a very high proportion of cardiac patients. Since cardiology is progressively more and more involved in the care of aged patients, a new area of Cardiology has been identified, the Geriatric Cardiology (GC).

METHODS

On the other hand, Cardiac Rehabilitation (CR) and GC show a wide overlap, and GC seems to be the application in the aged cardiac patient of the core-components that CR has already tested in younger cardiac patients.

RESULTS

Now, CR is probably the cardiological area that seems better equipped, both from a cultural and organizational point of view, to care the aged cardiac patients who are often complex and frail, with multimorbidity, and "frequent users" of the health care services.

CONCLUSIONS

The CR is therefore a concrete response, already ready and operative, to the demographic expansion of chronicity and aging. Beyond the definitions, CR and GC operate according to principles and methods which are in large part common; thus, CR and GC could merge themselves into a new area of cardiology, the Cardiogeriatric Rehabilitation (CGR).

How to define the relative contraindications to oral anticoagulant therapy

There is currently a lack of consensus on which anticoagulant therapy contraindications should be considered "absolute" and which should be considered "relative". Guidelines do not clearly identify absolute and relative contraindications to anticoagulant therapy. Recent guidelines on AF of the European Society of Cardiology underline the relevance of several factors and their use in scores, leaving anyway space to the clinical judgment of the physician. A high bleeding risk score should generally not result per se in a contraindication to anticoagulant therapy. Rather, bleeding risk factors should be identified and treatable factors corrected. A combined use of a more hierarchical classification of the different bleeding risk factors and the risk scores probably represents the best approach to maximize the benefit of anticoagulant therapy in various clinical settings.

Characteristics of structured physical training currently provided in cardiac patients: insights from the Exercise Training in Cardiac Rehabilitation (ETCR) Italian survey

BACKGROUND

Uncertainty exists about current delivery levels of exercise training (ET) during Cardiac Rehabilitation (CR) programmes.

AIM OF THE STUDY

To evaluate ET modalities in the real world of CR facilities in Italy.

METHODS

This was an observational survey of aggregate data, collected from CR facilities on a voluntary basis. Snapshots of a single working day at a local site were made, in terms of characteristics of patients and ET programmes delivered. RESULTS. Overall, 612 patients from 26 CR units were included, with an in-patient vs. out-patient ratio of 3:1. Coronary artery disease (57.6%), heart failure (20.3%), and valve disease/surgery (22.1%) were the most represented target groups. The prevalence of endurance continuous training, interval training, and resistance/strength training was 66.7%, 11.1%, and 9.0%; other non-aerobic endurance and non-resistance training modalities such as respiratory muscle training and calisthenics were reported in 39.9% and 42.9% of cases respectively. Workloads for endurance exercise training were determined by cardiopulmonary test, conventional 12-leads ECG exercise testing, 6min-walking test, theoretical determination of heart rate, and rating of perceived exertion in 9%, 8%, 27%, 9%, and 40% of cases respectively. The average duration of the programmes (on an intention to treat basis) was 25 sessions of 42±11  minutes, with a frequency of &gt;4 sessions/week in 67% of patients.

CONCLUSIONS

Despite advances in CR interventions, there is a significant need for improvement of functional evaluation and exercise training prescription, and consideration of a wider range of training modalities in Italy. .

[Follow-up strategies after percutaneous coronary intervention: prognostic stratification and multidisciplinary management based on patient risk profile]

The number of percutaneous coronary interventions (PCI) is increasing worldwide. Follow-up strategies after PCI are extremely heterogeneous and can greatly affect the cost of medical care. In the present paper, practical advises are provided with respect to a tailored follow-up strategy on the basis of patients' risk profile. Clinical and interventional cardiologists, cardiac rehabilitators, and general practitioners equally contributed to the creation of the present document and defined three follow-up strategies and types and timing of clinical and instrumental evaluations in post-PCI patients.

Prospective Use of Microvolt T-Wave Alternans Testing to Guide Primary Prevention Implantable Cardioverter Defibrillator Therapy

BACKGROUND

We hypothesized that a negative microvolt T-wave alternans (MTWA) test would identify patients unlikely to benefit from primary prevention implantable cardioverter defibrillator (ICD) therapy in a prospective cohort.

METHODS AND RESULTS

Data were pooled from 8 centers where MTWA testing was performed specifically for the purpose of guiding primary prevention ICD implantation. Cohorts were included if the ratio of ICDs implanted in patients who were MTWA "non-negative" to patients who were MTWA negative was >2:1, indicating that MTWA testing had a significant impact on the decision to implant an ICD. The pooled cohort included 651 patients: 371 MTWA non-negative and 280 MTWA negative. Among non-negative patients, 62% underwent ICD implantation whereas only 13% of MTWA-negative patients received an ICD (P<0.01). Despite a substantially lower prevalence of ICDs, long-term survival (6.9 years) was significantly better among MTWA-negative patients (68.2% non-negative vs. 87.1% negative, P=0.026).

CONCLUSIONS

MTWA-negative patients had significantly better survival than MTWA non-negative patients, the majority of whom had ICDs. Despite a very low prevalence of ICDs, long-term survival among patients with left ventricular ejection fraction ≤40% and a negative MTWA test was better than in the ICD arm of any study to date that has demonstrated a benefit of ICDs. This provides further evidence that MTWA-negative patients are unlikely to benefit from primary prevention ICD therapy.

[Measuring change in rehabilitative cardiology: reliability of a short questionnaire to assess an outcome]

The present Italian health planning demands the use of tools, care and treatments useful for the National Health Service, but with empirical effectiveness scientifically sustained. Aim of the present paper is to verify the validity, the reliability and the responsiveness of the factor "Perception of positive change" (named Schedule C) in cardiovascular rehabilitation.

METHOD

The reliability of the Schedule C of the CBA VE has been examined comparing the mean scores obtained from each item at the entry and just before the discharge through the t-Student for paired sample. To assess the concurrent validity we used the AD Short Scale to measure anxiety and depression. 100 patients who underwent cardiac surgery were enrolled during hospitalization for a Cardiac Rehabilitation Programme. Cronbach's alpha was used to assess internal consistency of each item.

RESULTS

Each item of the Schedule C demonstrated good internal consistency (Cronbach Alpha > .88) and elevated correlations item-total for each item. The strong correlation of anxiety and depression scores with the Schedule C points out appropriate concurrent validation.

CONCLUSIONS

We believe that the Schedule C of the CBA VE is endowed with suitable metric validity and then useful as outcome evaluation in cardiovascular rehabilitation settings.

[Prevention of sudden death in heart failure patients: cardiac resynchronization therapy with or without defibrillation back-up]

The prevalence and incidence of heart failure are progressively increasing in both Europe and the United States. Despite many advances in diagnosis and therapy, morbidity and mortality remain high and long-term prognosis is still poor in most heart failure patients. The use of implantable devices, cardiac resynchronization therapy and implantable cardioverter-defibrillators plays a pivotal role in the treatment of heart failure. Cardiac resynchronization therapy improves survival and reduces cardiac mortality due to either sudden or non-sudden death. In clinical practice, patients with an indication for cardiac resynchronization therapy should be carefully evaluated in view of a potential concomitant indication for defibrillator implantation. The combination of the two therapies may have maximal beneficial effects on prognosis.

Preoperative n-3 polyunsatured fatty acids are associated with a decrease in the incidence of early atrial fibrillation following cardiac surgery

BACKGROUND

Atrial fibrillation (AF) after cardiac surgery is associated with increased mortality, morbidity, and expenditure. Controversial data exist on possible preventive effects of n-3 polyunsatured fatty acids (PUFAs) against postoperative AF. We investigated whether preoperative PUFA therapy is effective in reducing AF after cardiac surgery during the surgical hospitalization and/or the cardiac rehabilitation period.

METHODS

Over a 4-year period, 530 patients (363 men, 68.5%) with a mean age of 66.4 +/- 10.9 years, undergoing cardiac surgery were monitored for ''early AF'' and ''late AF'' defined as AF documented in the surgical department or during the rehabilitation program, respectively.

RESULTS

The overall incidence of early AF in the whole study sample was 44.7%, whereas late AF occurred in 14.7% patients. Patients with AF had a longer length of hospital and rehabilitation stay (10.4 +/- 9.8 vs 9.5 +/- 9.2 days, P = .025 and 24.2 +/- 15.3 vs 21.1 +/- 8.3 days, P = .008, respectively). Early AF occurred in 31.0% of the patients with preoperative PUFAs compared with 47.3% of those without them (P = .006). Conversely, late AF was not influenced by preoperative PUFA regimen (11.9% vs 15.2%, P = .43). Preoperative PUFAs were independently associated with a 46% reduction in risk of early AF development (OR 0.54, 95% CI 0.31-0.92), after propensity score analysis.

CONCLUSION

Preoperative PUFA therapy is associated with a decreased incidence of early AF after cardiac surgery but not late AF. Patients undergoing cardiac surgery may benefit from a preventive PUFA approach.

[Risk stratification for sudden cardiac death: from the electrophysiological study to T-wave alternans]

T-wave alternans is a change, in the microvolt range, of T-wave amplitude on an ABABAB sequence. At present, various groups of patients have been evaluated, including those with myocardial infarction, congestive heart failure, implantable cardioverter-defibrillators and a clinical indication for programmed ventricular stimulation. In all clinical conditions analyzed, T-wave alternans analysis demonstrated a good diagnostic accuracy, suggesting a possible clinical use of the test in these settings.

Prognostic value of T-wave alternans in patients with heart failure due to nonischemic cardiomyopathy: results of the ALPHA Study

OBJECTIVES

The aim of this study was to assess the prognostic value of T-wave alternans (TWA) in New York Heart Association (NYHA) functional class II/III patients with nonischemic cardiomyopathy and left ventricular ejection fraction (LVEF) < or =40%.

BACKGROUND

There is a strong need to identify reliable risk stratifiers among heart failure candidates for implantable cardioverter-defibrillator (ICD) prophylaxis. T-wave alternans may identify low-risk subjects among post-myocardial infarction patients with depressed LVEF, but its predictive role in nonischemic cardiomyopathy is unclear.

METHODS

Four hundred forty-six patients were enrolled and followed up for 18 to 24 months. The primary end point was the combination of cardiac death + life-threatening arrhythmias; secondary end points were total mortality and the combination of arrhythmic death + life-threatening arrhythmias.

RESULTS

Patients with abnormal TWA (65%) compared with normal TWA (35%) tests were older (60 +/- 13 years vs. 57 +/- 12 years), were more frequently in NYHA functional class III (22% vs. 19%), and had a modestly lower LVEF (29 +/- 7% vs. 31 +/- 7%). Primary end point rates in patients with abnormal and normal TWA tests were 6.5% (95% confidence interval [CI] 4.5% to 9.4%) and 1.6% (95% CI 0.6% to 4.4%), respectively. Unadjusted and adjusted hazard ratios were 4.0 (95% CI 1.4% to 11.4%; p = 0.002) and 3.2 (95% CI 1.1% to 9.2%; p = 0.013), respectively. Hazard ratios for total mortality and for arrhythmic death + life-threatening arrhythmias were 4.6 (p = 0.002) and 5.5 (p = 0.004), respectively; 18-month negative predictive values for the 3 end points ranged between 97.3% and 98.6%.

CONCLUSIONS

Among NYHA functional class II/III nonischemic cardiomyopathy patients, an abnormal TWA test is associated with a 4-fold higher risk of cardiac death and life-threatening arrhythmias. Patients with normal TWA tests have a very good prognosis and are likely to benefit little from ICD therapy.

Metabolic syndrome in obstructive sleep apnea and related cardiovascular risk

BACKGROUND

There is little evidence available about the relationship between metabolic syndrome as a comprehensive clinical entity and obstructive sleep apnea (OSA) with respect to the cardiovascular risk of patients with coexisting metabolic syndrome and OSA.

METHODS

Eighty-nine consecutive patients (males 85%, aged 62 +/- 11 years) with newly-diagnosed OSA were evaluated for the presence of metabolic syndrome and the incidence of cardiovascular events after implementation of continuous positive airway pressure (CPAP) therapy was registered during medium-term follow-up. The diagnosis of OSA and metabolic syndrome was obtained by overnight polygraphy [with a presence of an apnea-hypopnea index (AHI) >or= 15] and following NCEP ATP III recommendations, respectively.

RESULTS

Forty-seven (53%) OSA patients had coexisting metabolic syndrome, with increased waist circumference (98%), high blood pressure (89%) and decreased high-density lipoprotein-cholesterol (83%) as the most frequent features. OSA patients with metabolic syndrome were also younger (58 +/- 11 years versus 65 +/- 4 years, P < 0.001) and presented an higher AHI (43.5 +/- 20.2 versus 34.8 +/- 17.3, P < 0.05) as compared to those without metabolic syndrome. Follow-up lasted 22 +/- 10 months. OSA patients who also presented metabolic syndrome suffered events less frequently compared to those who did not (6% versus 24%, P < 0.05), whereas the single end-points for follow-up (i.e. death, acute coronary syndrome, cerebrovascular event, peripheral vascular event, venous thromboembolism) did not significantly differ between the two groups.

CONCLUSIONS

Metabolic syndrome was a frequent comorbidity in OSA patients, reflecting higher degrees of sleep-disordered breathing, and did not increase the risk of cardiovascular events after adoption of CPAP therapy.

Metabolic syndrome in patients with intermittent claudication referred to vascular rehabilitation

AIM

The prevalence of the metabolic syndrome, a clustering of cardiovascular risk factors whose underlying pathophysiology is related to insulin resistance, was estimated in patients with intermittent claudication referred to a short-course intensive rehabilitation program focused on physical training. Improvements in walking distance at the end of the program were also compared among patients with and without the syndrome.

METHODS

The metabolic syndrome was documented among 34 (39%) out of 87 enrolled patients, without significant differences between those with and without the syndrome concerning sex (males 91% vs 92% respectively, P=0.816), age (64+/-8 vs 65+/-7 years, P=0.54), coronary heart disease (44% vs 32%, P=0.365), localization of peripheral arterial disease, and impairment of walking capacity as evaluated by constant treadmill test (initial claudication distance (ICD) 156+/-93 vs 176+/-126 m, P=0.428; absolute claudication distance (ACD) 429+/-324 vs 409+/-269 m, P=0.756).

RESULTS

At the end of the program, both ICD and ACD significantly improved without any of significant differences between the two groups (ICD +152% vs +174% respectively, P=0.518; ACD +112% vs +177%, P=0.053).

CONCLUSIONS

Metabolic syndrome is frequent among patients with intermittent claudication and is not associated with poor response to physical training. Our data highlight the need for considering vascular rehabilitation in these patients in order to both improve walking capacity and minimize cardiovascular morbidity and mortality.

Early EPS/ICD strategy in survivors of acute myocardial infarction with severe left ventricular dysfunction on optimal beta-blocker treatment. The BEta-blocker STrategy plus ICD trial

AIMS

This multicentre prospective randomised trial was undertaken to evaluate the usefulness of an electrophysiological study (EPS)-guided/implantable cardioverter defibrillator (ICD) strategy in patients at high risk of sudden death (SD) early after myocardial infarction (MI). Previous studies have shown the benefits of such a strategy only in high-risk patients late after MI.

METHODS AND RESULTS

We enrolled 143 survivors of acute MI (<1 month) with left ventricular ejection fraction < or = 35% and either frequent (> or =10/h) premature ventricular complexes (PVCs), or depressed heart rate variability (SDNN < 70 ms) or abnormal signal-averaged ECG, who were able to tolerate optimised beta-blocker therapy (68 +/- 40 mg/day of metoprolol). Of these, 138 were randomised, in a 2:3 ratio, to two therapeutic strategies: conventional (CONV) strategy (n = 59) or EPS-guided/ICD strategy (n = 79). The latter resulted in ICD implantation in 24 inducible patients and in CONV therapy in the remaining 55. During a mean follow-up of 540 +/- 378 days, 26 patients (19%) died: nine (6.5%) SD, nine (6.5%) non-SD, and four (3%) non-cardiac death; in four patients (3%) the cause of death was unknown. The actuarial overall mortality for the CONV and EPS-guided/ICD arms was 18% vs 14% after 1 year and 29.5% vs 20% after 2 years, respectively (P = 0.3 and 0.2).

CONCLUSIONS

Despite optimal therapy, mortality remains significant in high-risk patients following MI. Although there is a trend in favour of EPS-guided/ICD, our data are insufficient to demonstrate a survival benefit of this strategy early after MI.

Is physical training contraindicated in patients with deep vein thrombosis during cardiac rehabilitation?

Deep vein thrombosis is a potential complication in patients admitted to cardiac rehabilitation programs after acute coronary syndromes, episodes of acute congestive heart failure, and cardiac revascularization. A common clinical problem in these patients is to decide whether to start or continue physical training or not, given the risk of pulmonary embolism. Until definite evidence becomes available, careful patient selection and inpatient supervision may avoid the a priori withdrawal of such an important core component of cardiac rehabilitation programs.

Non-invasive sudden death risk stratification

Most sudden cardiac deaths are caused by fatal ventricular arrhythmias (ventricular tachycardia [VT] and fibrillation) in patients with and without known structural heart diseases. Given the large number of patients potentially at risk for developing ventricular arrhythmias, any strategy for treating them prophylactically requires efficient and effective risk stratification. Both non-invasive and invasive testing may be used for prognostic evaluation of patients with heart diseases. The optimal way to use them in the risk stratification for sudden cardiac death will depend in part on the goals of screening. At present risk markers perform better at identifying low-risk patients who may not need an implantable cardioverter-defibrillator (ICD), because all tests have a high negative predictive accuracy. In our opinion an electrophysiological test should not be performed and an ICD should not be implanted in post-myocardial infarction patients with moderate left ventricular dysfunction (left ventricular ejection fraction 30-40%) with a preserved autonomic balance and without non-sustained VT. In MADIT II-like patients electrophysiological testing does not seem necessary and an ICD could not be implanted only in patients with a negative T-wave alternans test. Most of the data available refer to patients with ischemic cardiomyopathy but the preliminary data on T-wave alternans suggest its usefulness in patients with non-ischemic cardiomyopathy too, although a large definitive study has not yet been completed in this important population.

Newly diagnosed carotid atherosclerosis in patients with coronary artery disease admitted for cardiac rehabilitation

BACKGROUND

The association of coronary artery disease (CAD) with carotid artery disease has been well documented. However, data focusing on CAD patients participating in cardiac rehabilitation programs are lacking. We studied the prevalence of newly diagnosed carotid artery disease in CAD patients admitted for cardiac rehabilitation.

METHODS

We performed carotid ultrasonography in 168 angiographically confirmed CAD patients admitted to two facilities. Patients with previous cerebrovascular episodes or carotid imaging were excluded.

RESULTS

Out of 168 patients considered (mean age 65 +/- 8 years; males 76%; chronic stable angina as the reason for cardiac rehabilitation 34%, silent ischemia 14%, and acute coronary syndrome 52%), 149 (89%) were found to have carotid atherosclerosis. Carotid atherosclerosis was present in 83, 87, 89, and 93% of patients with one-, two- and three-vessel disease and left main stem CAD respectively. Patients with severe CAD (i.e. three-vessel or left main stem) had a higher prevalence of > or = 50% carotid stenosis as compared to patients without severe CAD (26 vs 8%, p < 0.05). Severe CAD had a high negative (92%) and a low positive (26%) predictive value for the presence of > or = 50% carotid stenosis.

CONCLUSIONS

Silent and previously undetected carotid atherosclerosis is frequent in CAD patients admitted for cardiac rehabilitation. The absence of severe CAD reflects the absence of > or = 50% carotid stenosis.

Prevalence and prevention of venous thromboembolism in patients with acute exacerbations of COPD

BACKGROUND

Little information exists on the prevalence and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients admitted for acute exacerbations of chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To review available literature, we performed a Medline search on papers published on this topic between 1966 and 2003.

DATA SYNTHESIS

Pulmonary emboli have been frequently found (up to 30% of cases) in autoptic series that included patients who died from acute exacerbation of COPD, while the real incidence of PE during exacerbation has never been prospectively evaluated by large-scale clinical studies. Diagnosis of concomitant PE in these patients is often missed because symptoms of acute exacerbation of COPD may mimic PE, and non-invasive evaluation by pulmonary scintigraphy or CT scan is less specific. Even if not fatal, undetected and untreated PE may lead to long-term morbidity from pulmonary hypertension and predispose to recurrent venous thromboembolism (VTE). DVT of the lower extremities affects about 10% of patients with acute exacerbation of COPD at admission, but the rate is likely to be underestimated. The results of clinical trials conducted on general medical patients, including COPD patients, indicate that unfractionated heparin (UH) and low molecular weight heparin (LMWH) significantly reduce VTE rates. However, subgroup data on COPD patients are generally not available. In a single randomised, controlled trial specifically conducted on COPD patients, nadroparin reduced the rate of DVT from 28% to 15% without affecting mortality.

CONCLUSIONS

Despite a substantial lack of consistent data, VTE appears as a major threat to patients admitted for acute exacerbation of COPD, and pharmacologic prophylaxis should be considered in all high risk situations. However, methodologically rigorous studies in this setting are still needed.

The ALPHA study (T-wave alternans in patients with heart failure): rationale, design and endpoints

BACKGROUND

Sudden death and pump failure are the main causes of death in patients with heart failure. Patients with ischemic and non-ischemic cardiomyopathy are at similar risk of arrhythmic mortality; however, standard non-invasive and invasive tests are not routinely available for non-ischemic patients. T-wave alternans (TWA) has been proposed as a potential marker of susceptibility to ventricular tachycardia-fibrillation in several groups of patients.

METHODS

The ALPHA study was designed to evaluate the independent predictive value of the measurement of microvolt TWA on the combined occurrence, after 18 months of follow-up, of cardiac death and life-threatening arrhythmias in a population of patients with non-ischemic dilated cardiomyopathy and NYHA class II and III. This is a multicenter prospective observational study. A total of 370 patients, with measurable TWA, will be enrolled during routine follow-up for heart failure treatment; a logbook will be used to collect basic information on the whole screened population. Patients will be enrolled during a 2-year period and will be followed up for 18 months. The primary endpoint of the study will be the combined incidence of cardiac death and life-threatening ventricular arrhythmias. The study will complete recruitment by mid 2004 and report in 2006.

Economic evaluation of a short-course intensive rehabilitation program in patients with intermittent claudication

AIM

The aim of this study was to provide cost-description and cost-effectiveness of a short-course intensive in-hospital rehabilitation program in patients with intermittent claudication.

METHODS

Costs per case treated were calculated according to a local standard protocol including diagnostic evaluation of peripheral arterial disease and other related cardiovascular conditions, physical training, and secondary prevention. Three additional less structured scenarios were also evaluated.

RESULTS

All 107 enrolled patients (males 91%, mean age 65+/-8 years) completed the program (4-week duration; twice a day walking exercise) and showed significant increases in walking performance, as evaluated by constant treadmill-test. At admission, the mean values of initial claudication distance (ICD) and absolute claudication distance (ACD) were 150+/-111 and 432+/-327 m, respectively. At the end of the program, 12 (11%) patients completed the treadmill test without pain, while 31 (29%) completed the test without stopping due to maximal pain. Among the remaining 64 (60%) patients, the ICD and ACD increased by 137% and 112%, respectively. The cost per case treated ranged from Euro 1733.2 (standard protocol) to Euro 918.9 (physical training only). By adding the cost of hospitalization and indirect costs, the same costs ranged from Euro 4626.2 to Euro 3811.9. The average cost to walk one additional meter without pain as a result of the rehabilitation program was Euro 57.5, while the cost to walk one additional meter before stopping was Euro 27. As showed by sensitivity analysis, the maintenance of the expected level of treatment success was crucial for program's cost-effectiveness.

CONCLUSION

From the societal viewpoint, short-course intensive rehabilitation may be cost-effective in patients with stable intermittent claudication and could be considered in decision models evaluating different therapeutic options.

Upper extremity deep vein thrombosis and pulmonary embolism after coronary bypass surgery: a case report and preliminary results from a prospective study evaluating patients during cardiac rehabilitation

A 78-year-old woman with unstable angina underwent coronary bypass surgery with complete cardiac revascularization and no immediate postoperative complications. Six days after surgery, during hospitalization for cardiac rehabilitation, the patient developed severe respiratory distress and pulmonary embolism was diagnosed. Color duplex ultrasound revealed the presence of concomitant upper extremity deep vein thrombosis (UEDVT), ipsilateral to the site of placement of a central venous line, in the absence of lower extremity deep vein thrombosis. We describe this case and provide preliminary data from a prospective observational study evaluating the prevalence of catheter-related UEDVT and symptomatic pulmonary embolism (55 and 1.4% respectively) in a series of 71 consecutive coronary bypass surgery patients admitted to a cardiac rehabilitation facility. Catheter-related UEDVT and pulmonary embolism may complicate coronary bypass surgery and should be taken into consideration when managing patients after surgery.

Deep Vein Thrombosis Among Patients Entering Cardiac Rehabilitation After Coronary Artery Bypass Surgery

BACKGROUND

Little information is available about the prevalence of deep vein thrombosis (DVT) after discharge from cardiac surgery units and its impact on rehabilitation programs.

OBJECTIVES

To estimate the rate of DVT, in relation to different thromboprophylaxis strategies, in patients with a recent coronary artery bypass graft (CABG) entering cardiac rehabilitation.

METHODS

Two hundred seventy consecutive patients admitted to three rehabilitation facilities after CABG surgery from 19 cardiac surgery units (male patients, 81%; mean +/- SD age, 64 +/- 9 years; interval after operation, 4 to 19 days) underwent serial leg venous ultrasound examination on admission to three rehabilitative units.

RESULTS

At admission, antiplatelet treatment was present in all patients except 10 with absolute contraindications. In 171 patients (63%), heparin prophylaxis (low-molecular-weight heparin once daily, 87%; unfractionated heparin twice daily, 13%) was reported, limited to the early postoperative period (< or = 3 days) in 102 patients (38%). DVT was detected in 47 patients (17.4%). The rate of proximal and isolated distal DVT was 2.6% (7 cases) and 14.8% (40 cases), respectively. DVT was complicated in two cases (0.7%) by symptomatic pulmonary embolism, fatal in one case (0.4%). Clots were found in the leg contralateral to the saphenous vein harvest site in half of all DVT cases. Forty-three DVT cases (91%) were diagnosed at admission, while serial ultrasound testing allowed diagnosis of an additional 4 distal DVT cases. At multivariate analysis, female sex (p < 0.001) and length of stay in the surgery unit > 8 days (p < 0.05) were independently associated with risk of DVT in the rehabilitation setting. The adoption of heparin prophylaxis until discharge predicted the absence of DVT after adjustment for immobility (p < 0.05).

CONCLUSIONS

This study showed a high rate of DVT in patients entering cardiac rehabilitation after CABG surgery. Wearing unilateral graded compression stockings after CABG surgery had limited efficacy, as clots were often localized in legs contralateral to the saphenous vein harvest site.

T wave alternans is a predictor of death in patients with congestive heart failure

Few data are available about the prognostic role of T wave alternans in patients with congestive heart failure. To assess the ability of T wave alternans, used alone or in combination with other risk markers, to predict cardiac death in decompensated patients, we enrolled 46 patients, mean age 59+/-9, males 89%, ischemic etiology 61%, NYHA class III 35%, left ventricular ejection fraction 29+/-7%. After 1.6 years follow-up, seven patients died from cardiac death (16%), non-sudden in six (86%) and sudden in one (14%). T wave alternans was positive in 24 (52%), negative in 13 (28%), indeterminate in nine patients (20%). T wave alternans was positive in all patients with events (100%) but only in 16 of 37 patients without (41%) (P=0.02). Other predictors of cardiac death were O(2) consumption at the peak of exercise (P=0.03), standard deviation of all NN intervals (P=0.05) and Wedge pressure (P=0.03). When receiver operator characteristics curves were calculated, the highest area (0.73) was found for O(2) consumption at the peak of exercise considering the single variables and for O(2) consumption at the peak of exercise plus T wave alternans (0.79) for combination of them; the comparison of the two receiver operator characteristics curves did not reach statistical difference (P=0.5). In conclusion, this is the first study reporting that T wave alternans can predict cardiac death, with a marginal additional prognostic power when used in combination with measurement of O(2) consumption at the peak of exercise.

Autonomic modulation during acute myocardial ischemia by low-dose pirenzepine in conscious dogs with a healed myocardial infarction: a comparison with beta-adrenergic blockade

Experimental and clinical evidence documents the beneficial effects of blocking sympathetic activity and modulating heart rate to reduce risk for lethal events in ischemic heart disease. Beside beta-adrenergic receptor blockade, vagal activation is a meaningful approach but not yet easily attainable. Promising results were shown with low-dose atropine and scopolamine, but no follow-up was done because of significant adverse side effects. Pirenzepine is an atropine analogue approved to treat peptic ulcer disease in Europe that is devoid of central actions, which are mostly responsible for anti-muscarinic agents side effects. The vagomimetic action of IV low-dose pirenzepine was studied at rest under control conditions, at rest during acute coronary artery occlusion, and during exercise in conscious dogs with a healed anterior myocardial infarction (MI). The effects of pirenzepine were then compared, by internal control analysis, with those of atenolol (1 mg/kg). Increasing doses of pirenzepine (from 0.01 to 1 mg/kg) were tested in 11 dogs at rest by measuring time and frequency domain heart rate variability (HRV). The most effective dose (0.1 mg/kg) was used in the study. At the most effective dose, pirenzepine increased all measures of time domain HRV by 40-50%. However, the vagomimetic action of pirenzepine was lost during exercise and brief ischemia and no anti-arrhythmic action was observed. Conversely, pirenzepine effectively modulated the heart rate increase during acute ischemia at rest with an effect comparable to that of atenolol. The vagomimetic action of pirenzepine in the acutely ischemic heart supports the possibility that this intervention may be helpful for chronic autonomic modulation in post-MI patients.

A self administered tool for the evaluation of the efficacy of health educational interventions in cardiac patients

BACKGROUND

Since most cardiac rehabilitation and formal secondary prevention programmes for atherosclerotic cardiovascular disease include multidisciplinary interventions aimed at risk factors reduction and healthy lifestyle promotion, the use of specific outcome measurement instruments for the assessment of patients' knowledge before and after educational programmes should be included in usual clinical practice. For this reason we developed a new self-administered questionnaire (MaugerI CaRdiac preventiOn Questionnaire: MICRO-Q) addressed to the evaluation of information regarding secondary prevention in patients with coronary heart disease.

METHODS

The development of the questionnaire consisted of different phases aimed to define the content, the number of items and the choice of possible responses. The final version of questionnaire consists of 26 items, 18 true statements and 8 false ones, with responses true, false, or don't know. MICRO-Q provides three separate scores: correct (number of items answered correctly), misconceptions (number of items wrongly answered), uncertainty (number of items answered 'don't know'), and covers knowledge of risk factors and lifestyle, diet, pre-admission avoidable delay, and cardiac disease. MICRO-Q was administered to 250 coronary patients (206 males, 44 females), mean age 61 +/- 10 years, in different geographical areas of Italy. The questionnaire's reliability was evaluated and descriptive analyses were performed.

RESULTS

Spearman's Rho coefficient correlation (test-retest) for correct responses was 0.72, and the alpha value of the reliability analysis 0.68. Frequency analysis of each item was performed in detail. For the total score, the mean value was 18.90 (3.25) for the correct scale, 2.97 (1.66) for the misconceptions scale and 3.97 (3.56) for the uncertainty scale. Subgroups analysis of total scores showed no difference for gender and age, but patients with higher education had significantly higher scores on the correct scale (p < or = 0.0001), while patients with a lower level of education showed a higher score for misconceptions (p < or = 0.01).

CONCLUSIONS

MICRO-Q is a simple, self-administered, efficient outcome measurement tool for the assessment of the efficacy of educational interventions in cardiac rehabilitation and secondary cardiovascular prevention. Patients' level of education and some erroneous beliefs are important keys to be taken into account in planning tailored educational interventions. In patients with coronary artery disease the MICRO-Q could be an useful and reliable clinical and quality-of-care outcome indicator for cardiac rehabilitation professionals.