Massimo Sassara

L'attuale situazione nazionale comporta per le Aziende Sanitarie e Ospedaliere una continua contrazione dei costi e consumi apportata sempre più spesso da tagli lineari, con le risapute conseguenze in ambito organizzativo e di prestazioni finali per l'utenza. A luglio 2012 l'attuazione della Spending Review ha ulteriormente aggravato tale condizione, obbligando modifiche sulle strategie aziendali, con l'intento di ridurre il più possibile sprechi senza dimenticare l'attenzione ai risultati. Con l'intento di rendere più efficaci ed efficienti le risorse disponibili, l'AUSL Viterbo ha praticato da diversi anni la reingegnerizzazione dei processi, sui più disparati fronti, attuando nel pubblico una metodica caratteristica delle realtà private, permettendo ai sanitari di garantire prestazioni di qualità, fornendo prodotti e servizi nel contenimento di tempi e costi: il Public Organization Reenginee-ring mai come in questo momento è considerato lo strumento id...

Cardiac resynchronisation therapy has proven to be effective in refractory heart failure (HF) patients with QRS >120-130 ms. Therefore, the aim of our study was to verify the long-term effectiveness of cardiac resynchronisation therapy in HF patients with echocardiographic evidence of mechanical asynchrony regardless of QRS duration. One hundred and six patients with New York Heart Association class II-IV HF and echocardiographic documentation of interventricular and intraventricular asynchrony underwent biventricular stimulation. A clinical and functional evaluation was performed at baseline, 1, 3, 6 months, and every 6 months thereafter. After a median follow-up of 16 months, a significant improvement was noted in ejection fraction, left ventricular diameters, mitral regurgitation jet area, interventricular and intraventricular echocardiographic indexes of asynchrony, and the 6-min walking distance (P < 0.001 for all). Death rates for all causes and for cardiac causes were 18.2 (95% confidence interval 12.8-25.9) and 13.5 (95% confidence interval 9.0-20.3) per 100 person-years, respectively. Patients in New York Heart Association class IV had an almost three-fold increase in risk of dying as compared to class II-III (hazard ratio 2.97, 95% confidence interval 1.30-6.79). Interventricular and intraventricular asynchrony at echocardiography may be useful in identifying HF patients suitable for cardiac resynchronisation therapy, with results comparable to those obtained with QRS duration selection criteria.

Patients at risk of sudden cardiac death (SCD) after myocardial infarction (MI) can be offered therapy with implantable cardioverter defibrillators (ICDs). Whether plasma biomarkers can help risk stratify for SCD and ventricular arrhythmias (VT/VF) is unclear. The primary objective of the CAMI-GUIDE study is to assess the predictive role of C-reactive protein for SCD or VT/VF in ischaemic patients with the ejection fraction <30% and ICDs. Secondary endpoints included all-cause mortality, hospitalizations, and death from heart failure. Additional analyses incorporated cystatin-C and NT-ProBNP in multi-marker approach for the prediction of adverse outcomes. A total of 300 patients were enrolled. All-cause mortality at 2 years was 22.6%, mortality from heart failure was 8.3%. Primary endpoint occurred in 17.3%. At a competing risk multivariable analysis adjusted for baseline variables, no significant difference in primary endpoint was found between patients with C-reactive protein ≤3 vs. >3 mg/L [heart rate (HR) 0.91 (0.50-1.64) P = 0.76], while C-reactive protein >3 mg/L was strongly associated with mortality due to heart failure [HR: 3.17 (1.54-6.54) P = 0.002]. NT-proBNP above median was significantly associated with the primary endpoint [adjusted HR: 1.46 (1.020-2.129) P = 0.042]. A risk function, including the three biomarkers, NYHA class and resting HR, allowed stratification of patient mortality risk from 5 to 50%. C-reactive protein >3 mg/L is not associated with SCD or fast VT/VF, however, is a strong predictor of HF mortality. Biomarkers combined with clinical markers allow an excellent risk stratification of mortality at 2 years.