AIMS: Though various neurohormonal systems are concurrently activated during heart failure (HF), their biological effectors are not always easy to measure due to their short life in vivo, instability in biological samples, or very low concentrations. We measured the plasma concentrations of four stable precursor fragments of neurohormonal systems in patients with chronic HF and evaluated their relationship with outcome. METHODS AND RESULTS: This study was performed in 1237 patients with chronic and stable HF enrolled in the GISSI-heart failure trial (GISSI-HF). The following four precursor fragments, mid-regional pro-atrial natriuretic peptide (MR-proANP), mid-regional pro-adrenomedullin (MR-proADM), C-terminal pro-endothelin-1 (CT-proET-1) and C-terminal pro-vasopressin (CT-proAVP or copeptin), were measured at randomization and after 3 months. Baseline concentrations were independent predictors of clinical outcome (median follow-up 3.9 years). The addition of MR-proANP improved net reclassification for mortality when added to multivariable models based on clinical risk factors alone [net reclassification improvement (NRI)= 0.12, P = 0.0007] or together with NT-proBNP (NRI = 0.06, P = 0.01). Changes in MR-proANP concentrations were related to mortality [HR (95% CI) 1.38 (0.99-1.93), P = 0.0614 and 1.58 (1.13-2.21), P = 0.0078 in the middle and highest vs. lowest tertiles], while changes in the other markers were not. CONCLUSION: In patients with chronic and stable HF enrolled in a multicentre, randomized, clinical trial, measurement of stable precursor fragments of vasoactive peptides provided prognostic information independent of natriuretic peptides which are currently the best biomarkers for risk stratification.

Practice Pearl: These preliminary data from the SCOUT trial appear to demonstrate that sibutramine is well tolerated by high-risk cardiovascular patients. Original Article: Torp-Pedersen C, Caterson I, Coutinho W, et al; SCOUT Investigators. Cardiovascular responses to weight management and sibutramine in high-risk subjects: an analysis from the SCOUT trial.

PURPOSE: To analyse discharge prescription of recommended treatments in patients with ST-segment elevation myocardial infarction (STEMI) according to reperfusion strategies. METHODS: IN-ACS (Italian Network on Acute Coronary Syndromes) Outcome, an observational, multicenter study, enrolled 6045 ACS patients admitted within 48 h. In the present study we compared the discharge prescription rates of secondary prevention drugs among the 2144 patients with STEMI (72.5% men, age 65+/-13 years) who received primary percutaneous coronary intervention (pPCI) 1044 (48.7%) or thrombolytic therapy (TT) 575 (26.8%) or no reperfusion treatment (NR) 525 (24.5%). RESULTS: Despite the higher risk profile, NR patients respect to pPCI and TT were less frequently receiving antiplatelet (93.0% versus 99.7% versus 96.4%), dual antiplatelet (57.9% versus 93.9% versus 62.8%), beta-blockers (71.2% versus 82.9 versus 75.0%) and statins (68.4% versus 78.6% versus 76.9%)(P <0.0001) at discharge. After multivariable analysis, NR respect to pPCI was an independent predictor of not receiving antiplatelet (OR: 19.6; 95% CI: 6.0-62.5), dual antiplatelet (OR: 10.2; 95% CI: 7.6-13.5), beta-blocker (OR: 1.6; 95% CI: 1.3-2.0). CONCLUSIONS: According to our results NR patients with STEMI, despite their higher risk profile, were less likely to receive the recommended drugs at discharge compared to patients treated with pPCI.

BACKGROUND: Intensive cardiac care units (ICCUs) have shifted from the observation of patients with myocardial infarction to the care of different acute cardiac diseases. However, few data on such an evolution are available. METHODS AND RESULTS: From 7 to 20 April 2008, 6986 consecutive patients admitted to 81% of Italian ICCUs were prospectively enrolled. Patients observed were mainly elderly men (median age 72 years) with several co-morbidities. Most of them were triaged to ICCU from the emergency room, but 15% of admissions were transfer-in from other hospitals. Several diagnostic and therapeutic procedures were applied (78% had echocardiography and 35% coronary angiography) during the ICCU stay [median length 4 days, interquartile range (IQR) 2-5]. The discharge diagnosis was ST-elevation acute coronary syndrome (ACS) in 21%, non-ST-elevation ACS in 31%, acute heart failure (AHF) in 14% and other acute non-ACS, non-AHF cardiac diseases in 34%. Of those with ST-elevation ACS, 60% received reperfusion (15% fibrinolysis and 45% primary percutaneous coronary intervention). The overall in-ICCU crude mortality was 3.3%. CONCLUSION: The BLITZ-3 survey provides a unique snapshot of current epidemiology and patterns of care of patients admitted to ICCUs. Although ACS still remains the most frequent admission diagnosis, the number of non-ACS patients is substantial. However, the correct standard of care for these non-ACS patients has to be defined.

Abstract Background Randomized controlled trials have generated strong evidence on the efficacy of electrical device therapy in selected patients with heart failure (HF). The enrolment criteria of these three trials generated patient profiles that helped to shape current guidelines on chronic heart failure (CHF) treatment and sudden cardiac death (SCD) prevention. We investigated the prevalence of trial-generated profiles for implantable defibrillator or cardiac resynchronization therapy candidacy among HF outpatients; we explored differences between real-world and trial populations and we evaluated 1-year survival without device treatment. Methods We reviewed Italian Network on Congestive Heart Failure (IN-CHF) registry patients (n = 4977) enrolled in a period (1995-2000) roughly concurrent with the MADIT-II and SCD-HeFT trials. Results Regarding device eligibility, 14.5% IN-CHF patients at entry satisfied MADIT-II criteria, 6.8% satisfied CARE-HF criteria and as many as 47.9% fulfilled SCD-HeFT criteria. One-year overall mortality among non-implanted patients was 1.5 to 2-fold higher in each of these subgroups than in control arms of the corresponding trials. Among registry patients, different trial-profile combinations were associated with a wide range of 1-year outcomes (mortality, 8-35%; SCD/total mortality ratio, 0.35-0.57). Despite clear differences between registry and trial patients in pharmacological therapy (and clinical characteristics), none of the main drug classes independently predicted 1-year mortality in any of the IN-CHF subgroups. Conclusions As many as half the IN-CHF outpatients fulfilled current criteria for device implantation. Various subgroups had higher 1-year mortality than patients in trial control arms - a finding that may not be entirely attributable to differences in drug therapy (especially beta blockers).

BACKGROUND: Renal dysfunction is frequently associated with heart failure and strongly influences the outcome of heart failure patients. Although recommended pharmacological interventions for heart failure may contribute to the development of, or worsen renal dysfunction, their relations with renal function have not been fully explored in an unselected community population. METHODS AND AIM: We studied 1008 patients recruited in the Italian survey on acute heart failure to assess the prevalence, the prognostic role of renal function and the relations between the changes in renal function and the pharmacological interventions during hospitalization and at 6-month follow-up. Patients were categorized using the National Kidney Foundation cut-offs for degree of renal function measured by the glomerular filtration rate. RESULTS: Moderate-to-severe renal dysfunction was diagnosed in 59% of patients at hospital admission and 61% at discharge. These patients were older and had a higher prevalence of diabetes, anemia, history of hypertension, myocardial infarction and hospitalization for heart failure than those with normal or mildy impaired renal function. At admission the former were treated more frequently with diuretics, angiotensin converting enzyme-inhibitor (ACEi) or angiotensin receptor blockers (ARBs) than the latter. Diuretics were given at higher dose and for a longer time during the hospital stay while beta-blockers, digoxin, antialdosterone agents, ACEi and ARBs were given less frequently in patients who had moderate-to-severe renal dysfunction than those who did not. High-dose diuretic treatment, inability to start or maintain beta-blockers during hospital stay and the nonprescription of ACEi/ARBs at discharge emerged, by multivariate analysis, as predictors of death at 6-month follow-up (mortality rate = 14%), independent of the persistence of moderate-to-severe renal dysfunction over time, anemia, male sex and history of heart failure. CONCLUSIONS: In acute heart failure, renal dysfunction is frequent and impacts prognosis. In this setting, the pharmacological interventions are significantly associated with changes in renal function and 6-month mortality.

Imaging evaluation of uterine masses is important to assess the type of lesion and to target surgery, if surgical excision is necessary. This can be decisive in fertile women with benign masses resembling malignancies, in order to avoid overtreatment. In this study, the magnetic resonance imaging (MRI) appearance of cotyledonoid dissecting leiomyoma of the uterus, a rare benign variant of leiomyoma mimicking malignancy, is presented.

BACKGROUND:-Increased urinary excretion of albumin is an early sign of kidney damage and a risk factor for progressive cardiovascular and renal diseases and heart failure (HF). There is however, only limited information on the prevalence and prognostic role of urinary albumin excretion in patients with established chronic HF. METHODS AND RESULTS:-A total of 2131 patients enrolled in 76 sites participating in the GISSI-Heart Failure trial provided a first morning spot sample of urine at any of the clinical visits scheduled in the trial to calculate the urinary albumin-to-creatinine ratio (UACR). The relation between log-transformed UACR and all-cause mortality (428 deaths, time from urine collection to event or censoring) was evaluated with Cox multivariable models adjusted for all significant risk factors at the time of urine collection, in the study population and in patients without diabetes or hypertension. Almost 75% of the patients had normal urinary albumin excretion but 19.9% had microalbuminuria [30-299 mg/g creatinine] and 5.4% overt albuminuria [>/=300 mg/g]. There was a progressive, significant increase in the adjusted rate of mortality in the study population (HR [95%CI]= 1.12 [1.05-1.18] per 1 unit increase of log(UACR), p=0.0002) and in the subgroup of patients without diabetes or hypertension. Randomized treatments (n-3 polyunsaturated fatty acids or rosuvastatin) had no major impact on albumin excretion. CONCLUSIONS:-Independently of diabetes, hypertension or renal function, elevated albumin excretion is a powerful prognostic marker in patients with chronic HF.