European Heart Journal (1997) 18, 1457-1454
Survey on heart failure in Italian hospital cardiology
units
Results of the SEOSI study
The SEOSI Investigators
In 12 days, 3921 patients were enrolled. Mean age was
67 ± 12 years (median 69); 49% of the patients were in
NYHA class III-IV; atrial fibrillation was present in 27%;
35% of the cases were scheduled for hospital admission.
Ischaemic heart disease was the primary cause of heart
failure (42%); arterial hypertension accounted for 20%,
idiopathic dilated cardiomyopathy for 15% and cardiac
valve disease for 15%. A chest X-ray, ECG and echocardiogram were performed in 70-80% of cases; ambulatory
ECG in 36% and exercise testing in 11%. ACE inhibitors
were administered to 63-5%, calcium antagonists to 19%
and beta-blockers to 5-5%. No significant differences in
Introduction
Although chronic heart failure is a major and increasingly recognised public health problem, limited epidemiological data are available'1"21'. Recent studies show
that treatment of heart failure reduces morbidity and
mortality, which nonetheless remain extremely high.
Thus, the disease is common, responds to available
treatment but has a poor prognosis. A huge economic
burden ensues'22'231, hospitalization and instrumental
investigation being the major sources of expense.
Policies and the attitude of both physicians and patients
are the crucial determinants of the overall impact of the
disease on the national health system.
The Italian Association of Hospital Cardiologist
(ANMCO) undertook a nationwide observational study
Accepted 14 February 1997.
drug prescription were noted in relation to NYHA classification. Multidrug use was common (3-6 ± 1-6). Main advice
was: salt restriction (47%) and rest (44%); physical activity
and a formal exercise programme were prescribed to 10%
and 5% of patients, respectively. Most patients were
addressed to hospital follow-up.
Thus, heart failure represents a heavy burden for hospital
cardiology units. It can be estimated that about 190 000
patients with heart failure seek care at hospital cardiology
units each year and about 65 000 are admitted as inpatients.
Cardiologists are reasonably well oriented regarding
both examinations required and the prescribing of drugs.
Beta-blockers and physical exercise are prescribed very
cautiously. The format of the present trial, characterized by
brevity, simplicity and low cost, could be used as a tool to
gain periodical information on several aspects of national
health systems and physician behaviour.
(Eur Heart J 1997; 18: 1457-1464)
Key Words: Heart failure, heart failure units, epidemiology, cardiology hospital care unit, decision making.
aimed at assessing the impact of the disease on hospital
cardiology units. The hospital was considered as an
observatory of a cohort of patients having such symptoms who sought hospital medical care. The main goals
of the study were: (1) to evaluate how many patients with
suspected or known heart failure consecutively approach
a hospital cardiology unit; (2) to assess their clinical
characteristics; (3) to define the diagnostic-therapeutic
processes set in motion by the cardiologist; (4) to evaluate the social and emotional impact of the disease on the
patient. Thus this study was designed to explore one
particular area of the cardiological health system rather
than be an epidemiological study on heart failure.
Methods
The ANMCO network has extensive experience in
Correspondence: L. Tavazzi, Centro Studi ANMCO, Via La conducting large clinical trials (such as the GISSI
studies) and is well trained in pursuing cooperative
Marmora 36-50121 Florence, Italy.
0195-668X/97/091457+08 S18.00/0
© 1997 The European Society of Cardiology
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Three hundred and fifty nine cardiology units participated
in a study (SEOSI) coordinated by the Association of
Italian Hospital Cardiologists (ANMCO). The aim of the
study was to: (1) evaluate how many patients with suspected or known heart failure consecutively approach a
hospital cardiology unit; (2) assess their clinical characteristics; (3) define the diagnostic-therapeutic processes set
in motion by cardiologists; (4) evaluate the social and
emotional impact of the disease on the patient.
1458 SEOSI Investigators
investigations. In this favourable setting, a new investigation was set up. The format consisted of a registry
with simple forms to be filled in over a short period of
time. These were sent to all cardiology units. No grants
were offered to the investigators, and cardiologists
were invited to participate on the assumption that the
study data would lead to a better organized national
health system. Out of the 669 hospital cardiology units
operating in Italy, 359 centres (54%) participated.
Inclusion criteria
Data collection and analysis
Two questionnaires were to be completed, one by cardiologists, the other by patients. The latter investigated the
social and emotional impact of the disease and the
patient's satisfaction with the medical care. These results
are not reported here.
The cardiologist's questionnaire explored the following areas: (1) demography; (2) symptoms and signs
of the disease; (3) aetiology; (4) examinations required
at the index visit or performed within the previous 3
months; (5) therapy and advice; (6) where the patient
was referred to after the index visit. The study forms had
to be filled in at enrolment. Thus the examinations listed
in the forms were those required by the cardiologist
according to his/her intention at the visit.
The project was coordinated by ANMCO
Research Centre. ANMCO is organised in regional
networks; the regional delegates were responsible for the
Eur Heart J. Vol. 18, September 1997
Centres
Participating
Geographical area
North
Central
South
Centres' equipment
Catheterization laboratory
Catheterization laboratory
and cardiac surgery
None
All
41
25
34
37-5
24-5
38
11
9
9
8
80
83
preparation of the study in their areas. The analysis of
the data was performed by the Clinical Research Unit of
the Salvatore Maugeri Foundation, Gussago, Brescia.
A descriptive analysis of data was performed.
For comparison of clinical characteristics and treatments a chi-square test was used.
Results
Over 12 days, 3921 patients were enrolled. Two hundred
and nineteen units admitted less than 11 patients; 130
units between 11 and 30, 10 units more than 30 patients.
Diagnosis of heart failure was considered by the physician responsible as definite in 84% of the cases, probable
in 12%, possible in 3%, and undefined in 1%. It was
subsequently confirmed by the coordinating centre, according to the criteria described in the Method section,
in 75% of all cases. The main clinical characteristics
of the patients are reported in Table 1. Mean heart rate
was 85 ± 20 beats . min~'; mean systolic and diastolic
blood pressure was 139 ± 25 mmHg and 82 ± 12 mmHg,
respectively. Mean age was 67 ±12 years (median 69
years); 25% of patients were aged more than 75 years.
The cause of the heart failure was considered certain in
66% of the cases, presumed in 22%, and undefined in
12%. Ischaemic heart disease was the most frequent
aetiology (42%: 33% isolated, 9% combined). Seventy
percent of these subjects had had a previous myocardial
infarction. Hypertensive heart disease was considered to
be the primary cause in 15% of the patients (combined in
20%); 35% of these patients at the index visit had a
systolic pressure > 160 mmHg, while 30% had a diastolic
pressure >95 mmHg. Overall about half of the patients
enrolled were in NYHA class III—IV; more than one
quarter of the patients had sustained atrial tachyarrhythmias, atrial fibrillation being present in 27-1% of
cases, atrial flutter in 11%.
Table 2 reports the examinations done within the
previous 3 months or required at the index visit. Blood
chemistry, ECG, chest X-ray and echocardiogram were
performed routinely. Ambulatory ECG was required in
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The survey lasted 12 days (21 November to 2 December
1994). Over this time, all adult subjects (aged 15 years or
more) with proved or suspected heart failure examined
either as outpatients or admitted as inpatients to the 359
hospital cardiology units were enrolled. The cardiology
units were homogeneously distributed throughout the
country. The main cardiological equipment of the participating centres, compared to all Italy's cardiological
centres, is reported in Table 1, as a gross indicator of the
centres' status. The participating centres are representative of Italy's network of hospital cardiology units.
Heart failure was diagnosed as definite, probable, possible or undefined on the bases of the clinical
judgement of the physician. No diagnostic criteria were
provided, consequently no confirmation of diagnosis
was made by the responsible physician. Diagnosis was
subsequently checked by the coordinating centre, according to the presence of at least two major criteria or
one major and two minor criteria for heart failure in the
cardiologists' records. Major criteria were: paroxysmal
nocturnal dyspnoea, orthopnoea, pulmonary congestion
estimated by physical examination and/or by chest
X-ray, presence of third heart sound. Minor criteria
were: signs of peripheral congestion (oedema, hepatomegaly, ascites), dyspnoea, <400 m walked without
symptoms during normal daily activity.
Table I Characteristics of the Italian cardiological centres participating in the study with respect to all national
centres
Heart failure in Italian CUs
Table 2 Demographic and clinical characteristics
(n = 3921)
39-6
35-7
24-7
60 4
330
15-3
151
14-7
0-9
0-4
4-9
15-7
76
6-9
43-8
360
12 6
0-7
49-7
331
32-8
75-5
28-2
8-7
0-5
NYHA = New York Heart Association.
•"Combined: more than one aetiology primarily involved.
Table 3 Examinations required at the index visit or
performed within 3 months before enrolment
(n = 3921)
Electrocardiogram
Echocardiogram
Chest X-ray
Blood chemistry
Ambulatory electrocardiogram
Exercise test
Respiratory function
Coronary artery angiography
Right heart catheterization
Neurohumoral evaluation
Myocardial perfusion scintigraphy
Radioisotopic ventriculography
Cardiac biopsy
814
73-1
690
790
35-8
11-4
7-2
6-5
41
3-6
3-2
2-9
10
35% of the cases, all other examinations much less
frequently. Exercise testing was performed in about 11%
of patients, in half of them with determination of oxygen
consumption. Radioisotopic ventriculography was required in less than 3% of patients. Coronary angiography and perfusional myocardial scintigraphy were
mainly required in patients with ischaemic heart disease.
Drug treatment according to NYHA class is
reported in Table 3; Table 4 gives the medication
prescribed according to aetiology. Diuretics were administered to 77% of the patients, ACE inhibitors to 64%,
digitalis to 63% and nitrates to 40%. Calcium antagonists were prescribed to 32% of patients with hypertension, 24% of those with ischaemic heart disease, 12%
of those with valve disease and 6% of subjects with
idiopathic dilated cardiomyopathy. Beta-blockers were
administered to 6% and 7% of patients with ischaemic
heart disease and idiopathic cardiomyopathy, respectively, and to less than 5% of the other patients, including
those with valve disease or hypertension. No significant
differences were noted in drug prescription among
patients in relation to NYHA classes. The number of
drugs prescribed was 36 ± 1-6 and 3-5 ± 1-7 in patients
of NYHA classes I and IV, respectively.
Therapy was changed at the index visit in 1959
patients; in 72-5% of cases because of symptom deterioration, in 3% because of symptom improvement and in
6% as a result of new information derived from medical
literature. In 115 patients, changes in the treatment were
due to drug-related adverse effects: calcium antagonists
were replaced in 24% of the cases, digitalis in 20%, ACE
inhibitors in 19%. Interestingly, 1240 patients (32%)
were invited to directly manage the dosage of some
drugs, including diuretics (27%) and anticoagulant
agents (14%). In 24% of the cases, cardiologists stated
that they invited the patients to adjust the dosage of
drugs, although they failed to specify which drugs.
The advice given by the cardiologists is reported
in Table 5. Salt-restriction appears to be frequently
recommended to patients of all NYHA classes. Physical
exercise was suggested to relatively few patients and a
formal programme of physical activity was prescribed to
only about 5% of patients (including very light bed
exercise inpatients with advanced disease).
Twenty-six percent of the patients included were
already in hospital at the time of enrolment or admitted
immediately after examination as outpatients. A further
7% were listed for eventual hospital admission, and
1-5% were offered evaluation for heart transplantation.
Eight percent of the patients were referred to their
family physician after the visit and the remaining were
invited for subsequent follow-up visits at the hospital
cardiology unit.
Discussion
The SEOSI study evaluated and described the impact of
heart failure on Italian hospital cardiology units. It was
devised as an investigation of the health system in terms
of needs and medical care rather than as an epidemiological study of heart failure. Only those patients presenting themselves spontaneously or referred to hospital
cardiology units were considered. Although there are a
number of hospital cardiology units throughout the
country, a considerable number of patients with heart
Eur Heart i, Vol. 18, September 1997
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Age (years)
<65
65-75
>75
Sex
Male
Aetiology
Ischaemic heart disease
Idiopathic dilated cardiomyopathy
Arterial hypertension
Cardiac valve disease
Hypertrophic cardiomyopathy
Congenital heart disease
Others
Combined*
Symptom duration >2 years
NYHA functional
Class I
Class II
Class III
Class IV
Missing
Pulmonary congestion
Peripheral congestion
Third heart sound
<400 m walked without symptoms
Tachyarrhythmias
Pacemaker
Automatic cardioverter-defibrillator
1459
1460 SEOSI Investigators
Table 4 Medication (in percent) according to the NYHA classification
NYHA class
n
I
270
II
1718
III
1412
IV
495
All pts
3895*
Diuretics
ACE inhibitors
Digitalis
Anticoagulants
Antiplatelets
Nitrates
Calcium antagonists
Antiarrhythmics
Beta-blockers
58-5
64-8
43-3
151
29-3
30-7
21-5
17-4
12-6
74-4
65-6
59-4
19-8
33-6
35-9
196
180
61
82-6
65-5
70-9
230
30-5
45-8
19 3
19-5
40
79-0
55-2
630
22-6
26-7
39-4
15-8
18-4
3-4
76-8
63-5
62-8
20-9
31 3
396
19-2
18 5
5-5
NYHA = New York Heart Association.
*NYHA class evaluation was missing in 26 patients.
Table 5 Medication (in percent) according to aetiology
Valve
disease
Idiopathic
cardiomyopathy
Arterial
hypertension
1650
77-6
65-6
56 1
17-2
481
65-3
24-2
20-5
61
891
78-6
51-7
70-8
36-7
19 3
28-4
121
16-2
41
646
86-5
83-6
77-7
25-8
25-1
25-2
6-2
23-4
7-7
840
65-4
57-0
54-0
6-2
21 3
241
31-9
11-2
4-4
T h e total number is greater than 3921 because some patients had more than one aetiology
described.
failure are managed in other hospital departments,
mainly general medicine. These patients were not considered in our study. Furthermore, elementary information, such as diagnosis and aetiology of heart failure,
was left to the judgement of individual cardiologists,
without restricting predefinitions. Such neutrality, used
in other studies'5'91 was intentional, as we aimed at
obtaining a realistic picture of the daily impact of heart
failure (definite or suspected) on the hospital cardiology
units rather than a precise evaluation of the prevalence
of the syndrome.
The results show that the burden generated by
the disease on the health system is remarkable. Assuming that the 310 units not participating in the study show
a situation comparable to that of the participating 359
units, (as the type of units and regional distribution
would suggest) and that the condition over the short
12 day period can be extended to a year-long term, it
can be estimated that in Italy about 190 000 patients
with suspected or known heart failure are examined in
hospital cardiology units every year. Of these, about
65 000 will probably be admitted to hospital, while
about 70% of all patients will have blood examinations, electrocardiograms and echocardiograms. In
1994 the average length of admission for heart failure
in Italy was 11 -6 days. From this it follows that heart
Eur Heart J, Vol. 18, September 1997
failure accounts for about 777 000 days of cardiological bed occupation per year. A further large number of
patients is presumably cared for in general medicine
and geriatric units. These rough data illustrate the
extent of a public health problem largely unexplored.
This becomes critical in our country where until 1994
hospital discharge documents were only used statistically for records. The degree of accuracy (or inaccuracy) in their completion had no implications for either
the staff or the hospital of origin, and data were
not subjected to any verification. This is particularly
worrying for heart failure'24', which is a poorly defined
syndrome still difficult to diagnose'25261. In diagnosing
heart failure, the cardiologists involved in the SEOSI
study had a high degree of accuracy. Central validation
of diagnosis was mainly based on clinical evidence of
congestion, which in a cardiological setting is probably
reasonably specific but, due to the widespread use of
diuretics, is not very sensitive. Our criteria for definition
of heart failure were similar to those used in the
Boston'"'261 and Framingham classification studies'141.
They include symptoms and signs associated with
severe heart failure, making the recognition of mild or
compensated forms of the syndrome difficult.
The extent of the public health problem from
heart failure emerging from this study is similar to those
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Patients (n)*
Diuretics
ACE inhibitors
Digitalis
Anticoagulants
Antiplatelets
Nitrates
Calcium antagonists
Antiarrhythmics
Beta-blockers
Ischaemic
heart disease
Heart failure in Italian CUs
Table 6 Physician advice (in percent) according to
NYHA classification
NYHA class
Patients (n)
I
270
II
1718
III
1412
IV
495
All pts
3895*
None
Diet limitation
Salt restriction
Rest prescription
Bed rest prescription
Physical activity
Physical exercise programme
Missing
28-5
38-9
370
4-4
3-3
18 9
4-8
2-6
14-6
38-2
47-7
19-7
9-9
151
60
2-6
11-2
331
49-4
30-3
24-8
5-9
4-2
5-2
7-5
28-7
42-6
19-8
600
1-2
1-8
5-4
13 4
351
46-9
22-4
21-2
10-2
4-7
3-9
*NYHA class evaluation was missing in 26 patients.
Although different definitions, diagnostic procedures and enrolment criteria in epidemiological studies
lead to uneven rates of prevalence and incidence of heart
failure, it is clear that both increase markedly with
age'10'141. In Northern Italy, in a sample of 6529 subjects,
aged 20-64 years, prevalence of heart failure was 6%
in people aged 55-59 years and 11-4% in those aged
60-64'131. In 1323 patients consecutively admitted to 26
geriatric wards in Italy in 1992, the prevalence of heart
failure was 43-2% in those aged 65-74 years and 58-2%
in those >85 years'201. In the U.S.A."41, among the 9405
Framingham Heart Study participants followed for 40
years, the annual incidence of heart failure increased
from three cases/1000 in subjects aged 50-59 years to 27
cases/1000 in those aged 80-89. The prevalence also
increased from eight cases/1000 subjects aged 50-59
years to 66/1000 in those aged 80-89"41.
The mean age of patients enrolled in the SEOSI
was 67 years, the median 69, consistent with the observations of the Framingham Heart Study, which reported
that heart failure occurs in patients aged 70 years as a
mean'141. This aspect, on the mean age of the population,
is of great importance since existing clinical trials on
drug efficacy in heart failure refer to a decidedly younger
population29"321.
Enrolment through hospital cardiology units
may explain some general features of the study. In the
first place, the severity of the disease: about half the
patients had moderate to severe heart failure. Presence
of atrial fibrillation was frequent, affecting more than
one in four patients.
Secondly, the aetiology: 42% of patients had
ischaemic heart disease, 20% were hypertensive. This
latter figure is comparable to that observed in Sweden,
but lower than that recognised in the Framingham
Study'331. This probably reflects the fact that in Italy
patients with ischaemic, valvular or idiopathic heart
disease are preferentially referred to hospital cardiology
units, while those with hypertension are also referred to
general medicine units. A valvular aetiology was more
frequent in the SEOSI study than in others'331. Acute
rheumatic fever is now uncommon in Italy. Consequences of the disease, however, developing decades
later, still exist, especially in the Southern areas. In
addition, incidence of degenerative valve diseases is
increasing, particularly in the elderly.
Thirdly, the instrumental investigation: twodimensional echocardiography is the most frequently
used technique in patients with heart failure, confirming that in Italy ventricular function is preferentially
assessed by echocardiography. Exercise testing is uncommon and systematically performed only in those
hospitals with an interest in heart failure and in patients
with severe decompensation. Also, right heart catheterization is routine practice only in patients with severe
heart failure, mainly in candidates for heart transplantation. Despite the role of neurohumoral activation in
the evolution of the syndrome of heart failure, procedures to assess the neuroendocrine profile of patients
are poorly defined and not yet routinely practised in
hospital cardiology units.
Fourthly, drug treatment: the majority of patients, including those with mild failure, were receiving
ACE inhibitors and diuretics. ACE inhibitors are nonetheless still under-used, with a tendency to an even more
cautious prescription in severely ill or elderly patients, in
whom management of these drugs may be more difficult.
On the other hand, prescription of digitalis increased
with deterioration of symptoms. Use of nitrates, calcium
antagonists and antiarrhythmic agents is influenced
more by the aetiology than by the severity of heart
failure (i.e. NYHA class). Nitrates are mainly prescribed
Eur Heart J, Vol. 18, September 1997
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in other countries. In the U.S.A., it is estimated that
heart failure afflicts more than 3 million people and at
least 400 000 new cases of heart failure are diagnosed
each year. Despite the advances in therapy, heart failure
is the principal cause of death (40 000) and contributes
to 250 000 other deaths each year'23-271. In 1991, there
were 2 280 445 hospital discharges from non-federal
hospitals coded with a primary and secondary diagnosis
of heart failure, with an average length of hospitalization of 7-7 days'231. In 1990, 3 458 000 patients with
heart failure were seen in an outpatient setting, receiving
care over 11 396 000 appointments (3-4 per patient). In
1991, the economic burden of heart failure inpatient care
was estimated at 23-1 billion USS. The addition of 270
million USS for heart transplantation in 1800 end-stage
patients and the outpatients' costs makes the total health
care cost for heart failure in 1991 381 billion USS, that
is 5-4% of the total health care expenditure in the U.S.A.
that year'231. Similar figures are reported for Europe.
In 1989, data from the Swedish National Board of
Health and Welfare showed heart failure to be the
first-listed diagnosis, accounting for 20% of discharges
and more than 30% of days in hospital'221. The total
expenditure for heart failure was estimated to be more
than 1 million USS (about 800 million SEK for a
population of 8 million)'221. The estimated cost of heart
failure in the Federal Republic of Germany in 1985 was
almost 5 billion USS (6-8 billion DM) for a population
of 77 million'91. In the U.K. (with a population of
approximately 55 million) 100 000 to 200 000 cases of
heart failure are estimated to be admitted annually to
hospitals'91.
1461
1462
SEOSI Investigators
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therapy on mortality in chronic congestive heart failure.
Results of a veterans administrative cooperative study. N Engl
J Med 1986; 314: 1547-52.
[31] The SOLVD Investigators. Effect of enalapril on survival in
patients with reduced left-ventricular ejection fraction and
congestive heart failure. N Engl J Med 1991; 325: 293-302.
[32] The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in
patients with mild to moderate heart failure. JAMA 1988; 259:
539^4.
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in patients with ischaemic heart disease. Calcium antagonist administration remains relatively high, probably
more than is desirable. Antiarrhythmic drugs are prescribed to about one in five patients, independent of
the severity of heart failure. Beta-blockers are almost
unused. Multidrug therapy is common.
Fifthly, patient care: overall, during the study
period, care of most patients was provided by the
hospital cardiology units, either as in- or outpatients.
Few patients were referred to general practitioners. This
is probably peculiar to Italy's health system structure.
This information is important at a national level, as it
suggests that hospital cardiology units play a major role
in the care burden associated with this disease.
Sixthly, diffusion of heart transplantation: only
a few patients were evaluated for this procedure. This
is largely due to the advanced age of the population, but
at the same time confirms that in our country transplantation represents a solution for just a minority of
patients.
Finally, the widespread participation in this
study by hospital cardiology units is so encouraging that
the same model has been used for other nationwide
studies and could perhaps be used elsewhere. The overall
cost was only about 30 000 US$. In our view, the
brevity, simplicity and low cost of this investigational
approach make it a well-suited instrument for responding to public health demands concerning epidemiological evolution, physician behaviour, and the nationwide
activities of operative units or laboratories of critical use
or high cost. The key point underlining its feasibility is
that physicians want to be actively involved in the
organization of the new national healthy system, and
can do this by providing reliable data. Participation in
trials such as SEOSI should be considered part of
routine medical activity. Most Italian cardiologists have
shown that they agree with this concept.
Heart failure in Italian CUs
[33] Kannel WB, Ho K, Thorn T. Changing epidemiological
features of cardiac failure. Br Heart J 1994; 72 (Suppl): S3-S9.
Appendix
Participating clinical centres
Abbadia S. Salvatore (A. Totteri); Acireale (F. Porto); Acquaviva
delle Fonli (G. Grimaldi); Acqui Terme (G. Costantino); Agnone
(G. Attademo); Agordo (L. Parissenti); Albano Laziale S. Guiseppe
(M. R. Menaguale); Albano Laziale Regina Apostolorum (M.
Capo); Albenga (S. Magni); Ancona Umberto I (C. Campodonico);
Ancona Sestilli Divisione (L. Quattrini); Ancona Sestilli Servizio (S.
Bassotti); Ancona Lancisi II Divisione (G. P. Cesari); Ancona
Lancisi Servizio (L. Pasetti); Andria (G. Cannone); Aosta (V. Bigo);
Arco (G Mirante Manni); Arezzo (L. Tellini); Ariano Irpino (C.
Fiore); Arzignano (M. Boschello); Asti (G. Zola); Augusta (G.
Passanisi); Avellino Multizonale Divisione (G. Rosato); Avelhno
Multizonale Servizio (M. Genovese); Avezzano (F. Tiburzi);
Aviano (G. Calzavara); Badia Polesine (R. Rambaldi); Barga
(C. Volterrani); Bari-Carbonara (N. D'Amato); Bari CTO (N.
Locuratolo); Bari Mater Dei (M. Tritto); Bari Policlinico Divisione
(R. Guglielmi); Bari Policlinico Servizio (M. Campaniello);
Bari Policlinico Riabilitazione (G. Castallaneta); Barletta (F.
Cappabianca); Battipaglia (M. Maina); Belluno (O. Palatini);
Benevento (P. Silvestri); Bergamo (G. Tasca); Bibbiena (M. Marri);
Biella (D. Torta); Bisaccia (G. Macina); Bologna Bellaria (G. Di
Pasquale); Bologna Maggiore (G. Leonardi); Bologna Malpighi
(A. Mirri); Bologna S Orsola (A. Marchesini); Borgomanero (M.
Zanetta); Borgosesia (P. Devecchi); Bosisio Parini (G. Gullace);
Bovolone (G. Montresor); Brescia (P Faggiano); Brindisi (M. De
Giorgi); Cagliari Binaghi (G. Ghia); Cagliari Brotzu (M. Porcu);
Cagliari SS Trinita (S. Piras); Caltagirone (S. Cusumano); Camogli
(C. Marsano); Campi Salentina (V. Greco); Campoli del Monte
Taburno (L. Odierna); Camposampiero (F. Contessotto); Canicatti
(G. Marrone); Casarano (A. Marzo); Caserta Divisione (O. Di
Maggio); Caserta Servizio (S. Romano); Caserta Prevenzione e
Riabilitazione (B. Castellano); Casoli (D. Rotondo); Cassano
D'Adda (G. Gibelli); Cassano delle Murge (R. Lagioia); Castel San
Giovanni (M. Piepoli); Caslellammare Di Stabia (R. Padricelli);
Castelnuovo Garfagnana (P. R. Mariani); Castelnuovo Ne'Monti
(U. Guiducci); Castrovillari (F. Dulcetti); Catania S. Curro S Luigi
(F. Platania); Catania Cannizzaro Divisione (R. Coco); Catania
Cannizzaro Servizio (F. Raimondi); Catania Ferrarotto (V. Calvi);
Catania Garibaldi (R. Cardillo); Catania Ascoli Tomaselli (F.
Torcitto); Catanzaro Policlinico (M. Affinita); Ceccano (M. Iorio);
Cecina (F. Mazzinghi); Cento (N. Paparella); Cerreto Sannita
(G. Malgeri); Cesena (C. Garaffoni); Chiaravalle Centrale (A.
Raffaele); Chiari (G. Beghelli); Chien (E. Costantini); Cinisello
Balsamo (A. Lippolis); Citla di Castello (G. Arcuri); Codogno
(C. Guasconi); Colleferro (E. Venturini); Comacchio (P.
Yiannacopulu); Como Valduce (G. Tadeo); Como Sant'Anna (A.
Politi); Conegliano Venelo (F. Accorsi); Conversano (L. Martino);
Correggio (L. Lusetti); Cortona (G. Mannini); Cosenza INRCA (R.
Gallo); Cosenza DellAnnunziata (R. M. Manfredi); Cremona (C.
Bianchi); Cuasso al Monte (G. Lepori); Cuneo (U. Milanese);
Domodossola (G. Sauro); ££o/z (L. Faenza); Empoli (A. Taiti); £rtar
(D. Agnelli); Fabriano (P Domenella); Faenza (L.Pirazzini); Fano
(P. Rotatori); Fasano del Garda (C. Marchesi); Ferentmo (V.
Bernardi); Fermo (P. Paoloni); Ferrara (P. Gruppillo); Fidenza
(S. Cantoni); Firenze S. Giovanni (S. Badolati); Firenze Careggi
Divisione (R Valenti); Firenze Careggi Servizio (M. Ciacchen);
Firenze S. M Nuova (G. Zambaldi); Firenze Camerata (M. Toso);
Foligno (F. Patriarchi); /br/i Morgagni-Pierantoni Divisione (G. L.
Morgagni); For/i Morgagni-Pierantoni Servizio (M. Milandri);
Formia (E. Batosi); Fossombrone (G. Possanzini); Francavilla
Fontana (G. Vecchio); Frascati (M. Topai); Frosinone (M. Savona);
Fucecchio (A. Geri Brandinelli); Gagliano del Capo (G. Pisa);
Gallipoli (F. Mariello); Gavardo (A. Novali); Gemona del Friuli (E.
Spinelli); Genova DIMI (G. Molinari); Genova S. Martino I Divisione (P. Rossi); Genova S. Martino II Divisione (S. Mazzantini);
Genova S Martino Servizio (D. Papagna); Genova Galliera (F.
Chiarelli); Genova Nervi (L. Carratino); Genova Sampierdarena
(P. G. Abrile); Genova Sestri Ponente (G. Terzi); Genova Voltri (A.
Torriglia); Genzano (F. Gabbarini); Gerace (E. Sirleo); Gorizia (R.
Marini); Gravedona (M. R. De Iaco); Grosseto (G. Miracapillo);
Grollaglie (R. Ruta); Guastalla (E. lori); Gubbio (S. Sisani);
Gussago (M. Volterrani); Imola (S. Negroni); Imperia (S.
Acquarone); hernia (G. Evangelista); /vrea (G. Bergandi);
L'Aquila (A. Scimia); Lagonegro (V. Viggiano); Lamezia Terme (C.
Asciotti); Lanciano (T. Diodato); Larino (G. Laquaglia); Lavagna
(P. Rosselli); Z-ecce (M. R. Greco); Legnago (M. Gemelli); Z-eo«/orre (L. Vicari); Livorno (M. Formichi); Locn (G. Martelli); /.orfi
(C. Panciroli); Lugo (S. Delia Casa); Magenta (G. Bardelli);
Manfredonia (G. Prencipe); Mantova (A. Reggiani); Marino
(G. Sarli); Marsala (C. Attardo); Massa (A. Mariani); Massa
Marittima (M. Maestrini); Matera (L. Veglia); Mazara del Vallo (I.
Fiore); Mercalo San Severino (V. Capuano); Mesagne (V. Santoro);
Messina Papardo (A. Coglitore); Messina Piemonte (G. Di Tano);
Messina Regina Margherita (P. Iannello); Messina Policlinico (F.
Luzza); Meslre (G. Zuin); Milano Monzino (M. Guazzi); Milano
Istituto Nazionale Tumori (C. Materazzo); Milano Buzzi (A. Pini);
Milano FBF (F. Turazza); Milano Niguarda I Divisione (E.
Gronda); Milano Niguarda II Divisione (F. Recalcati); Milano
Mellom (M. Picca); Milazzo (C. Coppolino); Mirandola (V.
Malavasi); Modena (C. Cappelli); Monfalcone (E. Barducci);
Montebelluna (M. Baldo); Montescano (C. Opasich); Monza (F.
Valagussa); Morbegno (M. G. Songini); Mozzo (C. Malinverni);
yva/>o// C r O (V. Scotto Di Uccio); Napoli Fondazione Pascale (U.
Bianchi); Napoli Elena D'Aosta (A. Setaro); Napoli Nuovo Dei
Pellegrini (P. Capogrosso); Napoli S. Gennaro (A. Somelli); Napoli
Monaldi Divisione (F. D'Isa); Napoli Monaldi Riabilitazione
Eur Heart J, Vol. 18, September 1997
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Steering Committee: L. Tavazzi (Chairman), F. De
Giuli, R. Ferrari, A. Maggioni, C. Opasich.
Scientific Committee: A. Boccanelli, A. Gavazzi, E.
Gronda, C. Opasich, C. Rapezzi, M. Scherillo, G.
Sinagra.
Writing Committee: L. Tavazzi, R. Ferrari, C. Opasich.
Organizing Secretariat: M. Gorini, D. Lucci.
ANMCO Regional Delegates: G. Baduini, G. Borrello,
D. Bracchetti, E. Braito, A. Circo, C. De Luca, I. De
Luca, A. Dessi, F. Furlanello, E. Gatto, M. Giasi, T.
Lanzetta, A. Lopizzo, E. Musacchio, A. Notaristefano,
P. Pellegrini, E. Petz, G. Saccomanno, A. Santoboni,
F. Valagussa.
The study was endorsed by the National Association of Hospital Cardiologists. The SEOSI was helped
by grants from Schering-Plough and Sigma-Tau, neither
were involved in analysis or writing.
1463
1464 SEOSI Investigators
Eur Heart J, Vol. 18, September 1997
Policlinico Umberto I Divisione I (B. Fedele); Roma Policlinico
Umberto I Divisione II (M. Schiariti); Rossano (S. Salituri);
Rovereto (P. Bonmassari); Sacile (M. Valente); San Benedetto del
Tronlo (G. Sonaglioni); San Gavino Monreale (G. Giardina); San
Giovanni Rotondo (G. P. Perna); San Giovanni Valdarno (G.
Mantini); San Pietro Vernotico (S. Pede); San Vito al Tagliamento
(M. Duchi); Sanremo (G. C. Benza); Sansepolcro (P. Rossi);
Saronno (D. Nassiacos); Sarteano (S. Del Vecchio); Sarzana (D.
Bertoli); Sassari (L. Sannia); Sassuolo (P. Bellesi); Savona (A.
Gandolfo); Scandiano (G. P. Gambarati); Sciacca (P. Gambino);
Sci7/a (M. Musolino); Scorrano (O. De Donno); Semgallia (R.
Amici); Seriate (T. Nicoli); Siderno (M. Iannopollo); S/e«a (R.
Favilli); Sondalo (F. Fedeli); Sondrio (M. Marieni); Sora (G. Lilla
Delia Monica); Soveria Mannelli (A. Marotta); Spoleto (A.
Pagano); Sulmona (E. Conti); Teramo (P. Desiati); Terlizzi (F.
Troso); Termoli (A. Montano); 7e#-ni (D. Bovelli); Terracina
(A. De Angelis); 7%/ene (L. Bassan); rA/eji (G. Poddighe);
Torino Giovanni Bosco (M. G. Sclavo); Torino Maria Vittoria (S.
Sgambetterra); Tradale Fondazione S. Maugen (R. Bonelli);
Tradate Circolo Galmarini (M. Barenghi); Trapani (G. Ledda);
Trebisacce (P. Aragona); Trento (G. Mosna); Treviglio (R.
Achieri); Treviso (G. Renosto); Tricase (R. Mangia); Trieste
Maggiore Divisione (A. Di Lenarda); Trieste Maggiore Servizio (F.
Humar); Trieste Maggiore Riabililazione (P. Gori); Troina (A.
Puzzo); Udine 1st Medicina Fisica (G. Molinis); Udine S M della
Misericordia (M. C. Albanese); Urbino (G. Gheller); Valeggio sul
Mincio (G. Perini); Ka//o aW/a Lucania (G. Liguon); Kare.se Z)e/
Po«(e (I. Ghezzi); Varese Di Circolo (F. Morandi); Porto
(G. Levantesi); Venezia (S. Valente); Venosa (I. De Tommaso);
Verbania (P. Corsetti); Vercelli (J. Makmur); Verona Borgo Trento
(R. Rossi); Verona Borgo Trento Riabilitazwne (A. Vicentini);
Verona Borgo Roma (P. Benussi); Veruno (F. De Vito); Viareggio
(A. Pesola); Vigevano (C. Mazzini); Vimercate (G. Gentile); Viterbo
(D. Pontillo); Voghera (M. G. Bergognoni); Ko/ta Mantovana (F.
Mascaro); Volterra (L. Francardelli).
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(P. Sensale) Nardo (M. C. Carmillo); Negrar (H. Guilarte); Novara
(P. Dellavesa); Nuoro (L. Dettori); Olbia (A. Mauric); Oliveto Citra
(P. Bottiglieri); Orbassano (R. Pozzi); Oristano (M. Cossu); Ortona
(M. Manetta); ftst/a Lido (R. Neri); Padova Divisione (G. M.
Boffa); Padova Servizio (G. Bozza); Palermo Buccheri La Ferla FBF
(A. Castello); Palermo Civico e Benfratelli (C. Caruso); Palermo
Albanese (D. Di Vincenzo); Palermo Ingrassia (F. Clemenza);
Palermo Cervello (B. Di Maria); Palermo Policlinico (M. Traina);
Palermo Villa Sofia Divisione (A. Leto); Palermo Villa Sofia
Servizio (G. Di Piazza); Palmanova (F. G. Pidutti); Paola (M.
Balsano); Passirana-Rho (M. Palvarini); Pavj'a (S. Lucreziotti);
/>en/ie (A. Vacri); Perugia Silvestrini (G. Prodani); Perugia
Monteluce (M. Bentivoglio); Pesaro (G. Tarsi); Pescia (G.
Chiriatti); Piacenza (D. Gandolfini); Piazza Armerina (M.
Farruggio); Piedimonte Matese (F. Vitale); Pietra Ligure (C.
Mattiauda); Pinerolo (L. Riva); /Via S. Chiara Divisione (E.
Puccini); Pua S1. Chiara Divisione-CNR (C. Carpeggiani); Pua S.
Chiara Servizio (M. Ravani); Pistoia (A. Alfleri); Poggio Rusco (M.
Negrelli); Policoro (E. De Nittis); Polistena (F. Catananti); /"o//a
(F. Turturiello); Pontedera (D. Levantesi); Pordenone (E. Viel);
Ponoferraio (A. Davini); Potenza S. Carlo Divisione (M. T.
Stigliani); Potenza S. Carlo Servizio (A. Zarrillo); Prata (G. Lauri);
Ragusa (V. Spadola); Rapallo (G. Gigli); Ravenna (M. Piancastelli);
Reggio Calabria Morelli (E. Tripodi); Reggio Calabria MelacrinoBianchi (G. Neri); Reggio Emilia (F. Burani); R/io (R. Fornerone);
Riccione (P. Del Corso); R/e« (A. Mene); Rimini (M. Marzaloni);
Rogliano (A. Provenzano); /ioma CTO (G. Gattini); taa INRCA
(D. Del Sindaco); Roma to dell'Immacolata (G. L. Biava); Soma
Forlanmi (G Cacciatore); Roma 7-W (G. Speciale); Roma 5.
Camillo I Divisione (C. Greco); Roma 5. Camillo II Divisione (A.
Lacche); Roma 5. Camillo UTIC (M. Carelli); Roma S. Camillo
Servizio (L. Boccardi); Roma S. Camillo Poligrafia (G. Minardi);
Roma S. Filippo Neri (G. Ansalone); Roma S. Giovanni (G.
Scaffidi); Roma S. Pietro FBF (S. Capurso); Roma S. Eugenio
(G. Barbato); Roma Policlinico Casilino (A. Pappalardo); Roma