Showing papers in "Giornale italiano di cardiologia in 2006"

[Guidelines on the management of stable angina pectoris: executive summary].

Abstract: Authors/Task Force Members, Kim Fox, Chairperson*, Maria Angeles Alonso Garcia, Madrid (Spain), Diego Ardissino, Parma (Italy), Pawel Buszman, Katowice (Poland), Paolo G. Camici, London (UK), Filippo Crea, Roma (Italy), Caroline Daly, London (UK), Guy De Backer, Ghent (Belgium), Paul Hjemdahl, Stockholm (Sweden), José Lopez-Sendon, Madrid (Spain), Jean Marco, Toulouse (France), João Morais, Leiria (Portugal), John Pepper, London (UK), Udo Sechtem, Stuttgart (Germany), Maarten Simoons, Rotterdam (The Netherlands), and Kristian Thygesen, Aarhus (Denmark)

[Italian Network on Congestive Heart Failure: ten-year experience].

Abstract: IN-CHF is a multicenter registry, designed in 1995 to compile a large clinical database on the epidemiological, clinical characteristics, management and outcomes of heart failure outpatients. Main objectives of IN-CHF registry were to provide cardiological centers with a software to collect data of outpatients during office visit, for educational purpose; and to enter local data into a national registry (IN-CHF registry), for scientific purpose. Entry into the database required a diagnosis of heart failure according to the guidelines of the European Society of Cardiology. The central coordinator of the project was the ANMCO Research Center. The Italian cardiological centers participating in the project are 142, they are well representing the entire country and from March 1995 to July 2005 collected data from 23 855 outpatients. The mean age of the patients was 65+/-13 years and 71.3% were men. Main etiologies were ischemic in 39.4%, hypertensive in 15.8 %, and due to dilated cardiomyopathy in 29%. More than half of the patients (55.3%) had a history of admission for heart failure within the last year; 25.8% of the patients were in NYHA class III-IV, 9.5% showed a heart rate > 100 bpm and 16.5% third heart sound. Left ventricular ejection fraction was severely depressed ( 40% in 30.9%. Renal dysfunction was present in 3.6% of the patients (serum creatinine level > 2.5 mg/dl), pulmonary disease in 18.7%, diabetes in 16.8% and anemia (hemoglobin < 12 g/dl) in 18.7%. A history of arterial hypertension was common (30.3%); 20.0% and 18.5% of the patients showed atrial fibrillation and left bundle branch block, respectively. Data from our registry provide important insights into clinical and epidemiological characteristics of heart failure outpatients followed in Italian cardiological centers. Starting from this article, every 3 months, the most relevant epidemiological data collected by the IN-CHF investigators will be published.

Obesity and endothelial dysfunction

Abstract: The endothelium plays a crucial role in modulating vascular function and structure. In healthy conditions, nitric oxide produced by endothelial cells exerts not only vasodilating properties, but also several other protective actions toward the vessel wall against the development of atherosclerosis and thrombosis. Traditional cardiovascular risk factors are characterized by endothelial dysfunction caused by an enhanced production of oxidative stress leading to destroy nitric oxide, thus reducing its availability. Abdominal obesity is associated with endothelial dysfunction, through direct mechanisms, such as insulin resistance and the association with risk factors (including diabetes mellitus, hypertension and dyslipidemia), and direct, by the production of adipokines and pro-inflammatory cytokines, which in turn induce oxidative stress leading to a reduced nitric oxide availability. A reduced endothelium-dependent relaxation is a predictor of cardiovascular events in high-risk patients and represents a putative clinical parameter to stratify the cardiovascular risk and a useful marker for therapy efficacy. Weight loss and a modification of lifestyle ameliorate endothelial function in obese patients, an effect due not only to a better glycemic profile, but also secondary to reduced plasma levels of inflammatory markers and adipokines. At present, whether an improvement of endothelial dysfunction secondary to weight loss is significantly associated with a better cardiovascular prognosis is still unknown. (G Ital Cardiol 2006; 7 (11): 715-723)

[Screening for abdominal aortic aneurysm during transthoracic echocardiography. A prospective study in 1202 consecutive patients at high risk: incidence, correlation with risk factors, feasibility, diagnostic accuracy, and increase in echocardiography time]

Abstract: Background The rupture of abdominal aortic aneurysm is a pathology with a high mortality risk. Conversely, the study of the abdominal aorta is not routinely included in the echocardiography protocol, although it can be performed quickly and easily for screening of the aneurysm. The aim of this study was to evaluate screening of abdominal aortic aneurysm at the end of each echocardiographic exam performed at our laboratory. Methods From March 2002 to October 2003, 1202 patients aged > 40 years were studied at our echo-lab. After the first 4 months of screening, only patients at high risk were screened, namely men > 65 or 65 years with at least one risk factor for ischemic heart disease. We evaluated feasibility, diagnostic accuracy, incidence in the study population, interobserver variability, the correlation with risk factors for ischemic heart disease and the increase in total echocardiography time. Results The mean aortic diameter was 19.08 +/- 5.98 mm and feasibility was very high (95.6%). We found 62 unknown aneurysms and 20 localized aortic dilatations (incidence of 5.6 and 1.7%, respectively); the incidence of both of them was 9.1 in men and 1.6 in women. Multivariate analysis revealed male gender, older age and other arterial district pathologies as independent risk factors. The interobserver concordance was excellent as well as diagnostic accuracy. The mean time increase in routine echocardiography was 33.8 +/- 18.6 s. Conclusions The abdominal aortic study at the end of a routine echocardiography, in patients at risk of aortic pathology because of age or other risk factors, is a simple and accurate method for screening of abdominal aortic aneurysm. It showed a very low cost, also due to the short-time increase in routine echocardiography.

[Biochemical markers for predicting chemotherapy-induced cardiotoxicity: systematic review of the literature and recommendations for use].

Abstract: Chemotherapy is a well established therapeutic approach for several malignancies, but its clinical efficacy is often limited by related cardiotoxicity leading to cardiomyopathy evolving towards heart failure that may worsen the patient outcome. To detect cardiac damage, the most frequently adopted diagnostic approach is the estimation of left ventricular ejection fraction by echocardiography, showing, however, low sensitivity in early prediction of cardiomyopathy, when appropriate treatments could still improve the patient's outcome. Cardiospecific biomarkers, like cardiac troponins, show high diagnostic efficacy in the early, subclinical phase of disease, becoming positive approximately 3 months before clinical onset of cardiomyopathy. Furthermore, the increase in their concentrations is well correlated with the disease severity and may predict the occurrence of major cardiac events during follow-up. On the other hand, negative troponin concentrations may identify patients with a very low risk of cardiomyopathy (negative predictive value = 99%). For cardiac natriuretic peptides, definitive evidence about a diagnostic or prognostic role in predicting chemotherapy-induced cardiomyopathy is lacking and their practical use in this context cannot be recommended until their clinical efficacy is clearly defined.

La frequenza cardiaca: un fattore di rischio cardiovascolare che non può essere ignorato

Abstract: Thirty-eight articles have been published on the association between elevated heart rate and mortality. After adjustment for other risk factors, most studies found an independent association between heart rate and all-cause and/or cardiovascular mortality. This relationship has been found to be generally weaker among females. The four studies performed in hypertensive patients found a positive association between heart rate and all-cause mortality or cardiovascular mortality. In spite of this evidence, elevated heart rate remains a neglected cardiovascular risk factor in both genders. The pathogenetic mechanisms connecting high heart rate, hypertension, atherosclerosis and cardiovascular events have also been elucidated in many studies. Several trials retrospectively showed the beneficial effect of cardiac-slowing drugs, such as beta-blockers and non-dihydropyridine calcium antagonists on mortality, notably in patients with coronary heart disease, or heart failure, but no published data are available in patients with hypertension free of coronary heart disease. Although it has not been proven in existing trials, it would seem reasonable to recommend in hypertensive subjects with heart rate > 80-85 b/min, antihypertensive agents that decrease the heart rate. The f-channel blockers, selective heart rate-lowering agents with no effect on blood pressure, could also be profitably used in hypertensive subjects with fast heart rate.

Progetto PROVA E TRASPORTA: rete territoriale di teletrasmissione dell'elettrocardiogramma da postazioni fisse e ambulanze BLS. Utilità nella gestione della sindrome coronarica acuta con sopraslivellamento del tratto ST

Abstract: BACKGROUND Availability of a telematic system of electrocardiogram (ECG) transmission may improve the management of ST-elevation myocardial infarction (STEMI), by reducing time to treatment. The aim of this study was to show the effectiveness of telephone transmission of ECG in improving quality of care for patients with acute STEMI. METHODS Since January 1, 2003, we activated a management program of STEMI in healthcare district of Varese, located in the North-West of Lombardy (Italy), comprising one fourth-level hospital, equipped with a cath lab on call 24/24 h for primary angioplasty since 1993 and cardiac surgery, and 2 community hospitals, placed in a mountain area approximately 30 km far from Varese. The emergency medical system (EMS) transport was activated 24/24 h and has 15 basic life support (BLS) ambulances with trained nurse staff and 2 mobile units with medical staff, all of them equipped with semiautomatic defibrillator Lifepack 12, enabling a GSM telephone transmission of a 12-lead ECG, coupled with 3-lead continuous rhythm recording and clinical data, if necessary. The ECGs were transmitted to a core unit placed in the coronary care unit (CCU) of the Hospital di Circolo of Varese, directly connected with the EMS core unit. RESULTS From January 2003 to August 2005, a total of 2063 ECGs were transmitted, 538 of them (26%) recorded by EMS ambulances. Of 144 ECGs (7%) showing a persistent ST-elevation suggesting an acute STEMI (group A), 112 subjects underwent reperfusion: 73 were treated with angioplasty and 39 by lysis alone. By comparing data of group A with a group of 256 patients (180 reperfused) with acute STEMI, admitted to our hospital in the same period without ECG teletransmission (group B), we observed no statistical difference in mortality and reperfusion rates but a significative reduction in the pre-hospital and in-hospital times in group A patients treated by primary angioplasty and thrombolysis. CONCLUSIONS Our study confirms previous results in that an early availability of a 12-lead ECG, transmitted from peripheral community hospitals and BLS ambulances, is able to reduce time to management of patients with an acute STEMI, thus improving quality of decision-making and treatment.

[Psychosocial factors as predictors of atherosclerosis and cardiovascular events: contribution from animal models].

Abstract: Conventional risk factors (abnormal lipids, hypertension, etc.) are independent predictors of atherosclerosis and cardiovascular events; however, these factors are not specific since about half patients with acute myocardial infarction paradoxically result at low cardiovascular risk. Recent prospective studies provide convincing evidence that some psychosocial factors are independent predictors of atherosclerosis and cardiovascular events, as well. Psychosocial factors that promote atherosclerosis can be divided into two general categories: chronic stressors, including social isolation/low social support and work stress (subordination without job control) and emotional factors, including affective disorders such as depression, severe anxiety and hostility/anger. The emotional factors, such as the chronic stressors, activate the biological mechanisms of chronic stress: increased activity of the hypothalamic-pituitary-adrenal axis, sympathetic system and inflammation processes, which have atherogenic effects, and an increase in blood coagulation. In spite of the amount of published data, psychosocial factors receive little attention in the medical setting. About 30 years ago, Kuller defined the criteria for a causal relation between a risk factor and atherosclerosis and cardiac events. The first of these criteria states that experimental research should demonstrate that any new factor would increase the extent of atherosclerosis or its complications in suitable animal models. We carried out a bibliographic research in order to investigate whether the results of the studies dealing with animal examination and experimentation support the psychosocial factors as predictors of atherosclerosis. Contributions related to some of the psychosocial factors such as social isolation, subordination and hostility/anger have been found. In these studies atherosclerotic extension has been evaluated at necroscopy; however, the incidence of cardiovascular events has not been investigated. As regards the biological mechanisms of chronic stress, the hypothalamic-pituitary-adrenal axis and the sympathetic system have been investigated. The studies have mainly been carried out on primates, and, to a less extent, on other mammals such as rabbit and wolf and on some species of birds. In the animals under social isolation, subordination or hostility/anger, a significantly more severe atherosclerosis was present, besides an increased activity of the hypothalamic-pituitary-adrenal axis and sympathetic system. In conclusion, the results offered by animal models seem to satisfy the first of Kuller's criteria, as for the three above-mentioned psychosocial factors.

[Secondary prevention of acute coronary syndromes: are we following correctly the guidelines?].

Abstract: Heart diseases are the leading cause of death and morbidity in western countries and among them acute coronary artery diseases result to be the major contributor. During the last few decades a lot of energy has been mostly applied to the acute phase of non-ST-elevation acute coronary syndromes (ACS), where cardiac events concentrate. In fact a timely risk stratification along with an early aggressive invasive strategy and very powerful antithrombotic treatment have profoundly improved the in-hospital prognosis of such patients. Such a strong emphasis on the acute phase of ACS could have limited the interest in the equally important post-discharge therapies. However, several studies have demonstrated that different preventive treatments (aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, statins and clopidogrel) could substantially reduce the long-term mortality and morbidity of such patients. Therefore, current guidelines emphasize the role of aggressive secondary preventive treatments after ACS. However, a strong discrepancy between the indications of the guidelines and their application in the real world arises day by day. Such a discrepancy could be due to errors of omission or therapeutic paradoxes. Since patients with ACS are a subgroup of subjects where secondary preventive measures could be useful and cost-effective, cardiologists should not limit their attention to the acute phase of the disease but should eagerly concentrate their efforts on an aggressive secondary preventive treatment as well. Pursuing such a task could extend and magnify the benefits obtained with acute treatment of ACS and significantly improve the outcomes of such patients. Therefore, the role of the Scientific Societies is to improve the application of guidelines and the utilization of all evidence-based treatments even in such post-discharge phase.

[Occupational and leisure time physical activity: trend in the Italian population].

Abstract: Background Over the last decades a change in physical activity habits of the Italian population has been observed. The aim of this study was to compare occupational and leisure-time physical activity, to assess the relationship between physical activity and cardiovascular risk factors and the variation in cardiovascular risk profile measured 20 years apart in the Italian population. Methods In two populations aged 35-69 years (MATISS 1984-1987: 2041 men, 2424 women; OEC 1998-2002: 4214 men, 4206 women) gender-specific levels of occupational (occupational physical activity [OPA]-light, OPA-moderate, OPA-heavy) and leisure-time (leisure-time physical activity [LTPA]-low, LTPA-moderate, LTPA-high) physical activity were compared. Relationship between physical activity and cardiovascular risk factors was evaluated in the two samples using logistic regression models adjusted for age, heart rate, educational level and other possible confounding variables in men and women separately. The 10-year cardiovascular risk was assessed in the two periods and in different physical activity strata using the Progetto CUORE risk score. Results Comparing the two studies, prevalence of OPA-low had decreased, whereas the prevalence of LTPA-low had increased. With increasing LTPA blood pressure, heart rate and glycemia decreased, whereas high-density lipoprotein-cholesterol increased with a positive effect on obesity, smoking habit and cardiovascular risk. Conclusions Over the last 20 years, physical activity apparently changed: currently men and women dedicate more time to physical activity during leisure-time, and are less active at work. More active people have lower levels of major cardiovascular risk factors. Societal efforts are needed to increase physical activity levels in the population.

[Percutaneous coronary intervention and immediate re-transfer to the referring hospital for patients with acute coronary syndrome. A single-center experience].

Abstract: BACKGROUND Current guidelines recommend early transfer of patients with acute coronary syndromes from primary care centers to hospitals with cath lab facilities. Few data exist about safety of re-transfer to primary care centers immediately after successful percutaneous coronary interventions. METHODS We analyzed data regarding 102 consecutive patients (73 male, 29 female, mean age 69 +/- 10.9 years) transferred to the Bolzano hospital from centers without cath lab facilities for urgent percutaneous coronary intervention in acute coronary syndromes and planned immediate re-transfer after the procedure. Data about complications during re-transfer were obtained using a prepared data sheet completed by physicians and/or paramedics involved in the transport. RESULTS Eighty-eight (87.1%) patients were re-transferred immediately after the cath lab procedure. Arterial hemostasis was achieved with arterial closure devices before leaving the cath lab. During re-transfer, 61 (69%) patients were accompanied by physicians and 27 (31%) patients by paramedics. No ischemic, arrhythmic or hemorrhagic complications were observed. CONCLUSIONS In our experience immediate re-transfer to the referring hospital after successful urgent percutaneous coronary intervention for acute coronary syndrome is feasible and safe. If the patient is clinically stable after the procedure, re-transfer may not require the presence of a physician.

Atheromatosis of the thoracic aorta and risk of stroke

Abstract: Atrial fibrillation and severe carotid artery stenosis are the most common causes of stroke. However, several patients recognize unusual cause for their cerebral ischemia. At the beginning of the last decade after the introduction of transesophageal echocardiography (TEE) and other imaging techniques, atheromatosis of the thoracic aorta has been recognized as an important source of stroke or systemic embolism. Formerly in the pre-TEE era, this entity was included into cryptogenic strokes. Notably, aortic atheromas are found in about one quarter of patients presenting with embolic events and their grading by TEE correlates with the risk of future embolism, especially if mobile lesions or superimposed thrombi are present. Unfortunately, the diagnosis of aortic atheroma is mostly established when an embolic event has already occurred. The aim of this paper is to review the current evidence for aortic atheroma as an important independent risk factor for stroke, and to discuss the potential therapeutic options. Unfortunately, randomized studies addressing the treatment of patients with severe aortic atheroma are not yet completed. Furthermore, although warfarin and statins look promising in several retrospective series, their results are by most controversial so far. In conclusion, although the diagnostic criteria and the negative prognostic significance of aortic atheroma are almost defined, its therapeutic options are far to be clear. Therefore, clinical trials addressing this relevant pathologic condition are urgently needed.

Administrative databases as a basic tool for the epidemiology of cardiovascular diseases

Abstract: The broader availability of administrative databases, characterized by increasing data reliability, related to the various steps of the healthcare process, has became also in Italy an important resource for epidemiological studies. Specifically, the methodological developments in the handling and analysis of drug prescription files can be seen as the original and highly informative backbone of a comprehensive monitoring of healthcare delivery processes. The area of chronic cardiovascular treatments occupies a privileged space in these developments, which are illustrated in the paper, with a synthetic presentation of the methodology supported by a model analysis of the epidemiology of heart failure in a healthcare district and by a reference list which has been conceived to provide to the reader a comprehensive perspective on an area so far largely unexplored.

[Severe bradycardia in an asymptomatic young subject: is there an indication to permanent cardiac pacing?].

Abstract: Bradycardic effects of severe weight loss are well known like those observed in anorexia nervosa resulting from an increase in vagal tone associated with a low calorie-protein diet. We here report the case of a 19-year-old patient with asymptomatic severe bradycardia, which developed after voluntary weight loss of more than 30 kg during a few months. In absence of symptoms, ventricular arrhythmia or structural heart disease, and owing to normal ventricular function, no permanent pacemaker implantation was undertaken. After a follow-up of more than 15 years, clinical conditions are stable, the patient is asymptomatic and bradycardic, and no changes in weight are reported.

Surgical treatment of chronic thromboembolic pulmonary hypertension with pulmonary endarterectomy

Abstract: Acute pulmonary embolism is the third most common cardiovascular disease in Italy with approximately 65 000 new cases a year. Appropriate medical therapy does not necessarily prevent evolution of acute pulmonary embolism into chronic thromboembolic pulmonary hypertension (CTEPH), which occurs in 0.1-4.0% of cases. In our country, there are approximately up to 2600 new CTEPH patients a year. CTEPH is a progressive and potentially lethal disease. Medical therapy is palliative and only surgery can modify its natural history. Pulmonary endarterectomy (PEA) is the treatment of choice and lung transplantation should be considered only when PEA is contraindicated. Currently, nearly 4000 PEAs have been performed worldwide. Approximately ten centers are able to carry out this intervention with excellent and permanent results. Solid experience and close multidisciplinary collaboration allow appropriate patient selection, rigorous surgical technique, and adequate postoperative management. All these aspects represent the key to the success in the treatment of CTEPH. After PEA, quality and expected length of life are similar to the age-matched general population and the only therapy required is oral anticoagulation.

[Psychological characteristics of patients with vasovagal syncope: and observational study on sixty subjects].

Abstract: BACKGROUND Based on the relevant literature, the aim of this study was to analyze the psychosocial characteristics of patients with vasovagal syncope and to evaluate these factors as possible etiopathological components. METHODS The study sample consisted of 60 subjects divided as follows: the syncope group (n = 30) and the control group (n = 30, without prominent diseases). The two groups were matched with regard to age, sex, education and civil status. Each participant filled in the Twenty-Item Toronto Alexithymia Scale, acceptance of emotions scale, profile of mood state, attachment style questionnaire, and childhood traumatic events scale. RESULTS The syncope group showed a higher number of somatic diseases (p < 0.0002) and a higher drug use (p < 0.0001) than the control group. Moreover, the syncope group showed higher scores at the childhood traumatic events scale (p < 0.04) and more difficulties in emotion regulation (p < 0.02). The syncope group also showed higher scores at the need for approval scale (p < 0.0006) and lower scores at the confidence scale (p < 0.02) of the attachment style questionnaire, which reflect an insecure style of relationship with others. CONCLUSIONS A high number of traumatic events in infancy and adolescence, difficulties in the expression of emotions and an insecure style of relationship seem to characterize subjects with vasovagal syncope. These data show that syncope could be at least partiality due to a relational and emotional imbalance that finds expression through the body in the presence of insufficient mental processing. Treatment of this syndrome should therefore take these aspects into consideration.

Infarto miocardico transmurale ad eziologia embolica in un paziente con cardiomiopatia dilatativa e fibrillazione atriale permanente

Abstract: We report the case of an acute myocardial infarction due to coronary embolism in a patient with dilated cardiomyopathy and permanent atrial fibrillation. The patient underwent thrombectomy and stenting. The authors discuss the acute treatment in this clinical situation and the problem of dual antiplatelet therapy in patients with an indication for long-term oral anticoagulation undergoing percutaneous coronary intervention and stenting.

[Cardiac sonographers: a unique reality in Anglo-saxon countries? The experience of an Italian echo-lab which is employing them since 1984].

Abstract: Cardiac sonographers play a key role in the management of echo-laboratories in anglo-saxon countries. In Italy, and generally in "latin" countries nearly all echocardiographic studies are performed by cardiologists. However, because of the increasing demand for echocardiography, this practice will no longer be feasible (medical schools do not graduate enough cardiologists!), and cost-effective (the cost of echocardiography performed by cardiologists only is becoming too high!). Introduction of cardiac sonographers in Italian echo-laboratories may represent a feasible and cost-effective solution to the ever increasing demand for echocardiography. In order to contribute to the debate, we report the experience of our echo-laboratory that employs cardiac sonographers since 1984.

La tempesta aritmica nel paziente con defibrillatore automatico impiantabile: incidenza e problematiche terapeutiche

Abstract: Background. Electrical storm in implantable cardioverter-defibrillator (ICD) recipients is a dramatic experience for the patient and a hard emergency for the cardiology team. The aim of our study was to evaluate the incidence and the clinical significance of electrical storm in a standard population of ICD patients. Methods. We considered retrospectively 262 consecutive ICD patients (86% males, mean age 65 ± 10.7 years). Patients were divided into three groups: 88 patients without appropriate ICD therapy (group A); 140 patients with isolated ICD therapies (group B); 34 patients with electrical storm episodes (≥ 3 appropriate ICD therapies/24 h) (group C). Survival study (endpoint death) was performed for each group of patients. Results. There was no difference in age, sex, heart disease, ejection fraction or NYHA functional class among the three groups. ICD implant was performed for secondary prevention in 79% of group C patients and in 74.3% of group B patients, but only in 39.8% of group A patients (p < 0.0001). Mean follow-up was 31.1 ± 29.8 months in group A, 55.1 ± 38 months in group B, and 71.1 ± 51.7 months in group C. The endpoint was reached by 16 patients (18%) of group A, by 53 patients (38%) of group B, and by 20 patients (58%) of group C. Comparison of the survival curves of the three groups did not show significant differences. In group C patients, 54 electrical storm episodes were recorded (mean 1.5/patient). Conclusions. In our population of ICD patients, we observed electrical storm in 34 patients (12.9%). Survival in group with episodes of electrical storm was comparable to patients without electrical storm; thus, in our experience, electrical storm could not represent a negative prognostic factor.

Medical therapy in critical lower limb ischemia when immediate revascularization is not feasible

Abstract: Revascularization by either bypass surgery or endovascular recanalization is considered the first-choice treatment in patients with critical limb ischemia (CLI). Only conservative options are left in CLI patients in whom successful revascularization strategies are not possible: in these patients, at present, prostanoids (iloprost and prostaglandin [PGE1]) represent the pharmacological treatment of choice. Iloprost resulted more effective than PGE1, in a 6 month follow-up, in both limb savage and in prevention of cardiovascolar death, either in diabetic or non diabetic patients with unreconstructable CLI. In our experience, in patients who have responded to a first cycle of therapy (early responders), performed for at least 2-3 weeks, cyclic annual further treatments with iloprost are usually able to stabilize arterial disease, with a regression to Fontaine II stage and, in absence of further arterial complications, with complete limb preservation for an unlimited period of time. In non-responder patients, who are not urgently supposed to undergo amputation, a second cycle of iloprost carried out within few months from the first one, is able to increase the percentage of responders to prostanoids (late responders). Vice versa, in non-responders to repeat prostanoid cycles, it is useful to verify the outcomes of further attempts at saving, the symptomatic limb by surgical or endovascular re-timing, spinal cord stimulation, gene or stem cell therapy. Our recent better outcomes are related to earlier microvascular diagnosis and to earlier, repeat, pharmacological treatments with iloprost. Transcutaneous oxygen and carbon dioxide monitoring improves the possibility of an earlier diagnosis of microvascular damages and categorizes CLI patients in responders and non-responders after prostanoid treatments.

[The pro-inflammatory role of cytokines in the mechanism of atherosclerosis].

Abstract: Investigation of the mechanisms of atherosclerosis has determined that inflammation plays a central role in the development, progression, and outcome of acute coronary syndrome. Although C-reactive protein will remain over time a useful marker, cytokines will continue to be studied in order to understand the mechanisms of acute coronary syndrome and cytokine balance. This short review summarizes the experimental and clinical evidence regarding the role of some cytokines in acute coronary syndrome (interleukin [IL]-8, IL-10, IL-18, IL-2, tumor necrosis factor-� , interferon-� ).

[Aortic coarctation is correlated with bicuspid aortic valve and intracranial aneurysm: a case report and review of the literature].

Abstract: Aortic coarctation is often linked to bicuspid aortic valve and only rarely to congenital aneurysm of the circle of Willis. It is possible that a common pathogenetic substrate determines this association, but it has not yet been demonstrated. In this report we describe the case of a 32-year-old woman, affected by previous anamnestic functional cardiac murmur. She has suddenly presented a hemorrhagic stroke due to the breaking of the sylvian artery, angiographically demonstrated and surgically corrected. On the same occasion aortic angiography revealed aortic coarctation. Later, an echocardiographic exam demonstrated the coexistence of bicuspid aortic valve. Afterwards the patient underwent angioplasty in order to correct aortic coarctation. Any coexisting cardiac and vascular disease may influence survival in unoperated adults with aortic coarctation, which can even be lethal. In this case the simultaneous presence of these three malformations was particularly dangerous since the patient was not enough symptomatic and so an early diagnosis was not possible. Therefore, we strongly recommend to perform echocardiography in every young patient affected by hemorrhagic stroke and to take into consideration the possibility of performing cerebral angiography in all cases of aortic coarctation.

Procedure interventistiche coronariche percutanee in pazienti anziani: indicazioni cliniche e terapie farmacologiche concomitanti. Lo studio Italian Drug Evaluation in Angioplasty (IDEA)

Abstract: BACKGROUND Specific guidelines for interventional cardiology in elderly patients are not available, and it appears that aged patients are treated more conservatively. Nevertheless data on the real clinical practice are lacking. The aim of the study was to describe different therapeutic strategies in elderly patients enrolled in the Italian Drug Evaluation in Angioplasty (IDEA) study. METHODS The IDEA study is a registry of consecutive percutaneous coronary interventions (PCI) performed from September 15 to 29, 2003, at 79 Italian cath-labs. RESULTS Out of 1517 consecutive PCI patients, 491 (32%) were aged > or = 70 years. Compared to younger patients, those > or = 70 years old showed more frequently (p or = 70 years, acute coronary syndrome was the more frequent clinical indication for PCI (54 vs 49% in patients or = 70 years (2.9 vs 0.9%, p = 0.004), particularly in patients treated for acute coronary syndromes (5.5 vs 1.4%, p = 0.002). In these patients, more bleeding complications (7.1 vs 3.9%, p < 0.001) and heart failure (5.5 vs 1.6%, p = 0.004) were observed. CONCLUSIONS Compared to younger patients, elderly patients enrolled in the IDEA study had a higher risk profile and higher in-hospital morbidity and mortality. Except for a lower use of glycoprotein IIb/IIIa receptor antagonists for acute myocardial infarction, no discriminations were observed in elderly patients in terms of clinical indications, antiplatelet therapy and drug-eluting stent use.

Chirurgia coronarica a cuore battente: stato attuale delle evidenze

Abstract: Off-pump coronary artery bypass surgery is a well established surgical option for patients candidate to coronary artery bypass. Current evidence suggests that there are no differences between off-pump and on-pump coronary surgery in terms of major perioperative outcomes such as perioperative mortality, myocardial infarction, stroke, and renal failure, whereas off-pump coronary surgery seems to reduce some minor complications like atrial fibrillation, transfusion requirements, and postoperative hospital stay. However, some recent papers suggest that graft patency may be lower for grafts performed with the off-pump technique. In this paper we review current knowledge about pros and cons of off-pump and on-pump coronary bypass surgery.

Rheumatic fever and rheumatic heart disease

Abstract: Rheumatic heart disease, the sequel of acute rheumatic fever, is a very common cause of cardiovascular mortality and morbidity all over the world, and is the predominant indication for cardiac surgery in the industrialized countries. Diagnosis of rheumatic chronic carditis may sometimes be difficult because valvular regurgitation may not always be detected by routine clinical auscultation. A recent report from the World Health Organization Expert Committee recognizes the usefulness of echocardiography Doppler in providing supporting evidence for diagnosis of rheumatic carditis in the presence of equivocally pathological murmur, and recommends that patients with subclinical carditis should be managed as rheumatic heart disease until proven otherwise, because the disease still represents a major health problem. The aim of this review is to give an update on the disease by underlining changes made by the World Health Organization on disease diagnosis and patient management.

[Chronic total coronary occlusions: an overview].

Abstract: Chronic total coronary occlusion is defined as a > 3-month-old obstruction of a coronary artery with no anterograde filling of the distal vessel. Histologically it consists of various degrees of fibro-atheromatous plaque and thrombus depending on the mechanism of occlusion and its duration. It is identified in approximately one third of diagnostic catheterizations, but it accounts for only 10% of all percutaneous coronary interventions, as many coronary occlusions are left untreated or referred for coronary bypass surgery. Percutaneous recanalization of a coronary occlusion presents great challenges including immediate low success rates, high costs and high restenosis rates. An interventional approach is justified when ischemia or residual myocardial viability are demonstrated in the area supplied by an occluded vessel with favorable angiographic characteristics for stenting. A successful revascularization is associated with an improved long-term survival, less symptoms, a better left ventricular function and reduced need for coronary bypass surgery. The inability to cross the lesion with an angioplasty wire is the main reason for procedural failure. Stent implantation reduces the restenosis rate as compared to only balloon angioplasty, and drug-eluting stents probably further improve long-term results.

La terapia medica dell'ischemia critica degli arti inferiori non immediatamente rivascolarizzabile

Abstract: Con il termine di ischemia critica degli arti inferiori (ICAI) si definisce l’arteriopatia obliterante periferica cronica (AOPC), caratterizzata clinicamente dalla presenza di dolore cronico a riposo e/o lesioni trofiche, quali ulcere e/o gangrene, di natura aterosclerotica, insorti da oltre 15 giorni, documentata oggettivamente e il cui esito più probabile, in assenza di consistenti miglioramenti emodinamici, è rappresentato da un’amputazione maggiore nell’arco dei 612 mesi successivi1,2. Tale condizione, sul piano emodinamico, è caratterizzata dalla presenza di pressioni arteriose sistoliche ridotte, sia alla caviglia (< 50 mmHg) sia all’alluce (< 30 mmHg) e/o, sul piano microcircolatorio, dalla riduzione locale della tensione transcutanea di ossigeno (< 30 mmHg) all’avampiede sintomatico2. Rispetto alla più semplice classificazione di Leriche-Fontaine, in cui gli stadi III e IV sono definiti, rispettivamente, da presenza di dolore a riposo e di lesioni trofiche, il termine ICAI, introdotto nel 1991 dalla European Consensus Conference1 e confermato dalla TASC (TransAtlantic Inter-Society Consensus) del 20002, appare più appropriato, perché chiarisce, attraverso una coerente spiegazione fisiopatologica, come le ostruzioni macroangiopatiche dei principali distretti arteriosi degli arti inferiori determinino la presenza di dolore a riposo e/o di lesioni trofiche, soltanto in presenza di grave scompenso tissutale microvascolare regionale, conseguente all’abolizione o alla marcata riduzione del flusso nutrizionale capillare, al di sotto della domanda minima perfusionale tissutale locale. Inoltre, la successione temporale di AOPC, basata, secondo Leriche-Fontaine, sull’evoluzione in quattro stadi clinici, progressivamente ingravescenti, risulta scola

Organization of care for adults with congenital heart disease

Abstract: The increasing number of adult patients with congenital heart disease and the better survival of patients with complex disease into adulthood, as a result of the success of pediatric cardiology and cardiac surgery over the last years, have increased the need for specific structures, the so-called grown-up congenital heart disease units, able to provide comprehensive care to these patients. Many of the adult patients with congenital heart disease will require, over time, further operations, urgent in-hospital admission for a wide range of complications such as arrhythmias, hemorrhage, heart failure and bacterial endocarditis. Furthermore, these patients may often experience despair due to their awareness of residual morbidities and the knowledge of possible early mortality, or limitations in their social lives and educational or occupational attainment. Provision of care for children with congenital heart disease is well established in most parts of the world. In contrast, clinical services for the adults with congenital heart disease are scarce. In this scenario, adult cardiologists are not always equipped to deal with the range ad complexity of grown-up patients with congenital heart disease, whereas pediatric cardiologists cannot be expected to manage the many acquired adult diseases in a pediatric medical environment.