Showing papers in "Giornale italiano di cardiologia in 2009"

[Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation]

Abstract: [Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation]

[Pathophysiology of contrast-induced nephropathy].

Abstract: Contrast-induced nephropathy is one of the major causes of kidney failure in hospitalized patients. Its increased frequency is due to the high number of invasive procedures using contrast media performed for diagnostic or therapeutic purposes in patients with cardiovascular diseases with advanced age and chronic comorbidities such as diabetes and preexisting renal failure. There are two main causes of contrast-induced nephropathy: the direct toxic effect of contrast media on kidney tubules (as shown by morphologic alterations of these cells) and the tissue hypoxia of the renal medulla, secondary to the hemodynamic effects brought about by these agents, consisting in a reduction of vascular resistances. In vulnerable patients, these vasoconstrictor effects are not balanced by an effective vasodilatory reserve and probably by a reduced production of antiapoptotic proteins.

Percorso di valutazione del dolore toracico. Valutazione dei requisiti di base per l'implementazione negli ospedali italiani

Abstract: The evaluation of acute chest pain remains challenging, despite many insights and innovations over the past two decades. The percentage of patients presenting at the emergency department with acute chest pain who are subsequently admitted to the hospital appears to be increasing. Patients with acute coronary syndromes who are inadvertently discharged from the emergency department have an adverse short-term prognosis. However, the admission of a patient with chest pain who is at low risk for acute coronary syndrome can lead to unnecessary tests and procedures, with their burden of costs and complications. Therefore, with increasing economic pressures on health care, physicians and administrators are interested in improving the efficiency of care for patients with acute chest pain. Since the emergency department organization (i.e. the availability of an intensive observational area) and integration of care and treatment between emergency physicians and cardiologists greatly differ over the national territory, the purpose of the present position paper is two-fold: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the basic critical pathways (describing key steps for care and treatment) that need to be implemented in order to standardize and expedite the evaluation of chest pain patients, making their diagnosis and treatment as uniform as possible across the country.

[Echocardiographic evaluation of the athlete's heart: from morphological adaptations to myocardial function].

Abstract: The definition of the athlete's heart includes the mechanisms of cardiac adaptation to training, characterized by the increase of internal chamber dimensions, ventricular wall thickness, and atrial chambers. The morphology of the athlete's heart is intermediate between concentric and eccentric left ventricular hypertrophy (LVH), in relation to the large prevalence of mixed sports activities and training protocols (including both aerobic and anaerobic exercise). Echocardiography is the tool of choice for the assessment of the athlete's heart and also for the differentiation of physiologic and pathologic LVH (hypertrophic cardiomyopathy and LVH due to arterial hypertension). The initial echocardiographic approach includes the quantitative analysis of the left ventricle, in order to calculate left ventricular mass, left ventricular mass index and relative wall thickness for diagnosing concentric or eccentric LVH. Tissue Doppler (pulsed or color modality) and strain rate imaging (Doppler or two-dimensional modality) may give additional information to the standard indices of systolic function. Diastolic function can be evaluated not only by standard Doppler transmitral inflow measurements but also using pulsed tissue Doppler, which may allow to distinguish the athlete's LVH from diastolic impairment of hypertensive patients or hypertrophic cardiomyopathy by the simple determination of myocardial early diastolic velocity. Also the morphological and functional features of the left atrium and of the right ventricle can be assessed in the athlete's heart by combining standard echocardiography with new echocardiographic technologies.

Myocardial injury in carbon monoxide poisoning

Abstract: Carbon monoxide (CO) intoxication is the most common cause of accidental poisoning in developed countries and, although most published data relate to its neurological manifestations, it often leads to cardiac damage. Myocardial hypoxia due to the formation of carboxyhemoglobin is not enough to explain such damage fully as a major role is played by the direct effect of CO on the heart as a result of the reversible inhibition of mitochondrial respiration and oxidative stress. Cardiac damage secondary to CO poisoning can be detected not only in patients with known ischemic heart disease but also in subjects with undamaged coronary arteries. Given the wide range of cardiovascular manifestations (the entity of which is related to the severity of intoxication), useful information can be obtained by carefully recording the patient's medical history, analyzing electrocardiographic alterations, and determining the biochemical markers of cardiac necrosis. Moreover, echocardiographic examination may highlight the extent of the alterations in left ventricular function due to myocardial stunning associated with CO intoxication and evaluate its evolution over time. Clinical studies suggest that all patients admitted to hospital with moderate to severe CO poisoning should routinely undergo ECG and serial evaluation of cardiac markers, and that those with positive signs of myocardial cytonecrosis or preexisting ischemic heart disease should also undergo echocardiography. A finding of myocardial damage in patients with CO poisoning seems to indicate an unfavorable long-term prognosis, although it needs further confirmation.

Il rischio iatrogeno connesso all'impianto di pacemaker e defibrillatori

Abstract: The considerable evolution in technique and hardware, occurred over the past three decades, has greatly simplified the implantation procedure of pacemakers and cardioverter-defibrillators. Indeed, the introduction of relatively simple and safe methods of central venous access, and the miniaturization of the generator with subcutaneous placement have facilitated the implantation. However, inherent with cardiac pacing and defibrillating therapy is the potential for the occurrence of an early or delayed untoward event. Although skill, experience, and technique are all mitigating factors, every cardiologist should know potential complications and should be able to stratify overall risk related to a device implantation. Thus, both the implanting physician or the clinical cardiologist must be concerned not only with measures to avoid complications, but also with their early recognition and treatment.

[Wide QRS complex tachycardia: an old and new problem].

Abstract: Electrocardiogram; Preexcitation; Supraventricular tachycardia; Ventricular tachycardia. The correct diagnosis of wide QRS complex tachycardia is an old problem, but it is still a new problem since no simple approach aimed at solving it is up to now available, despite the amount of research devoted to this topic. A wide QRS tachycardia can be: 1) ventricular tachycardia; 2) supraventricular tachycardia with bundle branch block that may be either preexisting or due to aberrant conduction, namely tachycardia-dependent; a further possibility is the effect of antiarrhythmic drugs, which slow down intraventricular conduction, result- ing in marked QRS complex widening; 3) supraventricular tachycardia with conduction of impulses to the ven- tricles over an accessory pathway (preexcited tachycardia). The origin of a wide QRS complex tachycardia can be reliably identified using a "holistic" approach, name- ly taking into account all of the available items: no single criterion, thus, is able to provide a simple and quick solution to the problem in all cases. The electrocardiographic signs are, without any exception, suggestive of ectopy, namely ventricular origin of the impulses; supraventricular tachycardia with aberrant conduction may be diagnosed only by excluding all of the items favoring ectopy. The classic diagnostic criteria include: 1) atrio-ventricular dissociation, characterized by absence of any re- lationship between QRS complexes and P waves; this phenomenon is at times immediately recognizable but more often can be discovered only by means of a detailed analysis of the tracing; 2) second degree ventricu- lo-atrial block, characterized by a relationship between QRS complexes and P waves, but with more ventricu- lar complexes than P waves; 3) fusion and/or capture beats; 4) concordant precordial pattern, a sign that can be also expressed as absence of RS (or even rs, Rs, rS) complexes in the precordial leads; 5) an interval >100 ms from the beginning of the QRS complex to the nadir of S wave in any precordial lead. Vagal maneuvers and analysis of previous ECGs recorded during sinus rhythm, if available, can provide fur- ther keys to the diagnosis. Some criteria proposed in the past, such as QRS axis or ventricular complex dura- tion, are nowadays no longer considered; in addition, it has been demonstrated that items such as age, he- modynamic status, heart rate and regularity of R-R intervals may be misleading and should not be taken into account. Analysis of QRS configuration in leads V1 and V6 is a keystone in distinguishing the origin of wide QRS tachycardia: diagnostic criteria rely upon the assumption that aberration is due to a functional bundle branch block, whereas ectopy derives from a totally abnormal activation of the ventricles. Aberration, thus, results in a "typical" bundle branch block morphology, whereas ectopy is expressed by an "atypical" bundle branch block. Specific criteria, based on analysis of leads V1 and V6, have been developed to distinguish the two con- ditions from each other. The criteria based on QRS configuration, however, suffer from limitations since unex- pected complicating factors, such as a previous myocardial infarction, can result in an "atypical" form of bun- dle branch block even in the presence of supraventricular tachycardia. A new algorithm has recently been introduced, based on analysis of lead aVR only. Any of the following features, observed in this lead, pinpoints a diagnosis of ventricular tachycardia: 1) a dominant R wave (R or Rs complexes); 2) an initial q or r wave with duration >40 ms (qR or rS complexes); 3) a notch in the descending Q wave limb in a negative (Qr or QS) complex. In the absence of these signs, the ratio between the voltages recorded during the first and the last 40 ms of the QRS complex helps distinction between ectopy and aber- ration: a ratio ≤1 suggests ventricular tachycardia whereas a ratio >1 indicates supraventricular tachycardia. A hard diagnostic problem is associated with preexcited tachycardia, the condition resulting whenever supraventricular tachycardia impulses are conducted to the ventricles over an accessory pathway. This situa- tion is far more rare than ectopy and aberration, and can be ruled out in the presence of negative precordial concordance (QS complexes in all the chest leads) or deep q waves in a precordial lead other than V1. A QRS morphology not consistent with any of the typical patterns observed in the various locations of the accesso- ry pathways rules out a preexcited tachycardia, too.

Come aumentare le conoscenze dei pazienti con cardiopatia ischemica sulla loro malattia? Utilità di un incontro educazionale tenuto da infermieri

Abstract: p <0.0001), coronary vessel function (from 56 to 92%, p <0.0001) and the causes of cardiac necrosis or ischemia (from 58 to 88%, p <0.0001). Their awareness of the importance of correct lifestyles increased, especially the number of patients willing to increase fruit and vegetable consumption (from 56 to 77%, p <0.0001) or to increase physical activity (from 51 to 69%, p <0.0001) to avoid a recurrence. Conclusions. A health education meeting organized by nurses for patients admitted for CHD improves their knowledge of their illness and awareness of the benefits of correct lifestyles to prevent worsening of their disease.

[Mechanisms of myocardial cell protection from ischemia/reperfusion injury and potential clinical implications].

Abstract: Myocardial cell damage caused by myocardial ischemia results from several factors that include the duration of ischemia, oxygen demand by cardiomyocytes at the time of ischemia, and the presence and entity of collateral blood flow to the ischemic area. Importantly, myocardial cell injury may derive not only from ischemia itself but also from detrimental phenomena occurring during the restoration of myocardial blood flow after the ischemic episode (reperfusion damage). In the last decades a lot of studies have demonstrated that cardiomyocytes have several mechanisms that provide them protection against the damage deriving from ischemia-reperfusion, also allowing a prolongation of survival in the most severe cases. In this article we review some of these mechanisms, also discussing their present and/or potential therapeutic applications in the clinical setting. The topics include the interventions aimed at reducing cardiac work through a reduction of oxygen demand by myocardial cells or at optimizing the utilization of energetic resources by myocardial cells in situations of ischemia, the importance of phenomena such as ischemic preconditioning (early and delayed) and postconditioning of myocardial cells, and, finally, the theoretic possibility of interventions aimed at preventing cell death consequent to apoptosis.

Consensus document on endomyocardial biopsy of the Associazione per la Patologia Cardiovascolare Italiana

Abstract: The Italian Scientific Associations of Cardiologists and Cardiovascular Pathologists have produced this consensus document on the diagnostic role of endomyocardial biopsy (EMB) in terms of techniques, analysis and reporting. The document is intended for clinical cardiologists, hemodynamic experts, electrophysiologists, surgical pathologists, and cardiac surgeons. It has three main aims: a) to collocate EMB in the context of currently available tools for diagnosis of heart diseases; b) to provide recommendations for rational implementation; c) to outline key characteristics (standards) for Italian cardiology and surgical pathology centers that perform and analyze EMB. A general lack of prospective, controlled studies addressing EMB prohibited the use of traditional evidence-based recommendations that rely on classes of available evidence. Thus, it was agreed that three key points should be taken into account: a) the specific pathology to be diagnosed (or excluded); b) the existence of any alternative, non-invasive diagnostic techniques; c) the overall consequences of reaching a definite diagnosis on patients' clinical management. Accordingly, we propose recommendations for EMB based on the following levels of diagnostic value: level 1: no alternative method exists to reach a definite diagnosis that can have obvious consequences for clinical management; level 2a: no alternative method exists to reach a definite diagnosis; however, the implications for clinical management are uncertain; level 2b: no alternative method exists to reach a definite diagnosis; however, the diagnosis would not influence clinical management; level 3: an alternative method exists to reach a definite diagnosis. The second part of the document proposes current protocols for the preparation, analysis and reporting of EMB in the context of each main pathologic entity. Particular attention is given to tissue characterization and implementation of molecular tests.

Terapia con inotropi nello scompenso cardiaco acuto: rivisitazione critica delle evidenze scientifiche e cliniche per levosimendan nel contesto del trattamento tradizionale

Abstract: The clinical heterogeneity of acute heart failure and the low number of controlled trials, to date, are the main causes of the lack of agreement on therapeutic objectives, uncertainty on the most appropriate management, and difficulties to obtain robust evidence for the treatment of this syndrome. The inappropriate use of inotropic agents is one the most common pitfalls shown by registries. Two to 10% of patients admitted for acute heart failure present with a low output syndrome, a clinical profile associated with high mortality, where inotropes may be a rational therapeutic choice. Crucial points for an effective use of inotropes are an accurate evaluation and selection of patients, tailoring of therapeutic schemes and strict patient monitoring. Beta-adrenergic agonists and phosphodiesterase inhibitors increase myocardial oxygen demand, favor arrhythmias and may cause peripheral vasodilation with a secondary decrease in coronary perfusion pressure. These effects may translate in myocardial ischemia, loss of cardiomyocytes and accelerated ventricular remodeling with worse prognosis. Levosimendan, a novel inotropic agent studied according to the principles of evidence-based medicine, augments myocardial contractility without changes in intracellular calcium concentrations, and with minimal impact on myocardial oxygen consumption. This paper, based on an expert consensus, aims to suggest criteria for the appropriate use of inotropic agents in acute heart failure, based on a critical appraisal of the existing evidence and clinical experience.

[Clinical outcome of percutaneous revascularization by stent-assisted balloon angioplasty of femoro-popliteal and tibial vessels in diabetic patients with critical limb ischemia].

Abstract: BACKGROUND: The aim of this study was to assess the long-term clinical outcome of percutaneous peripheral interventions in diabetic patients with critical limb ischemia (CLI) in terms of occurrence of major amputation and mortality. METHODS: From January 2004 to December 2007, all diabetic patients undergoing peripheral angiography and percutaneous revascularization for the presence of CLI were enrolled in this registry and followed prospectively. Limb salvage, mortality, and repeat revascularization were reported at long term. RESULTS: 267 diabetic patients (mean age 72.2 +/- 9.6 years) with 290 ischemic limbs represent the study population. Hypertension was present in 227 patients (85%), hypercholesterolemia in 85 (32%), chronic renal failure in 61 (23%). Ischemic heart disease was present in 80 patients (30%), carotid disease in 75 (28%). According to the Texas Diabetic Ulcers Classification, 203 patients (70%) had type CIII lesion, 29 (10%) CII, 9 (3%) CI, 20 (7%) DIII, 23 (8%) DII, and 6 (2%) DI; 440 lesions (169 tibial arteries, 261 femoro-popliteal arteries, and 10 iliac arteries) were dilated with stent implantation in 290 of them (66%). The procedure was successful in 415 (94%) with restoration of direct flow in at least one tibial artery. The ankle-brachial index was 0.32 +/- 0.11 before procedure and increased to 0.77 +/- 0.23 (p<0.001). One patient died suddenly during hospital stay. Mean follow-up length was 17 +/- 11 months. Of the 290 limbs, major amputation was necessary in 17 (6%) of which 10 had an unsuccessful procedure. Amputation was fatal in 7 cases (41%). Complete foot lesion healing was obtained in 238 (82%) and partial healing in 35 (12%). Death occurred in 42 patients (16%) and it was related to cardiac events in 16 (6%), cerebrovascular events in 8 (3%), acute renal failure in 8 (3%), and cancer in 10 (4%). Repeat revascularization occurred in 67 patients (23%) in the target limb and in 29 (11%) in the contralateral limb. CONCLUSIONS: Peripheral angioplasty with stent implantation is an effective procedure for limb salvage in diabetic patients with CLI. The high mortality is probably related to the systemic atherosclerosis process with involvement of coronary and cerebral circulation that leads to heart and cerebral fatal ischemic events.

Iatrogenic risk of permanent pacemaker and defibrillator implantation

Abstract: The considerable evolution in technique and hardware, occurred over the past three decades, has greatly simplified the implantation procedure of pacemakers and cardioverter-defibrillators. Indeed, the introduction of relatively simple and safe methods of central venous access, and the miniaturization of the generator with subcutaneous placement have facilitated the implantation. However, inherent with cardiac pacing and defibrillating therapy is the potential for the occurrence of an early or delayed untoward event. Although skill, experience, and technique are all mitigating factors, every cardiologist should know potential complications and should be able to stratify overall risk related to a device implantation. Thus, both the implanting physician or the clinical cardiologist must be concerned not only with measures to avoid complications, but also with their early recognition and treatment.

[Alcohol-induced cardiac disease].

Abstract: Excessive and chronic ethanol consumption exerts deleterious and diffused effects on the myocardium, independent of coronary atherosclerosis, arterial hypertension, valvular disease or congenital heart disease. Although the effects of chronic alcoholism on systolic cardiac function are well known, diastolic involvement has been evaluated only partially. This short review summarizes the experimental and clinical evidence for alcohol-induced cardiac disease.

Ecocardiografia tridimensionale in tempo reale. Attuali applicazioni, vantaggi e limiti per lo studio del ventricolo sinistro

Abstract: Left ventricle; Myocardial dyssynchrony; Three-dimensional echocardiography. In the last decades the introduction and development of echocardiography allowed a significant improvement in the diagnosis as well as in the morphological and functional evaluation of several heart diseases, and to- day many therapeutic decisions are taken based on the results of the echocardiographic examination. One of the most important development in the field of echocardiography is three-dimensional imaging, which has evolved from the slow and labor-intense off-line reconstruction techniques to the faster and simpler real-time volumetric imaging, which has the potential to be integrated in routine clinical practice. One of the major proven advantages of real-time three-dimensional echocardiography is the evaluation of left ventricular vol- ume, mass and function, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. In this review we discuss the state-of-the-art and anticipate future develop- ments of real-time three-dimensional echocardiography that are relevant to its application to the left ventricle.

La prevenzione della nefropatia da mezzo di contrasto e la gestione del paziente a rischio

Abstract: Contrast agents; Contrast-induced nephropathy; Hemofiltration; N-acetylcysteine; Renal failure; Renal prevention. Radiological procedures that utilize intravascular iodinated contrast media are being widely applied for both diagnostic and therapeutic purposes and represent one of the main causes of contrast-induced nephropathy (CIN) and hospital-acquired renal failure. Owing to the lack of any effective treatment, prevention of this ia- trogenic disease, which is associated with significant in-hospital and long-term morbidity and mortality and increased costs, is the key strategy. However, prevention of CIN continues to elude clinicians and is a main con- cern during percutaneous coronary interventions, as patients undergoing these procedures often have multi- ple comorbidities. The purpose of this article is to examine the risk factors and clinical course of CIN, as well as the most re- cent studies dealing with its prevention and potential therapeutic interventions, especially during percuta- neous coronary interventions.

Modelli di telecardiologia attualmente in uso

Abstract: La telecardiologia viene utilizzata come supporto alla diagnostica delle sindromi coronariche acute nel servizio di emergenza 118. Diversi studi hanno dimostrato la fattibilità nell’utilizzo di un ECG a 12 derivazioni durante il periodo di preospedalizzazione1,2. ECG di qualità possono essere trasmessi con successo approssimativamente nell’85% dei pazienti nei quali è possibile effettuare un ECG a 12 derivazioni3. Lo scopo più importante dell’utilizzo dell’ECG a 12 derivazioni nella preospedalizzazione è la diagnosi tempestiva dell’infarto miocardico acuto (IMA) con sopraslivellamento del tratto ST4 e la comunicazione di questa informazione al medico di Pronto Soccorso prima dell’arrivo del paziente alla struttura ospedaliera. Nella preospedalizzazione il trasferimento dell’ECG a 12 derivazioni migliora l’accuratezza diagnostica della preospedalizzazione per i pazienti con diagnosi finale ospedaliera di IMA, angina o dolore toracico non ischemico5. L’ECG a 12 derivazioni ha quindi la potenzialità di poter migliorare la gestione dell’IMA nella preospedalizzazione, di ridurre il tempo di attesa in ospedale e di favorire un più rapido inizio della terapia di riperfusione. Si crea così una rete in cui il medico o la struttura sanitaria (spoke) che non hanno i mezzi o le conoscenze adatte per emettere una diagnosi corretta richiedono una consulenza riguardo ad un caso clinico ad un medico o ad una struttura sanitaria (hub) per poter quindi gestire al meglio il paziente fornendo tempestivamente le cure necessarie o trasferendolo in un centro più attrezzato. Inoltre le linee guida dell’American Heart Association per la rianimazione cardiopolmonare e il trattamento dell’emergenza cardiovascolare consigliano l’uso della diagnosi elettrocardiografica extraospedaliera in strutture paramediche urbane3.

[Heart failure epidemiology in Apulia, Italy, from 2001-2006].

Abstract: BACKGROUND Heart failure is one of the main causes of morbidity and mortality in western countries, engaging from 1% to 2% of the healthcare budget in Italy. The aim of this study was to evaluate the course of heart failure over time in the Apulia region on the basis of the hospitalization analysis. METHODS Analyses of the directional informative system data of the Apulia region, Italy, coming from hospital discharge records, allowed the estimation of the overall admission rate in Apulia from 2001 to 2006, of admissions for cardiovascular disease and heart failure as the main diagnosis, classified according to age, average hospitalization rates and of discharge units. RESULTS In Apulia, overall admissions decreased by 8.6% from 2001 to 2006, whereas the costs related to hospital admissions increased by 2.41%. Admissions for cardiovascular diseases decreased by 0.73% when shock and cardiac failure were excluded, whereas they increased by 1.3% when shock and cardiac failure were included. Admissions with DRG 127 stepped up by 15.26%; this increase was mainly related to a higher number of hospitalizations of patients > 75 years old. From 2001 to 2006, admissions for heart failure increased in Cardiology wards, whereas they decreased in coronary care units and Medicine wards. CONCLUSIONS The data related to the increase in hospital admissions for heart failure are relevant for their economic and organizational impact, landing support to the need for effective patient management in order to reduce high early rehospitalization rates.

Fisiopatologia della nefropatia da mezzo di contrasto

Abstract: Contrast-induced nephropathy is one of the major causes of kidney failure in hospitalized patients. Its in- creased frequency is due to the high number of invasive procedures using contrast media performed for diag- nostic or therapeutic purposes in patients with cardiovascular diseases with advanced age and chronic comor- bidities such as diabetes and preexisting renal failure. There are two main causes of contrast-induced nephropathy: the direct toxic effect of contrast media on kidney tubules (as shown by morphologic alterations of these cells) and the tissue hypoxia of the renal medul- la, secondary to the hemodynamic effects brought about by these agents, consisting in a reduction of vascu- lar resistances. In vulnerable patients, these vasoconstrictor effects are not balanced by an effective vasodila- tory reserve and probably by a reduced production of antiapoptotic proteins.

Il danno miocardico indotto dall'intossicazione acuta da monossido di carbonio

Abstract: Given the wide range of cardiovascular manifestations (the entity of which is related to the severity of intoxication), useful information can be obtained by carefully recording the patient’s medical history, analyzing electrocardiographic alterations, and determining the biochemical markers of cardiac necrosis. Moreover, echocardiographic examination may highlight the extent of the alterations in left ventricular function due to myocardial stunning associated with CO intoxication and evaluate its evolution over time. Clinical studies suggest that all patients admitted to hospital with moderate to severe CO poisoning should routinely undergo ECG and serial evaluation of cardiac markers, and that those with positive signs of myocardial cytonecrosis or preexisting ischemic heart disease should also undergo echocardiography. A finding of myocardial damage in patients with CO poisoning seems to indicate an unfavorable long-term prognosis, although it needs further confirmation.

[Clinical use of phosphodiesterase-5 inhibitors in cardiopulmonary diseases: from experimental evidence to clinical application].

Abstract: Phosphodiesterases are a class of proteins that primarily modulate intracellular levels of cyclic nucleotides such as cGMP and cAMP. Phosphodiesterase-5 (PDE5) is mainly involved in the smooth muscle cell cGMP inactivation. Chemical inhibition of PDE5 has recently become a valid therapeutic option of nitric oxide pathway potentiation via cell cGMP availability. More specifically, PDE5 inhibition appears successful for the treatment of idiopathic pulmonary arterial hypertension. Additional intriguing therapeutic properties are a protective effect on the myocardium through antihypertrophic and antiapoptotic mechanisms and on vascular function by improving endothelial responsiveness and tolerance to myocardial ischemia-reperfusion injury. These effects imply a potential usefulness in the treatment of coronary artery disease and heart failure. Evidence currently available for considering PDE5 inhibition an additional therapeutic opportunity in cardiovascular disorders is provided.

Evaluation of ventricular function in the fetus

Abstract: Congenital heart disease is the most frequent neonatal malformation, with an estimated prevalence between 0.8% and 1%. Echocardiography is an important tool for diagnosis and follow-up in cardiology, because it is easy to use, inexpensive, and noninvasive. The study of fetal heart by means of echocardiography allows early diagnosis and treatment of fetal heart anomalies and dysfunction, and such a technique is increasingly used. This exam is often required after morphological fetal echography, when a congenital heart disease is suspected or when there is an increased risk of congenital heart disease. Fetal echocardiography allows to evaluate the cardiac anatomy and function or cardiac rhythm. The purpose of this review is to summarize the main parameters and echocardiographic techniques for the assessment of heart rhythm and function: two-dimensional echocardiography, Doppler, tissue Doppler, and two-dimensional strain.

Documento di consenso sulla biopsia endomiocardica promosso dall'Associazione per la Patologia Cardiovascolare Italiana.

Abstract: Beta-blockers; Non-cardiac surgery; Pathophysiology; Perioperative myocardial ischemia. Cardiac complications are a major cause of morbidity and mortality after non-cardiac surgery, whose incidence varies according to patient risk stratification and type of patient cohorts investigated. Perioperative myocar- dial injury may be triggered by different conditions occurring in the perioperative phase, and patient risk fac- tors represent a favorable milieu for triggers to act. The majority of postoperative myocardial ischemia in high-risk patients tends to develop very early on the day of surgery, starting at the end of surgery and during emergence from anesthesia, or on the first postop- erative day. Most of postoperative episodes of myocardial ischemia are silent, and show ST-segment depres- sion rather than elevation. Preventive measures are aimed at improving perioperative cardiac outcome, but their identification and application in clinical practice require understanding of the pathophysiology of myocardial ischemia and in- farction in non-cardiac surgery patients. Among the protective strategies, beta-blocking agents are the most investigated since 1996, when data from atenolol administration showed a protective effect against myocar- dial ischemia and infarction in non-cardiac surgery. Since then several clinical studies have reported encourag- ing results, but conflicting data on possible serious side effects have recently raised concern and doubts about

Upstream therapy of atrial fibrillation in patients with heart failure

Abstract: Experimental data, results of retrospective studies and of small randomized trials suggest an efficacy of upstream therapy of atrial fibrillation (AF) with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers, statins and n-3 polyunsaturated fatty acids (PUFA). These drugs seem to act by antagonizing the renin-angiotensin system, inflammation, oxidative stress and endothelial dysfunction, all factors that play an important role in the genesis of the substrate of AF and atrial remodeling. However, the recent Italian GISSI-AF study, which is the first large, multicenter, prospective and randomized trial (valsartan vs placebo) dealing with upstream therapy in the secondary prevention of AF, offered negative results. A trend toward a lower incidence of AF recurrence was apparent only in the valsartan group in patients presenting with heart failure, even if statistical significance was not reached. On the basis of these recent data, we analyzed the contributions offered by the literature on upstream therapy of AF in patients with heart failure in order to evaluate a possible use of this treatment in clinical practice. Six retrospective studies dealing with the primary prevention of AF (3 with ACE-inhibitors/angiotensin receptor blockers and 3 with statins) have been published; in these studies, upstream therapy was constantly effective. A recent meta-analysis, which included trials dealing with the primary prevention of AF with ACE-inhibitors/angiotensin receptor blockers, showed that patients with heart failure benefited the most. Up to now, the contributions on upstream therapy in the secondary prevention of AF in patients with heart failure are very few. These results are still not enough to recommend the clinical use of upstream therapy of AF in patients with heart failure because of the retrospective design of the studies. However, it emerges a background to plan a large-scale prospective, randomized trial on upstream therapy in the primary prevention of AF in patients with heart failure.

Myocardial and cerebral infarction as initial presentation of antiphospholipid syndrome

Abstract: The antiphospholipid antibody syndrome is the most common acquired thrombophilia; it is a systemic autoimmune disease characterized by recurrent arterial and venous thrombosis and/or pregnancy loss, in association with circulating antiphospholipid antibodies. The pathogenic mechanisms in antiphospholipid antibody syndrome that lead to in vivo injury are incompletely understood. Like other autoimmune diseases, a combination of genetic and environmental factors is involved. We report the case of a 50-year-old woman suffering from an antero-lateral non-ST-elevation myocardial infarction. After few days, coronary angiography showed a severe occlusive arterial disease, involving anterior descending, circumflex e right coronary arteries. Percutaneous coronary intervention was performed with the implantation of a drug-eluting stent in the proximal segment of the anterior descending coronary artery. One day after discharge (10 days after the first hospitalization) the patient experienced dizziness, nausea, vomiting, swelling in absence of any electrocardiographic abnormalities or myocardial enzyme elevation; then she was hospitalized in the neurology department. Because of a similar episode, urgent cerebral computed tomography scan was performed 5 days later; it revealed two different acute ischemic areas, parietal in the right hemisphere and cerebellar in the left hemisphere. The diagnosis of antiphospholipid antibody syndrome was confirmed by high anticardiolipin antibody titers, also present in medium titer at 5 and 17 weeks apart. She was discharged without any sequelae, on warfarin and double antiplatelet therapy (aspirin and clopidogrel for 6 months), then warfarin and aspirin.

Endovascular treatment of thoracic aortic disease

Abstract: Aortic diseases are highly evolutive pathological entities that may often have an acute clinical presentation. The estimated 5-year risk of rupture of a thoracic aortic aneurysm with a diameter between 4 and 5.9 cm is 16%, but it rises to 31% for aneurysms of > or = 6 cm. Endovascular treatment is an emerging alternative option to surgery with low invasiveness, which allows to treat even high surgical risk patients. If almost all thoracic aortic diseases, acute or chronic, could be potentially treated with endovascular treatment, not all anatomic features of the aortic disorders allow it: vascular imaging is crucial for patient selection, endoprosthesis choice and planning of treatment. Early mid-term results of different published experiences are encouraging, but long-term results are necessary to definitively assess reliability of stent-graft materials and improvement in patient survival. In the choice between surgical or endovascular repair of thoracic aortic aneurysms, many factors must be considered, including clinical conditions, comorbidities, anatomic situation, efficacy of materials and last, but not least, experience of a working group.