[Blood gas analysis in the intensive cardiac care unit]. / La rapida lettura dell'emogasanalisi in unità di terapia intensiva cardiologica.

Arterial blood gas (ABG) analysis is a simple and quick test that can provide multiple respiratory and metabolic parameters. The interpretation of ABG analysis and acid-base disorders represents one of the most complex chapters of clinical medicine. In this brief review, the authors propose a rational approach that sequentially analyzes the information offered by the ABG to allow a rapid classification of the respiratory, metabolic or mixed disorder. The patient's history and clinical-instrumental assessment are the framework in which to insert the information derived from the ABG analysis in order to characterize the critical heart patient.

[The hypoxic patient in the intensive cardiac care unit: from nasal cannulas to oro-tracheal intubation]. / Il paziente ipossico in unità di terapia intensiva cardiologica: dalle cannule nasali all'intubazione oro-tracheale.

Acute respiratory failure is a frequent complication of patients admitted to the intensive cardiac care unit and it is associated with a poor short- and long-term outcome. Acute respiratory failure can be managed with traditional oxygen therapy, with high-flow nasal cannula, continuous positive airway pressure, non-invasive ventilation or invasive ventilation according to clinical and blood gas condition. The use of advanced respiratory therapies is associated with both respiratory and hemodynamic effects, therefore the intensivist cardiologist should know deeply these respiratory devices. The intensivist cardiologist should perform an early diagnosis of acute respiratory failure, an appropriate selection of the respiratory device, and accurate monitoring and management to obtain clinical improvement and to avoid mechanical invasive ventilation.

[From risk charts to guidelines: tools for evaluation and management of cardiovascular risk]. / Dalle carte del rischio alle linee guida: gli strumenti per la valutazione e la gestione del rischio cardiovascolare.

Despite the wide improvement of diagnostic techniques and the introduction of effective pharmacological and instrumental therapeutic strategies aimed to the treatment of cardiovascular diseases, their incidence and lethality are still elevated, with economic implications increasingly less sustainable by the public medical systems. The modern practice of cardiovascular prevention requires, thus, that diagnostic and therapeutic interventions, both at population level and on the single patient, should be more and more precise, effective, and appropriate. From this point of view, a correct global cardiovascular risk stratification assumes a preponderant relevance, in order to allow an adequate therapeutical response. For this purpose several work instruments, as risk charts and guidelines, namely dedicated to arterial hypertension and dyslipidemias, were developed and offered to clinicians interested in cardiovascular prevention. The aim of this review is to illustrate, in synthesis, those instruments, aiming to facilitate their implementation, thus reducing the actual gap between theoretical indications and the real world.

[About paroxysmal atrial fibrillation and difficulties in clinical practice. Dubito ergo sum]. / Dei parossismi e delle difficoltà della pratica clinica. Dubito ergo sum.

The differences in terms of cardioembolic risk of permanent and paroxysmal atrial fibrillation are reviewed. On the basis of the available literature, the authors suggest that their equivalence reported in the recent guideline for the management of patients with atrial fibrillation represents an oversimplification.

Transvenous cardioverter-defibrillator implantation with a double coil lead via persistent left superior vena cava.

A dual-coil defibrillation lead was inserted in a 64-year-old male through a persistent left superior vena cava draining into the coronary sinus. The lead, connected to a cardioverter-defibrillator (ICD) implanted in the left pectoral area, was looped in the right atrium positioning the proximal and distal lead coils in the coronary sinus and right ventricular outflow track respectively and resulting in a low and stable defibrillation threshold. Because of its relative ease and effectiveness, this procedure may be recommended in patients with persistent left superior vena cava requiring an ICD implant.

[Periprocedural myocardial damage: chronicle of a (cellular) death foretold]. / Il danno miocardico periprocedurale: cronaca di una morte (cellulare) annunciata.

Cardiac marker monitoring after percutaneous coronary intervention (PCI) is now widespread; thus, the recognition of just how frequently myocardial enzyme elevations result from even successful PCI has become increasingly important, despite some physician's interest in minimizing the significance of isolated asymptomatic creatine phosphokinase elevations without an angiographically apparent cause. The meaningfulness of elevated cardiac enzymes after revascularization procedures is one of the most controversial issues in interventional cardiology. The rate of periprocedural damage detection is highly dependent on the intensity of enzyme and ECG measurement. With the use of more sensitive and specific cardiac markers of myocardial necrosis, the traditional definition of "acute myocardial infarction" has been expanded to include even small and asymptomatic biomarker elevations. On the other hand, most debate has focused on the clinical relevance of an elevation in CK-MB levels to 1 to 3 times the upper limit of normal, and many cardiologists argue that the appropriate cut-off point after PCI is even higher. Doubts whether "small" cardiac marker elevations have per se any impact on survival after uncomplicated procedures, as well as the excess of fideism on the effectiveness of contemporary coronary stenting couple with the mistaken equation "excellent angiographic result = excellent clinical outcome". Pre and postprocedural ECG recording and serial cardiac marker measurement should be incorporated into clinical pathways, and routine CK-MB levels tracking is now mandatory even in asymptomatic subjects having successful PCI. A consensus about how to check myocardial damage after PCI (i.e. which and how serum markers should be measured and reported) is eagerly awaited. A broader agreement will contribute to a better understanding of pathophysiology and long-term prognostic implications of "minor" periprocedural myocardial damage, allowing to improve our strategies to prevent and treat it.

[Evaluation of the appropriateness of prescribing Holter dynamic electrocardiography]. / La valutazione dell'appropriatezza della prescrizione dell'elettrocardiogramma dinamico secondo Holter.

BACKGROUND: We evaluated the appropriateness of indications to Holter monitoring performed on ambulatory patients during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 863 prescriptions (population: 435 males, 428 females; mean age 64 years, range 15-90 years). The indications to the test were of class I (appropriate) in 59.6%, of class II (doubtfully appropriate) in 11.7%, and of class III (inappropriate) in 28.7% of the cases. In 33% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 37.9% of class I, in 36.7% of class II, and in 24.5% of class III exams (p < 0.05). The exam was considered useful in 46.7% of the cases. In particular, a useful result was found in 59.2% of class I, in 45.5% of class II, and in 21% of class III exams (p < 0.05). Cardiologists prescribed 373/863 tests (43.2%). Their indications were of class I in 67.6%, of class II in 12% and of class III in 24% of the cases vs 53.7, 11.4 and 34.9% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 40% of cardiologist- vs 27.6% of non-cardiologist-prescribed examinations (odds ratio 1.74, 95% confidence interval 1.31-2.32; p < 0.05); similarly, clinically useful information could be derived from 59.8% of cardiologist- vs 36.7% of non-cardiologist-prescribed examinations (odds ratio 2.56, 95% confidence interval 1.94-3.37; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, about 40% of Holter exams are inappropriate; appropriately prescribed exams are more often abnormal and useful; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.

[Primary angioplasty in a patient with acute inferior myocardial infarction: the unexpected trap]. / Angioplastica primaria in un caso di infarto miocardico inferiore: l'insidia inattesa.

We report a case of acute inferior myocardial infarction caused by occlusion of an anomalous right coronary artery, successfully treated with primary angioplasty. When an anomalous origin of a coronary artery is suspected, it is crucial to perform aortic angiography or left ventriculography in multiple projections.

[Epidemiology of Tako-tsubo cardiomyopathy: the Tuscany Registry for Tako-tsubo Cardiomyopathy ]. / Epidemiologia della sindrome di tako-tsubo nel mondo reale: dati del Registro Toscano della Miocardiopatia da stress tipo Tako-tsubo.

BACKGROUND: Tako-tsubo (stress) cardiomyopathy (TTC) is a recently described acute cardiac syndrome that mimics ST-segment elevation myocardial infarction. The TTC Tuscany Registry is an observational prospective multicenter registry established to define the prevalence, epidemiology and prognosis of TTC in the Tuscany area. METHODS: From January 1 to December 31, 2009, 105 consecutive patients hospitalized in the 14 Cardiology Units of the Tuscany Region with a diagnosis of TTC, were enrolled in the registry. TTC diagnosis was made using the Mayo Clinic modified criteria. Clinical, instrumental, laboratory and 6-month follow-up data were collected. Results. TTC represented 1.2% of all myocardial infarctions in the Tuscany Region during 2009, and it was diagnosed in 0.6% of the angiographic exams performed during the same year. The data collected showed that TTC affects mainly the female gender (91%) in the post-menopausal period (70 ± 11 years), though 5% of patients were ≤50 years old. An antecedent stressful event was frequently detected (74%). The main clinical presentation was chest pain (86%), associated with ST-segment elevation (59%). Mean left ventricular ejection fraction on admission was 40 ± 9%, and was associated with apical (37%), midapical (49%) or midventricular (5%) wall motion abnormalities. Left ventricular ejection fraction recovered to 51 ± 9% in 7 ± 9 days. Heart failure was the most common complication in the acute phase (14%), and 4 patients presented with cardiogenic shock. No patient died during the index hospitalization. At 6-month follow-up, no patient had TTC recurrence, 9 patients were rehospitalized (7 for noncardiac disease) and 2 patients died of noncardiac causes. CONCLUSIONS: Our data, which represent the largest prospective series of patients with a diagnosis of TTC, show that the prevalence of TTC in Tuscany is similar that described in other national and international studies. Moreover, the data highlight that TTC may occur also in male patients and in patients aged <50 years. The mid-term prognosis is good, but the risk of acute complications related to heart failure cannot be neglected.

Comparison of prolonged bivalirudin infusion versus intraprocedural in preventing myocardial damage after percutaneous coronary intervention in patients with angina pectoris.

Modern antithrombotic strategies for patients undergoing percutaneous coronary interventions (PCIs) must take into account the risk of ischemic and hemorrhagic complications. Bivalirudin decreases the risk of hemorrhagic complications after PCI; however, concerns have been raised about its efficacy in preventing ischemic complications. We evaluated the effectiveness of a prolonged intra- and postprocedural bivalirudin infusion versus a standard regimen in preventing PCI-related myocardial damage. One hundred seventy-eight consecutive patients with stable or unstable angina and complex coronary anatomy were enrolled in this single-center, randomized, single-blinded study. Patients were randomized to bolus plus bivalirudin infusion during PCI (n = 90) or bolus plus bivalirudin infusion during and after PCI (4 hours, n = 88). The primary end point was incidence of periprocedural myocardial damage (creatine kinase-MB increase >or=3 times upper limit of normal). Secondary end points were 30-day and 6-month major adverse cardiovascular events (death, new Q-wave myocardial infarction, target vessel revascularization) and in-hospital bleeding (major/minor). The 2 groups did not differ significantly in baseline and procedural characteristics. The primary end point of the study was significantly less frequent in the prolonged infusion group (6.8% vs 16.7%, p = 0.041). No significant differences for secondary end points were observed. In conclusion, in patients undergoing complex PCI, a prolonged bivalirudin infusion after PCI compared to an intraprocedural-only regimen significantly decreased the incidence of periprocedural myocardial damage.

[Coronary angiography in stable angina: friends and foes]. / Quando fare (e quando non fare) la coronarografia nel paziente con angina stabile.

Preventive intervention presupposes a threat that can be averted at an acceptable cost; in patients with stable coronary artery disease, the threat of subsequent myocardial infarction and death is generally low, and proper management can usually control symptoms and improve prognosis substantially. In general, patients who have indications for coronary angiography are also potential candidates for revascularization. The relation of typical angina to prognosis is mediated by its relation to the extent of coronary disease; since the risk of coronary occlusion is not proportional to stenosis severity, it is not surprising that treating one or more stable tight lesions does not reduce the rates of subsequent major cardiac events. Clinical evaluation, ventricular function, response to stress testing, and the extent of coronary artery disease are the key pieces of information to stratify patient risk. In subjects without a markedly positive stress test, the ischemic burden is helpful in decision-making with respect to selecting initial therapy, and contributes to risk assessment. An initial invasive strategy without prior functional testing is rarely indicated, and may only be considered for patients with severe valve disease, serious arrhythmias or when therapy has failed to control symptoms satisfactorily, with a view to revascularization. In the absence of uncontrolled symptoms, patients are potentially eligible for coronary angiography if noninvasive tests reveal a substantial area of myocardium at risk. Coronary angiography should also be undertaken in patients with moderate to severe ischemia who do not have a significant reduction of the ischemic burden with therapy, given their worse prognosis. Because the treatment of asymptomatic patients cannot improve their symptoms, recommendations for coronary angiography in this subset are weaker and limited to risk stratification in subjects with high-risk criteria. Invasive procedures require a high likelihood of success and acceptable risk of morbidity and mortality and patients should be fully informed of the risks of the therapeutic modality individually. Regardless of the treatment modality used (early invasive vs selectively invasive), noninvasive imaging of the ischemic burden may assist in both decision-making for initial therapy and determining therapeutic efficacy related to long-term outcome.

[Usefulness of an audiovisual support to informed consent before percutaneous coronary intervention procedures]. / Utilità di un supporto audiovisivo nella preparazione del paziente alle procedure di cardiologia invasiva.

BACKGROUND: Informed consent must be obtained from all patients undergoing medical procedures, especially when these imply a significant risk of severe adverse events. However, as for interventional cardiology, recall of information has been shown to be poor. In this study we evaluated the usefulness of an audiovisual support, in adjunct to the standard written informative form, in obtaining: (a) effective patient information before invasive coronary procedures, and (b) patient familiarization with the cath lab team, equipment, and the main procedural phases. METHODS: The audiovisual informative support was carried out through explicative interviews to the operators of the cath lab, animations, and realistic visualization of the procedural phases. Patient information was evaluated with a multiple-choice questionnaire. Self-assessment of the patient's emotional state was also evaluated using a semiquantitative scale. RESULTS: Patients receiving the audiovisual support in adjunct to written informative form showed a significantly lower rate of erroneous answers at the multiple-choice questionnaire with respect to patients receiving just written informative form (1.1 +/- 1.0 vs. 3.2 +/- 1.7; p < 0.001). Moreover, patients informed through the audiovisual support showed a slight, although statistically significant, reduction in semiquantitative indexes of anxiety (p = 0.0021) and experienced pain (p = 0.034). CONCLUSIONS: The use of an audiovisual support may favor patient's adequate information prior to written consent and, when prepared by the cath lab team operators, it may optimize his emotional state through a "familiarization effect".

Filters to prevent distal embolization during coronary artery stenting: the risk of mousetrap.

We describe a case of acute coronary syndrome treated with percutaneous intervention using a distal protection system that was complicated by filter entrapment into the stent struts. We discuss the advantages and concerns of distal protection and suggest some technical aspects to take into account when dealing with filter protection systems.

A computer protocol to evaluate subjects with chest pain in the emergency department: a multicenter study.

OBJECTIVE: Chest pain is a frequent cause of medical admission to the emergency department and the main differential diagnosis is between coronary and non-coronary chest pain. We elaborated a computer protocol for the management of patients with chest pain. METHODS: The computer protocol was made of three sections according to clinical, electrocardiographic and biochemical data. Each section was coded by a letter indicating the probability of coronary chest pain for each section. The combination of the three letters formed a score string used to assign patients to four subgroups of overall probability of coronary chest pain (low, medium-low, medium-high, and high). Low-probability patients were discharged from the emergency department, whereas high-probability patients were admitted to the coronary care unit. The medium-probability patients underwent further evaluation by means of a stress test and were re-classified as having a final low probability (negative test) or high probability (positive test). RESULTS: We evaluated 472 patients (mean age 64 years, range 18-97 years; 47% female). The incidence of coronary events in patients with low, medium-low, medium-high and high overall probability was 1.9, 12.8,13.5 and 68.0%, respectively (P < 0.05). The positive and negative predictive values of the protocol were 64.7 and 97.1%, respectively. CONCLUSIONS: Our computer protocol represents a reliable method for the management of patients with chest pain and a non-diagnostic electrocardiogram.