Repositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo.

OBJECTIVE: The purpose of this study was to determine the effectiveness of a new physical maneuver in the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. STUDY DESIGN: Case review. SETTING: Outpatient clinic. PATIENTS: The diagnosis of apogeotropic horizontal canal benign paroxysmal positional vertigo was based on the history of recurrent sudden crisis of vertigo associated with bursts of horizontal apogeotropic paroxysmal nystagmus provoked by turning the head from the supine to either lateral position. The patients were three men and five women ranging in age from 31 to 73 years (average, 49.2 yr). INTERVENTIONS: All patients were treated with a repositioning maneuver based on the hypothesis that the syndrome is caused by the presence of free-floating dense particles inside the endolymph of the anterior arm of the horizontal canal. The maneuver favors their shifting into the posterior arm of the canal. Patients were reexamined immediately after the treatment and underwent Gufoni's liberatory maneuver for the geotropic variant of horizontal canal benign paroxysmal positional vertigo. MAIN OUTCOME MEASURE: The treatment outcome was considered as responsive when, after one repositioning maneuver, nystagmus shifted from apogeotropic to geotropic. RESULTS: The repositioning maneuver resulted in a transformation from the apogeotropic variant into a geotropic variant of horizontal canal benign paroxysmal positional vertigo in all patients. CONCLUSION: This maneuver represents a simple and effective approach to the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. It favors the shifting of the canaliths from the anterior into the posterior arm of the horizontal canal from where they can migrate into the utricle with Gufoni's maneuver.

Pre-discharge initiation of beta-blocker therapy in elderly patients hospitalized for acute decompensation of chronic heart failure: an effective strategy for the implementation of beta-blockade in heart failure.

BACKGROUND: Current guidelines recommend beta-blockers in patients with heart failure and left ventricular systolic dysfunction. These agents, however, are largely underused in elderly patients because of the perception of up-titration complexity and the fear of side effects. METHODS: We prospectively assessed the feasibility, safety, tolerability, and 1-year outcome of the in-hospital initiation of carvedilol in elderly patients admitted for worsening heart failure. RESULTS: Among 164 eligible subjects (age > 70 years, left ventricular ejection fraction < 40% and no sign of congestion), 120 (73%) received carvedilol, on average 4.5 days after admission. The drug was permanently withdrawn in 10 out of 116 survivors (9%) at 60 days: 5 did not tolerate the starting dose because of worsening heart failure (n = 1), bradycardia (n = 1), and bronchospasm (n = 3). Two discontinued carvedilol during the in-hospital dose titration phase because of increasing premature ventricular beats and transient second degree atrioventricular block. The remaining 3 dropouts (fatigue in 2 and symptomatic bradycardia in 1 case) occurred after discharge. During the period between 60 days and 12 months, carvedilol was discontinued in 2 patients because of a depressive syndrome and symptomatic bradycardia. In no case these adverse events lead to death or were life-threatening, required hospitalization or resulted in any disability. The 1-year tolerability was 89%, the mortality was 17.5%, the frequency of hospitalization for worsening heart failure was 21%. CONCLUSIONS: Thus, our results show that the in-hospital initiation of carvedilol is feasible and well-tolerated in elderly patients with recent worsening heart failure, and allows rapid identification of the most intolerant patients. The proportion of subjects taking carvedilol after 1 year from discharge was very high. This unconventional approach could significantly modify the use of beta-blockers in clinical practice.

[Diastolic heart failure:a disease in search of his own identity]. / Lo scompenso cardiaco diastolico alla ricerca di un'identità.

Epidemiological surveys on congestive heart failure (CHF) in the community settings reveal that 30-70% of CHF patients presents a normal (> 50%) or only mildly depressed left ventricular ejection fraction. Usually it is tought that these patients suffer of "diastolic" heart failure (DHF). However, some authors contest the "real" existence of isolated DHF. This is a consequence of known difficulty to evaluate the diastolic function with available tests, the lack of a "simple" and unequivocal marker of diastolic dysfunction, the frequent co-existence of associated chronic diseases that may act as confounding factors. Accordingly, an integrated approach to patients with suspected DHF by means of an accurate clinical evaluation, combined with a Doppler-echocardiographic examination, brain natriuretic peptide (BNP) dosage and functional capacity tests (cardiopulmonary exercise test, 6-minute walk test) may represent a strategy in order to overcome such diagnostic difficulties.

[Screening for asymptomatic left ventricular systolic dysfunction in high-risk patients. Preliminary experience with a program based on the use of ECG and natriuretic peptide]. / Lo screening della disfunzione sistolica ventricolare sinistra asintomatica nei pazienti ad alto rischio cardiovascolare. esperienza pilota di un programma basato sull'utilizzo dell'ECG e dei peptidi natriuretici.

BACKGROUND: Patients with asymptomatic left ventricular systolic dysfunction (ALVSD) have an increased risk of heart failure (HF) and a worse life expectancy. Since valuable therapies may prevent such dismal evolution, screening programs for ALVSD have recently been advocated to detect as early as possible such ominous condition. Echocardiography represents the gold standard for the assessment of ALVSD but its indiscriminate use in screening programs is impractical. Clinical multivariate risk assessment associated with ECG and serum brain natriuretic peptide (BNP) may be a feasible strategy to screen ALVSD. We prospectively sought to investigate the feasibility and effectiveness of a screening program for ALVSD based on ECG and BNP used in a hierarchical sequence in patients at high risk for HF. METHODS: Patients > or =55 years old with > or =2 risk factors for HF or > or =70 years old with > or =1 risk factor for HF entered the study performing sequentially ECG, BNP and echocardiographic evaluation. ALVSD was defined as a left ventricular ejection fraction < or =50%. RESULTS: Thirty-three of 122 enrolled patients (27%) had ALVSD. They were older, presented more frequently a history of chemotherapy exposure, had often bundle branch block and higher BNP levels. No patient without any major abnormalities (atrial fibrillation, left ventricular hypertrophy, STT alterations of ischemic/strain origin, pathologic Q wave, bundle branch block) on ECG (n=31, 24.4%) had ALVSD. Among the 91 patients with abnormal ECG, ALVSD was observed in 33 (36%). The area under the receiver operating characteristic curve to detect ALVSD by BNP was 0.86 (confidence interval 0.79-0.94, p<0.0001) and BNP values of > or =43 pg/ml showed a sensitivity and a specificity of 94% and 57%, respectively. The proposed screening program was able to identify 95% (31/33) of patients with ALVSD saving 53% of echocardiographic examinations with a substantial reduction of the costs to diagnose ALVSD. CONCLUSIONS: Our prospective investigation confirms that ECG and BNP may be useful in detecting ALVSD in high-risk patients. A cost-effective screening program based on such simple and low-cost diagnostic tests might be employed for the prevention of HF in primary and secondary prevention programs in high-risk patients.