[Cardiovascular disease in early collagen diseases]. / Alterazioni cardiovascolari nelle fasi precoci delle malattie del connettivo.

AIM: The purpose of this paper was to verify whether there is any sign of involvement of the cardiovascular system in the early stages of collagen diseases. METHODS: Seventeen patients (10 female and 7 male, average age 41.35 +/- 9.85 years) (group A) recruited at the Ambulatory of Internal Medicine for suspected collagen diseases with period of onset of the symptomatology less than 6 months, were analyzed. Ten patients were excluded from the study: 8 had been suffering from systemic lupus erythematosus (SLE) for a number of years, 2 were older than 80 and were suffering from concomitant pathologies (diabetes mellitus and hypertension) which would have invalidated the evaluation of valvular changes like thickening. The patients were followed up for 2 years. Clinical diagnosis was made in many cases many months after the observation using the criteria of the American Rheumatic Association (ARA). All patients were subjected to titration of the following autoantibodies by means of the immuno-fluorimetry method: ANA, anti-ENA (SSA, SSB, SM, SM-RNP, SCL-70, Jo-1), anti-nDNA, anti-histones. The cardiological evaluation was carried out by echography (Cardioline 12 leads) and echocardiographic examination (Aloka 2000 and HP sonos 5500 with 2.5 and 3.5 MHz probe) looking for thickening of both valvular flaps (> 3 mm for the mitral and > 2 mm for the aorta), myocardial involvement by studying global and regional kinesis of the left ventricle; pericardial involvement. The control group consisted of 17 healthy subjects with the same sex and age distribution (10 male, 7 female, average age 40.35 +/- 9.80 years) (group B). RESULTS: Eleven patients (64%) proved to be suffering from SLE, 3 (17%) from mixed collagen diseases (MC), 3 (17%) from systemic sclerosis (SS). Cardiac anomalies were observed in 12 patients: in 3 (17%) mitral valve thickening was observed (2 with SLE, 1 with SS), in 2 (11%) thickening associated with mitral valve insufficiency (with MC), in 1 (5%) isolated mitral valve insufficiency (with SLE), in 1 (5%) thickening and slight aortic insufficiency (with SLE), in 1 (5%) mitral valve vegetations (with SLE), in 2 (11%) pericardial effusion (with SLE), in 2 (11%) diastolic changes (with SS). The parameters relative to wall thickness between the 2 groups showed statistically significant differences (mitral 3.1 +/- 0.7 vs 2.3 +/- 0.4 P = 0.0005; aorta 1.7 +/- 0.2 vs 1.5 +/- 0.3 P = 0.03). CONCLUSIONS: In patients observed in the early stages of collagen diseases, cardiac involvement was observed in 70% of cases, but the data require confirmation in a larger sample. The authors, however, believe that the early identification of such involvement is useful from both the diagnostic point of view and from the point of view of patient treatment.

[Prevalence of aneurysm of the interatrial septum in the general population and in patients with a recent episode of cryptogenetic ischemic stroke: a tissue harmonic imaging transthoracic echocardiography study in 5.631 patients]. / Prevalenza di aneurisma del setto interatriale nella popolazione generale e in pazienti con recente stroke criptogenetico: studio ecocardiografico transtoracico con seconda armonica tessutale in 5.631 pazienti.

Cerebral ischemia is among the principal causes of mortality and morbidity in industrialized countries being responsible of 10-12% of all deaths and of an elevated number of permanent disability. The cardio-embolic forms may be responsible of the 30-35% of cerebrovascular acute syndrome, nevertheless in a significant percentage of cases, especially among young people, cerebral ischemic episodes are not induced by these cardio-embolic forms: these cases are defined as cryptogenetic stroke/TIA. In these patients cardiac abnormalities represented by an aneurysm of the interatrial septum (ASA) and by a patent foramen ovale (PFO) have been frequently observed. The purpose of our prospective, study was to evaluate, through transthoracic echocardiography and tissue harmonic imaging (ETT-THI), the prevalence of ASA in the general population (group A) and the prevalence of ASA-FOP in a subgroup of patients with recent episode of cryptogenetic ischemic stroke/TIA (group B). We studied in a prospective manner from January 1 2003 to October 31t 2004 n. 5.631 patients. The presence of ASA was found in 3.2% of patients of group A, while in patients of group B we identified an ASA in 32% and a POF in 42% of the cases. Using a ETT-THI, our study shows in a wide range of a non selected population a prevalence of ASA greater than in previous studies. Such high prevalence in the general population of patients submitted to echocardiography and the higher frequency in subjects with recent cryptogenetic stroke, suggests to search carefully these abnormalities at the level of the interatrial septum using the harmonic imaging method.

Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report.

BACKGROUND AND STUDY OBJECTIVE: Echocardiographic detection of right heart thromboemboli (RHTE) during pulmonary embolism (PE) shows an uncommon but life-threatening event. The treatment of this condition is not well established. The aim of our study is to evaluate the efficacy and safety of recombinant tissue-type plasminogen activator (rt-PA) in treating RHTE. METHOD: We performed a transthoracic echocardiogram within (mean +/- SD) 120+/-45 min from onset of symptoms on 30 consecutive patients with proven massive PE. Seven patients (23%) showed RHTE, four patients (57%) had cardiogenic shock; and all patients showed echocardiographic features of acute cor pulmonale. The seven patients with RHTE received an IV infusion of 100 mg rt-PA over a period of 2 h with continuous echocardiographic monitoring. RESULTS: We observed complete RHTE lysis at 45 to 60 min from the onset of rt-PA infusion and significant reductions at 2 h in the following: 14% in right ventricle (RV) end-diastolic diameter (reduction, 40.8 to 35 mm; p < 0.01); 12% in RV/left ventricular ratio (reduction, 0.83 to 0.73; p < 0.01); and 17% in tricuspid regurgitant flow velocity (reduction, 3.5 to 2.9 m/s; p < 0.01). The interventricular septal and RV wall motions improved. An excellent clinical outcome was achieved rapidly in all patients. No adverse events were recorded. CONCLUSIONS: We demonstrated the rapid, effective, and safe action of rt-PA in RHTE resolution and an improvement in pulmonary perfusion. Our data confirm the important role of an early, systematic echocardiographic approach in order to detect RHTE quickly in patients with suspected massive PE.

[Results of a survey on knowledge and habits among hospital doctors concerning primary prevention of venous thromboembolism]. / Risultati di una indagine sulle conoscenze e sulle abitudini di medici ospedalieri riguardo alla prevenzione primaria del tromboembolismo venoso.

BACKGROUND: The purpose of this study was to analyse the attitudes towards and knowledge of primary prevention of venous thromboembolism (VTE) among hospital doctors in Calabria. METHODS: The survey was based on theoretical knowledge and practical management of hortopedics, surgeons, gynecologists and internists working in 14 hospitals. RESULTS: Out of a total of 340 physicians contacted, 154 (45%) agreed to take part in the survey. 82% of those who responded used VTE prophylaxis on a routine basis. Unfractioned heparin (71%) was the most frequently used methods; early deambulation (55%), low molecular weight heparin (49%) and elastic stocking (49%) were less frequently employed. Surprisingly, one third used aspirin. 75% of those contacted had modified their approach to prevention during the last few years, in particular owing to improvements in pharmacological therapy and increased awareness of the problem. In the survey of clinical practice, 80% of those who took part correctly identified the VTE risk, 86% suggested the best treatment, but only 27% assessed the exact frequency rate of deep venous thrombosis (DVT) and pulmonary embolism (PE) in the absence of prophylaxis. CONCLUSIONS: Most of the doctors contacted showed scant interest in the primary prevention of VTE. The 45% who agreed to be interviewed revealed a good practical approach but were not sufficiently aware of the real incidence of DVT and PE in a clinical risk context without prophylaxis. Although they must be interpreted with caution, these findings allow the real behaviour of hospital physicians in this region to be assessed with regard to the primary prevention of VTE and suggest the need for more correct information about this aspect of venous thromboembolic disease which is not yet sufficiently well known.

[A health education program for the prevention of heart diseases carried out in a population in Calabria]. / Un programma di educazione sanitaria per la prevenzione delle cardiopatie realizzato in un ambito di popolazione della Calabria.

BACKGROUND: To evaluate the behaviour and knowledge of students on cardiovascular risk factors and to programme a campaign for the prevention of cardiovascular diseases. METHODS: All students attending the last year of the secondary school of this province answered a questionnaire. An educational campaign followed the analysis of the questionnaire. RESULTS: The analysis of 3675 questionnaires shows that almost all students were between 18 and 20; 16% of males (m) and 7.4% of females (f) were overweight; 1.5% and 0.4% respectively were obese; 88.8% of m and 44% of were doing physical activity; 32.4% of m and 26.8% of f were cigarette smokers. Knowledge about cardiovascular risk factors were poor. Development of the prevention campaign. In the school districts four seminars were organized to discuss about cardiovascular prevention with science teachers of the province, using audiovisual materials. The same teachers devote 4-6 hours to the same matters during school lessons. In the next months conferences destined to the population of the province will be organized. CONCLUSIONS: This program allows to promote health education in the whole population, through the students, with a low cost.

[Thrombolytic therapy during cardiopulmonary resuscitation for acute massive pulmonary embolism. A case report]. / Terapia trombolitica durante rianimazione cardiopolmonare per embolia polmonare acuta massiva. Descrizione di un caso clinico.

Massive pulmonary embolism associated with cardiac arrest has an extremely high mortality in spite of cardiopulmonary resuscitation maneuvers. An early diagnosis of pulmonary embolism as cause of cardiac arrest and a rapid specific therapy able to obtain a restoration of pulmonary flow can improve the prognosis. The authors report a case of cardiac arrest for massive pulmonary embolism promptly diagnosed by echocardiography and treated by thrombolytic therapy with an initial favourable outcome.

[The usefulness of the association of clinical probability, rapid plasma measurement of D-dimer, compression echography of the lower limbs and echocardiography in the diagnosis of acute pulmonary embolism]. / Utilità dell'associazione di probabilità clinica, dosaggio rapido plasmatico del D-dimero, ecografia compressiva degli arti inferiori ed ecocardiografia nella diagnosi di embolia polmonare acuta.

BACKGROUND: The aim of this study was to investigate the diagnostic utility of clinical probability, rapid plasma D-dimer assay, compression ultrasonography (CUS) and transthoracic echocardiography (TTE) in patients with suspected pulmonary embolism. METHODS: One hundred forty consecutive outpatients with suspected pulmonary embolism were enrolled in a prospective trial. We evaluated sensitivity, specificity, positive and negative predictive value of a combination of clinical probability, D-dimer, CUS and TTE using perfusion lung scan and pulmonary angiography as a combined gold standard for determining the presence or absence of pulmonary embolism. Clinical probability was assessed in accordance with the PIOPED criteria. The D-dimer (Nycocard) level was considered as abnormal > 0.3 mg/l, the CUS if incompressibility of the leg veins was showed, and the TTE if right ventricular dilation was present, in the absence of chronic pulmonary disease. The combination of these tests was considered consistent with the presence of pulmonary embolism if D-dimer plus CUS and/or TTE showed abnormal results. A pulmonary embolism was excluded if D-dimer and CUS showed normal findings or a low clinical probability was associated with normal findings of CUS and TTE. RESULTS: One hundred eleven patients were evaluated. Pulmonary embolism was present in 45/111 (40%) patients. The combination of tests showed positive findings in 39/39 patients with pulmonary embolism, negative findings in 47/50 without pulmonary embolism and non-diagnostic results in 22/111 (20%) patients (95% confidence interval--CI 12-28%). There were three false positive and no false negative results. Sensitivity and specificity were 100 and 94% respectively (95% CI 92-100% and 87-100%); positive and negative predictive values were 93 and 100% (95% CI 85-100% and 93-100%). None of these tests, separately, showed enough sensitivity and specificity. CONCLUSIONS: The combination of clinical probability, D-dimer, CUS and TTE was highly accurate to confirm or rule out pulmonary embolism.

[Acute disfunction from thrombosis of a prosthetic mitral valve: thrombolysis with rt-PA in the clinical emergency phase]. / Disfunzione acuta da trombosi di protesi mitralica meccanica: trombolisi mediante rt-PA in fase di emergenza clinica.

Prosthetic valve thrombosis can determine different degrees of valvular insufficiency or obstruction, with a potentially fatal course. The current literature has not established whether the best treatment is thrombolysis or surgery (thrombectomy or valvular replacement). However, both treatments expose the patient to the risk of serious sequelae or death. Here we describe a case of acute thrombosis in a prosthetic mitral valve. At presentation, the patient was in pulmonary edema and had a low cardiac output. She was treated with recombinant tissue-type plasminogen activator infusion (rt-PA 100 mg in 2 hours). Both clinically as well as echocardiographically, we observed a quick regression of the obstruction, but after the treatment, the patient developed an ischemic stroke with aphasia and hemiplegia. The authors conclude that thrombolysis is a highly effective treatment in resolving prosthetic thrombosis. However, because it carries a significant risk of embolization, it should be limited to patients with hemodynamic deterioration in whom surgery could also entail a significant risk of death.

[The role of 2D-doppler electrocardiography in the early diagnosis of massive acute pulmonary embolism and therapeutic monitoring]. / Ruolo dell'ecocardiogramma 2D-doppler nella diagnosi precoce di embolia polmonare acuta massiva e nel monitoraggio terapeutico.

Early diagnosis is important for the prognosis of patients affected with pulmonary embolisms. The mortality rate ranges from 30% in untreated cases to 10% in cases getting early treatment. In this context, it is essential to obtain a correct diagnosis in order to start the best treatment for each patient. The aim of our study is to evaluated the contribution of mono- bidimensional echocardiography and color-doppler for the early diagnosis of acute massive pulmonary embolism. We examined 23 patients (14 women with a mean age of 67 +/- 13 years; 9 men with a mean age of 58 +/- 16 years) who were referred to us for observation over a 30-month period. These patients had been admitted to the intensive care unit for suspected acute massive pulmonary embolism and the diagnosis was subsequently confirmed by a pulmonary scintigraphy. None of the 23 patients showed a positive case history of previous heart disease and/or pulmonary disease. The patients were checked using 2D-doppler echocardiography, 120 +/- 45 minutes from the onset of the symptoms. They were then divided into two groups (A and B) based on the presence or absence of thromboembolus in the right cavity of the heart. Seven patients (30%) revealed thromboemboli and were treated effectively with rt-PA (100 mg/2 hours). An increase in the size of the right ventricle with an affected rate RV/LV > 0.6 and the abnormal kinetics of the ventricular septum proved to be the most sensitive parameters for right ventricular overload, as signs of acute massive pulmonary ambolisms were observed in all 23 patients. Tricuspid regurgitation speed (from 2.9 to 3.6 m/sec) and peak systolic pulmonary pressure (67 mmHg) were recorded in all patients. Our observations suggest that the hemodynamic effects of an acute massive pulmonary embolism can be enumerated and monitored by analyzing ventricle size and septum kinetics. To summarize, echocardiography proved to be a simple and realistic test. It enabled correct diagnosis and made it possible not only to start thrombolytic therapy without requiring other exams, but also to monitor and evaluate the effects of this therapy.

[Evaluation of an immunoenzymatic method for determining TSH and establishment of reference values]. / Valutazione di un metodo immunoenzimatico per la determinazione del TSH e definizione dei valori di riferimento.

In the present work we reported the results of the valuation of IMx Ultrasensitive hTSH assay which is a Microparticle Enzyme ImmunoAssay (MEIA) for quantitative determination of human stimulating hormone (hTSH) in the human serum or plasma. We have determined the method's precision, within run and between run, sensitivity and recovery. This method has been compared with another one (Immuno RadioMetric Assay). Also reference values have been calculated in the "normal" male and female population and shortly commented.

[Long-term captopril therapy in asymptomatic patients with severe chronic aortic insufficiency]. / Terapia a lungo termine con captopril in pazienti asintomatici con insufficienza aortica cronica di grado severo.

BACKGROUND: Clinical history of patients with severe chronic aortic regurgitation is characterized by a long period without any symptom, although the left ventricle enlarges progressively. The administration of oral vasodilators could reduce ventricular enlargement or its progression, delaying the development of myocardial dysfunction and/or the need for valvular surgery. OBJECTIVES: To verify the efficacy of long-term captopril therapy to reduce left ventricular mass and dimensions in patients with severe chronic aortic regurgitation. METHODS: This is a prospective echocardiographic study in which each individual patient is considered his own control case. Eleven asymptomatic patients with severe chronic aortic regurgitation in sinus rhythm, who had an ejection fraction greater than 50% and were not taking cardiovascular drugs, were orally administered captopril at the maximum tolerated dosage (127 +/- 13 mg/day). Follow-up lasted for 24 +/- 3 months. RESULTS: Left ventricular telediastolic diameter decreased from 69 +/- 5 to 61 +/- 3 mm (p < 0.01), telesystolic diameter decreased from 48 +/- 5 to 41 +/- 4 mm (p < 0.01); ejection fraction increased from 56 +/- 4 to 61 +/- 3% (p < 0.001); myocardial mass decreased from 208 +/- 32 to 174 +/- 27 g/m2 (p < 0.01), and mean wall stress from 264 +/- 35 to 203 +/- 25 mmHg (p < 0.001). All variations were still significant at 6 months. CONCLUSIONS: These results suggest that captopril has a favourable effect on left ventricular mass, dimensions and load conditions, and could favourably influence the natural history of chronic aortic regurgitation. The efficacy of medical treatment can be verified through serial echocardiographic study.

[Diltiazem in paroxysmal supraventricular tachycardia: electrocardiographic findings at termination]. / Diltiazem nella tachicardia parossistica sopraventricolare: quadri elettrocardiografici alla interruzione.

The effects of diltiazem hydrochloride (0.3 mg/kg i.v. over 2 min.) was studied by continuous electrocardiographic monitoring in 60 patients. Conversion to sinus rhythm was achieved in 55 patients (91%). Electrocardiographic findings were: undisturbed sinus rhythm in 20 patients; A-V junctional rhythm in 4 patients; complex ventricular arrhythmias (ventricular tachycardia or complex VPCs) in 19 patients. Patients with complex ventricular arrhythmias were matched against patients with normal sinus rhythm, with respect to the following parameters: age, sex, heart disease, tachycardia duration, tachycardia cycle length, sinus cycle length, pre- and post-infusion blood pressure. No differences between the two groups of patients were found. Ventricular arrhythmias occurring at the termination of supraventricular tachycardia are difficult to explain. Nevertheless, these arrhythmias are not associated with organic heart disease. They could be the expression of triggered activity.

[The prevalence and clinical characteristics of heart failure in a population sample of Calabria]. / Prevalenza e caratteristiche cliniche dell'insufficienza cardiaca in un campione di popolazione della Calabria.

Two-hundred and fourteen patients with congestive heart failure were identified over a six-month period in the general practice of 29 GPs covering an adult population of 29,959 subjects residing in the region of Calabria, in southern Italy, with an overall prevalence of 7 per 1000. Males represented 52% of the cases and females 48%, with a median age of 75 years. On average, the condition was first diagnosed 41 months before the present examination. Patients generally had a high body mass index (28 kg/m2). Patients were classified as follows in the NYHA classification: 9.4% in class I, 45.3% in class II, 39.2% in class III, 6.1% in class IV. Hypertension, either alone or associated with ischemic heart disease (totally about 75% of cases), was the most common etiology, while COPD was the most commonly associated chronic condition. Clinical symptoms and signs were used to classify patients in a simplified version of the Boston score which was reported in 48% of cases as definite, 12% as possible, 6% as improbable and 34% as absent. A specific treatment was already ongoing in 97% of patients. The most commonly administered drugs were diuretics (83%), ACE-inhibitors (77%), and digitalis (67%). This three-drug combination (alone or with other drugs) covered 46% of patients. A comparison of four predefined typologies of treatment against the Boston score suggested that at least part of the outcome in classifying patients using this procedure was due to pathomorphosis of the syndrome induced by early pharmacological treatment.