[Intramyocardial bridges: anatomo-pathological characteristics, diagnosis, and therapeutic strategies]. / I ponti intramiocardici: caratteristiche anatomo-patologiche, diagnosi e strategie terapeutiche.

Intramyocardial bridge is defined as the segment of a major epicardial coronary artery that runs within the cardiac muscle wall (coronary tunneling). Usually, this kind of anatomic variant is asymptomatic but sometimes it may lead to acute coronary syndrome and/or arrhythmias, and more rarely to sudden cardiac death. Treatment for symptomatic patients is pharmacological, using beta-blockers.

Kounis syndrome: inferior ST-segment elevation myocardial infarction following a bumblebee sting.

The Kounis syndrome was first described in 1991 as'the allergic angina syndrome'which could progress to acute myocardial infarction which was named'allergic myocardial infarction. There are several causes underlying this syndrome including drugs, various conditions and a variety of environmental exposure factors such as animal stings. Hymenoptera stings can induce Kounis syndrome because hymenoptera venom contains allergenic proteins and peptides. The following case report describes a patient who experienced an anaphylactic shock associated with coronary artery ischaemia (inferior ST-segment elevation myocardial infarction) after a bumblebee sting.

[Tamoxifen treatment and pulmunary embolism: a case report and literature review]. / Trattamento con tamoxifene e rischio di embolia polmonare: un caso clinico e revisione della letteratura.

Breast carcinoma is becoming a spread disease that needs a specif teraphy. Tamoxifen is the first line treatment in patients with positivity of expression of estrogen receptors. The risk of thromboembolism is high in patients treated with tamoxifene indipendent from the neoplastic disease. This work focuses the attention on tamoxifen mechanism of thrombosis.

Multiorgan paradoxical embolism consequent to acute pulmonary thromboembolism with patent foramen ovale: a case report.

Paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt. It is a relatively rare phenomenon, representing about 2% of all cases of arterial embolism. We report a case of a 79-years-old woman admitted to hospital because of dyspnea and lower left limb pain. CT scan revealed multiple thrombi to kidney, lower limb and superior mesenteric artery during acute pulmonary embolism. Echocardiogram documented a patent foramen ovale with a right-to-left shunt. The patient was treated with thrombolytic therapy and heparin with progressive improvement of symptoms and resolution of pulmonary embolism and peripheral thrombosis. Patent foramen ovale closure was not performed because a life-long anticoagulation therapy was necessary, a tunnel-type patent foramen ovale may increases difficulty in realizing device implantation and there are no clear evidence-based guidelines to date addressing treatment in presence of a patent foramen ovale.

Worsening renal function in patients hospitalised for acute heart failure: clinical implications and prognostic significance.

BACKGROUND: Renal function is a powerful prognostic variable in patients with heart failure (HF). Hospitalisations for acute HF (AHF) may be associated with further worsening of renal function (WRF). METHODS AND RESULTS: We analysed the clinical significance of WRF in 318 consecutive patients admitted at our institute for AHF. WRF was defined as the occurrence, at any time during the hospitalisation, of both a > or =25% and a > or =0.3 mg/dL increase in serum creatinine (s-Cr) from admission (WRF-Abs-%). RESULTS: Patients were followed for 480+/-363 days. Fifty-three patients (17%) died and 132 (41%) were rehospitalised for HF. WRF-Abs-% occurred in 107 (34%) patients. At multivariable survival analysis, WRF-Abs-% was an independent predictor of death or HF rehospitalisation (adjusted HR, 1.47; 95%CI, 1.13-1.81; p=0.024). The independent predictors of WRF-Abs-%, evaluated using multivariable logistic regression, were history of chronic kidney disease (p=0.002), LV ejection fraction (p=0.012), furosemide daily dose (p=0.03) and NYHA class (p=0.05) on admission. CONCLUSION: WRF is a frequent finding in patients hospitalised for AHF and is associated with a poor prognosis. Severity of HF and daily furosemide dose are the most important predictors of the occurrence of WRF.

Bisoprolol in the treatment of chronic heart failure: from pathophysiology to clinical pharmacology and trial results.

Clinical trials have consistently shown the benefits of beta-blocker treatment in patients with chronic heart failure (HF). As a result, bisoprolol, carvedilol, and metoprolol succinate are now indicated for the treatment of all patients with chronic HF who do not have major contraindications. Bisoprolol is the first beta-blocker shown to improve survival in an outcome trial. In the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), all-cause mortality and sudden death were reduced in patients treated with bisoprolol compared with those on placebo (11.8% vs 17.3%; p < 0.0001 and 3.6% vs 6.3%, p < 0.002; respectively) regardless of age, NYHA functional class, and co-morbidities. Further studies have shown both the efficacy of bisoprolol on secondary endpoints and patients subgroups as well its high cost effectiveness. More recently, CIBIS-III has shown similar efficacy and safety of the initiation of HF treatment with either bisoprolol or enalapril, with a tendency to a survival advantage with bisoprolol. Nowadays, the role of bisoprolol, as well as that of carvedilol and metoprolol succinate, in HF treatment is firmly established and research is mainly focused on implementation of treatment and better dosing. This article will summarize evidence for the efficacy of bisoprolol in the treatment of HF.

Anemia and heart failure: a cause of progression or only a consequence?

Anemia is one of the most frequent co-morbidities in the patients with heart failure. Its prevalence increases from 4-7% in the subjects with asymptomatic left ventricular dysfunction to >30% in the patients with severe heart failure. Renal insufficiency, activation of inflammatory mediators, and treatment with renin-angiotensin antagonists seem to be its main determinants. The results of many studies agree in showing that anemia is a powerful independent determinant of survival in patients with heart failure. However, the mechanisms of this relation are still incompletely understood. Moreover a favourable effect on prognosis of the correction of anemia has not been shown, yet, and also controlled studies assessing its effects on exercise tolerance have yielded controversial results.