ST segment elevations: always a marker of acute myocardial infarction?

Chest pain is one of the chief presenting complaints among patients attending Emergency department. The diagnosis of acute myocardial infarction may be a challenge. Various tools such as anamnesis, blood sample (with evaluation of markers of myocardial necrosis), ultrasound techniques and coronary computed tomography could be useful. However, the interpretation of electrocardiograms of these patients may be a real concern. The earliest manifestations of myocardial ischemia typically interest T waves and ST segment. Despite the high sensitivity, ST segment deviation has however poor specificity since it may be observed in many other cardiac and non-cardiac conditions. Therefore, when ST-T abnormalities are detected the physicians should take into account many other parameters (such as risk factors, symptoms and anamnesis) and all the other differential diagnoses. The aim of our review is to overview of the main conditions that may mimic a ST segment Elevation Myocardial Infarction (STEMI).

Preterm birth after loop electrosurgical excision procedure (LEEP): how cone features and microbiota could influence the pregnancy outcome.

OBJECTIVE: In the last years, the mean age of women who underwent cervical treatment for high-grade cervical intraepithelial neoplasia (CIN 2-3) is similar to the age of women having their first pregnancy. The aim of this study was to evaluate the risk of preterm birth in subsequent pregnancies after loop electrosurgical excision procedure (LEEP). PATIENTS AND METHODS: From January 2013 to January 2016 the study identified a total of 1435 women, nulliparous, who underwent LEEP for CIN 2-3, and who wished to have their first pregnancy. Before surgery, the lengths of the cervix were calculated by transvaginal sonography. After the treatment, the dimension of the removed tissue was evaluated. During the pregnancy, all women carried out periodic transvaginal sonography and vaginal-cervical swabs. RESULTS: The average age of patients was 31.96±5.24 years; the interval between the surgical procedure and pregnancy was 12.04±4.67 months; the gestational age at births was 37.53±2.91 weeks. The first vaginal and cervical swab performed during pregnancy was negative in 81.8% of patients. The most prevalent infections were related to C. Albicans, G. Vaginalis, and Group B Streptococcus (GBS). The rate of preterm delivery was significantly higher in women with a minor cervical length. CONCLUSIONS: The length and the volume of cervical tissue excised have been shown to be directly related to the risk for preterm birth. Furthermore, vaginal infections and their persistence during pregnancy in women with a history of LEEP may be associated with an increased risk for preterm birth, compared with women with no history of LEEP.

Cervicovaginal bacteria and fungi in pregnant diabetic and non-diabetic women: a multicenter observational cohort study.

OBJECTIVE: We evaluated the prevalence of cervicovaginal Bacteria, group B Streptococcus (GBS), Gardnerella vaginalis (GV), Candida spp., Chlamydia trachomatis (CT), Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) in pregnant women with and without diabetes mellitus (DM). PATIENTS AND METHODS: Cervicovaginal swabs were gathered from 473 pregnant patients divided into 127 diabetic and 346 non-diabetic. The results were correlated to gestational age, parity and glycemic control. RESULTS: A higher prevalence of MH/UU (p=0.012) was found in the diabetic patients. After the 28th week of pregnancy, the prevalence for all investigated microorganisms appeared similar except for MH/UU (p=0.014). In multigravida, there were statistical differences between two groups in testing for Bacteria (p=0.015) and for MH/UU (p=0.037). The diabetic condition correlated to the state of multigravida in cases positive for Candida spp. (p=0.049) and in those testing positive for at least one microorganism (p=0.043). Pregnant with a blood glucose > 92 have twice the risk of being positive to a single microbiological test than those with better glycemic control. CONCLUSIONS: The higher prevalence of MH/UU after the 28th weeks can be explained with the physiologically reduced insulin tolerance characteristic of this gestational period. Among the diabetic testing positive to Candida spp. the statistically significant association was observed only in multigravida condition. These data suggest that diabetic multigravida women are at increased risk for Candida spp. infection in relation to the improper glycemic control.

Cardiac function and sympathetic activity in young diabetics.

This study was aimed at evaluating cardiac function, both systolic and diastolic, in young type 1 diabetics with a mean duration of the disease of 10.9 +/- 6 years and without evidence of cardiac autonomic neuropathy and micro- or macroangiopathy. Thirteen diabetics, with good metabolic control, and 10 normal matched subjects were studied by echocardiography at rest and by radionuclide ventriculography both at rest and during effort. The level of plasma catecholamines was also determined. The echocardiographic data were comparable in the two groups. Scintigraphic data showed an increased peak ejection and peak filling rate (P less than 0.001) in diabetics while the other indices of cardiac function were comparable. Norepinephrine (P less than 0.01) and epinephrine (P less than 0.001) were higher in diabetics. A hypothesis is formulated that the higher indices of flow velocities in type 1 diabetics are supported by a sympathetic overactivity.

[Cardiac effects of GH]. / Effetti cardiaci del GH.

To investigate cardiac effects of excess and deficiency of growth hormone (GH) we studied twenty acromegalic subjects and eleven adult patients with GH deficiency by means of a non invasive method, the Doppler echocardiography. The results obtained in the group of patients were compared with those of two groups of twenty and eleven normal subjects, respectively, age and sex matched. The age of the acromegalic patients ranged from 20 to 62 years. Nineteen patients were considered to have active acromegaly at the time of the study. Mean duration of disease since treatment was 12 +/- 5 years (range 5 to 24 years). The age of GH deficient adults ranged from 21 to 33 years. All these patients have been treated with extractive GH over nine years and the therapy withdrawal was performed at least three years before entering the study. In the group of acromegalic patients, a subgroup including nine patients with mild to moderate hypertension was considered. All subjects gave informed consent and the study protocol was approved by the Ethical Committee of the Medical School of Naples. Right ventricular free wall thickness resulted significantly increased in acromegalic patients (8 +/- 2 vs 4 +/- 1 mm; p < 0.001). Left ventricular mass index was augmented both in the whole group and in the subgroups of normotensive and hypertensive acromegalics as compared with normals (134 +/- 33 p < 0.001, 115 +/- 20 p < 0.01 and 156 +/- 31 p < 0.001 vs 80 +/- 18 g.m-2). Ejection phase indices were normal in patient group, while impaired left and right ventricular diastolic filling was found.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardioscintigraphic evaluation of obese subjects with or without arterial hypertension]. / Valutazione cardioscintigrafica dell'obeso con o senza ipertensione arteriosa.

A group of normotensive obese subjects (group A), a group of hypertensive obese subjects (group B) and a group of control subjects (group C) were submitted to radionuclide ventriculography using 99mTc to investigate cardiac function and haemodynamic situation in the presence of an increased preload (group A), preload and afterload (group B). Results show a significant reduction in ejection fraction and systolic blood pressure/end systolic volume in group A. Group B shows better cardiac function probably for the presence of cardiac concentric hypertrophy. Left ventricle work either in a minute and for each beat is greatest in patients of group B. Thus the simultaneous presence of obesity and hypertension can cause a worse prognosis in such patients for cardiac ischaemia and/or sudden death.

Influence of atenolol on the relationship between heart rate and QT interval in patients with exercise-induced myocardial ischemia.

The aim of this study was to analyze the relationship between heart rate and QT interval (HR-QT) during exercise in control subjects (Group A) and in patients with coronary artery disease (CAD) with effort angina and without previous myocardial infarction (MI) (Group B). The diagnosis of CAD was confirmed by coronarographic examination. The correlation HR-QT was significant (p < 0.001) in both groups on effort and at recovery. The analysis of the regression HR-QT was carried out separately, both on effort in upright position and at rest in supine position, to avoid the influence of posture on QT length. During effort, the regression line showed lower slope and intercept values in Group B (p < 0.001) than those for Group A. A similar behavior was also observed at rest. Thus, at the highest heart rate, where ECG signs of ischemia (ST depression > 1 mm) frequently occurred, a longer QT interval was present in Group B. Moreover, in Group B, the QT interval in the presence of ECG signs of ischemia was significantly longer (p < 0.01) than in Group A at comparable heart rates both on effort and at rest, thereby confirming the result obtained by comparing both regression lines. The same effort protocol was repeated in Group B patients after acute administration of atenolol 100 mg per os. After atenolol administration, the analysis of the regression HR-QT in Group B clearly showed a shorter QT interval than that obtained in washout period during the baseline test at the highest heart rates where the ECG frequently showed signs of ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Pacemaker malfunction due to subcutaneous emphysema--a case report.

The authors describe a cas of pacemaker malfunction due to a critical increase of impedance resulting from air entrapment in the pacemaker pocket.

Subacute cardiac rupture complicating myocardial infarction. A case report.

The authors have focused this study on the emergence of subacute ventricular free wall rupture in a seventy-six-year-old patient admitted to hospital for inferior acute myocardial infarction. After six days he showed clinical signs of bradycardia and hypotension evolving to electromechanical dissociation. Given an adequate pharmacologic therapy, the patient was submitted to echocardiography, which was believed to be consistent with myocardial rupture, showing a moderate to large pericardial effusion. Pericardiocentesis of 150 mL of bloody fluid resulted in a further improvement in his hemodynamics. The patient underwent cardiac surgery with repair of the myocardial rupture through a large diaphragmatic infarction by a Dacron polyester fiber graft and pacemaker placement. In conclusion the authors confirm the relevant role of clinical data such as persistent chest pain and hemodynamic instability and the value of echocardiography in identifying subacute myocardial free wall rupture after an episode of acute myocardial infarction.

Evaluation, by noninvasive methods, of the effects of acute loss of thyroid hormones on the heart.

To evaluate the effects of the acute loss of thyroid hormones on the heart the authors studied 11 women with acute hypothyroidism. The cardiac study was performed by means of electrocardiography (ECG), radionuclide ventriculography (RNV) at rest and under effort, and monodimensional echocardiography (MD-echo) and was repeated with ECG and MD-echo after six months of thyroxine suppressive therapy. The ECG showed a significant prolongation of QT interval and flattening and inversion of T wave with normal heart rate. The MD-echo revealed left ventricular function in the normal range and normal left ventricular dimensions. RNV showed the ejection fraction in the lower normal range at rest, which increased to a smaller extent under effort in comparison with a control group. The ECG performed during suppressive therapy with L-thyroxine yielded normal findings with an increase of heart rate and of R wave amplitude, and the MD-echo showed no significant variations of cardiac function due to the increase of heart rate.

Diagnosis of coronary artery disease with Tc 99m-methoxy isobutyl isonitrile and transesophageal pacing.

Recently the use of a new radioactive agent with physical and biological properties more favorable than those of thallium 201, methoxy-isobutyl-isonitrile (MIBI) labeled with technetium 99m (Tc 99m), has permitted simultaneous performance of perfusion and function studies in ischemic cardiopathy. Transesophageal atrial pacing (TAP) technique has evolved as an alternative provocative test of ischemia. The authors compared the capability of Tc 99m-MIBI myocardial scintigraphy, combined with TAP, with that of Tc 99m-MIBI, combined with maximal stress test, in the diagnosis of ischemic cardiopathy. They studied 11 patients with a clinical history of angina pectoris. Myocardial scintigraphy was performed at rest, after stress test, and after TAP. Finally, all the patients underwent coronary angiography. The analysis of myocardial perfusion images on both Tc 99m-MIBI associated with TAP and with stress demonstrated, in 165 myocardial segments examined: 143 normal, 20 reversible defects, 2 irreversible defects. The concordance of localization between coronarographic data and scintigraphic reversible and irreversible defects was 85%. In conclusion TAP proves to be a valid and sensitive provocative test of ischemia when combined with myocardial scintigraphy and with Tc 99m-MIBI.

Phase image analysis in Wolff-Parkinson-White syndrome. Role of transesophageal pacing.

Phase image analysis (first Fourier harmonic transformation) has been performed in 5 men with WPW syndrome to define the abnormal patterns of ventricular emptying during sinus rhythm and transesophageal pacing at different rates. All patients but one showed basal ventricular preexcitation. Of the 4 patients with basal ventricular preexcitation the earliest ventricular emptying occurred in the left ventricular free-wall in 1 patient and in the right ventricular free-wall in 3 patients. In the patient without ventricular preexcitation at rest transesophageal pacing at a rate of 100 bpm induced first ventricular activation in the left lateral ventricular free-wall while at a rate of 120 bpm it returned to normal. In the patients with ventricular preexcitation at rest, the basal image abnormalities become more evident as preexcitation was augmented. Of interest, in 1 patient with basal type B ventricular preexcitation the sequential phase image analysis, at a rate of 100 bpm confirmed the earliest ventricular activation in the right ventricular free-wall while at a rate of 120 bpm showed the earliest emptying in left ventricular free-wall suggesting the presence of 2 accessory connections. We conclude that phase mapping combined with transesophageal pacing may be a useful and reliable method to localize single as well as multiple accessory pathways in patients with ventricular preexcitation.

Clinical experience with the transvenous Medtronic Pacer Cardioverter Defibrillator (PCD) System.

We review our experience with the transvenous Medtronic Pacer Cardioverter Defibrillator System (Model 7217B), a multifunction implantable pacer defibrillator combined with a transvenous lead system (Transvene). From April 1991 to October 1992, we implanted this device in 19 consecutive patients (11 men and 8 women; average age, 56.5 years). Nine patients (47.4%), 5 with coronary artery disease and 4 with dilated cardiomyopathy, had an ejection fraction of < 30%. The average operative time was 129 minutes. In 18 patients (94.7%), the transvenous lead system provided effective sensing, pacing, and defibrillation during intraoperative testing. In each of these cases, the defibrillation threshold was less than 18 J. In 1 patient (5.3%), it was necessary to switch to epicardial leads, which were implanted through a left thoracotomy. All patients were extubated in the recovery room. The average hospital stay was 8 days. There was no early mortality or morbidity. During a maximum follow-up period of 17 months (mean, 9.2 months), no sudden death occurred. The implantable system terminated 245 ventricular tachycardia episodes in 14 patients (73.7%) and 82 ventricular fibrillation episodes in 13 patients (68.4%). Two hundred eleven (86.1%) of the ventricular tachycardia episodes were resolved by antitachycardia pacing alone. In 2 patients (10.5%), the caval electrode became dislocated; repositioning of the electrode was followed by repeat defibrillation threshold evaluation. Our experience shows that the transvenous Medtronic Pacer Cardioverter Defibrillator System provides safe, effective treatment of ventricular tachyarrhythmias. Because the perioperative mortality and morbidity are extremely low, use of this device may be particularly beneficial in patients with a high operative risk. Moreover, the lower number of unpleasant therapeutic shocks should increase patient a acceptance of the device.

A retrospective review of factors associated with vasovasostomies in United States military members.

BACKGROUND: Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal. METHODS: All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed. RESULT: A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy. CONCLUSION: Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.

[Computerized follow-up cards for ambulatory patients with implanted pacemaker or defibrillator]. / La carta sanitaria informatizzata nella gestione ambulatoriale del paziente con pacemaker o defibrillatore impiantabile.

The follow up of pacemaker and defibrillator dependent patients has a significant role for both the evaluation of pacing effectiveness and check of hemodynamic advantages about patient's quality of life. The bulky paper archives are often inaccurate, hampering the consultation. At present the paper card is the only document which can be utilized to record some data concerning the implant and patient clinical story. Therefore, there is the necessity for a card that can include all patient's data, and the implant and programming pacemaker/defibrillator data during follow up. This new pacemaker card has portable file or data-base including shared data with safety mechanism, which can be utilized in several controls by different users (physicians, hospital ward, primary care units, insurance companies). The pacemaker card includes a chip that permits to store a considerable amount of data; it can be update in every further medical control, in observance of laws. The card Chip Operating System (C.O.S.) consists of a microchip with a memory completely managed by the operating system inside the chip itself. The card can be read by means of a GCR-200 modem linked with a PC IBM-compatible computer and the data can be updated during the follow up. The pacemaker-defibrillator card will appear immediately on screen, and it can be printed, updated and/or modified by a Microsoft Windows operating programme. With this pacemaker card we are able to ensure serviceable medical work, particularly in terms of cost/benefit ratio giving to patient more and more reasoning and safe service.

Efficacy of ticlopidine in the prevention of thromboembolic events in patients with VVI pacemakers.

This study was designed to evaluate whether long-term treatment with ticlopidine reduces the incidence of thromboembolic episodes in patients with a VVI pacemaker. One hundred eleven patients with a VVI pacemaker were randomly assigned to two groups: group A (52 patients) was treated with ticlopidine at the dose of 250 mg a day; and group B (59 patients) was not treated and served as a control group. The primary analysis of efficacy of ticlopidine was based on the occurrence of thromboembolic episodes and of cardiovascular and cerebrovascular deaths. The mean follow-up period was 66 months. In group A, there was a significant reduction in the incidence of thromboembolic episodes (P less than 0.05) with a smaller incidence of total cardiovascular and cerebrovascular deaths (8 in group A and 18 in group B; P = 0.05) as compared with group B. Twelve percent of patients had moderate side effects with 1 dropout (epistaxis). Our data confirm the high incidence of thromboembolic events in patients with a VVI pacemaker and demonstrate the efficacy of ticlopidine in preventing them.

[Exercise electrocardiogram in the evaluation of coronary atherosclerosis: correlations between electrocardiographic signs of ischemia and a coronarographic study]. / Elettrocardiogramma da sforzo nella valutazione dell'aterosclerosi coronarica: correlazione tra segni elettrocardiografici di ischemia ed esame coronarografico.

We divided 51 patients (Group C) with stable effort angina into 2 groups: Group A of 30 patients without previous myocardial infarction, Group B of 21 patients with previous myocardial infarction. The aim of this study was to test the relation between some ECG signs of ischemia and coronary artery disease (CAD) severity and to propose a new simple angiographic score of CAD. The patients, after a pharmacological wash-out period, were submitted to a treadmill effort test and to a coronarography. Stenoses were quantified using a score system recently proposed in the literature and a new simple score obtained summing the coronary stenosis in percent. Significant correlations between the time to the onset of ischemia (TSI) and the recovery time (TR) with the CAD severity in Groups A, B, and C using both scores were observed. The total stress time and the new index obtained summing the total effort time and the time to the onset of ischemia were related to the severity of CAD in Groups A and C using both scores. The multivariate discriminant analysis suggested that the TSI is the most sensitive variable to predict CAD severity in our patients. A good correlation between the 2 scores was also observed.

Acebutolol and nifedipine in the treatment of arterial hypertension: efficacy and acceptability.

The antihypertensive efficacy and the acceptability of nifedipine (NI, Adalat) and the usefulness of its combination with a beta 1-selective blocking drug, acebutolol (AC), were studied in a placebo controlled trial on 15 patients with moderate hypertension. The study consisted of three phases: 1. An acute test, including the single blind comparison of three different single doses of NI (5, 10, 20 mg), alone and in combination with AC 200 mg, with placebo and with AC alone (200 mg), showed an early hypotensive effect, with no differences for the three doses of NI, reaching the maximum between 50 and 240 min, greater than the one of AC, and smaller in comparison with the one of the combinations, which didn't differ at the three doses of NI. Heart rate (HR) and side effects, instead, increased with the increasing doses of NI, suggesting a worse acceptability for the greater doses. 2. A long-term treatment, including a double-blind comparison of three separate periods of 4 weeks of treatment with NI (10 mg three times a day), AC (200 mg three times a day) and with the combination of the same doses, showed a significant reduction of systolic and diastolic blood pressure (BP) for each treatment, not significantly different at rest for the three single drugs but greater for the combined treatment, assuring also a better control of systolic BP during exercise. A reduced number of side effects was seen with the combined therapy which seems to contribute to a better compliance.(ABSTRACT TRUNCATED AT 250 WORDS)