Incidence and predictors of heart failure hospitalization and death in permanent pacemaker patients: a single-centre experience over medium-term follow-up.

AIM: The aim of this study was to assess the incidence and clinical predictors of the development of new-onset heart failure (HF) over medium-term follow-up, in patients treated with permanent pacing in daily clinical practice. METHODS AND RESULTS: We retrospectively enrolled all consecutive patients who underwent single- or dual-chamber pacemaker implantation at the study centre. Patients with a left ventricular ejection fraction (LVEF) ≤35% or a prior diagnosis of HF were excluded. Ventricular leads were routinely implanted in the right apex. Pacemakers were implanted in 490 patients with a standard pacemaker indication and LVEF >35%. Left bundle-branch block (LBBB) was reported in 30 (8%) patients, and an LVEF <50% in 64 (13%) patients. During a follow-up of 27 ± 21 months, 32 (7%) patients reached the combined endpoint of HF death or hospitalization. On multivariate analysis, LBBB (HR, 3.50; 95% CI, 1.1-11.1; P = 0.033) and LVEF <50% (HR, 5.1; 95% CI, 1.9-14.2; P = 0.002) were confirmed as independent predictors of HF death or hospitalization. Patients with LVEF <50% and/or LBBB displayed significantly higher rates of HF death or hospitalization (log-rank test, all P<0.001). CONCLUSION: The majority of patients with a standard indication for permanent pacing and normal LV function remained in a clinically stable condition after pacemaker implantation. However, ∼7% of patients developed new-onset HF over a period of follow-up of 27 months, and the presence of LBBB and LVEF <50% at the baseline predicted HF death or hospitalization.

Baseline apnoea/hypopnoea index and high-sensitivity C-reactive protein for the risk of recurrence of atrial fibrillation after successful electrical cardioversion: a predictive model based upon the multiple effects of significant variables.

AIMS: We tested apnoea/hypopnoea index (AHI), high-sensitivity (hs) C-reactive protein and clinical/instrumental variables as predictors of atrial fibrillation (AF) recurrence over 1-year follow-up after successful electrical cardioversion. METHODS AND RESULTS: We enrolled 158 consecutive patients. Apnoea/hypopnoea index was assessed with standard overnight polysomnography and hs-C-reactive protein with immunonephelometry assay the day before electrical cardioversion. Atrial fibrillation recurrences occurred in 81 patients (51%). Predictors at univariate analysis were: AHI > or = 15 events/h (P = 0.001), hs-C-reactive protein >0.30 mg/dL (P = 0.009), AF duration >3 days (P = 0.008), diabetes (P = 0.03), and ongoing anti-arrhythmic therapy at the time of electrical cardioversion (P = 0.03). Survival analysis confirmed that patients with AHI > or = 15 events/h and hs-C-reactive protein > 0.30 mg/dL had a higher recurrence rate of AF (log rank P = 0.0006 and P = 0.01, respectively). Predictors at multivariate analysis were: AHI > or = 15 events/h (P = 0.003), hs-C-reactive protein > 0.30 mg/dL (P = 0.01) and ongoing anti-arrhythmic therapy (P = 0.04). A predictive model based upon the multiple effects of significant variables plus age as a continuous variable stratified the risk of AF recurrence, more than tripled with all dichotomized variables altered with respect to normal variables (85 vs. 27%). CONCLUSION: AHI > or = 15 events/h and hs-C-reactive protein > 0.30 mg/dL are the strongest predictors of the predictors chosen of AF recurrence after successful electrical cardioversion over 1-year follow-up.

Sustained ventricular tachycardia in a thalidomide-treated patient with primary plasma-cell leukemia.

BACKGROUND: A 68-year-old man diagnosed with primary plasma-cell leukemia was given thalidomide maintenance treatment for his disease. He had previously failed induction therapy with cyclophosphamide, vincristine, adriamycin, and dexamethasone, but achieved complete remission after melphalan therapy. Multiple syncopal episodes started to occur during thalidomide treatment, and a Holter electrocardiogram showed multiple abnormalities, with an episode of sustained ventricular tachycardia. INVESTIGATIONS: Blood tests, peripheral blood smear, bone-marrow biopsy and aspirate, Holter electrocardiogram. DIAGNOSIS: Sustained ventricular tachycardia possibly owing to thalidomide treatment. MANAGEMENT: Thalidomide withdrawal, dexamethasone maintenance therapy, monthly oral courses of combined melphalan and prednisone, salvage therapy with bortezomib.

C-reactive protein and P-wave in hypertensive patients after conversion of atrial fibrillation.

AIMS: P maximum/P dispersion and high-sensitivity C-reactive protein (hs-C-reactive protein) have been proposed as useful markers for predicting the history and recurrence of atrial fibrillation. We tested the association between hs-C-reactive protein and maximum P-wave duration (P maximum)/P-wave dispersion (P dispersion) in hypertensive patients after conversion of atrial fibrillation. METHODS: We enrolled 92 patients. Hs-C-reactive protein was assessed before cardioversion, the 12-lead ECG was recorded immediately after sinus rhythm restoration. RESULTS: At univariate analysis P maximum above 120  ms was associated with male sex (P = 0.0009), body mass index at least 25  kg/m (P = 0.03) and hs-C-reactive protein greater than 0.30  mg/dl (P = 0.0001), and left atrium diameter greater than 40 mm nearly significant (P = 0.05). P dispersion above 40  ms was associated with hs-C-reactive protein greater than 0.30  mg/dl (P = 0.0001) and left atrium diameter greater than 0.40  mm (P = 0.03). P maximum/P dispersion (mean ±â€ŠSD) was significantly longer in patients with hs-C-reactive protein greater than 0.30  mg/dl compared to patients with hs-C-reactive protein 0.30  mg/dl or less (P = 0.0001 for both). At multivariate analysis P maximum above 120  ms was associated with male sex (P = 0.01) and with hs-C-reactive protein greater than 0.30  mg/dl (P = 0.002), whereas P dispersion above 40  ms was associated only with hs-C-reactive protein greater than 0.30  mg/dl (P = 0.0006). CONCLUSION: Male sex and hs-C-reactive protein were associated with P maximum above 120  ms; hs-C-reactive protein was also associated with P dispersion above 40  ms in hypertensive patients after conversion of atrial fibrillation. Subclinical inflammation may be associated with delayed/inhomogeneous atrial activation in hypertensive patients affected by atrial fibrillation.

[Management of ST-elevation myocardial infarction in the Umbria region: results from the observational prospective Umbria-STEMI registry]. / La gestione dell'infarto miocardico acuto con sopraslivellamento del tratto ST nella regione Umbria: risultati del registro prospettico osservazionale Umbria-STEMI.

BACKGROUND: In the last few years, advances have been made in the diagnosis and management of ST-segment elevation myocardial infarction (STEMI). Recent guidelines have been developed to improve outcome of STEMI patients by implementation of the recommendations into clinical practice. In order to assess the disease burden, the treatment modalities and the mid-term outcome of STEMI in the Umbria region, Italy, we performed a prospective observational study of all patients hospitalized with a diagnosis of STEMI from October 14, 2006 to April 14, 2008 (Umbria-STEMI registry). METHODS: All the medical emergency services (118) and all the emergency, internal medicine and cardiology departments were involved in the project. Three typologies of cardiology departments are operating in our region: a) intensive care units (ICUs) with percutaneous coronary intervention (PCI) facilities fully operating 24 h/day and 7 days/week (1 center), b) ICUs with PCI facilities operating 6 h/day and 5 days/week (2 centers); c) ICUs without PCI facilities (4 centers). The Umbria-STEMI health area includes about 850 000 inhabitants. RESULTS: Overall, 868 patients (70% male, mean age 66.5 +/- 13.3 years) were enrolled. Patients with late presentation (> 12 h) or non-persistent ST-segment elevation (9.9%) were excluded. 86.7% of patients underwent reperfusion treatment: 45.9% with primary angioplasty and 40.8% with thrombolysis (64 of them had rescue angioplasty). Primary angioplasty was mainly performed in the hospital with PCI facilities operating 24 h/day. 104 patients with STEMI (13.3%) did not receive any type of coronary reperfusion therapy. In a logistic regression analysis, the direct admission to the hospital with fully operating PCI facilities was the strongest positive predictor of reperfusion therapy utilization, whereas the time delay, older age and TIMI risk index were negative predictors. The mean door-to-needle time for lytic therapy was 60 min, and the door-to-balloon time for primary angioplasty was 156 min. In-hospital mortality was 5.9%. CONCLUSIONS: The Umbria-STEMI registry disclosed several discrepancies between guidelines-recommended treatments and their utilization in daily practice. Efforts should be made to reduce the delay from symptom onset to intervention.

[Risk factors for cardiovascular diseases: what is the role for homocysteine?]. / Fattori di rischio delle malattie cardiovascolari: esiste ancora un ruolo per l'omocisteina?

Cardiovascular diseases are commonly related to classical risk factors, but other risk markers have been identified, including homocysteine. Homocysteine is a sulphurated amino acid which derives from methionine. The causes of hyperhomocysteinemia are multifactorial, such as genetic defects, pathophysiological conditions, lifestyle and drugs-related. Hyperhomocysteinemia favors atherothrombosis through endothelial dysfunction, enhancement of inflammation and thrombophilic profile. A number of clinical and laboratory trials exist regarding the association between homocysteine levels and an increased risk of cardiovascular disease. However, the lack of homogeneity in the data, together with the high number of factors capable of influencing homocysteine plasma levels, and the disappointing results of therapeutic trials do not permit us at present to consider homocysteine as an independent and major risk factor for cardiovascular disease.