Markers of hypercoagulability and inflammation predict mortality in patients with heart failure.

BACKGROUND AND AIMS: Plasma levels of inflammatory markers are increased in chronic heart failure (HF) and are also subclinical indicators of future HF. Inflammation is strictly correlated with clotting activation, but the association between inflammation, hypercoagulability and prognosis in HF has not been previously reported. METHODS AND RESULTS: Markers of inflammation (interleukin-6; IL-6, and C-reactive protein; CRP) and hypercoagulability (D-dimer; DD, and thrombin-antithrombin III complex; TAT) were prospectively assessed in 214 subjects with New York Heart Association (NYHA) functional class II-IV HF. During a median follow-up of 8.5 months, 32 patients had an event: 13 died and 19 were hospitalized because of worsening of HF. IL-6, DD and TAT levels were all significantly associated with increased risk of death after adjustment for other known HF prognostic factors (age, gender, traditional cardiovascular risk factors, NYHA class, systolic left ventricular function, renal failure, hemoglobin, serum sodium) in a Cox multivariate proportional hazard model (P = 0.003, P = 0.01 and P = 0.02, respectively). When these markers were added simultaneously to the known prognostic factors in a new Cox multivariate model, only DD levels were significant predictors of mortality (hazard ratio [95% confidence interval; CI]: 11 [2.7-45.1], P = 0.001). The Kaplan-Meier curve revealed a significantly better outcome in patients with DD below 450 ng mL(-1). NT-pro-BNP was the only significant predictor of rehospitalization (HR [95% CI]: 5.3 [2.0-13.8], P < 0.001). CONCLUSION: Hypercoagulability and inflammation, as assessed by DD, TAT and IL-6 levels, are associated with an increased mortality risk in HF.

[Acute pericarditis in pregnancy. Report of a case]. / Pericardite acuta in gravidanza. Descrizione di un caso.

In this study the authors describe a case of acute pericarditis occurring at 26 weeks' gestation in a woman affected by Wolff-Parkinson-White Syndrome and with a history of Hodgkin's Lymphoma and autoimmune hypothyroidism. The patient was first admitted to the 4th Medical Pathology Unit of the University of Florence, where moderate pericardic effusion with no evidence of heart tamponade was documented by ultrasound scan. Subsequently the patient was cared for on outpatient basis at the Centre of Perinatal Medicine of the Department of Obstetrics and Gynaecology of the University of Florence. Since all examinations and tests aimed at defining the etiology of pericardial effusion were negative, an idiopathic acute pericarditis was diagnosed. The patient was given prednisone at a dose of 75 mg per day; owing to episodes of paroxystic atrial fibrillation, propaphenon was also administered intravenously to treat acute episodes and orally as prophylaxis. The patient underwent close control of both heart function (by means of ultrasound scans of the heart and dynamic EKG) and pregnancy (blood tests, ultrasound scans and Doppler velocimetry). At 36.5 weeks' gestation a healthy fetus was spontaneously delivered. Three months after delivery, the patient underwent an ultrasound scan that demonstrated the complete reabsorption of the effusion.

[Volume increase of the left leg and dyspnea as clinical manifestation of ruptured abdominal aorta aneurysm: problems of diagnostic assessment]. / Aumento di volume dell'arto inferiore sinistro e dispnea come presentazione clinica di rottura di aneurisma dell'aorta addominale: problemi di inquadramento diagnostico.

The case of a 74-year-old man who presented with abdominal pain, worsening dyspnea and swelling of the left lower limb is described. Careful history taking and clinical examination enabled diagnosis of the rupture of an abdominal aortic aneurysm.

[Rational bases for the therapy of supraventricular tachycardias and their management]. / Basi razionali della terapia delle tachicardie sopraventricolari e sua conduzione.

Supraventricular arrhythmias are frequently encountered in clinical practice. Despite their common anatomical origin above the division of His' bundle into bundle branches, these arrhythmias have profoundly different electrophysiological mechanisms, clinical significances and responses to treatment. Although 12-lead surface ECG usually enables correct identification, facilitating treatment choice in the emergency room, electrophysiologic testing to determine the site of origin and the pathway of the arrhythmia may be necessary for the management of definitive treatment. Drug therapy is efficient for conversion to sinus treatment in 80-90% of patients with new onset arrhythmias. Class Ic antiarrhythmics (propafenone and flecainide) are particularly useful for atrial fibrillation, while adenosine and verapamil are the drugs of choice for reentry tachycardias. Atrial flutter is a noteworthy exception, and DC shock is often required to terminate the arrhythmia. The results of antiarrhythmic therapy for long term prevention of recurrences are often disappointing. Recent surgical and technological developments, in particular transcatheter ablation procedures, now allow definitive resolution of most reentrant arrhythmias, including preexcitation syndrome. This report discusses current concepts regarding the management of supraventricular arrhythmias.

Acute left ventricular dysfunction due to Tako-tsubo syndrome after induction of general anesthesia.

Tako-tsubo cardiomyopathy is a recently described form of transient ventricular dysfunction that is not associated with coronary vessels obstruction, although its clinical manifestations are often similar to those of myocardial ischemia. This syndrome is possibly due to an excess of catecholamines, and it is associated with emotional and physical stress and surgery. However, the pathophysiological relation to anaesthesia has not yet been clarified. We report a case of Tako-tsubo cardiomyopathy that ensued immediately after induction of general anaesthesia for elective surgery in a patient submitted to laparoscopic cholecystectomy. The patient was first treated as if affected by myocardial ischemia, but a rapidly performed emergency coronary angiography showed normal epicardial coronary vessels with a significant reduction of left ventricular function. The coronary angiography ruled out the diagnosis of typical myocardial ischemia and allowed for the arrival at the correct diagnosis. The transient ventricular ballooning was attributed to the recently described Tako-tsubo syndrome. Prompt treatment allowed control of symptoms, and the patient was safely treated and discharged on day 15. Although it is difficult to identify the cause of this syndrome, it may be argued that, during general anaesthesia and particularly at induction, the imperfect control of catecholamine excess may induce cardiac damage in predisposed subjects.