The "thirsty dropsy": Early descriptions in medical and non-medical authors of thirst as symptom of chronic heart failure.

BACKGROUND: Patients with chronic heart failure may suffer from severe thirst, even if mechanisms that cause thirst in subjects affected by this condition are not clear. Medical and non-medical authors may have already recognized this symptom during the classical age. METHODS: We analyzed association between thirst and dropsy (an ancient medical term used to indicate different conditions including chronic heart failure) in past medical and non-medical literature. RESULTS: Hippocrates and Celsus first recognized thirst as a symptom of dropsy in the classical age. Greco-Roman intellectuals (Polybius, Ovid, Horace) and theologians belonging to the first years of the Christian era (Augustine, Caesarius, Gregory I) showed to know that dropsy people were often thirsty. These authors also influenced medieval poets and writers, including Dante Alighieri. In the Renaissance, the physician and alchemist Paracelsus again evidenced this symptom and the iatrochemist Robert Fludd tried to explain pathophysiology of dropsy, basing on thirst. CONCLUSIONS: The relationship between thirst and dropsy was well known by physicians and intellectuals in the classical age and in the first years of the Christian era, so influencing the Renaissance physicians.

Infarto cerebral como forma de presentación de un síndrome takotsubo / Cerebral infarct as a clinical presentation of takotsubo syndrome

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Stem cells mobilization in acute myocardial infarction (stem-AMI trial): preliminary data of a perspective, randomized, single blind trial.

AIM: Clinical trials demonstrated that granulocyte colony-stimulating factor (G-CSF) administration seems to be safe in patients with acute myocardial infarction but the results about the effectiveness are not so encouraging. The main problem is to distinguish the effects that early revascularization and regenerative therapy have on left ventricular (LV) function. The purpose of our perspective randomized trial is to evaluate the efficacy of G-CSF administration, assessed by improvement of LV ejection fraction by cardiac magnetic resonance imaging (MRI), in patients with acute anterior myocardial infarction undergoing primary percutaneous coronary intervention (PCI) and with evidence of LV dysfunction. METHODS: Fifty consecutive patients with first anterior ST-elevation myocardial infarction (STEMI), undergoing primary PCI, with symptom to balloon >2 and <12 hours and ejection fraction (EF) =or<45%, are randomized to 150 microg/m2 G-CSF bis in die subcutaneously (from day 0 to day 4) in addition to standard care. Patients are submitted to echocardiography, Holter monitoring, gated single photon emission computed tomography (SPECT) and MRI at baseline and at 6 months of follow up. Coronary angiogram is repeated at 6 months to evaluate in-stent restenosis. RESULTS: From July 2006 until August 2007, 13 consecutive patients were enrolled and 5 of them were assigned to G-CSF administration. All patients underwent PCI and stenting of left anterior descending artery. Mean baseline EF evaluated by echocardiography, SPECT and MRI was respectively 36%, 33% and 38%. No adverse events were observed during G-CSF administration. The mean white blood cells count, in the treatment arm, was 36.1 x 10(9)/L +/- 2.90 on day 5. CONCLUSION: Preliminary data of our study do not support any conclusive result. However, the characteristics of our population could allow us to distinguish the effects that revascularization and regenerative therapy have on LV function in patients with acute myocardial infarction.

Reaching and grasping phenotypes in the mouse (Mus musculus): a characterization of inbred strains and mutant lines.

Skilled movements, such as reaching and grasping, have classically been considered as originating in the primate lineage. For this reason, the use of rodents to investigate the genetic and molecular machinery of reaching and grasping has been limited in research. A few studies in rodents have now shown that these movements are not exclusive to primates. Here we present a new test, the Mouse Reaching and Grasping (MoRaG) performance scale, intended to help researchers in the characterization of these motor behaviors in the mouse. Within the MoRaG test battery we identified early phenotypes for the characterization of motor neurone (Tg[SOD1-G93A](dl)1Gur mice) and neurodegenerative (TgN(HD82Gln)81Dbo transgenic mice) disease models in addition to specific motor deficits associated with aging (C3H/HeH inbred strain). We conclude that the MoRaG test can be used to further investigate complex neuromuscular, neurological, neurodegenerative and behavioral disorders. Moreover, our study supports the validity of the mouse as a model for reaching and grasping studies.

[Prevention of cardiovascular diseases by an antihypertensive program in the elderly, a cohort study]. / Prevención de eventos cardiovasculares en hipertensos mayores de 65 años bajo el cuidado de un programa de control. Estudio de cohorte.

INTRODUCTION: We started on year 2000 a Complex Intervention Program addressed at hypertension control among our patients. AIM: To compare the risk of cardiovascular events and of dying in hypertensive patients under Program care. METHOD: We started follow-up of a cohort of 1922 patients over 65 years in August 2000. Hipertension diagnosis was ascertained if patient reported to be hypertensive, or was under anti hypertensive treatment or if he/she had two blood pressure measurements = 140/90 mm Hg. Cardiovascular events were considered to be admissions due to coronary disease, cardiac insufficiency or stroke. Incidence is reported by 100 person years follow-up. Relative risks between hypertensive and normotensive patients were calculated and Cox regresión was used to adjust for potential confounders. We compared time to first cardiovascular event and to death with Log Rank Test. RESULTS: Fourty eight point three percent of patients were hypertensive and differed from normotensive patients as to age (79 (5) years vs. 77 (5) p < 0.001), proportion of diabetic patients (16.1% vs. 7.6% p < 0.001). Mean follow-up time was 28 months. Mortality RR was 1.04 (95% CI 0.69-1.58). As to incidence of cardiovascular events it was 1.86 in normotensive vs. 3.02 (RR 1.62 95% CI 1.09-2.42). When adjusted by age, sex, smoking, dislipemia and diabetes, OR was 1.3 (95% CI 0.86-1.98). CONCLUSIONS: Hypertension did not increase the risk in cardiovascular events among our hypertensive patients at 2.3 years follow-up.

Prevención de eventos cardiovasculares en hipertensos mayores de 65 años bajo el cuidado de un programa de control. Estudio de cohorte / Prevention of cardiovascular diseases by an antihypertensive program in the elderly. Cohort study

Introducción: Iniciamos en el 2000 un programa de control para la hipertensión arterial. Objetivo: Conocer el riesgo de morir y de presentar eventos cardiovasculares en los hipertensos bajo el cuidado del programa. Método: Se conformó una cohorte de 1.922 mayores de 65 años en agosto del 2000. Se consideró hipertenso si se conocía como tal, si recibía fármacos antihipertensivos o si tenía dos tomas de presión ≥ 140/90mmHg. Evento cardiovascular a las internaciones por enfermedad coronaria, insuficiencia cardiaca y accidente cerebrovascular. Expresamos densidad de incidencia (DI) de mortalidad y de eventos cardiovasculares cada100 persona-años en hipertensos y en no hipertensos y practicamos regresión de cox para ajustar por factores de riesgo en estudio. Se compara el tiempo al primer evento cardiovascular y a la muerte con Log Rank Test. Resultados: Edad 77,6 (± 5,4) años, 73,9% mujeres, el 48,3% eran hipertensos, diferentes significativamente con respecto a los normotensos en edad 79 (± 5) vs. 77 (± 5) p < 0,001, porcentaje de diabéticos (16,1 vs. 7,6%) p < 0,001. La DI del total de eventos fue de 1,86 vs. 3,02 (RR1,62, IC95% 1,09-2,42) La DI de mortalidad fue de 2,2 vs. 2,1 (RR 1.04,IC95% 0,69-1,58) Tiempo promedio de seguimiento 28 meses, el porcentaje de pacientes libre de eventos a este tiempo fue de 93% (hta) vs.96% (no hta) (p < 0,001). En el multivariado fueron significativas: diabetes,dislipidemia, tabaquismo, edad y sexo, perdiendo peso la hipertensión arterial, OR 1.30 (IC95% 0,86-1,98). Conclusiones: La hipertensión no incrementó el riesgo de presentar eventos cardiovasculares en nuestros hipertensos a 2,3 años

Introduction: We started on year 2000 a Complex Intervention Program addressed at hypertension control among our patients. Aim: To compare the risk of cardiovascular events and of dying inhypertensive patients under Program care. Method: We started follow-up of a cohort of 1922 patients over 65 years in August 2000. Hipertension diagnosis was ascertained if patient reported to be hypertensive, or was under anti hypertensive treatment or if he/she had two blood pressure measurements ≥ 140/90 mm Hg. Cardiovascular events were considered to be admissions due to coronary disease, cardiac insufficiency or stroke. Incidence is reported by 100 person years follow-up. Relative risks between hypertensive and normotensive patients were calculated and Cox regresión was used to adjust for potential confounders. We compared time to first cardiovascular event and to death with Log Rank Test. Results: Fourty eight point three percent of patients were hypertensiveand differed from normotensive patients as to age (79 (5) years vs. 77 (5) p< 0.001), proportion of diabetic patients (16.1% vs. 7.6% p < 0.001). Mean follow-up time was 28 months. Mortality RR was 1.04 (95% CI 0.69-1.58). As to incidence of cardiovascular events it was 1.86 in normotensive vs. 3.02 (RR 1.62 95% CI 1.09-2.42). When adjusted by age, sex, smoking,dislipemia and diabetes, OR was 1.3 (95% CI 0.86-1.98) Conclusions: Hypertension did not increase the risk in cardiovascular events among our hypertensive patients at 2.3 years follow-up

Radial artery flow-mediated dilatation in heart failure patients: effects of pharmacological and nonpharmacological treatment.

Congestive heart failure (CHF) is associated with an impaired flow-mediated vasodilation that reflects an impaired endothelial function. Limited information is available, however, on whether and to what extent this impairment is improved by pharmacological or nonpharmacological treatment. We measured radial artery diameter and blood flow by an echo-tracking Doppler device both at baseline and after 4 minutes of hand ischemia, which increases diameter through NO secretion mediated by an increase in flow and shear stress. Data were collected from 44 CHF patients (New York Heart Association class I to III) under standard treatment (diuretic, digitalis, and enalapril, 20 mg/d), in whom CHF severity was assessed by a cardiopulmonary stress test, and from 16 age- and sex-matched controls. CHF patients were then randomized to maintain for (A) 2 months of standard treatment (n=11), (B) treatment with double the ACE inhibitor dose (n=11), (C) standard treatment with an angiotensin II antagonist (losartan, 50 mg/d; n=11), or (D) standard treatment with bicycle training for 30 minutes, 3 times a week (n=11). At baseline, radial artery diameter and flow were similar in CHF patients and controls; CHF patients had a modest although significant impairment in flow increase (-36%) and a striking impairment (-78%) in diameter increase following the 4 minutes of ischemia. After 2 months, baseline diameter and flow remained unaltered in the 4 groups. After the 4 minutes of ischemia, radial artery flow and diameter increased as before in the group under standard treatment (A), whereas in the other 3 groups, the increase was significantly (P<0.05) and, for diameter, markedly (B, 83%; C, 92%; and D, 95%) greater. The vasodilatation induced by trinitroglycerin was similar in CHF and control subjects and not affected by treatments. In CHF, radial artery shows a marked reduction in flow-mediated vasodilation, reflecting impairment of endothelial function. This impairment can be markedly improved by treatments that effectively block the renin-angiotensin system either at ACE or at ACE plus angiotensin receptor level. This is the case also with nonpharmacological treatment of CHF.

Echocardiography-guided pericardiocentesis with probe-mounted needle: report of 53 cases.

Fifty-three pericardiocentesis procedures were performed on 48 patients from 1993 to 2000 at our coronary care unit. Percutaneous puncture (anterior thoracic in 43 cases, subxiphoid in 10 cases) was performed at the site closest to the exploring probe, where the largest amount of fluid was detected. A needle carrier supported by a bracket with two fixed angulations was mounted on the probe. The needle was advanced through the tissues and inside the pericardial space under continuous visualization. The procedure was successful in 52 of 53 cases. In 1 case of diagnostic pericardiocentesis, the pericardial space was impossible to reach because of the minimal amount of pericardial fluid. In 1 case of acute tamponade after transcatheter ablation of the atrioventricular node, the pericardial puncture caused a pleural-pericardial shunt with consequent drainage of pericardial fluid into the pleural space and symptom resolution. In 1 case, a transient atrioventricular type III block occurred. Emergency surgical drainage was not required in any of the cases. No puncture of cardiac walls ever occurred in this series of patients. No major complications occurred; the incidence of minor sequelae was lower than the incidence reported by other studies on pericardiocentesis without continuous visualization. Our technique appears to be safe and easy to perform even in the presence of minimal amounts of pericardial fluid.

Socio-occupational differences in acute myocardial infarction case-fatality and coronary care in a northern Italian population.

AIMS: To appraise 28-day case-fatality of myocardial infarction (MI) among socio-occupational classes; to assess the consistency of the results for different degrees of MI severity; to explore if such differences are related to differences in management and treatment of the acute attack. METHODS: All coronary events (n = 1077), registered in 1993-1994 among the 35-64 year old male residents in MONICA Area Brianza were investigated and classified into diagnostic categories according to MONICA criteria. For all cases standardized information on acute coronary care and interventions before and during hospitalization was collected. Classification of social classes was derived from the Erikson-Goldthorpe-Portocarero social class scheme, based on information on occupational characteristics widely available in European countries. RESULTS: An increasing rate of case-fatality for decreasing levels of socio-occupational class was found. The social gradient resulted mainly from the higher incidence of out-of-hospital cardiac arrests. Treatment before and during the acute attack cannot explain the observed differences. CONCLUSION: Combining these results with those obtained in other MONICA centres, it appears that further decreases in coronary mortality might be achieved through specific programmes addressed in particular to the reduction of out-of-hospital case-fatality in lower social classes.

Epidemiology of post-infarction risk stratification strategies in a country with a low volume of revascularization procedures. GISSI-Prognosis Investigators.

AIMS: The aims of the GISSI Prognosis Registry were to describe the diagnostic strategies initiated in acute myocardial infarction patients by a representative sample of Italian cardiological centres, and to determine which clinical or hospital characteristics were associated with the initiation of invasive diagnostic or therapeutic procedures. METHODS AND RESULTS: Baseline characteristics, major in-hospital events and the indication and results of invasive and non-invasive procedures were collected on 1489 acute myocardial infarction patients discharged alive from 65 Italian cardiological centres over a period of 3 months. Twenty-five percent of centres had on site catheterization laboratories while the rest did not. Statistical significance was analysed by chi-square tests for categorical variables. A two-sample Student t-test was used to compare continuous variables. The adjusted analysis was performed utilizing multiple logistic regression models. The most performed procedures were standard, non-invasive: 57.8% of the patients underwent an exercise stress test, 70.8% ambulatory ECG monitoring and 95.6% two-dimensional echocardiography. Nuclear or echocardiographic imaging tests were performed in 40% of acute myocardial infarction survivors. Overall, coronary angiography was planned in 549 patients (36.9%). Variables independently associated with the indication for coronary angiography were residual ischaemia, younger age, contraindication to exercise stress testing, level of patients' education, higher volume of non-invasive diagnostic tests, and male sex. Overall, during a 6-month follow-up period, coronary angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass surgery were performed, respectively in 35%, 10% and 8% of the study population. CONCLUSIONS: The setting where cardiologists practise determines the patterns of care in acute myocardial infarction patients more than the characteristics of the patient. The absence of evidence-based guidelines on the more complex and expensive procedures favour empirical attitudes and practices. The confirmation in a prospective cohort of patients, which aims to represent the care of a whole country, suggests that more effort should be given to the implementation of controlled studies rather than periodical reformulation of guidelines not supported by hard data.

[Changes in the treatment of cardiac emergencies and their influence on fatalities. Data from the MONICA Project, Brianza Area]. / Mutamenti nel trattamento della emergenza cardiologica e loro influenza sulla letalità. Dati del Progetto MONICA Area Brianza.

BACKGROUND: During the last decade, clinical trials consistently modified the therapeutic approach to coronary disease, and particularly to acute myocardial infarction. However, the magnitude of the contribution to the observed reduction in case fatality rates due the therapeutic improvement is still being debated. OBJECTIVES: To determine the real degree of implementation of the "suggested treatments" on clinical practice, and to evaluate their global effect on coronary mortality. METHODS: Analysis of the type of administered treatment in two consecutive series of acute coronary events, observed during the year 1986 (500 events) and 1989 (907 events), registered by the MONICA Project-Brianza Area. We evaluated: pre-coronary times; type of hospitalization; type of treatment before, during and after the event; occurrence of cardiac arrest and cardiopulmonary resuscitation both in and out of hospital; global and specific fatality rates at 28 days. RESULTS: In the study period, overall coronary fatality rates changed from 29.4 to 23.6% (19% decrease-p < 0.05), fatality of confirmed AMI changed from 16.4 to 8.3% (49.4% decrease-p < 0.005); specific fatality for out of hospital cardiac arrest was unchanged (99%). Pre-coronary times were unmodified in the two periods of observation: hospitalization < 1 hr. in 20%, < 6 hr. in 50%, > 24 hr. in 10% of events. The percentage of cases admitted in CCU changed from 47.4 to 54.8% (from 71.6 to 86.4% of patients with confirmed AMI-p < 0.025). Thrombolysis in confirmed AMI changed from 29.3 to 43.2% (p < 0.001); antiplatelets treatment changed from 19.7 to 81.9% (p < 0.001); the use of betablockers went from 16.6 to 44% (p < 0.001) while the use of other agents was unmodified. Coronary arteriography and revascularization procedures continue to play a marginal role. CONCLUSIONS: The MONICA registry experience shows that very important changes occurred in the treatment of coronary emergencies, particularly in the acute phase of myocardial infarction, suggesting that in our area, standardization of the therapeutic protocols might be responsible for the observed reduction of coronary fatality even though the advantages were observed only in hospitalized patients.