Psoriasis and the risk of acute coronary syndrome in the elderly.

BACKGROUND: Psoriasis has been associated with a higher prevalence of cardiovascular disease risk factors. However, there is inadequate quantification on the association between psoriasis and acute coronary syndrome (ACS), particularly in the elderly. Therefore, the aim of the present study was to assess the risk of ACS according to history of psoriasis in subjects aged 75 years and older. METHODS: We carried out a case control study based on 1455 cases and 1108 controls. Cases were all the patients admitted in the randomized Elderly ACS 2 trial. Controls were selected from subjects aged ≥75 years included in the Prevalence of Actinic Keratoses in the Italian Population Study (PraKtis), based on a representative sample of the general Italian population. Odds ratios (OR) of ACS according to history of psoriasis were obtained using a multiple logistic regression model including terms for age, sex and smoking. RESULTS: The prevalence of psoriasis was lower among cases (12/1455, 0.8%) than among controls (18/1108, 1.6%). The multivariate OR of ACS according to history of psoriasis was 0.51 (95% confidence interval: 0.23-1.09). CONCLUSIONS: Our data does not support an association between psoriasis and risk of ACS in the elderly.

Rest perfusion abnormalities in hypertrophic cardiomyopathy: correlation with myocardial fibrosis and risk factors for sudden cardiac death.

AIM: To measure the prevalence of abnormal rest perfusion in a population of consecutive patients with known hypertrophic cardiomyopathy (HCM) referred for cardiovascular MRI (CMR), and to assess any associations between abnormal rest perfusion and the presence, pattern, and severity of myocardial scar and the presence of risk factors for sudden death. MATERIALS AND METHODS: Eighty consecutive patients with known HCM referred for CMR underwent functional imaging, rest first-pass perfusion, and late gadolinium enhancement (LGE). RESULTS: Thirty percent of the patients had abnormal rest perfusion, all of them corresponding to areas of mid-myocardial LGE and to a higher degree of segmental hypertrophy. Rest perfusion abnormalities correlated with more extensive and confluent LGE. The subgroup of patients with myocardial fibrosis and rest perfusion abnormalities (fibrosis+/perfusion+) had more than twice the incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring in comparison to patients with myocardial fibrosis and normal rest perfusion (fibrosis+/perfusion-) and patients with no fibrosis and normal rest perfusion (fibrosis-/perfusion-). CONCLUSIONS: First-pass perfusion CMR identifies abnormal rest perfusion in a significant proportion of patients with HCM. These abnormalities are associated with the presence and distribution of myocardial scar and the degree of hypertrophy. Rest perfusion abnormalities identify patients with increased incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring, independently from the presence of myocardial fibrosis.

Subacute left ventricular free-wall rupture in early course of acute myocardial infarction. Clinical report of two cases and review of the literature.

Left ventricular free wall rupture (LVFWR) may complicate an acute myocardial infarction (AMI); its frequency ranges from 1 to 6 percent. In the era of coronary care units, LVFWR is the second cause of in-hospital death, after pump failure. The subacute presentation accounts for 2-3 percent of total hospital admissions for AMI. Heart rupture may not be suddenly fatal and sometimes there is enough time for surgical repair. Electromechanical dissociation is neither the only nor the main clinical presentation. More subtle symptoms occurring hours or days before the final event include unexplained hypotension and transient bradycardia and some ECG features such as persistent ST-segment elevation with T-waves failing to invert in the same leads. On echocardiographic subcostal view, pericardial effusion of more than 5-10 mm, with echo-dense masses overlying the heart independently of cardiac tamponade, is highly suggestive of heart rupture. If pericardiocentesis yields hemorrhagic fluid, surgical intervention is mandatory, providing both diagnostic confirmation and definitive treatment. Medical management strategies (prolonged bed rest, beta-blockade therapy) are still experimental but could become suitable for particular subsets of patients (elderly patients and patients at a high surgical risk). We report two cases of subacute LVFWR and review the currently available literature.

Fixed subaortic stenosis associated with hypertrophic cardiomyopathy: report of a rare familial occurrence.

INTRODUCTION: Fixed subaortic stenosis is considered to be an acquired condition. It is often associated with congenital heart disease, creating a turbulence in the left ventricle outflow tract. Familial forms of fixed subaortic stenosis are very unusual. We report a remarkable familial cluster in which fixed subaortic stenosis is associated with hypertrophic cardiomyopathy. METHODS: Fourteen relatives of a patient affected with hypertrophic cardiomyopathy and fixed subaortic stenosis underwent cardiological examination, electrocardiogram and echo-doppler study. RESULTS: Two of the proband's sisters showed an association between asymmetrical hypertrophic cardiomyopathy and fixed subaortic stenosis. The brother presented a subaortic ridge and concentric left ventricular hypertrophy. The other members of the family (another brother and the third-generation relatives) were unaffected. CONCLUSIONS: While the association between fixed subaortic stenosis and hypertrophic cardiomyopathy has commonly been reported, there is little in the literature to suggest the family-related nature of this association. The familial occurrence of this association reveals genetic transmission, with a recessive autosomal pattern of inheritance. This finding goes against the usual autosomal dominant pattern of inheritance in hypertrophic cardiomyopathy. Familial studies of FSS are needed in order to gain a better understanding of the genetic background of these patients.

Effect of lipid-lowering treatment on progression of atherosclerotic lesions--a duplex ultrasonographic investigation.

The Prevenzione Aterosclerosi Studio Torino (P.A.S.T.) was a prospective, randomized trial testing the effect on carotid and femoral atherosclerotic lesions of lipid-lowering therapy, as assessed by duplex scanning (DS) technique, in 85 patients (12 women, 73 men), forty-five to fifty-five years old, with ischemic heart disease (IHD), and randomly assigned to a hypolipidemic diet or diet + 250 mg acipimox (a nicotinic acid compound) two to three times/day. Forty-one patients, without inclusion criteria, were compared with the randomized groups as a reference population. All three groups were submitted to DS and to hematic monitoring of lipid levels at the beginning and at the end of the study. During three years of treatment, there was a significant reduction (-6.5%) in total plasma cholesterol in the diet + drug group (P = 0.04) and a simultaneous elevation of high-density lipoprotein cholesterol, significant in the treatment groups (respectively, +15% P = 0.02 in the diet and +16% P = 0.016 in the diet + drug group). Every group showed a trend toward the increasing number of lesions in all explored areas and toward the progression in size of the already existing ones. Whereas in the initial DS the prevalence of lesions was significantly lower in the nonrandomized group in every site, at the end of the study the total number of lesions did not differ among groups, and there was a significant increase of plaques in carotid area in the nonrandomized group in comparison with the treatment groups. The final number of stable plaques was greater in the treatment groups as compared with the nonrandomized group (P = 0.01 diet vs nonrandomized, P = 0.03 diet + drug vs nonrandomized). In conclusion, lipid-lowering treatment, with diet and with diet + drug, was useful in slowing the natural progression of atherosclerosis; particularly, it reduced the development of new lesions in the carotid and femoral arteries and increased the stability of the already existing ones. In these patients, diet was equivalent to diet + drug in regard to progression of lesions. The most favorable results in the treatment groups seem to correlate with high-density lipoprotein cholesterol, significantly increased in comparison with the nonrandomized group.

[Do our patients follow the clinical indications prescribed after coronary angiography?]. / I nostri pazienti seguono le indicazioni cliniche prescritte dopo la coronarografia?

BACKGROUND: Aim of the study is to evaluate patients compliance with therapeutic recommendations after coronary angiography. METHODS: We analyzed all patients who underwent coronary angiography in an university center during 1990. One of the following treatments were recommended: medical therapy without revascularization, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting. A cohort of 392 patients was assessed one year after coronary angiography in order to evaluate clinical predictors of non compliance with the treatment recommended. RESULTS: Of the 141 patients, for whom medical treatment was recommended, 16 (11%: 95% confidence interval 6-17%) had revascularization. By stepwise discriminant regression analysis, older age, congestive heart failure and critical lesion of the left anterior descending artery were statistically significant predictors of non compliance. Of the 137 patients, for whom PTCA was recommended, 8 (6%: 2-9%) were non compliant. No variables were predictive of non compliance. Of the 114 patients, for whom CABG was recommended, 15 (13%: 7-19%) were non compliant. By stepwise regression analysis, absence of typical angina was predictive of non compliance. For 12 patients non compliance was related to personal preferences, for 10 to clinical deterioration, for 9 to a second opinion, and 3 were still in the surgical waiting list one year after coronary angiography. One year mortality was not affected by non compliance. CONCLUSIONS: Non compliance to recommended treatment after coronary angiography is uncommon and is mainly related to patients preference towards a less invasive treatment or to a change of clinical conditions over time.