[Prognostic value of supraventricular arrhythmias in heart failure]. / Valore prognostico delle aritmie sopraventricolari nello scompenso cardiaco.

Supraventricular tachyarrhythmias can be responsible for severe hemodynamic derangement which may contribute to the progression and worsening of heart failure. The resultant effect of these arrhythmias, however, is conditioned by several concomitant factors, such as age of the patients, left ventricular systolic function, and ventricular rate response. If the role of such arrhythmias in functional class, morbidity, and functional capacity is well accepted, controversial data are available on their role on mortality in patients with heart failure.

Effect of ursodeoxycholic acid on hypertransaminasaemia and bile acid composition in patients undergoing bone marrow transplantation--a double-blind randomized control study.

A double-blind randomized placebo controlled trial of ursodeoxycholic acid was performed in 31 patients undergoing T-cell depleted allogeneic or autologous bone marrow transplantation to determine the effectiveness of this hydrophilic bile acid in improving the increase in serum liver enzymes that generally accompanies this procedure. Neither group showed any significant difference in magnitude of the increases in serum transaminases and gamma-glutamyltranspeptidase following the conditioning regimen that included chemotherapy and total body irradiation. In the 6 months after transplantation, serum enzymes decreased in both groups, but were consistently higher in the placebo treated patients, indicating that ursodeoxycholic enhances normalization of liver. Faecal bile acid showed that following chemotherapy and irradiation in which intestinal bacteria are ablated, secondary bile acid formation was practically abolished and faeces contained mainly cholic and chenodeoxycholic acids. During bile acid treatment, ursodeoxycholic acid accounted for 31.3 +/- 10.9% of faecal bile acids compared with 4.0 +/- 2.1% in the basal period. Serum and urinary ursodeoxycholic acid concentrations (mean +/- SD, 13.3 +/- 6.9 mumol/L and 2.65 +/- 0.84 mumol/L, respectively) were significantly higher in patients receiving bile acid than in thos on placebo (mean +/- SD, 0.15 +/- 0.12 mumol/L and 0.29 +/- 0.35 mumol/L, respectively) thus confirming compliance.

[The noninvasive identification of patients with angina and normal coronary arteries]. / Riconoscimento non invasivo dei pazienti con angina a coronarie normali.

BACKGROUND: Although patients with syndrome X (angina and normal coronary arteries, in absence of coronary spasm, cardiomyopathy or valvulopathy) and those with stable angina as well as documented coronary artery disease share a similar clinical presentation (effort related symptoms, positive exercise stress testing and reversible perfusion defects), their prognosis is markedly different. Coronary atherosclerosis is usually progressive relative to morbidity and mortality. Conversely prognosis both in terms of persistence of pain and mortality appears to be benign in syndrome X. Most cardiologists favor proceeding with coronary angiography in all patients presenting with exercise induced ST depression and reversible perfusion defects. However, it should not be assumed that this strategy will remain the preferred one. The aim of this study was to assess whether non invasive testing could identify underlying coronary artery anatomy, thus prognosis in the above subset of patients. The approach was selected on a clearly stated objective of how isosorbide dinitrate and verapamil may influence coronary flow reserve, thus exercise stress testing in syndrome X. Nitrates have been shown to reduce coronary flow reserve during stress tachycardia. The opposite occurs with calcium blockers. METHODS: We studied 48 patients with effort angina referred to our laboratory for diagnostic evaluation. All patients underwent two separate sessions at one-day interval. Each session consisted of exercise stress testing before and after isosorbide dinitrate (s.l.; 5-10 mg) or verapamil (i.v.; 10 mg), given in a randomized crossover fashion. Angiography was performed within 3 months from testing. Efficacy of drugs in terms of exercise capacity was assessed by using the following criteria: 1) prevention of significant (> or = 0.1 mV) ST depression while reaching same workload levels attained during baseline testing; 2) improvement in the ischemic thresholds, that is an increase in: time to 0.1 mV ST depression > or = 120 sec., with heart rate (> or = 10 bpm) and rate pressure product (> or = 2 U x 1000) greater than those attained during baseline testing; 3) increase in time to peak exercise (> or = 120 sec). RESULTS: In syndrome X, both drugs resulted ineffective in one patient, one patient showed a favourable response to isosorbide dinitrate whereas the remaining 13/15 patients improved exercise capacity following verapamil, but not isosorbide dinitrate. The opposite occurred in coronary artery disease patients: both isosorbide dinitrate and verapamil were effective in 21/33 patients, and ineffective in 8/33 patients. The remaining 4 patients responded to isosorbide dinitrate but not to verapamil. CONCLUSIONS: 1) Verapamil, but not isosorbide dinitrate, improves exercise capacity in syndrome X; 2) this does not apply to patients with stable angina; 3) a favourable response to verapamil but not to isosorbide dinitrate is both a sensitive (86%) and specific (100%) method for identifying patients with angina and normal coronary arteries; 4) non invasive testing may select those effort angina patients who have to proceed directly to coronary angiography; 5) some patients with effort related angina may not require further investigation.

[Myocardial infarct with normal coronary vessels: an association with dysfunction of the coronary microcirculation]. / Infarto miocardico con coronarie normali: associazione con la disfunzione del microcircolo coronarico.

The association of acute myocardial infarction (AMI) with normal coronary arteries was analyzed prospectively. A series of 128 consecutive patients underwent coronary angiography within 1 week from AMI. Seven patients, all females, had no coronary artery lesions and were considered eligible for the study. All 7 patients underwent atrial pacing (10 g/min increments every 2 min), ergonovine testing (E; total dose 0.650 mg i.v.). Great cardiac vein flow (GCVF; thermodilution technique), mean aortic pressure (MAP), anterior coronary resistance (ACR) and myocardial lactate extraction [(Lac art-Lac gcv)/Lac art] were measured at baseline and during testing. Pacing-induced typical chest pain occurred in 5 patients: 4 of them showed concurrent significant (> or = 0.15 mV) ST downsloping. At peak pacing, GCVF increased only by < 50%, or even decreased, in all patients. Baseline lactate extraction (0.13 +/- 0.11) changed to lactate production (-0.15 +/- 0.10) in 7/7 patients. None of the patients showed focal epicardial coronary artery spasm following E. During testing, however, all 7 patients showed decrease in GCVF (110 +/- 47 versus 74 +/- 21; p < 0.005), increase in ACR (0.92 +/- 0.29 versus 1.43 +/- 0.20; p < 0.001), and significant coronary lactate production (-0.18 +/- 0.12). Six patients referred slight to moderate chest pain, which was accompanied by ST downsloping in 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular dynamics after aortic valve replacement: a long-term, combined radionuclide angiographic and ultrasonographic study.

Between January 1985 and July 1990, we studied 71 patients at our institution who underwent aortic valve replacement for either aortic valve regurgitation (40 patients) or stenosis (31 patients). The following prostheses were implanted: 25 St. Jude Medical valves (bileaflet), 16 Björk-Shiley (monoleaflet, tilting disc, 60 degrees convexo-concave), 16 Medtronic-Hall (monoleaflet, tilting disc), and 14 Starr-Edwards (caged ball). The patients were evaluated pre-and postoperatively by means of gated blood-pool scintigraphy and Doppler echocardiography. Postoperatively, each patient was studied at 6 months, 1 year, and then annually. The evaluations focused upon 1) scintigraphically assessed left ventricular performance indicators (end-diastolic and end-systolic volume, as well as resting and exercise ejection fraction) and 2) Doppler-derived hemodynamic indexes (peak and mean transvalvular pressure gradient, effective orifice area, regurgitant flow, and systolic wall stress). Early after aortic valve replacement, 55 (77.5%) of the patients had substantial symptomatic relief, with normal hemodynamic values both at rest and during exercise (New York Heart Association functional class I or II); another 6 patients (8.5%) maintained their preoperative status in those classes. Within a year after surgery, a majority of patients showed a significant reduction in left ventricular dimensions. The patients with preoperative aortic valve stenosis had a significantly reduced end-diastolic and end-systolic volume (p<0.05), a moderately reduced left ventricular mass index (p<0.01), and a significantly increased exercise ejection fraction (p<0.05); moreover, in all 31 of these cases, systolic wall stress returned to normal or lower-than-control values (p<0.005). The patients with preoperative aortic valve regurgitation had a significant reduction in end-diastolic and end-systolic volume (p<0.005), diastolic wall stress (p<0.005), and a significant increase in exercise ejection fraction (p<0.01); however, their left ventricular mass index was not significantly reduced. Optimal long-term survival was afforded by the St. Jude valve in the small size (21 mm) and the Starr-Edwards valve in the large size (27 mm). This study represents the first reported use of a serial, combined radionuclide and echocardiographic procedure for the follow-up of patients undergoing aortic valve replacement. During the 5(1/2)-year follow-up period, this combined technique proved highly accurate for collecting follow-up data, often complementing or correcting simple ultrasound results. This diagnostic approach enabled us to 1) obtain information comparable to or better than that provided by cardiac catheterization, 2) identify complications early, 3) differentiate between valvular and ventricular failure, and 4) suggest the valve of choice (not always that with the best hemodynamic performance) in patients with different cardiac variables. Further research is needed to confirm this study, the results of which could change many medical and surgical strategies for clinical management of the diseased aortic valve.