[The methods of using the echocardiogram in outpatients. The role of the cardiologist for more appropriate use of the procedure. The Ligurian Group of the Italian Society of Cardiovascular Echocardiography]. / Modalità di utilizzazione dell'ecocardiogramma in pazienti ambulatoriali. Ruolo del cardiologo per l'appropriatezza della prescrizione. Gruppo Ligure della Società Italiana di Ecografia Cardiovascolare.

Concerns about the increasing medical care costs are causing the medical community to focus its attention on the appropriate of diagnostic tests such as echocardiography. Prerequisite to a better utilization of the limited economic resources assigned to our health care system is an analysis of how, why, and with which results diagnostic tests with a widespread use and relevant cost, like echocardiography, are requested. During the last 2 weeks of September 1994, a transversal, observational study was carried out at 13 hospital echocardiographic laboratories. Ordering physician characteristics, reasons for ordering the test, cardiological diagnostic tests previously performed and their relationship with the test results, were evaluated with a questionnaire completed by the physician who performed the test, in all the out-patients undergoing echocardiogram in that fortnight. Five hundred and sixteen consecutive questionnaires were successfully completed. Fourty-five percent of the echocardiograms were ordered by cardiologists, 35% by general practitioners, 10% by internists, and 10% by other specialists. Hypertension (16.4%) and ischemic heart disease (14.8%) were the most common indications for the test, followed by palpitations or arrhythmias (7.5%), mitral valve prolapse or mitral valve disease (7.3%), chest pain or angina pectoris (6.3%), cardiac murmur (5.5%), dyspnea or heart failure (5.2%), aortic valve disease (5%), prosthetic heart valve evaluation (4.6%), others (27%). Before undergoing the echocardiogram, 433 (84%) patients underwent an electrocardiogram, 242 (47%) a cardiological clinical evaluation, 196 (38%) a chest X-ray, and 191 (37%) had had a previous echocardiogram. The most common echocardiographic diagnosis was normal (29.2%) followed by hypertensive heart disease (16.2%), mitral valve disease (12.3%), aortic valve disease (10.5%), ischemic heart disease (9.3%), cardiomyopathy (4.9%) normal prosthetic heart valve function (4.5%), pericardial effusion (3.8%), others (11.3%). Among the echocardiograms ordered by cardiologists, 21.8% were normal in comparison with 35.4% of those ordered by general practitioners (p < 0.004), 35.3% of those ordered by internists (p = 0.04), 35.3% of those ordered by other specialists (p = 0.04). Among the 284 patients whose echocardiograms were not requested by a cardiologist, only 215 (76%) had undergone an electrocardiogram and only 68 (24%) a clinical evaluation by a cardiologist. In these patients, the frequency of normal echocardiograms was not influenced by having undergone a previous electrocardiogram or a chest X-ray. Conversely, patients in whom the echocardiogram was ordered after a cardiology consult showed a significant lower frequency of normal results compared to patients not evaluated by a cardiologist (23% vs 39%; p < 0.05). More than 50% of the echocardiograms performed in out-patients are ordered by physicians who are not cardiologists. Among these echocardiograms, about 1 out of 3 results normal. This finding suggests an improper use of echocardiogram as a screening tool by non-cardiologists in out-patients. A preceding clinical evaluation by a cardiologist, but not an electrocardiogram or a chest X-ray alone, may determine a more appropriate use of the test being associated with a reduced frequency of normal results.

[Balanced beta--alpha-blocker treatment with carvedilol in mild-moderate arterial hypertension]. / Trattamento beta-alpha-bloccante bilanciato con carvedilolo nell'ipertensione arteriosa lieve-moderata.

The search for the ideal antihypertensive drug is ongoing. Carvedilol is a new beta-adrenoceptor antagonist which also causes peripheral vasodilation primarily via alpha 1-adrenergic blockade. Twenty patients with mild to moderate essential hypertension and previous intolerance and side effects to other antihypertensive drugs were studied. After initial baseline assessment, patients received 25 mg carvedilol orally q.d. The treatment lasted 60 days. In our study carvedilol was well tolerated and no important side effect was recorded. Blood pressure decreased significantly to normal values, without orthostatic blood pressure decreases. Heart rate decreased significantly too, but no significant bradycardia was induced. No negative effects on serum lipids and no clinical evidence of increase in peripheral resistance were observed. Ventricular arrhythmia on Holter monitoring were significantly reduced after treatment with carvedilol.

[Neurohormonal mechanisms in cardiac insufficiency. Possible therapeutic implications]. / Meccanismi neurormonali nell'insufficienza cardiaca. Possibili implicazioni terapeutiche.

Neurohormonal mechanisms play an important role in pathogenesis of left ventricular dysfunction. Analysis of traditional therapeutic strategies for heart failure used in the past is disappointing. Recent therapeutic strategy that aims to treat earlier patients with ventricular dysfunction with agents that counteract neurohormonal activation, seems to be more effective. However conventional drugs such as vasodilator agents, digitalis and diuretics are still useful for treatment of overt heart failure, due to their proven hemodynamic benefits. A lot of current clinical trials, in the future, can help us to solve this problem. In this issue evolving concepts of pathophysiology of chronic heart failure and how these pathophysiologic concepts lead to the rational treatment are discussed.

[Mitochondrial disease and complete heart block. Kearns-Sayre syndrome. Description of a case]. / Malattie mitocondriali e blocco cardiaco completo. Sindrome di Kearns-Sayre. Descrizione di un caso.

Defects of the mitochondrial respiratory chain form a clinically and biochemically heterogeneous group of diseases. Mitochondrial diseases include myopathies and multisystem disorders that are defined either by biochemical abnormalities of the mitochondria or by the presence of "ragged red fibers" in muscle-biopsy specimens stained with modified Gomori's trichrome stain. Several syndromes have been identified. Typical Kearns-Sayre syndrome is a sporadic condition that is characterized by an onset before the age of 20, progressive external ophthalmoplegia, pigmentary retinopathy and cardiac disorders. Mitochondrial DNA deletions were found in patient with Kearns-Sayre syndrome. We report the case of a 33 year-old woman, with neuromuscular syndrome of the Kearns-Sayre type, insulin-sensitive diabetes and complete heart block, who was implanted a pacemaker.

[Primary malignant lymphoma of the heart. Description of a case and review of the literature]. / Linfoma maligno primitivo del cuore. Descrizione di un caso e revisione della letteratura.

Primary cardiac tumors are rare. Approximately 25% of primary cardiac tumors are malignant, with the majority of these being sarcomas. Primary lymphoma of the heart is a very rare malignancy, usually recognized at autopsy or fatal within a few weeks of diagnosis. we report the case of a patient with diffuse large uncleaved cell lymphoma of the heart who had dyspnea, distention of the neck veins, edema of the face and arms. The diagnosis in this patient was aided by 2D-echocardiography, CT scan of the chest and superior vena caval angiography. The diagnosis was confirmed at operation and by histological examination. Surgical procedures were only palliative and aimed at prolonging life. However, prognosis remained severe and unchanged.

[Ventricular hyperkinetic arrhythmias: a current therapeutic problem. The possible greater use of beta blockers]. / Le aritmie ipercinetiche ventricolari: problema terapeutico attuale. Possibile maggiore impiego per i betabloccanti.

The therapeutic approach to cardiac arrhythmias is constantly evolving due to our improved understanding of their mechanisms and clinico-prognostic implications, even if uncertainties and controversies continue to be a marked feature of this sector, perhaps more than in any other field of medicine. The frequent finding of cardiac arrhythmias in the healthy and cardiopathic population justifies the importance which the question of the diagnosis and treatment of cardiac rhythm disorders has now assumed, even if, as far as the latter is concerned, the aggressive approach has been considerably modified over the past years. This has occurred in view of the still unproven value of indiscriminate anti-arrhythmic treatment for the purposes of prolonging life. This treatment has only been demonstrated to be of value in a few studies in selected subgroups of high-risk patients. In addition, it should be underlined that it has been reported that anti-arrhythmic drugs may possible aggravate or induce new arrhythmia. This potential pro-arrhythmic effect has become increasingly recurrent due to the widespread use and diffusion of this category of drugs. Such considerations should therefore encourage greater caution in the use of these drugs. Cardiac arrhythmias may be benign or life-threatening, symptomatic or asymptomatic; they may be a warning sign of sudden death, or be the cause or effect of heart failure, be the expression of an acute or chronic heart disease, or the clinical manifestation, at a cardiac level, of an extracardiac pathology. Within this broad-ranging clinical context, arrhythmia often gives rise to therapeutic dilemmas which must be resolved with extreme rationality, taking into account the results of all available clinical trials. The results of the Cardiac Arrhythmias Suppression Trial (CAST) showed that clinical judgements of therapeutic efficacy, made in the absence of carefully controlled studies, are often incorrect. On the basis of these findings beta-blocking drugs may find increasing use, since while they are not anti-arrhythmic drugs in the strict sense of the term, they are safer due to their negligible pro-arrhythmic effect, the lower incidence of collateral effects and their proven efficacy in post-infarction. The role of beta-blockers in the treatment of manifest heart failure should not be over-looked, since by countering the deleterious effect of increased catecholamines they may improve the prognosis, thus reducing the incidence of sudden death.

[Primary malignant cardiac tumors]. / Tumori cardiaci maligni primitivi.

Primary tumours of the heart are extremely rare, occurring in only 0.0017 to 0.28 per cent of large postmortem series. About only one-forth of all cardiac tumors are malignant. Modern techniques of diagnosis and surgical treatment have changed the benign cardiac tumor from a curiosity found at postmortem examination to an almost uniformly curable form of heart disease. Unfortunately, the same cannot be said for malignant cardiac tumors, which are both rare and almost always fatal. We reviewed the medical literature to summarize all cases of primary malignant tumors of the heart. Recently it has been pointed out that better survival in this group of patients could be a result of prompt diagnosis and treatment. Surgical intervention is rarely of benefit except for establishing a tissue diagnosis. On the contrary, survival may be enhanced by irradiation and probably by chemotherapy (sometimes as postoperative procedures).

[Ventricular function in dilated cardiopathy]. / La funzione ventricolare nelle cardiopatie dilatative.

Global and regional systo-diastolic ventricular function evaluation is of primary importance in the study of patients suffering from heart disease. The finding of intact global systolic function in subjects with documented heart disease is not rare. However a variety of cardiovascular diseases can alter, at an early stage, the characteristics of the diastolic function. Functional alterations during the initial diastolic phase can be found in patients with early stage heart disease and with normal regional systolic function suggesting that regional and global diastolic evaluation could be useful in the diagnostic approach to patients with still normal global and regional systolic function.