[Risk stratification on 206 patients with acute coronary syndrome at Rome Policlinico Umberto I Emergency Department]. / Stratifi cazione del rischio su 206 pazienti con sospetta Sindrome Coronarica Acuta presso il Dipartimento di Emergenza-Urgenza-Accettazione del Policlinico Umberto I di Roma.

OBJECTIVES: The objective of this study on patients with suspected Acute Coronary Disease (ACS) was to verify with the risk stratification any differences between patients in which the AHA/ACC guidelines were not systematically applied and the same patients in which, retrospectively, the AHA/ACC guidelines were adhered to. MATERIALS AND METHODS: Retrospective examination was carried out in our Emergency Department at Rome Policlinico Umberto I on 206 patients (age range 21-88, median age 56.6 +/- 18.9 years) (54.3% males) with symptoms compatible with ACS. All the patients underwent "triage" using code green or code yellow and were sub-divided into 7 subgroups based on degree of risk for death or non-fatal myocardial infarction (MI) at 30 days, (labelled A to G, with A representing highest risk and G the least at-risk) in accordance with the ACC/AHA guidelines. Each patient was then examined for: fi nal outcome, admittance and discharge from hospital, refusal of admittance, death. RESULTS: Of the 206 patients, 48 were judged improperly (23.3%) Of these, 13 were assigned code green rather than code yellow and 11 were assigned code yellow instead of code green. By risk stratification in accordance with the AHA/ACC guidelines, 128 patients (62.1%) belonging to subgroups A,B,C and D should have required hospitalization. Seventy eight patients belonging to subgroups E,F and G should have been sent for observation at the Chest Pain Unit (CPU), 54 from this group would have been potentially discharged after 6-12 hours of negative clinical observation. Actually, hospitalization was requested for 132 patients (64%) of whom 78 accepted, 50 declined and 4 were deceased before admission; 74 patients (35.9%) were discharged after brief observation. Risk stratification for 30 day mortality or non fatal MI emphasizes that 8 of the patients hospitalized should have been treated at the CPU (unwarranted hospitalization). Twenty four of the 50 patients who declined hospitalization should have benefited by brief observation at the Chest pain Unit. Twenty eight of the 78 patients examined in the Emergency Department and later discharged should have been hospitalized (wrong discharge). CONCLUSIONS: This study, even if limited by time restriction, provides enough evidence in support of the effectiveness of the ACC/AHA guidelines to determine subgroups and to correctly determine groups according to level of risk, thus limiting unwarranted hospitalizations and wrong discharges.

Morphological and functional changes of cardiovascular system in postmenopausal women.

BACKGROUND: The incidence of cardiovascular events in reproductive age women is 3 times lower than in men, whereas this ratio noticeably changes on menopausal beginning. Postmenopausal women are more exposed to the effects of risk factors, which are present in a noticeably different entity in physiological or surgical menopause; and in the latter whether on substitutive hormonal treatment or not. METHODS: This study, carried out in Rome and Latina, has involved 743 postmenopausal women, of whom 545 with physiological menopause and 198 with iatrogenic menopause. RESULTS: The average blood pressure value as well as the incidence of hypertension, hypercholesterolemia, diabetes mellitus, obesity and smoking have a significantly different trend in physiological versus iatrogenic postmenopausal women; and in the latter whether on substitutive hormonal treatment or not. CONCLUSIONS: Studying life-style and evaluating risk factors in postmenopausal women, and giving an up-to-date view about the prevalence oh health conditions at risk, will allow us to promote both primary and secondary prevention actions.

Cortisol circadian rhythm and 24-hour Holter arterial pressure in OSAS patients.

Obstructive sleep apnea syndrome (OSAS) is a syndrome in which the principal symptom is apnea during sleep. Hypoxia in OSAS is a stress condition, which when prolonged in time, could alter hypothalamo-hypophysial-suprarenal control and the cortisol cicadian rhythm. We studied 28 patients with OSAS (30-60 years old), 20 female and 8 male. We calculated the OSAS class according to the Simmons classification. Twenty of the 28 patients maintained unmodified cortisol circadian rhythms, while 8 had cortisol levels more elevated in late and nocturnal hours. Holter monitoring showed arterial hypertension in 8 of the 28 patients (the same patients with cortisol circadian rhythm alteration). Our data seem to indicate that when the OSAS patients lack cortisol circadian rhythm they are having arterial hypertension.

Thrombus formation in the left atrial appendage in the course of atrial fibrillation.

BACKGROUND: Thromboembolism in patients with nonvalvular atrial fibrillation is secondary to emboli arising from atrial cavities, particularly left atrial appendage. Stroke Prevention Atrial Fibrillation (SPAF) III study showed washing flow, left appendage ejection fraction, natural echocontrast, and left appendage volume and morphology, as risk parameters of thromboembolism. METHODS: The authors examined 69 patients by transesophageal echocardiography, subdividing them into 3 groups: 26 patients in sinus rhythm in Group A (Gr.A), 22 patients in atrial fibrillation without thrombi in the left atrial appendage in Group B (Gr.B), 21 patients with tromboembolism and with thrombus in the left atrial appendage (Gr.C). RESULTS: Atrial volume in sinus rhythm (SR) patients (41.9 +/- 23.4 cm3) was lower than the one in Gr.B (86.2 +/- 47.9 cm3, p < 0.001) and Gr.C (78.6 +/- 28.5 cm3, p < 0.01), whereas no difference was found between Gr.B and Gr.C (86.2 vs. 78.6 cm3; p > 0.05). No difference was found between Gr.A and Gr.B left atrial appendage fraction (31.8% versus 29.1%, p > 0.05), whereas it was found related to Gr.C (31.8% versus 15.4% p < 0.01). Flow velocity within left atrial appendage was significantly higher in Gr.A in relation to the other two groups (p < 0.001); flow velocity in Gr.B was lower than in Gr.A but higher than in Gr.C and in all cases such differences were statistically significant (p < 0.001). Gr.A flow duration was approximately twice as much compared to the one in Gr.B (616.8 +/- 94.1 msec vs. 483.3 +/- 172.6 msec, p < 0.01), whereas it was approximately four times higher compared to the one in Gr.C (616.8 +/- 94.1 msec vs. 165.7 +/- 53.7 msec; p < 0.001). Such duration, if related to the corresponding cardiac cycle, indicates the percentage of time during which blood flows through a cycle within the left atrial appendage; this value is about 85% of cardiac cycle in Gr.A, while it is 65% in Gr.B (p < 0.01) and about 21% in Gr.C (p < 0.001). CONCLUSIONS: Such results add a new parameter to the ones suggested in the SPAF III study for the evaluation of TE risk, that is flow duration measurement within the left atrial appendage, and its ratio to the cardiac cycle. The availability to measure this parameter, by recording the transesophageal pulse wave sample volume positioned in the atrial appendage, makes the evaluation of TE risk more reliable.

What sedation to use during endoscopic procedure.

Many endoscopists sometimes prefer to perform endoscopies without anaesthetic support, using only benzodiazepines. Endogenous opioid peptides are believed to play an important role in the modulation of pain within the endogenous analgesic system. A group of 40 patients undergoing diagnostic and therapeutic Endoscopic Retrograde Cholangiography and Pancreatography (ERCP) was recruited. Patients were divided into 2 groups according to Visual Analog Scale: pain 1-5 (Group A) and pain 6-10 (Group B). The beta-endorphin baseline values were significantly different between patients of Group A and Group B. Our data show that patients with levels of beta-endorphin over 8 pmol/L were less sensitive to pain, so that they become candidates for a traditional utilization of the benzodiazepines. However in the patients with beta-end levels less of 8 pmol/L should be suitable an anaesthetic as propofol because strong pain might provoke neurohumoral reflexes, cardiovascular alterations, and even a heart attack.

Skin diseases as extrahepatic manifestations of HCV. Review of some clinical cases.

Among extra-hepatic manifestations of hepatitis C virus (HCV) infection particular interest is focused on some dermatological diseases such as: leukocytoclastic vasculitis, oral lichen planus, pruritus-urticaria, psoriasis. Aim of this paper is to analyze these typical dermatoses in a population of patients with HCV infection and describe the characteristic clinical pictures. These clinical pictures confirm the importance of liver examination in presence of skin diseases not related to other pathogenetic mechanisms.

ET-1 levels in cardioischemic patients undergoing atrial pacing.

Atrial pacing (AP) procedure was carried out in 11 cardioischemic patients to reproduce tachycardia-induced myocardial ischemia. Six control subjects underwent the same procedure until the maximum pacing rate was reached. During the procedure, endothelin-1 (ET-1) and plasma lactate levels were measured in the coronary sinus and in the aortic root. In all the patients, atrial pacing provoked electrocardiographic signs and metabolic evidence of myocardial ischemia and a significant decrease (p<0.001) in left ventricular ejection fraction. At AP-induced ischemia, coronary sinus (17.31 +/- 4.20 pg/mL) and arterial (9.60 +/- 3.31 pg/mL) ET-1 plasma levels were significantly different (p<0.001) in the patients. On the contrary, at maximum pacing rate, no significant difference (p=0.186) emerged between coronary sinus (9.72 +/- 1.09 pg/mL) and arterial (8.95 +/- 0.75 pg/mL) plasma ET-1 levels in the control group. These results suggest that, in cardioischemic patients, tachycardia can induce the coronary endothelium to release significant amounts of ET-1.

Met-enkephalin levels during PTCA-induced myocardial ischemia.

Met-enkephalin (Met-enk) has been demonstrated to modulate myocardial-ischemia mechanisms via the opioid receptors, but no studies are now available on Met-enk levels in the coronary circulation. In this experience Met-enk levels were evaluated in aortic root and in coronary sinus at baseline (T0), during PTCA induced transient ischemia (T1) and during reperfusion (T2). No significant differences were found at any time. Thus, it appears that there is no Met-enk extraction from the coronary circulation during provoked myocardial ischemia and no Met-enk release from the ischemic heart.

The role of met-enkephalin in silent myocardial ischemia in diabetic patients.

Met-enkephalin plasma levels were evaluated in 20 cardioischemic diabetic patients. All the patients had ECG ischemic signs. Ten patients with diabetic autonomic neuropathy, experienced no pain during myocarial ischemia. Met-enkephalin levels in the diabetic patients with silent myiocardial ischemia were significantly lower compared to those in the symptomatic patients. This demonstrates that the absence of myocardial ischemic pain in neuropathic diabetic patients is not accounted for by met-enkephalin action.

Mitral prolapse. A heart anomaly in a clinical neuroendocrine context.

Mitral valve prolapse was identified as a separate nosological entity by Barlow in 1963. A characteristic of this cardiac anomaly is blood reflux into the left atrium during the systole owing to the lack of adhesion between valve flaps. The presence of symptoms linked to neuroendocrine dysfunctions or to the autonomic nervous system lead to the onset of the pathology known as mitral valve prolapse syndrome (MVPs). It is usually diagnosed by chance in asymptomatic patients during routine tests. MVPs includes complex alterations to the neurovegetative system and a high clinical incidence of neuropsychiatric symptoms, like anxiety and panic attacks. A neuroendocrine mechanism thought to underlie panic attacks was recently proposed based on a biological model. In general, the cardiovascular anomaly manifested by patients with MVPs could be defined in neuroendocrine-constitutional terms.

A case of chronic adrenocortical insufficiency with iatrogenic anasarca.

The decrease in active hormones that characterizes chronic adrenal insufficiency results in hypovolemia. In some patients, residual adrenal function, mineralocorticoid therapy, and concomitant heart or liver failure, or both, can paradoxically provoke edema. The case report that follows describes a patient with iatrogenically induced anasarca resulting from the unhappy confluence of usually appropriate therapy and coexisting medical conditions.

Revealing deterministic structures in click-evoked otoacoustic emissions.

Click-evoked otoacoustic emissions (CEOAEs) were studied by means of recurrence quantification analysis (RQA) and were found to be endowed with a relevant amount of deterministic structuring. Such a structure showed highly significant correlation with the clinical evaluation of the signal over a data set including 56 signals. Moreover, 1) one of the RQA variables, Trend, was very sensitive to phase transitions in the dynamical regime of CEOAEs, and 2) appropriate use of principal component analysis proved able to isolate the individual character of the studied signals. These results are of general interest for the study of auditory signal transduction and generation mechanisms.

Are elevated levels of soluble ICAM-1 a marker of chronic graft disease in heart transplant recipients?

Positivity for circulating intercellular adhesion molecule-1 (ICAM-1) in heart transplant recipients has been claimed to predict the development of coronary artery disease and risk of graft failure. Soluble ICAM-1 were evaluated in 32 heart transplant recipients. Five of these patients, who had undergone transplantation several years before, were positive for soluble ICAM-1 but did not present any clinical sign of graft rejection. Furthermore, although heart graft coronary disease was diagnosed in 15 of the 32 patients, they did not show significantly higher titres of soluble ICAM-1 compared to the remaining patients. These findings suggest that major caution is necessary when considering ICAM-1 positivity as a marker of graft disease.

Clinical importance of thrombomodulin serum levels.

Thrombomodulin is a glycoprotein that can bind to thrombin and activate protein C, thus mitigating the effects of cytokines produced by inflammatory and immunological processes. The molecule exerts a protective function on endothelial cells. Thrombomodulin is cleaved to its soluble form by neutrophil elastase and by other substances produced during acute and chronic inflammatory responses, immunologic reactions and complement activation. ELISA technique yields normal serum levels of 3.1 +/- 1.3 ng/ml; in males these levels are higher; TM levels also rise during menopause. Other circumstances associated with an increase of serum TM levels are smoking, disseminated intravascular coagulation (DIC), cardiac surgery, atherosclerosis, ARDS, liver cirrhosis, diabetes mellitus, cerebral and myocardial infarction, and multiple sclerosis. Serum levels of TM represent an useful prognostic index, because they are associated with an increase in mortality rate, or however a progression of the underlying pathological condition.

The relationship between glycated hemoglobin and polymorphonuclear leukocyte leukotriene B4 release in people with diabetes mellitus.

In order to evaluate polymorphonuclear leukocyte (PMN) activity in diabetes mellitus, leukotriene B4 (LTB4) levels were measured in sixty patients, 31 affected with Type 1 diabetes mellitus and 29 affected with Type 2 diabetes mellitus. The LTB4 levels (12.1+/-0.2 pg/100 microl) in diabetic patients were higher compared to those of the control group (7.9+/-0.1 pg/100 microl) (P < 0.001), and remained significantly higher (P < 0.001) (12.8+/-0.2 pg/100 microl) than in the control group (11.0+/-0.2 pg/100 microl) after stimulation with calcium ionophore. A significant and positive correlation between glycated hemoglobin and LTB4 was demonstrated (P < 0.001, r = 0.80). This study demonstrates that in diabetic patients there is a PMN activation and that this activation is correlated to glycated hemoglobin level.

Anti-neutrophil cell antibodies in newly diagnosed patients with type-1-diabetes.

Both anti neutrophil cell antibodies and anti endothelial cell antibodies were found in 7 out of 30 newly-diagnosed type-1 diabetic patients. This confirms the abnormal activation of the immunological system in the early stage of type-1 diabetes mellitus.

Adrenomedullin assay and its clinical significance.

Adrenomedullin (Am) is a recently discovered peptide, first purified from pheochromocytoma specimens, with a chemical structure similar to that of CGRP and amylin. Adrenomedullin is present in numerous human body tissues and its powerful vasodilatatory activity is thought to play an essential role in cardiovascular and renal homeostasis.

CGRP and ET-1 plasma levels in normal subjects.

OBJECTIVE: Calcitonin gene-related peptide (CGRP) is a 37 amino acid peptide displaying about 50% homology with amylin which is secreted from the pancreatic islets of Langerhans. The main form, the beta-CGRP, is produced by the enteric nervous system and perivascular nerves of the vasa-vasorum. It represents one of the most powerful vasodilator yet discovered but its role is not yet completely clarified. High levels of this peptide have been shown in patients affected with thyroid medullary carcinoma, phaemocromocytoma and lung carcinoma. Recently circulating levels of CGRP have been found in normal subjects. Endothelin-1 (ET-1), a potent vasoconstrictor peptide, isolated from porcine endothelial cells, is an important regulator of the vascular tone acting in physiological antagonism with atrial natriuretic hormone (ANH). With this study we intended to investigate the presence of any correlation between CGRP and ET-1 in normal subjects. PATIENTS: For the study we considered 20 normal subjects (11 males and 9 females) aged 23 to 50. MEASURES: Plasma levels of CGRP and ET-1 were measured by radioimmunological Kit. RESULTS: A positive and significant correlation between calcitonin gene-related peptide and endothelin-1 was found. CONCLUSIONS: Our results confirms that CGRP and ET-1 have opposing actions on vessels and that they can act together in haemodinamic regulation.

Increased plasma concentration of atrial natriuretic hormone in myotonic dystrophy.

Atrial natriuretic hormone (ANH) concentrations were measured in 16 patients affected with myotonic dystrophy (MyD) undergoing 24-hour Holter ECG and in 15 age-matched normal subjects. Although the MyD patients did not show overt left ventricular function impairment, their plasma ANH levels were found to be higher (183.76 +/- 113.25 pg/ml) compared to those of the control subjects (39.73 +/- 9.95 pg/ml, p < 0.001). Nine patients with arrhythmias and some echocardiographic alterations formed subgroup A. Seven patients without cardiac alterations formed subgroup B. No significant difference in ANH emerged between the two subgroups. This evidence suggests that high plasma ANH levels in MyD cannot always be related to overt or latent heart failure and to arrhythmias.

Plasma atrial natriuretic hormone in hyperthyroidism.

In 22 hyperthyroid patients, atrial natriuretic hormone (ANH) levels (71.91 +/- 21.03 pg/ml), measured during a 3-h-Holter, were found to be significantly higher (p < 0.001) than those in 20 age-matched normal subjects (37.22 +/- 8.73 pg/ml). We have demonstrated that the presence of tachiarrhythmias does not influence ANH release. The positive and significant correlation of FT3 with both ANH and heart rate confirms the hypothesis of a direct action of thyroid hormones on ANH release.