Systematic basic and advanced resuscitation training in medical students and fellows: a proposal from the Working Group on Cardiovascular Urgences and Emergencies of the Italian Society of Cardiology.

Sudden cardiac arrest is a leading cause of death in Europe. High-quality cardiopulmonary resuscitation (CPR) and guidelines compliance of rescuers have been associated with better outcomes after cardiac arrest. However, wide variability in attempting bystander CPR manoeuvres has been reported. Educational programmes for teaching CPR to medical students and fellows are highly advisable in this context. However, there is no homogeneity regarding the CPR education offered by academic institutions. We surveyed 208 Italian medical students and 162 fellows in cardiology regarding the educational offer and needs in CPR. Among the 11 medical schools surveyed, 8 (73%) offer basic (BLS) courses but only 3 (38%) with formal certification of 'BLS provider', while none offers advanced (ACLS/ALS) courses. Among the 30 specialization schools in cardiology surveyed, 10 (33%) offer a BLS course (6 with formal certification of 'BLS provider'), and 8 (27%) offer an ACLS/ALS course (5 with formal certification). Only a minority of students and fellows perceive themselves as highly proficient either in BLS or ACLS/ALS, although most of the fellows were involved at least once in rescuing a cardiac arrest. The present position paper analyses and suggests the strategies that should be adopted by Italian medical and specialization schools to spread the CPR culture and increase the long-standing retention of CPR-related technical and nontechnical skills.

[HCF-ANMCO/AICPR/GIEC/ITAHFA/SICOA/SICP/SIMG/SIT Cardiological Societies Council Consensus document: Anticoagulant therapy in venous thromboembolism and atrial fibrillation of the patient with cancer. Current knowledge and new evidence]. / Documento di consenso della Consulta delle Società Cardiologiche HCF-ANMCO/AICPR/GIEC/ITAHFA/SICOA/SICP/SIMG/SIT: La terapia anticoagulante nel tromboembolismo venoso e nella fibrillazione atriale del paziente con cancro. Le attuali conoscenze e le nuove evidenze.

Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, either symptomatic or incidental, is a common complication in the history of cancer disease. The risk of VTE is 4-7-fold higher in oncology patients, and it represents the second leading cause of death, after cancer itself. In cancer patients, compared with the general population, VTE therapy is associated with higher rates of recurrent thrombosis and/or major bleeding. The need for treatment of VTE in patients with cancer is a challenge for the clinician because of the multiplicity of types of cancer, the disease stage and the imbricated cancer treatment. Historically, in cancer patients, low molecular weight heparins have been preferred for treatment of VTE. More recently, in large randomized clinical trials, direct oral anticoagulants (DOACs) demonstrated to reduce the risk of VTE. However, in the "real life", uncertainties remain on the use of DOACs, especially for the bleeding risk in patients with gastrointestinal cancers and the potential drug-to-drug interactions with specific anticancer therapies.In cancer patients, atrial fibrillation can arise as a perioperative complication or for the side effect of some chemotherapy agents, as well as a consequence of some associated risk factors, including cancer itself. The current clinical scores for predicting thrombotic events (CHA2DS2-VASc) or for predicting bleeding (HAS-BLED), used to guide antithrombotic therapy in the general population, have not yet been validated in cancer patients. Encouraging data for DOAC prescription in patients with atrial fibrillation and cancer are emerging: recent post-hoc analysis showed safety and efficacy of DOACs for the prevention of embolic events compared to warfarin in cancer patients. Currently, anticoagulant therapy of cancer patients should be individualized with multidisciplinary follow-up and frequent reassessment. This consensus document represents an advanced state of the art on the subject and provides useful notes on clinical practice.

European Cardiac Arrhythmia Society Statement on the cardiovascular events associated with the use or abuse of energy drinks.

Energy drinks are increasingly used by young people and young athletes in order to improve their performance alone or in association of other substances, particularly alcohol. In recent years, a number of reports of reports have raised attention on the side-effects associated with the use or abuse of energy drinks particularly serious cardiovascular events. The European Cardiac Arrhythmia Society (ECAS) has undertaken a systematic and critical review of reported data on cardiovascular events including life-threatening arrhythmias with or without cardiac arrest and other cardiovascular events, and discussed in this review the possible causal effect of caffeine and other ingredients contained in energy drinks and the reported events. Twenty-two cardiovascular events were reported in association with the use or abuse of energy drinks. The European Cardiac Arrhythmia Society would like to draw attention on the possible cardiovascular complications that may occur with the consumption of these beverages and to emphasize the prevention measures to be taken particularly in the young population. Well-designed prospective studies are needed to clarify the possible role of energy drinks in inducing the cardiovascular events reported.

In vitro Bioaccessibility, Bioavailability, and Plasma Protein Interaction of New Oral Anticoagulants in the Presence of Macronutrients.

BACKGROUND: Over the last years, a new generation of oral anticoagulants (NOACs), including apixaban, rivaroxaban and dabigatran, has been developed for the control of thrombosis and related disorders. The presence of food within the gastrointestinal (GI) tract can potentially affect the oral bioavailability of drugs. OBJECTIVE: In the present paper, we evaluated the stability of these drugs in in vitro GI digestion, with and without the main macronutrients such as proteins, lipids, carbohydrates, and fibers, and their ability to enter into the systemic circulation. In addition, we examined the percentage of the drug binding to plasma proteins, such as human serum albumin, high density- and low density lipoproteins. METHODS: The NOACs bioaccessibility was evaluated by an in vitro procedure simulating the gastrointestinal enzymatic system, while their bioavailability was studied by cell culture of Caco-2 cells and in vitro study of transepithelial transport. The in vitro transepithelial permeated NOACs were added to plasma protein solutions simulating the average fasting plasma protein concentrations. The NOACs detection was carried out by HPLC-DAD/ESI-MS analysis. RESULTS: GI digestion significantly reduces intestinal bioaccessibility and bioavailability of NOACs, especially as regards apixaban and dabigatran. Interestingly, the co-digestion of fibers led to a strong decrease of NOAC intestinal bioaccessibility and bioavailability, while the effects of the other macronutrients, as well as a low fiber standard meal, had no significant influence in this sense. CONCLUSION: Dabigatran, rivaroxaban and apixaban may be administered independently of a standard meal, provided that it does not include a high amount of dietary fibers.

[Appropriateness criteria for the treatment of atrial fibrillation with dronedarone: practical issues. An Italian cardiologists' expert opinion]. / Criteri di appropriatezza nel trattamento della fibrillazione atriale con dronedarone: aspetti pratici. L'opinione di un gruppo di esperti cardiologi italiani.

Antiarrhythmic agents are among the therapeutic options available for the treatment of atrial fibrillation when a rhythm control strategy is required. Although their efficacy seems to be generally comparable to that of nonpharmacological interventions, the use of these agents remains controversial. In particular, among this class of drugs, the use of dronedarone in clinical practice is a matter of debate. In this paper, the authors aimed to address these issues, involving a team of expert cardiologists who discussed about the potential use of dronedarone in different clinical scenarios. The RAND/UCLA appropriateness method was used to develop appropriateness measures for the optimal management of patients treated with dronedarone, by combining the best available scientific evidence with the collective judgment of experts. To this purpose, a group of experts was identified and asked to rate the benefit-to-harm ratio of 52 clinical scenarios. Each indication was classified as "appropriate", "uncertain" or "inappropriate" in accordance with the panelists' median score. The classification of each scenario has led to the development of several recommendations for clinical practice. The use of dronedarone for the management of paroxysmal and persistent atrial fibrillation has evolved over time: this antiarrhythmic drug appears to be useful not only in monitoring symptoms, but also in reducing hospitalization and mortality rates in patients with atrial fibrillation.

Endothelial dysfunction in type 2 diabetic patients with normal coronary arteries: a digital reactive hyperemia study.

BACKGROUND: To assess endothelial function (EF) in type 2 diabetic patients with angiographically normal coronaries compared to diabetic patients with obstructive coronary artery disease (CAD) and to non-diabetic patients, with and without CAD. METHODS: One hundred eighty-three patients undergoing coronary angiography were divided in: group 1 with diabetes mellitus (DM) and CAD (n = 58); group 2 with DM without CAD (n = 58); group 3 with CAD without DM (n = 31) and group 4 without CAD and DM (n = 36). EF was assessed by reactive hyperemia index (RHI) using a fingertip peripheral arterial tonometry and compared to values obtained in 20 healthy volunteers. RESULTS: RHI was significantly lower in patients with DM compared to patients without DM (1.69 ± 0.38 vs 1.84 ± 0.44; p = 0.019). RHI was comparable among groups 1, 2 and 3, each value being significantly lower compared to group 4 (2 ± 0.44; p<0.001 vs group 1; p<0.005 vs group 2; p<0.002 vs group 3). At multivariate analysis DM and CAD were significant predictors of endothelial dysfunction (ED) (OR = 2.29; p = 0.012; OR = 2.76; p = 0.001, respectively), whereas diabetic patients (n = 116) CAD and glycated haemoglobin (HbA1c) were independent significant predictors of ED (OR = 3.05; p = 0.009; OR = 1.96; p = 0.004, respectively). Diabetic patients with ED (n = 67) had higher levels of HbA1c than diabetic patients with normal endothelial function (7.35 ± 0.97 vs 6.87 ± 0.90; p = 0.008) and RHI inversely correlated to HbA1c (p = 0.02; r = -0.210). CONCLUSIONS: Diabetic patients with and without CAD show significantly impaired peripheral vascular function compared to non-diabetic patients without CAD. ED in diabetic patients without CAD is comparable to that of patients with CAD but without DM. HbA1c is a weak independent predictor of ED.

[Public access defibrillation in the Sorrento Peninsula]. / Il progetto di defibrillazione precoce della Penisola Sorrentina.

Early cardiac defibrillation is the only effective therapy to stop ventricular fibrillation or pulseless ventricular tachycardia. It is still considered the gold standard for the treatment of ventricular tachycardia/fibrillation, and is the only intervention capable of improving survival in cardiac arrest survivors. Timing of intervention, however, is crucial because after only 10 min success rates are very low (0-2%). Unfortunately, adequate relief cannot always be provided within the necessary time. The purpose of the public access defibrillation project in Sorrento was to create fixed and mobile first aid with automated external defibrillators in combination with the local 118 emergency system. With the involvement of pharmacies, bathing establishments and schools, 31 equally distant sites for public access defibrillation were made available. This organization was supplemented by mobile units on the cars of the Municipal Police and Civil Protection, and on patrol boats in the harbor.

[Early defibrillation with automated external defibrillators during sports events]. / Defibrillazione precoce con defibrillatore semiautomatico negli ambienti sportivi.

Sports-related cardiovascular events may occur in both young athletes and the general population, the latter having a higher absolute risk. In mass gathering sports events, the availability of an onsite emergency response plan including early access to automated external defibrillators by trained lay rescuers has been shown to improve survival among spectators and staff with out-of-hospital cardiac arrest and to reduce subsequent neurological deficit. In addition, in athletes experiencing cardiac arrest, the implementation of public access defibrillation programs demonstrated a favorable mortality trend, with survival rates comparable to those observed in adult sedentary subjects. In Italy and much of Europe, current emergency action plans at sporting events still need full implementation. In particular, in Italy no scientific statements on this topic have been developed. In order to compensate this lack of information, an ad hoc task force has been established with representatives of the major scientific societies involved in sports-based health and disease prevention, with the aim to address public access defibrillation programs for sporting events, and to promote awareness of appropriate cardiovascular emergency care at sports arenas.

[Medical-legal issues in remote monitoring of implantable cardioverter-defibrillators]. / Aspetti medico-legali del controllo remoto dei defibrillatori impiantabili.

Patients with implanted automatic defibrillators should undergo careful monitoring during follow-up and may require access to the emergency department or hospitalization for device-related problems. Nowadays, the progressive development of information technology allows remote monitoring of patients with cardiac defibrillators using dedicated systems which make it possible to transfer clinical and technical data derived from device interrogation to the Cardiology Center through telephonic line. In patients with an implantable defibrillator, remote monitoring is effective in identifying device malfunctioning and clinical problems, such as heart failure, to an extent similar to traditional ambulatory monitoring, while allowing significant advantages for the patient quality of life and savings in resource management. This different way of organizing care has created new problems in terms of responsibility for manufacturers, responsible for the technical aspect, for the healthcare system, responsible for service supply and management, and for the physician, who should supervise the whole process and ensure the safety of the information provided. Telemedicine is configured as a highly complex activity and therefore any treatment provided through it will, in terms of responsibility, be assessed bearing in mind that "if performance involves the solution of technical problems of special difficulty, lenders are not liable for damages, except in cases of intent or gross negligence". Also important are minor legal issues, such as permissions, problems of inaccessibility to the service, the assessment of medical liability compared to the activity of the team, and all issues related to informed consent and privacy protection.

Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators.

Patients with an implantable cardioverter defibrillator (ICD) have an ongoing risk of sudden incapacitation that might cause harm to others while driving a car. Driving restrictions vary across different countries in Europe. The most recent recommendations for driving of ICD patients in Europe were published in 1997 and focused mainly on patients implanted for secondary prevention. In recent years there has been a vast increase in the number of patients with an ICD and in the percentage of patients implanted for primary prevention. The EHRA task force on ICD and driving was formed to reassess the risk of driving for ICD patients based on the literature available. The recommendations are summarized in the following table and are further explained in the document, (Table see text). Driving restrictions are perceived as difficult for patients and their families, and have an immediate consequence for their lifestyle. To increase the adherence to the driving restrictions, adequate discharge of education and follow-up of patients and family are pivotal. The task force members hope this document may serve as an instrument for European and national regulatory authorities to formulate uniform driving regulations.

[Management of electrical storm in implantable cardioverter-defibrillator recipients]. / La gestione della tempesta aritmica nel paziente portatore di defibrillatore impiantabile.

The term "electrical storm" (ES) indicates a state of cardiac electrical instability manifested by several episodes of ventricular tachyarrhythmias (VTs) within a short time. In patients with an implantable cardioverter-defibrillator (ICD), ES is best defined as three appropriate VT detections in 24h, treated by antitachycardia pacing, shock or eventually untreated but sustained in a VT monitoring zone. ES seems to have a low immediate mortality (1%) but frequently (50-80%) leads to hospitalization. Antiarrhythmic drugs have been shown to be very effective in treating ES in patients without ICD, whereas in ICD recipients, device programming is probably a key issue to prevent ES. Since sympathetic overreactivity is an important trigger, the risk of shock delivery should be minimized. Antitachycardia pacing can successfully terminate a significant percentage of fast VTs. Important parameters such as the number of VT cycles needed for VT detection can be increased from nominal values to allow spontaneous termination, and safety features that deliver a shock after a programmable time window independent of programming of antitachycardia pacing (sustained rate duration) should be prolonged or disabled. In some cases it may be advisable to turn off the ICD tachy mode to avoid multiple ineffective shocks. Substrate mapping and VT ablation may be useful for the treatment and prevention of ES.

[Responsibilities for the remote monitoring of heart failure patients]. / La responsabilità nel controllo a distanza del paziente con scompenso cardiaco.

Heart failure patients may frequently undergo repeat hospitalizations, and for this reason recent guidelines recommend a multidisciplinary approach including remote clinical state management through systems such as electronic devices, portable or implantable, with the aim of simplifying patient management and optimizing healthcare resources. This different way of healthcare organization has brought about new levels of responsibility, including device manufacturers responsible for the technical aspects, healthcare facilities responsible for the information systems used for patient clinical data transmission and for ambulatory patient access, and in particular the clinicians who should ensure the process supervision by providing prompt medical assistance if alarm signals are received. The use of telemedicine, however, may engender technical problems of varying difficulties. In terms of responsibility, service providers are not liable for damage deriving from technical default, except in the case of willful misconduct or gross negligence. No less important are the legal issues concerning permissions, conflicts of jurisdiction among nations, problems of service inaccessibility, as well as the identification of medical liability in relation to the activity of a multidisciplinary team, besides issues relating to informed consent and privacy protection. In conclusion, risk management with telemedicine may provide more accurate information and better traceability of operators' activity.

Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators.

Patients with an implantable cardioverter defibrillator (ICD) have an ongoing risk of sudden incapacitation that might cause harm to others while driving a car. Driving restrictions vary across different countries in Europe. The most recent recommendations for driving of ICD patients in Europe were published in 1997 and focused mainly on patients implanted for secondary prevention. In recent years there has been a vast increase in the number of patients with an ICD and in the percentage of patients implanted for primary prevention. The EHRA task force on ICD and driving was formed to reassess the risk of driving for ICD patients based on the literature available. The recommendations are summarized in the following table and are further explained in the document. [table: see text] Driving restrictions are perceived as difficult for patients and their families, and have an immediate consequence for their lifestyle. To increase the adherence to the driving restrictions, adequate discharge of education and follow-up of patients and family are pivotal. The task force members hope this document may serve as an instrument for European and national regulatory authorities to formulate uniform driving regulations.

Efficacy of automatic mode switching in DDDR mode pacemakers: the most 2 study.

BACKGROUND: Effective automatic mode switching (AMS) algorithms capable of detecting a range of supraventricular tachyarrhythmias is important given evidence of atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT) post-implantation of pacemakers. OBJECTIVES: The aim of the study was to assess the efficacy, defined as ability to detect a specific atrial rate and activate AMS, of five different AMS mechanisms during simulation of AF, AFL, and AT. MATERIALS AND METHODS: A total of 48 subjects (35 men, 13 women; mean age: 69 +/- 8 years) implanted with DDDR pacemakers utilizing five different AMS mechanisms (mean atrial rate, rate cut-off, complex 'fallback' algorithm, retriggerable atrial refractory period, and physiological band 'beat-to-beat') were tested using an external electronic device that simulated the occurrence of supraventricular tachyarrhythmias. AF, AFL, and AT were simulated by delivering low voltage pulse trains at 350, 250 and 160 beats/min, respectively. RESULTS: Mean efficacy for all AMS mechanisms was 81% [range: 57% to 100%] at 350 beats/min, 81% [range: 57-100%] at 250 beats/min, and 79% [range: 57-100%] at 160 beats/min. The AMS mechanisms that yielded 100% efficacy were the rate cut-off and physiological band 'beat-to-beat.' CONCLUSION: Not all AMS algorithms are equally efficacious at detecting atrial arrhythmias and subsequently activating AMS. Our results suggest that the most efficacious AMS algorithms are those that use rate cut-off and physiological band 'beat-to-beat' to detect supraventricular tachyarrhythmias.

Recurrent unexplained palpitations (RUP) study comparison of implantable loop recorder versus conventional diagnostic strategy.

OBJECTIVES: The aim of the study was to compare the diagnostic yield and the costs of implantable loop recorder (ILR) with those of the conventional strategy in patients with unexplained palpitations. BACKGROUND: In patients with unexplained palpitations, especially in those with infrequent symptoms, the conventional strategy, including short-term ambulatory electrocardiogram (ECG) monitoring and electrophysiological study, sometimes fails to establish a diagnosis. METHODS: We studied 50 patients with infrequent (< or =1 episode/month), sustained (>1 min) palpitations. Before enrollment, patients had a negative initial evaluation, including history, physical examination, and ECG. Patients were randomized either to conventional strategy (24-h Holter recording, a 4-week period of ambulatory ECG monitoring with an external recorder, and electrophysiological study) (n = 24) or to ILR implantation with 1-year monitoring (n = 26). Hospital costs of the 2 strategies were calculated. RESULTS: A diagnosis was obtained in 5 patients in the conventional strategy group, and in 19 subjects in the ILR group (21% vs. 73%, p < 0.001). Despite the higher initial cost, the cost per diagnosis in the ILR group was lower than in the conventional strategy group (euro 3,056 +/- euro 363 vs. euro 6,768 +/- euro 6,672, p = 0.012). CONCLUSIONS: In subjects without severe heart disease and with infrequent palpitations, ILR is a safe and more cost-effective diagnostic approach than conventional strategy.

Haemodynamic effects of dual-chamber pacing versus ventricular pacing during a walk test in patients with depressed or normal left ventricular function.

PURPOSE: Dual-chamber rate-modulated pacing provides haemodynamic benefits compared with ventricular pacing at rest, but it is unclear whether this also holds true during physical exercise in patients with heart failure. This study assessed the haemodynamic response to a walk test during dual-chamber pacing and ventricular pacing in patients with depressed or normal left ventricular (LV) function. METHODS: Twelve patients with an LV ejection fraction <50% and 11 patients with an LV ejection fraction >or=50% underwent two randomised 6-min walk tests under dual-chamber rate-modulated pacing and ventricular pacing at a fixed rate of 70 beats/min. All patients had a dual-chamber pacemaker implanted for complete heart block. LV function was monitored by a radionuclide ambulatory system. RESULTS: In patients with depressed LV function, the change from dual-chamber pacing to ventricular pacing induced a decrease in end-systolic volume at the peak of the walk test (P<0.05), with no difference in end-diastolic volume. As a consequence, higher increases in LV ejection fraction (P<0.0001) and stroke volume (P<0.01) were observed during ventricular pacing. No difference in cardiac output was found between the two pacing modes. In patients with normal LV function, the change from dual-chamber pacing to ventricular pacing induced a significant decrease in cardiac output (P<0.005 at rest and P<0.05 at the peak of the walk test). CONCLUSION: Compared with dual-chamber rate-modulated pacing, ventricular pacing improves cardiac function and does not affect cardiac output during physical activity in patients with depressed LV function, whereas it impairs cardiac output in those with normal function.

[Evaluation of BLS-D training in lay people]. / Valutazione dell'apprendimento delle manovre di BLS-D da parte di personale laico.

BACKGROUND: The possibility of saving persons with sudden cardiac arrest (SCA) lowers of 10% every minute since the beginning of the event. The early defibrillation (within 4 min) of a person with SCA performed by first responders suitably trained increases the survival rate up to 50%. The basic aim is that early defibrillation is performed as soon as possible by the first responder. METHODS: Within the Public Access Defibrillation (PAD) "Napoli Cuore" Project, 220 highway patrol agents of the Campania Region district were trained through theoretical and practical courses to acquire suitable psychomotor skills to perform the first aid. The learning evaluation was performed with a written exam and a practical test to assess how much every agent had learned about basic life support-defibrillation (BLS-D) schemes. RESULTS: 98.5% of the participants passed the exams and obtained the BLS-D rescuer license, and 15.5% of them obtained the highest score. The analysis of the report cards showed that most of the participants expressed an excellent opinion about this experience. CONCLUSIONS: To implement a PAD project it is necessary to awaken all the structures involved in the campaign against SCA. Hence, it is important that all emergency specialists, public institutions and police departments work all together to make everyone feels safe.

[Transthoracic cardioversion in patients with atrial fibrillation: comparison of three different waveforms]. / Cardioversione elettrica esterna in pazienti con fibrillazione atriale: confronto fra tre differenti forme di onda.

BACKGROUND: Transthoracic electrical cardioversion represents the most effective therapy in converting atrial fibrillation (AF) to sinus rhythm. External cardioverter-defibrillators discharge a current with monophasic and most recently biphasic waveforms. Lately, many articles support the superiority of the biphasic waveform over the monophasic one. Moreover, we have the opportunity to use different biphasic waveforms. The aim of this study was to compare the efficacy (success rate and energy delivered) of a monophasic wave and two different biphasic waves, in patients with persistent AF undergoing external electrical cardioversion. The monophasic wave was delivered by a Zoll M series NM PDMA-9, while the so-called "rectilinear" biphasic waveform was used by a Zoll M series PDM-7S and the biphasic truncated exponential wave by a Laerdal Heartstart 4000. METHODS: Sixty-four patients with clinical indications to undergo external electrical cardioversion were randomized into three groups. All the groups were homogeneous for almost all characteristics, particularly atrial dimensions, body surface area, and duration of AF and therapy. Eighteen patients underwent external cardioversion with monophasic waveform (group 1), 22 patients were treated with rectilinear biphasic waveform (group II), and 24 patients with biphasic truncated waveform (group III). A cardioversion protocol, providing up to 5 shocks, with incremental energy levels was used. A blood sample was obtained 6 hours later to evaluate myocardial damage due to shock therapy for each patient. RESULTS: Both biphasic devices demonstrated to be more effective than the monophasic one (group I 78%, group II 95%, group III 100%). Moreover, none of them caused any significant myocardial damage, evaluated in terms of cardiac enzyme release. Nonetheless, the biphasic truncated exponential wave demonstrated an efficiency of 10 0% compared to 95 % of the rectilinear one and 78% of the monophasic one, using less energy/patient (873 +/- 101 J group I, 390 +/- 48 J group II, and 280 +/- 42 J group III), at almost the same shock attempts. CONCLUSIONS: Biphasic truncated exponential wave seems to be more effective at a lower energy level.

Role of semiautomatic defibrillators in a general hospital: "Naples Heart Project".

In Italian hospitals, 85% of patients hospitalized in general medical wards who experience cardiac arrest die, while the incidence is much lower in patients in intensive care units. Defibrillation, in Italian hospitals, often occurs very late, either due to a lack of defibrillators, or due to architectural and structural barriers. The object of an in-hospital emergency service is to prevent and treat cardiac arrest without subsequent complications, such as brain damage, renal failure etc. The Naples Heart Project was based on a feasibility study of the in-hospital emergency service to evaluate and analyze problems associated with type of structure, departmental and institutional dislocation, internal practicability (architectural features and preferential ways), staff numbers and distribution, the calling system for emergency, and the equipment available. The Naples Heart Project began in July 2001, since then it has already created 835 BLSD first responders among the hospital staff; 440 were physicians and physicians still in training, 310 were nurses and 85 were administrative staff.