Left ventricular hypertrophy in primary hyperparathyroidism. Effects of successful parathyroidectomy.

OBJECTIVE: The association between primary hyperparathyroidism (PHPT) and increased mortality mainly from cardiovascular disease is still debated. The increased mortality previously reported in PHPT was not confirmed in a recent population based study. A high prevalence of left ventricular (LV) hypertrophy was, however, reported in this disease. Although arterial hypertension is regarded as the principal factor, the pathogenesis of LV hypertrophy in PHPT is complex and not completely defined, moreover the effects of successful parathyroidectomy (PTX) are not fully elucidated. The aims of this study were: to ascertain the prevalence of LV hypertrophy in a series of patients with PHPT in comparison to a control population, to seek for relationship between biochemical markers of disease, blood pressure (BP) levels and LV measurements and to evaluate the effects of successful PTX on LV hypertrophy during short-term follow-up. SUBJECTS AND DESIGN: Forty-three patients affected by active PHPT (16 males and 27 females, mean age 60.2 +/- 12.7 years) and 43 controls age- and sex-matched with the same prevalence of arterial hypertension were studied in a case-control analysis. Each subject underwent a M- and 2D mode echocardiographic evaluation and repeated BP measurement. In 21 PHPT submitted to surgery the echocardiographic measurement was repeated 6 months after successful PTX. MEASUREMENTS: Serum concentrations of parathyroid hormone (PTH), total-(Ca) and ionized calcium (iCa), phosphate, creatinine, total alkaline phosphatase (TALP) were measured in patients with PHPT at diagnosis and six months after PTX in the subgroup operated on; BP values were measured in three different occasion; mono and 2D echocardiographic evaluation was performed in control subjects and patients with PHPT either before and after PTX. RESULTS: LV hypertrophy, measured by LV mass index (LVMI), was present in 28/43 PHPT patients (65.1%) and in 15/43 (34.8%) controls, P < 0.05; among hypertensive subjects, 21/21 (100%) PHPT patients and 13/21 (61.9%) controls P < 0.05 were hypertrophic while among normotensive subjects, these figures were 7/22 (31.8%) for PHPT patients and 2/22 (9%) for controls, P = 0.67. At multiple regression analysis in a model including biochemical parameters and BP values, serum PTH levels were associated with LVMI values as the strongest predicting variable (0.46, P < 0.02). Six months after PTX, LVMI decreased (137.8 +/- 37.3 vs 113.0 +/- 28.5, P < 0.05) without changes in mean BP values and ratio of hypertensive patients. CONCLUSION: The present data confirm the high prevalence of LV hypertrophy in primary hyperparathyroidism also in a group of patients with an asymptomatic clinical presentation. The correlation between PTH values and left ventricular mass index suggests an action of the hormone in the pathogenesis of LV hypertrophy confirmed also by the decrease of left ventricular mass index after the reduction of PTH levels. The reversal of left ventricular mass index after parathyroidectomy could affect mortality in primary hyperparathyroidism. An echocardiographic study could be suggested in the clinical work-up of primary hyperparathyroidism in order to evaluate heart involvement and the response to successful parathyroidectomy.

[Primary angioplasty in acute inferior myocardial infarct with anterior ST-segment depression: the long-term follow-up]. / Angioplastica primaria nell'infarto miocardico acuto inferiore con sottoslivellamento anteriore del tratto ST: follow-up a lungo termine.

BACKGROUND: Concomitant anterior ST-segment depression is a marker of severe prognosis in inferior myocardial infarction. PATIENTS AND METHODS: Prospective observational study in patients with inferior acute myocardial infarction and ST-segment depression > or = 4 mm in the anterior leads, who were treated with primary angioplasty. Angiography was performed at hospital discharge and at six months, and a clinical follow-up was obtained at one year after the infarction. RESULTS: Sixty-three patients were included in the study. Pre-hospital and in-hospital delay were 147 +/- 70 minutes (20-355) and 54 +/- 11 minutes (18-80), respectively. Angioplasty was successful in all patients and 48 stents were implanted in 36 patients (57%). Angiography was performed at hospital discharge in 55 patients (87%) and showed a TIMI grade 3 coronary flow in the infarct-related artery in all cases. The left ventricular ejection fraction was 0.55 +/- 0.09 (0.4-0.8). One patient (1.6%) died before discharge, two (3.2%) had ischemic complications (one had non-fatal reinfarction, another had recurrent angina at rest), and three (4.9%) had local vascular complications. At the six-month follow-up, none of the patients had died. One had suffered reinfarction (1.6%) and another had been readmitted for recurrence of angina at rest (1.6%); none had symptoms of stable angina. The ejection fraction was 0.56 +/- 0.12 and eight patients (14%) showed angiographic restenosis. At twelve months, two patients had died (1.6%) and five (8%) had required readmission to hospital. CONCLUSIONS: Primary angioplasty yielded favorable results in this group of patients. Our data confirm the efficacy of primary angioplasty for the treatment of acute myocardial infarction, with a low rate of clinical (3.2%) and angiographic (14%) restenosis at six months, and a high rate (87%) of event-free survival at one year follow-up.

[The use of a check list for quality assurance of the treatment of acute myocardial infarction in the coronary care unit]. / Uso di un registro per il controllo di qualità del trattamento dell'infarto miocardico acuto in unità coronarica.

UNLABELLED: The implementation of Quality Assurance programs for the treatment of acute myocardial infarction in the Cardiac Intensive Care Unit may be specially important. In fact several therapeutic options are available in these patients, and delay in treatment must be as short as possible. A Quality Assurance program has been started in our center with a registry of all patients admitted within 24 hours of onset of acute myocardial infarction. PATIENTS AND METHODS: The following data were recorded: 1) indicators of Organization: pathway to admission, pre-hospital and in-hospital delay; 2) Process Indicators: duration of hospital stay, initial choice of therapy (conservative, intravenous lysis, primary angioplasty), and further diagnostic and interventional procedures; 3) Outcome Indicators: mortality and complications during admission, and 6-12 months follow-up. RESULTS: Since february 1994 to August 1995, 211 consecutive patients were included in the registry; 156 were male, mean age 66 years. Mean pre-hospital delay was 286 minutes. Admission was decided by a physician in 99 cases and by the patient him/herself in 112 cases; pre-hospital delay was 390 min. In the former group, and 194 min. In the latter (p < .001). Mean in-hospital delay was 61 minutes. Conservative treatment, intravenous lysis, and primary angioplasty were chosen by the attending cardiologist in 89 patients (group A), 69 patients (group B), and 53 patients (group C) respectively. The latter group included patients with highest risk on the basis of clinical and electrocardiographic characteristics. In-hospital mortality was 17, 7 and 9% In the 3 groups, respectively. An echocardiogram and coronary angiography were performed before discharge in 81% and 57% of patients, respectively. The mean duration of hospital stay was 11 days, irrespective of the initial therapeutic choice. CONCLUSIONS: A registry for patients with acute myocardial infarction provides information which is essential in the evaluation of therapeutic protocols; it may also help in improving the cooperation between the Emergency Department, the attending cardiologists, and the family physicians.

Doppler echocardiographic patterns in patients with acromegaly.

Cardiovascular problems have long been recognized as responsible for an increased morbidity and mortality in patients with acromegaly. The aim of the present study was to evaluate echocardiographically the prevalence of cardiomyopathy in a cohort of acromegalic patients and to analyze the results in relation to demographic, clinical and hormonal data. This study, a retrospective controlled clinical trial, was performed in 25 acromegalic patients, 12 men and 13 women aged 26-66 years (mean: 52.6). Fifteen patients had an active disease, 10 were cured by previous pituitary surgery. The same echocardiographic parameters were analyzed in 50 healthy subjects aged 30-70 years (mean: 51.4). Serum GH was determined on at least 4 samples drawn over 24 hours and plasma IGF-I on a single point. Standardized parameters of diastolic and systolic function were evaluated by real-time Doppler echocardiography. Twelve patients with active acromegaly underwent also 48-hour ECG registering. Left ventricular (LV) hypertrophy was found in 14/25 patients (56%). No difference was found between patients with active disease (53%) and patients with cured acromegaly (60%). LV mass index was significantly increased in acromegalics in comparison with healthy subjects (137 +/- 43 g/m2 vs 96 +/- 16 g/m2, p < 0.01) and also the indices of LV diastolic function were significantly impaired. Asymmetric septal hypertrophy was found only in one patient. Hypertension was detected in 9/25 patients (36%) without difference between patients with active or cured disease (40% vs 30%, NS). No significant correlation was found between hormonal or clinical data and echocardiographic findings. During Holter monitoring, heart rate of acromegalics was not significantly different from that of controls (78 +/- 12 bpm vs 72 +/- 10 bpm, NS) and only isolated supraventricular or ventricular premature complexes (Lown class 1) were detected. In conclusion, this study provides evidence of subclinical LV dysfunction in acromegaly in the absence of other known causes of heart disease and no significant difference in echocardiographic pattern was apparent between active or cured acromegalics.

[Emergency angioplasty in high-risk acute infarct]. / Angioplastica d'emergenza nell'infarto acuto ad alto rischio.

BACKGROUND: Primary coronary angioplasty in acute myocardial infarction yields superior results in terms of effective vessel patency, recurrent ischemia and acute morbidity, as compared to intravenous thrombolysis. Despite obvious logistic and economic limitations, this early invasive approach could be strictly indicated in selected groups of patients. AIM: A prospective study to test the immediate and short-term results of an early invasive strategy with angioplasty in patients with high-risk acute myocardial infarction. METHODS: Forty-one consecutive patients with high-risk acute myocardial infarction were submitted to coronary angiography and angioplasty of the involved vessel within 12 hours of onset of symptoms. Twenty-eight had anterior myocardial infarction and 6 were in cardiogenic shock. RESULTS: Primary success was achieved in 38 patients (93%): 30 of these were discharged without complications or further revascularization procedures, and none has symptoms or re-infarction at one-month follow-up. CONCLUSIONS: Immediate invasive treatment with angioplasty in high-risk acute myocardial infarction seems to achieve good results, due to both effective infarct vessel recanalization, and early identification of candidates to urgent complete surgical revascularization.

[A study of the variations in myocardial perfusion induced by systemic thrombolysis in acute myocardial infarct using sequential scintigraphy with 201-thallium]. / Studio delle variazioni di perfusione miocardica indotte dalla trombolisi sistemica nell'infarto miocardico acuto mediante scintigrafia sequenziale con tallio 201.

To assess scintigraphic changes induced by intravenous streptokinase therapy, serial rest redistribution thallium-201 perfusion imaging was performed in 62 patients with acute myocardial infarction lasting less than 6 hours. Twenty-seven patients randomized to treatment with intravenous streptokinase (group A) and 35 to conventional therapy (group B) underwent thallium-201 scintigraphy as soon as possible after admission to the coronary care unit (early study). Regional myocardial perfusion was assessed using thallium-201 scintigraphy 7-9 days later in each patient (late study). The size of the perfusion defect was evaluated using a semi-quantitative score. The size of the perfusion defect decreased in serial scans in both group A (preintervention score: 12.1 +/- 6.8; redistribution score: 11.4 +/- 6.8; late study: 8.8 +/- 7.0) and group B (12.8 +/- 6.5; 12.3 +/- 6.7; 10.6 +/- 7.5, respectively). No statistical difference in myocardial perfusion was found between the two groups, on late study. Peak serum creatine kinase MB (CKMB) was earlier in group A than in group B (1030.8 +/- 326.6 vs 1361.0 +/- 271.1: p less than 0.001). The fast CKMB release group (onset of symptoms-peak of CKBM less than or equal to 900 minutes) exhibited higher thallium-201 uptake when compared to the slow CKMB release group, at the time of late study (perfusion defect score: 6.1 +/- 5.7 vs 10.7 +/- 7.3: p = 0.03). Reversibility was observed in 21/62 patients (34%). Reversibility corresponded to unchanged or improved perfusion defect score on late study in 18/21 patients (86%). Nevertheless 20/41 (49%) patients not showing redistribution of thallium-201 within pre-treatment defect had an improvement in regional perfusion on late study. Reversibility was observed in 9/14 (64%) patients with fast CKMB release and in 12/47 (26%) patients with slow CKMB release. We conclude that the early peak of CKMB is associated with a higher uptake of thallium-201 on late study. Furthermore, the reversibility of perfusion defect on redistribution imaging forecasts evolution of scintigraphic perfusion, but, when this is not present, it doesn't rule out late improvement of thallium-201 myocardial uptake. The low sensitivity and specificity of redistribution imaging and the procedure related delay in instituting therapy make thallium-201 scintigraphy unreliable in the evaluation of myocardial reperfusion following thrombolysis.

[Risk stratification after uncomplicated myocardial infarct: the usefulness of the echocardiographic-dipyridamole test]. / Stratificazione del rischio dopo infarto miocardico non complicato: utilità del test eco-dipiridamolo.

To assess the value and safety of echo-dipyridamole test in risk stratification soon after an uncomplicated acute myocardial infarction, 56 consecutive patients were enrolled in a prospective study with a 1-year follow-up period for new coronary events. Echo-dipyridamole and symptom-limited ECG stress test were performed respectively 14 to 20 days and 4 to 5 weeks after acute event. Echo-dipyridamole test was performed administering 0.84 mg/kg iv of the drug in 10 min: any worsening of left ventricular regional wall motion was considered as a positive test. Up to December 1989, 43 out of 56 patients had their follow-up period completed: the infarction was anterior in 13 (30%), inferior in 22 (51%), non-Q wave in 8 (19%); mean age was 55 +/- 10; basal echocardiographic ejection fraction was 52 +/- 6%. There were no major complications during echo-dipyridamole test. Coronary events occurred in 7 patients (16%): reinfarction in 3, angina in 4; there were no cardiac deaths. A positive echo-dypiridamole test was observed in 12/43 patients (28%); sensitivity versus coronary events was 43%, specificity 75%, negative predictive value 87%. Ten out of 43 patients (23%) had positive and 9/43 (21%) non valuable ECG stress test: sensitivity versus coronary events was 50%, specificity 75%, predictive negative value 88%. The 2 tests showed no significant difference in detecting patients at risk of future coronary events.(ABSTRACT TRUNCATED AT 250 WORDS)

[Contribution of computerized radioisotope angiocardiography to the diagnosis of arrhythmogenic dysplasia of the right ventricle]. / Contributo della angiocardiografia radioisotopica computerizzata all'equilibrio al riconoscimento della displasia aritmogena del ventricolo destro.

Radionuclide angiography phase analysis was performed in two patients presenting with recurrent right-sided ventricular tachycardia without angiographic evidence of valvular or ischemic heart disease. A dilated, poorly contracting (EF = 20%) right ventricle with localized dyskinetic areas was found in contrast with normal left ventricular function. The suggested diagnosis of Arrhythmogenic Right Ventricular Dysplasia was confirmed by right ventricular angiography performed in one patient. The diagnostic interest of radionuclide angiography phase analysis in patients with Arrhythmogenic Right Ventricular Dysplasia is stressed.

[Treatment using radiofrequency stimulation of supraventricular paroxysmal tachycardia in W.P.W. syndrome]. / Trattamento mediante stimolazione a radiofrequenza di tachicardia parossistica sopraventricolare in sindrome di W.P.W.

The case of woman patient suffering from W.P.W. syndrome and recurrent attacks of supraventricular paroxysmal tachycardia refractory to medical treatment is reported. After electrophysiological study, a radiofrequency coil is implanted. This is activated by the patient during attacks and leads to rapid interruption. The modalities under which paroxysmal tachycardias are interrupted by means of electrostimulating units are discussed and indications for radiofrequency stimulation assessed.