Systemic hypertension counteracts potential benefits of growth hormone replacement therapy on left ventricular remodeling in adults with growth hormone deficiency.

BACKGROUND: Systemic Hypertension (SH) is the main cause of left ventricular (LV) hypertrophy in the general population, but only scanty data are available on LV geometric remodeling (LVGR) in hypertensive patients with GH deficiency (GHD). AIM: We investigated hypertensive LVGR in adult-onset GHD patients, before (T0) and after 55±16 months (T1) of individualized GH replacement therapy (GHRT). SUBJECTS: Fifty-one patients, aged 45±15 yr, 29 women, were enrolled. Fifteen patients met criteria for SH (group A) whereas 36 were normotensive (group B). METHODS: An echocardiogram was performed on all patients, at least twice (at T0 and T1). LV geometric remodeling as a relationship between LV mass (LVM) index and relative wall thickness (RWT), LV volumes, and ejection fraction were measured. RESULTS: At T0, group A showed higher LV mass and LVM index values than group B; LV hypertrophy was found in 40% and 22% of patients, respectively (p=0.06). At T1, IGF-I levels had increased significantly in both groups. LV hypertrophy rate consistently increased in group A (from 40 to 60%, p<0.05), whereas slightly decreased in group B (from 22 to 19%, ns). Body surface area (p<0.001), age (p<0.05), and systolic blood pressure (p<0.05) were main determinants of LVM at multivariate analysis. CONCLUSIONS: Along with body surface area and age, SH was significantly related to abnormal LVGR (LV hypertrophy) in GHD patients. As a result, blood pressure management and caloric intake restrictions are deemed necessary for this subset of patients.

A comparison of coronary artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery: five year clinical follow up.

BACKGROUND: Stent implantation for isolated stenosis of the proximal left anterior descending coronary artery (LAD) with preserved left ventricular function has been found to have a better clinical and angiographic outcome at one year than balloon angioplasty (PTCA). OBJECTIVE: To establish whether those results are maintained at five year follow up. METHODS: Patients were followed at least every six months. For those who died during follow up, data were obtained from medical records. MAIN OUTCOME MEASURES: Freedom from death, non-fatal myocardial infarction, cerebrovascular accident, and repeated target lesion revascularisation. Secondary end points were revascularisation in a remote region and freedom from angina. RESULTS: Follow up was complete in all patients. At five years, the primary end point was reached more often by patients randomised to stent implantation than to PTCA (80% v 53%; odds ratio (OR) 0.29 (95% confidence interval (CI) 0.13 to 0.69); p = 0.0034). In the PTCA group, 35% of patients underwent target lesion revascularisation v 15% in the stent group (OR 0.33, 95% CI 0.13 to 0.80; p = 0.014). There was a trend towards increased mortality in the PTCA group than in the stent group (17% v 7%; OR 0.36, 95% CI 0.10 to 1.21; p = 0.098). No significant differences were found between PTCA and stent groups for non-fatal myocardial infarction (8% v 5%; OR 0.58, 95% CI 0.13 to 2.54; p = 0.46) or cerebrovascular accident (2% v 0%). CONCLUSIONS: In patients with isolated stenosis of the proximal LAD, a five year clinical follow up confirmed a better outcome in those treated with stenting than with PTCA.

Ibutilide for cardioversion of atrial flutter: efficacy of a single dose in recent-onset arrhythmias.

AIM: Ibutilide is particularly effective in rapid termination of atrial flutter (AFL) with few adverse effects. Despite the recommendation of 2 infusions, cardioversion may occur up to 70 minutes after a single dose. We investigated the feasibility, efficacy and safety of a single dose ibutilide treatment of AFL in a single-center, observational study. METHODS: Fifty-nine consecutive patients (44 males, mean age 70 +/- 12), referred to our CCU for paroxysmal AFL (mean arrhythmia duration 10 +/- 18 days), were treated with 1 mg ibutilide. In case of inefficacy, a 2nd dose could be administered 10 to 60 minutes later on the basis of the ECG examination for QTc prolongation and AFL cycle variations. Successful cardioversion was defined as sinus rhythm (SR) restoration within 2 hours. RESULTS: Forty-four patients (75%) converted to SR after ibutilide, 31 with single dose (53%, Group 1), and 13 with double dose (22%, Group 2). AFL duration was shorter in Group 1 (4 +/- 5 vs 16 +/- 29 days). The mean time to the 2nd dose administration was 34 +/- 11 minutes in responders, 51 +/- 23 minutes in non-responders. Only 3 (5%) significant adverse events, all observed after a single dose, occurred. CONCLUSION: Ibutilide is highly effective and safe, in a monitored environment, for rapid termination of AFL. Recent onset AFL may be terminated with a single infusion in many cases; yet, cardioversion should be waited for no more than 30 minutes after the end of the 1st dose, before administering the 2nd one, in order not to reduce the possibility of SR restoration.

Acute thrombosis of the sinus node artery: arrhythmological implications.

A 53 year old woman was referred for percutaneous coronary intervention because of a recent inferior myocardial infarction. During right coronary artery stent implantation, intermittent occlusion of the coronary side branch for the sinus node occurred, associated with intermittent sinus arrest and junctional escape rhythm. This led to speculation about the potential mechanisms for sinus node dysfunction. Degenerative fibrosis of nodal tissue is actually considered the most common cause of bradyarrhythmias. Yet, in everyday practice, no particular attention is usually paid to other potential pathogenic mechanisms such as coronary artery disease. This may be particularly true for elderly patients or patients with multiple risk factors. Thus, sinus node dysfunction may be an unrecognised marker of coronary artery disease.

[Detection of left ventricular endocardial border with tissue harmonic imaging]. / Vantaggi della seconda armonica tissutale nella identificazione del bordo endocardico ventricolare sinistro.

BACKGROUND: Ultrasonic wave propagation in human tissues is not linear. As a consequence, harmonic waves, whose frequency is a multiple (harmonic) of the emitted frequency, are generated. Tissue Harmonic Imaging (THI) processes only the second harmonic frequency in order to improve the signal-to-noise ratio of the received signal. The study was aimed at investigating the impact of THI on the detection of the Left Ventricular (LV) endocardial border. Attention was paid to determine which LV walls were analysed more clearly with THI rather than with conventional Fundamental Frequency Imaging (FFI). METHODS: We compared the FFI and the THI visualization of the 16 LV segments and of the 6 LV walls in 30 consecutive patients by scoring the images as bad, sufficient or good. The equipment used was a GE Vingmed System Five (Orten, Norway). RESULTS: Images were good in 85% of segments explored with THI, whereas FFI provided good images in 47% of segments (p<0.001). From the apical window, visualization of the apex, lateral wall and anterior wall significantly improved with THI; using the parasternal approach, imaging of posterior wall was definitely better with THI than with FFI. CONCLUSIONS: THI enhances both endocardial visualization and global image quality. Tech-nical development, however, increases the diagnostic possibilities of echocardiography but does not substitute the operator's experience.

[Compression therapy in deep venous thrombosis]. / La terapia compressiva della trombosi venosa profonda.

External compression, both intermittent by pneumatic pumps and continuous by anelastic or elastic bandages and by graduate compression stockings, play a pivotal role in prophylaxis of Deep Venous Thrombosis (DVT). The use of external compression in DVT therapy and in prophylaxis of pulmonary embolism (PE) and of post-thrombotic syndrome has not been validated as well as in DVT prophylaxis. The pathophysiologic properties of the external compression and the most recent evidences about the early mobilization of the patients with DVT and about Low Molecular Weight Heparin (LMWH) therapy suggest the advantages of the external compression. The authors review the most important clinical investigations about early use of external compression in DVT joined with pharmacological therapy: the results have been the reduction of the growth of the thrombus, the reduction of PE ratio, the prevention of the post-thrombotic syndrome, the indirect improvement of the quality of life. Finally the authors confirm the recommendations about the use of physical therapy with early mobilization and external compression joined with LMWH anticoagulation in DVT.

Piroxicam--a literature review of new results from laboratory and clinical studies.

Piroxicam is a chemically unique, long-acting, potent antiinflammatory/analgesic agent now available for the treatment of arthritis and other inflammatory diseases in over 80 countries around the world. The literature of the last 2 years on preclinical and clinical results with piroxicam has been reviewed. Recent laboratory experiments have given insights into additional actions of piroxicam which may play a role in its broad spectrum of antiinflammatory activity. In various animal models, piroxicam inhibits cell migration into an inflamed site. In vitro, piroxicam inhibits both superoxide anion production and lysosomal enzyme release from human neutrophils and also inhibits IgM-rheumatoid factor production by human lymphocytes. The safety and excellent toleration of piroxicam in animals has been reconfirmed. Extensive clinical trials in over 66,000 patients have demonstrated the high efficacy and excellent toleration of piroxicam in rheumatoid arthritis, osteoarthritis, gout, various musculoskeletal disorders and pain of varied etiology. Patient preference and compliance has consistently been higher for patients on piroxicam therapy. A single 20 mg, daily oral dose produces 24 hour control of symptoms. Piroxicam has been shown to be a useful addition to the physicians armamentarium.