Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope.

BACKGROUND: Head-up tilt testing is extensively used to determine the vasovagal origin of syncope in patients with otherwise unexplained loss of consciousness, although issues remain regarding the method of the test. The diagnostic value of a shortened head-up tilt test potentiated with sublingual nitroglycerin was assessed in patients with unexplained syncope. METHODS: Two hundred two patients (mean age 49+/-19 years) with syncope of unknown origin and 34 subjects in a control group (mean age 45+/-17 years) were studied. The patients and the subjects in the control group were tilted upright to 60 degrees for 20 minutes. If syncope did not occur, sublingual nitroglycerin (400 microg) was administered, and observation was continued for 25 more minutes. RESULTS: During the unmedicated phase syncope occurred in 22 (11%) patients and in one member of the control group. After nitroglycerin was administered, syncope occurred in 119 (59%) patients and in 1 (3%) member of the control group. False-positive response (exaggerated response) was observed in eight (4%) patients and in four (12%) subjects in the control group. The total positivity rate of the test was 70% with a specificity rate of 94%. CONCLUSIONS: Short-duration head-up tilt test potentiated with sublingual nitroglycerin provides an adequate specificity and positivity rate in patients with unexplained syncope.

[Unstable angina in coronary intensive care units without hemodynamics: is admissible a strategy limiting the indications for coronarography?]. / Angina instabile in UTIC senza emodinamica: è ammissibile una strategia che limiti le indicazioni alla coronarografia?

In coronary care units (CCU) without cardiac catheterization facilities, coronary angiography is rarely carried out when a successful medical treatment in the acute phase of unstable angina has been obtained. However, the unstable angina still has an uncertain prognosis when the remission of pain is obtained with drugs. This study presents a follow-up of 147 consecutive patients (aged 66.8 +/- 10.4 years) admitted to our CCU in 1991 and 1992 for unstable angina; 33 of them (22.4%) were in Braunwald class I. 2 (1.4%) in class II and 112 (76.2%) in class III. The patients were treated according to the usual therapy protocols and class III patients received i.v. heparin. In selected cases we used thrombolysis (10 patients) and intra-aortic balloon pump (5 patients). During hospitalization 1 patient died (0.7%), 5 patients (3.4%) suffered an acute myocardial infarction and 9 patients (6.1%) had angina. Stabilization of unstable angina was achieved in 132 patients (89.9%): in 113 (76.8%) during the first 48 hours, and in 19 (12.9%) later. Coronary angiography was carried out in non-stabilized patients and in 46 (34.8%) of the 132 with successful treatment (Group I). Eighty-six patients, without indication to coronary angiography were discharged in medical therapy (Group II). During the follow-up (mean of 15.0 +/- 9.0 months) Group I 10 patients (18.2%) had cardiac events (death, myocardial infarction, or recurrent angina) vs 26 of Group II (p < 0.05). In Group I coronary angiography together with clinical criteria of high risk allowed the identification of candidates to coronary revascularization (61.8% of Group I patients while). These data show that the initial success of treatment during the acute phase of unstable angina should not be considered as a favourable prognostic index. Coronary angiography appears to be indicated for clinical evaluation and therapeutical decision.

[Verapamil poisoning for suicidal purposes. A case report]. / Avvelenamento da verapamile a scopo suicida. Descrizione di un caso.

We report the case of an 82-year-old woman who developed bradyarrhythmia with A-V dissociation and shock, followed by an acute pancreatitis, after ingestion of 2400 mg of verapamil per os for suicidal purposes. Despite her advanced age, the patient promptly improved by a conventional therapy even though started several hours after ingestion of the drug.

Asymmetric septal hypertrophy in uremic-normotensive patients on regular hemodialysis. An M-mode and two-dimensional echocardiographic study.

We have observed a high incidence (36.4%) of asymmetric septal hypertrophy (ASH), detected with the use of M-mode (MME) and two-dimensional echocardiography (2DE), in normotensive patients with chronic renal failure on maintenance hemodialysis without signs of cardiac diseases. ASH was detected by conventional MME in 11 cases and was confirmed with the use of 2DE in 8 cases showing a diagnostic concordance of 72.7% between the two methods. After dialysis the MME study of the left ventricular (LV) performance showed an evident impairment of cardiac index (CI) due to reduction of LV volume in addition to an abnormality of septal function. The presence of ASH does not impair the percentage of fractional shortening (FS%), the mean circumferential shortening (mean Vcf) and the ejection fraction (EF%), probably because of a compensatory performance of the LV posterior wall. Predialysis serum creatinine and fasting triglycerides have been found significantly higher in the group with ASH. ASH may be considered as a focal and early form of myocardial involvement in uremic patients on regular hemodialytic treatment.

[Relation between asymmetrical hypertrophy of the interventricular septum and plasma levels of catecholamines in normotensive chronic uremic patients undergoing hemodialysis treatment]. / Relazione tra ipertrofia asimmetrica del setto interventricolare e concentrazione plasmatica di catecolamine in pazienti uremici cronici normotesi in trattamento emodialitico.

Sympathetic-adrenergic activity has been evaluated in 23 chronic uremic, normotensive patients on regular hemodialysis, 7 of which (30.4%) with M-mode and bidimensional echocardiographic finding of asymmetric septal hypertrophy. The sympathetic function has been assessed by measuring arterial plasma norepinephrine and epinephrine levels before and after postural activation, just before and after dialysis. After dialysis, standing caused a significant increase of plasma norepinephrine levels in patients with asymmetric septal hypertrophy in comparison with patients without asymmetric septal hypertrophy and with the control non uremic group. Moreover, a significant decrease in blood pressure and a sharp heart rate increase were noted in the patients without asymmetric septal hypertrophy, whereas mean blood pressure and heart rate were unchanged in the patients with asymmetric septal hypertrophy. These results suggest that increased plasma norepinephrine concentration may have a role in the development of interventricular septal hypertrophy.

[Asymmetric hypertrophy of the intraventricular septum in normotensive patients with chronic uremia during hemodialysis therapy. M-mode echocardiographic study]. / Ipertrofia asimmetrica del setto interventricolare in pazienti uremici cronici normotesi in trattamento emodialitico. Studio ecocardiografico M-mode.

Cardiovascular complications are very common in uraemic patients on regular dialytic treatment and are often the cause of death. In these patients many echocardiographic studies have been carried out to establish the presence of cardiac alterations. In particular some M-mode echocardiographic investigating have shown a significant incidence of asymmetric septal hypertrophy (ASH), but often the patients had associated cardiomegaly or arterial hypertension. In the present paper M-mode echocardiogram and carotid pulse tracing were recorded after dialysis in 23 normotensive long-term hemodialyzed patients. The aim of the study was to detect the incidence of ASH and to assess the functional behaviour of the left ventricle in relation to the presence of the septal abnormality. ASH as ratio of interventricular septal to posterior wall thickness (IVS/PWT) of 1.3 or greater, without systolic anterior motion of anterior mitral leaflet (SAM), was found in 52.1% of patients. The group with ASH showed an obvious reduction of the cardiac index (CI), after dialysis, due to reduction of left ventricular size and to the abnormal septal function. CI was normal in patients without ASH. On the other hand the presence of ASH did not significantly influence the percentage of fractional shortening (FS%), the velocity of circumferential fiber shortening (Vcf) and the ejection fraction (EF%) which were similar in both groups of patients. A long-term echocardiographic follow-up of these patients may be important to outline the natural history of ASH and to evaluate its relation to chronic renal failure on hemodialytic treatment.