[Appropriateness in Cardiology: a statement of the ANMCO Veneto Region]. / L'appropriatezza prescrittiva in Cardiologia: documento dell'ANMCO Regione Veneto.

Inappropriate tests are responsible for longer waiting lists, higher economical costs for the National Health System and major clinical risks due to radiation exposure from prescription abuse of diagnostic testing. Clinical inappropriateness frequently derives from poor knowledge of guidelines, "defensive medicine" approach and/or repeat requests of patients and family members. About one third of non-invasive imaging tests are considered inappropriate.In order to define the most appropriate instruments for the follow-up of the most common cardiovascular diseases with the highest risk of inappropriateness, all the cardiologists of the Veneto Region (Italy), along with the local chapters of the main national cardiology societies and general practitioners have been involved by the Regional Section of the Italian Association of Hospital Cardiologists (ANMCO) in several scientific meetings on the following topics: hypertension, chronic ischemic heart disease, valvular heart disease, heart failure, and atrial fibrillation. This has led to the present document where: (i) the most appropriate clinical and diagnostic strategies are taken into account, and (ii) the most robust scientific evidence is provided for the regulatory commission of the Veneto Region Health Service to identify inappropriateness, prescription unsuitability, and economical sustainability.

Addition of Exercise to Dipyridamole Stress Echocardiography in Order to Carry on the Ischemic Cascade: Role in the Diagnosis of Coronary Artery Disease and Prognostic Value.

BACKGROUND: Sensitivity of dipyridamole stress echocardiography (SE) is often lower than required. The aim of the present work is the evaluation of the association of dipyridamole and exercise echocardiography. METHODS: From June 2007 to January 2011, 259 consecutive patients referred to Camposampiero Echocardiography Laboratory underwent SE. Stress protocol started with dipyridamole infusion of 0.84 mg/kg over 6 min. In patients without a new dyssynergy after dipyridamole, SE was carried on with supine exercise. If endocardial border detection was suboptimal, ultrasound contrast agent was used. Coronary angiography was performed in positive patients. The events recorded during the follow-up were cardiac death, nonfatal myocardial infarction (hard events), and coronary revascularization. RESULTS: Of 259 patients, 74 had a positive result: 37 were positive after infusion of dipyridamole, and 37 became positive during exercise. All 74 positive patients underwent coronary angiography: 67 had significant coronary artery disease (36 positive with dipyridamole, and 31 positive with exercise), and 7 had not significant artery disease. In positive patients, the coronary revascularizations were 40. Furthermore, 3 of the 185 negative patients underwent coronary revascularization. During follow-up of 20 ± 10 months, 6 (8.1%) hard events occurred in positive patients. No hard event was observed in negative patients. CONCLUSIONS: Dipyridamole SE with the addition of exercise can be proposed as a strategy to carry on the ischemic cascade and to identify the patients who elude the dipyridamole alone SE. A negative result is suggestive of a very good prognosis, free from hard events at 20 ± 10 months.

Sine-wave pattern on the electrocardiogram and hyperkalaemia.

Hyperkalaemia is an electrolyte disturbance that can have effects on myocardial conduction causing electrocardiographic changes. Several factors may predispose to and promote potassium serum level increase leading to typical electrocardiographic abnormalities. We describe the case of a patient who presented with hyperkalaemia and an electrocardiographic aspect consistent with a sine-wave pattern.

Transoesophageal echocardiographic evaluation of pulmonary vein anatomy in patients undergoing ostial radiofrequency catheter ablation for atrial fibrillation: a comparison with magnetic resonance angiography.

OBJECTIVE: A detailed definition of pulmonary vein (PV) anatomy is of great importance in patients undergoing radiofrequency catheter ablation for atrial fibrillation. In fact, it is known that variations in the number and anatomy of the PV ostia are more frequent than thought. The aim of this study was to assess the usefulness of transoesophageal echocardiography (TOE) in defining the exact PV anatomy by comparing it with magnetic resonance angiography (MRA), which is proven to be very accurate. METHODS: Forty-five consecutive patients (39 male, 6 female, mean age 50 + or - 6 years) affected by drug-refractory atrial fibrillation underwent radiofrequency catheter ablation. They were all studied with MRA and then with TOE in order to exclude intra-atrial thrombi and to assess PV anatomy. RESULTS: TOE visualised the superior PVs in 100% of cases and the right and left inferior PVs in 98% and 94% of cases, respectively. Only 19 patients (42%) showed typical PV anatomy, with two left and two right distinct PV ostia. In 14 patients (31%), one or two intermediate right PVs and in 12 patients (27%) a common left trunk were detected. The concordance with MRA was high (95%). CONCLUSIONS: TOE is accurate in assessing PV anatomy and in showing anatomic variations in the PV ostia compared with MRA. Anomalous pulmonary venous drainage is more frequent than expected. TOE can provide functional Doppler information, thus being particularly useful in the follow-up after radiofrequency catheter ablation.

Unusual tumor-like calcification of the mitral annulus: diagnosis and tissue characterization by ultrasound, computed tomography and magnetic resonance imaging.

Calcification of the mitral annulus is a common echocardiographic finding in the elderly, particularly in females. Calcium deposits are generally located in the posterior mitral ring, sometimes extending to the whole mitral annulus and involving the mitral valve apparatus. The present report refers to 2 patients with a very atypical mass-like calcification of the mitral annulus resembling a cardiac tumor. A detailed evaluation of the mass was obtained at transthoracic and transesophageal echocardiography; the differential diagnosis with other intracardiac masses was aided by the use of computed tomography and magnetic resonance imaging. To our knowledge there has been no prior report of such a lesion evaluated at cardiac magnetic resonance imaging.

Left ventricular diastolic function in pregnancy-induced hypertension.

BACKGROUND: Hypertension occurs in some 10% of pregnancies and its effects on the left ventricular (LV) morphology and systolic function have been well elucidated. Little is known, however, about the changes in LV diastolic function in such a condition. The aim of this study was to evaluate the LV diastolic function in women with pregnancy-induced hypertension (PIH) using new Doppler echocardiographic methods. METHODS: Twenty-two women with PIH (mean age 31.0 +/- 4.1 years) were examined during the third trimester of pregnancy. Other 15 normotensive pregnant women (mean age 31.8 +/- 5.7 years, p = NS) were used as controls. Doppler parameters of diastolic function included: mitral inflow variables, pulmonary venous flow (PVF) variables, M-mode color Doppler of LV inflow and pulsed tissue Doppler of the mitral annulus. Furthermore, patients underwent an echocardiographic evaluation immediately after delivery and 1 month later. RESULTS: PIH women showed an increased E/A ratio and an increase in the diastolic forward components of PVF. The ratio of systolic to diastolic time-velocity integral and the systolic fraction of time-velocity integrals subsequently decreased. Women with PIH also presented a significantly increased velocity of reversal PVF at atrial contraction, a decrease in the ratio between mitral and PVF duration at atrial contraction and a slower flow propagation velocity with M-mode color Doppler. LV wall thickness and mass were significantly higher in hypertensive pregnant women. In women with PIH the abnormal PVF parameters became similar to those of controls immediately after delivery, while the E/A ratio, M-mode flow propagation velocity and LV mass did so after 1 month. CONCLUSIONS: Hypertension complicating pregnancy significantly affects ventricular diastolic filling. These alterations chiefly involve PVF, mitral inflow and intraventricular flow propagation velocities. The LV systolic function is preserved, in the presence of a transient LV remodeling.

Dynamic Left Ventricular Outflow Tract Obstruction During Myocardial Ischemia in Mitral Valve Prolapse Syndrome.

Systolic anterior motion of the mitral valve (MV) with dynamic left ventricular (LV) outflow tract obstruction is a well known phenomenon in hypertrophic cardiomyopathy, or other forms of hyperdynamic LV function associated with hypovolemic states, or LV hypertrophy. We report three patients with MV prolapse in the absence of the above predisposing factors, who developed an LV outflow dynamic gradient during acute transient myocardial ischemia. An interaction between structural abnormalities of the mitral apparatus and ischemia-dependent LV shape deformity most likely accounted for the outflow gradient.