Feasibility of simultaneous Tc99m sestamibi and 2D-echo cardiac imaging during dobutamine pharmacologic stress. Preliminary results in a female population.

Feasibility of simultaneous 2D-Echo and SPECT Tc99m Sestamibi imaging during dobutamine infusion was evaluated in a female population with suspected coronary artery disease and scheduled for diagnostic coronary angiography. A total of 49 consecutive subjects were studied. Patients under continuous ECG and 2D-Echo monitoring underwent standard dobutamine infusion at increasing doses to a diagnostic end-point. Tc99m Sestamibi was administered at the peak of the dobutamine effect. With this approach, 35 patients were identified correctly by 2D-Echo (Sensitivity = 60.1%; Specificity = 83.3%; Agreement = 71.4%; k = 0.43). Perfusion imaging with Tc99m Sestamibi resulted in correctly identifying 41 patients (Sensitivity = 83%; Specificity = 84%; Agreement = 83.6%; k = 0.67). Combining information obtained from the two tests resulted in increased specificity (92%) and decreased sensitivity (64%). Simultaneous assessment of perfusion and function with Tc99m Sestamibi and 2D-Echo imaging during dobutamine administration is easily performed without added risk or discomfort to the patient. Tc99m Sestamibi appeared to be slightly superior to 2D-Echo for the detection of CAD in this population, but the difference does not reach conventional statistical significance. The combined use of the two independent tests did not substantially improve the diagnostic accuracy of each method.

[Standardization of the methods of lipid determination according to WHO in the regional project of prevention of cardiovascular diseases in Friuli-Venezia Giulia]. / La standardizzazione dei metodi per la determinazione dei lipidi secondo l'OMS, nel progetto regionale di prevenzione delle malattie cardiovascolari del Friuli-Venezia Giulia.

BACKGROUND: The recognition of dyslipidemias as a major modifiable risk factor for atherosclerosis and coronary heart disease underlines the need to obtain precise and accurate assay results of plasma lipids. Today the use of automatic laboratory methods and of internal quality control favours the precision of the results but does not guarantee accuracy. The efficiency of a laboratory can be ensured by a standardization programme, systematically monitoring precision and accuracy by means of independent internal and external quality control, international reference standards (e.g. those of CDC-NHLBI and WHO) and protocols to identify and reduce the errors due to biological variability and pre-analytical factors. After the foundation of the Regional Project for Prevention of Cardiovascular Diseases in Friuli-Venezia Giulia, a lipid standardization programme was set-up, covering the 20 chemico-clinical laboratories of the Region. The programme was directed by the International WHO-MONICA-Lipid Reference Centres of Prague-Udine. METHODS: During the years 1993-1994, three sets of lyophilized human serum samples were dispatched to each laboratory for the blind evaluation of total cholesterol, triglycerides and HDL-cholesterol. The samples were obtained by the combination of three serum pools at least at different lipid concentration. The first set included 20 samples to be tested in 5 weeks, the second set included 30 samples to be tested in 8 weeks and the third set included 21 samples to be tested in 9 weeks. The assay results were sent to the Prague-Udine WHO-MONICA Centres where they were computerized and evaluated, particularly considering precision for each set, estimated by the variation coefficient (i.e. standard deviation/mean value of the measurements per cent) and accuracy (the bias was computed as mean of the measurement minus the reference value/reference value per cent). RESULTS: In the three assay series for total cholesterol, almost all the laboratories showed the variation co-efficient (precision) to be less than the WHO-MONICA limit of 3.7% (for a cholesterol level of 250 mg) (Tab. II) and in 8 cases out of 20, less than the CDC limit of 3%; the accuracy bias was less than the WHO-MONICA limit of 5% in 17 laboratories out of 20 and less than the CDC limit of 3% in 11 cases out of 20. For the HDL-cholesterol standardization programme the reference values were based upon the phosphotungstate method. However, the pools were also controlled by the other precipitation methods used in the 20 participating laboratories: 11 laboratories worked within the WHO-MONICA limits of precision and accuracy (respectively 6.5% and 7.5%) in at least two of the three sets. Concerning triglycerides, the regional laboratories showed a greater variability and, though most of the variation coefficients were within the WHO-MONICA limit of 5%, half of the accuracy biases were greater than the limit of 10%. The bias of the measurement average of all the laboratories was excellent for total and HDL-cholesterol, not quite good but acceptable for triglycerides. Laboratory performance improved progressively from the first to the last set, on more than one occasion. CONCLUSIONS: The lipid standardization experience carried out in the framework of the Regional Project for Prevention of Cardiovascular Disease demonstrates that it is possible to set up a wide and co-ordinated collaboration with laboratories of an entire region with positive and improving results. For this global quality control system, the resource allocated is limited but widely rewarded by the community benefits in terms of assay reliability and savings at medical care level, basic research and population studies.

Longitudinal evaluation of prostate-specific antigen levels in a case-control study.

BACKGROUND: Over the last period--late 1970 to early 1990--the incidence of prostate carcinoma has nearly doubled, even though many more patients die with prostate cancer rather than of it. This finding, together with the slow growth of this tumor and the absence of a controlled trial, makes early diagnosis for this pathology quite questionable. On the other hand, it is well known that prostatic carcinoma is curable as long as it is intracapsular and that there is an ever increasing encouragement for early detection in all diseases. Since prostatic pathology increases its incidence as age advances, the first step in early diagnosis is to be able to discriminate between healthy, benign prostatic hyperplasia and cancer cases with a well-accepted and easily understandable method. The problem is to find the best method to do it. METHODS: We measured serum prostate-specific antigen (PSA) levels in 435 men participating in an epidemiological study, at first in 1987 and again in 1992. Men with PSA levels above 4 ng/ml (in 1992) were invited to undergo other diagnostic tests (digital rectal examination, transrectal ultrasonography, biopsy) in sequence on the basis of the results of the previous tests. The pathological findings from biopsies were the reference test to determine the presence or absence of prostate cancer (2.5% of the population). RESULTS: We divided PSA concentrations into three categories, according to the most used cutoffs ( < 4, 4-10, > 10 ng/ml); in the meantime, we took into account the change rate in PSA concentration in time, defined as delta PSA. By the comparison between PSA categories and delta PSA, we found out that the first one does not discriminate between benign and malignant pathologies, while the use of delta PSA strongly discriminates them (p < 0.001). CONCLUSION: On the basis of our results, we think that delta PSA might be the best parameter to indicate the presence of prostate cancer cases in an asymptomatic population.

Signal-averaged electrocardiography and Doppler echocardiographic study in predicting acute rejection in heart transplantation.

BACKGROUND AND METHODS: In a prospective protocol for noninvasive diagnosis of acute cardiac rejection, 83 routine endomyocardial biopsies, followed each time by the analysis of signal-averaged electrocardiography and by a cardiac Doppler echocardiographic study, were performed in 18 heart transplant recipients. The follow-up time was 5 +/- 3.6 months. To detect noninvasively acute cardiac rejection, we compared biopsy findings with the presence of late potentials at signal-averaged electrocardiography and with two diastolic indexes, pressure half-time, and isovolumic relaxation time obtained from Doppler echocardiographic study. RESULTS: Thirteen acute rejection crises requiring modification of immunosuppression were diagnosed by means of endomyocardial biopsy. This clinically relevant acute cardiac rejection was associated with the presence of late potentials in 69% of cases and with the presence of pressure half-time < or = 55 msec and isovolumic relaxation time < or = 60 msec in 69% and 62% of cases, respectively. Sensitivity and specificity were as follows: for late potentials, 69% and 71%; for pressure half-time < or = 55 msec, 69% and 76%; for isovolumic relaxation time < or = 60 msec, 62% and 83%, respectively. The presence in a single patient of at least one abnormal parameter showed a sensitivity of 100% and a specificity of 60% in detecting important rejection. CONCLUSIONS: These data support the use of combined signal-averaged electrocardiography and Doppler echocardiographic study of the left ventricular diastolic function in the screening of acute cardiac rejection. Such results can suggest when endomyocardial biopsy should be performed, with the reliance that a normal noninvasive study highly excludes the presence of acute cardiac rejection requiring intensified immunosuppression.

[Percutaneous closure of congenital and iatrogenic coronary arterial fistulas]. / La chiusura percutanea delle fistole arteriose coronariche congenite e iatrogene.

Coronary arteriovenous fistulas (CAF) are the most common hemodinamically significant congenital coronary anomalies. Surgery has been the only therapeutic option for ages. We describe three cases of percutaneous occlusion of CAF, congenital and iatrogenic, that we treated with different devices, to fit their different anatomic and functional characteristics. Case 1). Male patient (pt) 20 years old, asymptomatic, affected with CAF between the right coronary artery and the right ventricle, with aneurysmatic vessel dilatation and occlusion of the posterolateral branches. CAF has been occluded with a detachable, valvulated latex balloon, wedged into the proximal neck of the aneurysm. Case 2). Female pt 63 years old, who was symptomatic for exertion angina, affected with multiple CAF which originated from proximal and distal circumflex artery, proximal left anterior descending artery (LAD), all of which flowed into the left inferior lobar pulmonary artery. The fistulas have been occluded with steel and tungsten coils. Case 3). Male pt 62 years old, who underwent orthotopic cardiac transplantation in 1990 for dilated cardiomyopathy. Coronary angiogram at one year was normal, but subsequently a multilocular CAF between LAD in the middle portion and the right ventricle became evident. During angiographic follow-up an increase of the size of the fistula was observed, together with a reduction of that of distal LAD. For this reason a percutaneous occlusion with multiple tungsten coil has been performed. The three procedures have had a favorable outcome and we did not observe any acute or late complications; clinical and angiographic follow-up confirmed this satisfactory results at six months. Based on the data of the literature and on this experience, we conclude that percutaneous occlusion is the first line therapy of CAF and that the different devices can be tailored to meet different anatomic and functional characteristics.

[Transesophageal and epicardial echocardiography in the evaluation of conservative surgery of the mitral valve. Complementary methods?]. / L'ecocardiografia transesofagea ed epicardica nella valutazione della chirurgia conservativa della valvola mitrale. Metodiche complementari?

BACKGROUND: Over the last two decades several new surgical methods for repairing a regurgitant mitral valve have been proposed. Unfortunately, early applications of such techniques were not always encouraging because the evaluation in the operating room led to false optimism due to a marked difference between static and functional anatomy of the repaired valve. By means of intraoperative echocardiography, be it transesophageal or epicardial, it is now possible to assess the functional result immediately after valvuloplasty and to decide about further surgery, right at the operating table. MATERIALS AND METHODS: Thirty-six patients (mean age 61.8 years) who underwent mitral valve repair were studied; all underwent preoperative transthoracic echocardiography in the week preceding surgery, and intraoperative transesophageal echo before cardiopulmonary bypass. The surgical results were evaluated by epicardial and/or transesophageal echocardiography in the operating room, and by transthoracic and/or transesophageal approach during follow-up. RESULTS: In 5 patients with intraoperative echocardiography done before valve repair, leaflets pathology and subvalvular apparatus were better evaluated. Besides, in 3 patients the more evident calcification of the leaflets led the surgeon to decide on direct replacement rather the reconstruction of the valve. The postoperative assessment has shown an unsatisfactory correction in 8 patients (24%). In 4 of these patients an important mitral regurgitation was reported and in 2 there was a moderate regurgitation. In the last 2, a iatrogenic stenosis had resulted. Of these 8 patients, 6 underwent valve replacement using an artificial valve. The other 2 patients (one with moderate stenosis and the other with moderate regurgitation) did not undergo a second operation because of the excessive operating time taken for valvuloplasty and the advanced age of the patients. During follow-up, from 6 to 54 months, a remarkable mitral regurgitation was present in 4 patients, one being severe and the other moderate. A persistence of ventricular dilatation was present only in these patients, while in the remainder the left ventricular diameters were normal. Finally, the mitral valve area after six months was between 1.5 an d4 cm2. CONCLUSIONS: Intraoperative echocardiography, both transesophageal and epicardial, can help the surgeon by giving him useful diagnostic information, if carried out before reconstructing the mitral valve with regurgitation. Its application is even more useful if applied straight after the surgical intervention. Unsatisfactory results may be evidenced at once and the operating team will decide right at the table for further repair or replacement, thus avoiding a second operation and the relevant risks.

[The usefulness of transesophageal echocardiography in the follow-up of patients operated on for replacement of the ascending aorta with a tubular-valvular prosthesis (Cabrol's intervention)]. / Utilità dell'ecocardiografia transesofagea nel follow-up dei pazienti operati di sostituzione dell'aorta ascendente con protesi tubulo-valvolata (intervento di Cabrol).

OBJECTIVES: The usefulness of transesophageal echocardiography (TEE) in assessing the postoperative results of aortic root replacement (Cabrol's procedure) was evaluated. METHODS: Between 1986 and 1993, 31 patients underwent replacement of the aortic valve and ascending aorta by a composite graft using the Cabrol procedure. Twenty-six patients had annuloaortic ectasia, two type I DeBakey dissection and four type II dissection. Hospital mortality was 9.7%. Studies were performed in 18 patients, two to 70 months (mean 27.5 months) after composite graft replacement. The following features were examined: prosthetic aortic valve function, coronary graft morphology and function, tubular graft and aneurysm wrapped around morphology and dimensions, presence of intimal flap, false lumen and thrombus in the false lumen and persistence of right atrial fistula. RESULTS: Periprosthetic leakage with significant regurgitation was detected by TEE in 3 (16.6%) of 18 patients. In one patient with infected aortic graft a fistula between the periprosthetic space and the right ventricle was detected (confirmed at reoperation). In another patient occlusion of the graft for left coronary artery was noted. In three patients (16.6%) an aneurysm of the periprosthetic space with perivalvular leakage and persistence of the fistula with the right atrium was visualized. In the two patients operated for DeBakey type I dissection an intimal flap persisted distal to the graft and in one patient flow was detected in the false lumen, while it was totally obliterated in the other. CONCLUSIONS: 1) Complications after Cabrol's procedure are not infrequent; although the real importance of some of them (periprosthetic aneurysm, persistence of dissection) is uncertain, a careful follow-up may be essential to improve the long term survival. 2) TEE is a useful and well-tolerated procedure for postoperative follow-up of patients who underwent aortic root replacement with Cabrol's procedure.

The cellular basis of dilated cardiomyopathy in humans.

The present investigation was designed to evaluate whether end-stage cardiac failure in patients affected by dilated cardiomyopathy (DC) was dependent upon extensive myocyte cell death with reduction in muscle mass or was the consequence of collagen accumulation in the myocardium independently from myocyte cell loss. In addition, the mechanisms of ventricular dilation were analysed in order to determine whether the changes in cardiac anatomy were important variables in the development of intractable congestive heart failure. DC is characterized by chamber dilation, myocardial scarring and myocyte hypertrophy in the absence of significant coronary atherosclerosis. However, the relative contribution of each of these factors to the remodeling of the ventricle is currently unknown. Moreover, no information is available concerning the potential etiology of collagen deposition in the myocardium and the changes in number and size of ventricular myocytes with this disease. Morphometric methodologies were applied to the analysis of 10 DC hearts obtained from patients undergoing cardiac transplantation. An identical number of control hearts was collected from individuals who died from causes other than cardiovascular diseases. DC produced a 2.2-fold and 4.2-fold increase in left ventricular weight and chamber volume resulting in a 48% reduction in mass-to-volume ratio. In the right ventricle, tissue weight and chamber size were both nearly doubled. Left ventricular dilation was the result of a 59% lengthening of myocytes and a 20% increase in the transverse circumference due to slippage of myocytes within the wall. Myocardial scarring represented by segmental, replacement and interstitial fibrosis occupied approximately 20% of each ventricle, and was indicative of extensive myocyte cell loss. However, myocyte number was not reduced and average cell volume increased 2-fold in both ventricles. In conclusion, reactive growth processes in myocytes and architectural rearrangement of the muscle compartment of the myocardium appear to be the major determinants of ventricular remodeling and the occurrence of cardiac failure in DC.

Structural basis of end-stage failure in ischemic cardiomyopathy in humans.

BACKGROUND: Ischemic cardiomyopathy is characterized by myocyte loss, reactive cellular hypertrophy, and ventricular scarring. However, the relative contribution of these tissue and cellular processes to late failure remains to be determined. METHODS AND RESULTS: Ten hearts were obtained from individuals undergoing cardiac transplantation as a result of chronic coronary artery disease in its terminal stage. An identical number of control hearts were collected at autopsy from patients who died from causes other than cardiovascular disease, and morphometric methodologies were applied to the analysis of the left and right ventricular myocardium. Left ventricular hypertrophy evaluated as a change in organ weight, aggregate myocyte mass, and myocyte cell volume per nucleus showed increases of 85%, 47%, and 103%, respectively. Corresponding increases in the right ventricle were 75%, 74%, and 112%. Myocyte loss, which accounted for 28% and 30% in the left and right ventricles, was responsible for the difference in the assessment of myocyte hypertrophy at the ventricular, tissue, and cellular levels. Left ventricular muscle cell hypertrophy was accomplished through a 16% and 51% increase in myocyte diameter and length, whereas right ventricular myocyte hypertrophy was the consequence of a 13% and 67% increase in these linear dimensions, respectively. Moreover, a 36% reduction in the number of myocytes included in the thickness of the left ventricular wall was found. Collagen accumulation in the form of segmental, replacement, and interstitial fibrosis comprised an average 28% and 13% of the left and right ventricular myocardia, respectively. The combination of cell loss and myocardial fibrosis, myocyte lengthening, and mural slippage of cells resulted in 4.6-fold expansion of left ventricular cavitary volume and a 56% reduction in the ventricular mass-to-chamber volume ratio. CONCLUSIONS: These results are consistent with the contention that both myocyte and collagen compartments participate in the development of decompensated eccentric ventricular hypertrophy in the cardiomyopathic heart of ischemic origin.

[Recurrent ventricular fibrillation, right bundle-branch block and persistent ST segment elevation in V1-V3: a new arrhythmia syndrome? A clinical case report]. / Fibrillazione ventricolare recidivante, blocco di branca destra, persistente sopraslivellamento del tratto ST in V1-V3: una nuova sindrome aritmica? Descrizione di un caso clinico.

In this report we describe a patient with a rare arrhythmic syndrome, recently reported and characterized by aborted sudden death, right bundle branch block and persistent ST segment elevation in precordial leads. The patient is a 65-year-old man, who had survived recurrent episodes of ventricular fibrillation (VF). The ECG during sinus rhythm revealed the coexistence of right bundle branch block and persistent ST segment elevation (1-4 mm) in leads V1-V3. The clinical and laboratory investigations, including echocardiography, cardiac catheterization and right endomyocardial biopsy, could not identify any significant morphological and functional cardiac abnormalities. The presence of late potentials (high gain ECG), and the inducibility of VF during the electrophysiological study, suggest a functional reentry as arrhythmogenic substratum. During a 60-month follow-up period, high-dose amiodarone per os, and subsequent AICD therapy successfully treated recurrent VF episodes. This clinical case confirms the existence of a new idiopathic malignant arrhythmic syndrome. Aggressive antiarrhythmic therapy seems fundamental in this type of patients.

Risk stratification and prognosis of patients treated with amiodarone for malignant ventricular tachyarrhythmias after myocardial infarction.

Seventy-seven consecutive patients (mean age 62 years) with episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) after acute myocardial infarction (AMI) were evaluated to assess the long-term efficacy of first-line amiodarone treatment and to identify clinical and laboratory factors associated with a high risk of death or arrhythmia recurrence. The presenting arrhythmia was VT in 41 cases (53%) and VF in 36 (47%). VT or VF occurred between the 4th and 90th day after AMI in 45 cases (58%) and later (more than 90 days) in the remaining 32 (42%). The mean number of arrhythmic episodes was 4.2. Forty patients (52%) were in New York Heart Association (NYHA) class I or II, and 37 (48%) were in class III or IV. Mean left ventricular ejection fraction was 32%; ventricular aneurysm was present in 41 subjects. Most patients had multivessel coronary artery disease. Amiodarone was administered as a first-choice drug in all patients, in combination with other antiarrhythmic drugs in 14. By ventricular stimulation after loading doses of amiodarone, sustained VT was inducible in 46 (62%) and noninducible in 28 (38%). During a mean follow-up of 28 months the incidence of cardiac mortality at 1, 3, and 5 years was 21%, 37%, and 47%; of sudden death was 7%, 19%, and 23%; of nonfatal VT recurrence was 13%, 13%, and 24%, respectively. The overall incidence of amiodarone side effects was 35%.2+ was a weak predictor only by univariate analysis (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and determinants of carotid atherosclerosis in a general population.

BACKGROUND AND PURPOSE: The aim of this study was to assess the prevalence of asymptomatic carotid atherosclerotic lesions and their relation to principal risk factors. The importance of the relation between asymptomatic carotid atherosclerotic lesions, stroke, and coronary atherosclerosis has been widely discussed, but there are few transversal and longitudinal studies on a general population. METHODS: A noninvasive examination was carried out using high-resolution B-mode ultrasonography, which has been shown to be a reliable tool for epidemiological studies. We examined 630 men and 718 women aged 18-99 years (participation rate, 74.9%). RESULTS: The global prevalence of carotid atherosclerosis was 25.4% in men and 26.4% in women. Intimal-medial thickening was found in 9.4% of men and 11.7% of women. Plaque prevalence was 13.3% in men and 13.4% in women; prevalence of stenotic plaques was 2.7% and 1.5%, respectively. Subjects aged < or = 39 years showed a very low prevalence of any asymptomatic carotid atherosclerotic lesions. In the multiple logistic regression, the analysis of subjects aged > or = 40 years showed a positive significant association between the severity of carotid atherosclerotic lesions (plaques and stenosis) and age (p < 0.001), systolic blood pressure (p < 0.01), cigarette smoking (p < 0.0001), and the protective effect of high density lipoprotein cholesterol (p < 0.037). This analysis did not provide evidence of a clear-cut association between risk factors and intimal-medial thickening. CONCLUSIONS: This population study shows the high prevalence of asymptomatic carotid atherosclerotic lesions in a general population (approximately 25% of adults) and its relation with the classic risk factors. It emphasizes the value of ultrasonography in the detection of early atherosclerotic lesions.

[Paroxysmal atrial arrhythmias in arrhythmogenic cardiomyopathy of the right ventricle with a familial character: the role of right atrial involvement]. / Aritmie atriali parossistiche in cardiomiopatia aritmogena del ventricolo destro a carattere familiare: ruolo dell'interessamento dell'atrio destro.

Arrhythmogenic right ventricular cardiomyopathy presents a rather frequent familial occurrence. In the present study the cases of two brothers (25 and 30 years old, respectively) presenting with the peculiar finding of early involvement of right atrium, are described. Both subjects were investigated because of recurrent complex arrhythmias, including supraventricular (sustained atrial flutter, atrial tachycardia) and ventricular tachyarrhythmias (very frequent premature beats, nonsustained ventricular tachycardia). The associated echo-angiographic aspects of the right atrium and right ventricle were those typically described in arrhythmogenic right ventricular cardiomyopathy. The familial occurrence of simultaneous right atrial and ventricular involvement, to the best of our knowledge not previously described, can likely be due to the similar phenotypic expression of the same genotype. The prognostic significance of atrial involvement in right ventricular arrhythmogenic dysplasia is still to be defined and the clinical follow-up of these two cases may contribute to it.

Role of family history in patients with myocardial infarction. An Italian case-control study. GISSI-EFRIM Investigators.

BACKGROUND: A family history of heart disease has been reported to increase the risk of coronary heart disease. We examined the relation between family history of myocardial infarction (MI) and risk of acute MI to establish the independency of this association, the degree of risk in relation to the number and age of relatives affected, and the possible interaction between family history and other major risk factors for MI. METHODS AND RESULTS: In a case-control study conducted in Italy within the framework of the GISSI-2 Trial, 916 cases of newly diagnosed MI and 1,106 hospital controls were identified. Using a structured questionnaire, data were collected on the history of MI in first-degree relatives and the age at which the event occurred. Compared with subjects without family history of MI in first-degree relatives, the relative risk (RR) of MI was 2.0 (95% confidence interval, CI, 1.6-2.5) in those with one and 3.0 (95% CI, 2.0-4.4) in those with two or more relatives affected (chi 2(1) test for trend, 54.1; p less than 0.001). Such an increase was not substantially affected by allowance for recognized risk factors. The risk related to family history involving at least two relatives was higher for early MI (less than 55 years) (RR, 20.0; 95% CI, 3.3-121.2) compared with later MI (less than or equal to 65 years) (RR, 3.5; 95% CI, 1.8-6.6). When known risk factors were considered for their interaction with family history, the effect on RR was approximately multiplicative for several variables, including smoking, serum cholesterol, hypertension, and hyperlipidemia but not for diabetes and body mass index. Thus, the presence of both family history and smoking and cholesterol levels greater than or equal to 226 mg/dl led to an RR of 14 (95% CI, 3.7-50.0) and 8.3 (95% CI, 1.8-38.7), respectively. CONCLUSIONS: This study indicates that a family history of MI is an independent risk factor for MI, and that the number of relatives and the age at which they were affected is related to the strength of the association. There is a multiplicative effect on RR between family history and several major risk factors for MI.

Transient myocardial ischemia during daily life in rest and exertional angina pectoris and comparison of effectiveness of metoprolol versus nifedipine.

The clinical characteristics of 65 patients with mixed angina were classified by means of (1) a questionnaire investigating the proportion of symptoms occurring at rest and on effort, (2) an exercise stress test, (3) 24-hour ambulatory Holter monitoring, and (4) coronary arteriography. According to the questionnaire, the proportion of effort-induced anginal episodes ranged from 1 to 99%. The ischemic threshold during exercise testing ranged from 110 x 10(2) to 350 x 10(2) mm Hg x beats/min. At least 1 episode of ST-segment depression was observed in 29 of the 65 patients during Holter monitoring. Ischemic episodes during Holter monitoring were more frequent (p less than 0.05) in patients reporting greater than or equal to 50% of anginal attacks on effort, with moderate to severe limitation of exercise capacity and with multivessel coronary artery disease. The effect on ambulatory ischemia of a 6-week treatment with a beta blocker (metoprolol CR, 200 mg once daily) or a dihydropyridine calcium antagonist (nifedipine retard 20 mg twice daily) were then compared according to a double-blind, parallel group design. Metoprolol significantly reduced the number and duration of the ischemic episodes during daily life (p less than 0.05) irrespective of the patients' clinical characteristics. Nifedipine was ineffective, particularly in patients with angina predominantly on effort and with a moderate to severe reduction in exercise tolerance. It is concluded that in patients with mixed angina, ischemic episodes during daily life are more likely to occur in patients with a clinical presentation suggesting poor coronary reserve.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous aortic valvuloplasty in adults: prediction of the immediate result and current indications]. / La valvuloplastica aortica percutanea nell'adulto: predittività del risultato immediato ed attuali indicazioni.

Here we present a series of 45 patients (21 M and 24 F) between the ages of 36 and 91 (average age: 71 +/- 8), who underwent Percutaneous Aortic Valvuloplasty (PAV) between Oct. 1986 and Dec. 1989. We used the traditional retrograde technique with balloon catheters sized 20 or 23 mm, with the exception of the first stage in which the kissing balloon technique was used in 7 cases. The calculated mean increase in aortic valve area (AVA) was 55.6 +/- 38% (from 0.49 +/- 0.11 cm2 to 0.74 +/- 0.07 cm2) and the peak gradient was reduced from 83 +/- 16 to 41 +/- 13 mmHg. We could observe only two relevant complications, i.e., two pulsating femoral artery haematomas at the site of catheter insertion. This artery underwent elective surgical resection two weeks after PAV. The dishomogeneity of the survey, due not only to the complexity of the valvular stenosis functional anatomy, but also to the changes in the PAV indications observed during the three-year period, led us to appraise our results by using a score based on the following features: valvular calcification degree (0-2); commissural fusion extent (0-4); bicuspid of tricuspid valve (0-2); and predilatation valve area less than 0.5 or greater than or equal to 0.5 cm2. In this way we were able to identify two groups of patients, one having a score of less than or equal to 6 (group I, 25 patients) and the other having a score of greater than or equal to 8 (group II, 20 patients). Mean AVA increase was 29% in group I and 84% in group II. At 24 +/- 6 months clinical follow-up, a significant discrepancy was maintained; the two groups showed a 5% and a 37.5% improvement, respectively. The score we suggest seems to single out cases with a high likelihood of success, i.e. the achievement of an AVA higher than 0.9 cm2. This seems to be helpful for a better selection of patients. Using this score as the basis for such an immediate result predictability, we believe that PAV could be advisable in the following cases: a) palliation for elderly patients (greater than 80 years) or patients with contraindications for valve replacement; b) as a bridge to surgical intervention; c) emergency procedures such as bailout valvuloplasty; d) diagnostic clarification in the most complex cases where a severe reduction in ventricular function and cardiac output, together with a low transvalvular gradient are present.

[Isolated chronic complete occlusion of the common trunk of the left coronary artery. Description of a case with preserved function of the left ventricle]. / Occlusione completa, cronica, isolata del tronco comune della coronaria sinistra. Descrizione di un caso con funzionalità ventricolare sinistra conservata.

We report the case of a patient with isolated occlusion of the left main and normal left ventricular function. The presenting symptom was effort angina. Three major coronary risk factors were present: family history of CAD, cigarette smoking and type IIB hyperlipoproteinemia. Coronary angiography showed a right dominance and an effective collateral circulation to the left anterior descending and circumflex arteries. Surgical revascularization was considered the first choice treatment. We reviewed the most important literature on this topic and we concentrated especially on collateral circulation. We maintain it plays a role not only in preserving left ventricular function but also in precipitating left main occlusion by means of a flow competition mechanism.

[Malignant ventricular arrhythmias in the subacute and late phases of myocardial infarction. Clinical arrhythmological characteristics and prognostic value]. / Contributo allo studio delle aritmie ventricolari maligne nella fase subacuta e tardiva dell'infarto miocardico. Caratteristiche clinico-aritmologiche e significato prognostico.

The purposes of this study are as follows: 1) to describe the clinical and arrhythmological characteristics of 30 patients (23 male, 7 female, mean age: 61 years) who suffered from episodes of ventricular tachycardia and/or ventricular fibrillation between the 7th and the 90th day following acute myocardial infarction; 2) to evaluate the effectiveness of treatment with amiodarone also taking into account the results of electrophysiologic study; 3) to correlate our results with data from previous studies. The site of the acute myocardial infarction was anterior in 16 patients, inferior in 12, and anterior and inferior in 2. Twenty patients had early post-acute myocardial infarction complications (67%) such as cardiac failure (16), bundle branch blocks (9) and ventricular fibrillation in the first 48 hours (6). The mean ejection fraction was 33 +/- 8% and a left ventricular aneurysmatic evolution was observed in 13 patients (43%). The first episodes of spontaneous ventricular arrhythmias occurred after a mean interval of 32 +/- 24 days following acute myocardial infarction. These occurred in the form of ventricular fibrillation in 19 patients (63%) and of ventricular tachycardia in the other 11 (37%). The patients experienced 5.6 +/- 5 episodes of ventricular fibrillation or ventricular tachycardia. Of the 30 patients, 28 received amiodarone, 1 procainamide and 1 propafenone. Five of the 28 patients treated with amiodarone were also given either procainamide or propafenone due to the early recurrence of ventricular tachycardia or fibrillation. One patient underwent early left ventricular aneurysmatic resection due to refractory ventricular fibrillation. Two groups of patients were distinguished on the basis of the electrophysiologic study results obtained during anti-arrhythmic treatment: group A consisted of 17 cases in which a sustained ventricular tachycardia was inducible (57%), group B consisted of 13 cases in which a sustained ventricular tachycardia was not inducible (43%). During a mean follow-up period of 31.6 +/- 26 months the total mortality rate was 23% in group A and 46% in group B (p = ns), the incidence of sudden death was 17% in group A and 23% in group B (p = ns), the incidence of non fatal ventricular tachycardia or ventricular fibrillation recurrences was 24% in group A and 0% in group B (0.05 less than p less than 0.1). One group A patient successfully underwent a heart transplant. The negative predictive value of ventricular stimulation in relation to sudden death and to non-fatal arrhythmic recurrences was 77% and 100%; the positive predictive value was 17 and 28%.(ABSTRACT TRUNCATED AT 400 WORDS)