Left main coronary artery disease. Clinical and angiographic features. A retrospective study regarding two groups of patients with left main coronary artery disease and three-vessel disease.

BACKGROUND: The aim of this study was to assess the ability of clinical and instrumental features to identify patients with left main coronary artery disease (LMCD) compared with a three-vessel coronary artery disease group. METHODS: A cohort of 70 patients with LMCD was matched with another one of 66 patients with three-vessel disease. A history of angina before angiography was similar in both groups; the higher degrees of stable angina and the forms of unstable angina were moderately prevalent in the group with LMCD. RESULTS: In the last subgroup a significantly reduced incidence of previous acute myocardial infarction (AMI) was observed (p < 0.05). The resting electrocardiogram (ECG) showed higher incidence of atrial fibrillation (fa) and left bundle branch block (BBS) in the subjects with LMCD, with a statistic value (p < 0.05). The exercise test performed by a lot of patients appeared equally positive for inducible ischemia in the 2 groups. Significantly higher exercise peak load was achieved by the patients with three-vessel disease (p < 0.05). The coronary angiography showed a prevalence of right dominant circulation in the 2 groups; significantly the collateral circulation was more represented in the subjects with three-vessel disease (p < 0.05). Most patients with LMCD underwent a bypass coronary artery graft surgery (CABG surgery) more frequently than the ones with three-vessel disease (p < 0.01). In the former group the cardiovascular mortality within an average 2-year follow-up proved higher as to the latter group even if without statistic significance. CONCLUSIONS: Nevertheless this retrospective study showed some limitations. Particularly the incidence of clinical and instrumental variables and their capacity to differentiate LMCD patients from those with three-vessel disease were not demonstrated.

[Non-invasive evaluation of coronary reperfusion. Analysis of the ST segment before and after thrombolysis in acute myocardial infarct]. / Valutazione non invasiva della riperfusione coronarica. Analisi del tratto ST prima e dopo trombolisi durante infarto miocardico acuto.

BACKGROUND: The aim of this study was to determine the role of the ST segment elevation resolution > 50% between the ECG before and 2 hours after thrombolytic therapy as a predictor of acute myocardial infarction (AMI)-related artery patency, assessed by a coronary angiography performed 1 month after AMI. MATERIALS AND METHODS: This study enrolled 95 patients, 75 men and 20 women, 58 years mean aged, admitted to the coronary care unit with diagnosis of AMI. Patients were treated with thrombolysis within 6 hours from the onset of chest pain, according to the GUSTO trial. RESULTS: The findings showed a significant prevalence of ST segment elevation resolution > 50% in inferior AMI (p < 0.01). It has been observed that the ST segment resolution is correlated with lower (p < 0.01) and earlier (p < 0.05) peak in serum creatinekinase (CK) and CK MB release and with less damage of left ventricular ejection fraction assessed by ventriculography (p < 0.01). All these findings indicated a lower extensive myocardial damage. Patients with ST segment resolution presented a prevalence of one or two-coronary vessel disease, with an infarct-related vessel narrowing like that observed in the other patients without ST resolution. Nevertheless a TIMI grade 2 or 3 flow was observed more frequently, but not significantly, in the subjects with ST resolution; a significant prevalence was limited to TIMI 3 grade flow (p < 0.05). In the present study ST segment elevation resolution > 50% represented a highly sensitive and a poor specific predictor of vessel patency in inferior AMI, but with a poor sensitivity and specificity in anterior AMI. CONCLUSIONS: Personal experience suggested that the thrombolytic therapy has a less favourable effect on the artery patency assessed 1 month after AMI, rather than in the acute phase as reported in previous studies. Dynamic changes of flow or a following worsening in atherosclerotic plaque could be probably responsible of reocclusion of an initially reperfused coronary artery.

[Myocarditis in legionellosis. A case report]. / Miocardite in corso di legionellosi. Descrizione di un caso.

Cardiac involvement during Legionnaires' disease has been rarely described; few cases of myocarditis, pericarditis and endocarditis were reported. We describe a case of myocarditis associated to pneumonia, with high antibody title suggesting a disease due to Legionella pneumophila. The patient had severe myocardial damage, with overt heart failure and important ECG and Doppler-echocardiographic abnormalities, without associated multiorgan involvement.

[Diagnosis of pulmonary thromboembolism by transesophageal echocardiography. Report of a case]. / Diagnosi di tromboembolia polmonare mediante ecocardiografia transesofagea. Descrizione di un caso.

We describe the case of a 73-year-old man, admitted after several days of moderate dyspnea, followed by sincopal episode. Transesophageal echocardiography clearly demonstrated a high resolution image indicating thromboembolus of the proximal right main pulmonary artery. The patient's clinical conditions were moderately impaired; a treatment with heparin followed by warfarin was started. At 15 and 30 days interval, TEE controls were performed, showing an incomplete but evident resolution of pulmonary thromboembolism, associated to an improvement of clinical ECG and scintigraphic parameters. Our TEE observation, in accordance with the small number of similar observations reported in literature, showed a clear direct visualization with high resolutive diagnostic possibilities for pulmonary thromboembolism; successful resolution was confirmed by repeated TEE studies.

[Bacterial endocarditis in pregnancy. Report of a clinical case diagnosed postpartum]. / Endocardite batterica in gravidanza. Descrizione di un caso clinico diagnosticato dopo il parto.

Bacterial endocarditis in pregnancy shows a low incidence; it is often associated with a prior history of rheumatic or congenital heart disease. In the large part of reports the illness tends to run a subacute course and to recognize a major frequency in the third trimester of pregnancy. We presented the case of a 29 year-old woman with mitral and aortic bacterial endocarditis. Transthoracic echocardiography performed one week after spontaneous delivery suggested valve vegetations. Antibiotic therapy turned out to be partially successful, in fact cerebral embolizations subsequently occurred. Conservative surgery appeared to be favourable and the patient shows a satisfactory present clinical state.

[Female gender and acute myocardial infarction: what role does it play in the early and late prognosis]. / Sesso femminile ed infarto miocardico acuto: quale ruolo nella prognosi a breve e medio termine?

The primary purpose of this study is to examine the influence of the female gender on the early and 1-year post-discharge prognosis after acute myocardial infarction (AMI). Moreover, the therapeutic approaches are compared between the two sexes during the early phase of AMI. We performed a retrospective cohort study of 341 patients, 219 men and 122 women, consecutively admitted to the coronary care unit with AMI. Among the baseline characteristics, the age greater than 70 years, the systemic hypertension and the diabetes mellitus are more represented in women; on the contrary cigarette smoking is prevalent in the male gender. The analysis of laboratory and clinical parameters does not show any statistic differences between the two sexes, except the ejection fraction and the coronary reperfusion. The first turns out to be lower in the females and the second one is more often observed in the males. As for the intra-hospital complications, the cardiogenic shock is prevalent in the female gender, the early mortality gets to 26% in women and 11% in men (p < 0.01). The late mortality during the follow-up does not present any difference between the two sexes. From our data, we conclude that transmural AMI, cardiogenic shock, ventricular fibrillation and 2-3 degree atrio-ventricular blocks are significantly bound to a higher early mortality in women. In them the atrial fibrillation is the only predictor of 1-year mortality. Finally, thrombolysis, beta-blockers and significantly aspirin and heparin (p < 0.05), are less used in the female patients, while diuretics and digoxin are more employed.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of age on early and late mortality after an acute myocardial infarct]. / Influenza dell'età sulla mortalità precoce e tardiva dopo infarto miocardico acuto.

The purpose of this study is to define the importance of age as predictor of early and late mortality following acute myocardial infarction (AMI). At the same time, effects coming from the use of various therapeutic approaches are considered. We have studied 341 patients, 188 aged < 70 years and 153 > or = 70 years, consecutively admitted to the coronary care unit with diagnosis of AMI. Our findings show that age > or = 70 years, female gender, cardiogenic shock, ventricular fibrillation and early post-infarction angina are significantly connected to higher intra-hospital mortality. As for predictors of 1-year mortality, they turned out to be the age > or = 70 years, indirect signs of more extensive infarction as previous necrosis, acute heart failure, cardiogenic shock, new bundle branch blocks and pre-discharging lower ventricular ejection fraction. In patients aged > or = 70 years, especially in ultra eighty-year old men, thrombolysis, heparin, beta-blockers and aspirin are significantly less employed. All drugs used in the early hours of AMI turned out to be bound to beneficial effects with reduced mortality, except diuretics and antiarrhythmics. The only drugs correlated with an improved 1 year survival are betablockers, aspirin and thrombolysis. On the contrary, the use of diuretics and digoxin is limited to patients with a greater clinical dysfunction. These drugs are associated to a higher late mortality. The present study confirms the finding that elderly patients with AMI who are submitted to less aggressive therapeutic approaches and are more frequently represented by women, have a higher mortality.

[Circadian variations in the incidence of transient ischemic myocardial episodes during hospitalization for acute myocardial infarct]. / Variazioni circadiane nell'incidenza di episodi di ischemia miocardica transitoria nel periodo pre-dimissione dopo infarto miocardico acuto.

The aim of this research was to evaluate the incidence and circadian variation of episodes of transient myocardial ischemia in the predischarge period after acute myocardial infarction (AMI). One hundred and ninety patients were selected in stable clinical condition, 83 with inferoposterior AMI, 61 with anterior AMI, 12 with lateral AMI (34 patients with non Q AMI). The patients with unstable clinical course during the first 48 hours after admission were excluded. All patients underwent dynamic electrocardiography (Pathfinder 3 Reynolds Medicals) between the tenth and the fifteenth day of the in-hospital phase. Sixteen/190 patients showed ECG changes due to transient myocardial ischemia, with a length higher than 60 sec and with an interval between episodes higher than 60 sec. Ten patients had ST depression, 6 patients had ST elevation. In total, the ischemic episodes were 25, silent 21 and symptomatic 4, with incidence from 1 to 4 during 24 hours, with a length from 1 to 17 min (mean 8 min); mean heart rate increased during ischemic episodes. Seventeen/25 ischemic episodes occurred between the twelfth and the twenty-fourth hours. A follow-up of 15 +/- 3 months was carried-out: 1 patient died after reinfarction, 1 patient died of non cardiac cause, 6 patients showed unstable angina (in 4 of them myocardial revascularization procedure was performed), 8 patients were asymptomatic; on the contrary, 32/174 patients without episodes of myocardial ischemia presented cardiac events, with lesser incidence than ischemic patients (p < 0.01). This retrospective analysis showed higher evidence of episodes due to transient myocardial ischemia during the afternoon and evening hours in the in-hospital phase after AMI.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognostic significance of thallium-201 scintigraphy in patients with previous myocardial infarct]. / Valore prognostico della scintigrafia con tallio-201 nei pazienti con pregresso infarto miocardico.

With the purpose of ascertaining the predictive value of residual myocardial ischemia, in stable clinical conditions at a distance after myocardial infarction, on the incidence of late cardiac events, we evaluated 55 patients 24.2 +/- 11.4 months after myocardial infarction with thallium-201 stress test imaging. All patients were either asymptomatic or with stable effort angina pectoris, well controlled with medical treatment. In the next follow-up period, whose duration has been 22.4 +/- 14.4 months, the incidence of unfavourable cardiac events, like unstable angina, reinfarction, coronary bypass surgery, sudden cardiac death has been monitored. Thirty-one patients (56.4%) presented a reversible perfusion defect (RPD) in one or more myocardial segments; 17 of these 31 showed cardiac events during follow-up. Only 2 patients of the remaining 24 without RPD had cardiac events, with a significant difference (p less than 0.01). The patients with RPD only in peri-infarct areas had a relatively smaller number of cardiac events, with respect to those patients with RPD also or only in distant areas. Fifteen of 21 patients with RPD in 2 or more segments manifested cardiac events, compared to 2 of 10 patients with RPD in only one segment (p less than 0.01). In 10/55 patients, increased lung uptake of thallium-201 activity was observed; 8 of them presented cardiac events (p less than 0.01). This analysis confirms the high predicting value of thallium-201 RPD imaging on the incidence of cardiac events in patients controlled at a distance after myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)