Endovascular treatment of iliac and common femoral arteries disease by the transradial access: A prospective, feasibility study.

AIM: To report feasibility and safety of endovascular interventions on iliac and common femoral arteries, using the transradial access (TRA). METHODS: 100 consecutive patients (19 women; mean age 71, range 37-90years) with critical limb ischemia (30%) or claudication, and TASC A-D lesions in iliac or common femoral arteries, were prospectively enrolled, from January 2013 to June 2015, to be treated via the TRA. Exclusion criteria included no palpable radial arteries (RA) and the presence of a fistula for hemodialysis. Patients were evaluated for procedural technical success, in-hospital complications, and 30days clinical success (defined as improvement of at least one grade in the Rutherford classification of symptoms). RESULTS: A total of 131 iliac and common femoral arteries lesions were treated (58 in common iliac arteries, 38 in external iliac arteries and 35 in common femoral arteries). Ninety-two stents were deployed in 58 patients. Procedural technical success was achieved in 91% of the lesions; with 95% technical success rate in common iliac arteries, 87% in external iliac arteries and 89% in common femoral arteries; with 72% technical success rate in occlusions and 98% in stenosis. No in-hospital complications were observed. At 30days, 93 patients (93%) had an improvement of at least one category in the Rutherford classification of symptoms (clinical success rate 93%); 12 patients (12%) had an asymptomatic occlusion of the RA. CONCLUSIONS: TRA can be used to treat iliac and common femoral arteries lesions with a high grade of technical success and a low rate of complications.

Guidewires for lower extremity artery angioplasty: a review.

The guidewire (GW) is probably the most important tool for the endovascular treatment of arterial obstructions. In fact, the treatment of a lesion is only possible when the GW is passed beyond the target lesion. Lower limb percutaneous arterial revascularisation can be achieved using a variety of GWs which may differ in calibre, body, tip or coating. As the choice of an appropriate GW is critical for the success of a lower limb artery angioplasty, knowledge of the properties and performances of different GWs should be well known in order to tailor the choice of the device to the lesion characteristics and location, as well as to the intended revascularisation strategy. The aim of the present paper is to describe the constructive characteristics of GWs for lower limb arterial revascularisation, and to evaluate groups of GWs for each segment of the lower limb arterial vasculature.

Tailored use of transradial access for above-the-knee angioplasty.

PURPOSE: To report the results and complications of a single-center experience of above-the-knee angioplasty via transradial access (TRA). METHODS: In a prospective study, 110 consecutive patients (88 men; mean age 72 years, range 37-90) referred for critical limb ischemia (26, 24%) or claudication were eligible for lower limb angioplasty via TRA (patients with TASC D lesions of the superficial femoral artery and below-the-knee lesions were excluded). RESULTS: The majority of patients (84, 76%) were treated via a left TRA. A total of 170 lesions were addressed, of which 38 (22%) were occlusions; 113 stents were positioned in 82 patients. The overall technical success rate was 91%, with a 63% success rate in occlusions and a 98% success rate in stenoses; by location, the success rates were 91% in suprainguinal lesions and 90% in infrainguinal lesions. No hemorrhagic or local complications requiring surgery were observed. At 1-month follow-up, 101 patients had a downward shift of at least one category in the Rutherford classification of symptoms (clinical success rate 92%); 18 (16%) patients had occlusion of their access radial artery, but none had symptoms or discomfort. CONCLUSION: The present study demonstrates that TRA is a safe and effective approach for lower extremity arterial revascularization, at least for interventionists with longstanding experience in TRA and in selected anatomical subsets.

Safety and feasibility of iliac endovascular interventions with a radial approach. Results from a multicenter study coordinated by the Italian Radial Force.

BACKGROUND: Percutaneous angioplasty of lower limb disease is commonly performed with a transfemoral access. In the coronary field, a transradial approach has shown to reduce access-site bleeding and adverse clinical events. This route has not yet been well studied for the majority of peripheral interventions, like those involving the iliac arteries. In this study we sought to evaluate the feasibility and safety of this approach for iliac interventions. METHODS: Multicenter study was performed at high-volume centers with experience in transradial percutaneous interventions. Primary endpoint of the study was procedural success; secondary endpoints included in-hospital bleeding, 1-month freedom from adverse events and the rate of radial occlusion. Feasibility of this technique was evaluated by recording procedural and fluoroscopy time and contrast load. RESULTS: A total of 149 patients from 5 centers were enrolled. The population had a medium risk profile, with 48% of patients having TASC 2 or 3 lesions. Procedural success was achieved in 98.7% of the population, and we did not register in-hospital complications, including both vascular access site and procedural-related complications. An ancillary transfemoral approach was used in 13% of patients. One-month freedom from symptoms was achieved in 97.3% of patients, and the rate of radial occlusion was 2.7%. Major determinants of an unsuccessful procedure were the use of normal 6 or 7-Fr introducer with guiding catheter, TASC D lesion attempt, lesion length>30 mm and total occlusion. CONCLUSIONS: A transradial approach for iliac disease may be a feasible and safe alternative to the transfemoral route in experienced hands, in the light of significant technical improvements and dedicated devices.

Transradial access for peripheral and cerebrovascular interventions.

OBJECTIVES: In the present review, we report indications, equipment, techniques, results, and complications of transradial access (TRA) in peripheral as well as in cerebrovascular interventions. BACKGROUND: Percutaneous peripheral and cerebrovascular interventions are usually performed using transfemoral access; however, the risk of vascular complications with this approach is not negligible. Moreover, femoral access may be precluded by advanced vascular disease, and brachial access has been traditionally used as an alternative approach despite the risk of local complications. While TRA has gained wide acceptance for coronary procedures, little is known about its use for peripheral and cerebrovascular interventions. Thanks to dedicated equipment, most vascular territories may now also be treated by TRA. CONCLUSIONS: TRA may become the alternative access of choice for peripheral and cerebrovascular interventions when femoral access is precluded. In addition, TRA may become the preferred access for the treatment of selected peripheral lesions.

Radial artery access for above the knee angioplasty: a feasibility study.

AIMS: Lower limb angioplasty is usually performed by transfemoral access despite the risk of local complications. Transradial access (TRA) has gained acceptance for coronary interventions. The aim of this study was to evaluate the feasibility and safety of TRA for above the knee (ATK) angioplasty. METHODS AND RESULTS: Twenty-five consecutive patients (eight females; mean age 72, range 55-85 years; seven symptomatic for critical limb ischaemia, 18 for claudication) underwent ATK angioplasty by left (19) or right (6) TRA. A total of 32 lesions were addressed; 16 stents were positioned in 12 patients with an overall success rate of 81%, and a success rate of 38% on occlusions and of 96% on stenoses. The overall success rate on the 16 supra-inguinal lesions was 81%, (success rate 60% on occlusions and 91% on stenoses). The overall success rate on the 16 infra-inguinal lesions was 81%, (success rate 0% on occlusions and 100% on stenoses). Any haemorrhagic complications or local complications needing surgery were observed in the cohort of patients. CONCLUSIONS: TRA can represent a feasible and safe alternative for ATK angioplasty in case of difficult femoral access.

[Transradial access for percutaneous coronary and non-coronary interventions]. / Accesso radiale per la diagnostica e l'interventistica coronarica e non coronarica.

The transfemoral access is still the most widely used approach for percutaneous coronary and non-coronary interventions. However, the transradial access has been increasingly used, mostly because it is associated with less hemorrhagic complications. The present review is aimed at evaluating the use of the transradial access for percutaneous vascular interventions. In many institutions, the radial artery is already the preferred vascular access for coronary procedures for routine coronary angiography but also for complex interventions such as primary angioplasty and angioplasty for stenosis at coronary bifurcations or coronary bypass grafts, or for treating chronic coronary occlusions. The radial artery can be used also as a vascular access for percutaneous peripheral interventions. Supra-aortic vessels (carotid, subclavian and vertebral arteries) can be treated via the radial route when obstructions of the femoro-iliac tract preclude groin access or also to circumvent anatomic variations such as bovine aortic arch. For renal artery angioplasty, the transradial access can be considered ideal for anatomic reasons, at least for those operators who use this access routinely for coronary interventions. At present, the transradial access can also be used, although in specific cases, to treat stenosis of the lower limb arteries in above the knee segments.

[New-onset left bundle branch block as an early electrocardiographic feature of takotsubo cardiomyopathy]. / Blocco di branca sinistra di nuova insorgenza come prima manifestazione elettrocardiografica della cardiomiopatia takotsubo.

Takotsubo cardiomyopathy is a recently described syndrome characterized by reversible left ventricular dysfunction, chest pain, ST-segment elevation, and minor elevation in serum levels of cardiac enzymes, in the absence of significant coronary artery disease. ST-segment elevation is the most common electrocardiographic finding on the admission ECG of patients, followed by evolutionary T-wave inversions. We report a case of takotsubo cardiomyopathy characterized by the unusual feature of a new onset transient left bundle branch block as first electrocardiographic manifestation. New left bundle branch block increases heterogeneity in the broad spectrum of electrocardiographic findings of takotsubo syndrome, contributing to ambiguity in the early recognition and affecting potential management strategies.

[Chest pain evaluation project]. / Percorso di valutazione del dolore toracico. Valutazione dei requisiti di base per l'implementazione negli ospedali italiani.

The evaluation of acute chest pain remains challenging, despite many insights and innovations over the past two decades. The percentage of patients presenting at the emergency department with acute chest pain who are subsequently admitted to the hospital appears to be increasing. Patients with acute coronary syndromes who are inadvertently discharged from the emergency department have an adverse short-term prognosis. However, the admission of a patient with chest pain who is at low risk for acute coronary syndrome can lead to unnecessary tests and procedures, with their burden of costs and complications. Therefore, with increasing economic pressures on health care, physicians and administrators are interested in improving the efficiency of care for patients with acute chest pain. Since the emergency department organization (i.e. the availability of an intensive observational area) and integration of care and treatment between emergency physicians and cardiologists greatly differ over the national territory, the purpose of the present position paper is two-fold: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the basic critical pathways (describing key steps for care and treatment) that need to be implemented in order to standardize and expedite the evaluation of chest pain patients, making their diagnosis and treatment as uniform as possible across the country.

[Appropriateness of prescription of exercise stress test, echocardiography, Holter monitoring and vascular echography]. / L'appropriatezza dei test cardiologici non invasivi. studio osservazionale sull'appropriatezza della prescrizione del test da sforzo, dell'ecocardiogramma, dell'ECG dinamico e dell'ecografia vascolare.

BACKGROUND: The aim of this study was to evaluate the appropriateness of prescription of non-invasive cardiological tests (exercise stress test, echocardiography, Holter monitoring and vascular echography), consecutively performed in our outpatient laboratory during 4 weeks. METHODS: We collected the following data: the appropriateness of prescription (according to the Italian Federation of Cardiology guidelines); test indications; the prescribing physician (cardiologist/non-cardiologist); type of prescription (elective/urgent); clinical utility (useful/useless) and result (normal/abnormal) of each test. RESULTS: We evaluated 960 prescriptions (320 exercise tests; 282 echocardiograms; 158 Holter tests; 200 vascular echographies). Test indications were appropriate (class I) in 37%, doubtfully appropriate (class II) in 39% and inappropriate (class III) in 24% of the cases. The appropriateness was slightly better for vascular echography and echocardiography (class I: 44% and 43%, respectively), markedly worse for exercise test (class I: 27%). The tests were considered useful in 46% and abnormal in 39% of the cases. Cardiologist-prescribed exams resulted more often appropriate (class I: 53 vs 30%; class II: 41 vs 38%; class III: 6 vs. 32%; p = 0.0001), more often useful (74 vs. 34%; p = 0.0001) and more frequently abnormal (43 vs. 37%; p = 0.05), when compared to non-cardiologist-prescribed exams. No differences in appropriateness, utility and test result have been detected between elective and urgent exams. Exercise test, echocardiogram and Holter monitoring resulted more often appropriate and useful when prescribed by cardiologists. CONCLUSIONS: This study confirms that only one third of prescriptions for non-invasive cardiological tests are appropriate. Cardiologist-prescribed exams are more often appropriate, useful and abnormal.

A computer protocol to evaluate subjects with chest pain in the emergency department: a multicenter study.

OBJECTIVE: Chest pain is a frequent cause of medical admission to the emergency department and the main differential diagnosis is between coronary and non-coronary chest pain. We elaborated a computer protocol for the management of patients with chest pain. METHODS: The computer protocol was made of three sections according to clinical, electrocardiographic and biochemical data. Each section was coded by a letter indicating the probability of coronary chest pain for each section. The combination of the three letters formed a score string used to assign patients to four subgroups of overall probability of coronary chest pain (low, medium-low, medium-high, and high). Low-probability patients were discharged from the emergency department, whereas high-probability patients were admitted to the coronary care unit. The medium-probability patients underwent further evaluation by means of a stress test and were re-classified as having a final low probability (negative test) or high probability (positive test). RESULTS: We evaluated 472 patients (mean age 64 years, range 18-97 years; 47% female). The incidence of coronary events in patients with low, medium-low, medium-high and high overall probability was 1.9, 12.8,13.5 and 68.0%, respectively (P < 0.05). The positive and negative predictive values of the protocol were 64.7 and 97.1%, respectively. CONCLUSIONS: Our computer protocol represents a reliable method for the management of patients with chest pain and a non-diagnostic electrocardiogram.

Relevance of coronary microvascular flow impairment to long-term remodeling and systolic dysfunction in hypertrophic cardiomyopathy.

OBJECTIVES: This study sought to evaluate whether the entity of microvascular dysfunction, assessed by positron emission tomography (PET), predicts the long-term development of left ventricular (LV) remodeling and systolic dysfunction in hypertrophic cardiomyopathy (HCM). BACKGROUND: A subgroup of patients with HCM developed LV dilation and systolic impairment. A causal role of coronary microvascular dysfunction has been suggested as the underlying pathophysiological mechanism. METHODS: Fifty-one patients (New York Heart Association functional class I to II) were followed up for 8.1 +/- 2.1 years after measurement of resting and dipyridamole (Dip) myocardial blood flow (MBF). Left ventricular systolic dysfunction was defined as an ejection fraction (LVEF) <50%. RESULTS: The Dip-MBF was blunted in HCM patients compared with a group of healthy control patients (1.50 +/- 0.69 ml/min/g vs. 2.71 +/- 0.94 ml/min/g; p < 0.001). At final evaluation, 11 patients (22%) had an LVEF <50%; in most (n = 7), systolic dysfunction was associated with a significant increase in LV cavity dimensions (>5 mm) during follow-up. These 11 patients showed lower Dip-MBF than the 40 with preserved LV function (1.04 +/- 0.38 ml/min/g vs. 1.63 +/- 0.71 ml/min/g, respectively; p = 0.001); Dip-MBF was particularly blunted in five patients with clinical progression to severe heart failure symptoms or death (Dip-MBF 0.89 +/- 0.15 ml/min/g). At multivariate analysis, the two independent predictors of systolic dysfunction were Dip-MBF in the lowest tertile (<1.1 ml/min/g; relative hazard, 7.5; p = 0.038) and an end-diastolic LV dimension in the highest tertile (>45 mm; relative hazard, 12.3; p = 0.031). CONCLUSIONS: Severe microvascular dysfunction is a potent long-term predictor of adverse LV remodeling and systolic dysfunction in HCM. Our findings indicate microvascular dysfunction as a potential target for prevention of disease progression and heart failure in HCM.

Short-term prevention of thromboembolic complications in patients with atrial fibrillation with aspirin plus clopidogrel: the Clopidogrel-Aspirin Atrial Fibrillation (CLAAF) pilot study.

BACKGROUND: We evaluated the short-term safety and efficacy of aspirin-plus-clopidogrel as antithrombotic therapy in nonvalvular atrial fibrillation (AF). METHODS AND RESULTS: Thirty patients (11 women, 45 to 75 years of age) with non-high-risk permanent (n = 12) or persistent AF awaiting cardioversion (n = 18) underwent transesophageal echocardiography to exclude left heart thrombi and were then randomly assigned to receive warfarin (international normalized ratio, 2 to 3 for 3 weeks) or aspirin (100 mg/d alone for 1 week)-plus-clopidogrel (75 mg/d added to aspirin for 3 weeks). Bleeding time and serum thromboxane B2 were measured at entry and at 3 weeks. Bleeding time, not affected by warfarin, was prolonged by 71% by aspirin (P <.05) and further, by 144%, by adding clopidogrel (P <.01 vs aspirin alone; +319%, P <.01, vs baseline). Thromboxane B2, not affected by warfarin, was reduced by aspirin (-98%, P <.01) but not further by clopidogrel. No thrombi or dense spontaneous echo-contrast were found at the 3-week transesophageal echocardiography. Seven of 9 patients receiving warfarin and 7 of 9 patients receiving aspirin-plus-clopidogrel, undergoing electrical cardioversion, achieved sinus rhythm. No thromboembolic or hemorrhagic events occurred in both arms throughout the 3-week treatment and a further 3-month follow-up. CONCLUSIONS: Aspirin-plus-clopidogrel and warfarin were equally safe and effective in preventing thromboembolism in this small group of patients with non-high-risk AF.

Cost-effectiveness analysis of noninvasive strategies to evaluate patients with chest pain.

We evaluated clinical and economic outcomes of diagnostic strategies on the basis of pharmacologic stress echocardiography (PhSE) versus exercise electrocardiography test (EET) in 527 patients with chest pain (274 women; age 59 +/- 10 years) who underwent both EET and PhSE. We investigated 3 strategies, ie, coronary angiography: after positive EET (strategy 1); after positive PhSE (strategy 2); or after a positive PhSE performed after a positive EET (strategy 3). A patient was correctly identified if he or she had negative test results and no events, or had positive test results and abnormal coronaries. The cost per patient correctly identified was calculated as the ratio between the cost of each strategy and the number of patients correctly identified. The accuracy in correctly identifying the patients was 78%, 92%, and 91% with strategies 1, 2, and 3, respectively. The cost of each patient correctly identified was 1572 US dollars, 1097 US dollars, and 1081 US dollars with strategies 1, 2, and 3, respectively. In conclusion, PhSE-based strategies are cost-effective versus EET.

Coronary microvascular dysfunction and prognosis in hypertrophic cardiomyopathy.

BACKGROUND: Microvascular dysfunction, reflected by an inadequate increase in myocardial blood flow in response to dipyridamole infusion, is a recognized feature of hypertrophic cardiomyopathy. Its long-term effect on the prognosis is unknown. We prospectively evaluated a cohort of patients with hypertrophic cardiomyopathy after they had undergone quantitative assessment of myocardial blood flow by positron-emission tomography (PET). METHODS: Fifty-one patients (New York Heart Association class I or II) were followed for a mean (+/-SD) of 8.1+/-2.1 years after PET. Twelve subjects with atypical chest pain served as controls. Measurement of flow was performed at base line and after the infusion of the coronary vasodilator dipyridamole, with the use of nitrogen-13-labeled ammonia. Patients were then divided into three equal groups with increasing values of myocardial blood flow. RESULTS: The response of myocardial blood flow to dipyridamole was severely blunted in the patients, as compared with the controls (1.50+/-0.69 vs. 2.71+/-0.94 ml per minute per gram of tissue, P<0.001). Sixteen patients (31 percent) had an unfavorable outcome (death from cardiovascular causes, progression to New York Heart Association class III or IV, or sustained ventricular arrhythmias requiring the implantation of a cardioverter-defibrillator) 2.2 to 9.1 years after PET. Reduced blood flow in response to dipyridamole was strongly associated with an unfavorable outcome. Multivariate analysis showed that among patients in the lowest of the three flow groups the age-adjusted relative hazard of death from cardiovascular causes was 9.6 (P=0.02) and the relative hazard of an unfavorable outcome (a combined end point) was 20.1 (P=0.003), as compared with patients in the two other flow groups. Specifically, all four patients who died from heart failure and three of five who died suddenly were in this subgroup. CONCLUSIONS: In patients with hypertrophic cardiomyopathy, the degree of microvascular dysfunction is a strong, independent predictor of clinical deterioration and death. Severe microvascular dysfunction is often present in patients with mild or no symptoms and may precede clinical deterioration by years.

[Evaluation of the appropriateness of prescribing non-invasive cardiologic tests]. / La valutazione dell'appropriatezza della prescrizione dei test cardiologici non invasivi.

BACKGROUND: We evaluated the appropriateness of the prescription of echocardiography, exercise testing, Holter monitoring and vascular sonography for ambulatory patients, performed during 4 weeks in 21 outpatient laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs noncardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 5614 prescriptions (patients: 3027 males, 2587 females; mean age 63 years, range 14-96 years). The indication to the test was of class I (appropriate) in 45.3%, of class II (doubtfully appropriate) in 34.8% and of class III (inappropriate) in 19.9% of the cases. The test was abnormal in 58.3% of class I exams vs 17% of class III exams (p < 0.05). The test was useful in 72.4% of class I exams vs 17.1% of class III exams (p < 0.05). The test was prescribed by a cardiologist in 1882 cases (33.5%). Cardiologist-prescribed exams were of class I in 57.3%, of class II in 32.4% and of class III in 10.3% of the cases vs 39.2, 36.1 and 24.7% of non-cardiologist-prescribed exams (p < 0.05). Cardiologist-prescribed exams were abnormal in 53.4% of the cases vs 39% of those of non-cardiologists' (odds ratio 1.76, 95% confidence interval 1.58-1.97; p < 0.05). Cardiologist-prescribed exams were useful in 64.7% of the cases vs 44.4% of those of non-cardiologists' (odds ratio 2.26, 95% confidence interval 2.02-2.53; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, less than half of the prescriptions for non-invasive diagnostic tests are appropriate: appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are more often appropriate, abnormal and useful.

[Evaluation of the appropriateness of prescribing echocardiography]. / La valutazione dell'appropriatezza della prescrizione dell'ecocardiogramma.

BACKGROUND: We evaluated the appropriateness of indications to echocardiography for ambulatory patients performed during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 2848 prescriptions (patients: 1450 males, 1398 females; mean age 62 years, range 15-90 years). The indications to test were of class I (appropriate) in 43.6%, of class II (of doubtfully appropriateness) in 36.8% and of class III (inappropriate) in 19.6% of the cases. In 60.8% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 83.8% of class I, in 56.6% of class II and in 17.8% of class III exams (p < 0.05). The exam was considered useful in 51.1% of the cases. In particular, a useful result was found in 78.9% of class I, in 39% of class II and in 12.1% of class III exams (p < 0.05). Cardiologists prescribed 856/2848 tests (30%). Their indications were of class I in 58.8%, of class II in 29.8% and of class III in 11.4% of the cases vs 37, 39.9 and 23.1% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 74.3% of cardiologist- vs 55% of non-cardiologist-prescribed examinations (odds ratio 2.45, 95% confidence interval 2.04-2.92; p < 0.05); similarly, clinically useful information could be derived from 63.1% of cardiologist- vs 46% of non-cardiologist-prescribed examinations (odds ratio 2.07, 95% confidence interval 1.75-2.45; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, about half of the prescriptions for echocardiography can be considered inappropriate; appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.

[Evaluation of the appropriateness of prescribing Holter dynamic electrocardiography]. / La valutazione dell'appropriatezza della prescrizione dell'elettrocardiogramma dinamico secondo Holter.

BACKGROUND: We evaluated the appropriateness of indications to Holter monitoring performed on ambulatory patients during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 863 prescriptions (population: 435 males, 428 females; mean age 64 years, range 15-90 years). The indications to the test were of class I (appropriate) in 59.6%, of class II (doubtfully appropriate) in 11.7%, and of class III (inappropriate) in 28.7% of the cases. In 33% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 37.9% of class I, in 36.7% of class II, and in 24.5% of class III exams (p < 0.05). The exam was considered useful in 46.7% of the cases. In particular, a useful result was found in 59.2% of class I, in 45.5% of class II, and in 21% of class III exams (p < 0.05). Cardiologists prescribed 373/863 tests (43.2%). Their indications were of class I in 67.6%, of class II in 12% and of class III in 24% of the cases vs 53.7, 11.4 and 34.9% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 40% of cardiologist- vs 27.6% of non-cardiologist-prescribed examinations (odds ratio 1.74, 95% confidence interval 1.31-2.32; p < 0.05); similarly, clinically useful information could be derived from 59.8% of cardiologist- vs 36.7% of non-cardiologist-prescribed examinations (odds ratio 2.56, 95% confidence interval 1.94-3.37; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, about 40% of Holter exams are inappropriate; appropriately prescribed exams are more often abnormal and useful; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.