[Transesophageal echocardiography in patients with atrial fibrillation, candidates for cardioversion: usefulness and limitations]. / L'ecocardiografia transesofagea nei pazienti in fibrillazione atriale candidati a cardioversione: utilità e limiti.

BACKGROUND: Thromboembolic complications after electrical cardioversion (CV) of atrial fibrillation (AF) have been attributed to the dislodgment of preexistent left atrial thrombus during the resumption of atrial contraction. Transesophageal echocardiography (TEE) has been used to identify patients without thrombus, who potentially could undergo CV without anticoagulation. However, embolic events after CV in patients without evidence of thrombus on TEE have recently been reported. AIM OF THE STUDY: To evaluate if absence of thrombi or prethrombotic conditions such as spontaneous echo contrast or left atrial appendage disfunction can justify electrical CV without anticoagulant therapy. METHODS: Seventy-four patients with AF and candidates for CV underwent monoplane TEE. Patients were cardioverted without anticoagulation in case of: 1) absence of thrombus and/or spontaneous echocardiographic contrast and 2) good visualization of left atrial appendage, with a well defined peak blood flow velocity greater than 20 cm/sec. In all other cases, patients underwent anticoagulant therapy which started 3 weeks before CV and continued for 4 weeks afterwards. RESULTS: Forty-six patients, without thrombus or "prethrombotic" conditions, did not receive anticoagulation, while 28 followed traditional therapy with warfarin. Four patients with a thrombus in the left atrial appendage were identified: 1 died of cerebral embolism 3 days after the beginning of anticoagulation, in another one CV was definitely deferred because of the persistence of thrombus after 1 month of warfarin therapy. One patient, with left atrial appendage disfunction, died suddenly after 5 days of anticoagulation. Two patients reverted spontaneously in sinus rhythm. Two patients refused electrical CV. The remaining 67 patients underwent electrical CV which was successful in 56 of them. Cerebral embolism occurred 24 hours after CV in one patient who did not receive anticoagulation. Repeat TEE soon after embolism showed absence of thrombus or spontaneous echo contrast, but the presence of low flow velocity in the left atrial appendage. CONCLUSIONS: In patients in AF candidates for CV, exclusion of thrombi or prethrombotic conditions by TEE does not exclude the risk of thromboembolic events and the need for anticoagulant therapy. Left atrial appendage function can be stunned or impaired immediately after CV, favouring a thrombogenic milieu and subsequent embolic events. Therapeutic anticoagulation at the time of as well as after cardioversion is actually recommended.

How the exercise electrocardiogram is used in clinical practice in patients with suspected coronary artery disease.

Clinical use of a test should be evaluated not only on the change of pretest probability but also on the increased confidence in the judged probability, and on the decision of recommending additional tests or therapy after test results. Before and after the test, cardiologists referring a patient for exercise electrocardiogram for suspected coronary artery disease were asked to estimate the probability of coronary artery disease and the minimal and maximal value of their estimate (plausible range), to judge whether to refer the patient for coronary angiography, and to specify patient's treatment. After the test, the percentage of patients with estimated probability < or = 20% increased (from 53 to 69%; p = 0.005) and the percentage of patients with intermediate probability (between 21 and 80%) decreased (from 37 to 16%; p = 0.0001). The mean plausible range decreased from pre- to post-test assessment (31 +/- 23 to 15 +/- 16%; p = 0.0001), indicating an increase in cardiologists' confidence in their estimates. After the test, the percentage of cardiologists who wished to either refer or not refer patients for coronary angiography increased (from 4 to 13%, p < 0.005; and from 37 to 65%, p < 0.0001, respectively). Test results enable cardiologists to change the assessment of disease probability, the confidence in their own estimates, and their judgment of whether to refer patients for coronary angiography.

[HDL cholesterol in diabetes mellitus type II]. / Colesterolo HDL in corso di diabete mellito tipo II.

The results of a study conducted on 60 diabetics are reported. The HDL cholesterol levels of the diabetics and healthy controls of the same sex and age were compared and no statistically significant differences were found: 49.3 +/- 12 (diabetics) versus 47.6 +/- 9 (controls).

Atypical chest pain: coronary or esophageal disease?

Retrosternal pain can be caused both by cardiac and esophageal disease. This work presents the results of cardiac and esophageal investigations in 55 patients, who had atypical chest pain. Isolated esophageal disease was found in 45% of the subjects while 14.5% had significant coronary arterial disease. Both diseases were found in 10.9% of the patients and neither disease in 29%. We conclude that esophageal disease is very frequent in patients with atypical chest pain but it does not always completely account for the symptoms. Such patients should, in our opinion, be submitted to an electrocardiographic stress test. If the result is positive or non-diagnostic, coronary cineangiography should be performed, irrespective of the results of esophageal investigations. If the electrocardiographic stress test is negative, coronary investigations can be deferred. Esophageal investigations can account for the symptoms in about half of such cases.