[Exercise two-dimensional echocardiography in recent myocardial infarction. Is it useful in the detection of multivessel disease?]. / L'ecocardiografia bidimensionale da sforzo nell'infarto miocardico recente. E utile nell'individuazione di malattia multivascolare?

Exercise two-dimensional echocardiography (2D-ECHO) can be used to detect coronary artery disease in patients (pts) by the development of stress-induced transient asynergy in areas without wall motion abnormalities when at rest. The aim of the study is to verify the accuracy of exercise 2D-ECHO in the identification of high risk pts with multivessel disease after the first acute myocardial infarction (AMI). Technically adequate 2D-ECHO examinations were obtained in 21 of 28 (75%) consecutive patients after acute myocardial infarction. 30-50 days after acute myocardial infarction, these 21 pts (19 males and 2 females, mean age +/- SD = 54.3 +/- 8.7) underwent 2D-ECHO during bicycle exercise in supine position. The marker of multivessel disease was the development, during the stress test, of new areas of asynergy not adjacent to the infarcted area (i.e. transient remote asynergy). Two months after acute myocardial infarction all pts underwent coronary angiography to verify the severity of coronary obstruction (reduction of luminal diameter greater than or equal to 75% in the non infarct related vessel).(ABSTRACT TRUNCATED AT 250 WORDS)

A reappraisal of the factors affecting early patency of aortocoronary saphenous vein bypass grafts. Current experience with extensive revascularization employing sequential grafting techniques.

A number of factors potentially influencing the patency rates of aortocoronary bypass grafts were investigated in a consecutive series of 50 patients by control angiography at 28 +/- 26 days and by univariate and multivariate analysis of a selected set of clinical, surgical and angiographic predictors. There were 234 anastomoses in this series, a mean of 4.7 per patient (range 1 to 9), 215 of which were connected to sequential vein grafts. After surgery, 40 patients were treated with anticoagulants and/or platelet inhibitors. Of the 234 coronary anastomoses studied, 219 were patent (93.6%). Coronary artery diameter, patient's age and previous myocardial infarction were shown to be independent predictors of increased risk of anastomotic occlusion. Arteries less than 1.5 mm in diameter had a patency rate of 84.9%, versus 96.1% for vessels 1.5 mm or larger (p = 0.009). The use of side-to-side anastomoses with sequential grafts seemed to counterbalance the unfavourable effect of small arterial size. Patients aged 65 or older had a lower probability of having all their grafts patent than younger patients did (50 vs 89%, p = 0.01). Patients with previous myocardial infarction similarly had a lower probability of having all their grafts patent compared to patients without previous infarction (68 vs 95%, p less than 0.05); this correlation was explained by a more frequent occlusion rate of grafts directed to fibrotic left ventricular areas. The effect of anticoagulants and of platelet-inhibitors was favourable, but did not reach statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pharmacologic myocardial revascularization in acute infarct. Experience with 52 cases]. / La rivascolarizzazione miocardica farmacologica nell'infarto acuto. Esperinza relativa a 52 casi.

Coronary thrombosis is frequently demonstrated in the early hours of acute myocardial infarction. Local infusion of thrombolytic agents has been proposed in order to dissolve intracoronary thrombi and to restore myocardial perfusion. We report our initial experience in 52 patients. Thirty-nine males and 13 females had a coronary angiogram performed within 5 hours from the beginning of persistent ischemic pain (mean 2h 34 min +/- 68 min; range 20 min--5h 30 min). In all an ST segment elevation was documented on an ECG recording. Coronary occlusion was found in 86.5% (45/52) of our cases. Flow restoration was obtained in 39 of 45 of patients (86.6%) within 45 +/- 28 min. The mean dose of streptokinase employed was 272,140 +/- 112,484 IU (range 120,000--400,000 IU). Myocardial reperfusion was accompanied by the reduction of ischemic pain and ST elevation. In 8 cases severe ventricular arrhythmias occurred. Serious haemorrhagic complications were observed only in one patient. Eight patients developed a new myocardial infarction within few days from the procedure and two died 2 hours and 6 days respectively after myocardial revascularization. Thirty-two of thirty-nine patients underwent a angiographic control study within 11-128 days and coronary patency was shown in 75% (24/32). Seven patients underwent a coronary artery bypass procedure. At surgical inspection no clear evidence of myocardial necrosis was observed. Coronary flow restoration is rapidly and safely obtained i acute myocardial infarction by means of intracoronary streptokinase infusion but the efficacy of the procedure in salvaging myocardium has not been demonstrated yet.

[Problems appearing after pharmacologic thrombolysis in acute myocardial infarct]. / Problemi emergenti dopo trombolisi farmacologica nell'infarto miocardico acuto.

Pharmacologic myocardial reperfusion is a new strategy in the treatment of acute myocardial infarction, but its widespread use has raised several problems which are still unsolved. The time limit from the onset of ischemic pain until the beginning of thrombolysis is undefined yet. Experimental and clinical observations set this time within three hours. A reopened vessel is still at risk for reocclusion and anticoagulants are not always effective in the prevention of this. It is likely therefore that pharmacologic thrombolysis is only one step in the process of myocardial salvage and that other techniques like transluminal coronary angioplasty and/or coronary bypass surgery, should follow shortly. Intracoronary thrombolysis does not carry an increased risk for acute myocardial infarction patients. However haemorrhagic complications are expected to occur in less than 6% of cases during their hospital stay. To evaluate the extent of myocardial salvage quantitative ventriculography and intracoronary thallium 201 scintigraphy represent the most reliable techniques. Only the results of the continuing randomized trials will clarify the efficacy of this new way of therapy for morbidity, mortality and myocardial salvage.

Chest thump and ventricular tachycardia.

Chest thump is a simple method of treatment of some paraxysmal arrhythmias. Its therapeutic efficacy, electrophysiological bases and clinical utility have been studied in 17 patients during 45 episodes of ventricular tachycardia (VT). Thumping the precordium interrupted the VT in 22 episodes. Three types of interruption of VT have been observed: (1) In 15 episodes, single ventricular premature beats induced by the blow, occurring randomly in the cycle, stopped the arrhythmia; (2) In 5 episodes, a run of premature beats, induced by a rapid succession of blows, interrupted the tachycardia; (3) In 2 episodes, chest thump caused a short period of asystole followed by sinus rhythm. Chest thump is an antiarrhythmic treatment of definite clinical utility. The complications are rare, although there is a possibility of ventricular fibrillation. Therefore, it should be performed only under careful supervision.

[Evaluation and comparison of five antianginal treatments by means of a bicycle ergometer exercise test (author's transl)]. / Valutazione e confronto dell'efficacia di 5 trattamenti antianginosi mediante prova da sforzo al cicloergometro

The antianginal effect of three drugs (isosorbide dinitrate-nifedipine-oxprenolol) and of two drug associations (isosorbide dinitrate-oxprenolol; nifedipine-oxprenolol) was studied in six patients, by means of a bicycle ergometer exercise test. The study was double blind; placebo was also included in the test. Treatments were administered according to the sequence of a 6 X 6 "balanced" latin-square design. After treatment with isosorbide dinitrate and nifedipine a significant delay in the appearance of angina and of signs of electrocardiographic positivity was observed while after treatment with oxprenolol a significant delay was noticed only in the time of appearance of electrocardiographic positivity. On the contrary, placebo did not determine significant changes in the studied parameters. The best results were achieved with the associations oxprenolol-isosorbide dinitrate and oxprenolol-nifedipine. With these treatments, angina appeared during the exercise test in only two patients while the others had to stop the test because of muscular exhaustion; electrocardiographic signs of ischemia did not appear in one patient. The favourable results of the associations oxprenolol-isosorbide dinitrate and oxprenolol-nifedipine can be explained by the pharmacologic effect of these drugs and by their complementary action.

[Oxprenolol in the treatment and prevention of cardiac arrhythmias]. / L'oxprenololo nel trattamento e nella profilassi delle aritmie cardiache

Authors have analyzed the antiarrhythmic effect of oxprenolol, a beta blocking agent, in the treatment of various types of arrhythmias and in the prophylaxis of recurrences of auricular flutter and fibrillation. The results obtained in a group of 68 cases of different arrhythmias may be summarized in the following way: a) the drug efficiently reduces the ventricular rate in sinus tachycardia and in atrial flutter and fibrillation with high ventricular rate, even if resistant to treatment with digitalis; b) in patients with asynchronous pacemaker oxprenolol leads to disappearance or an important reduction of competitive rhythms; c) in supraventricular paroxysmal tachycardias the results are positive in the majority of cases (while on the contrary in 2 cases of ventricular tachycardias the drug was not effective). A group of 116 cases with auricular flutter or fibrillation (in which sinus rhythm had been restored with quinidine or cardioversion has been analyzed to study the prophylactic activity of oxprenolol in these arrhythmias. The cases have been divided at random into two groups and have been treated with quinidine (g 0.80 p.d.) or with an association of oxprenolol (mg 60 p.d.) and quinidine (g 0,60 p.d.). The observation period varied from a minimum of 1 month to a maximum of 3 years and 3 months. The curves showing the percentage of persistance of sinus rhythm in the two groups were very similar and after 3 years and 3 months 100% of patients observed presented a recurrence of arrhythmias.