[Non-hemorrhagic stroke, of possible aortoembolic origin, in the course of acute myocardial infarct treated with thrombolysis]. / Stroke non emorragico, di possibile origine aortoembolica, in corso di infarto miocardico acuto trattato con trombolisi.

We describe the case of a middle-aged man with nonhemorrhagic stroke occurred during thrombolysis for acute myocardial infarction. The ischemic etiology of stroke was demonstrated by cerebral computed tomography scan. Transthoracic echocardiogram excluded left ventricular thrombosis. Transesophageal echocardiogram displayed complicated atheromas of the aortic arch. The reported case emphasizes that aortic atheromas may be the source of emboli during thrombolytic therapy.

[Atrial fibrillation: always cardioversion? No]. / Fibrillazione atriale: cardiovertire sempre? Parere contro.

Two major treatment strategies have emerged in the management of patients with atrial fibrillation (AF): restoration of sinus rhythm and antiarrhythmic drug prophylaxis versus ventricular rate control and chronic anticoagulation. Besides the potential benefits of the restoration of sinus rhythm, several considerations support the choice of controlling the heart rate, mainly the poor efficacy of antiarrhythmic drug prophylaxis. The decision of pursuing the AF cardioversion should be based mainly on the importance of sinus rhythm restoration and the probability of sinus rhythm maintenance. The factors conditioning the maintenance of sinus rhythm following cardioversion are the duration of AF, cardiac size and function, underlying heart disease, the NYHA functional class, and the timing and number of AF recurrences. At least one attempt at cardioversion is warranted in the majority of patients with a first ever episode of AF; however, it seems advisable to give up even the first attempt at cardioversion in the mildly symptomatic patients who are very old, in patients with AF episodes dating back more than 24-36 months and in those with severe valvular heart disease or severe left ventricular dysfunction. A repeated attempt at cardioversion is usually indicated at the first recurrence of AF; repeated cardioversion seems unadvisable in patients with long-standing AF and early recurrence, in case of failure of amiodarone prophylaxis or of side effects of antiarrhythmic drugs, and when the patient is inclined not to undergo a new electrical cardioversion procedure. In patients with further recurrences of AF it is convenient to give up the cardioversion in case of mild symptoms, of failure of several antiarrhythmic drug regimens and when the withdrawal of oral anticoagulant therapy following sinus rhythm restoration is not safe. With regard to mortality, morbidity, quality of life and cost-effectiveness, the strategy of choice has not yet been established. Several large prospective randomized clinical trials comparing cardioversion and antiarrhythmic prophylaxis versus ventricular rate control are ongoing. The results of these studies could, in the near future, provide useful indications for the choice of the therapeutic regimen to be employed.