[The use of cardiac markers bed test in acute coronary syndrome in emergency department]. / Utilizzo dei biomarcatori cardiaci bed-test nella sindrome coronarica acuta nel Dipartimento di Emergenza.

AIMS: The evaluation of the patient with chest pain in the emergency department is one of the most common situations that the doctor has to face. The diagnostic procedure supposes an observation period of at least 6-12 hours, a well organized medical facilities and the identification of all SCA cases to reduce inappropriate admission. MATERIALS AND METHODS: In our study we have estimated the utility of the marker assay that is associated to the use of risk scores (TIMI and GRACE risk score) to obtain indication about the most appropriate assistance level. In particular, we used the assay of necrosis markers to highlight the damage along with the assay of natriuretic peptides for their role in the diagnosis and in the monitoring of the patients with cardiac damage. RESULTS: Also PCR has an important role such as marker of plaque stability and of inflammation. These markers associated to the necrosis markers could give important clinical information of independent nature. DISCUSSION: The sensibility of laboratory markers, without important necrosis, is low and it is not possible to exclude in a few time a SCA There is now an alternative strategy: a precocious risk stratification. Using clinical criteria it is possible to do a first evaluation of the probability of SCA and the complications.

[Therapy optimization of heart failure through the evaluation of the plasma concentration variation of B-type natriuretic peptide]. / Ottimizzazione della terapia dello scompenso cardiaco attraverso il monitoraggio delle variazioni delle concentrazioni plasmatiche del peptide natriuretico di tipo B.

AIM: Our research was based over the critical evaluation of the plasmatic concentration variation of B-type Natriuretic Peptide in emergency in patients with heart failure during therapy with diuretics, anti-aldosterone, ACE-inhibitors, beta-blockers and nitroderivates. MATERIALS AND METHOD: We selected 108 patients: 30 control subjects (average 58.40 +/- SD13.32 for 20 M, and 65 +/- SD 14.74 for 10 W), and 78 subjects (average 75.90 +/- SD 9.60 for 41 M, and 77.89 +/- SD 8.62 for 37 W) arrived to the emergency and reception department for dyspnea and/or precordialgia and/or palpitations with heart failure diagnosis according to NYHA Classification. The variation of BNP concentration was evaluated in these subjects at the admission, after 1 week, and 1 month from the beginning of the therapy. RESULTS: Patients with heart failure had a BNP concentration high during all measurements. The values were high during admission, but after 1 week and after 1 month, they reduced reaching the balance. CONCLUSIONS: BNP evaluation is a good indicator for the diagnosis of heart failure and for improving the therapy. The main limit of BNP diagnostic role is the need of knowing in advance the specific values for each patient.

Prognostic significance of admission levels of troponin I in patients with acute ischaemic stroke.

OBJECTIVES: Successful prediction of cardiac complications early in the course of acute ischaemic stroke could have an impact on the clinical management. Markers of myocardial injury on admission deserve investigation as potential predictors of poor outcome from stroke. METHODS: We prospectively investigated 330 consecutive patients with acute ischaemic stroke admitted to our emergency department based stroke unit. We analysed the association of baseline levels of cardiac troponin I (cTnI) with (a) all-cause mortality over a six month follow up, and (b) in-hospital death or major non-fatal cardiac event (angina, myocardial infarction, or heart failure). RESULTS: cTnI levels on admission were normal (lower than 0.10 ng/ml) in 277 patients (83.9%), low positive (0.10-0.39 ng/ml) in 35 (10.6%), and high positive (0.40 ng/ml or higher) in 18 (5.5%). Six month survival decreased significantly across the three groups (p<0.0001, log rank test for trend). On multivariate analysis, cTnI level was an independent predictor of mortality (low positive cTnI, hazard ratio (HR) 2.14; 95% CI 1.13 to 4.05; p = 0.01; and high positive cTnI, HR 2.47; 95% CI 1.22 to 5.02; p = 0.01), together with age and stroke severity. cTnI also predicted a higher risk of the combined endpoint "in-hospital death or non-fatal cardiac event". Neither the adjustment for other potential confounders nor the adjustment for ECG changes and levels of CK-MB and myoglobin on admission altered these results. CONCLUSIONS: cTnI positivity on admission is an independent prognostic predictor in acute ischaemic stroke. Whether further evaluation and treatment of cTnI positive patients can reduce cardiac morbidity and mortality should be the focus of future research.

[The Moschkowitz syndrome in emergency department. Case report]. / La sindrome di Moschkowitz nel Dipartimento di Emergenza. Case report.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening multisystem disorder of unknown etiology, first described by Moschkowitz in 1924. TTP is a thrombotic microangiopathy characterized by microvascular lesions with platelet aggregation. TTP is more common in adults and is associated with pregnancy; diseases such as HIV, cancer, bacterial infection, and vasculitis; bone marrow transplantation; and drugs TTP is a hematologic emergency. It is a multisystem disease that can cause rapid deterioration of the patient's neurologic, renal, and hematologic status. TTP is an uncommon disease with a high fatality rate if untreated or misdiagnosed. Rapid diagnosis and aggressive treatment by therapeutic plasma exchange are necessary to reduce the risk of a fatal outcome. Current clinical criteria for initiating therapy are: thrombocytopenia, and absence of other disease entities that could explain the thrombocytopenia. Early recognition and management are essential for patient survival. TTP is difficult to diagnose because the patient's presentation can be nonspecific and the characteristic pentad of symptoms may not occur together. Other disease entities can have some of the same symptoms. We discuss a case report of Moschkowitz syndrome in Emergency Department.

Telecar: an Italian telecardiology project.

The Telecar (tele-assistance cardiology) project was an example of tele-assistance between health centres of the Regione Lazio in Italy. The project was approved by the Ministry of Health, financed with 500,000,000 lire and carried out by an operative station within 'La Sapienza' University (Rome). About 40 of the health centres in Lazio that did not have cardiologists or electrocardiography (ECG) equipment were provided with telematic instruments (Cardiophone and fax). With this equipment, they were able to transmit ECG signals and receive copies of ECG reports. The 40 health centres included first-aid clinics, 'guardia medica' surgeries and community centres. The project was carried out between 1989 and 1992. During these three years the health centres transmitted a total of 4807 ECGs, 2057 (43%) of which were routine, the remaining 2750 (57%) being suspected emergencies. Of the suspected emergencies, 681 cases (25%) had a confirmed abnormality. We can confirm that telematic aids are very important for an operative station, where all kinds of emergencies must be dealt with.

[Praecox feeling in medicine]. / Praecox gefüll in medicina.

In this work the idea of praecox gefüll or praecox feeling is resumed by H. C. Rumke in 1941 and by Minkowski in 1968 for patient with schizophrenia. The diagnosis is not done only by patient's examination and by symptoms, but also by diligent examination which the psychiatry does about himself. To perceive one and to diagnose by praecox feeling is a personal ability, but it is a training with ourselves: to be sensible of the "effect" of disease in us. The praecox feeling, attributed in psychiatry, may be expanded in other medical areas. Case report gives evidence about this.

[The evaluation of in-hospital precoronary times. The experience of a department of emergency medicine]. / Valutazione dei tempi precoronarici intraospedalieri. Esperienza di un dipartimento di medicina d'urgenza.

The above study was aimed at evaluating the "in-hospital precoronary times" of patients with acute myocardial infarction presenting to the Emergency Department of Policlinico Umberto I, Rome. From April to August 1993, 58 cases of acute myocardial infarction were admitted. In six of these, over 24 hrs had elapsed before admission. In 24 of the remaining cases thrombolysis was indicated. Mean time before admission to the coronary unit was 5 hrs for 52 patients. Mean in-hospital delay before starting thrombolysis was 40 +/- 20 minutes; mean delay before admission to the coronary unit was 3 h/45 min. In-hospital time before thrombolysis was one of the lowest in the literature and shows the efficient organization of the department. Delay until transfer to the coronary unit was long and is a sign of the paucity of these specialized beds. Therefore, the possibility to perform thrombolytic therapy immediately in the emergency department becomes even more essential.

[Drug-induced toxic hepatitis]. / Epatite tossica da farmaci.

The case is described of a woman with drug hepatotoxicity, who was a psychiatric patient. The case is reported because the diagnosis occurred by a "praecoxfeeling", in fact physician's intuition is a personal structure which is born from same external incitements instead of other. The diagnosis was confirmed by clinical tests and by subsequent clinical research.

Enhanced release of atrial natriuretic factor during exercise-induced myocardial ischaemia in patients after acute myocardial infarction.

To determine whether acute myocardial ischaemia induced by dynamic exercise can lead to changes in plasma levels of atrial natriuretic factor, we performed symptom-limited bicycle electrocardiographic tests in 20 males with recent acute myocardial infarction and in 8 control males. Ten patients developed exercise-induced myocardial ischaemia and 10 patients did not. There were no significant differences between the two groups with regard to age, site of myocardial infarction, urinary sodium, atrial sizes, radionuclide left ventricular ejection fraction, workload, baseline and peak-exercise heart rate, baseline and peak-exercise rate-pressure product, duration of exercise. Also baseline atrial natriuretic factor concentrations were similar in both groups (ischaemic patients: 34.51 +/- 15.73 pg/ml; nonischaemic patients: 27.17 +/- 8.74 pg/ml, NS), while peak-exercise atrial natriuretic factor concentrations were higher in patients with exercise-induced myocardial ischaemia (112.31 +/- 35.5 pg/ml) than in the others (80.46 +/- 23.43 pg/ml) (P less than 0.05). After 15 minutes of recovery, plasma atrial natriuretic factor levels were still raised only in the ischaemic patients (63.3 +/- 15.44 pg/ml, P less than 0.01), returning to baseline after 30 minutes in both groups. In control subjects, the behaviour of atrial natriuretic factor resembled that of the patients without exercise-induced ischaemia, with a significant increase at peak-exercise (from baseline levels of 23.1 +/- 10.5 pg/ml to peak-exercise levels of 91.3 +/- 14.5 pg/ml, P less than 0.0005) and a rapid return to baseline levels after 15 minutes of recovery (28.5 +/- 10.6 pg/ml, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[Changes in the atrial natriuretic factor and the renin-angiotensin-aldosterone axis induced by maximum exertion in subjects with a recent myocardial infarct]. / Modificazioni del fattore atriale natriuretico e dell'asse renina-angiotensina-aldosterone indotte dallo sforzo massimale in soggetti con recente infarto del miocardio.

To examine the effect of exercise-induced myocardial ischemia (EIMI) on atrial natriuretic factor (ANF), plasma renin activity (PRA) and aldosterone (PA), a maximal exercise test in 12 patients with recent acute myocardial infarction (AM) was performed. ANF, PRA and PA were measured by radioimmunoassay at baseline, peak-exercise and at 15 min after recovery. Four patients developed EIMI (group I) and 8 patients did not (group II). ANF increased in all patients from baseline to peak-exercise (27.7 +/- 9.5 pg/mL vs 92.7 +/- 26.7 pg/mL, p less than 0.0005) and it was still elevated 15 min after recovery. Baseline ANF was similar in both groups while at peak-exercise it was higher in group. I than in group II (112 +/- 15 pg/mL vs 82 +/- 26 pg/mL p less than 0.05). After 15 min of recovery, ANF was higher in group I than in group II (67 +/- 20 pg/mL vs 32 +/- 10 pg/mL, p less than 0.01), resulting higher than at baseline only in group I (p less than 0.05). PRA and PA also increased during exercise but their values rose more slowly and were the same in both groups. Thus, ANF, PRA and PA increase during exercise in patients after AMI, and EIMI is associated with higher ANF plasma levels.

[Effects of flecainide in patients with non-sustained ventricular tachycardia and impaired left ventricular function]. / Effetti della flecainide in pazienti con tachicardia ventricolare non sostenuta e ridotta funzione ventricolare sinistra.

Anti-arrythmia efficacy and effects on left ventricular function of flecainide have been evaluated in 9 patients with symptomatic non sustained ventricular tachycardia (NSVT) and left ventricular ejection fraction (LVEF) lower than 30%, respectively detected by Holter monitoring and radionuclide angiocardiography in basal conditions. Seven to eleven days after starting flecainide therapy (100 mg b.i.d.), Holter and radionuclide angiocardiography were repeated. In 56% of patients a ventricular premature beats (VPB) reduction more than 70% was obtained and total VPB suppression was achieved in 33% of patients. Total suppression of NSVT was obtained in 67% of patients; LVEF did not show significant changes. Thus, antiarrhythmic efficacy of flecainide resulted in agreement with the previous reports, whereas no patient developed signs or symptoms of heart failure or pro-arrhythmia.

Early hepatitis during intravenous amiodarone administration.

Two patients with acute changes suggesting acute hepatitis after parenteral amiodarone administration are described. No other explanation for liver damage was found in these patients. Normalization of liver function in spite of continuation of drug infusion was observed.

Antiplatelet treatment with ticlopidine in unstable angina. A controlled multicenter clinical trial. The Studio della Ticlopidina nell'Angina Instabile Group.

We conducted a controlled multicenter trial with central randomization and evaluation of events under blind conditions involving 652 patients with unstable angina. Patients were treated either with conventional therapy alone (group C) (n = 338) or with conventional therapy combined with an inhibitor of platelet aggregation, ticlopidine 250 mg b.i.d. (group C + T) (n = 314). Patients were assigned randomly within 48 hours of admission and followed up for 6 months. With the "intention-to-treat" approach, the primary end points, vascular death and nonfatal myocardial infarction, were observed in 13.6% of the patients in group C and in 7.3% of the patients in group C + T, which is a reduction in risk of 46.3% (p = 0.009). Vascular mortality was 4.7% in patients in group C and 2.5% in patients in group C + T, which is a reduction in risk of 46.8% (p = 0.139). The risk of nonfatal myocardial infarction was reduced by 46.1% (p = 0.039), with a frequency of 8.9% in patients in group C and 4.8% in patients in group C + T. New Q wave myocardial infarction occurred with a frequency of 6.8% in patients in group C and 3.8% in patients in group C + T, which is a reduction in risk of 44.1% (p = 0.091). Fatal and nonfatal myocardial infarction was 10.9% in patients in group C and 5.1% in patients in group C + T, which is a reduction in risk of 53.2% (p = 0.006). These findings confirm the importance of platelets in the pathogenesis of unstable angina and the usefulness of antiplatelet treatment for the prevention of cardiovascular events.

[Monitoring of respiratory exchange during ergometric test in patients with heart failure: current aspects and prospects]. / Monitoraggio degli scambi respiratori durante test ergometrico in pazienti con scompenso cardiaco: attualità e prospettive.

The current techniques of respiratory gas-exchange monitoring during stress testing in patients with congestive heart failure have provided new physiopathologic and clinical data. The "breath-by-breath" measurement of oxygen consumption and carbon dioxide production and the evaluation of the relationship between these parameters and respiratory volumes, allow to determine both ventilatory and metabolic responses during exercise, thus giving a precise estimate of the effective cardiopulmonary functional capacity. The demonstration of peripheral vascular and metabolic abnormalities by these techniques have provided new insights into the mechanism of dyspnea and fatigue in patients with heart failure. Although the relationship between respiratory and metabolic parameters and hemodynamics has been extensively studied, its mechanisms are still unclear. Moreover, controversy still exists as to the link between functional capacity and prognosis. Finally, recent studies on the cardiopulmonary adaptations to exercise training in patients with left ventricular dysfunction, have clearly demonstrated clinical and hemodynamic improvement after conditioning. These data, if confirmed, may provide a new approach in the management of patients with this disorder.

[Computers in emergency medicine]. / L'informatica in medicina d'urgenza.

Computer's applications in emergency medicine are reviewed. In the Emergency Health Care computer science provides support to the solution of medical problems (with diagnostic and medical decision making softwares) and to the management of emergency departments. Computer interfaced to instrumental equipments allows the monitoring of biomedical signals and their transmission at distance. Finally, the possibilities of computer-aided instruction are presented. Teaching methods such as the tutor-system and the simulation are discussed.

[Holiday heart syndrome: spontaneous reversibility of the electrocardiographic and echocardiographic alterations]. / "Holiday heart syndrome": reversibilità spontanea di alterazioni elettrocardiografiche ed ecocardiografiche.

The holiday heart syndrome is characterized by symptomatic arrhythmias more often supraventricular, elicited by alcohol ingestion, typically during the week-end period. After admission, electrocardiographic changes, which disappear in few days, are often reported. A case of an alcoholic with syncopal episodes related to alcohol ingestion is described. In this patient, remarkable changes of ventricular repolarization on the electrocardiogram associated with impairment of ventricular diastolic function on the Doppler echocardiographic study are showed. ECG and echo-Doppler data reversed to normality after few days of alcohol withdrawal.