[Appropriateness in Cardiology: a statement of the ANMCO Veneto Region]. / L'appropriatezza prescrittiva in Cardiologia: documento dell'ANMCO Regione Veneto.

Inappropriate tests are responsible for longer waiting lists, higher economical costs for the National Health System and major clinical risks due to radiation exposure from prescription abuse of diagnostic testing. Clinical inappropriateness frequently derives from poor knowledge of guidelines, "defensive medicine" approach and/or repeat requests of patients and family members. About one third of non-invasive imaging tests are considered inappropriate.In order to define the most appropriate instruments for the follow-up of the most common cardiovascular diseases with the highest risk of inappropriateness, all the cardiologists of the Veneto Region (Italy), along with the local chapters of the main national cardiology societies and general practitioners have been involved by the Regional Section of the Italian Association of Hospital Cardiologists (ANMCO) in several scientific meetings on the following topics: hypertension, chronic ischemic heart disease, valvular heart disease, heart failure, and atrial fibrillation. This has led to the present document where: (i) the most appropriate clinical and diagnostic strategies are taken into account, and (ii) the most robust scientific evidence is provided for the regulatory commission of the Veneto Region Health Service to identify inappropriateness, prescription unsuitability, and economical sustainability.

Intraventricular conduction disturbances and paroxysmal atrioventricular block in a young patient with MELAS.

We present the case of a 36-year-old male patient with MELAS (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) who developed intraventricular conduction disturbances and syncopal episodes due to a paroxysmal atrioventricular block. This case suggests that in MELAS, as well as in other mithochondriopathies, intraventricular conduction disturbances and atrioventricular block can be features of the disease. In our case, progression toward atrioventricular block was rapid, suggesting that in MELAS patients presenting with worsening conduction system anomalies, pacemaker implantation has to be considered without delay, irrespective of age.

[Right ventricular mural endocarditis: description of a case]. / Endocardite murale del ventricolo destro: descrizione di un caso.

We report the case of a 45-year-old man addicted to intravenous drug abuse who was admitted to our hospital for dyspnea, fever and chest pain. Chest X-ray showed diffuse right lung opacity and pleural effusion. Transthoracic echocardiography and contrast-enhanced cardiac magnetic resonance imaging revealed a plurilobated, highly mobile mass in the right ventricle originating from the moderator band near the apical trabeculae. Cardiac structure and valves were normal. Blood cultures were positive for Staphylococcus hominis. The diagnosis of infective endocarditis with mural vegetation was made. Specific antibiotic therapy was started with success and after 3 weeks the mass disappeared. Infective endocarditis with mural vegetation in the absence of valvular lesions is uncommon. Differential diagnosis is always required, but clinical course should be our guide in decision making.

Metastatic tumor of the heart: description of a case.

We present the case of a 67-year-old man with a carcinoma of the lung and a metastatic tumor of the heart. The diagnosis was made on the basis of echocardiogram. In this patient, the first and unique cardiac symptom was irreversible sustained ventricular arrhythmia leading to death.

[When and how to treat ventricular ectopic beats]. / L'extrasistolia ventricolare isolata: quando e come trattarla.

Ventricular ectopic beats are commonly observed in daily clinical practice, either in symptomatic or asymptomatic subjects. In many subjects these arrhythmias are casually detected during a screening visit. Their occurrence is usually associated with no clinical significance. However, in some cases the presence of ventricular ectopic beats indicates susceptibility towards life-threatening arrhythmias or ventricular dysfunction. Appropriate ECG analysis and clinical evaluation are important to detect subjects in whom effective treatment is necessary.

Persistent atrial fibrillation associated with syncope due to orthostatic hypotension: a case report.

A 40-year-old man was referred to our Cardiology Unit because of three syncopal episodes. The ECG showed atrial fibrillation with a mean heart rate of 104 bpm. The patient was unable to maintain the upright position because of marked orthostatic hypotension associated with bradycardia and presyncope. Two days later the patient underwent direct current shock with sinus rhythm restoration. After the procedure both symptoms and orthostatic hypotension disappeared. A tilt test induced marked hypotension and bradycardia only after nitroglycerine. This is the first report of a patient with persistent atrial fibrillation associated with syncope caused by orthostatic hypotension and bradycardia. The patient's clinical features and positive tilt test only after nitroglycerine lead us to hypothesize that the arrhythmia plays a more important role in the etiology of symptoms with respect to autonomic impairment and that the pathophysiological mechanism responsible for these symptoms could be mainly the baroreceptor reflex.

Menopause does not affect blood pressure and risk profile, and menopausal women do not become similar to men.

OBJECTIVE: Menopause is considered to be a cardiovascular risk factor, but this belief is based on opinions rather than on evidence. Confounding effects of age are often neglected. DESIGN: Population-based study with further subanalysis of case-to-case age-matched cohorts of men and fertile and menopausal women. SETTING: Epidemiology in primary, public, institutional frame. PARTICIPANTS: Nine thousand three hundred and sixty-four men and women aged 18-70 years representative of Italian general population followed-up for 18.8 +/- 7.7 years. MAIN OUTCOME MEASURES: Blood pressure (BP), prevalence and incidence of hypertension, serum total, high-density lipoprotein and low-density lipoprotein cholesterol, glucose tolerance, body adiposity, vascular reactivity, target organ damage, overall and cardiovascular mortality and morbidity, by gender and by menopausal status. RESULTS: Cross-sectional: crude BP, pressor response to cold, orthostatic BP decrease, BMI, skinfold thickness, fasting and postload blood glucose and insulin, serum lipids, left ventricular mass, serum creatinine, microalbuminuria and augmetantion index were higher in menopausal than in fertile women, and comparable in menopausal women and men, a difference that was no longer present when adjusting for age or considering age-matched cohorts. Longitudinal: BP increase during follow-up, cardiovascular mortality and morbidity were greater in menopausal than in fertile women, and comparable in menopausal women and men, a difference no longer present in age-matched cohorts. Menopausal status was rejected from multivariate Cox analysis also including age. CONCLUSION: The cardiovascular effects usually attributed to menopause seem to be a mere consequence of the older age of menopausal women.

Electrocardiographic criteria of left ventricular hypertrophy in general population.

The question on whether the electrocardiographic criteria are reliable for detection of left ventricular hypertrophy (LVH) and play a role in predicting outcome is open. Answer can only proceed from population-based studies over unselected people followed up for years. In this study, 1,699 subjects from general population underwent echocardiogram and standard electrocardiogram (ECG) codified for LVH with Minnesota code and with other five methods. Other items were also recorded and used as covariables. Left ventricular mass index (LVMI) was 127.6 +/- 44.9 g m(-2) in men and 120.8 +/- 41.2 g m(-2 )in women, and correlated directly with age in both genders. Prevalence of echocardiographic LVH was 36.6% in men and 53.4% in women. LVMI correlated directly with the Sokolow-Lyon score in both genders at any age, with the Romhilt-Estes, Cornell and R(aVL) scores in all subjects but elderly men, and with the Lewis score in men and women aged < or =69 years. Sensitivity and the predictive value of electrocardiographic tests, as well as the prevalence of LVH diagnosed with electrocardiographic criteria, were always low. Specificity was high for all the tests, and in particular for the Cornell index. Only when diagnosed with echocardiogram or with the Sokolow-Lyon criterion, LVH was an independent predictor of mortality. We conclude that electrocardiographic tests cannot be used as a surrogate of echocardiogram in detecting LVH in the general population because their positive predictive value (PPV) is unacceptably low. On the contrary, they could replace echocardiography in the follow up and for prediction of outcome, when LVH has previously been correctly diagnosed with other methods.

Effects of the C825T polymorphism of the GNB3 gene on body adiposity and blood pressure in fertile and menopausal women: a population-based study.

OBJECTIVES: The 825T allele of the GNB3 gene is implicated in adipose distribution, predisposing to obesity and hypertension. Menopause is also considered a condition leading to excess adiposity and hypertension. The aim of the present study was to clarify whether the effects of menopause on body weight and blood pressure are influenced by the C825T polymorphism of the GNB3 gene. METHODS: The study involved 1339 subjects (43% men) aged 18-95 years, genotyped at the GNB3 825 locus, undergoing, in an epidemiological population-based frame, questionnaire, anthropometrics and blood examinations. RESULTS: Mean skinfold thickness (MST), truncal obesity and excess subcutaneous adiposity (MST greater than median) were higher in women than in men. A significant interaction was detected between menopausal status and the C825T polymorphism (Pint > 0.0001). MST, truncal obesity and excess subcutaneous adiposity were lower in CC fertile than menopausal women, but were comparable in TT fertile and menopausal women. In a multivariate logistic model for excess subcutaneous adiposity, the relative risk of menopause was 4.12 (95% confidence interval 2.35-7.22) in CC women but was insignificant in the other two genotypes. In fertile women only, higher systolic blood pressure (SBP) was detected in TT than in CC genotypes. CONCLUSION: An interaction exists between the C825T polymorphism and menopause in controlling body adiposity and blood pressure in women. Adiposity and SBP are higher in menopausal than in fertile women, provided they have the CC genotype. TT fertile women show the same adiposity as those in menopause. Men have the same excess adiposity as menopausal women, independent of the GNB3 genotype.

Atrio-ventricular block during left atrial flutter ablation.

We present a case of a patient treated with catheter ablation for atrial fibrillation aiming to pulmonary veins isolation. During ablation, atrial fibrillation organized into a left atrial flutter. Electroanatomic and electrophysiologic mapping revealed the anterior left atrium area between the mitral annulus and left atrium septum as a critical region for flutter ablation. After a few pulses of radiofrequency, complete atrio-ventricular block appeared. Finally, we propose pace mapping of the mitral annulus to detect left dislodgment of the compact atrio-ventricular node.

Long-term outcome of patients with atrioventricular node reentrant tachycardia.

BACKGROUND: Little information is available on the natural history of patients with AVNRT. The purpose of this study was to compare the outcome of patients with Atrioventricular node reentrant tachycardia (AVNRT) who underwent ablation with those on antiarrhythmic therapy and those not receiving drugs. METHODS: 93 consecutive patients (mean age=33.5+/-18.1 years) with AVNRT referred to our institution from 1988 to 1993 were prospectively followed-up for a mean of 13.2+/-2.0 years (range=11.4-16.1 years). RESULTS: 18 patients underwent ablation (group 1), 24 received antiarrhythmic therapy (group 2), 38 received no drugs or remained on drug therapy for only few months (group 3), 3 died and 10 were lost to follow-up. The frequency of symptoms at the baseline was higher in group 1 than in groups 2 and 3 (7.8+/-3.7, 3.5+/-2.3, 2.3+/-1.9 episodes/month, respectively; p<0.02 in group 1 vs. group 3). At the end of the follow-up 18/18 (100%) of group 1, 14/23 (61%) of group 2 and 17/38 of group 3 (44.7%) reported being asymptomatic for the previous 3 years. Group 3 patients who became asymptomatic had a shorter duration of symptoms before enrolment (3.7+/-1.5 vs. 7.1+/-3.6 years, p<0.05) and a shorter mean length of the tachycardia episodes (3.8+/-2.4 vs. 42.6+/-17.8 min, p<0.02) than patients from the same group who remained symptomatic. CONCLUSIONS: The main result of this study is that during a long-term follow-up a considerable number of untreated patients with AVNRT become asymptomatic. This finding should be considered for choosing treatment modality and for calculating healthcare costs of ablation vs. medical therapy.

Effect of body weight loss on blood pressure after 6 years of follow-up in stage 1 hypertension.

BACKGROUND: Although it is known that weight reduction reduces blood pressure (BP) in overweight patients, the optimal body weight (BW) loss in terms of BP response is not yet established. We evaluated the relationship between decrease in BW and BP over time in 796 stage 1 hypertensives. METHODS: The 166 subjects who lost BW were divided into four groups according to percent of BW loss at the end of a 74-month follow-up (G1, >2% to 5%, G2, >5% to 9%, G3, >9% to 13%, and G4, >13%) and were compared to the 219 subjects without changes in BW (G0, -2% to +2%). The BW increased (>2%) in the remaining 411 subjects. RESULTS: Among subjects with BW loss there was a progressive decrease in final systolic BP associated with BW loss category up to G3 (P = .007), therefore at the end of follow-up G3 had systolic BP 6.2 mm Hg lower than G0 (P = .06). However, among G3 and G4 subjects systolic BP decrease was almost identical (-6.2 nu -5.7 mm Hg, respectively, P = not significant). Similar results were obtained for diastolic BP, which declined up to G3 (P = .013). G3 had final diastolic BP 3.6 mm Hg lower than G0 (P = .037), whereas change in diastolic BP in G4 subjects was similar to that in G0 (-0.9 nu +0.1 mm Hg, respectively, P = not significant). Similar results were obtained in the group with body mass index (BMI) >27 kg/m(2). CONCLUSIONS: Our results indicate that in stage 1 hypertensives followed for more than 6 years the dose-response relationship between BW loss and decrease in BP is not linear irrespective of initial BW. The BW loss >13% of initial weight did not elicit additional BP decrease.

Heart rate as a predictor of development of sustained hypertension in subjects screened for stage 1 hypertension: the HARVEST Study.

OBJECTIVE: Whether heart rate predicts the development of sustained hypertension in individuals with hypertension is not well known. We carried out a prospective study to investigate whether clinic and ambulatory heart rates assessed at baseline and changes in clinic heart rate during 6 months of follow-up were independent predictors of subsequent blood pressure (BP). METHODS: The study was conducted in a cohort of 1103 white, stage 1 hypertensive individuals from the HARVEST study, never treated for hypertension and followed-up for an average of 6.4 years. Data were adjusted for baseline BP, age, sex, body fatness, physical activity habits, parental hypertension, duration of hypertension, cigarette smoking, alcohol consumption, and change of body weight from baseline. RESULTS: Clinic heart rate and heart rate changes during the first 6 months of follow-up were independent predictors of subsequent systolic blood pressure (SBP) and diastolic blood pressure (DBP) regardless of initial BP and other confounders (all P < 0.01). A significant interaction was found between sex (male) and baseline resting heart rate on final SBP (P = 0.017) and DBP (P < 0.001). The ambulatory heart rate and the heart rate white-coat effect did not add prognostic information to that provided by the clinic heart rate. Patients whose heart rate was persistently elevated during the study had a doubled fully adjusted risk (95% confidence interval 1.4-2.9) of developing sustained hypertension in comparison with subjects with a normal heart rate. CONCLUSIONS: Baseline clinic heart rate and heart rate changes during the first few months of follow-up are independent predictors of the development of sustained hypertension in young persons screened for stage 1 hypertension.

Pace mapping of Koch's triangle reduces risk of atrioventricular block during ablation of atrioventricular nodal reentrant tachycardia.

INTRODUCTION: Slow pathway (SP) ablation of AV nodal reentrant tachycardia (AVNRT) can be complicated by second- to third-degree AV block. We assessed the usefulness of pace mapping of Koch's triangle in preventing this complication. METHODS AND RESULTS: Nine hundred nine consecutive patients undergoing radiofrequency ablation of AVNRT were analyzed. Group 1 (n=487) underwent conventional slow pathway ablation. Group 2 (n=422) underwent ablation guided by pace mapping of Koch's triangle, which located the anterogradely conducting fast pathway (AFP) based on the shortest St-H interval obtained by stimulating the anteroseptal, midseptal, and posteroseptal aspects of Koch's triangle. In group 2, AFP was anteroseptal in 384 (91%), midseptal in 33 (7.8%), and posteroseptal or absent in 5 (1.2%). In 32 of 33 patients with midseptal AFP, slow pathway ablation was performed strictly in the posteroseptal area. In 4 of 5 patients with posteroseptal or no AFP, retrograde fast pathway was ablated. Two patients refused ablation. Persistent second- to third-degree AV block was induced in 7 (1.4%) of 487 group 1 patients versus 0 (0%) of 422 group 2 patients (P=0.038). Ablation was successful in all patients in whom ablation was performed. CONCLUSION: Pace mapping of Koch's triangle identifies patients in whom the AFP is absent or is abnormally close to the slow pathway. In these cases, guiding ablation helps to avoid AV block.

[Circumferential isolation of pulmonary veins with transcatheter radiofrequency ablation in the treatment of atrial fibrillation]. / Isolamento circonferenziale delle vene polmonari mediante ablazione transcatetere con radiofrequenza per il trattamento della fibrillazione atriale.

BACKGROUND: Circumferential anatomical isolation of the pulmonary veins by radiofrequency transcatheter ablation is a new technique for the treatment of atrial fibrillation (AF). The aim of our study was to evaluate the efficacy and the safety of circumferential radiofrequency ablation of the pulmonary veins and to analyze clinical, echocardiographic and procedural parameters as possible predictors of clinical success. METHODS: We performed circumferential isolation of the pulmonary veins in 33 patients with paroxysmal (15 patients) or persistent AF (18 patients) refractory to at least two antiarrhythmic drugs. All patients continued antiarrhythmic therapy after the procedure for at least 12 months. RESULTS: At the end of the follow-up (mean 13.7 +/- 5.1 months) 70% of the patients resulted responders to the ablation, with no differences between patients with paroxysmal and persistent AF. Complications were observed in 3% of patients. Among clinical, echocardiographic and procedural parameters analyzed none turned out to be predictor of clinical success. CONCLUSIONS: Circumferential isolation of the pulmonary veins by radiofrequency transcatheter ablation associated with antiarrhythmic drugs was efficacious in 70% of patients with either paroxysmal or persistent AF. None of the analyzed variables predicted clinical success.

Variables correlated with early relapses after external electrical cardioversion of persistent atrial fibrillation.

BACKGROUND: The aim of this study was to identify the clinical and echocardiographic variables possibly correlated with the early relapses of atrial fibrillation (AF) after external electrical cardioversion (EC) in a large cohort of patients with persistent AF. METHODS: Two hundred patients (117 males, 83 females, mean age 67.9 +/- 8.7 years) with successful EC of persistent AF (> 72 hours) were included in the present study. In order to identify the predictors of early relapses (within 7 days) of AF, 16 clinical and echocardiographic variables were compared at univariate analysis. The variables with a p value < 0.10 at univariate analysis were subsequently analyzed at multivariate analysis. RESULTS: Seventy-five patients (37.5%) had relapses of AF within 7 days of EC. By univariate analysis only a younger age (65.9 +/- 8.9 vs 69.0 +/- 8.3 years, p = 0.01) was found to be significantly correlated with a higher incidence of early relapses of AF. At multivariate analysis no variable was found to be significantly correlated with early relapses of AF. CONCLUSIONS: In patients with persistent AF, recurrences of this arrhythmia within 7 days of EC occur frequently (37.5%). Multivariate analysis did not reveal any clinical or echocardiographic variable significantly correlated with the early recurrence of AF.

Electrophysiological demonstration of dissociation of pulmonary vein potentials through electroanatomically guided circumferential ablation.

A 57-year-old woman with frequent isolated and repetitive premature atrial contractions initiating paroxysmal atrial fibrillation, underwent electrophysiological study and catheter ablation. A real-time three-dimensional map of the left atrium was reconstructed using a nonfluoroscopic navigation system. By means of a deflectable decapolar catheter, the left superior pulmonary vein (PV) was identified as the arrhythmogenic vein, and PV potentials were found in the left inferior and right superior veins. Ablation was performed under electroanatomic guidance. After circumferential ablation outside the PV ostia, dissociation of PV potentials was obtained in the left superior vein, and PV potentials were eliminated in the other two veins.

Effects of verapamil and metoprolol on recovery from atrial electrical remodeling after cardioversion of long-lasting atrial fibrillation.

The aim of this prospective, randomized study was to investigate the effect of pretreatment with two different intracellular calcium-lowering drugs (verapamil and metoprolol) on recovery from atrial effective refractory period (AERP) shortening after internal electrical cardioversion (EC) of persistent atrial fibrillation (AF) in patients on amiodarone. Twenty-one patients on amiodarone for at least 30 days were referred to our hospital for internal EC of a persistent AF refractory to external EC. They were randomized to receive only amiodarone (group AMI, n=7), or amiodarone and verapamil 240 mg/day (group VER, n=7), or amiodarone and metoprolol 100 mg/day (group MET, n=7). Left AERP was measured 10 min and 24 h after EC. AERP was also determined in 13 controls. The AERP after 10 min was significantly shorter in group AMI (201 (31) ms, P<0.02) and group MET (203 (34) ms, P<0.03) than in controls (249 (45) ms), but not in group VER (237 (51) ms, P=NS). The AERP after 24 h was still significantly shorter in group AMI (204 (38) ms, P<0.04) than in controls, but not in group MET (225 (52) ms, P=NS) or in group VER (290 (36) ms, P=NS). Pretreatment with amiodarone and verapamil prevents AERP shortening, while pretreatment with amiodarone and metoprolol only accelerated AERP recovery.

Radiofrequency ablation of atrioventricular nodal reentrant tachycardia: the risk of intraprocedural, late and long-term atrioventricular block. The Veneto Region multicenter experience.

BACKGROUND: Radiofrequency ablation of either the fast or the slow pathway in atrioventricular nodal reentrant tachycardia (AVNRT) can be complicated by transient or permanent atrioventricular (AV) block. Little is known about the possibility of AV block occurring during the first weeks after the procedure and nothing about the risk of AV block during the long-term follow-up. METHODS: To clarify these latter points, from February 1990 to December 2000 we enrolled 510 consecutive patients (56 males, 454 females, mean age 55 +/- 16 years) with AVNRT. The target of ablation was the fast pathway in 29 patients (group A) and the slow pathway in 474 (group B), while in 7 (group C) the slow pathway was targeted after unsuccessful fast pathway ablation. Follow-up was available for 488/510 (95.6%). The length of follow-up was 8.2 +/- 2.4 years in group A, 3.4 +/- 2.4 years in group B (83 group B patients had a follow-up > 6 years: 7.3 +/- 0.8 years), and 7.3 +/- 2.4 years in group C. RESULTS: The success rates were 93, 99 and 100% in the three groups respectively. Intraprocedural II-III degree AV block occurred in 6/29 patients (20%) of group A, in 11/474 patients (2.3%) of group B and in 3/7 patients (42%) of group C. In all patients of groups A and C, the II-III degree AV block was transient. In contrast, in 6/474 patients of group B (1.2%, 2 II degree and 4 III degree AV block) the block still persisted at the end of the procedure. Within 7 days of the procedure, a late persistent II-III degree AV block developed in 1/29 patients (3.4%, 1 III degree) of group A, in 1/474 patients (0.2%, 1 II degree) of group B and in 0/7 patients of group C. In 1 out of 6 patients of group B who developed an intraprocedural persistent AV block, 1:1 conduction resumed within the first week. A definitive pacemaker was implanted for permanent III degree AV block in 1/29 patients of group A (3.4%), in 4/474 patients (0.8%) of group B and in 0/7 patients of group C. In the remaining 2/474 group B patients with permanent II degree AV block, a pacemaker was not implanted. During follow-up, no patient presented with a II-III degree AV block related to the ablation. In group B, 2 patients received a pacemaker implant for reasons unrelated to the ablation (1 sick sinus syndrome, 1 progressive intraventricular conduction disease). CONCLUSIONS: The risk of permanent AV block in patients who undergo fast or slow pathway ablation is low and limited to the procedure or to the days immediately after the procedure, and there is no risk of II-III degree AV block during long-term follow-up.