HIV-related pulmonary hypertension. From pathogenesis to clinical aspects.

HIV-related pulmonary hypertension (HIV-PH) is a cardiovascular complication of HIV infection that has been recognized in the last years with increasing frequency. HIV-related pulmonary hypertension is a clinical disorder which carries a bad prognosis. While a direct HIV infection of the pulmonary vessels in the pathogenesis of this disorder was not demonstrated, currently a multifactorial pathogenesis of this disease could be hypothesized. Echocardiography has been found to be the most useful screening imaging modality for the diagnosis of HIV-PH, with a high predictive negative value and a low positive predictive value. For this reason Doppler echocardiography is not the gold standard in the diagnosis of HIV-PH. The treatment of HIV-PH is complex and controversial. To date, no study determining the agent of choice for the treatment of this disease exists. Different studies have shown variable results in patiens with HIV-PH treated with highly active antiretroviral therapy (HAART) but only HAART seems not to be effective in lowering pulmonary hypertension in these patients, and in some patients, HIV-PH develops in spite of a previous HAART. It seems reasonable in HIV-PH patients that a treatment with oral vasodilator drugs can improve the adherence of a long-lasting and complex antiretroviral therapy.

About cardiovascular risk in non-cardiac surgery.

The perioperative management of patients at risk for cardiovascular diseases who undergo non-cardiac surgery has been subject of debate over the past few decades and is still of great interest. An adequate perioperative management may modify postoperative mortality and morbidity and may improve the long-term prognosis. The purpose of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative and postoperative management. In spite of the available guidelines (the American College of Cardiology and the American Heart Association of 1996) and of several studies on this subject, many controversies still persist. The main questions are: 1) the preoperative cardiovascular evaluation through non-invasive tests (and the true predictive value of the increased cardiovascular risk) and 2) the real benefit of coronary revascularization before non-cardiac surgery. The last part of this review highlights many recent clinical observations and experimental studies regarding the efficacy of the extensive use of beta-adrenergic receptor blockers and optimized anti-ischemic pharmacological therapy in reducing the cardiovascular risk of non-cardiac surgery and in improving the long-term prognosis.

[Syndrome of cholesterol crystal embolism: clinical case]. / Sindrome da embolia di cristalli di colesterolo: un caso clinico.

Cholesterol crystal embolization syndrome is a multiorgan disease that frequently occurs as a complication of invasive cardiovascular procedures and of thrombolytic or anticoagulant therapy. The symptoms are due to the displacement of atheromatous material dislodged from unstable or injured, by mechanical manipulation, plaque to arteriolar vessels. The real incidence of cholesterol embolization is not known. Often the diagnosis is missed because of the time between intervention and clinical findings and because the organs involved can be many and various. The most common clinical manifestations are acute renal failure and hypereosinophilia. The prognosis is poor and the mortality high because of the progression of renal failure. In this case report we present the clinical history of a 62-year-old male patient with a history of cigarette smoking and hypertension who was submitted to emergency surgery following the acute dissection of a type A aortic aneurysm. About 2 weeks after surgical intervention the patient developed a multiorgan disorder (gastroenteric, neuromuscular and renal involvement) associated with hypereosinophilia and with increased levels of the markers of inflammation. The symptoms were transient and probably due to embolization of cholesterol crystals; no specific therapy was administered. On the other hand, no therapeutic regimen has been codified to date. The best clinical approach is prophylactic, that means identifying those patients who are at high risk for an invasive vascular procedure.