Sensitivity, specificity and predictive accuracy of Q wave, QX/QT ratio, QTc interval and ST depression during exercise testing in men with coronary artery disease.

One hundred forty-three subjects (107 with coronary artery disease [CAD], 23 without CAD [evaluated by coronary angiography] and 13 athletes) were selected for this study. All subjects underwent exercise testing to evaluate sensitivity, specificity and predictive value of Q wave, QX/QT ratio, QTc interval and ST depression. The Q-wave analysis revealed less sensitivity (49%) and less specificity (83%) than ST depression (71% and 97%, respectively). The QTc criterion had greater sensitivity (80%) than ST depression but less specificity (11%). The QX/QT criterion was no different in sensitivity (74%) but had less specificity (69%). To establish the statistical evaluation of the positive predictive value in CAD, variations in the prevalence of the disease were considered. A 90% prevalence gives the best positive predictive value on all evaluated measurements, between 100% for ST depression and 89% for the QTc criterion. A 5% prevalence, however, gives an acceptable positive predictive value only on ST-segment depression (57%).

Left ventricular function in thalassemia major: protective effect of deferoxamine.

OBJECTIVE: To test the hypothesis that chelation therapy with deferoxamine would prevent alterations in left ventricular systolic and diastolic function due to transfusional iron overload in patients with thalassemia major. DESIGN: A consecutive series of patients receiving chronic transfusional and chelation therapy were studied by two-dimensional and Doppler echocardiography. SETTING: Primary clinic. PATIENTS: Eight thalassemic patients (four men and four women), mean age 22 years (range 14 to 28) and seven age and sex matched control subjects. INTERVENTIONS: All patients had received transfusional therapy since birth, with mean annual load of red blood cells of 200 mL/kg. Iron chelation therapy with deferoxamine, using a subcutaneous infusion pump, was administered from age two years in the younger patients and from age 16 years in the two older cases. Doses were 25 mg/kg/day in children and 1.5 to 4 g per 12 h in adults to maintain ferritin blood levels at 1000 to 1500 ng/L. MAIN RESULTS: No significant differences were found in the following Doppler diastolic indexes: isovolumic relaxation time, early flow velocity (E wave), late flow velocity (A wave), E:A ratio, rate of deceleration of flow velocity in early diastole (EF slope), flow velocity deceleration time and end-diastolic volume. Ejection fraction was similar in the two groups (59 +/- 7 versus 64 +/- 5%), but contractility, expressed as end-systolic pressure/end-systolic volume index, appeared slightly depressed (4.6 +/- 1 versus 6.7 +/- 0.8) in the thalassemic group. CONCLUSIONS: Deferoxamine prevents alteration of left ventricular diastolic function in chronic transfusional therapy for thalassemia major. Depression of contractility, in spite of a normal ejection fraction, may be an early sign of worsening systolic performance, unavoidable even with chelation therapy.

Lidoflazine and physical training in the treatment of stable angina pectoris.

An additive effect in the treatment of angina pectoris by combining lidoflazine and physical training was postulated. Twenty-four patients were randomly divided into placebo and drug groups and subsequently underwent a 6-month physical training program. The drug group had a significantly greater reduction in submaximal heart rate than the placebo group. Similar improvements in symptom-limited exercise capacity were observed in both groups. Resting and maximal exercise coronary sinus blood flow and left ventricular oxygen consumption were not significantly changed with training in either group. Physical training and lidoflazine appear to influence exercise tolerance in the same manner.

Natural and post-surgical history of mitral stenosis and mitral stenosis and insufficiency: an observational study.

Natural and post-surgical history has been investigated in 410 pts with mitral stenosis and 209 pts with mixed mitral stenosis and regurgitation. They had undergone cardiac catheterization in the years 1968-1980. Hemodynamic data and clinical status (NYHA class) have been statistically analyzed in order to obtain prognostically useful parameters. In mitral stenosis peak pulmonary artery pressure is the most important parameter for natural history, whereas cardiac index is the leading parameter in the operated patients. Commissurotomy has a very low surgical mortality, largely due to the better conditions of the patients undergoing this type of conservative surgery. Results are similar in mixed mitral stenosis and regurgitation. Surgery markedly improves survival in comparable patients. Therefore, intervention seems to be indicated especially in patients with elevated pulmonary artery pressure, because they can get the maximum advantage at a minimal risk.

[Company Wide Quality Control (total quality): methodological principles and intervention techniques for step-by-step improvement]. / Company Wide Quality Control (qualità totale): principi metodologici e tecniche di intervento per un miglioramento continuo a piccoli passi.

The concept of Quality is particularly up to date and not a new one for the Journal. The need for better Quality is a must also in Medical care. Quality doesn't mean additional costs and excessive burden for the co-workers. On the contrary, initial costs can be compensated for through a more rational utilisation of the resources. The consequent better service for the patient results in an ameliorated working environment, with high profits. Fundamental requirements for reaching concrete results are: 1) the convinced involvement in the idea of all levels (division, service, laboratory) in order to have the different groups act in synergism towards common goals; 2) the knowledge of appropriate methods. The Authors examine this last point with a deep analysis of the techniques involved in Company Wide Quality Control (C.W.Q.C.) or Total Quality. The improving process has to the continuous and proceed in small steps, each time being constituted by 4 different phases, represented by the PDCA cycle, or Demining wheel, where: P = PLAN, which means plan before acting; D = DO, perform what has been planned; C = CHECK, verify the results; A = ACT, standardize if the results are positive, repeat the process if negative. Each process of improvement implies a prior precise definition of a project, i.e. a problem whose solution has been planned. The project must always presume: a specific subject--a goal--one or more people to reach it--a limited time to work it out. The most effective way to ameliorate Quality is performing projects. Step by Step amelioration is synonymous of performance of many projects. A brilliant way to produce many projects remains their "industrialization", which can be reached by means of 6 basic criteria: 1) full involvement of the Direction; 2) potential co-working in the projects of all employees; 3) employment of simple instruments; 4) respect of a few procedural formalities; 5) rewarding of personnel; 6) continuous promotion of the concepts of quality and ongoing improvement. The Authors describe for each of the previous criteria approaching methods and best operative techniques, according C.W.Q.C.

Left main coronary artery stenosis: the influence of aortocoronary bypass surgery on survival.

A retrospective study was carried out in 114 unoperated and 197 operated patients having left main coronary artery (LMCA) stenosis greater than or equal to 50%. Including the operative mortality of 9.1%, survival at seven years was significantly greater following pure aortocoronary bypass graft surgery, 77.5% as compared to 48.5% for the unoperated patients (P less than 0.01). The surgical mortality was significantly less during the last five years (1972-1976), 6.2% as compared to 17% during 1969-1971 (P less than 0.025). The three year survival in patients operated since 1972 was 90.2% as compared to 60.4% for unoperated patients. Survival remained significantly higher in the operated patients when studied as subsets on the basis of the severity of the LMCA stenosis (less than 70% as opposed to greater than or equal to 70%), and on the extent of associated obstructive disease of major coronary arteries (0-1 versus 2-3 arteries). It was significantly higher, however, only in operated patients with associated stenosis greater than or equal to 70% of the right coronary artery. Survival was higher following surgery only when the ejection fraction was at least 0.45, or the left ventricular end-diastolic pressure below 20 mm Hg.

[Pseudo-normalization of diastolic filling in severe aortic stenosis]. / Pseudonormalizzazione del riempimento diastolico nella stenosi aortica serrata.

We report the case of a 79-year-old woman with severe aortic stenosis and alteration of left ventricular diastolic filling demonstrated by Doppler echocardiography, with inverted early/end diastolic flow profile. A sixteen month prospective follow-up study demonstrated progression of the illness, with further augmentation in transvalvular gradient and increased wall hypertrophy, but with apparent concomitant normalization of transmitral flow velocity profile. We conclude that a "normal" velocity pattern does not exclude an altered diastolic filling pattern, and must be interpreted with caution, in the light of all clinical and technical data.

[A case of double-chamber right ventricle operated on in adulthood]. / Un caso di ventricolo destro bicamerato operato in età adulta.

A 49-year-old patient suffering from recurrent effort lipothymia and palpitation was referred for cardiac catheterization. A diagnosis of marked hypertrophy of right ventricular outflow tract and double chamber right ventricle with intraventricular gradient of 50 mm Hg was made. Operation was delayed until age 49 when an anomalous intraventricular hypertrophic band was resected. The first 2D and Doppler echocardiogram after operation disclosed a previously unrecognised intraventricular septal defect. Three years after operation the patient is asymptomatic.

[Revision and optimization of processes: a fundamental timing for adequate use of the resources and technological innovation. An example of intervention in the cardiology field and considerations on "total quality" in medicine]. / Revisione ed ottimizzazione dei processi: momento indispensabile per un adeguato utilizzo delle risorse e dell'innovazione technologica. Esempio di intervento in ambito cardiologico e considerazioni sulla "qualità totale" in medicina.

UNLABELLED: The Cardiology Unit of the Este General Hospital began its activity in 1988. We soon identified a mismatch between a good, up-to-date diagnostic instrumentation with growing customers' demand and an inadequate utilization of the instruments. Waiting lists were getting longer, customers were not satisfied, no-shows at the appointments increased and we had a progressive loss in image. We therefore decided to intervene on our processes, starting the project "TOTAL QUALITY IN CARDIOLOGY". We focused our attention on two main fields, namely (1) electrocardiography, (2) other diagnostic techniques, separately analyzed because of important differences. Point (1) is basically worked out by paramedical personnel, in high numbers and with stable demand, while point (2) is determinantly linked to medical activity, although with concomitant need for paramedical support. The figures are lower for point (2) but are steadily growing. In the two operating fields we further identified two separate adverse effects: 1). ELECTROCARDIOGRAPHIC EXAMINATIONS (ECG) ARE TOO TIME CONSUMING, 2) THE NUMBER OF DIAGNOSTIC PROCEDURES IS TOO LOW FOR THE INSTRUMENTS AVAILABLE. We used preliminary analysis with process flow diagrams and our interventional methods were policy deployment and daily routine work. ELECTROCARDIOGRAPHIC EXAMINATIONS ARE TOO TIME CONSUMING. From cause-effect diagram for cause classification and subsequent Pareto analysis we identified two groups of main causes: 1. the paramedical-patient team is not able to optimise usage of the instrument; in particular, total time for undressing of the patient, lead attachment, dressing of the patient, change in ECG conductivity cream and, if necessary, repetition of ECG for mistakes in procedure is much longer than operative time of the instrument; 2. the necessary copy of the ECG done by the instrument was too time consuming (2') as compared to total procedure time. Implementation plans have been as follows: activity was concentrated in one single room at constant temperature (20 degrees); we augmented the number of dressing rooms and nurses (from 1 to 2 unit); we substituted the ECG conductivity cream with a water-alcoholic solution and the copy with a photocopy. RESULTS: decrease in mean time for ECG from 6'52" to 3'25" (for example: total ECGs 1992: 14,827, total spared time: 852 working hours); reductions in dead times; capability to cope rapidly with high demand; consequent possibility to utilise paramedical personnel for other activities; reduction in copy costs from 156 to 50 Lit each (total reduction 1,571,662 Lit). EXPECTATIONS. further revision of the procedures to keep pace with new electrocardiographic instruments and to achieve shorter operative times.

Loss of the improvement of angina between 1 and 7 years after aortocoronary bypass surgery: correlations with changes in vein grafts and in coronary arteries.

Improvement of effort angina following pure aortocoronary bypass graft surgery was related to postoperative control angiographic studies of grafts and coronary arteries in 75 unselected patients. Clinical and angiographic evaluations were carried out at approximately 1 year and at 5 to 7 years after surgery. At 1 year, 61 (81.3%) were improved (52 without angina and 9 with partial improvement by at least two functional classes), whereas 14 were unimproved (18.7%). At approximately 6 years, loss of improvement (reappearance of angina or aggravation by at least two functional classes) was observed in 22 of the 61 improved patients, representing an attrition of 36.1% over a 5-year period. Graft occlusion or a narrowing of over 50% was observed in two of the 39 patients in whom improvement had continued (5.1%), whereas it was found in six of the 22 patients (27.3%) whose results deteriorated (p less than 0.05). Similarly, progression to occlusion of a preexisting stenosis of over 50% or appearance of a new stenosis of over 50% in a major coronary artery (distal to a graft or in an unbypassed artery) was observed in five of the 39 patients with continued improvement (12.8%) and in 11 of the 22 patients whose condition deteriorated (p less than 0.01). Changes in a graft or in a coronary artery were noted in 63.6% (14/22) of the patients with loss of improvement as compared to only 18% (7/39) of the patients whose improvement did not deteriorate. Improvement of angina was also evaluated in all survivors among our first 500 cases who had preoperative effort angina and pure bypass surgery with or without angiographic studies. Of these 260 patients, 70.4% were angina-free or improved by two to three functional classes at 1 year, and only 41.9% at 7 years after surgery. It is concluded that the effect of aortocoronary bypass graft surgery is transient in a high proportion of patients and that deterioration of results is related to late graft modifications and progression of atherosclerosis, particularly in ungrafted coronary arteries.

Progression of obstructive coronary artery disease 5 to 7 years after aortocoronary bypass surgery.

Changes in the native coronary circulation were evaluated 5 to 7 years (72 +/- 10 months) after aortocoronary bypass surgery in 108 patients; 104 had had previous angiographic controls between 6 and 18 months following surgery. Coronary artery narrowings were graded on a scale of 0 to 6, 0 being normal, grade 1 and 2, < or = 50%; grade 3, 51-75%; grade 4, 76-90%; grade 5, 91-99% narrowing and grade 6 total occlusion. Progression of disease was significant when a preexisting stenosis increased at least 1 grade or a new lesion > 50% developed. Nongrafted vessels were compared to arteries with patent or occluded grafts. During the first year following surgery, the rate of progression was much higher in grafted arteries with patent or occluded grafts than in nongrafted arteries 157 and 53% vs 9.5% respectively, P < 0.001). During the subsequent period of approximately 5 years, however, grafted arteries did not change, whereas the rate of progression in nongrafted arteries increased from 9.5 to 46%. At 5 to 7 years after surgery, grade 1 and 2 (< or = 50%) narrowings progressed slightly more frequently in grafted arteries because of surgically related events. However, for narrowings > 50% and for new lesions, there was no difference in the rate of progression between grafted and nongrafted vessels. In conclusion, the rate of progression of atherosclerosis in nongrafted coronary arteries is important. At 5 to 7 years after surgery, there is little or no difference in the severity of the disease in the proximal segments of grafted and nongrafted coronary arteries.

Aortocoronary saphenous vein bypass graft changes 5 to 7 years after surgery.

Control angiographic studies were carried out 54 to 88 months after aortocoronary saphenous vein bypass surgery (70 +/- 10 months) in 100 unselected patients who were known to have at least one patent graft 6 to 18 months following the operation. Only 17 of the 159 grafts were found occluded during this interval of 5 years, giving an average yearly attrition rate of 2.1% after the first year. The mean yearly attrition rate was 0.7% in our second series of near consecutive patients operated on after 2 years of experience and modifications of surgical techniques, and it compares favorably with the 2.4% yearly attrition rate found in our first series of patients (P < 0.05). Of the 37 grafts having localized stenoses at 1 year, eight became occluded (21.6%), and four became worse. Grafts with localized stenoses were more prone to late occlusion, whereas no late occlusion was observed in normally appearing grafts at 1 year. Diffuse graft narrowing noted during the first year showed no further change during the subsequent 5 years, and it did not appear to lead to late occlusion. Finally, in 14 grafts, localized narrowing developed after the first year, at a yearly rate of 1.5%. Atherosclerosis appears to be the most likely etiology, being found in two of these instances at reoperation.

Prediction of multivessel disease after inferior myocardial infarction.

We correlated clinical parameters with angiographic findings in 108 men with a previous isolated inferior myocardial infarction, to determine if these parameters could predict accurately which patients had multivessel disease. Of 71 men in angina class 2-3, 42 had three vessel disease versus only seven of the 37 who were either asymptomatic or angina class 1 (P less than 0.001). Multivessel disease was present in 35 of the 36 who had anterior ST-T abnormalities at rest (P less than 0.001) and 16 of the 17 with cardiomegaly. Among men 55 years and older, the incidence of multivessel disease was 94% compared to 70% in men less than 55 (P less than 0.03). We conclude that functional angina class, age, and the presence of resting anterior ST and T abnormalities are highly predictive of associated left system disease in survivors of inferior infarction.

Improved efficiency of treadmill exercise testing using a multiple lead ECG system and basic hemodynamic exercise response.

One hundred consecutive men with a normal ECG at rest had a maximal treadmill test using 14 leads during and post-exercise. Coronary arteriography performed the following day revealed coronary stenoses greater than or equal to 70% in 66 patients. Test results obtained from a V5 lead were compared to different lead combinations and were correlated with arteriographic findings. A positive exercise test occurred in 37 men using an isolated V5 lead compared to 50 men (P less than 0.05) using 11 leads, 52 men (P less than 0.05) using a combined CM5, CC5, Cl (inferior) lead system and 58 (P less than 0.001) men using all 14 leads. The predictive value of a positive test varied between 89-95% and was not changed significantly by the addition of multiple leads. The 14 lead ECG was positive in 43/45 (96%) patients with multivessel disease. Parameters which helped to predict multivessel disease using 14 leads were 1) the time that ischemia first appeared 2) the pressure-rate product at the time ischemia first appeared, and 3) the maximum workload that could be attained. In general, the magnitude of ST-segment depression and the time required for a positive ECG to return to normal postexercise were not useful predictors of multivessel disease. We conclude that the use of multiple leads improves the sensitivity and efficiency of the maximal treadmill exercise test. The usefulness of exercise test results can be further improved if multiple leads are combined with physiologic data collected during exercise.

[Results of emergency aortocoronary bypass in complicated coronary angioplasty]. / Risultati del bypass aortocoronarico d'urgenza per angioplastica coronarica complicata.

Sixteen out of 293 (5.4%) procedures for percutaneous transluminal coronary angioplasty, performed between 1985 and 1988, were complicated by acute closure and required emergency revascularization surgery. The injured vessel was the left anterior descending artery in 14 cases and the right coronary artery in 2 cases. All patients had persistent chest pain associated with ST-segment elevation in 14 cases and ST-segment depression in 2 cases. Two patients developed cardiogenic shock and were in cardiac arrest at the beginning of operation; one of these died immediately after the operation. Thus the overall mortality rate was 6.2%. Enzyme evidence of myocardial infarction (CPK-MB greater than 40 UI/I) occurred postoperatively in 8 patients (50%), but only the 6 patients (37.5%) with electrocardiographic evidence of myocardial necrosis (new Q-waves or loss of R-wave voltage) showed akinesis of the myocardium perfused by the occluded vessel at the echocardiographic examination performed two weeks after the operation. The occurrence of myocardial infarction was correlated with the degree of preoperative ischemia and hemodynamic deterioration. A collateral flow was present in 3 cases and none of these showed evidence of myocardial necrosis after the operation. Our results show that emergency bypass surgery for failed coronary angioplasty is less satisfactory than elective surgery, and has a higher mortality and myocardial infarction rate. Thus, the risk of emergency operation for complicated dilation must be considered when selecting of candidates for coronary angioplasty.

[Coronary angioplasty in unstable angina. Immediate and short-term results]. / L'angioplastica coronarica nell'angina instabile. Risultati immediati e a breve termine.

We report the results of percutaneous transluminal coronary angioplasty (PTCA) in 67 consecutive patients with unstable angina. Twenty patients had new onset (less than 2 months) angina, 33 patients had crescendo angina and 14 had early postinfarction angina. Fifty-one patients had one-vessel disease, 12 patients had two-vessel disease and two patients had three-vessel disease; two patients had a stenosis of a venous graft. In cases with multivessel disease, we performed only the dilatation of the ischaemia-related vessel identified by morphologic features of coronary lesion and electrocardiographic changes during chest pain. The procedure was successful in 54 cases (80.6%). Seven patients (10.4%) had major complications. Emergency coronary artery bypass graft surgery was performed in 6 cases (8.9%) because of occlusion of the left anterior descending artery; despite emergency operation one patient died and two patients sustained a myocardial infarction. One patient had occlusion of the right coronary artery and inferior myocardial infarction. In all patients in whom angioplasty was successful unstable angina disappeared. At 6 months follow-up there were no infarctions or deaths but 14 of 42 patients (33%) had recurrent angina. Restenosis occurred in 16 of 33 patients (48%) who had repeat coronary angiography. Four patients with recurrence of unstable angina had repeat angioplasty; it was successful in 3 cases. One patient died of refractory cardiac arrest. The mortality rate of 71 procedures performed in 67 patients was 2.8% (2/71) and the overall myocardial infarction rate was 4.2% (3/71).(ABSTRACT TRUNCATED AT 250 WORDS)