International Society for Extracellular Vesicles Workshop. QuantitatEVs: multiscale analyses, from bulk to single extracellular vesicle.

The 'QuantitatEVs: multiscale analyses, from bulk to single vesicle' workshop aimed to discuss quantitative strategies and harmonized wet and computational approaches toward the comprehensive analysis of extracellular vesicles (EVs) from bulk to single vesicle analyses with a special focus on emerging technologies. The workshop covered the key issues in the quantitative analysis of different EV-associated molecular components and EV biophysical features, which are considered the core of EV-associated biomarker discovery and validation for their clinical translation. The in-person-only workshop was held in Trento, Italy, from January 31st to February 2nd, 2023, and continued in Milan on February 3rd with "Next Generation EVs", a satellite event dedicated to early career researchers (ECR). This report summarizes the main topics and outcomes of the workshop.

Clinical characteristics, management, and prognosis of octogenarians with acute heart failure admitted to cardiology wards: results from the Italian Survey on Acute Heart Failure.

BACKGROUND: Heart failure is the leading cause of hospitalization among the elderly. This study compares clinical characteristics, management, and prognosis of octogenarians (OLD) with younger (YOUNG) patients in the Italian Survey on Acute Heart Failure (AHF). METHODS: A nationwide, prospective, observational study on AHF was done. Two hundred six Italian departments with intensive cardiac care units enrolled 2,807 patients in 3 months. RESULTS: Octogenarians (mean age 84 +/- 4 years) represented 28% of enrollees. Females were 50% in the OLD group versus 36% in the YOUNG group (P < .0001). Risk factors such as obesity, diabetes, and smoking were more frequent in the YOUNG group. Comorbidities such as anemia and renal dysfunction were more common in the OLD group (64% vs 53%, P < .0001, and 56% vs 43%, P < .0001). More octogenarians were admitted with cardiogenic shock and pulmonary edema, whereas younger patients presented more frequently in New York Heart Association class III to IV (P = .002). Left ventricular ejection fraction was measured in 90% of octogenarians versus 93% of the younger ones and was preserved in 41% of the OLD group versus 31% of the YOUNG group (P < .0001). Coronary angiography was performed in 20% of the YOUNG group and 10% of the OLD group. In-hospital mortality was twice as high in the OLD group (11.8% vs 5.6%, P < .001). In multivariable analysis, the strongest predictors of this event were use of inotropic agents, advanced age (> or =80 years), and elevated troponin at admission. CONCLUSIONS: Octogenarians represent more than one fourth of the admissions for AHF and have a more severe clinical presentation. Their management is less aggressive, and treatments recommended by guidelines are underused. In-hospital mortality is high in the OLD group independently of left ventricular ejection fraction.

Impact of the main implantable cardioverter-defibrillator trials in clinical practice: data from the Italian ICD Registry for the years 2005-07.

AIMS: Several studies have demonstrated the life-saving role of implantable cardioverter-defibrillator (ICD) therapy. In order to evaluate the effects of major trials in clinical practice, we report the clinical data of patients enrolled in the Italian ICD Registry for the years 2005-07. METHODS AND RESULTS: The Registry collects prospectively national ICD implantation activity on the basis of EURID Card. The number of ICDs per million of inhabitants was 180.6 in the year 2005, 192.5 in the year 2006, and 220.6 in the year 2007 (P = 0.02). The median age was 69 years for all 3 years considered. Implantable cardioverter-defibrillator implantation for primary prevention concerned 4692 patients in 2005 (44.2%), 5938 patients in 2006 (52.2%), 7324 patients in 2007 (55.7%) and for secondary prevention 5921 patients in 2005 (55.8%), 5447 patients in 2006 (47.8%), and 5828 patients in 2007 (44.3%). Single-chamber ICDs were implanted in 30.9, 31.0, and 28.5% of patients, dual chamber ICDs in 31.9, 31.5, and 31.7%, and biventricular ICDs in 37.2, 37.5, and 39.8%, respectively. CONCLUSION: The ICD implantation rate in Italy increased significantly in the period 2005-07. The registry showed a significant increase in prophylactic and biventricular ICD use, reflecting a favourable adherence to trials and guidelines in the clinical practice.

Improved workflow, sonographer productivity, and cost-effectiveness of echocardiographic service for inpatients by using miniaturized systems.

AIMS: The aim of this study was to assess the cost-effectiveness of using certified sonographers and miniaturized echocardiography systems to perform echocardiograms at bedside in comparison to moving inpatients from the admission department to the echocardiography laboratory (echo-lab). METHODS AND RESULTS: From 26 September 2005 to 27 October 2005, 112 patients admitted in six hospital wards connected through a 100 Mbit LAN to the echo-lab were scanned within the admission ward by sonographers using a miniaturized echo system. Logistical data were collected and results were compared with those obtained from 194 consecutive patients coming from the same wards and studied in the echo-lab with high-end machines between 8 March 2005 and 15 April 2005. Performing echocardiograms in the admission department avoided long waiting time of the inpatients in the echo-lab before and after the study, increased the percentage of patients studied within 3 and 5 days from request (88 vs. 77% and 100 vs. 95%, respectively; P = 0.03), increased both sonographer (by 33.9%; P < 0.001) and echo-lab productivity (by 41%; P < 0.001), and reduced costs of echocardiograms by 29%. CONCLUSION: Implementation of digital echocardiography, certified sonographers, and a miniaturized echo system allowed improvement of the cost-effectiveness of the service provided by the echo-lab for inpatients, and avoided patients' discomfort derived from prolonged waiting time before and after the exam.

Fast data acquisition and analysis with real time triplane echocardiography for the assessment of left ventricular size and function: a validation study.

AIMS: To assess accuracy and reproducibility of real time simultaneous triplane echocardiography (RT3PE) for the assessment of left ventricular (LV) volumes and ejection fraction (EF) using cardiac magnetic resonance (CMR) as a reference method. METHODS AND RESULTS: A total of 24 patients with various degrees of LV dysfunction (EF from 36 to 57%) in sinus rhythm with good image quality were enrolled in the study. Digital loops of apical views were recorded with standard two-dimensional imaging and with RT3PE. Echocardiography and CMR were performed within 1 hour. RT3PE measurements of LV end-diastolic volume, end-systolic volume, and EF resulted closely correlated to CMR (r = 0.95, 0.97, and 0.95, respectively) with small biases (-4 ml, -6 ml, and 1%, respectively) and narrow limits of agreement (SD = 15 ml, 12 ml, and 6%, respectively). Two-dimensional echocardiography (2DE) showed a weaker correlation with CMR (r = 0.85, 0.91, and 0.83, respectively; P < 0.06) with similar biases (-4 ml, -10 ml, 5%, respectively), but wider limits of agreement (SD = 28 ml, 21 ml, 10%, respectively, P < 0.007). RT3PE showed lower interobserver variability for the assessment of EF (SD = 2% vs. 5%, P = 0.03) and lower measurement time of LV EF (175 +/- 54 sec vs. 241 +/- 49 sec, respectively; P < 0.0001), as compared to 2DE. CONCLUSION: RT3PE allows simple and fast image acquisition and volume calculation. In addition, it allows more accurate and reproducible EF measurements than conventional 2DE.

Radiofrequency ablation of drug-refractory atrial fibrillation: an observational study comparing 'ablate and pace' with pulmonary vein isolation.

AIMS: To compare clinical characteristics, procedure complexity, acute and long-term outcome of 'ablate and pace' (A&P) with pulmonary vein isolation (PVI) in patients with drug-refractory atrial fibrillation (AF). So far, only few small studies have compared the two procedures. METHODS AND RESULTS: We analysed retrospectively a cohort of symptomatic consecutive patients with drug-refractory AF. Group 1 included 100 patients treated with A&P and Group 2 included 144 patients treated with PVI. Group 1 patients were older (74 +/- 8 vs. 56 +/- 9 years; P < 0.0001), had lower left ventricular ejection fraction (50 +/- 13% vs. 59 +/- 7%; P < 0.05), and a lower prevalence of paroxysmal AF (46% vs. 65%; P < 0.05). Acute success was not statistically different (98% vs. 92.3%, P = ns). Group 1 patients had shorter procedure time and lower radiation exposure with respect to Group 2 patients (70 +/- 15 vs. 204 +/- 58 min, and 8 +/- 4 vs. 57 +/- 22 min; P < 0.0001, respectively). After a median follow-up of 29 months (I, III quartile; 15, 40 months) vs. 25 months (I, III quartile; 8, 36 months) (P = ns), all the patients in Group 1 were free of symptomatic AF, while 113 patients (79%) of Group 2 were in stable sinus rhythm (P < 0.0001). Persistent or permanent AF has been documented in 58 patients (58%) of Group 1 vs. 11 (8%) of Group 2 (P < 0.0001). CONCLUSION: In this series (i) patients treated with A&P and PVI for drug-refractory AF showed significant differences in clinical profile; (ii) A&P is a shorter and less complex procedure, but is associated with a higher rate of persistent AF; (iii) symptomatic recurrences of paroxysmal AF were more frequent in PVI group. Randomized studies appear necessary to identify the best strategy in selected cases.

Comparison of early dobutamine stress echocardiography and exercise electrocardiographic testing for management of patients presenting to the emergency department with chest pain.

This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.

Are hospitalizations for percutaneous coronary procedures missed opportunities for teaching rules of secondary prevention?

BACKGROUND AND AIMS: Percutaneous coronary intervention (PCI) is the most frequently used revascularization approach, often repeatedly applied. The quest for the ultimate revascularization procedure however may capture cardiologist's attention and lead them to minimize the issue of secondary prevention in their patients. Aims of this study were to assess: 1. The individual risk factor profile, 2. The relation between the risk factors correction and the number of hospital admissions for elective procedures, 3. The appropriateness of medical treatment in patients admitted for elective coronary invasive procedures (diagnostic and interventional). 4. The patients knowledge of threshold values for cardiovascular risk factors. PATIENTS AND METHODS: 100 patients (71% males, mean age 68 years) consecutively admitted for elective coronary angiography or PCI. They underwent a classical risk factors assessment and were divided in three groups according to the number of admissions for coronary angiography and in two groups according to the number of PCIs. RESULTS: Fifty-seven% of patients had been previously admitted for invasive examination at least three times and 58% had already been treated with at least one PCI. Seventy-one% were treated with beta-blockers but only 25% of them received a dosage found effective in RCTs (randomized clinical trials). Sixty% were treated with ACE-inhibitors and 83% received the dosage found effective in RCTs. Fifty-two% were treated with statins and 95% received a dosage found effective in RCTs. Nine% were still active smokers. Fourty-nine% had a LDL cholesterol level above 100 mg/dL. The percentage of patients not on target was unrelated to the number of hospital admissions for invasive procedures. CONCLUSIONS: Modern cardiology is quickly embracing high tech procedures and trials results but often fails to spend enough time teaching how to control risk factors according to the recommendations of the evidence-based guidelines, even independently of the number of hospitalizations for invasive cardiovascular procedures.

Stented bioprosthetic valve hemodynamics: is the supra-annular implant better than the intra-annular?

BACKGROUND AND AIM OF THE STUDY: The use of stented bioprostheses for aortic valve replacement (AVR) in elderly patients with a small aortic annulus may result in unsatisfactory hemodynamic performance of the prosthesis. To overcome this limitation, new bioprostheses have been designed for complete supra-annular implantation, but the actual hemodynamic advantage of the supra-annular implant over the intra-annular has not been fully investigated. Accordingly, the hemodynamic performance of the same stented bioprosthesis (except for sewing ring design) implanted in the supra-annular and conventional intra-annular seating was compared. METHODS: Twenty-two patients received an intra-annular implant, and 38 a supra-annular implant. Age (74 +/- 5 versus 76 +/- 5 years, p = 0.54), gender (55% versus 50% males, p = 0.79) and body surface area (1.74 +/- 0.2 versus 1.81 +/- 0.2 m2, p = 0.13) were similar in both subgroups, who underwent echocardiography at 8 +/- 2 and 6 +/- 2 months after surgery, respectively (p = 0.09). RESULTS: The two patient subgroups had similar preoperative left ventricular outflow tract diameters (2.06 +/- 0.2 and 2.1 +/- 0.2 cm; p = 0.62), average size of implanted prosthesis (21.0 and 21.3 mm; p = 0.44) and mean transprosthetic flow rate (246 +/- 70 and 218 +/- 58 ml/s; p = 0.12). Mean (8 +/- 3 and 19 +/- 8 mmHg, p < 0.0001), and peak (17 +/- 6 and 40 +/- 13 mmHg; p < 0.0001) transprosthetic gradients were lower, and mean effective orifice area (EOA) (1.78 +/- 0.4 and 1.45 +/- 0.5 cm2, p = 0.006) was higher in patients with supra-annular implants than in those with intraannular. The incidence of patient-prosthesis mismatch (EOA index < 0.85 cm2/m2) decreased from 50% to 34% (p < 0.0001), with no case of severe mismatch using the supra-annular implant. During follow up, a left ventricular mass reduction occurred in patients with supra-annular implants (from 225 +/- 110 to 173 +/- 59 g/m2; p < 0.03), but not in patients with intra-annular implants (173 +/- 62 and 186 +/- 64 g/m2; p = 0.87) CONCLUSION: The study results showed that, compared to intra-annular implantation, supra-annular implantation of bioprosthetic stented valves in the aortic position was associated with a significantly better hemodynamic performance of the prosthesis and significant regression of left ventricular hypertrophy.

Outcome of urgent and elective percutaneous coronary interventions after pharmacologic reperfusion with tenecteplase combined with unfractionated heparin, enoxaparin, or abciximab.

OBJECTIVES: The aim of this study was to evaluate percutaneous coronary intervention (PCI) in the Assessment of the Safety and Efficacy of New Thrombolytic Regimens (ASSENT-3) trial. BACKGROUND: In the ASSENT-3 trial, co-therapy with abciximab (ABC) or enoxaparin (ENOX) reduced ischemic complications after ST-elevation acute myocardial infarction treated with tenecteplase when compared with unfractionated heparin (UFH). The effect of these new co-therapies on the results of PCI is unknown. METHODS: Clinical outcomes in patients who received co-therapy with ABC, ENOX, or UFH and subsequently underwent an elective (n = 1,064) or urgent (n = 716) PCI in the ASSENT-3 trial were compared. RESULTS: No significant differences in clinical end points were observed in patients who underwent an elective PCI. A non-significant trend toward fewer in-hospital myocardial re-infarctions was seen with ABC and ENOX when compared with UFH (0.5% vs. 0.6% vs. 1.5%, respectively). The incidence of bleeding complications was similar in the three treatment arms. Significantly fewer ABC- and ENOX-treated patients needed urgent PCI compared with UFH (9.1% vs. 11.9% vs. 14.3%; p < 0.0001), but outcomes in these patients were in general less favorable (30-day mortality: 8.2% vs. 5.4% vs. 4.5%; 1-year mortality: 11.0% vs. 8.5% vs. 5.6%; in-hospital re-infarction: 3.9% vs. 2.5% vs. 2.7%; major bleeding complications: 8.8% vs. 7.0% vs. 3.4%). In pairwise comparisons with UFH, the higher one-year mortality and major bleeding rates after ABC were statistically significant (p = 0.045 and p = 0.012, respectively). CONCLUSIONS: Clinical outcomes after elective PCI were similar with the three antithrombotic co-therapies studied in ASSENT-3. Although fewer patients needed urgent PCI with ABC and ENOX, clinical outcomes were less favorable in this selected population, especially with ABC.

The Italian Implantable Cardioverter-Defibrillator Registry. A survey of the national activity during the years 2001-2003.

BACKGROUND: In recent years several trials demonstrated the efficacy of implantable cardioverter-defibrillator (ICD) therapy for sudden cardiac death prevention and total mortality reduction in particular high-risk groups of patients. The aim of this review was to report the main epidemiological data and the most important clinical characteristics of patients enrolled in the Italian ICD Registry in the years 2001-2003. METHODS: The Italian ICD Registry--official member of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC)--collects 85% of the data concerning the national ICD implantation activity, based on the European Implantable Defibrillator form (EURID). Data are validated for quality of information and uniqueness at the moment of data entry and in successive steps at the time of the annual analysis. RESULTS: The number of ICDs implanted in Italy has been continuing to increase during the last years according to the general trend in European and non-European countries: 2400 in the year 2001, 3934 in the year 2002, and 5318 in the year 2003. The number of ICDs per million of inhabitants in Italy was 42.1 in the year 2001 (+11.8% with respect to 2000), 69.0 in the year 2002 (+63.9% with respect to 2001), and 93.3 in the year 2003 (+35.2% with respect to 2002). The number of implanting centers increased progressively from 273 in the year 2001 to 304 in the year 2002, and 340 in the year 2003. The median age of patients treated with ICD implantation was 67 years in the years 2001-2002, 68 years in the year 2003. The prevalence of male patients was significantly higher (79.3% in 2001, 82.3% in 2002, and 81.4% in 2003). The main indication was syncope (25.5, 29.3, and 32.9% in the years 2001, 2002, and 2003, respectively), followed by palpitations (17.7, 18.5, and 16.4% in the years 2001, 2002, and 2003, respectively), and cardiac arrest (10.0, 13.1, and 16.5% in the years 2001, 2002, and 2003, respectively). The use of ICD in patients considered at risk but without history of sustained ventricular tachycardia had a 3-fold increase during the 3 years, from 6.4% in 2001 to 18.2% in 2003. Ventricular tachycardia was the main arrhythmia in 50.4 to 55.0% of cases, ventricular fibrillation in 13.5 to 18.1%, both in 4.1 to 6.5%. The vast majority of patients presented at the enrolment either a mild or severe reduction in ejection fraction (30 to 50%, < 30%). Amiodarone was administered alone or in combination with antiarrhythmics in 29.7 to 40.0% of patients. Single-chamber ICDs were implanted in the years 2002 and 2003 in 45.7 and 39.2% of patients, dual-chamber ICDs in 34.9 and 32.4%, biventricular ICDs in 19.4 and 28.4%, respectively. CONCLUSIONS: The ICD implantation rate in Italy increased significantly in the period 2001-2003, similarly to the trend in the other western countries and following the publication of controlled studies in the field of primary and secondary prevention of sudden cardiac death. The Italian ICD Registry showed during the last 3 years an important increase in prophylactic ICD utilization. A sophisticated ICD, including dual-chamber pacing or cardiac resynchronization therapy, was chosen in a high percentage of patients.

The Left Ventricular Dysfunction Questionnaire: Italian translation and validation.

UNLABELLED: Patients affected by heart failure have a compromised quality of life (QOL) and in the last few years "health related quality of life" has become an important outcome indicator for the evaluation of heart failure treatment. METHODS: Translation into Italian of the Left Ventricular Dysfunction Questionnaire (LVD-36), a new, 36-item, disease-specific health status instrument for patients with congestive heart failure, and its subsequent validation by administration to 50 consecutive patients in our heart failure outpatient clinic. The Italian LVD-36 was compared to the "The Minnesota Living with Heart Failure Questionnaire" (MLHF). RESULTS: The Italian version of the LVD-36 correlates well with MLHF for ejection fraction (EF), NYHA class I and II, etiology and therapy. Since, however, the LVD-36 has only one domain, it may be able to offer more synthetic information than MLHF about patients' status. CONCLUSIONS: The Italian version of the LVD-36 appears to be a reliable instrument for assessing patients' QOL and the degree of limitations imposed on them by the disease. It is short, clear and easy to complete. In patients with heart failure the LVD-36 correlates well with the MLHF and may be considered a new disease-specific instrument to estimate changes in health status, and an useful support in optimizing therapeutic options.

The Italian MacNew heart disease health-related quality of life questionnaire: a validation study.

Patient-centered treatment outcomes such as health-related quality of life are recommended in clinical care and research studies. Health-related quality of life questionnaires need to be validated in the language of the target population. The reliability and validity of the Italian version of the MacNew Questionnaire was determined in patients with angina, myocardial infarction, or ischemic heart failure. Sociodemographic and clinical data were collected on 298 patients [angina, n = 88; MI, n = 106; heart failure, n = 104; mean age, 64.8 (±10.6) years] at three centers in Italy. MacNew mean scores were higher (p < 0.001) in patients with myocardial infarction than in patients with either angina or heart failure with no floor and minimal ceiling effects. The three-factor structure of the original MacNew form was largely confirmed explaining 54.6% of the total variance. The Italian MacNew version demonstrates high internal consistency reliability (Cronbach's α ≥ 0.86), confirms the convergent validity hypotheses with strong correlations on six of eight comparisons (r ≥ 0.86), partially confirms discriminative validity with the SF-36 health transition item, and fully confirms discriminative validity with the Hospital Anxiety and Depression Scale. The Italian version of the MacNew Questionnaire demonstrates satisfactory psychometric properties, and is reliable and valid in Italian-speaking patients with angina, MI, or heart failure. Responsiveness could not be tested due to the cross-sectional design of the parent study, and needs to be investigated in an intervention study.

Acute coronary syndromes complicated by symptomatic and asymptomatic heart failure: does current treatment comply with guidelines?

BACKGROUND: Patients with acute coronary syndromes (ACS) complicated by heart failure (HF) are at increased risk of death. Treatment with angiotensin-converting enzyme inhibitors (ACEI), beta-blockers, and early invasive risk stratification are recommended for these patients. AIM: The purpose of the current study was to assess adherence to treatment guidelines of patients with ACS complicated by HF in Europe and the Mediterranean region. METHODS AND RESULTS: Of the 10,484 patients who participated in Euro-Heart ACS survey, 9587 had known HF status and were without cardiogenic shock; 7058 (74%) did not have symptomatic HF and 2529 (26%) presented with or developed symptomatic HF during hospitalization. HF patients were older and had more cardiovascular risk factors. ACEI were more commonly used in HF patients (75% vs 56%, P < .01), whereas beta-blockers were less frequently used (75% vs 82%, P < .01). Coronary angiography and in hospital revascularization rates were lower among HF patients (42% vs 57% for coronary angiography, P < .01, and 32% vs 42% for revascularization, P < .01). Similar trends were noticed among patients with left ventricular dysfunction (symptomatic and asymptomatic).Adjusted in-hospital mortality risk was higher among patients with ACS complicated by symptomatic HF regardless of electrocardiographic type of ACS: (ST-elevation ACS, OR 2.5, 95% CI 1.6-3.9; non-ST-elevation ACS, OR 8.9,95% CI 4.5-17.7; undetermined-ECG ACS, OR 9.3, 95% CI 2.5-34). CONCLUSIONS: Patients with ACS complicated by HF were at increased risk of dying. A relatively high percentage of HF patients were treated with ACEI and beta-blockers in accordance with current recommendations. Rates of coronary angiography and revascularization were significantly lower in ACS patients with HF versus those without HF, which potentially contributed to their worse mortality [corrected]

Sequential (201)Tl imaging and dobutamine echocardiography to enhance accuracy of predicting improved left ventricular ejection fraction after revascularization.

UNLABELLED: 201Tl imaging and dobutamine echocardiography (DE) can both identify viable myocardium. Prediction of functional outcome after revascularization remains suboptimal with either technique because of the relatively low specificity of (201)Tl and low sensitivity of DE. This study was undertaken to develop an optimal testing strategy for prediction of post-revascularization functional outcome. METHODS: Seventy-three patients (mean [+/-SD] left ventricular ejection fraction [LVEF], 32% +/- 8%) underwent DE and resting (201)Tl SPECT (4-h delayed imaging) before surgical revascularization. Dysfunctional segments with (201)Tl activity > or = 50% or with contractile reserve were considered viable. LVEF was assessed before and 3-6 mo after revascularization. RESULTS: Analysis of receiver operator characteristic curves showed that the optimum criteria to predict improvement (> or = 5%) in LVEF after revascularization were > or = 6 viable dysfunctional segments (using a 16-segment model) on (201)Tl and > or = 4 segments on DE. Sensitivity and specificity were 84% and 63% for (201)Tl (P < 0.05 vs. DE) and 63% and 85% for DE (P < 0.05 vs. (201)Tl). Changing the (201)Tl criteria to improve specificity to 78% (> or = 8 segments) yielded a low sensitivity of 44%, and changing the DE criteria to improve sensitivity to 84% (> or = 2 segments) lowered specificity to 56%. Two sequential testing strategies were explored to achieve optimal sensitivity and specificity. In strategy 1, 33 (45%) of 73 patients with an intermediate likelihood of viability by (201)Tl (5-8 viable segments) underwent DE. In strategy 2, 31 (42%) of 73 patients with an intermediate likelihood of viability by DE (2-4 viable segments) underwent (201)Tl. For strategy 1, sensitivity did not change significantly (69%), whereas specificity was improved significantly (93%, P < 0.01 vs. (201)Tl). For strategy 2, sensitivity improved significantly (78%, P < 0.05 vs. DE) and specificity remained unchanged (80%). CONCLUSION: Sequential testing by (201)Tl SPECT and DE in a subgroup of patients with an intermediate likelihood of viability by either test significantly enhanced prediction of post-revascularization improvement of LVEF.

Contrast echocardiographic evaluation of early changes in myocardial perfusion after recanalization therapy in anterior wall acute myocardial infarction and their relation with early contractile recovery.

Temporal changes in myocardial perfusion after recanalization and their relation with functional recovery in patients with acute myocardial infarction (AMI) using intravenous myocardial contrast echocardiography (MCE) have not yet been clarified. To address this issue, 19 patients with first, uncomplicated anterior wall AMI were studied using intravenous MCE within 24 hours of recanalization and before discharge. MCE was performed using harmonic power Doppler. Each asynergic left ventricular (LV) myocardial segment was scored for myocardial perfusion (1 = complete, 0.7 = patchy but >50%, 0.3 = patchy <50%, and 0 = absent) and a regional perfusion index was calculated within the dysfunctioning myocardium. During the day-1 study (11 +/- 2 hours from recanalization), the regional perfusion index was 0.4 +/- 0.3 and the LV wall motion score index was 1.9 +/- 0.2. During the study before discharge (7 +/- 4 days from admission), all but 2 patients showed an improvement of either perfusion index (0.6 +/- 0.3, p <0.0001) or wall motion score index (1.7 +/- 0.4, p <0.0001). Changes in perfusion score from 24-hours to before discharge showed a significant correlation with LV segment contractile recovery at 2-month of follow-up (R(2) = 0.42, 95% confidence interval 0.33 to 0.50, p <0.0001). Thus, our data show that after recanalized AMI, there is a significant amount of microvascular obstruction that recovers in the days after, and the extent of this perfusion improvement appears to be related with early myocardial contractile recovery. Our data provide clinical evidence for a transient microvascular dysfunction after successfully recanalized AMI.

Prevalence, clinical characteristics, quality of life, and prognosis of patients with congestive heart failure and isolated left ventricular diastolic dysfunction.

Prevalence of isolated left ventricular (LV) diastolic dysfunction has been reported to be as high as one-third of all heart failure (HF) cases, with an increasing prevalence in the elderly population. However, there is a paucity of prospective data about the prevalence and prognosis of isolated LV diastolic dysfunction in an unselected population of patients hospitalized with HF. Therefore, we prospectively evaluated 179 consecutive patients discharged from our hospital with HF to assess the prevalence of systolic versus diastolic LV dysfunction among patients hospitalized with HF and to compare their demographics, clinical features, self-perceived quality of life (QOL), and 6-month readmission rate and mortality. Among them, 133 (59% men, median age 74 years) showed in sinus rhythm and had no significant primary valvular disease. LV diastolic dysfunction was diagnosed on the basis of the European Study Group on Diastolic HF echocardiographic criteria. QOL was assessed at hospital discharge and 6-month follow-up visit using the Minnesota Living with HF questionnaire. Survival of patients with HF was compared with that of age- and sex-matched general population. In all, 29 patients (22%) had isolated LV diastolic dysfunction and 102 (78%) had prevalent LV systolic dysfunction (ie, LV ejection fraction

Amyloidosis of epicardial and intramural coronary arteries as an unusual cause of myocardial infarction and refractory angina pectoris.

The present case report refers to a 65-year-old male patient with subocclusion of the right coronary artery who had an inferior myocardial infarction that was treated with coronary angioplasty. The patient subsequently developed intractable angina pectoris in the absence of critical coronary stenosis at serial coronary angiography. Doppler wire velocity demonstrated an impaired coronary flow reserve. The patient died of cardiogenic shock. Postmortem examination revealed amyloid involvement of the media of the epicardial coronary arteries and severe amyloid deposition in the media and adventitia with obstruction of the lumen of the intramyocardial coronary arteries. Widespread ischemic areas were present in the myocardium with only slight amyloid deposition. In this patient myocardial infarction and unstable angina were a rare initial manifestation of primary amyloidosis.

New cardiovascular risk factors: homocysteine and vitamins involved in homocysteine metabolism.

Among various cardiovascular risk factors, hyperhomocysteinemia has recently emerged as an important one. While there are currently no doubts on the relationship between severe hyperhomocysteinemia and vascular disease, some uncertainty still persists on the relationship between mild hyperhomocysteinemia and vascular disease. Several group B vitamins, namely vitamin B6, vitamin B12, and folate, influence homocysteine metabolism, being cofactors of the main metabolic pathways which allow the disposal of this amino acid. There are also, however, suggestions from the literature that group B vitamins, and in particular vitamin B6 (pyridoxine/pyridoxal-phosphate), are modulators of cardiovascular risk independent of homocysteine. The results of a recent study of ours, with a long follow-up, indeed suggest that homocysteine and vitamin B6 are independent and additive cardiovascular risk factors.

Patients with chronic heart failure encountered in daily clinical practice are different from the "typical" patient enrolled in therapeutic trials.

BACKGROUND: The aim of this study was to compare the clinical characteristics of patients enrolled in randomized clinical trials on congestive heart failure treatment with those of real-world patients encountered in daily clinical practice. METHODS: We searched the Cochrane review methodology, Medline and SilverPlatter databases to obtain the clinical characteristics of both patients enrolled in therapeutic clinical trials and real-world patients with heart failure. We selected 27 clinical trials, and 8 prospective epidemiological studies or registries published between 1987 and 2001 which enrolled 53,859 and 18,207 patients, respectively. RESULTS: On average, compared to real-world heart failure patients, patients enrolled in clinical trials were younger (63 +/- 10 vs 75 +/- 11 years respectively, p < 0.0001), and more likely to be male (72 vs 54% respectively, p < 0.0001). Clinical trial patients showed a lower ejection fraction (26 +/- 7 vs 38 +/- 15% respectively, p < 0.0001) but a lower prevalence of NYHA functional class III-IV (62 vs 75% respectively, p < 0.0001) than real-world patients. In clinical trial patients, the prevalence of ischemic heart disease (67 vs 42% respectively, p < 0.0001) and a history of previous myocardial infarction (62 vs 42% respectively, p < 0.0001) were higher than in real-world patients. Conversely, the prevalence of chronic atrial fibrillation (12 vs 31% respectively, p < 0.0001) and of diabetes (22 vs 24% respectively, p < 0.02) was lower in trial patients than in real-world patients. CONCLUSIONS: Our data suggest that most clinical trials on congestive heart failure, on which the guidelines for clinical practice are based, have generally included patients who are not representative of the whole spectrum of patients actually managed in clinical practice.