Carotid intimal-media thickness and endothelial function in young patients with history of myocardial infarction.

AIM: The aim of the study was to evaluate the prevalence of carotid atherosclerosis and endothelial dysfunction in 45 young patients (38 mens and 7 females) with myocardial infarction (MI), age 29-45, mean age 42+/-3 years, to verify its possible role as a marker of coronary atherosclerosis. METHODS: Vascular echography was performed to verify the presence of carotid atherosclerosis and/or endothelial dysfunction in 45 young patients with MI and in 45 healthy control subjects well matched for age and sex. RESULTS: We observed a normal intima media thickness (IMT) only in 30% of patients with juvenile myocardial infarction (JMI) compared with 66% in the control group (P<0.0001) and 34% of patients showed an increased IMT compared with 24% of healthy subjects (P<0.0001). Compared with control subjects, patients with JMI had lower flow-mediated reactivity of the brachial arteries (P<0.05). There was a negative linear relationship between flow-mediated dilation and IMT (P<0.001). The severity of coronary artery disease (CAD) was correlated with increased IMT and with a lower flow-mediated dilation. Finally, multiple regression analysis, demonstrated that both brachial-artery reactivity and carotid IMT were significantly and independently correlated with severity of CAD. CONCLUSIONS: Structural (carotid atherosclerosis) and functional changes (endothelial dysfunction) were present at an early age in the arteries of persons with history of JMI.

Clinical significance of macrophage colony stimulating factor levels in acute coronary syndrome.

AIM: The aim of this paper was to ascertain whether macrophage colony stimulating factor (MCSF) serum levels, measured during the acute phase of coronary syndromes (ACS), are useful to predict short term outcomes. METHODS: Seventy-four consecutive patients (mean age: 66+/-12), admitted to the Intensive Coronary Care Unit of Palermo University Hospital (Italy) affected by ACS were observed; 39 patients showed a non ST elevation (NSTEMI) and 35 showed a ST elevation myocardial infarction (STEMI). During the hospital stay, all patients underwent echocardiography and 84% of patients received coronary angiography. Peripheral venous blood samples were collected for the determination of serum levels of MCSF, C-reactive protein (CRP), fibrinogen, I troponin and complete lipid pattern. RESULTS: There was no significant difference in MCSF concentrations for STEMI versus NSTEMI patients (326.65+/-143.87 vs 297.15+/-110.43 pg/mL, P=NS). Higher levels of MCSF (363.00+/-147.61 vs 251.00+/-186.69, P=0.03) and CRP (1.04+/-0.40 vs 0.97+/-0.50 mg/L, P=0.03) were found in patients with a worst in hospital stay (recurrence of angina, re-infarction, death) and with a more severe coronary artery disease (330.03+/-241.51 vs 223.61+/-128.29 pg/mL, P=0.04 and 1.14+/-0.50 vs 0.60+/-0.22 mg/L, P=0.05). CONCLUSIONS: MCSF levels are useful in the prediction of short term prognosis in ACS patients.

In-hospital stay of patient with acute coronary syndrome with or without diabetes mellitus.

AIM: Type 2 diabetes is associated with an increase in the risk of coronary heart disease, by a factor of two to four. The scientific community has suggested that all patients with diabetes could be treated as if they had a prior coronary heart disease. METHODS: A computer review of 11-year prevalence (from 1991 to 2002) of type 2 diabetes among 3242 patients admitted to the Intensive Coronary Care Unit of the Division of Cardiology of the University Hospital ''Paolo Giaccone'', Palermo, was carried out, with the diagnosis of ST elevation myocardial infarction (STEMI) (51%), non ST elevation myocardial infarction (NSTEMI) (6%) or unstable angina (UA) (43%). RESULTS: Prevalence of type 2 diabetes was 31.5% on the overall population; in particular, a higher prevalence was found among STEMI affected patients (37% of the diabetic patients). The average number of days of an in-hospital stay was of 10.4+/-3.1 for diabetic patients without complications (N.=602) and of 15.9+/-4.4 for diabetic patients with clinical complications (N.=421) as compared with non diabetic patients non complicated (N.=1821) or complicated (N.=398), with an average in-hospital stay of 7.4+/-1 and 12.8+/-3.2 days respectively; P<0.005. CONCLUSIONS: Diabetic patients with acute coronary syndrome had more clinical complications (41.1% vs 17.9%, P=0.0001) and a longer in-hospital stay period, resulting in an increased management costs, in comparison with non diabetic patients.

Short term prognostic role of NT-proBNP in patients after myocardial infarction.

AIM: The clinical and prognostic role of cardiac natriuretic peptides (CNP) in patients with heart failure is well known; recently, several studies have evaluated the possibility of using CNP to evaluate their potential prognostic role in patients with acute coronary syndromes (ACS). The aim of this study was to evaluate the short term prognostic value of NT-proBNP in 70 patients admitted for ACS. METHODS: The authors studied 70 patients with ACS, evaluating, at admission, clinical-anamnestic, instrumental and laboratory characteristics including NT-proBNP plasma levels. Patients were monitored in a 6-month-follow-up to record adverse fatal events and their possible correlation with baseline characteristics. RESULTS: The incidence of adverse events during the follow-up period was 28% (10 patients). In patients with adverse events, the authors observed lower left ventricle ejection fraction (P=0.01), higher prevalence of ST elevation myocardial infarction (P=0.03) and higher NT-proBNP levels (P=0.03), compared to those without adverse events. Moreover, the logistic regression analysis underlined how ST elevation myocardial infarction (P=0.05) and higher NT-proBNP levels (P=0.05) were the only predictive variables for adverse events during the follow up period. CONCLUSIONS: This study demonstrates the short term prognostic role of NT-pro BNP in patients admitted for ACS.

Extracoronary atherosclerosis in patients with chronic ischemic heart disease: relationship with risk factors and the severity of coronary artery disease.

AIM: The aim of the present study was to investigate the prevalence of carotid and/or peripheral atherosclerotic lesions in patients with chronic ischemic heart disease (previous acute myocardial infarction [AMI] or stable angina). METHODS: We studied 248 patients (168 male and 80 female), mean age 63+/-10 years, which were investigated for traditional risk factors. Systolic blood pressure, body mass index, lipid profile, fasting glucose and plasma fibrinogen were also measured. We assessed the prevalence of atherosclerotic lesions in carotid and lower limb arteries, by ultrasound duplex scanning (UDS). RESULTS: Angina was present in 33% of the patients, a previous AMI in 67%, a previous transient ischemic attack in 4% and a previous ischemic stroke in 6% of patients. A total of 195 patients underwent coronary angiography: 1 vessel was involved in 48% of patients, 2 vessels in 33%, and 3 vessels in 19%. Detecting peripheral atherosclerotic lesions by UDS, increased intima-media thickness (IMT) or plaques in carotid arteries were found in 232 patients (94%) and carotid stenosis >70% in 13 patients (5%). In lower limb arteries, IMT or plaques were present in 202 patients (82%) and a stenosis >70% in 18 patients (7%). Severity of coronary artery disease (CAD) was correlated to extracoronary atherosclerosis: carotid and lower limb arterial atherosclerosis was detected in 73% of patients with 1 vessel, in 83% of patients with 2 vessel, in 87% of those with 3 vessel CAD. CONCLUSION: Our study suggests that in patients with CAD, it is useful to screen the peripheral circulation by non-invasive tests, such as UDS. Patients with the diagnosis of ischemic heart disease and combined extracoronary atherosclerosis need a careful follow-up and a more aggressive therapy for secondary prevention.

Inefficiency of renin-angiotensin inhibitors in preventing atrial fibrillation in patients with a normal heart.

AIM: Recent scientific evidence has emphasized the possible role of inhibitors of the renin-angiotensin system in preventing arrhythmic relapses in patients with paroxysmal or persistent atrial fibrillation and co-existing left ventricular hypertrophy or left ventricular dysfunction. METHODS: In order to verify the effects of these drugs on patients with a normal heart, we collected a series of 187 patients admitted to our division of cardiology for paroxysmal or persistent atrial fibrillation. All patients underwent cardioversion (with antiarrhythmic drugs and/or by electrical cardioversion) and were discharged in sinus rhythm. Episodes of recurrent arrhythmia were recorded during a mean follow-up period was 2 years. Patients were subdivided into 2 groups according to therapy: group 1 comprised patients receiving renin-angiotensin system inhibitors, group 2 comprised those not receiving therapy with these agents. All 91 patients in group 1 and 76 of those in group 2 had hypertension. Among the 91 patients in the group 1, 55 were treated with angiotensin-converting enzyme (ACE) inhibitors and 36 with angiotensin receptor blockers. There were no statistically significant differences in cardiovascular risk factors or antiarrhythmic drug use between the 2 groups. RESULTS: In group 1, 83% of patients experienced <2 recurrences of atrial fibrillation during the follow-up period, while 17% had >2 episodes. In group 2, 86% of patients experienced <2 relapses during the follow-up period, while the remaining 14% had >2 relapses. There was no statistically significant difference between the 2 groups (P=0.85). A subgroup analysis showed that treatment with angiotensin receptor blockers, beta-blockers, diuretics, and calcium-channel blockers brought no advantage in sinus rhythm maintenance. CONCLUSION: In our sample of hypertensive patients with a healthy heart, treatment with ACE inhibitors showed no statistically significant advantage in the prevention of atrial fibrillation relapses.

Carotid and peripheral atherosclerosis in patients who underwent primary percutaneous coronary intervention and outcome associated with multifocal atherosclerosis.

AIM: The aim of our study was to determine if patients with multifocal atherosclerosis have a worse prognosis than patients with atherosclerosis only in the coronary bed. METHODS: We studied 45 subjects admitted to intensive coronary care unit of the Division of Cardiology with the diagnosis of acute myocardial infarction (AMI). Traditional cardiovascular risk factors were investigated and laboratory analysis included measurement of plasma lipids, glycemia, fibrinogen and high-sensitivity-C-reactive protein (hs-CRP). Each patient underwent coronary-angiography as well as carotid and peripheral arterial ultrasound examination. A follow-up of 13+/-2 months was performed. RESULTS: We found that the severity of coronary atherosclerosis is significantly associated with the presence of carotid (P<0.05) and peripheral atherosclerosis (P<0.005). Markers of inflammation, hs-CRP (P<0.005) and fibrinogen (P<0.05), were significantly associated with multifocal atherosclerosis. We have shown that an increased number of coronary vessels with atherosclerotic stenosis is associated with a higher value of carotid (P<0.0001) and peripheral intima media thickness (P<0.0001). During 13 months of follow-up the incidence of fatal or non fatal events was 18%. The multivariate analysis showed that the variables independently associated with fatal and non fatal events were: male sex (P<0.001), family history of cardiovascular disease (P<0.005), hypertension (P<0.01), diabetes mellitus (P<0.05), higher levels of total cholesterol (P<0.05), smoking habit (P<0.05), and multifocal atherosclerosis (P<0.05). CONCLUSIONS: The ultrasound examination of carotid and peripheral atherosclerotic lesions may be useful in placing patients with AMI in a category of higher risk of cerebrovascular and cardiovascular events. Moreover, the precocious identification of patients at risk can suggest a more aggressive pharmacological treatment and a more accurate follow-up in order to avoid future events.

Quantitative criteria for the diagnosis of the congenital absence of pericardium by cardiac magnetic resonance.

BACKGROUND: Congenital absence of the left ventricular pericardium (LCAP) is a rare and poorly known cardiac malformation. Cardiac Magnetic Resonance (CMR) is generally used for the diagnosis of LCAP because of its high soft tissue contrast, multiplanarity and cine capability, but the diagnosis is usually made by only qualitative criteria. The aim of the present study was to establish quantitative criteria for the accurate diagnosis of LCAP on CMR. METHODS: We enrolled nine consecutive patients affected by LCAP (mean age 26±8years, 7 males), 13 healthy controls, 13 patients with dilated cardiomyopathy (DCM), 12 patients with hypertrophic cardiomyopathy (HCM) and 13 patients with right ventricular overload (RVO). All patients underwent CMR. The whole-heart volume was measured in end-systole and end-diastole. Whole-heart volume change (WHVC), was the systo-diastolic change of volume, expressed percentage of the end-diastolic volume. The angle of clockwise-rotation of the heart was also measured in the end-diastolic phase of the axial cine stack. RESULTS: The WHVC was significantly higher in LCAP (21.9±5.4), compared to healthy subjects (8.6±2.4, p<0.001), DCM (7.1±1.8, p<0.001), HCM (9.3±2.4, p<0.001) and RVO (8±2.4, p<0.001). The clockwise-rotation was significantly higher in LCAP (76±14°) than healthy controls (40±11°, p<0.001), DCM (41±5°, p<0.001), HCM (30±6°, p<0.001) and RVO (49±8°, p<0.001). WHVC had the highest sensitivity (100%) and specificity (100%) for diagnosing LCAP, using a threshold of >13%. CONCLUSIONS: In LCAP the systo-diastolic WHVC was significantly higher than controls, DCM, HCM and RVO patients and resulted an optimal quantitative criteria for the diagnosis of LCAP.

Selective pacing sites.

he right ventricular apex (RVA) has always been the most used pacing site, because it is easily accessible and provides a stable lead position with a low dislodgment rate. However, it is well-known that long-term right ventricular apical pacing may have deleterious effects on left ventricular function by inducing a iatrogenic left bundle branch block, which can have strong influences on the left ventricle hemodynamic performances. More specifically, RVA pacing causes abnormal contraction patterns and the consequent dyssynchrony may cause myocardial perfusion defects, histopathological alterations, left ventricular dilation and both systolic and diastolic left ventricular dysfunction. All these long-term changes could account for the higher morbidity and mortality rates observe in patients with chronic RVA pacing compared with atrial pacing. This observation led to the reassessment of traditional approaches and to the research of alternative pacing sites, in order to get to more physiological pattern of ventricular activation and to avoid deleterious effects. Then, attempts were made with: right ventricular outflow tract (RVOT) pacing, direct His bundle pacing (DHBP), parahisian pacing (PHP) and bifocal (RVA + RVOT) pacing. For example, RVOT pacing, especially in its septal portion, is superior to the RVA pacing and it would determine a contraction pattern very similar to the spontaneous one, not only because the septal portions are the first parts to became depolarized, but also for the proximity to the normal conduction system. RVOT is preferable in terms of safety too. DHBP is an attractive alternative to RVA pacing because it leads to a synchronous depolarization of myocardial cells and, therefore, to an efficient ventricular contraction. So it would be the best technique, however the procedure requires longer average implant times and dedicated instruments and it cannot be carried out in patients affected by His bundle pathologies; furthermore, due to the His bundle fibrous area, higher pacing thresholds are required, causing accelerated battery depletion. For all these reasons, PHP could be considered an important alternative to DHBP, to be used on a large scale. Finally, bifocal pacing in CRT candidates, provides better acute hemodynamic performance than RVA pacing, derived from a minor intra- and interventricular dyssynchrony, expressed also by the QRS shortening. Then, bifocal pacing could be taken into account when RVA pacing is likely to be the origin of serious mechanical and electrical dyssynchrony or when CRT is contraindicated or technically impossible. So, whatever chosen as selective pacing site, you must look also at safety, effectiveness and necessary equipment for an optimal pacing site.

Left ventricular filling rate at rest and during exercise in patients with previous myocardial infarction.

The purpose of this investigation was to define, with radionuclide technique, the variation on left ventricular filling rate in patients with coronary artery disease, and to determine the effects of dynamic exercise on this variation. The study was carried out on 91 subjects, 46 patients with anterior and 30 with inferior previous transmural myocardial infarction; 15 healthy subjects were studied as control group. All the patients underwent coronary angiography and left ventriculography. From the left ventricular time activity curve we considered the diastolic parameters of the peak filling rate (PFR). We considered also the relative end-diastolic volume (rEDV) and the relative end-systolic volume (rESV). These parameters were determined at rest and at the fifth minute of a symptom limited dynamic exercise taken in the supine position, on an ergometric bicycle. In normal subjects rest mean PFR values is 3.08 +/- 0.51 edv/s, during exercise occurs a physiological increase and mean PFR values becomes 5.48 +/- 1 edv/s. The patients with previous myocardial infarction show a PFR significantly smaller than in normal subjects. Abnormal PFR indices during exercise are present in a large number of these patients and the higher anomalies of PFR during exercise were found among patients with anterior myocardial infarction. In these patients we found an increase of rESV during exercise. In conclusion myocardial infarction induces significant alterations of the PFR; physical exercise reveals PFR alterations not exhibited at rest and rESV increase during exercise could be responsible for the PFR alteration observed.

Cardiac changes in subclinical and overt hyperthyroid women: retrospective study.

BACKGROUND: This retrospective and descriptive 4-year study was undertaken to describe cardiac changes in subclinical and overt hyperthyroidism. METHODS: We revised the charts of 386 consecutive cardiopathic women whose blood samples were referred to the Radioimmunoassay Laboratory to evaluate thyroid function from 1 January 1997 through 31 December 2000. RESULTS: After excluding women because euthyroid or hypothyroid, or taking amiodarone and women with hypertension, rheumatic disease, myocardial infarction, a total of 31 hyperthyroid women were thus selected for the study: 19 with subclinical hyperthyroidism and 12 with overt hyperthyroidism. The prevalence of atrial fibrillation did not differ between subclinical (48%) and overt (67%) hyperthyroid women, as well as left atrial dimension; the latter was larger in hyperthyroid (27.8+/-7.8 cm(2)/m(2)) than in control women (18.9+/-2.8 cm(2)/m(2)) (P<0.001). In the subclinical and overt hyperthyroidism, the heart rate (HR) was increased and left ventricular end diastolic (LVED) volume was reduced; in addition, only in overt hyperthyroidism, left ventricular (LV) mass was increased. A significant correlation between LV mass and free triiodothyronine was found. CONCLUSION: HR increase and LVED decrease, both in subclinical and overt hyperthyroidism, indicate a global impairment of diastolic heart performance, complicated in overt hyperthyroidism by LV concentric hypertrophy. So, in our opinion, subclinical hyperthyroidism, far from being considered a simple laboratory finding, in clinical practice should be taken into serious consideration.

Exercise test: trend of the leukocyte flow properties, polymorphonuclear membrane fluidity and cytosolic Ca2+ content in normals, in subjects with previous acute myocardial infarction and in subjects with aortocoronary by-pass.

We evaluated, during an exercise test, the leukocyte flow properties, the polymorphonuclear leukocyte (PMN) membrane fluidity and PMN cytosolic Ca2+ content in normals, in subjects with previous acute myocardial infarction (AMI) and in subjects previously submitted to a aortocoronary by-pass. Leukocyte flow properties were evaluated using the St. George filtrometer. Examination of the PMN membrane fluidity was effected employing the probe TMA-DPH; while evaluation of the PMN cytosolic Ca2+ content was carried out using the probe Fura 2-AM. At baseline, in both cardiopathic groups a significant difference in PMN filtration parameters and in PMN cytosolic Ca2+ content was evident compared to normals. In normals, at peak of exercise, there was an evident reduction of mononuclear filtration parameters, while during recovery a slight increase of the PMN cytosolic Ca2+ content was observed. In subjects with previous AMI and in subjects with aortocoronary by-pass, however, we observed, at peak of exercise, a decrease of the mononuclear filtration parameters, a reduction of the PMN membrane fluidity and an increase of the PMN cytosolic Ca2+ content. In both groups, the changes in PMN membrane fluidity and cytosolic Ca2+ content remained during recovery. The trend of the PMN membrane fluidity and cytosolic Ca2+ content found in the cardiopathic subjects during the exercise test suggest the PMN activation may be more evident in these subjects.

[Effect of collateral circulation on myocardial perfusion using thallium-201]. / Influenza del circolo collaterale sulla perfusione miocardica al tallio-201.

BACKGROUND: The influence of collateral circulation (CC) on thallium-201 myocardial uptake was studied in 69 patients with coronary artery disease who underwent a coronary angiography. MATERIALS AND METHODS: According to Cohen and Rentrop a CC of 2nd and 3rd degree only was considered. A stress-early redistribution 201Tl scintigraphic protocol was utilized. The images were divided into five segments in each projection; the segments with higher uptake were considered as normal (100%). 1035 segments were analyzed and each segment was related to the donor artery on the basis of the 201Tl and angiographic evaluation. Patients were distinguished in single or multi-vessel disease with or without CC. In collateralized segments related to occluded or functionally more severe coronary stenosis, a somewhat significant prevalence of normal thallium-201 perfusion was observed, while in the non collateralized segments a higher prevalence of irreversible thallium defects was observed. CONCLUSIONS: The data suggest that CC is one of the factors responsible for the presence of normal scintigraphic images in patients with severe coronary stenosis or complete occlusion.

[A new method for calculating the mass of the left ventricle by angiocardiography]. / Una nuova metodica per il calcolo della massa del ventricolo sinistro mediante angiocardiografia.

The authors describe a simplified method to determine left ventricular volume and mass from the ventricular silhouette, taken from a right oblique anterior angiographic projection at 30 degrees, used to measure the telediastolic surface and major axis, and of measuring the telediastolic thickness of the ventricular wall in the postero-lateral segment of the silhouette taken from a left oblique anterior angiographic projection at 60 degrees. Sixty-four ventricular silhouettes were analysed in patients undergoing left kineventriculography for coronaropathy and ventricular mass was determined using both the new and traditional methods. Using the new method mass values (mean value 87.85 g/sq.mt. and SD 34.04) were obtained which were significantly correlated (r = 0.999) with values obtained using the standard method (mean value 88.02 g/sq mt and SD 34.11). The practical advantages of the new method are discussed (simplicity of calculating equation without determining the minor axis of the ventricular silhouette), together with its limits due to the monoplanar technique used to calculate the volume and the measurement of wall thickness in those cases in which the postero-lateral wall is considered the most representative of the mean thicknesses of the left ventricular wall. Lastly, the paper discusses the possibility of applying this method to non-invasive procedures, such as the two dimensional echocardiogram, where more reliable mass values could be obtained even in the event of non-uniform wall thickness.

[Magnetic fields in physical medicine. General and special criteria of application]. / I campi magnetici in medicina fisica. Criteri di applicazione generali e particolari.

The influence of magnetic fields on living creatures has been studied, and the physical characteristics, biological effects (stimulating and analgesic) as well as therapeutic applications are described. In particular, the authors discuss: traumatic bone lesions, bone grafting and internal prostheses in orthopedic surgery, neurodystrophic lesions, painful musculo-articular syndromes, osteomyelitis, sluggish wounds, and peripheral nerve lesions.

[Sports in functional rehabilitation of the lumbar spine]. / L'attività da sport nella rieducazione funzionale della colonna lombare.

Having analyzed the biomechanics of the spine, especially of the lumbar spine, the authors describe postural lumbalgia, a very topical problem As a matter of fact, standing is not always actively maintained by the alpha-tonic system but by capsulo-ligamentous resistance. For the latter type of pathologic or "passive" orthostatic position, postural gymnastics according to Mézière's technique after thorough objective examination of the patient is the ideal treatment. But sports after postural reeducation are a valid means for the maintenance of muscular tonicity and trophism. The sports to be recommended should be non competitive and non traumatic such as walking, swimming, rowing, and other activities involving the muscles of the trunk and all four limbs.

[Dynamic balance in the prevention of growth disorders]. / L'equilibrio dinamico nella prevenzione delle alterazioni dell'accrescimento.

The authors examine the characteristic of the standing position and the successive developmental phases of proprioceptive afferent stimuli which lead to the coordination of muscles responsible for the control of static and dynamic balance. Subsequently, they analyze pathological changes due to intrinsic factors which are likely to be involved in dysmorphisms of the spine, and to extrinsic factors such as those brought about by orthotic or surgical intervention on the spine. The authors conclude stressing the clinical and prognostic importance of global evaluation of kinetic alterations resulting from zonal changes in the entire complex of the locomotor system.

[Problems and techniques of functional rehabilitation of upper limb stump]. / Problemi e tecniche di rieducazione funzionale del moncone di arto superiore.

The authors discuss problems and techniques of rehabilitation in subjects who have undergone upper limb amputation, as well as the requirements for good application of a prosthesis. Various types of prostheses are described: passive ones, those moved by the body and externally operated ones. The amputee undergoes three stages of rehabilitation: a general preparatory phase for maintenance of good joint function and muscle efficiency; a phase of specific rehabilitation with the help of electromyometry and an electronic training device for the use of the prosthesis, and finally individual and group exercises in laboratories with special facilities.

[Surgical treatment of gonarthrosis]. / Trattamento chirurgico della gonartrosi.

Gonarthosis, a frequent complaint in women over 50, brings about changes in the knee which alter its macro and micro structure and are responsible for alteration of the anatomical axis of the lower limb. The most frequent consequence is knock-knee leading to overloading of the medial compartment and reduction of the internal interosseous space. Whereas in the initial forms symptomatic therapy is the treatment of choice, in severe and advanced cases with complete articular blockage arthroprosthesis is the alternative and in cases with minor limitations of joint movement the best results are obtained by osteotomy intended to restore the correct axis. In order to evaluate which of the surgical techniques available is the most appropriate, the authors analyzed 40 cases of tibial osteotomy performed between 1974 and 1984. On the basis of the results obtained, cupuliform osteotomy above the tuberosity appears to lead to the highest success rate.

Comparison of coronary artery flow impairment in diabetic and hypertensive patients with stable microvascular angina.

OBJECTIVE: Stable microvascular angina (SMVA) describes patients with angina, findings compatible with myocardial ischemia and normal coronary angiograms. The aim of this study was to evaluate the impact of diabetes on the coronary microcirculation troughs angiography indexes (TIMI Frame Count, Myocardial Blush Grade, Total Myocardial Blush Score) and a new index: Total TIMI Frame Count (TTFC). PATIENTS AND METHODS: The study population included 310 patients with SMVA that we split into two populations: diabetic-non hypertensive (164 patients) and non-diabetic-hypertensive (146 patients). We calculated, on angiographic images of each patient, TIMI Frame Count (TFC), Myocardial Blush Grade (MBG) and Total Myocardial Blush Score (TMBS) using the protocol described by Gibson and Yusuf. On the basis of Yusuf's experience we imagined a new index: TTFC like sum of the three coronary TFC. RESULTS: We found a worse coronary microcirculation in diabetic-non hypertensive patients with lower values of TFC, MBG and TMBS (p = 0.02), compared with non-diabetic hypertensive. New index TTFC is usually higher in diabetics-non hypertensive than non-diabetic hypertensive patients. Patients with positive scintigraphy had a worse TMBS than patients with a negative one, with a high statistical significance (p = 0.003). CONCLUSIONS: Analysis of diabetic non hypertensive and non-diabetic and hypertensive patients with cardiac syndrome X has led to asses that the diabetic population has a greater involvement of microcirculation. Also the new index, TTFC, proved to be a good marker, in agreement with results of other indexes.