Systematic review and meta-analysis on coronary calcifications in COVID-19.

Chest CT is valuable to detect alternative diagnoses/complications of COVID-19, while its role for prognostication requires further investigation. Non-pulmonary radiological findings such as cardiovascular calcifications could increase the predictivity of clinical outcomes of COVID-19 patients beyond pulmonary involvement. Several observational studies have reported mixed results on the role of coronary calcifications in COVID-19 patients as a predictor of hospitalization, ventilatory support, and mortality. The purpose of the study is to systematically review the available evidence on the predictive role of cardiovascular calcifications in SARS-CoV2 disease. The meta-analysis confirms the prognostic significance of coronary calcifications on hospital mortality, and coronary calcifications (CAC ≠ 0) were associated with an OR for mortality of 2.19 (95% CI 1.36-3.52). CAC was neutral on respiratory outcomes, but it was associated with an increased trend of cardiovascular events. Coronary calcium appears as a promising biomarker imaging even in short-term outcomes (MACEs, hospital mortality) in a non-cardiovascular disease such as Sars-CoV2 infection. Further large studies are needed to confirm promising results of this imaging biomarker in non-cardiovascular disease.

A multicenter observational study on the management of hyperglycemia in patients with acute coronary syndrome.

AIM: To assess the prevalence, risk and management of hyperglycemia in patients with acute coronary syndrome (ACS). DESIGN: a multicenter prospective observational study of a representative sample of patients with ACS consecutively admitted to intensive cardiac care units (ICCU). SETTING: 31 out of 61 ICCUs in Lombardy, the most heavily populated Italian region. From May 2009 to April 2010 1260 patients (69.4% male; mean age 68 ± 13 years) were included in the study: 301 (23.9%) were known diabetic patients (D) and 265 (21.0%) had hyperglycemia (H) (blood glucose >180 mg/dL) at hospital admission, 174 with a history of diabetes (D+H+) and 91 without (D-H+). On the first day after admission intravenous insulin infusion was prescribed to 72 D+H+ (41.4%) and 10 D-H+ (11.0%), according to different protocols. Approximately one third of D+H+ patients (59) and one fifth (17) of D-H+ maintained mean blood glucose higher than 180 mg/dL during the first day in the ICCU. Patients with diabetes or hyperglycemia had a higher incidence of major adverse cardiovascular events or death in hospital. However, at multivariable analysis neither diabetes nor blood glucose at admission was associated with a poor prognosis whereas mean blood glucose on the first day was an independent negative prognostic predictor (OR 1.010, 95% CI 1.002-1.018, p = 0.016). CONCLUSION: Hyperglycemia is frequent in patients with ACS and is independently associated with a poor in-hospital prognosis if it persists in first day. Unfortunately, however, this condition is still poorly treated, with far from optimal blood glucose control.

Prognostic value of the admission electrocardiogram in acute coronary syndromes.

CONTEXT: The presence of ischemic changes on electrocardiogram (ECG) correlates with poorer outcomes in patients with acute chest pain. OBJECTIVE: To determine the prognostic value of various ECG presentations of acute myocardial ischemia. DESIGN: Retrospective analysis of the presenting ECGs of patients enrolled in Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb). SETTING: Three hundred seventy-three hospitals in 13 countries in North America, Europe, Australia, and New Zealand. PATIENTS: A total of 12142 patients who reported symptoms of cardiac ischemia at rest within 12 hours of admission and had signs of myocardial ischemia confirmed by ECG. On presenting ECG, 22% of patients had T-wave inversion, 28% had ST-segment elevation, 35% had ST-segment depression, and 15% had a combination of ST-segment elevation and depression. MAIN OUTCOME MEASURE: Ability of presenting ECG to predict death or myocardial reinfarction during the first 30 days of follow-up. RESULTS: The 30-day incidence of death or myocardial reinfarction was 5.5% in patients with T-wave inversion, 9.4% in those with ST-segment elevation, 10.5% in those with ST-segment depression, and 12.4% in those with ST-segment elevation and depression (P<.001). After adjusting for factors associated with an increased risk of 30-day death or reinfarction, compared with those who had T-wave inversion only, the odds of 30-day death or reinfarction were 1.68 (95% confidence interval [CI], 1.36-2.08) in those with ST-segment elevation, 1.62 (95% CI, 1.32-1.98) for those with ST-segment depression, and 2.27 (95% CI, 1.80-2.86) for those with combined elevation and depression. An elevated creatine kinase level at admission correlated with a higher risk of death (odds ratio [OR], 2.36; 95% CI, 1.92-2.91) and death or reinfarction (OR, 1.56; 95% CI, 1.32-1.85). The ECG category and creatine kinase level at admission remained highly predictive of death and myocardial infarction after multivariate adjustment for the significant baseline predictors of events. CONCLUSIONS: The ECG at presentation allows immediate risk stratification across the spectrum of acute coronary syndromes. An elevated creatine kinase level at admission is associated with worse outcomes.

Amiodarone used alone or in combination with propranolol: a very effective therapy for tachyarrhythmias in infants and children.

The aim of the study was to evaluate the efficacy of amiodarone used alone or in combination with propranolol in infants and children affected by life-threatening or drug-resistant tachyarrhythmias. The study included 27 children (median age 3 months), affected by life-threatening and/or drug-resistant supraventricular or ventricular tachyarrhythmias. The loading dose of amiodarone was 10-20 mg/kg/day and the maintenance dose ranged between 3 and 20 mg/kg/day. When amiodarone was ineffective, propranolol was added at a dosage of 2-4 mg/kg/day. The study population was divided into two groups: group A was composed of patients <1 year and group B of patients >1 year. The effectiveness of the therapy was assessed by clinical evaluation, Holter monitoring, exercise testing, and, in patients with reentry tachycardias, electrophysiological testing. Amiodarone used alone was effective or partially effective in 4/14 (28%) patients in group A and in 11/13 (85%) patients in group B (p < 0.006). Among amiodarone-resistant patients, the combined therapy with propranolol was effective in 8/10 patients in group A and 2/2 patients in group B. Therefore, amiodarone used alone or in combination with propranolol was effective in 25/27 (93%) patients. During the follow-up (20.5 +/- 13 months) there were no arrhythmic effects but side effects were noted in 5/27 (18.5%) patients. Amiodarone seems to be an effective drug in the control of the life-threatening and/or drug-resistant supraventricular and ventricular tachyarrhythmias in children. The addition of propranolol can significantly enhance the success rate of this class III drug, especially in the treatment of reentry tachycardias due to accessory pathways.

Isolated neonatal atrial flutter: clinical features, prognosis and therapy.

BACKGROUND: Concern exists in literature about the clinical course, the best acute and chronic treatment and the prognosis of idiopathic neonatal atrial flutter. The aim of our study was to evaluate this in a population of our patients with this type of arrhythmia. METHODS: Six infants (3 M, 3 F, mean age 42 +/- 62 days, range 1-150) affected with atrial flutter without structural heart disease were studied and then acutely and chronically treated. The effectiveness of chronic antiarrhythmic treatment was evaluated with Holter monitoring every 3 months for the first year of life and with transesophageal atrial pacing. RESULTS: Mean arrhythmia cycle length was 180 +/- 34 ms with atrioventricular conduction ratio ranging between 1:1 and 3:1. Two patients with clinical signs of heart failure were successfully treated with DC shock. Transesophageal overdrive atrial pacing was successfully used in one patient treated with i.v. propafenone without benefit. In the remaining three patients, cardioversion was achieved with amiodarone after digoxin had failed in all three and propafenone had failed in two of them. To prevent recurrences, we treated four patients with amiodarone, one with amiodarone combined with propranolol and one with digoxin. During the follow-up (22 +/- 11 months), neither arrhythmia recurrences nor side-effects of the therapy occurred. CONCLUSIONS: Neonatal atrial flutter is an arrhythmia with significant acute morbidity but an excellent long-term prognosis. Electrical cardioversion is the first-choice treatment when the arrhythmia is not well-tolerated hemodynamically, while class III antiarrhythmic drugs such as amiodarone should be preferred in the other cases.

[Spontaneous coronary dissection as a cause of acute myocardial infarct: description of a case and review of the literature]. / La dissecazione coronarica spontanea quale causa di infarto miocardico acuto: descrizione di un caso e revisione della letteratura.

Spontaneous coronary artery dissection is a rare cause of acute myocardial ischemia or death that is generally not detected until an autopsy is performed. It occurs in relatively young people and particularly in females. To date, its prognosis and treatment are not well defined. We describe our experience with one patient with acute myocardial infarction due to spontaneous dissection of the right coronary artery, which was treated successfully through direct coronary angioplasty. A 48-year-old man, heavy smoker, was admitted to our CCU for an acute inferior myocardial infarction with right ventricle involvement, which was complicated by the onset of cardiogenic shock (severe arterial hypotension, cold, pale and clammy skin, decrease in mental alertness, marked bradycardia due to a complete atrioventricular block). Since systemic thrombolysis was contraindicated (syncope followed by cranial trauma at the onset of symptoms), the patient underwent urgent coronary angiography that showed a proximal right coronary subocclusion with a filling defect and oblique linear density indicating possible dissection. Primary angioplasty was successfully attempted and a good distal flow was achieved (TIMI 3), but coronary artery dissection became more evident, with a double lumen extending over the distal segment just to the crux. Coronary stenting was not performed because optimum anticoagulant therapy was contra-indicated due to cranial trauma. Standard medical therapy was started after the procedure and coronary angiography, which was repeated before the patient was released from hospital, showed complete healing of the right coronary artery without any signs of dissection. The patient remained asymptomatic at a six-month follow-up check, with a negative exercise test. In our opinion, coronary angioplasty is a suitable therapeutic option in the treatment of spontaneous coronary dissection. More extensive experience is needed in order to standardize the most suitable therapeutic procedure in this rare cause of myocardial ischemia.

[Inferior infarct with associated anterior ST elevation: an unusual presentation of right ventricular involvement. Description of three cases and a brief review of the problem]. / Infarto inferiore con sopraslivellamento del tratto ST anteriore associato: una presentazione inusuale del coinvolgimento del ventricolo destro. Descrizione di tre casi e breve revisione del problema.

ST segment elevation in the left precordial leads in the setting of an acute inferior myocardial infarction may represent an unusual electrocardiographic pattern of right ventricular infarction. We present our experience about three patients with first inferior acute myocardial infarction in whom concomitant anterior ST segment elevation was observed. All patients were submitted to urgent coronary angiography because of repeated episodes of myocardial ischemia (case 1) or hemodynamic derangement (case 2, 3) with hypokinetic arrhythmias (case 3). In all patients 2D echocardiographic examination performed before angiography showed a dilated, hypo-akinetic right ventricle and wall motion abnormalities only in inferior, posterior and/or lateral segments of the left ventricle. Proximal right coronary occlusion was found in all patients, and coronary angioplasty was successfully attempted in all but one case. In patients with first inferior myocardial infarction, left precordial ST segment elevation mimicking an anterior infarction may be the less frequent ECG pattern of right ventricle ischemic involvement. Routine right chest leads and early echocardiographic examination allow to identify the patients with right ventricle infarction and concomitant anterior ST segment elevation. In these patients, early and correct diagnosis is important in order to choice the appropriate therapeutic pathway.

[Anatomo-clinical correlations of cardiopathies diagnosed during fetal life: analysis of 110 cases of cardiopathies]. / Correlazioni anatomo-cliniche delle cardiopatie diagnosticate durante la vita fetale: analisi di una casistica di 110 cardiopatie.

BACKGROUND: Fetal echocardiography has achieved high sensibility and specificity rates and it has become a reliable tool to detect intra-uterine congenital heart defects. OBJECTIVES: The purpose of the present study was to clarify the potential of anatomo-clinical correlation in fetal echocardiography not only for diagnosing heart defects, but also for understanding and following their morphogenesis and natural history in utero. METHODS: Nine hundred pregnancies, referred by several first-level centers, have been followed up from the sixteenth week to birth, and the newborn baby has been studied, too. In case of either voluntary abortion, or intra-uterine or neonatal death, a post-mortem examination was performed whenever possible. RESULTS: Since 1982, 110 fetal heart defects have been detected: 94 were diagnosed by means of fetal echocardiography (in 21/94 an autopsy was carried out) and 16 were directly observed at the post-mortem (spontaneous or voluntary abortions not previously referred). The heart defects most commonly observed were the atrioventricular (14.5%), ventricular (9.0%), and atrial (7.2%) septal defects, the absent left atrioventricular connection (8.1%), and atrial isomerism (6.3%). The congenital heart defects diagnosed in utero vary from those observed in the newborn and infants in terms of distribution (because of difficulties in diagnosis, selection of pregnancies, and differences in manifestation) and morphology (because of the coexistence with other extracardiac malformations, the changes due to altered fetal hemodynamics, and the intrauterine evolution of the morphology of cardiac defects). CONCLUSIONS: Heart defects observed in utero have a peculiar prevalence and a different morphology in respect to their infantile counterparts and can be followed in their morphologic evolution.

[Atenolol i.v. in the acute phase of AMI: the indications, contraindications and interactions with thrombolytic drugs in the GISSI-2 study. The GISSI-2 Researchers. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico]. / L'atenololo ev nella fase acuta dell'IMA: indicazioni, controindicazioni, interazioni con i farmaci trombolitici nello studio GISSI-2. I ricercatori del GISSI-2.

BACKGROUND: In the pre-thrombolytic era, several studies showed the effectiveness of beta-blocker administration in the treatment of patients (pts) with acute Myocardial Infarction (MI). Results from the ISIS-1 and GISSI trials suggested that the combined administration of beta-blocker and of thrombolytic drugs in the acute phase of infarction could lead to a better prognosis. The possibility of synergic effects from the associated administration of these drugs was confirmed by small clinical trials. In GISSI-2 study a large number of patients treated with thrombolytic drugs were given i.v. atenolol (10 mg) as recommended therapy, not following a randomized study design. AIM: We reviewed the data of the GISSI-2 study population in order to evaluate: 1) the number of pts treated with i.v. atenolol; 2) the anamnestic and clinical characteristics of treated und untreated pts; 3) the causes of exclusion from the beta-blocker therapy; 4) the causes of scheduled dose withdrawal and the incidence of side effects related to atenolol administration; 5) the interaction between atenolol and streptokinase (SK) and rtPA; 6) the incidence of relevant clinical events and the causes of death during the in-hospital period. RESULTS: Among 12377 evaluated pts, 5616 (45.4%) were given atenolol i.v., 2772 received SK (49.5%) and 2844 (50.5%) rtPA. Mean age was 59.5 +/- 11.3 yrs in atenolol treated pts vs 63.4 +/- 10.9 yrs in untreated pts (p < 0.001); 34.1% of pts aged > 70 yrs vs 48.6% of younger pts (p < 0.00001) and 42.1% of females vs 46.2% of males (p < 0.003) received atenolol. Pts with previous MI received less frequently atenolol than those without MI (17.5% vs 13.5%, p < 0.00001). 88.5% of the treated pts was in Killip class I at entry (untreated 69.5%, p < 0.00001); anterior and lateral site, non-Q type and > or = 5 electrocardiographic leads with ST segment elevation were more frequently found in atenolol treated pts, inferior and unknown site in untreated pts. Among 6761 untreated pts, 32% did not receive atenolol for the occurrence of bradycardia, 15.2% for hypotension, 14.1% for heart failure, 7.2% for bronchospasm or history of asthma, 6.2% for bradycardia and hypotension, 0.3% for death; in 25% of the untreated pts, none of the above-mentioned causes was detectable. 1064 pts (18.9%) did not complete the scheduled dose of atenolol for the occurrence of bradycardia or atrioventricular block > or = II degree (7.3%), hypotension (7%), bradycardia and hypotension (1.8%), heart failure (0.7%), death (0.03%), other causes (1.9%). Transient hypotension was found more frequently in pts treated with SK than in those receiving rtPA (9.3% vs 4.8%, p < 0.0001), but the rate of persistent hypotension was not different in both groups (4.6%). During the hospital phase a higher incidence of advanced atrioventricular block (12.3% vs 4.3%), need of temporary or permanent pacing (5.6% vs 1.9%), sustained ventricular tachycardia (4.5% vs 2.8%), heart failure (12% vs 7.1%), ventricular fibrillation (8% vs 4.9%) and death (11.9% vs 5.1%) were shown in pts that were not given i.v. atenolol. Heart failure was the main cause of death in both groups (untreated 2.3% vs 2.2%); ventricular fibrillation (0.2% vs 0.48%), cardiac rupture (0.5% vs 1.4%), and electromechanical dissociation (0.9% vs 1.9%) were less frequent in treated pts. CONCLUSIONS: The absence of randomized design of atenolol administration limits the value of the differences found in the clinical outcome of the two groups of pts. In spite of that, the low incidence of death and side effects in treated pts, and the high percentage of pts who completed the scheduled dose of atenolol, confirm that the iv. administration of beta-blockers in the acute phase of the myocardial infarction is safe, well tolerated and suitable in almost an half of the patients submitted to thrombolytic therapy with SK or rtPA.(ABSTRACT TRUNCATED AT 400 WORDS)

[Clinical and instrumental elements predictive of left ventricular insufficiency in acute myocardial infarct: multivariate analysis in patients treated with thrombolytic therapy]. / Elementi clinico-strumentali predittivi di insufficienza ventricolare sinistra in corso di infarto miocardico acuto: analisi multivariata in pazienti trattati con terapia trombolitica.

BACKGROUNDS: During the course of acute myocardial infarction (AMI), the appearance of signs of left ventricular failure (LVF) (cardiogenic shock, acute pulmonary edema, congestive heart failure) is a prognostically negative event which is still relatively frequent even in patients receiving fibrinolytic therapy. The early identification of patients exposed to such a risk would allow adequate diagnostic and therapeutic preventive measures to be taken. AIM: To evaluate, in a population of AMI patients undergoing thrombolysis and without any serious complications at the moment of hospitalisation, which anamnestic, clinical and instrumental data obtained within the first 24 hours best identify those who will subsequently develop full-blown LVF. Secondary aim is to evaluate the role that extension of coronary disease plays in determining the occurrence of LVF. METHODS: The study involved 104 consecutive patients aged < 75 years admitted to hospital for AMI with ST-segment elevation, within 12 hours of the onset of symptoms, in Killip class 1-2 upon entry to the CCU, and treated with thrombolytic therapy. The study design included the collection of anamnestic and clinical data upon admission to the CCU; an enzymatic curve during the first 4 days; the ECG at entry, and 4 and 24 hours after the beginning of fibrinolysis; the chest X-ray, the 2D-echocardiography (2D-echo) and the hemodynamic measurements within the first 24 hours; a coronary angiography on the tenth day (or earlier if clinically necessary). RESULTS: Seventeen patients (16%) presented signs of LVF; 8 (7.6%) with cardiogenic shock, 9 with congestive heart failure: 3 died (3%), all for shock. Univariate analysis correlated LVF with: 1) the indices of the extension of ischemic/necrotic damage: number of derivations with ST elevation (p < 0.04) and Q waves (p < 0.05) at first ECG, maximum peak of myocardial enzyme (p < 0.02), wall motion score index (p < 0.001), percentage extension of asynergy (p < 0.001), presence of remote asynergy (p < 0.001), left ventricular (LV) end-systolic (p < 0.001) and end-diastolic volume (p < 0.01), and LV ejection fraction (EF) (p < 0.001) at 2D-echo; 2) the indices of hemodynamic involvement: Killip class 2 at entry (p < 0.02), pulmonary venous flow diversion at chest X-ray (p < 0.001), systolic (p < 0.05), diastolic (p < 0.01) and mean (p < 0.01) pulmonary pressure, capillary wedge pressure (p < 0.01), and the LV systolic work index (p < 0.05). Multivariate analysis showed that the only independent variable predictive of LVF was the EF at 2D-echo (p < 0.001): the sensitivity and specificity of EF was respectively 36% and 97% at cut-off value of 0.30, and 93% and 69% at cut-off value of 0.45. Multivessel coronary disease was found more frequently in patients who developed LVF (p < 0.05) and was correlated with 2D-echo LV involvement: presence of remote asynergies (p < 0.0001), lower EF (p < 0.01), higher wall motion score index (p < 0.001) and percentage extension of asynergy (p < 0.01). CONCLUSIONS: The incidence of LVF in patients with AMI, without serious complications at onset, is still relatively high (16%) even if they are treated with thrombolysis. Of all evaluated clinical and instrumental indices, multivariate analysis showed that EF at 2D-echo was the only independent variable predictive of LVF. Extension of coronary disease correlated with development of LVF. Moreover, worse LV performance and greater regional contractility involvement at 2D-echo correlated with extension of coronary disease. Consequently, echocardiography would appear to be bed-side, simple, reliable and accurate mean of establishing a prognosis from the moment a patient with AMI is admitted to a CCU.

[The resolution of right atrial thrombosis of recent onset during the intravenous infusion of rtPA: a report of 3 cases with continuous echocardiographic monitoring]. / Risoluzione della trombosi atriale destra di recente insorgenza durante infusione endovenosa di rtPA: descrizione di tre casi con monitoraggio continuo ecocardiografico.

We performed continuous echocardiographic examination during the i.v. administration of rtPA in three patients with recent-onset, mobile right atrial thrombosis, in order to assess both the timing and mode of thrombus resolution. In all these cases, right atrial thrombus disappeared before the scheduled dose (100 mg i.v. within three hours) was completed: 60 mg of rtPA were required in the first patient, and 50 mg in the other two. In the first case, the thrombus divided into numerous smaller fragments chaotically moving in the right chambers before disappearing; in the second, the echo reflectivity of the thrombus gradually diminished and the mass showed multiple echo-lucent cavities before disappearing; in last case, the atrial mass migrated from the right atrium to the right ventricle before disappearing. None of the patients experienced any symptoms at the dissolving of the thrombus; bleeding complications occurred in all three (in one, at the site of previous PTCA; in another, at the site of arterial and venous puncture; in the third the haematoma was localized at the site of a previous orthopedic operation) but only two required blood transfusion. In patients with right atrial thrombosis, continuous echocardiographic examination allows us to identify both the timing and mode of thrombus resolution, and the occurrence of new-onset peripheral pulmonary embolization. This information can help in optimizing the dosage of the drug in patients in whom bleeding complications can be suspected to occur after thrombolytic therapy.

Usefulness of color Doppler in the diagnosis of ventricular septal rupture after myocardial infarction.

Ten consecutive patients with ventricular septal rupture complicating acute myocardial infarction were studied by means of Doppler echocardiography (including two-dimensional, conventional and color Doppler techniques) and bedside right heart catheterization using a Swan-Ganz catheter. One patient died before an operation could be performed. Seven critically ill patients underwent emergency cardiac surgery without preoperative cardiac catheterization, while in two patients it was also possible to undertake coronary angiography before surgery. Two-dimensional echocardiography diagnosed post-infarction ventricular septal rupture in 6 out of 10 patients. Color Doppler revealed the presence and the location of septal rupture in all 10 patients. The color Doppler diagnosis was confirmed either by surgery or necropsy. The estimates of pulmonary artery pressure, obtained by color Doppler-guided continuous wave Doppler beam, were very close to those measured by simultaneous right heart catheterization. In 3 patients, patch leakage occurred 3 days, 15 days and 1 year after the operation. Two-dimensional echocardiography revealed the patch leakage in only one of 3 patients while its location was visualized by color Doppler in all 3 patients. In one patient the color Doppler diagnosis was confirmed at necropsy. In the remaining 2 patients, a small left-to-right shunt was demonstrated by radionuclide studies. Color Doppler echocardiography is a highly sensitive and rapid technique in the diagnosis of postinfarction ventricular septal rupture. In critically ill patients it offers relevant information and may obviate the need for any invasive preoperate investigation.

[A prospective study of the evolution of coronary lesions: clinico-morphologic correlations]. / Studio prospettico sulla evolutività delle lesioni coronariche: correlazioni clinico-morfologiche.

In order to evaluate the evolution (progression and regression) of coronary atherosclerosis, 61 patients (8 with stable angina, 9 with unstable angina, 15 with a recent myocardial infarction, 29 with multivessel coronary artery disease and treated with successful one-vessel angioplasty) were enrolled in a prospective study. In the angioplasty group, only untreated vessels were considered for the analysis. All patients underwent coronary angiography before hospital discharge and after one year, in accordance with the study protocol. In 13 patients (21%) a repeat angiography was performed at 6.3 +/- 2.7 months for clinical reasons (myocardial infarction, changing pattern angina, angina recurrence). All patients were asymptomatic or mildly symptomatic on medical therapy between the angiographic studies. Progression (decrease in internal luminal diameter at the site of stenosis greater than or equal to 20%; new onset of lesions, new episodes of total occlusions) was found in 16 out of 216 stenoses (7%) and in 14 out of 61 patients (23%). Regression (increase greater than or equal to 20% in internal luminal diameter; reopening of a previously occluded vessel) was found in 11 out of 227 lesions (5%) and in 7 out 61 patients (11%). At repeat angiography, the increase in severity was found more frequently in stenoses greater than 5 mm in length and with a reduction of greater than or equal to 75% in luminal diameter. Regression was more frequent in the occluded vessel supplying a recently infarcted area. No significant relationship was observed between lesion morphology (concentric, eccentric, with plaque ulceration, thrombi, border irregularities) and progression or regression. Lesions with plaque ulceration (with or without superimposed thrombi) were found only in patients submitted to coronary angiography close to an acute ischemic attack. Morphologic regression (disappearance of ulceration, border irregularities, thrombi) was also observed, without any significant changes occurring in the severity of the underlying stenosis. Progression may occur independently of worsening in the clinical status; on the contrary, regression was only found in patients without new cardiac events. Nevertheless, clinical status does not seem to be closely correlated to progression, regression, or changes in plaque morphology.

Exercise testing and dipyridamole echocardiography test before and 48 h after successful coronary angioplasty: prognostic implications.

The purpose of the present study was to determine the value of exercise testing (ET) and dipyridamole echocardiography test (DET) in the early functional evaluation after a successful coronary angioplasty (PTCA) and in the prediction of angina recurrence. 52 patients underwent ET and DET before and 48 h after a successful PTCA. During a 6-12 month follow-up period they all underwent clinical evaluation. Before PTCA, ET was positive in 49 of 52 patients (94%) and new asynergies were detected by DET in 47 of 52 patients (90%). 48 h after PTCA 23 patients (44%) had positive ET results and 10 had a positive DET response. During the follow-up, 17 patients experienced recurrence of angina. Positive predictive value (PPV) for angina recurrence of ET and DET performed early after the PTCA were, respectively, 57 and 80%. The PPV of ET increased to 88% when electrocardiographic (ECG) positivity was accompanied by angina. Negative predictive values of ET and DET were, respectively, 86% and 79%. Early after PTCA, exercise ECG positivity was not predictive of symptom recurrence while ECG positivity associated with angina revealed a high PPV, similar to that of DET.

Effectiveness of calcium antagonist drugs in patients with unstable angina and proven coronary artery disease.

Eighty-five patients admitted to our CCU for unstable angina (UA) with proven coronary artery disease, in whom i.v. therapy with nitroglycerin (N) and heparin (H) did not reduce both painful and painless episodes of myocardial ischaemia, were treated by i.v. administration of verapamil (V) and diltiazem (D) in order to assess the efficacy of calcium antagonists in reducing myocardial ischaemia. All patients were given i.v. N + H throughout the whole study period; none showed significant increase in serum CK MB concentration. V and D were assigned following a double-blind, cross-over, placebo-controlled design after a 48 h period of N + H therapy. Continuous Holter monitoring (CHM) was performed during the whole study period. V and D significantly reduced the total number of ischaemic episodes day-1 (N + H = 6.8 +/- 3.9; D = 2.1 +/- 2.3, P less than 0.001; V = 1.7 +/- 2.7, P less than 0.001), the number of silent episodes (SE) (N + H = 5.2 +/- 3; D = 1.4 +/- 1.4, P less than 0.001; V = 1.5 +/- 2.5, P less than 0.001) and the duration of SE (N + H: 428 min for all patients, D: 61 min, V: 112 min). In patients with UA and proven CAD in whom i.v. N and H are ineffective to control myocardial ischaemia, V and D given i.v. reduced both painful and painless ischaemic episodes and allow safe delay of coronary arteriography and myocardial revascularization without adjunctive risk. Continuous Holter monitoring is important to detect the total ischaemic burden.

Indications for surgical treatment in post-infarction angina.

In order to evaluate whether or not criteria for surgical revascularization in patients with early post-infarction angina (EPIA) should be different from those commonly used for patients with angina, the incidence and prognostic implications of EPIA were analysed in 188 AMI patients in Killip's class I or II on admission. Sixty-two patients (33%) complained of EPIA (Group I) and 126 patients were symptom-free (Group II). There were no differences between the two groups in in-hospital and late mortality and reinfarction. On the contrary, severity of angina was significantly associated with the occurrence of in-hospital and late cardiac death, reinfarction and revascularization procedures. EPIA patients underwent revascularization procedures significantly more frequently than group II patients, both during hospitalization (29% versus 1%; P less than 0.001) and follow up (10% versus 1%; P less than 0.01). Coronary artery involvement was significantly more severe in group I than in group II and in the operated patients compared with the non-operated ones. Our data suggest that the severity of angina should be the leading criterion for surgery, as it is able to identify most of the patients with severe coronary artery disease and poor prognosis.

[Comparison between the hemodynamic effects of nitroglycerine ointment and oral isosorbide dinitrate in the treatment of left ventricular failure (author's transl)]. / Effetti emodinamici della trinitroglicerina pomata e dell'isosorbide dinitrato per os a confronto nel trattamento dell'insufficienza ventricolare sinistra.

The hemodynamic effects of standard dose of Nitroglycerin (NTG) ointment (23 +/- 4 mg) and oral Isosorbide Dinitrate (ISDN) 10 mg were compared in the treatment of left ventricular failure. Ten patients, 8 males and 2 females (mean age 59 +/- 9 years), affected by acute myocardial infarction (7 cases). Ischemic cardiomyopathy (2 cases) and hypertensive cardiomyopathy (1 case) were submitted to right heart catheterization by triple lumen Swan-Ganz catheter. Heart Rate (HR), mean Arterial Pressure (AP), Right Atrial Pressure (RAP), mean Pulmonary Artery Pressure (PAP), Pulmonary Wedge Pressure (PWP), Stroke volume (SV), Cardiac Index (CI), Stroke Work Index (SWI), Systemic Vascular Resistances (SVR), Pulmonary Total Resistances (PTR) were controlled every 30 minutes until the disappearance of the hemodynamic effects. ISDN did not produce any statistically significant changes; on the contrary NTG ointment caused significant changes in: (formula: see text). Decrease of RAP, PAP, PWP, PTR and increase of SV, CI, SWI were statistically significant from 30 until 180 minutes after NTG ointment administration. These changes were statistically different from those produced by ISDN (p less than 0,05). Thus NTG ointment, at this dose, improved cardiac performance, while oral ISDN 10 mg did not. It is concluded that the hemodynamic effects of NTG ointment are prompt and sustained.