Care manager to control cardiovascular risk factors in primary care: the Raffaello cluster randomized trial.

BACKGROUND AND AIM: This cluster randomized trial evaluated the efficacy of a disease and care management (D&CM) model in cardiovascular (CVD) prevention in primary care. METHODS AND RESULTS: Eligible subjects had ≥ 1 among: blood pressure ≥ 140/90 mmHg; glycated hemoglobin ≥ 7%; LDL-cholesterol ≥ 160 or ≥ 100 mg/dL (primary or secondary prevention, respectively); BMI ≥ 30; current smoking. The D&CM intervention included a teamwork including nurses as care managers for the implementation of tailored care plans. Control group was allocated to usual-care. The main outcome was the proportion of subjects achieving recommended clinical targets for ≥ 1 of uncontrolled CVD risk factors at 12-month. During 2008-2009 we enrolled 920 subjects in the Abruzzo/Marche regions, Italy. Following the exclusion of L'Aquila due to 2009 earthquake, final analyses included 762 subjects. The primary outcome was achieved by 39.1% (95%CI: 34.2-44.2) and 25.2% (95%CI: 20.9-29.9) of subjects in the intervention and usual-care group, respectively (p < 0.001). The D&CM intervention significantly increased the proportion of subjects who achieved clinical targets for both diabetes and hypertension, with no differences in hypercholesterolemia, smoking status and obesity. CONCLUSIONS: The D&CM intervention was effective in controlling cardiovascular risk factors, in particular hypertension and diabetes. Numbers needed to treat were small. Such intervention may deserve further consideration in clinical practice. REGISTRATION NUMBER: ACTRN12611000813987.

Serial measurements of NT-proBNP are predictive of not-high-dose anthracycline cardiotoxicity in breast cancer patients.

BACKGROUND: The aim of this study was to assess the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in predicting late cardiotoxicity in patients treated with not-high-dose chemotherapy (NHDC), and to compare the predictive value of NT-proBNP and cardiac troponin I (cTnI). METHODS: In 71 patients undergoing NHDC with anthracyclines, NT-proBNP and cTnI levels were measured before and 24 h after each NHDC cycle. Left ventricular (LV) function was assessed by echocardiography at baseline, every two NHDC cycles, at the end of chemotherapy, and at 3-, 6- and 12-month follow-up. RESULTS: During NHDC, only NT-proBNP showed abnormal values. According to NT-proBNP behaviour, patients were divided into two groups: group A (n=50) with normal (n=23) or transiently elevated NT-proBNP levels (n=27), and group B (n=21) with persistently elevated NT-proBNP levels. At follow-up, LV impairment was significantly worse in group B than in group A. %Δ (baseline-peak) NT-proBNP was predictive of LV impairment at 3-, 6- and 12-month follow-up, with a cutoff of 36%. CONCLUSION: Serial measurements of NT-proBNP may be a useful tool for the early detection of patients treated with NHDC at high risk of developing cardiotoxicity.

Left ventricular surgical remodeling after the STICH trial.

Surgical treatment of anteroseptal scars has been, and still is, a challenging task for cardiac surgeons. Most patients are in heart failure and the infarcted areas can include different parts of the septum and the anterior wall. The core problem of ischemic congestive heart failure is the undue demand placed on the residual viable left ventricle myocardium. The surgical techniques used to correct the mismatch between contractile and asynergic areas differ, but the evolution of surgical techniques for left ventricular surgical remodeling (LVSR) is still a work in progress. The most popular one was proposed by Dor et al. in the 1980s and is still in general use. This technique addressed the problem of recovering a predictable volume but not necessarily the problem of rebuilding a physiologically conical shape. This anatomical aspect is becoming increasingly important, and the purpose of septal reshaping, as proposed by us in 2004, is more to recover a conical shape than to achieve volume reduction. Thus, we use the Dor operation only when septoapical scars are present. The need for a different surgical strategy is emphasized by the result of the STICH trial, which reports the data of 1000 patients randomized for coronary artery bypass grafting (CABG, n = 499) or CABG and LVSR (n = 501) and which failed to show any benefit of LVSR. However, the only surgical technique used was the classic Dor operation, where the purpose was to reestablish volume and not to recreate a physiological shape. This study, however, does not provide a definitive answer, as echocardiography results included only 212 patients in the CABG arm and 161 in the CABG and LVSR arm. Furthermore, previous myocardial infarction (MI) was not a prerequisite for study inclusion (13 % of patients in each group had no previous MI) and whether a previous MI was Q-wave or not was not specified. In conclusion, the long-term results after LVSR are satisfactory but appear to be better if a conical shape has been recreated. The role of preemptive surgery in selected cases and how to establish the limits of LVSR (grade of preoperative diastolic dysfunction, diastolic diameter, ventricular volumes, function of the remote zone, etc.) is still unclear. The impact of each individual treatment in the individual patient (medical treatment, CABG alone, CABG and LVSR) has still to be identified.

Relation between coronary atherosclerotic plaques and traditional risk factors in people with no history of cardiovascular disease undergoing multi-detector computed coronary angiography.

AIMS: To prospectively investigate the prevalence of coronary artery plaques (CAP) as detected by computed tomography-based angiography in a large number of consecutive individuals with no history of coronary artery disease (CAD) or acute coronary syndrome; to evaluate whether traditional risk factors are related to prevalence of CAP and to the expected 10-year risk of first major or fatal cardiovascular event (CVE). DESIGN: Prospective, single-centre, cross-sectional study. SETTING: The division of Cardiology at Fondazione Cardiocentro Ticino Lugano, Switzerland. METHODS: We prospectively included 920 consecutive individuals with no history of CAD who underwent computed tomography coronary angiography (CTCA). Risk estimation of fatal and non-fatal CVE was assessed using Global Assessment Risk (GAR) and Systematic Coronary Risk Evaluation (SCORE), respectively. Logistic regression was used to assess the association of risk factors with the prevalence of CAP. RESULTS: CAP was found in 459 (49.9%) individuals. Older age, higher body mass index, male gender, diabetes, hypertension and dyslipidaemia all increased the likelihood of the CAP burden at univariable analysis (p<0.001). At the multivariable analysis older age, male gender, hypertension and diabetes independently increased the likelihood of CAP burden (p<0.001). An increase in likelihood of CAP was observed in the presence of one, two and three or more risk factors and with an increasing value of GAR and SCORE. Notably, about 18% of subjects with CAP did not report any traditional risk factors and among individuals without CAPs, 12% had three or more risk factors. CONCLUSIONS: A direct relation between the prevalence of CAP, number of risk factors and the related 10-year risk of CVE was found. 18% of subjects without risk factors had CAP. In these individuals CTCA may help in further optimising the risk reduction strategies on an individual basis.

Polymer-coated quartz crystal microbalance chemical sensor for heavy cations in water.

A flow type quartz crystal microbalance (QCM) (bio)chemical sensor was developed for the real time determination of heavy metal ions that is suitable for environmental monitoring. A new process has been developed which enables to obtain surface-modified gold electrodes with high heavy metal ions complexing ability. The sensing performances of the piezoelectric sensor used in a flow-through setup were investigated by monitoring the frequency variation induced by the presence of heavy metal ions, such as copper and lead, as model ions, in aqueous media. X-Ray Reflectivity (XRR) and Atomic Force Microscopy (AFM) were carried out to characterize the unmodified and modified gold surfaces.

Structure, production and function of erythropoietin: implications for therapeutical use in cardiovascular disease.

Erythropoietin (EPO) is a 30,400 daltons glycoprotein, consisting of 165 amino acids produced mainly in the kidney and in the liver and regulating erythrocyitosis. It primarily acts on erythroid precursor cell at colony-forming units-erythroid stage inhibiting the apoptosis. EPO binds on a specific membrane receptor thereby activating at least three specific intracellular signaling pathways, such as phosphatidylinositol 3-kinase/ protein kinase B, Ras-mitogen-activated protein kinase and some members of the signal transducers and activators of transcription family. In addition to kidney and liver, EPO mRNA has been detected in other tissues; accordingly EPO receptor has been identified in several type of cells and recent reports have suggested new roles for EPO in non-haematopoietic tissues with a robust evidence for neuroprotective and cardioprotective activity. In different animal models, in vitro, in isolated perfused heart and in vivo, recombinant human erythropoietin protects heart from ischemia reperfusion injury and reduces myocardial damage. EPO tissue protective activity can be separated from erythropoietic activity. Molecules owing the first property but not the second one have been described. In patients with acute myocardial infarction serum EPO level correlates inversely with infarct size. Acute coronary syndrome, extracorporeal circulation and percutaneous coronary intervention are potential fields of application for tissue protective EPO activity to reduce myocardial damage, increase cardiac function ad improve outcome.

Chlamydia pneumoniae infection in patients with acute coronary syndrome: a clinical and serological 1-year follow-up.

The role of Chlamydia pneumoniae infection in pathogenesis and prognostic stratification of patients with acute coronary syndromes is still unclear. However, a limitation of many studies is the evaluation of the long-term prognostic role of a sample obtained during the acute phase, whereas the assessment of the temporal trend of antibody titers could be more useful. One-hundred and fourteen consecutive patients with acute coronary syndromes (71 with acute myocardial infarction and 43 with unstable angina) were studied. Blood samples were obtained immediately after hospital admission and 1, 3, 6 and 12 months after the acute event. The microimmunofluorescence test was used to detect C. pneumoniae specific antibodies. The incidence of new coronary events (death, myocardial infarction, recurrent angina) was recorded during the 1-year follow-up period. No significant difference was found between patients with (n = 35) or without (n = 79) new coronary events (N.C.E.) regarding baseline and serial values of C. pneumoniae antibodies. The rate of high titers at any time of follow-up was also similar in the two groups: IgG > or =1:512 were present in 52%, 64%, 55% and 32% of N.C.E.+ patients, and in 48%, 54%, 52% and 36% of N.C.E.- patients at 1, 3, 6 and 12 months respectively; IgA > or =1:256 were present in 26%, 23%, 30% and 23% of N.C.E.+ patients and in 20%, 30%, 25% and 19% of N.C.E.- patients at 1, 3, 6 and 12 months respectively. Our data indicate that elevated titers of C. pneumoniae antibodies, even with a serial 1-year evaluation, are not a predictor of future coronary events in patients with acute myocardial infarction or unstable angina.

Possible involvement of plasma antioxidant defences in training-associated decrease of platelet responsiveness in humans.

The aim of this study was to evaluate in sedentary individuals the effects of a 20-week exercise training program on ex vivo platelet responsiveness and the possible involvement of plasma antioxidant defences in relation to the mechanisms controlling platelet sensitivity. A statistically significant decrease in ADP- and collagen-evoked platelet aggregation was observed after physical training together with an increase in plasma total antioxidant capacity (TEAC), superoxide dismutase activity, and high-density lipoprotein cholesterol (HDL-C) concentration. Additionally, a rise in lag time for in vitro low-density lipoprotein (LDL) oxidation as well as a decreased plasma level of secondary products of lipid peroxidation were observed after training, and the values for lag time were significantly correlated with TEAC and HDL-C. Nitrate/nitrite (NOx) content both in plasma and in platelet cytosol was significantly enhanced at the end of the training period and a significant positive correlation was found between plasma and intraplatelet NOx values. Furthermore, intraplatelet NOx content was positively correlated with HDL-C levels. The findings of the current study suggest that the improvement of antioxidant defences induced by moderate regular exercise may be involved in desensitising blood platelets most likely through the inhibition of LDL oxidation and the simultaneous enhancement of plasma and intraplatelet NOx bioavailability and HDL-C level.

Influence of acute exercise on human platelet responsiveness: possible involvement of exercise-induced oxidative stress.

The aim of this study was to evaluate in sedentary male subjects the effects of an acute bout of strenuous and moderate exercise on ex vivo platelet responsiveness and its possible relationship with exercise-associated modifications of oxidant-antioxidant status. An increased ADP- and collagen-evoked platelet aggregation associated with modified membrane fluidity and ion homeostasis was observed after exhaustive exercise. After moderate exercise, we found a decrease of platelet aggregation evoked by low concentrations of agonists. Strenuous exercise, but not moderate exertion, resulted in the enhanced accumulation of secondary products of lipid peroxidation, decreased total antioxidant capacity, including a diminished superoxide dismutase activity, and increased susceptibility of low-density lipoprotein (LDL) to in vitro oxidation. Acute elevation of plasma nitrite/nitrate (NOx) content was observed following each single session of physical test, whilst the platelet NOx content was decreased after strenuous exercise and increased after moderate exercise. Findings of the present study suggest that oxidative stress induced by acute strenuous exercise may interfere with platelet responsiveness most likely by promoting oxidized LDL-mediated platelet activation and by decreasing plasma and platelet-derived nitric oxide (NO) bioactivity. Moreover, our results further suggest that platelet responsiveness following an acute moderate physical stressor may depend on the efficiency of plasma and intraplatelet NO to desensitize platelets to agonist stimulation.

Prevalence of Chlamydia pneumoniae in peripheral blood mononuclear cells in Italian patients with acute ischaemic heart disease.

Chlamydia pneumoniae infection generally starts in the respiratory tract and probably disseminates systemically in the blood stream within alveolar macrophages. We investigated the prevalence of C. pneumoniae DNA in peripheral blood mononuclear cells (PBMC) in patients with acute ischaemic heart disease. Samples of blood were obtained from 93 consecutive patients with acute ischaemic heart disease and from 42 healthy subjects, for detection of C. pneumoniae DNA in PBMC by polymerase chain reaction (PCR) and for serology. C. pneumoniae DNA in PBMC was detected in 25.8% (24/93) of the patients with acute ischaemic heart disease and in 4.8% (2/42) of the healthy subjects (P=0.008). C. pneumoniae IgG was found in 76.3% of patients and in 45.2% of healthy subjects (P=0.0008) while C. pneumoniae IgA was found in 59.1% and in 33.3%, respectively (P=0.01). No correlation was found between anti-C. pneumoniae antibody titers and positive PCR results. The detection of C. pneumoniae DNA in PBMC may aid in selecting patients who may benefit from antibiotic treatment; however, to support this contention, longitudinal studies on patients treated with antibiotics would also be necessary.

Possible involvement of increased susceptibility of LDL to oxidation in age-related platelet activation.

Fifteen long-lived and fifteen young healthy subjects were enrolled in this study to verify the involvement of age-associated oxidative challenge in the mechanisms that control platelet activation. Our results showed in old subjects an enhancement of ex vivo platelet responsiveness to ADP and collagen, measured both in whole blood and in platelet rich plasma, an increased cytosolic calcium content, a decreased membrane fluidity and a lower intraplatelet nitrate/nitrite (NO(x)) amount. Additionally, an increased plasma content of peroxidative by-products (TBARS) and a decreased antioxidant plasma capacity together with a reduced lag time for in vitro oxidation of low density lipoprotein (LDL) and a diminished plasma NO(x) bioavailability were observed in aged subjects. Lag time for LDL oxidation was negatively correlated with plasma TBARS level, and positively correlated with intraplatelet NO(x) content. Findings of this study may support the speculation that advancing age increases the susceptibility of LDL to oxidative modifications and favors platelet activation by oxidized LDL-induced decrease of nitric oxide bioactivity.

Sleepiness in a population of Italian shiftwork policemen.

The aim of this study was to evaluate the effects of shiftwork on sleepiness, sleep disorders and sleep related accidents in a population of policemen. Data concerning age and physical characteristics, working conditions, sleep problems and accidents were collected by a questionnaire. Sleepiness was evaluated by the Epworth Sleepiness Scale (ESS) while the presence of sleep disorders was evaluated by a score (SD-score) drawn from indicators of insomnia, breathing disorders, periodic limb movements-restless leg syndrome and hypersomnia. The effects of age, gender, body mass index, working condition and seniority on ESS, SD-score and accidents were analysed by linear and logistic regression. Participants were 1280 policemen: 611 shiftworkers and 669 non-shiftworkers. The ESS scores were not higher in shiftworkers than in non-shiftworkers, but the SD-score was found to be significantly influenced by shiftwork condition and seniority. The occurrence of sleep-related accidents was found to have been significantly increased for shiftworkers and related to the presence of indicators of sleep disorders. The sleepiness could be underestimated or even overcome by the influence of stressing conditions. However our data should alert occupational health physicians for the diagnosis and prevention of possible lurking intrinsic sleep disorders likely to influence health problems and risk of accidents in shiftworkers.

Assessment of regional left ventricular function during exercise test with pulsed tissue Doppler imaging.

To investigate whether mitral annular velocity, measured by tissue Doppler imaging (TDI), is able to get a feasible quantitative evaluation of global and regional left-ventricular function during exercise test, 29 patients with previous uncomplicated myocardial infarction were studied by exercise echocardiography. All patients underwent coronary arteriography within 10 days of stress echocardiography. All of them were in sinus rhythm and had no right or left bundle branch block or significant mitral regurgitation as observed by left ventriculography. A total of 12 patients had anteroseptal and/or posteroseptal wall asynergies and left anterior descending involvement; 9 patients had lateral and/or posteroinferior asynergies and left circumflex coronary artery involvement; 8 patients had inferior and posteroseptal wall asynergies and right coronary artery involvement. Twelve subjects of same age and sex with normal cardiovascular findings were selected as a control group. TDI sample volumes were set on the mitral annuli corresponding to anteroseptal, posterior, posteroseptal, lateral, anterior, and inferior wall in 4-chamber, 2-chamber, and long-axis views. There was a significant correlation between the left-ventricular ejection fraction (0.41 +/- 0.8) and the means of the systolic (S) values (6.1 +/- 0.9 cm/sec, r = 0.83, p < 0.01). The mean S at the sites corresponding to the infarct regions (5.5 +/- 0.4 cm/sec) was significantly lower than the control group (11 +/- 0.8 cm/sec, p < 0.001). After stress, in patients with multivessel disease, S values corresponding to remote regions were significantly lower (p < 0.01) compared with control subjects. Thus, the parameters obtained from mitral annular velocities with pulsed TDI in patients with previous myocardial infarction reflect left ventricular asynergy corresponding to the infarct regions and reversible regional dysfunction after exercise.

Usefulness of echocardiography in the prognostic evaluation of non-Q-wave myocardial infarction.

Patients with non-Q-wave myocardial infarction (MI) are a heterogeneous population with a wide range of coronary disease severity and extent of myocardial necrosis, showing, therefore, different electrocardiographic findings and different outcomes. To evaluate the role of echocardiography in the management of non-Q-wave MI patients, 192 consecutive patients without previous MI were studied (78 with ST segment elevation, 56 with ST depression and 58 without ST modifications). All patients underwent 2-dimensional echocardiography (16-segment model) within 24 hours of admission to the coronary care unit. Wall-motion abnormalities, wall-motion score index, ejection fraction, and end-diastolic and end-systolic volumes were evaluated. In 35 patients, death, reinfarction, recurrent angina, or severe heart failure occurred during the in-hospital phase, whereas the remaining 157 patients had a good outcome. Patients with a poor prognosis were older (68 +/- 6 vs 59 +/- 5 years, p < 0.01), had a worse left-ventricular function (wall-motion score index 1.4 +/- 0.4 vs 1.25 +/- 0.3, p < 0.05; end-systolic volume 54 +/- 25 vs 38 +/- 12 mL/m2, p < 0.01; ejection fraction 50 +/- 10 vs 58 +/- 8%, p < 0.01), and presented more frequently with ST segment depression (49 vs 25%, p < 0.01). The positive and negative predictive values for early clinical events were, respectively: ST segment depression 0.30 and 0.87; wall-motion abnormalities in > 3 segments 0.28 and 0.86; wall-motion score index > 1.33 = 0.28 and 0.87; end-diastolic volume > 46 mL/m2 = 0.49 and 0.91; ST segment depression and wall-motion abnormalities in > 3 segments 0.60 and 0.88. These results underline the usefulness of echocardiography in the early risk stratification of non-Q-wave MI patients, together with electrocardiographic data. Patients with ST segment depression and more extensive wall-motion abnormalities are at higher risk and their management needs a more aggressive approach.

Usefulness of transesophageal echocardiography in the assessment of aortic dissection.

The acute dissection of the ascending aorta requires prompt and reliable diagnosis to reduce the high risk of mortality; in addition, prognosis is influenced by long-term complications. The aim of this article is to discuss transesophageal echocardiography (TEE) and (1) its diagnostic accuracy in the presurgical evaluation of patients, (2) its role in reducing time of diagnosis and surgery, and (3) its ability to reduce hospital mortality. TEE has also been tested as a screening method in the postsurgical follow-up of these patients. The retrospective investigation concerns a sample of 80 cases of acute dissection of the aorta, submitted for surgical intervention from April 1986 to February 1999. TEE has allowed a precise estimation of aortic diameters and optimal visualization of intimal flap and tear entry with a fine distinction between true and false lumen. A direct comparison of the results of TEE and of transthoracic echocardiography has demonstrated that some elements (visualization of flap and diameters in descending aorta, sites of entry and reentry, direction of jet trough intimal tears, phasic intimal flap movement, diastolic collapse of flap on the valvular plane, false lumen thrombosis, coronary involvement, intramural hematoma, and aortic fissuration) were identified only by TEE, whereas other additional diagnostic elements (cardiac tamponade, aortic valve insufficiency, left ventricular function) show a similar pattern of significance. Routine employment of this method has confirmed a reduction of hospitalization time (about 1.5 hours of waiting time), and hospital mortality has changed from 42.8% to 17.3%. In the follow-up of patients operated on for aortic dissection, fundamental information may be obtained from TEE (assessment of the progression of thrombosis in the false lumen with its complete obliteration and modifications in aortic diameter with a consequent, possible worsening of aortic valve insufficiency). In conclusion, our study demonstrated that TEE may provide fast and efficient detection of acute aortic dissection. In the postsurgical follow-up, TEE has confirmed detection of major complications that can influence long-term prognosis and may be proposed as a method with easy access-one that is repeatable and inexpensive for the screening of aortic dissection surgical patients.

Value of transesophageal dobutamine stress echocardiography in assessing coronary artery disease.

The introduction of digital echocardiography has significantly enhanced our ability to select the best set of frames for analysis. However, despite the beneficial attributes of transthoracic dobutamine stress echocardiography, poor quality 2-dimensional images continue to be a significant limiting factor in patients with chest deformities, severe chronic obstructive lung disease, marked obesity, and previous chest surgery. Transesophageal echocardiography provides a new window to monitor left ventricular contractility without the interference of bone and air-filled structures of the thoracic cage. The transesophageal dobutamine stress test is a logical but poorly explored modality to image/stress the heart in certain patients with known or suspected myocardial ischemia. Overall sensitivity (< or = 85%) and specificity (< or = 95-100%) of transesophageal dobutamine stress echocardiography appear to be similar to that of previous transthoracic studies, although no direct comparison has been accomplished between transthoracic and transesophageal stress images. False negative transesophageal dobutamine stress echocardiography results have been described in patients with single-vessel disease in whom ischemic regions may not have been visualized throughout the entire study. False positive study results may be present in patients with hypertension and myocardial hypertrophy that may have signs and symptoms of myocardial ischemia in absence of obstructive disease of the epicardial coronary arteries, presumably related to either microvascular disease or impaired vasodilatory reserve. The proportion of patients with coronary artery disease who need a transesophageal examination for reliable assessment of echocardiographic response to stress varies depending on the operators' skills, the interpreters' experience, and the use of videotape or digitizing systems for image analysis. Although clinically useful in its present transthoracic and transesophageal form, a major limitation of dobutamine stress echocardiographic study is the subjective visual interpretation of endocardial motion and wall thickening, which is only semiquantitative. Color kinesis and tissue Doppler imaging (TDI) are 2 novel echocardiographic techniques that color code endocardial motion and myocardial velocity online and have the potential to objectively quantify regional left ventricular function. Quantitative standardization of transthoracic and transesophageal data interpretation, such as establishing endocardial motion by color kinesis or velocity thresholds by TDI for an abnormal segmental response to stress, has the potential to decrease interobserver variability and increase interinstitutional agreement.

Modifications of whole blood filterability during acute myocardial infarction.

Experimental evidences underline that hemorheological alterations observed in acute myocardial infarction (AMI) are strictly involved in the decreased perfusion of the damaged area and in the extension of the necrotic regions. We have analyzed whole blood filterability as an index of erythrocyte deformability in 60 AMI patients compared with 30 patients with non-acute coronary artery disease and 52 healthy subjects. Nucleopore polycarbonate membranes with a pore diameter of 5 microm and a filtering pressure of -20 cm H2O were used. The results are expressed as the volume of whole blood filtered in 1 minute (index of filterability, IF). In normal subjects IF was 1.16 +/- 0.24. Among AMI patients IF was 0.70 +/- 0.30 at admission, 0.68 +/- 017 at day 10 and 0.78 +/- 0.14 at day 20. These values were significantly lower than those obtained in normal subjects and in patients with non-acute coronary artery disease. In addition, AMI patients treated with thrombolytic therapy showed, at admission, a significantly higher IF value than that obtained in patients who did not receive thrombolytic treatment (0.85 +/- 0.34 vs 0.60 +/- 0.22; p < 0.01). These results demonstrate an evident reduction of whole blood filterability in AMI patients that may be considered as an index of erythrocyte deformability. Thrombolytic therapy seems to have a positive effect on blood filterability and may produce beneficial effects through its therapeutical action other than the lysis of the coronary thrombus.

[Diagnostic and therapeutic strategies in post-infarct]. / Strategie diagnostiche e terapeutiche nel post-infarto.

It is of primary importance for the clinical cardiologist to keep in mind the parameters allowing an adequate prognostic stratification in post-infarct patients in view of making the best diagnostic and therapeutic choices. A diagnostic strategy, based on a pathophysiologic approach, should evaluate four aspects: spontaneous and stress-induced ischemia, myocardial viability, and ventricular arrhythmias. Spontaneous ischemia has an undefined prognostic value, especially in the thrombolytic era; therefore it seems reasonable to perform invasive procedures in patients who are not stabilized by an adequate medical therapy or with large jeopardized areas. In asymptomatic patients, a provocative stress test allows a more articulated decisional iter. It is preferably to perform the test by the most physiological exercise EKG, together with the echocardiographic imaging, after the acute phase. It has a high negative predictive value, but a low positive predictive value. The detection of myocardial viability is frequently performed, mainly in patients with large post-ischemic myocardial dysfunction. Among all the proposed methods, the echo-dobutamine test mainly allows to estimate patients in whom revascularization may result in more benefit. The role of ventricular arrhythmias as an independent prognostic factor is debated and has to be always considered in relationship to other parameters, particularly left ventricular function. Regarding the therapeutic strategy, the indications from recent trials, related to antithrombotic drugs, beta-blockers, ACE-inhibitors, nitrates, Ca-blockers and antiarrhythmic drugs, are emphasized.