Heart rate variability in patients with variant angina: effect of the presence of significant coronary stenosis.

BACKGROUND: The syndrome of variant angina occurs in patients with a wide spectrum of coronary disease ranging from angiographically normal coronary arteries to severe three-vessel disease. Survival and choice of therapy for these patients are determined by the extent of underlying fixed coronary obstruction. We examined whether heart rate variability (HRV) due to reduced vagal outflow may correlate with the severity of coronary stenoses in such patients. METHODS: Fifteen men and 2 women with clinically unstable variant angina underwent 24-hour Holter monitoring from which low and high-frequency power, standard deviation of mean 24-hour RR interval, proportion of adjacent RR intervals that differed by more than 50 ms, and mean root square of differences between successive RR intervals were extracted by power spectral analysis. Coronary angiography was later performed to determine coronary pathology and verify variant angina. As controls we studied an age-matched control group of 8 subjects (5 men, 3 women) with no clinical and/or electrocardiographic evidence of coronary heart disease or spasm as shown by negative treadmill exercise and hyperventilation tests. RESULTS: All measured components of HRV were significantly lower in the 9 patients with severe coronary artery disease compared to the 8 patients with normal coronary arteries or < 40% stenosis. The two groups were otherwise similar in terms of age and clinical parameters. CONCLUSIONS: These preliminary findings on a small but carefully selected group of patients with variant angina indicate that the analysis of HRV can select patients with severe disease for a more intensive approach. These findings require confirmation on a larger patient series.

Calcium antagonists in the therapy of acute myocardial infarction.

The theoretical background and experimental evidence of the use of calcium antagonists in the treatment of acute myocardial infarction are summarised. The main clinical trials that have studied the effects of the three different groups of these drugs in patients with myocardial necrosis are then reviewed. Finally, the conclusion is drawn that there is no proof of the efficacy of calcium blockers in the therapy of patients with acute myocardial infarction but that, in some subgroups of these subjects (Q-wave myocardial infarction with good left ventricular function, non Q-wave myocardial infarction), non-dihydropyridinic compounds should be effective, in particular in patients with contraindications to beta-adrenergic blockade.

An uncommon case of variant angina.

This case report describes a 48-year-old woman patient with variant angina who died because of severe myocardial ischemia and cardiogenic shock, in spite of chronic therapy with nitrates and calcium-antagonists and acute intravenous administration of nitrates, calcium-antagonists and tissue-type plasminogen activator. Her Holter monitoring showed a reduction of time domain measures of heart rate variability. The hemodynamic study exhibited a normal ventriculography and angiographically normal epicardial coronary arteries. The provocative testing, performed (during intravenous therapy with nitrates and diltiazem) by intracoronary injection of progressively increasing doses of ergonovine, induced only a mild vasoconstriction of proximal left anterior descending artery, without symptoms or ST-T segment changes. This case reminds us that variant angina can be a lethal disease, confirms that a negative result of intracoronary ergonovine testing performed during intravenous therapy with nitrates and calcium-antagonists does not assure the prevention of new episodes during chronic oral therapy with the same drugs, suggests a possible prognostic value of the reduction of heart rate variability indexes and shows an unusual response to nitrate administration.

[The results of large clinical trials comparing primary angioplasty and thrombolysis]. / I risultati dei grandi trials clinici di confronto tra angioplastica primaria e trombolisi.

One of the main cardiological debate is about which one, between primary angioplasty (PTCA) and thrombolysis, is to prefer for the therapy of acute myocardial infarction. The data available in the literature do not show that one of these two therapeutical choices is definitely better than the other one. Since the main therapeutical goal in patients with acute myocardial infarction is the early and persisting recovery of the anterograde coronary flow, the best therapy for every patient is the one that can be performed more quickly and safely. Therefore, PTCA has to be preferred whenever it can be done quickly, by expert personnel and with cardiosurgical support, especially in patients considered to be at high risk or with contraindications to thrombolysis. Otherwise, thrombolytic therapy should be better. Stent implantation seems to be better than conventional angioplasty, in particular for the reduction of restenosis and reocclusion. These conclusions, however, derive from small studies and require further evidences. Moreover, there are not trials directly comparing primary PTCA and stent implantation with thrombolysis. Rescue PTCA, after failure of thrombolytic therapy, is useful when the coronary flow of the culprit lesion is TIMI 0 or 1, but not when the flow is TIMI 2; there are neither indications to early, but not rescue, angioplasty in all the patients already thrombolyzed. Finally, for patients with acute myocardial infarction and cardiogenic shock, the data currently available, derived more from observational than from randomized studies, suggest revascularization by PTCA.

[Intrahepatic cholestasis]. / Colestasi intraepatica.

The intrahepatic cholestasis is not an common syndrome, in particular way in people between 50 and 60 years of age. It is often unknown or confused, because of itching, with allergic or dermatologic diseases. The most frequent causes of intrahepatic cholestasis are primary sclerosing cholestasis, primary biliary cirrhosis and hepatic cirrhosis. The pathogenetic mechanism is the faulty secretion of bile and, more bile salts. The diagnosis is allowed by anamnesis, objective examination and, above all, biochemical markers of cholestasis, echography, TC, NMR and liver biopsy. Therapy consist of generic (hypolipidic diet, liposoluble vitamin and others) and specific (UDCA, SAMe) measures.

[Chronic viral hepatitis: diagnosis and treatment]. / Epatiti virali croniche: diagnosi e trattamento.

HBV and HCV cause most of chronic hepatitis; the HDV is a co-infectious virus and it rend the help of HBV to duplicate; HAV and HEV do not induce chronic hepatitis. Etiology is not the same, without apparent reasons, in all the world and the distinction between persistent chronic hepatitis and active idiopathic chronic hepatitis is meaningless, because one can shift in the other. Diagnosis is possible using serologic tests and by determination of the DNA of the HBV and RNA of the HCV. Interferon is a good therapeutic tool either for B hepatitis than for C hepatitis in about 50% of case. On the contrary, the results obtained with liver transplantation are disappointing and those achieved with ribavirin have not been conclusive yet. The treatment with INF for more than one year and with full dosages, gives good results in about 50% of patients with hepatitis D. In the other patients it is not useful a second cycle with INF or the introduction of pure antiviral drugs alone or in association with INF.

Circadian variation of ischemic threshold in syndrome X.

To evaluate whether the ischemic threshold has a circadian rhythm in patients with syndrome X, we analyzed 90 episodes of ST depression detected on 24-hour Holter recordings of 12 such patients. Ischemic threshold was considered as heart rate (HR) at 1 mm ST depression. To correct for differences in basal HR among patients, however, the ischemic threshold was also calculated as a normalized index of HR at 1 mm ST depression: [(HR at 1 mm ST-24-hour modal HR)/24-hour modal HR]-100. Mean hourly values of both absolute and normalized HRs at 1 mm ST depression were obtained by grouping and averaging respective values of all episodes detected in every hour of the day in all patients. Chronobiologic analysis was performed by single cosinor method. A significant circadian rhythm was found for HR (mesor 76 beats/min, amplitude 10 beats/min, acrophase at 2:16 P.M., p < 0.001), number of episodes of ST depression (mesor 3.75, amplitude 2.9, acrophase at 2:45 P.M., p < 0.001) and cumulative time of ischemia, with a high correlation of distributions. Episodes of ST depression showed a double peak initially in the morning, and again in the afternoon. Both raw and normalized values of HR at 1 mm ST depression also had a significant circadian variation in ischemic threshold, which was lower in the night and early morning hours, progressively increased until the first afternoon hours, and subsequently decreased in the evening.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neurovegetative changes before and during episodes of silent ischemia in variant angina]. / Modificazioni neurovegetative prima e durante episodi di ischemia silente nell'angina variante.

In order to evaluate whether variations in autonomic nervous tone have a significant role in the induction of coronary arterial spasm in variant angina, we analyzed the changes in heart rate variability (HRV) related to spontaneous episodes of ST-segment elevation, recorded during 24-hour ambulatory ECG monitoring, in 13 patients with variant angina (9 men and 4 women, aged 63 +/- 12 years). In order to obtain an accurate analysis of HRV changes, we only included ischemic episodes characterized by silent ST-segment elevation, lasting at least 3 min and without any ST change in the previous 30 min. HRV indexes in the time domain (RR interval, standard deviation of RR intervals [SD], pNN50, r-MSSD) and in the frequency domain (LF = 0.04-0.15 Hz, HF = 0.15-0.40 HZ, LF/HF ratio) were calculated on 2 min intervals, centered at 15 min before (15B), 5 min before ed 1 min before (1B) the appearance of ST elevation, as well as at peak of ST-segment elevation. Of 161 ischemic episodes found on 24-hour Holter recordings, 60 (37%) fulfilled the inclusion criteria for analysis (4.6 +/- 3.5 episodes/patient, range 1-12). The duration of the selected episodes was 6 +/- 2.5 min and ST elevation was 2.2 +/- 1.0 mm. Heart rate (HR) did not have any change before ST elevation, whereas it showed a small, but significant increase at peak ST (73 +/- 12 versus 67 +/- 11 b/min at 15B, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Infective endocarditis]. / Endocardite infettiva.

The authors underline the recent increase in the incidence of infective endocarditis (IE) involving the right side of the heart, because of instrumental procedures and, above all drug-addiction. They describe the epidemiology, congenital and acquired predisposing heart diseases, the most common portals of entry of the infective agents, etiology, pathogenesis, pathology, cardiac and extracardiac clinical manifestations and complications, clinical and instrumental diagnosis, medical and surgical therapy, prognosis and prevention of disease.

[Paget's disease]. / Il morbo di Paget.

The authors have observed several cases of Paget's disease in their Centre for the Study, Diagnosis and Therapy of Osteoporosis. They define this disease and describe the probable etiology by Paramyxoviruses, the macro- and microscopic anatomopathological changes, the clinical manifestations, the complications (that are sometimes deadly: sarcoma), the diagnostic resources and, finally, the latest therapeutic possibilities (combined calcitonin and diphosphonate) that are useful only in patients with pain or complications.

Effects of slow-release verapamil and nitrendipine on office and 24-hour ambulatory blood pressure in hypertensive patients.

The aim of the present study was to compare the effects of slow-release verapamil (V), 240 mg and nitrendipine (N), 20 mg, administered once daily, on office (OBP) and 24-h ambulatory blood pressure (ABP) in patients with mild-to-moderate hypertension. Twenty patients were entered into this open, randomized, two-group (V, N) parallel study. The study groups had similar age and sex distribution. The OBP (V, 155/103 +/- 19/8 mm Hg; N, 141/98 +/- 13/4 mm Hg), heart rate (HR) (V, 74 +/- 7 beats/min; N, 77 +/- 10 beats/min), daytime systolic ABP (V, 149 +/- 14 mm Hg; N, 147 +/- 13 mm Hg), and nighttime ABP of the two groups were not statistically different after a 2-week washout period. The daytime diastolic ABP (V, 99 +/- 6 mm Hg; N, 93 +/- 6 mm Hg) was slightly lower (p less than 0.05) in group N. Both the OBP (V, 136/90 +/- 19/9 mm Hg; N, 135/85 +/- 10/4 mm Hg) and daytime ABP (V, 132/85 +/- 14/4 mm Hg; N, 136/87 +/- 13/8 mm Hg) dropped in the two groups after 8 weeks of treatment. Nonparametric analysis did not show statistical differences between the groups in OBP and ABP percentage drop. There was no significant change in nighttime ABP, HR (V, 73 +/- 10 beats/min; N, 74 +/- 12 beats/min), ECG, and laboratory exams. We conclude that both verapamil SR and nitrendipine are effective in reducing blood pressure in hypertensive patients without altering the HR.

[Orthostatic hypotension in the aged]. / Ipotensione ortostatica nell'anziano.

The authors consider the remarkable incidence and the important consequences of orthostatic hypotension in the elderly. They underline the etiologic importance of primary and secondary alterations of the autonomic nervous system and other concomitant causes. They illustrate the pathophysiologic mechanisms and specify how to arrive at the correct diagnosis. Finally they recommend to use drugs only after the failure of behavioral and physiatric measures.

[The cardiovascular system and antidepressive drugs]. / Apparato cardiovascolare e farmaci antidepressivi.

The authors consider the ever-increasing number of depressed patients, related to the stress of modern life and to the prolongation of life span. They stress that these patients are often cardiopathic or impaired by the senile heart. Finally they illustrate the cardiovascular effects of antidepressant drugs and how to avoid them.

[Pemphigus vulgaris: severe osteoporosis during cortisone therapy. Description of a case]. / Pemfigo volgare: grave osteoporosi in corso di terapia cortisonica. Descrizione di un caso.

The authors review the etiopathogenesis of pemphigus vulgaris and the good results of cortisone plus immunodepressive therapy. They then underline the high frequency of cortisone osteoporosis and the measures apt to prevent it.

[Aneurysm of the abdominal aorta. Description of a case]. / Aneurisma dell'aorta addominale. Descrizione di un caso.

Having recalled the insidious onset, etiopathogenesis, incidence, clinical and instrumental diagnosis, and the very severe prognosis of abdominal aortic aneurysm, as well as the excellent results obtained by elective surgery, the authors describe a case they had occasion to observe and in which sudden rupture of the aneurysm was fatal.

[Cardiac risk in noncardiac surgery]. / Rischio cardiaco della chirurgia non cardiaca.

After recalling cardiac disorders and the cardiac risk of non cardiac surgery, the authors illustrate the methods for evaluating clinical risk in individual patients, the instrumental procedures appropriate for the diagnosis of ventricular dysfunction or myocardial ischemia which are responsible for the majority of cardiac complications during surgery. Finally, they describe alternative therapies for high-risk patients.

[Sacrococcygeal chordoma. A case report]. / Cordoma sacro-coccigeo. Descrizione di un caso.

The authors describe the diagnosis of a rare neoplasm, a sacrococcygeal chordoma, which was suspected in view of compressive symptoms and diagnosed with the aid of endoscopic and x-ray methods (barium enema and CT). Diagnosis was confirmed at surgery.

[Tuberculosis: a disease that is difficult to eradicate. Description of a case]. / Tubercolosi: una malattia difficile da eradicare. Descrizione di un caso.

The authors stress the recent increase of tuberculosis, especially in high-risk areas and populations. They illustrate the changes the disease has undergone lately, also with reference to a case they had occasion to observe. They describe 9-month and 6-month treatment schemes as well as the drugs that can be applied in cases of drug resistance which is rather frequent in AIDS patients.

[Carcinoma of the pancreas and description of 5 cases]. / Carcinoma del pancreas e descrizione di 5 casi.

Having reviewed the frequency of pancreatic cancer, its symptomatological insidiosity, the risk factors, the present excellent diagnostic possibilities, the surgical techniques, which are unfortunately radical only in 30% of the cases, the potentialities related to the recent discovery of sex-hormone receptors in the tumor, the authors underline the necessity of an early diagnosis, considering carefully the vague, but precious, initial symptoms.