[Ventricular pre-excitation: electrophysiopathology, criteria for interpretation and clinical diagnosis. References for geriatrics]. / La pre-eccitazione ventricolare: elettrofisiopatologia, criteri interpretativi e inquadramento clinico. Riferimenti di Geriatria.

The authors review the state-of-the-art on ventricular pre-excitation in medical and arrhythmological literature in order to facilitate the recognition of the various clinical forms, like classic and occult Wolff Parkinson withe syndrome and Lown Ganong Levine syndrome. A historical introduction reviews our electrophysiopathological knowledge of the electrical activation and conduction of ventricular pre-excitation compared to normal, starting from the anatomic discovery of conduction pathways to the possible use of transesophageal electrostimulation and endocavity mapping to study electric potentials. Avantgarde technologies have also been developed to eliminate anomalous pathways firstly by using a direct current dirscharge and secondly radiofrequency. Atrioventricular electric activation has been widely illustrated in normal subjects in order to create a model for comparison with pathological ventricular pre-excitation: the upper left portion of the septum is no longer the first zone to trigger the kinetic mechanism compared to the early fascicular fraying of the homonymous branch. Instead the upper right part of the septum is activated earlier owing to the anomalous fascia connected on this side to the right branch through their septal arborisations. As a result, this new conduction pathway activates the ventricular masses earlier through an anomalous route, given that there is no further contact with the atrioventricular nodes which act as a control. A similar situation is found in the left branch block where the ventriculogram is late with a normal PR, unlike pre-excitation when an early delta wave is present with a short PR. Electric conduction is also illustrated based on new knowledge of the circuit structures and the rings theory. Orthodromic tachycardia is distinguished from the antidromic form, double accessory pathway tachycardia, ectopic reciprocant atrial fibrillation tachycardia and occult bundle tachycardia which is studied using transesophageal stimulation with a time threshold of 70 ms for ventricular-atrial retrograde activation. The stimulation techniques using single or repeated extrastimulus are explained for this purpose, as well as those with serial extrastimulation and the physical characteristics of the circuit based on the ratio between voltage and resistance. The authors also report the practical aims of electrostimulation for determining the electric threshold of the anomalous circuit in terms of refractoriness, electric atrial stability, reciprocity and the occurrence of the macro re-entry. Lastly, the authors describe electric conduction by anomalous pathways based on the criterion of conduction and activation, both of which are analysed and compared on the basis of the intrinsicoid deflection morphology on the surface ECG: the aberrant qRs usually suggests an antidromic ventricular activation and retrograde conduction between atrium and ventricle, while normal intrinsicoid deflection demonstrates that the activation is orthodromic and the conduction anterograde, namely ventricle-atrial. Having been reproduced in a synoptic synthesis, these manifestations show a regular electrophysiological pattern because they are dissimilar from the behaviour of the monophasic bioelectric potential of the cardiac cells specialised in the conduction of the stimulus, whether they represent a normal or pathological electric pathway. The study is rounded off by the analysis of the reciprocant tachycardias and their re-entry varieties related to the type of the anomalous bundles. A number of types of re-entry can be identified: sinusal re-entry (micro re-entry), atrial re-entry, re-entry in the atrio-ventricular node, re-entry tachycardia and the so-called triggered type. The discussion of the electrophysiopathological aspects of pre-excitation is followed by the clinical forms of ventricular pre-excitation that can be divided into 3 main types. The different ECG clinical pictures are set out in the summary table, together with the type of shunt and activation and possible variants, following Rosenbaum s classic paint: the common type B, the rare type A and a last variant, the C type. This section also describes the positional peculiarities of the Kent-Paladino bundle, the left ventricular, septal (anterior and posterior) and the multiple-bundle ones. The authors also illustrate the criterion and meaning of endocavity mapping in the search for anomalous bioelectric potentials that identify the pathway or the location of the endocardiac bundle and/or foci to be eliminated. A new echocardiographic technique is described with a conventional M mode, digitalised 2D and tissular Doppler which has a comparable ability to identify the anomalous pathways of electric conduction using a non-invasive method. (ABSTRACT TRUNCATED)

[Ventricular pre-excitation in Wolff Parkinson White syndrome in the aged]. / La pre-eccitazione ventricolare da sindrome di Wolff Parkinson white nell'anziano.

AIM: To evaluate any differences in ventricular pre-excitation secondary to Wolff Parkinson White syndrome in the aged compared to young and adult patients. EXPERIMENTAL DESIGN: a clinical study was performed using a comparative prospective criterion with retrospective analysis. The duration of follow-up ranged between one and ten years. SETTING: the series was collected from the Cardiology Clinic of the Health District and the Cardiology Division of Gorizia, both forming part of no. 2 Isontina Health Service. PATIENTS OR PARTICIPANTS: the series included 17 patients suffering from Wolff Parkinson White syndrome who were divided into two study groups: 9 elderly patients and 8 young patients. The latter were subdivided into a first subgroup of 4 cases with Wolff Parkinson White syndrome with ECG positive for the presence of delta waves, and a second subgroup also with Wolff Parkinson White syndrome secondary to bundle. INTERVENTIONS: some young patients with Wolff Parkinson White syndrome who were symptomatic for tachycardia underwent ablative surgery with radiofrequency of the bundle. PARAMETERS: all patients underwent cardiological screening focused in particular on surface electrocardiogram. Those cases with Wolff-Parkinson White syndrome with occult bundle underwent transesophageal electrostimulation to find the conduction threshold of the anomalous bundle. RESULTS: Adult-elderly patients: six subjects were diagnosed with antero-septal and left ventricular Kent's bundle (type B common) and 3 cases with Mahaim-Wiston bundle (type A rare). Surface ECG revealed the presence of left ventricular hypertrophy in 6 cases, left anterior hemiblock and total block of the left branch in 3 cases, as well as myocardial pseudonecrosis correlated to Wolff Parkinson White syndrome. Young patients: four out of this group were affected by Kent's bundle with type B Wolff Parkinson White syndrome and the same number suffered from the same syndrome caused by occult bundle. Patients in the first subgroup showed an antero-septal, transitional and left ventricular orientation of Kent's bundle, with the onset of 2 cases of orthodromic and antidromic reciprocal rhythm respectively and 1 case of atrial fibrillation. The refractory nature of the anomalous pathway was not very high in 2 cases, equal to 60 milliseconds and 240 milliseconds with the proposed ablation of the anomalous bundle.

[Arterial hypertension in an ambulatory population of elderly subjects. Epidemiologic and clinical study in Isonzo]. / L'ipertensione arteriosa in una popolazione ambulatoriale di soggetti anziani. Studio epidemiologico e clinico nel territorio isontino.

The authors examine the clinical connotations of arterial hypertension in a geographical population of 1002 patients attending the Cardiological Outpatient Clinic of Unit no.2 in the Isonzo area (Monfalcone) using the most appropriate statistical methods, such as SPSS (Statistical Package for the Social Sciences) implemented on PC IBM AT 286, for multiple linear regression using a stepwise method. 1) Arterial hypertension was the result of a phenomenon which was striking owing to its mean value of 184.7 +/- 20.915 mmHg with equal mode and median of 180 mmHg. In the subgroup of 720 elderly patients this mean value differed slightly, 186.9 +/- 20.648 mmHg, with the same mode and median, whereas in the group of 282 adults the mean was 170.0 +/- 20.540 mmHg with a mode and median of 160 and 175 mmHg respectively. In the overall population 154 cases (15.4%) were affected by slight arterial hypertension with a mean of 158.9 mmHg, and 848 cases (84.8%) presented moderate-severe arterial hypertension with mean values of 189.4 mmHg. In elderly patients the mean rose to 190.4 mmHg whereas it was 186.3 mmHg in adults. 2) Mean age was 65.3 +/- 11.093 years: 70.7 +/- 7.396 years in older patients and 51.7 +/- 6.106 years in adults. Surface ECG showed signs of left ventricular hypertrophy in 292 elderly patients (40.5%) and 85 adults (30.0%), signs of ischemic cardiopathy due to T wave alteration in 246 elderly patients (34.1%) and 101 adults (35.7%), and due to ST tract in 340 (47.2%) and 102 (36.2%) respectively, with equal involvement of the free surface of the left ventricle. The radiographic enlargement of the cardiac shadow in elderly patients was observed in slight form in 153 cases (21.3%) and in moderate and marked form in 222 cases (30.8%), and in adults in 36 (12.8%) and 43 (15.2%) cases respectively. 3) Body weight was normal on average and equivalent to 77.3 +/- 13.578 kg, but of this series 713 cases were overweight and 237 were obese; 504 of elderly patients (70%) were pathological with 346 (48.1%) overweight and 158 (21.9%) obese, and of 209 pathological adults (74.1%), 130 (46.1%) and 79 (28.0%) were respectively overweight and obese. BMI oscillated from 1.70 to 5.60 with a mean of 2.80 +/- 0.409: from 1.70 to 4.21 in elderly patients with a mean of 2.70 +/- 0.379 and in adults from 2.00 to 5.60 with a mean of 2.90 +/- 0.460. 4) Mean cholesterolemia was 237 +/- 48.029 mg% and levels were normal in 203 cases and high in 799 subjects. Elderly patients showed the same mean level with a total of 580 pathological cases (80.5%) divided into 305 (42.3%) cases of slight hypercholesterolemia with a mean of 227.2 mg% and 275 (38.2%) severe cases with levels of 283.7 mg%. Adults presented a mean serum level of 236 +/- 47.588 mg%: 63 (22.3%) cases of normocholesterolemia, 117 (41.5%) cases of slight cholesterolemia with mean serum level of 224.8 mg%, and 102 (36.2%) severe cases with a mean level of 286.2 mg%, resulting in a total of 219 pathological cases (77.7%).

[Nisoldipine in the treatment of ischemic cardiopathy in the aged. Study of electric systole]. / La nisoldipina nel trattamento della cardiopatia ischemica dell'anziano. Studio della sistole elettrica.

The authors examine the behaviour of electric systole during nisoldipine treatment using doses of at least 10 mg/die in association with modifications of ischemic signs recorded using surface ECG in a series of 70 elderly patients. Patients were subdivided into three groups according to the results obtained from a comparison of real electric systole (QT) with that corrected for ventricular frequency (Qtc), as well as the difference expressed in mean values (VM). 1) Patients with elongated QT. Following nisoldipine treatment this group showed a mean elongation of electric systole of 0.393" +/- 0.025 with a R correlation index between electric systoles before and after treatment of 0.633" which expresses the amplitude of the elongation for each starting QT unit (p < 0.001). The mean value in the two conditions increased from -1.381 +/- 2.111 contraction units to 3.568 +/- 2.697 elongation units and mean deviation was 4.886 +/- 2.170 units with an absolute value of 211.0 units which expresses the elongation of the electric systole in the overall sample compared to calcium antagonists as an iatrogenic phenomenon. Ischemic signs improved or disappeared in 40 out of 44 cases (90.91%) for the T wave and in 36 out of 41 cases (87.80%) for the ST tract. 2) Patients with normalised QT. In 6 cases which showed elongated pretreatment electric systole, it was observed that values became normal passing from a mean of 0.390" +/- 0.40 to 0.377" +/- 0.053. Mean deviation diminished from 3.833 +/- 0.983 units to 1.333 +/- 1.211 units with statistical significance only for paired data in 2 groups (p < 0.001), without correlation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hasharon hemoglobinopathy in a family]. / Su un gruppo familiare di emoglobinopatia Hasharon.

The authors describe an 18 year old athlete, a carrier of Hasharon haemoglobinopathy, pathology which had been checked in some ascendants too. Such a haemoglobinopathy, which has at first been verified in Ashkenazy Hebrew people and is nowadays rather common in North East Italy, shows clinical and laboratory features which are slightly or not at all mentioned in the literature. The leading reference point in the disease's development is the connection between splenomegaly and repetitive low erythrocytosis with serum iron deficiency and increase of the reticulocyte number. The same laboratory data had been observed in his father and in his paternal grandmother; both of them proved to te heterozygous carriers of Hasharon haemoglobinopathy. In all cases we caught the diagnostic validation by the means of isoelectrophoresis involving haemoglobin lysate in polyacrylamide gel. The authors think that the Hasharon shape they verified may be a variant of the classic phenotype: the splenomegaly and erythrocytosis may signify a brisk and primitive erythropoiesis with increasing reticulocytes, which might compensate for the anomalous synthesis of the alpha chains. Serum iron deficiency may signify an increase of the iron consumption. Moreover, the authors do not exclude the possibility of further associational abnormalities.

[Pravastatin in hypercholesterolemia in the elderly. Increase of the caseload and control of the results with a regional study on the elderly population of the Monfalcone and Grado areas]. / La pravastatina nell'ipercolesterolemia dell'anziano. Aumento della casistica e verifica dei risultati con uno studio territoriale di una popolazione anziana nel monfalconese e nel gradese.

The authors confirm--by increasing the ambulatory randomized series in the territories which depend on Monfalcone and Grado (USL 2 Goriziana)--the results of previous studies of lipid improvement owing to the use of pravastatine. The average cholesterolemic rate has decreased of 26.50% in comparison with the initial value, that is from 310.44 +/- 52.587 mg% to 228.16 +/- 28.354 mg%; the addition of each individual rate from 19868 mg% to 14602 mg% (p < 0.001). Within the sample, the elder's undergroup reduced blood cholesterol by 25.76%, that is from 307.69 +/- 42.057 mg% to 228.44 +/- 28.126 mg%, with an addition from 13846 mg% to 10280 mg% (p < 0.001); the adults' undergroup of 28.26%, that is from 316.95 +/- 72.744 mg% to 227.47 +/- 29.654 mg%, with an addition from 6022 mg% to 4322 mg% (p < 0.001). The LDL-lipoprotein value showed a decrease from 30.66% in the average value, which lowered from 206.87 +/- 51.485 to 143.43 +/- 32.940 mg% (relative addition from 13239 mg% to 9179 mg%); in the old patients from 211.45 +/- 52.758 mg% to 143.66 +/- 35.654 mg% (relative addition from 9515 mg% to 6465 mg%), in the adults from 196.01 +/- 47.923 mg% to 142.86 +/- 26.264 mg% (relative addition from 3724 mg% to 2714 mg%. Triglyceridemia fell from 38.37%; the average circulating value fell from 245.13 +/- 348.415 mg% to 151.08 +/- 130.347 mg%; the complete series showed the same average decrease ie from 15688 mg% to 9669 mg%. In the elderly we showed a reduction from 207.87 +/- 250.784 mg% to 149.91 +/- 144.606 mg% (relative addition from 9354 mg% to 6746 mg%), in adults from 333.37 +/- 509.360 mg% to 153.846 +/- 91.321 mg% (relative addition from 6334 mg% to 2923 mg%).

[The treadmill test in the clinical evaluation of the lower limbs. With special reference to an elderly population group]. / Il treadmill nella valutazione clinica degli arti inferiori. Riferimento ad una popolazione di pazienti anziani.

The authors show that the treadmill is a good method for studying the peripheral circulation of the inferior limbs, without altering the coronary district capacity. This technique is fitter than the test of Master and/or cycloergometry because it swits the characteristics of elderly patients. The estimate of the vascular function has been carried out by the means of the Winsor Index (WI), which is based on the proportion between the values of the occluding arterial pressure of the posterior tibial in comparison with the humeral arterial pressure. This quotient is able to discriminate the real peripheral vascular insufficiency from the borderline cases as well as from the normal ones, even if not in the presence of painful pathology. We have examined 50 patients; in this group 17 subjects (34%) resulted affected by peripheral arteriopathy of the inferior limbs; 8 of them presented a bilateral form with a pathologic WI; 2 patients of the same above mentioned group resulted symptomatic for pain. The remaining 9 presented a unilateral arteriopathy; of these patients, 6 resulted symptomatic for pains and 3 of them had an already pathologic WI before the stress test. On the contrary, no patients visualized signs of coronary disease; the superficial ECG suffered no alteration; the cardiac frequency has in total increased by 5.8 heart rate.

[Captopril and hydrochlorothiazide in treating arterial hypertension in the elderly patient. An enlarged case series and verification of the results]. / Captopril e idroclorotiazide nel trattamento dell'ipertensione arteriosa dell'anziano. Aumento della casistica e verifica dei risultati.

A group of 171 hypertensive patients were treated using 100 mg captopril and 50 mg hydrochlorothiazide over a period of four months. The group was subdivided into two subgroups of 138 elderly patients and 33 patients aged under sixty all of whom had a systolic blood pressure of over 180 mmHg, or over 160 mmHg if they had undergone previous treatment using another drug. Patients were monitored after one month and at the end of hypotensive therapy. The study showed a statistically significant reduction of blood pressure in both groups. In the elderly group blood pressure diminished from a mean basal level of 198.8/104.5 mmHg to 140.4/80.5 mmHg, whereas in the adult group pressure values were reduced from 190.1/108.4 mmHg to 134.0/80.6 mmHg. These results match those of an earlier study and, in conclusion, the Authors affirm that this combinations is a suitable "geriatric drug" since it responds to the needs of elderly hypertensive patients. Using captopril and hydrochlorothiazide it is possible to improve the quality of life of elderly hypertensive patients who are otherwise notoriously difficult to treat.

[Simvastatin in the treatment of hypercholesterolemia in the aged. An epidemiological and clinical study]. / La simvastatina nel trattamento dell'ipercolesterolemia dell'anziano. Studio epidemiologico e clinico.

The paper review the literature on the subject and underlines the importance of hypercholesterolemia. It also reports the findings of the large trials, works and consensus studies, including the results of the Framingham Study, the Lipidic Research Clinics Program and the main international conferences. On the basis of these findings, it assesses the hypocholesterolemic effect of simvastatin in a sample group of 51 mainly geriatric outpatients following a standard period of preliminary dietary therapy. Subjects were treated with 20 mh/day simvastatin for not less than one month, after which lipidic parameters were evaluated and revealed significant variations: circulating cholesterin was reduced from 322 mg% +/- 49.4 to 225 mg% +/- 37.6 (p less than 0.001), the LDL-lipoprotein level fell from 229 mg% +/- 6.6 to 152 mg% +/- 36.3; HDL-lipoproteins showed no significant variation, nor did other tests to ascertain possible hepatic involvement or other parenchymas secondary to the use of simvastatin. Overall cholesterol levels decreased from 16423 mg% to 11511 mg%, equivalent to 29.9%. Lastly, simvastatin also proved to be clinical efficacious, and was easy to manage and well tolerated by elderly patients. All subjects responded equally well to treatment independent of their general condition and sex. Basal cholesterolemia in elderly subjects decreased from 320 mg% +/- 46.3 to 226 mg% +/- 33.2 (p less than 0.001) and in adults from 325 mg% +/- 56.6 to 224 mg% +/- 46.5 (p less than 0.001); LDL-cholesterol decreased from 232 mg% +/- 46.5 to 153 mg% +/- 35.6 (p less than 0.001) and from 224 mg% +/- 46.6 to 147 mg% +/- 38.7 (p less than 0.001) respectively.

[Informatics in medicine: drug monitoring in the elderly. Software for clinical procedures]. / Informatica in medicina: il monitoraggio dei farmaci per l'anziano. I software per l'operatività clinica.

The Author describes the main procedure for the clinical control of pharmacokinetics and therapeutical programmes in medical practice, taking the use of digitalic alkaloids as an example. The procedure entails: a) Data records: this comprises a system for loading the patient's data into three different structures. The first record contains general information regarding the patient and it is used independently during the therapeutic regimen selection phase. The second record contains details of previous therapy, while the third concerns the input of digitalemic vales. b) The programme: it elaborates the main pharmacokinetic constants (Ka, Kcp, Kpc, Kslope, VC) of the predicted two-compartment model and Sheiner's expression is used to correct it for the reference statistical population. c) Distribution values in the compartments: the chapter illustrates the mean values of alkaloid tissue distribution in normal subjects, the mean value of digoxin with protein binding, the importance of circulating pharmacological ranges and the digitalisation load in relation to tissue deposits. d) Print-out: this represents the observation and therapy selection phase. A typical example of digoxin therapy is illustrated using a dot-matrix plotter and the methods are discussed for interpreting the results of this print-out.

[The heart, the elderly, and diabetes mellitus. Epidemiologic study of 333 ambulatory clinical cases]. / II cuore, il vecchio, il diabete. Studio epidemiologico di 333 osservazioni cliniche ambulatoriali.

The paper proposes a new classification to describe the normal senile heart and its pathological forms: "small aortic heart" (nonhypertrophic-dilatative myocardiopathy and its ischemic form) and "large aortic heart" (hypertrophic-dilatative myocardiopathy and its ischemic form). The statistical distribution of 241 elderly patients with diabetes mellitus using this classification was compared to a control group of 92 elderly non-diabetic subjects. The results reveal the significant epidemiological incidence of ischemic cardiopathy with small aortic heart in diabetic patients compared to the control group in which more ischemic hypertrophic-dilatative cardiopathies were present. This observation supports the hypothesis that senile diabetic cardiopathy begins with a metabolic block with reduced contractile energy, and the overlying important ischemic component leads to the development of the small-size clinical phenotype.

[Captopril in heart failure in the elderly]. / Il captopril nello scompenso cardiaco dell'anziano.

The paper confirms the value of captopril in a sample group of 20 elderly patients (mean age 72.9 years) affected by overall cardiac decompensation in more or less clinically evident phases. All patients were randomly selected and received ACE-inhibition treatment for six months; doses of 25 mg or 50 mg captopril were given twice a day and all other drugs were suspended except for digitalis which was used by all patients without success. During the course of the trial the most important clinical results were the reduction of systemic blood pressure due to the diminution of peripheral resistance, the reduction of postload and ventricular filling pressure, and the consequent improvement of cardiac decompensation. All elderly patients treated in this manner experienced a stable improvement in the quality of life, with a considerable reduction in the consumption of diuretics to which they are particularly vulnerable. Following a broad ranging comparison with other reports, the Authors conclude that captopril is a geriatric drug which should be used as early as possible during the phases of latent cardiac insufficiency or at the first signs of a hypertensive crisis.

[Captopril and hydrochlorothiazide for the treatment of arterial hypertension in the elderly]. / Captopril e idroclorotiazide nel trattamento dell'ipertensione arteriosa dell'anziano.

A clinical trial was performed to assess the association of captopril-hydrochlorotiazide in a large population of hypertensive outpatients divided into two groups: elderly subjects and control group of adults. The hypotensive effect was evaluated and statistical differences between basal values after some months of treatment were highly significant. Together with results, variations in blood as a result of lower pressure are reported, whereas renal functions, and the glucose and electrolytic metabolism remained constant. The characteristics of the pharmacological compound, which may be used to treat any degrees of arterial hypertension, are discussed together with its utility in geriatric patients and the pharmacological synergy between the ACE-inhibitor and the diuretic agent.

[The aging heart and its pathology. An epidemiological study of 229 cases based on a clinical and radiological classification]. / Il cuore senile e la sua patologia. Studio epidemiologico di 229 osservazioni, in base ad una classificazione clinica e radiologica.

The paper studies epidemiological distribution of the aging heart and its pathology in a sample of 229 subjects (101 male and 128 female) on the basis of a clinical and radiological classification into cardiological phenotypes. This study involved the use of mathematical statistical procedures following a standard method using SIR database (Scientific Information Retrieval) software implemented on the CDC Cyber 170/730 mainframe in the Trieste University Computing Center that is connected with the Chair of Geriatric Pathology. Using this software it was possible to assess the epidemiological significance of the usual clinical parameters, and show that the most representative cardiopathy is the 3rd type, i.e. the hypertrophic-ischemic cardiopathy belonging to the large aortic heart. Its natural pathogenesis is independent of risk factors and relates to the aging of muscular and connective tissues in which the coronary circulation is involved in the deterioration of the cardiovascular system and is therefore different from the primary ischemias of adults.