[Appropriateness of prescription of exercise stress test, echocardiography, Holter monitoring and vascular echography]. / L'appropriatezza dei test cardiologici non invasivi. studio osservazionale sull'appropriatezza della prescrizione del test da sforzo, dell'ecocardiogramma, dell'ECG dinamico e dell'ecografia vascolare.

BACKGROUND: The aim of this study was to evaluate the appropriateness of prescription of non-invasive cardiological tests (exercise stress test, echocardiography, Holter monitoring and vascular echography), consecutively performed in our outpatient laboratory during 4 weeks. METHODS: We collected the following data: the appropriateness of prescription (according to the Italian Federation of Cardiology guidelines); test indications; the prescribing physician (cardiologist/non-cardiologist); type of prescription (elective/urgent); clinical utility (useful/useless) and result (normal/abnormal) of each test. RESULTS: We evaluated 960 prescriptions (320 exercise tests; 282 echocardiograms; 158 Holter tests; 200 vascular echographies). Test indications were appropriate (class I) in 37%, doubtfully appropriate (class II) in 39% and inappropriate (class III) in 24% of the cases. The appropriateness was slightly better for vascular echography and echocardiography (class I: 44% and 43%, respectively), markedly worse for exercise test (class I: 27%). The tests were considered useful in 46% and abnormal in 39% of the cases. Cardiologist-prescribed exams resulted more often appropriate (class I: 53 vs 30%; class II: 41 vs 38%; class III: 6 vs. 32%; p = 0.0001), more often useful (74 vs. 34%; p = 0.0001) and more frequently abnormal (43 vs. 37%; p = 0.05), when compared to non-cardiologist-prescribed exams. No differences in appropriateness, utility and test result have been detected between elective and urgent exams. Exercise test, echocardiogram and Holter monitoring resulted more often appropriate and useful when prescribed by cardiologists. CONCLUSIONS: This study confirms that only one third of prescriptions for non-invasive cardiological tests are appropriate. Cardiologist-prescribed exams are more often appropriate, useful and abnormal.

[Acute antineoplastic drug cardiotoxicity: a case report of life-threatening left ventricular failure associated with severe hyperglycemia]. / Cardiotossicità acuta da antineoplastici: descrizione di un caso di grave insufficienza ventricolare sinistra associata a severa iperglicemia.

Anthracyclines represent an established therapy for various hemopoietic and solid tumors; however the cardiotoxicity of these agents continues to limit their therapeutic potential in many cancer patients. Acute life-threatening cardiac toxicity which occurs immediately after a single dose of therapy is very rare under current treatment protocols. This form of toxicity occurs unexpectedly owing to a large variation in individual sensitivity. It may cause transient arrhythmias, hypotension, a pericarditis-myocarditis syndrome, or acute left ventricular failure. We report the case of a 43-year-old woman recently operated on for breast cancer, with acute life-threatening left ventricular failure associated with severe hyperglycemia, occurring a few hours after the first dose of anthracyclines for adjuvant chemotherapy. Severe regional wall motion abnormalities and a significant impaired systolic left ventricular function associated with high creatine phosphokinase-MB and troponin levels were observed. At discharge the regular insulin treatment was interrupted since glycemia was normalized, and complete recovery of the cardiac function was observed 1 month later. Differential diagnosis and the underlying pathogenetic mechanisms are discussed. This life-threatening event is rare, but considering the widespread use of anthracyclines in cancer treatment, it is important for the cardiologist to be aware of the potential acute cardiac toxicity of these agents for early diagnosis and management.

[Feasibility and accuracy of a rapid evaluation of the abdominal aorta during routine transthoracic echocardiography]. / Fattibilità ed accuratezza di una rapida valutazione dell'aorta addominale durante l'esame ecocardiografico transtoracico.

BACKGROUND: Mass screening for occult abdominal aortic aneurysm is not realistic for the low prevalence of this condition in the general population. Screening in a high-risk population, especially during standard echocardiographic examination, could be more cost-effective than a separate screening program. The aim of this study was to evaluate the feasibility and accuracy of a rapid evaluation (examination arbitrary time-limit of 2 min) of the abdominal aorta at the end of a routine transthoracic echocardiographic examination. METHODS: One hundred and eighty-one male patients (average age 61 years, range 45-79 years) were studied. A subgroup of 83 patients was also blindly examined by a radiologist for diagnostic accuracy evaluation. RESULTS: Abdominal aortic aneurysm was defined as an aortic diameter enlargement > or = 3.0 cm. Sixteen patients were excluded due to suboptimal aortic wall imaging or to examination lasting > 2 min (feasibility 91%). An occult aneurysm was found in 7 patients (3.8%). As regards the presence/absence of aneurysms in the subgroup of patients undergoing double examination, sensitivity and specificity were 80 and 100% respectively. CONCLUSIONS: Rapid evaluation of the abdominal aorta for aortic screening during routine echocardiography is highly feasible and accurate without any significant prolongation of the examination time and should therefore be routinely performed during standard examination.

P-wave signal-averaged electrocardiogram predicts atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: AF is one of the most common complications after CABG. The aim of the study was to identify the risk factors for postoperative AF. METHODS: Between June and December 2000, 129 consecutive patients (72 men, 47 women; mean age 67 +/- 6 years) underwent preoperative signal-averaged electrocardiogram (SAECG) with assessment of filtered P-wave duration (fPWD) and of the root mean square voltage of the last 10 and 20 ms of atrial depolarization (RMSV10 and RMSV20, respectively) before CABG. RESULTS: Fifty-six (43%) patients developed one episode of AF lasting > 30 seconds at a mean distance of 2.6 +/- 1.8 days after surgery (group A), while 73 patients remained in sinus rhythm (group B). No differences between the two groups were found in terms of age, sex, P-wave duration on the standard ECG, left atrial dimensions, and operative characteristics. In contrast, group A patients showed a significantly longer fPWD (138 +/- 10 vs 111 +/- 9 ms; P < 0.001) and smaller RMSV10 and RMSV20 (2.8 +/- 1.0 vs 4.3 +/- 1.1 microV, P < 0.001; 4.2 +/- 2.1 vs 6.2 +/- 2.0 microV, P < 0.001). Multivariate analysis indicated only fPWD as an independent predictor of AF (P = 0.009). With a cut-off value of 135 ms for fPWD, the occurrence of AF could be predicted with a sensitivity of 84%, a specificity of 73%, a negative predictive value of 85%, and a positive predictive value of 70%. CONCLUSION: Preoperative SAECG is a simple exam that correctly identifies patients at higher risk of AF after CABG. A more widespread use of this technique can be suggested.

[Evaluation of the appropriateness of prescribing non-invasive cardiologic tests]. / La valutazione dell'appropriatezza della prescrizione dei test cardiologici non invasivi.

BACKGROUND: We evaluated the appropriateness of the prescription of echocardiography, exercise testing, Holter monitoring and vascular sonography for ambulatory patients, performed during 4 weeks in 21 outpatient laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs noncardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 5614 prescriptions (patients: 3027 males, 2587 females; mean age 63 years, range 14-96 years). The indication to the test was of class I (appropriate) in 45.3%, of class II (doubtfully appropriate) in 34.8% and of class III (inappropriate) in 19.9% of the cases. The test was abnormal in 58.3% of class I exams vs 17% of class III exams (p < 0.05). The test was useful in 72.4% of class I exams vs 17.1% of class III exams (p < 0.05). The test was prescribed by a cardiologist in 1882 cases (33.5%). Cardiologist-prescribed exams were of class I in 57.3%, of class II in 32.4% and of class III in 10.3% of the cases vs 39.2, 36.1 and 24.7% of non-cardiologist-prescribed exams (p < 0.05). Cardiologist-prescribed exams were abnormal in 53.4% of the cases vs 39% of those of non-cardiologists' (odds ratio 1.76, 95% confidence interval 1.58-1.97; p < 0.05). Cardiologist-prescribed exams were useful in 64.7% of the cases vs 44.4% of those of non-cardiologists' (odds ratio 2.26, 95% confidence interval 2.02-2.53; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, less than half of the prescriptions for non-invasive diagnostic tests are appropriate: appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are more often appropriate, abnormal and useful.