Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope.

BACKGROUND: Head-up tilt testing is extensively used to determine the vasovagal origin of syncope in patients with otherwise unexplained loss of consciousness, although issues remain regarding the method of the test. The diagnostic value of a shortened head-up tilt test potentiated with sublingual nitroglycerin was assessed in patients with unexplained syncope. METHODS: Two hundred two patients (mean age 49+/-19 years) with syncope of unknown origin and 34 subjects in a control group (mean age 45+/-17 years) were studied. The patients and the subjects in the control group were tilted upright to 60 degrees for 20 minutes. If syncope did not occur, sublingual nitroglycerin (400 microg) was administered, and observation was continued for 25 more minutes. RESULTS: During the unmedicated phase syncope occurred in 22 (11%) patients and in one member of the control group. After nitroglycerin was administered, syncope occurred in 119 (59%) patients and in 1 (3%) member of the control group. False-positive response (exaggerated response) was observed in eight (4%) patients and in four (12%) subjects in the control group. The total positivity rate of the test was 70% with a specificity rate of 94%. CONCLUSIONS: Short-duration head-up tilt test potentiated with sublingual nitroglycerin provides an adequate specificity and positivity rate in patients with unexplained syncope.

Pheochromocytoma crisis caused by contemporary ergotamine, caffeine, and nimesulide administration.

Pheochromocytoma is a rare tumor that secretes excess catecholamines. Pheochromocytoma crises may be precipitated by the use of several drugs. This article describes the case of a patient affected by pheochromocytoma in whom multiple organ failure developed after contemporary administration of ergotamine, caffeine, and nimesulide. The patient recovered completely long after surgical intervention.

[Unstable angina in coronary intensive care units without hemodynamics: is admissible a strategy limiting the indications for coronarography?]. / Angina instabile in UTIC senza emodinamica: è ammissibile una strategia che limiti le indicazioni alla coronarografia?

In coronary care units (CCU) without cardiac catheterization facilities, coronary angiography is rarely carried out when a successful medical treatment in the acute phase of unstable angina has been obtained. However, the unstable angina still has an uncertain prognosis when the remission of pain is obtained with drugs. This study presents a follow-up of 147 consecutive patients (aged 66.8 +/- 10.4 years) admitted to our CCU in 1991 and 1992 for unstable angina; 33 of them (22.4%) were in Braunwald class I. 2 (1.4%) in class II and 112 (76.2%) in class III. The patients were treated according to the usual therapy protocols and class III patients received i.v. heparin. In selected cases we used thrombolysis (10 patients) and intra-aortic balloon pump (5 patients). During hospitalization 1 patient died (0.7%), 5 patients (3.4%) suffered an acute myocardial infarction and 9 patients (6.1%) had angina. Stabilization of unstable angina was achieved in 132 patients (89.9%): in 113 (76.8%) during the first 48 hours, and in 19 (12.9%) later. Coronary angiography was carried out in non-stabilized patients and in 46 (34.8%) of the 132 with successful treatment (Group I). Eighty-six patients, without indication to coronary angiography were discharged in medical therapy (Group II). During the follow-up (mean of 15.0 +/- 9.0 months) Group I 10 patients (18.2%) had cardiac events (death, myocardial infarction, or recurrent angina) vs 26 of Group II (p < 0.05). In Group I coronary angiography together with clinical criteria of high risk allowed the identification of candidates to coronary revascularization (61.8% of Group I patients while). These data show that the initial success of treatment during the acute phase of unstable angina should not be considered as a favourable prognostic index. Coronary angiography appears to be indicated for clinical evaluation and therapeutical decision.

[Right atrial metastasis as an initial clinical manifestation of adenocarcinoma of the colon]. / Metastasi atriale destra come prima manifestazione clinica di adenocarcinoma del colon.

We report the case of a young woman suffering from colonic mucinous adenocarcinoma with the unusual clinical presentation as a right atrial metastasis. The tumor was successfully resected, and after histopathological characterization, the primary lesion was searched for and discovered. The tumor had the clinical appearance and echocardiographic pattern of a pedunculated atrial myxoma. The aspects of echo-patterns useful for differential diagnosis are discussed.

[Efficacy of intravenous and per os propafenone in the ambulatory treatment of recent-onset atrial fibrillation]. / Efficacia del propafenone e.v. e per os nel trattamento ambulatoriale della fibrillazione atriale di recente insorgenza.

Propafenone efficacy in conversion of atrial fibrillation to sinus rhythm has been well documented. In this study we considered propafenone efficacy according to a graduated protocol of administration. Forty-two patients with recent-onset atrial fibrillation, without left ventricular failure, ischemic symptoms and in absence of antiarrhythmical treatment, were treated according to the following protocol: propafenone 1 mg/kg i.v. (5 min) followed, in the non-responder patient group, by a second dose, 0.5 mg/kg i.v. (15 min). Patients with persistent atrial fibrillation received 900 mg/daily of propafenone per os, at home for two days. Thereafter, patients still not restored to sinus rhythm were considered non-responders. Patients who were converted to sinus rhythm received 450 mg daily of the drug (oral administration), at home, as antiarrhythmical prophylaxis, for three months. Thirty-nine patients were converted to sinus rhythm (92.8%), 24 of them after intravenous propafenone (57.2%), and the other 15 (35.6%) after oral administration of the drug. The average heart rate in patients not converted to sinus rhythm with intravenous propafenone was significantly reduced after drug administration, compared to basal values (from 136.4 +/- 18.1 to 107.1 +/- 17.6, p < 0.01), allowing home treatment. No major cardiac effects were observed after infusion, nor after oral administration of propafenone. During a three-month follow-up we observed 3 cases of relapsed atrial fibrillation and 2 discontinued treatments due to minor gastroenteric side effects. In conclusion, propafenone therapy in ambulatory regimen is safe and effective in patients with recent-onset atrial fibrillation. In many patients refractory to IV treatment, further therapeutic success may be achieved following oral propafenone administration.

[Comparison of lidoflazine and quinidine in the conversion to sinusal rhythm in atrial fibrillation of recent onset]. / Confronto fra lidoflazina e chinidina nella conversione a ritmo sinusale della fibrillazione atriale di recente insorgenza.

In order to compare the efficacy of oral lidoflazine (240 mg/die) and oral quinidine (1200 mg/die) in re-establishing sinus rhythm, we studied 115 patients (mean age 63.8 years; range 32-91) with atrial fibrillation of recent onset (less than 3 months). Patients with cardiac failure, acute myocardial infarction, severe intraventricular conduction disturbances, kaliemia less than 3.8 mEq/L or digoxinemia greater than 2 ng/ml were not included. Patients were randomly given one of the 2 drugs, until conversion to sinus rhythm was achieved, severe side effects occurred or for a maximum therapy of 5 days. No significant differences were present between the 2 groups in terms of age, male/female ratio, duration of atrial fibrillation, presence of an enlarged left atrium, presence of organic heart disease (or arterial hypertension) or digitalis therapy. Sinus rhythm resumption was obtained in 41/58 (71%) patients treated with quinidine and in 47/57 (82%) patients treated with lidoflazine (p = ns). In successful cases, the mean treatment time was 79 +/- 33 (SD) hours for quinidine and 66 +/- 36 hours for lidoflazine (p = ns). Both drugs showed the same efficacy in 3 subgroups of patients in whom the arrhythmia had different duration (less than 24 hours; between 24 hours and 3 days; more than 3 days). Treatment was stopped in 5 patients receiving quinidine (gastrointestinal side effects) and in 3 patients receiving lidoflazine (frequent premature ventricular beats in 2 and polymorphic ventricular tachycardia of the "torsade de pointes" type in 1).(ABSTRACT TRUNCATED AT 250 WORDS)

[Duplication of the mitral valve associated with aneurysm of the interventricular septum and isthmic coarctation of the aorta. Description of a case]. / Duplicazione della valvola mitralica associata ad aneurisma del setto interventricolare ed a coartazione istmica dell'aorta. Descrizione di un caso.

The case presented concerns a patient of whom the double mitral valve diagnosis was made by means of both the M-mode and two dimensional echocardiography. Diagnosis was not pronounced after the first cineangiocardiography test, but it was confirmed by the following test. The double mitral valve was associated with an aneurysm of the interventricular septum, bicuspid aortic valve, and isthmic coarctation of the aorta.

Efficacy of mexiletine in the medium-term treatment of ventricular arrhythmias. A randomized, double-blind, crossover trial against placebo in ambulatory patients.

A double-blind, crossover study was designed to compare the safety and efficacy of mexiletine with that of placebo in reducing premature ventricular complexes (PVC) in ambulatory patients and to find out the dose which gives a good therapeutic response with a minimal incidence of side-effects. Twenty-six patients, who had on average 427.9 PVCs/hour, were admitted to the study. The doses given were designed to reduce the frequency of PVCs by 50% or more from the baseline value. Two out of the twenty-six patients stopped treatment because of major side-effects. In the remaining twenty-four patients the 3 weeks of treatment with mexiletine significantly reduced the rate of PVCs by comparison with placebo (-63.8% versus +7.5%). In the nineteen responders (per cent reduction of PVCs over 50%) the dose of mexiletine was 600 mg daily (200 mg every 8 hours). In the non-responders plasma levels of mexiletine proved to be in the therapeutic range, not in any way different from responders. The most frequent side-effects were digestive difficulties (fifteen patients taking mexiletine and six taking placebo). These results show that mexiletine is an effective anti-arrhythmic drug in the management of ventricular arrhythmias occurring in ambulatory patients. In the majority of patients mexiletine was found to be effective even at the lowest dose studied of 600 mg/day.

Improvement of the cardiac function after electrical cardioversion of atrial fibrillation. Echocardiographic study in patients with and without mitral stenosis.

The improvement of the cardiac function after electrical cardioversion of atrial fibrillation has been studied by echocardiography by few authors and only in patients without mitral stenosis. Moreover, discordant results have been obtained. We have studied nine patients with mitral valve disease as well as nine other patients with ischemic heart disease. Both groups were cardioverted within five days of onset of atrial fibrillation, and appropriate echocardiographic measurements were made one hour before and two hours after cardioversion. We found a significant decrease of left atrial diameter in both groups, as well as a significant increase of the end-diastolic diameter and volume of left ventricle and an improvement of the cardiac index. These changes were significantly more pronounced in patients with mitral valve disease and they appear in accordance with the improvement of the cardiac function demonstrated with invasive hemodynamic studies after cardioversion to sinus rhythm. In the group of patients with mitral valve disease and a very dilated left atrium (more than 6 cm. of diameter) atrial fibrillation recurred within the next twelve months. In spite of the limitations of M-mode approach for calculating left ventricular volumes, echocardiography appears to be sensitive and useful for evaluating in the single patient the changes in left ventricular performance after cardioversion of atrial fibrillation to sinus rhythm.

Abnormal diastolic motion of interventricular septum during inspiratory phase. Echocardiographic study.

We report on a patient without heart disease who had pulsus paradoxus, associated with echocardiographic evidence of abnormal and exaggerated diastolic motion of interventricular septum. Both phenomena appeared at the peak of the inspiratory phase of respiration, and seemed to be produced from the same haemodynamic variations, of which the echocardiographic pattern appears to be a more sensitive index than the sphygmographic one.