Linac-based STereotactic Arrhythmia Radioablation (STAR) for ventricular tachycardia: a treatment planning study.

OBJECT: To analyze geometrical approaches, prescription modalities, and delivery efficiency for linear accelerator (Linac)-based STereotactic Arrhythmia Radioablation (STAR) for ventricular tachycardia. METHODS: The anatomy and planning target volume (PTV) of the first Italian STAR patient were used. To assess geometrical approaches, 3 plans prescribed to 75% isodose-line, differing for number, length of arcs, and couch rotations, were generated and compared (Plans#1-3). Volumetric-arc with 6-MV flattening-filter-free (FFF) was employed. To evaluate prescription modality and delivery, the best geometrical plan was compared with other plans prescribed on 70%, 65%, and 60% isodose-line and with another one using 10MV-FFF beams (Plans#4-7). RESULTS: For Plans#1-3, PTV coverage, mean cardiac dose, monitor units (MUs), and beam-delivery-time (BDT) were 96-98.5%, 4.9-5.2 Gy, 7047-7790, and 5-6 min, respectively. Plans#4-7 were similar in terms of mean cardiac dose, MUs and BDT to Plans#1-3, except in maximum dose and lower time for 10MV-FFF plan. CONCLUSION: Linac-based STAR is safe and efficient in terms of BDT and MUs. To ensure high dose to PTV, different dose prescription modalities should be evaluated. The 10FFF approach was the faster but not suitable in patient with cardiac implantable electronic devices.

Correlation between coronary microvascular function and angina status in patients with stable microvascular angina.

BACKGROUND: Classical anti-ischemic drugs are the first-line form of treatment in patients with microvascular angina (MVA), but they often fail to achieve a satisfactory control of angina symptoms. It is unknown whether there is any relation between improvement of angina status and changes in microvascular function induced by classical anti-ischemic drugs in MVA patients. AIM: To assess whether, in MVA patients, the effects of classical anti-ischemic drugs on symptoms and quality of life (QoL) are related to changes in coronary microvascular function. PATIENTS AND METHODS: We studied 51 patients (59±10 years; 15 men) with MVA. Coronary blood flow (CBF) response to adenosine (ADO) and to cold pressor test (CPT), Seattle Angina Questionnaire (SAQ) and EuroQoL scale were assessed at baseline, in pharmacological washout, and after 12 months under anti-ischemic therapy. Patients were divided into 2 groups: (1) Group 1 included patients with no improvement of QoL (EuroQoL score change < 10 points); (2) Group 2 included patients with QoL improvement (increase in EuroQoL score ≥ 10 points). RESULTS: At baseline, the 2 groups were similar in age, gender, cardiovascular risk factors, CBF response to ADO and to CPT, SAQ and EuroQoL scores. At follow-up the 2 groups differed only for beta blockers use (27% vs. 88% in group 1 and 2, respectively; p < 0.001). A significant improvement in SAQ score was observed only in group 2. CBF response to both ADO and CPT showed a similar improvement in the 2 groups. No relation was found between changes in coronary microvascular function and in angina status. CONCLUSIONS: In MVA patients beta-blockers are more effective than other anti-ischemic drugs in improving angina symptoms. The improvement of angina status does not seem to be mediated by changes in coronary microvascular function.

The patient with chronic ischemic heart disease. Role of ranolazine in the management of stable angina.

Ischemic heart disease (IHD) is a major cause of death in Western Countries and accounts for very high costs worldwide. In this review we discussed the pathogenesis, symptoms, diagnosis, prognosis and management of chronic IHD. In particular, we discussed about the percutaneous coronary interventions and coronary artery bypass grafting, as well as to clinical trials that evaluated the advantages of one approach versus another. Pharmacological treatment is among major objectives of the review and for each class of therapeutic agents an evaluation of well-conducted clinical trials is provided. The most important drug classes in IHD treatment are betablockers, calcium channel blockers, nitrates, antiplatelet agents, and ACE-inhibitors. In addition to these agents, also new treatment options are evaluated in patients with stable IHD. Ranolazine, in particular, is a innovative anti-anginal drug with a great successful in the management of patients with refractory angina. A pharmacological as well as clinical profile of this drug is provided.

Effect of bariatric surgery on peripheral flow-mediated dilation and coronary microvascular function.

BACKGROUND AND AIMS: To assess the effects of bariatric surgery (BS) on peripheral endothelial function and on coronary microvascular dilator function. METHODS AND RESULTS: We studied 50 morbidly obese patients (age 38 ± 9, 13 M) who underwent BS and 20 comparable obese controls (age 41 ± 11, 6 M) without any evidence of cardiovascular disease. Peripheral vascular dilator function was assessed by brachial artery diameter changes in response to post-ischemic forearm hyperaemia (flow-mediated dilation, FMD). Coronary microvascular function was assessed by measuring coronary blood flow (CBF) velocity response to i.v. adenosine and to cold pressor test (CPT) in the left anterior descending coronary artery by transthoracic Doppler echocardiography. The tests were performed at baseline and at 3-month follow-up. At baseline, FMD and CBF response to adenosine and CPT were similar in the 2 groups. Compared to baseline, FMD at follow-up improved significantly in BS patients (5.9 ± 2.7% to 8.8 ± 2.4%, p < 0.01), but not in controls (6.3 ± 3.2% vs. 6.4 ± 3.1%, p = 0.41). Similarly, a significant improvement of CBF response to adenosine (1.63 ± 0.47 to 2.45 ± 0.57, p < 0.01) and to CPT (1.43 ± 0.26 to 2.13 ± 0.55, p < 0.01) was observed in BS patients but not in controls (1.55 ± 0.38 vs. 1.53 ± 0.37, p = 0.85; and 1.37 ± 0.26 vs. 1.34 ± 0.21, p = 0.48, respectively). The favourable vascular effects of BS were similar independently of the presence and changes of other known cardiovascular risk factors and of basal values and changes of serum C-reactive protein levels. CONCLUSIONS: Our data show that, in morbidly obese patients, together with peripheral endothelial function, BS also improves coronary microvascular function. These effects suggest global improvement of vascular function which can contribute significantly to the reduction of cardiovascular risk by BS reported in previous studies.

Low glucose blood levels are associated with abnormal cardiac sympatho-vagal balance in type 2 diabetic patients with coronary artery disease.

BACKGROUND AND OBJECTIVES: Glycemic control has been suggested to improve prognosis in diabetic patients, but recent trials failed to show benefits from intensive glycemic control. Hypoglycaemic episodes or large variability in glucose blood levels causing a sympatho-vagal imbalance of cardiac autonomic function (CAF) might play a role in this result. In our study we assessed whether blood glucose fluctuation may be related to variations in CAF during daily life in diabetic patients with coronary artery disease (CAD). MATERIALS AND METHODS: Twelve patients with type 2 diabetes mellitus with CAD (65+/-4 years, 2 women) underwent simultaneous 48-hour ECG Holter monitoring and continuous interstitial glucose measurements. The highest and lowest glucose levels for each 3-hour segments of the day were identified and heart rate variability (HRV) parameters were measured on Holter recordings on 5-minute intervals centred on these times. RESULTS: Overall, 294 glucose levels were available for analysis. In the whole population several HRV indices were significantly lower in correspondence of the lowest glucose blood levels and this difference was much more evident in patients who were not taking beta-blockers, than in patients who were taking beta-blockers. A significant, although mild, correlation was found between glucose blood levels and several time-and frequency domain HRV variables in patients not taking beta-blockers, but not in these on beta-blockers therapy. DISCUSSION: Our data suggest that, in type 2 diabetic patients with CAD, hypoglycaemic episodes are associated with depressed HRV and that beta-blocking agents are able to contrast this relation. These interesting results merit to be investigated in a larger population of patients.

Cardiac adrenergic nerve function and microvascular dysfunction in patients with cardiac syndrome X.

OBJECTIVE: To assess whether abnormalities in cardiac uptake of (123)I-metaiodobenzylguanidine (MIBG) correlate with coronary microvascular dysfunction in patients with cardiac syndrome X (CSX). SETTING: University hospital. PATIENTS: 29 patients (aged 59 (SD 7) years, 11 men) with typical CSX and a matched group of 20 healthy subjects (aged 56 (7) years, 8 men) were studied. INTERVENTIONS: Planar and single photon emission computed tomography (SPECT) MIBG myocardial scintigraphy was performed in all subjects. Coronary flow response (CFR) to adenosine and to cold pressor test (CPT) in the left anterior descending (LAD) coronary artery was assessed in all CSX patients and in 12 controls by transthoracic Doppler echocardiography. MAIN OUTCOME MEASURES: Abnormalities in cardiac MIBG scintigraphy were observed in 25 CSX patients (86.2%), but in no healthy control (p<0.001). Compared to controls, CSX patients showed a lower heart/mediastinum (H/M) ratio of MIBG uptake (1.69 (0.24) vs 2.2 (0.3), p<0.001) and a higher cardiac MIBG defect score (25 (22) vs 4 (2), p = 0.002). Both CFR to adenosine (3.31 (1.1) vs 1.94 (0.6), p<0.001) and CFR to CPT (2.35 (0.5) vs 1.63 (0.4), p<0.001) were lower in CSX patients than in controls. In CSX patients, however, no correlation was found between MIBG H/M ratio and CFR to adenosine (r = 0.17; p = 0.38) and to CPT (r = -0.28; p = 0.13), as well as between MIBG uptake score in the LAD territory and CFR to adenosine (r = 0.14; p = 0.47) and to CPT (r = 0.06; p = 0.73). CONCLUSION: Our data show striking abnormalities in cardiac adrenergic nerve function and in coronary microvascular function in CSX patients. However, no significant relation between the two abnormalities was found. Further studies are needed to clarify the mechanisms and the role of MIBG defects in CSX patients.

[Risk of chromosomal pathology in fetus with abnormal umbilical artery flowmetry]. / Rischio di cromosomopatie in feti con alterazioni flussimetriche dell'arteria ombelicale.

BACKGROUND: Goal of this study is to consider the incidence of chromosomal abnormalities in fetuses by velocimetry abnormalities. METHODS: The author select 64 pregnancies by velocimetry abnormalities of umbilical artery diastolic flow (ARED: Absent or Reverse end Diastolic Flow). RESULTS: The fetal cariotype from amniociti or from umbilical blood at delivery moment is resulted abnormal in 5 cases. Fetal-maternal risk factors of chromosomopaties are: malformations; fetal growth retardation; maternal age > or = 35. CONCLUSIONS: Other studies and other results are necessary for this discussion.

[Usefulness of ultrasonography of the cervical canal in the screening of pregnant women at risk of premature labor]. / Utilità dello studio ecografico del canale cervicale nello screening delle gestanti a rischio di parto pretermine.

BACKGROUND: Goal of the study is to evaluate the utility of cervical sonography in the second quarter as screening of pregnancies with risk of preterm labor. METHODS: A.A. evaluate, by transvaginal sonography (TVS) of the uterine cervix, 75 pregnancies with history of preterm labor and 25 with risk of preterm labor between XXIV and XXXIII week of pregnancy. The uterine cervix length < 40 mm and width > 5 mm, funneling were pathological and predictive factors of preterm labor. RESULTS: Eighty-five percent of pregnancies that have, at sonography TVG, abnormal values of length and width of uterine cervix, delivered before XXXVI week. CONCLUSIONS: These results confirm the importance of the high frequency ultrasonography transvaginal, TVS, for its predictive value and for treatment in pregnancies with risk of preterm labor.

Spirometric prediction equations for male Italians 7-18 years of age.

The purpose of this study was to develop spirometric predictive equations (SPE) for forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and maximum midexpiratory flow (MMF25-75) derived from a large sample of healthy italian boys and male adolescents. We used the univariate and multiple linear regression models and considered as independent variables age and the following anthropometric measurements: height, weight, chest circumference. The predictive power of multivariate models was slightly higher than that of the univariate model using height as independent variable for FVC, FEV1 and MMF25-75.