Time course of serum collagen types I and III metabolism products after reperfused acute myocardial infarction in patients with and without systemic hypertension.

We examined 55 consecutive patients successfully treated with primary percutaneous coronary intervention (PCI) for a first acute myocardial infarction with left ventricular (LV) systolic dysfunction. In all patients we performed echocardiographic examination, dosage of plasma brain natriuretic peptide, serum carboxy-terminal propeptide and telopeptide of procollagen type I and amino-terminal propeptide of procollagen type III at days 1 and 3, and at 1 and 6 months after index infarction. The hypertensive patients (group 1; n=30) differed for higher baseline blood pressure (133+/-4 mm Hg vs 118+/-4 mm Hg; P=0.03), greater LV mass index (108+/-5 vs 94+/-4 g m(-2), P=0.03) and lower mitral E/A wave peak (0.8+/-0.06 vs 1.1+/-0.12, P=0.02) with respect to non-hypertensive patients (group 2; n=25). From day 1 to month 6 carboxy-terminal propeptide of procollagen type I and amino-terminal propeptide of procollagen type III increased (P<0.005 and P<0.05, respectively) in both groups, whereas carboxy-terminal telopeptide of procollagen type I increased from day 1 to day 3 (P<0.01 in both groups, respectively) and then decreased from day 3 to month 6 (P<0.01 and P<0.05 in both groups, respectively). From day 1, brain natriuretic peptide decreased in both groups (P<0.005). There was no significant difference between the two groups in values of procollagens and natriuretic peptide. Finally, LV diastolic volume and function at 6 months were similar in the two groups. Thus, in patients with reperfused acute myocardial infarction and LV dysfunction, antecedent hypertension was not associated with a different pattern of serum procollagen release and ventricular remodelling at 6 months of follow-up.

Left ventricular mass and cardiovascular morbidity in essential hypertension: the MAVI study.

OBJECTIVES: This study investigated the prognostic value of left ventricular (LV) mass at echocardiography in uncomplicated subjects with essential hypertension. BACKGROUND: Only a few single-center studies support the prognostic value of LV mass in uncomplicated hypertension. METHODS: The MAssa Ventricolare sinistra nell'Ipertensione study was a multicenter (45 centers) prospective study. The prespecified aim was to explore the prognostic value of LV mass in hypertension. Admission criteria included essential hypertension, no previous cardiovascular events, and age > or =50. There was central reading of echocardiographic tracings. Treatment was tailored to the single subject. RESULTS: Overall, 1,033 subjects (396 men) were followed for 0 to 4 years (median, 3 years). Mean age at entry was 60 years, and systolic/diastolic blood pressure was 154/92 mm Hg. The rate of cardiovascular events (x100 patient-years) was 1.3 in the group with normal LV mass and 3.2 in the group (28.5% of total sample) with LV mass > or =125 g/body surface area (p = 0.005). After adjustment for age (p < 0.01), diabetes (p < 0.01), cigarette smoking (p < 0.01) and serum creatinine (p = 0.03), LV hypertrophy was associated with an increased risk of events (RR [relative risk] 2.08; 95% CI [confidence interval]: 1.22 to 3.57). For each 39 g/m(2) (1 SD) increase in LV mass there was an independent 40% rise in the risk of major cardiovascular events (95% CI: 14 to 72; p = 0.0013). CONCLUSIONS: Our findings show a strong, continuous and independent relationship of LV mass to subsequent cardiovascular morbidity. This is the first study to extend such demonstration to a large nationwide multicenter sample of uncomplicated subjects with essential hypertension.

Prognostic implications of restrictive left ventricular filling in reperfused anterior acute myocardial infarction.

OBJECTIVES: We sought to assess the relative prognostic role of a restrictive left ventricular (LV) filling pattern after a first anterior acute myocardial infarction (AMI) in patients treated with primary percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: In thrombolized patients, a short Doppler-derived mitral deceleration time (DT) of early filling is a powerful independent predictor of heart failure and death. However, it is still unknown whether the outcome of patients with AMI with a short DT may be improved by a more aggressive treatment. METHODS: In 104 patients, two-dimensional and Doppler echocardiograms were obtained three days after the index AMI. Coronary angiography was performed in all patients one and six months after PTCA. The patients were classified into two groups according to the DT duration: group 1 (n = 34) with DT < or = 130 ms and group 2 (n = 70) with DT >130 ms. All patients were followed-up for a mean (+/- SD) period of 32 +/- 10 months. RESULTS: During the follow-up period, 14 patients (13%) were admitted to the hospital for congestive heart failure, and 9 patients (9%) died. All cardiac deaths (n = 7) occurred in group 1. The survival rate at mean follow-up was 79% in group 1 and 97.2% in group 2 (p = 0.003). Multivariate Cox analysis showed that only age and restrictive filling were independent predictors of event-free survival. Furthermore, when survival with no cardiovascular events was analyzed, a short DT still emerged as the most powerful independent predictor. CONCLUSIONS: Patients with a restrictive LV filling pattern early after anterior AMI have a poor clinical outcome, even if treated with primary PTCA.

Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction.

A paucity of data exists on the importance of gender in contributing to the mortality rate after primary angioplasty, although it is has been shown that women with acute myocardial infarction (AMI) are less likely than men to undergo reperfusion treatments. This study analyzes gender-related differences in 6-month clinical and angiographic outcomes in nonselected patients with AMI who underwent primary angioplasty or stenting. We compared clinical and angiographic outcomes of 230 women and 789 men who underwent primary angioplasty or stenting from January 1995 to August 1999. The women were older than the men, and had a greater incidence of diabetes and cardiogenic shock. The 6-month mortality rate was 12% in women and 7% in men (p = 0.028). Nonfatal reinfarction occurred in 3% of the women and in 1% of the men (p = 0.010). There were no differences in repeat target vessel revascularization rates. After multivariate analysis, gender did not emerge as a significant variable in relation to 6-month mortality or to the combined end point of death, reinfarction, and repeat target vessel revascularization. Both women and men with stented infarct arteries had lower restenosis rates (29% and 26%, respectively) than patients without stents (52% and 39%, repectively). The results of outcome analysis in nonselected patients suggest that sex is not an independent predictor of mortality after primary angioplasty for AMI, and that the benefit of primary stenting is similar in men and women.

Primary stenting in nonselected patients with acute myocardial infarction: the Multilink Duet in Acute Myocardial Infarction (MIAMI) trial.

Most randomized trials comparing primary stenting with primary coronary angioplasty (PTCA) excluded patients at high risk from enrollment, thus arising the important question about the generalizability of the randomized trial results to all patients with AMI. The aim of this study was to assess the feasibility and effectiveness of a primary infarct-related artery (IRA) stenting strategy using a second-generation tubular stent in nonselected patients with acute myocardial infarction (AMI). All patients with AMI were considered eligible for primary IRA stenting. No restriction was made based on age or clinical status on presentation, or coronary anatomy, except in cases of a reference IRA diameter < 2.5 mm. The primary endpoint of the study was clinical target vessel failure defined as death, reinfarction, or repeat TVR due to restenosis or reocclusion of the IRA. Between June 1998 and March 1999, 201 consecutive patients with AMI underwent mechanical recanalization of the IRA. The mean age was 64 +/- 12, and 16% of patients were aged 75 years or over. The incidence of shock was 9%. Primary IRA stenting was performed in 89% of the patients. Patients who underwent PTCA alone had a smaller IRA diameter as compared to patients with a stented IRA (2.48 +/- 0.46 mm vs. 3.15 +/- 0.37 mm; P < 0.001). There were no stent deployment failures. The 6-month primary endpoint rate was 15% (2 deaths, 27 repeat TVR, 0 reinfarctions), while the 6-month angiographic restenosis rate was 22%. Primary IRA stenting in nonselected patients with AMI is highly feasible and associated with favorable clinical and angiographic outcomes. Cathet. Cardiovasc. Intervent. 51:273-279, 2000.

Comparison of electrocardiographic criteria for diagnosis of left ventricular hypertrophy in hypertension: the MAVI study.

BACKGROUND: Standard electrocardiography (ECG) is a specific, but poorly sensitive tool for diagnosis of left ventricular (LV) hypertrophy. In a large population of subjects with hypertension we tested some standard ECG criteria in their sensitivity and specificity for LV hypertrophy. LV mass at echocardiography was the reference standard. METHODS: In the setting of the MAVI (MAssa Ventricolare sinistra nel soggetto Iperteso) study, the ECG and echocardiographic tracings of 947 hypertensive subjects were read blindly in a central office. RESULTS: Prevalence of LV hypertrophy at ECG was 0.6, 3.0, 4.8, 7.1, 11.1, 11.9 and 18.4%, respectively, using the following criteria: Wilson, typical strain, Romhilt-Estes score > or = 5 points, Gubner-Ungerleider, Sokolow-Lyon, Cornell voltage (S(V3)+R(avL) > 2.8 mV in men or 2.0 mV in women) and Perugia score (positivity of at least one of the following: S(V3)+R(aVL) > 2.4 mV in men or > 2.0 mV in women, a typical strain pattern, or a Romhilt-Estes point score >or = 5). Prevalence of LV hypertrophy at echocardiography ranged from 27.2% (LV mass > 125 g/m2) to 49.9% (LV mass > 51.0 g/m2.7). Using the latter gold standard, sensitivity and specificity of the above ECG criteria were 0.8 and 99.6% (Wilson), 3.8 and 97.9% (strain), 5.9 and 96.4% (Romhilt-Estes), 9.7 and 95.6% (Gubner-Ungerleider), 11.2 and 91.1% (Sokolow-Lyon), 15.2 and 91.4% (Cornell), and 22.2 and 85.4% (Perugia score). CONCLUSIONS: Sensitivity of traditional ECG criteria for LV hypertrophy in subjects with hypertension is poor. However, the combination of three highly specific criteria (Romhilt-Estes, LV strain and Cornell) in a cumulative score produces a rise in sensitivity without excessive deterioration of specificity, with a prevalence of LV hypertrophy at ECG of 18.4%. Traditional interpretation of ECG is valuable and should be reconsidered in the clinical work-up of subjects with hypertension.

Stenting for in-stent restenosis.

Intravascular ultrasound studies have shown that additional stent implantation is the only percutaneous technique that allows for recovery of all the lumen area of the original implantation procedure. Despite this theoretical advantage, information on systematic additional stent implantation is still forthcoming, especially concerning the impact of new stent designs. This prospective study evaluated the efficacy of routine additional stent implantation for treatment of in-stent restenosis in 68 consecutive patients. Repeat stenting was successful in all cases, and second-generation tubular stents were used in 84% of patients. The mean additional stent length was 19.2 +/- 9.4 mm, and 15% of patients had multiple stent implantation. The postprocedure minimum lumen diameter was 3.11 +/- 0.41 mm, and the percentage residual stenosis was 2% +/- 7%. At a mean clinical follow-up of 10 +/- 8 months (follow-up rate 100%), the incidence of major adverse events was 21% (1 death, 13 target vessel revascularizations). Overall, angiographic restenosis rate was 32% (angiographic follow-up rate 79%). By multivariate analysis, the only predictors of recurrence after additional stenting were unstable angina at the second procedure (OR 8.70, 95% CI 1.50-50.33, P = 0.019), and early clinical recurrence after the first stent procedure (OR 4.83, 95% CI 1.13-20.71, P = 0.038). Additional stenting is a safe and effective treatment modality for the majority of patients with in-stent restenosis. Alternative treatments should be considered only for patients with in-stent restenosis presenting as unstable angina or early recurrence after a first stent procedure.

Efficacy of a "stent-like" PTCA strategy in current clinical practice.

Retrospective analysis within the BENESTENT-l trial has shown that patients having a "stent-like" result after standard PTCA had angiographic and clinical outcomes similar to those of patients receiving a stent. The objective of this study is to assess the efficacy of a "stent-like" PTCA strategy in native coronary arteries in non-selected patients. From our data base, 503 consecutive patients who underwent successful PTCA or stent supported PTCA were stratified according to a target lesion length < 15 mm, a reference vessel diameter > or = 2.5 mm, and a postprocedural residual stenosis < 30%. After stratification, 132 patients with "stent-like" PTCA, and 88 with single stent implantation were compared on two-year clinical outcomes. Two-year event-free survival rate was 70% in the "stent-like" PTCA group, and 83% in the stent group (p = 0.022). Stent-like PTCA is associated with a higher restenosis rate and higher adverse events rate as compared to single stent supported PTCA, whatever the indication for stenting.

Prevalence and correlates of echocardiographic determined left ventricular hypertrophy in 2318 asymptomatic middle-aged men: the ECCIS project. Epidemiolgia e Clinica della Cardiopatia Ischemica Silente.

It is well established that left ventricular hypertrophy is a strong and independent risk factor for cardiovascular morbidity and mortality. This study was designed to determine the prevalence and correlates of left ventricular hypertrophy (LVH) among a sample population of 2318 totally asymptomatic men aged 40-59. This sample is a subset of the participants in the ECCIS Project. Left ventricular mass was estimated by echocardiography. The following individual variables were employed in the multiple linear regression analyses: age, diastolic and systolic blood pressure at rest and at peak exercise, body mass index, body surface area, conditioning physical activity. Three indexes of left ventricular mass were used: left ventricular mass/height, left ventricular mass/body surface area and "adjusted left ventricular mass" derived from adjustment, using a regression model, of left ventricular mass by age, body mass index and body surface area. The sample was subdivided in 3 blood pressure classes; normotensive (n = 1605), borderline (n = 390) and hypertensive (n = 323). All the variables considered with the exception of diastolic blood pressure both at rest and peak exercise were significantly correlated with left ventricular mass. Upper normal limits for left ventricular mass indexed to height and body surface area and of adjusted left ventricular mass were 143 g/m, 129 g/m2, and 245 g respectively. The prevalences of left ventricular hypertrophy, as determined by the reference standard of left ventricular mass/height, left.ventricular mass/body surface area and adjusted left ventricular mass, ranged 2.7-3.2% in the normotensive group, 4.2-5.4% in the borderline group and 11.8-14.5% in the hypertensive group, and were lower using adjusted left ventricular mass index. The results of this study show that the prevalence of left ventricular hypertrophy using adjustment by age, body surface area and body mass index reduces variability of left ventricular mass associated with age and body size and may be useful for the correct identification of left ventricular hypertrophy and hypertensive heart disease.

[Efficacy and duration of effect of two delayed-action preparations of gallopamil in patients with exercise angina]. / Efficacia e durata di effetto di due formulazioni di gallopamil, pronta e ritardo, in pazienti con angina da sforzo.

In 15 subjects (13 male, 2 female) with reproducible threshold ischaemic effort angina, the efficacy and the duration of the effect of two different formulations of gallopamil in equal doses were evaluated. One of these was gallopamil slow release administered twice daily (at 7.00 a.m. and 6.00 p.m.) in doses of 100 mg. The other was action gallopamil immediate release administered four times daily (at 7.00 a.m., 1.00 p.m., 6.00 p.m., 11.00 p.m.) in doses of 50 mg. The double-blind study followed the cross-over model. After one week of run-in with placebo and two-weeks of treatment with active preparations, the patients underwent a clinical examination, an ambulatory electrocardiogram monitoring for 24 hours and two cycloergometric effort tests. The ergometric tests were carried out at 10.00 a.m. and at 5.00 p.m. on the same day so that there was a three-hour interval between the administration of both preparations (slow release and immediate release) and the morning test. The ergometric test which was carried out at 5.00 p.m. was at a ten-hour interval from the administration of slow release and at a four-hour interval from the administration of immediate release. For each period of treatment the gallopamil plasma concentrations were dosed during the ergometric test. In both these tests, the two preparations significantly increased the duration of the exercise compared to the basal values with placebo (7.9 +/- 2.3 minutes with placebo, 9.2 +/- 2.0 minutes with slow release.(ABSTRACT TRUNCATED AT 250 WORDS)

[Study of myocardial perfusion at rest using technetium Tc 99m methoxy-isobutylisonitrile: comparison with labeled microspheres and thallium 201]. / Studio della perfusione miocardica a riposo con 99mtecnezio-metossi-isobutil-isonitrile: confronto con microsfere marcate e con 201tallio.

In order to evaluate the potential usefulness of 99m technetium (Tc)-methoxy-isobutyl-isonitrile (MIBI) as a myocardial perfusion tracer in man, its myocardial distribution at rest was compared with that of 201thallium (TI). Perfusion images obtained with 99mTc-labelled microspheres, whose myocardial distribution is exclusively coronary flow dependent, were used as reference. The study was performed on twelve patients (10 males and 2 females, mean age 55.4 +/- 6.4) with suspected effort angina and without a history of previous myocardial infarction. In the space of two weeks patients underwent rest and exercise 99mTc-MIBI myocardial scintigraphy, exercise-redistribution 201TI myocardial scintigraphy, 99mTc-labelled microsphere scintigraphy after microsphere injection in the left ventricle at rest during catheterization before performing left ventriculography and coronary angiography. The comparison with microsphere distribution was limited to rest 99mTc-MIBI scintigraphy and redistribution 201TI images. Single photon emission tomography (SPECT) was employed. SPECT was performed using a double-head Rotacamera with a 360 degrees rotation arc. Ninety projections of 20 seconds each were acquired; subsequently image reconstruction was performed using an iterative algorithm. To evaluate regional perfusion the left ventricular wall was divided into 18 segments; the uptake pattern of each segment was graduated according to a qualitative score (0: severe defect; 1: moderate defect; 2: normal uptake). The quality of tomographic myocardial 99mTc-MIBI and 99mTc-microspheres images was higher than that of 201TI tomograms in account of the different physical characteristics of the two radionuclides.(ABSTRACT TRUNCATED AT 250 WORDS)

Silent myocardial ischemia during ambulatory electrocardiographic monitoring in patients with effort angina.

The frequency and characteristics of asymptomatic ischemic attacks were investigated in 39 patients with effort angina. During 24 hour Holter monitoring, 32 of the 39 patients displayed one or more episodes of ischemic ST depression. Eight patients had attacks (n = 25) always accompanied by pain; 9 patients had only asymptomatic ischemic episodes (n = 40) and 15 patients had both symptomatic (n = 29) and asymptomatic attacks (n = 76). In the 15 patients exhibiting both symptomatic and asymptomatic attacks, mean duration of symptomatic episodes was longer (probability [p] less than 0.001) and mean maximal ST depression was greater (p less than 0.001). When patients exhibiting only symptomatic episodes were compared with those exhibiting only asymptomatic attacks, differences were not significant. All symptomatic and asymptomatic attacks during Holter monitoring were correlated with the results of stress testing: patients experiencing a delayed response to pain after the onset of St ischemic depression during stress testing had a higher ratio of asymptomatic to symptomatic attacks during Holter monitoring compared with those patients reporting pain before or at the moment of the appearance of ischemic electrocardiographic features during stress testing. It is concluded that: 1) asymptomatic episodes of ischemia are more frequent than symptomatic episodes in patients with effort angina; 2) in the same patient, the severity of ischemia is generally a fundamental factor in determining the presence or absence of pain during an ischemic attack; and 3) differences among patients with respect to predominance of symptomatic or asymptomatic attacks probably depend on individual factors.

[Ambulatory ECG monitoring in effort angina (author's transl)]. / Il monitoraggio ambulatoriale dell'elettrocardiogramma nell'angina da sforzo.

In 20 male subjects with effort angina, an ambulatory ECG monitoring (AEM) was registered and an exercise test was carried out immediately afterwards. Usual indications for termination of test have been modified to detect the temporal relationship between the appearance of ischemic ST changes and appearance of pain. During AEM 15 patients (pts) presented ischemic episodes with a total of 80 episodes, of which 46 were asymptomatic and 34 accompanied by pain. Among the ischemic episodes registered by AEM, the mean duration of asymptomatic episodes was less that of symptomatic ones. The same can be said for the mean entity of maximum ST depression. On the basis of the temporal relationship between the appearance of ischemic ECG features and pain during exercise test, we classified 4 groups of patients: 1) pts with an almost contemporary appearance of ST alterations and pain (5 pts); 2) pts where pain appeared with a delay variable between 10 and 30 sec (6 pts); 3) pts where pain appeared with a delay of more than 30 sec (4 pts); 4) pts with absence of pain (5 pts). In these pts the exercise test was stopped either because ST depression had reached 3 mm or because ST alterations persisted for 3' without pain. Comparing the responses of the exercise test with the data of AEM, a statistical relationship was found between patients from the different groups and the prevalence of asymptomatic or symptomatic episodes of ischemia. Asymptomatic ischemic episodes during AEM are more frequent in pts who during exercise test show ischemic ECG features without pain or in pts where pain appears with a noticeable delay in comparison to ECG ischemic alterations.