Italian heart journal : official journal of the Italian Federation of Cardiology最新文献

Background: The aim of this study was to compare the outcomes of carotid endarterectomy (CEA) in the current practice of our department of vascular surgery with international benchmarks.

Methods: In-patient data from 488 CEA performed in both symptomatic 145 (29.7%) and asymptomatic 343 (70.3%) patients with a > or = 60% stenosis at the level of the internal carotid artery. Comprehensive retrospective review of the records for all the CEAs performed during a 2-year period. The main outcome measures were death rate, and fatal and non-fatal stroke rates perioperatively, and at 30 and 180 days.

Results: The fatal and non-fatal stroke rates of symptomatic patients were: 0.7% perioperatively, 0.7% at 30 days, and 0.7% at 180 days. The fatal and non-fatal stroke rates of asymptomatic patients were: 0.6% perioperatively, 0.6% at 30 days, and 0.3% at 180 days. The death rates of symptomatic patients were 0% for all time periods. The death rates of asymptomatic patients were: 0% perioperatively, 0% at 30 days, and 0.3% at 180 days.

Conclusions: The present comprehensive audit shows that our surgeons achieve CEA outcomes comparable with international benchmarks.

Background: Evidence of a lack of relationship between psychiatric disorders and physical status during a heart transplantation (HT) program would configure mental well-being as an independent endpoint deserving specific interventions.

Methods: We report a prospective, longitudinal study on patients (n=127) undergoing HT in order to investigate the relationship between psychiatric disorders and physical status.

Results: At pre-HT evaluation, at least one psychiatric disorder according to the DSM-IV diagnoses was present in 27 patients (21%); the prevalence of psychiatric disorders was not related (p > or = 0.150) to physical status (assessed by clinical, electrocardiographic, echocardiographic, and hemodynamic parameters). At post-HT evaluation 1 year after HT, all clinical-instrumental parameters significantly improved (p < or = 0.016), but not the prevalence of psychiatric disorders, which were diagnosed in 34 patients (p = 0.016 vs pre-HT).

Conclusions: During the HT program, no significant relationship exists between physical status and prevalence of psychiatric disorders, which increases after the operation. This finding indicates the need for the mandatory provision of adequate psychological support during all of the phases of the HT experience.

We present an evidence-based diagnostic and therapeutic pathway for the treatment of subjects with suspected acute elevated ST-segment myocardial infarction (STEMI). The pathway was developed to aid the reorganization of the emergency service (ES) of the Lazio Region of Italy. Pathway development followed several phases: a) setting up of a multidisciplinary panel comprising all professional figures involved in the management of STEMI subjects; b) drafting of a list of important research questions with a particular focus on areas of clinical and organization uncertainty; c) systematic searches for relevant international scientific evidence to answer research questions; d) assessment, synthesis and classification of identified evidence according to the quality of evidence; e) formulation of management recommendations by their strength according to the methods used by the national guidelines program; f) presentation of draft findings and recommendations; g) external peer review of the draft document; h) editing the final version of the document. Our document identifies possible action scenarios (community, emergency room, major accident and emergency departments) and the following critical points: 1) quick diagnosis and individual risk definition; 2) rapid transmission of the electrocardiogram and vital parameters to the ES control center or to the competent coronary care unit (CCU) depending on where the event took place; 3) a direct link between the ES control center and the competent CCU; 4) the structuring of the regional CCU into a Hub & Spoke model; 5) electronic communication of data between ambulance, ES control center and the competent CCU. Our document also defines Hub regional reference centers and local Spoke centers. The pathway details roles and responsibilities of all players in the emergency chain for STEMI sufferers and critical points for the delivery of the pathway: regional programs on early warning, functions of relevant ES personnel and of emergency room physicians, efficiency of the electronic network and identification and organization of the regional Hub & Spoke network.

Background: On May 2003 the Emilia-Romagna Regional Commission for Cardiology and Cardiac Surgery launched a project aimed at improving health service ability to adopt interventions of well-known effectiveness for the treatment of patients with acute myocardial infarction. One of the main goals was to stimulate the clinical and organizational responsibilities operating at the local level, in order to improve the frequency of use of primary percutaneous coronary intervention.

Methods: In assessing the overall impact of this regional project, an interrupted time series regression analysis was conducted, relying on information drawn from the regional hospital discharge database. Overall, 18 957 patients admitted for acute myocardial infarction during the period January 2001-June 2004 were considered.

Results: One year after the inception of the regional project, the estimate of its effect documented a statistically significant increase in the frequency of use of percutaneous coronary angioplasty (5.8%, 95% confidence interval 4.6%-6.9%), paralleled by an increase (3.2%, 95% confidence interval 1.14%-5.0%) in the number of those directly admitted to centers with interventional cardiology facilities. No effect was observed as for the proportion of patients admitted to highly specialized departments.

Conclusions: Despite the obvious limitations due both to source of information and study design, our findings document that the regional project had indeed some tangible impact, although variable across the different geographic areas of the region, on key aspects of the patterns of care of patients with acute myocardial infarction.

The use of angiotensin-converting enzyme (ACE) inhibitors early after acute myocardial infarction has been demonstrated to be useful for the primary prevention of ventricular remodeling. This treatment has also shown significant and early beneficial effects on mortality, whereas the observed effect in terms of prevention of absolute volume increase was definitely small, and mainly in large infarcts. These results suggest that other effects of ACE-inhibition could contribute to the observed improvement in clinical endpoints. All this has increased the interest in pathophysiologic studies on cardiac remodeling, like the GISSI-3 Echo Substudy, which has shown the complexity and heterogeneity of the phenomenon. In this context comorbidity and mortality are increasing with age, but information on remodeling in the elderly with preserved ventricular function is still lacking. Post-infarction patients > 65 years of age with preserved ventricular function (ejection fraction > 40% by echocardiography) have then been randomized into the Perindopril and Remodelling in the Elderly with Acute Myocardial Infarction (PREAMI) trial. Although mortality and hospitalization for congestive heart failure were not affected significantly by 1-year 8 mg/day of perindopril treatment, a significant beneficial treatment-related effect was observed on left ventricular remodeling. These results suggest the great need for analyzing the heterogeneity of remodeling in the context of different populations with myocardial infarction. This could lead to more individualized and aggressive diagnostic, prognostic and therapeutic approaches even in patients at low risk with a small myocardial infarction.

Background: L-arginine in addition to cardioplegia stimulates the release of nitric oxide and increases coronary blood flow, decreasing platelet activation and leukocyte adhesion. The aim of our study was to determine the feasibility and the efficacy of the addition of L-arginine to antegrade and retrograde blood cardioplegia in reducing myocardial damage and stress.

Methods: Twenty-eight consecutive patients who underwent coronary artery bypass grafting were randomized to receive 7.5 g of L-arginine in 500 ml of cardioplegic solution. To assess safety of use of L-arginine, hemodynamic evaluation was performed before sternum opening, at sternum closure, and 1 hour after arrival in the intensive care unit to measure cardiac index, systemic and pulmonary vascular resistances, and pulmonary capillary wedge pressure. Moreover, transesophageal echocardiography was performed to assess myocardial contractility. To determine the effects on myocardial stress, blood samples were taken from the retrograde coronary sinus catheter for lactate, interleukin (IL)-2 receptor, IL-6 and tumor necrosis factor (TNF)-alpha levels. Serum samples (preoperatively, 2, 18 and 42 hours after aortic cross-clamping removal) were also analyzed to measure creatine phosphokinase, creatine kinase-MB mass, cardiac troponin T, platelets, and leukocytes.

Results: We found statistical differences for IL-2 receptor, IL-6, TNF-alpha, platelets and leukocytes, in favor of the treated group, and decreasing trends in creatine kinase-MB mass and troponin T levels.

Conclusions: The present study shows the positive effects of the addition of L-arginine to cardioplegia. Reduced IL-2 receptor, IL-6 and TNF-alpha indicate a decrease in myocardial stress. Safety of Larginine is related to lower values of systemic vascular resistances and pulmonary capillary wedge pressure observed in group A postoperatively that could improve the patient's outcome in terms of a reduced need for inotropic support. Moreover, the decrease in platelet and leukocyte count in the treated group might express a reduced no-reflow phenomenon and a better reperfusion, limiting endothelial injury from oxygen radical production.