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

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.

Transient left ventricular apical ballooning is a quite rare clinical event mostly described in the Japanese population. It is also known as tako-tsubo-like syndrome due to the peculiar shape on endsystolic left ventriculogram which is like a tako-tsubo, an ancient device used for trapping octopuses in the Japanese sea. The clinical features of this cardiomyopathy, which mimicked an acute coronary syndrome in an Italian 78-year-old man, are described. Acute left ventricular dysfunction with the typical left ventriculogram and normal epicardial coronary arteries followed an acute emotional and physical stress: the patient felt off his boat, while lifted well up above the water of a great Italian lake during routinary servicing, with consequent chest and head traumas. The combination of emotional and physical stress with the dive in the lake cold water could have caused a brisk and marked increase in catecholamines with possible direct myocardial injury. The occurrence of a rare case of a Japanese cardiomyopathy, also mentioned by a device used in sea-fishing, in an Italian patient following an accidental dive in a lake, appears at least peculiar.

Background: The safety of pulmonary artery catheterization has been questioned. We report our experience on the incidence of complications in a large series of patients requiring cardiac operations by evaluating the learning curve of the operators.

Methods: Since 1988 at our Institution a pulmonary artery catheter (PAC) register records the following data from each patient: type of surgical procedure, insertion site of the venous introducer, type of PAC used, final position of the catheter, and complications associated with central venous access and those determined by PAC positioning and stay. During 16 years (from April 1988 to April 2004) 9071 PACs were registered.

Results: Complications associated with the access to the central venous pool consisted of carotid arterial puncture in 191 patients (2.1%) and pneumothorax in 4 patients (0.04%). Complications associated with PAC positioning consisted of runs of ventricular ectopic beats (> 6 s) in 62 patients (0.68%), atrial fibrillation in 2 patients (0.022%), complete atrioventricular block in 2 patients (0.022%), ventricular fibrillation in 1 patient (0.011%), nodal rhythm in 6 patients (0.066%), perforation of the right ventricular wall in 1 patient (0.011%), hematoma of the right ventricular wall in 2 patients (0.022%), anonymous vein lesion in 2 patients (0.022%), and pulmonary artery rupture in 2 patients (0.022%).

Conclusions: Pulmonary artery catheterization performed by experienced team appears to be a safe procedure in cardiac surgery patients.

Depressed mood and other depressive symptoms frequently appear after acute myocardial infarction and it is known how these patients have an increased risk for morbidity and mortality compared to patients without depression. Many risk factors promote the development of clinical depression in patients with recent myocardial infarction. Although a large number of studies underline the negative prognostic impact of depression on the infarcted patient, only rarely depressed patients are appropriately diagnosed and treated. Furthermore it should be borne in mind that the use of psychotropics in medically ill patients requires attention. These compounds, in fact, may interact with the disease causing several complications. In addition since the cardiologic patient is often treated with other drugs, the risk of clinically significant pharmacological interactions is obviously improved. It seems appropriate to give some considerations about therapy and management of the infarcted patient with depression.

Background: Reperfusion therapy of ST-elevation myocardial infarction (STEMI) with primary coronary angioplasty (PTCA) is becoming an accepted therapeutical strategy because of a lower incidence of reinfarction, of hemorrhagic stroke and for a greater reduction of the infarct size in comparison to thrombolytic therapy. In this study we evaluated the feasibility and the effectiveness of such a strategy in two hospitals without on-site heart surgery but with a high volume of admission for acute coronary syndrome and a high caseload of elective interventional procedures.

Methods: Since January 2001 we started a program of primary PTCA for all STEMI patients presenting within 12 hours of symptom onset. An interventional team (physician, nurse and technician) were on call in a 24/7/365 fashion. Aspirin, heparin and abciximab were administered in the emergency room to all patients. Immediately after the procedure patients were given clopidogrel.

Results: Up to December 2003, 464 patients (mean age 63 +/- 12 years, 19.8% female) underwent primary PTCA. The symptom-emergency room interval was 3 +/- 3.9 hours, while the door-to-balloon time was 52.5 +/- 39.4 min. A TIMI 0-1 flow in the infarct-related artery was present in 55.8% of patients. Seventy patients (15.1%) presented with shock. In 430 patients (92.7%) a TIMI 3 flow was restored followed by a reduction in ST-segment elevation > 50% in 356 patients (76.7%). Total in-hospital mortality was 4.9% (23 out of 464 patients). The mortality of patients with shock was 31.4% (22 out of 70 patients). Two patients (0.4%) underwent emergency bypass. Four patients (0.8%) were electively referred to surgery prior to discharge in order to complete revascularization, which could not be obtained with further PTCA. The rate of major hemorrhagic complications was 0.8%.

Conclusions: Primary PTCA for STEMI is a reperfusion strategy feasible and effective even in hospitals without on-site heart surgery, provided that a high volume of routine and emergency interventional procedures is maintained and when such a strategy is timely performed according to international guidelines.

Background: QT dispersion (QTd) is the difference between the maximum and the minimum QT interval in the 12-lead ECG. There is currently no information on the relationship between QTd and creatine kinase (CK)-MB release in patients undergoing percutaneous coronary intervention (PCI).

Methods: Among 118 patients undergoing successful PCI stenting, QTd and corrected QTd (QTdc) were measured at standard 12-lead ECG before PCI and at 6 and 18 hours after PCI. The median of QTdc variation (deltaQTdc = baseline QTdc - QTdc at 6 hours) was 9.5 ms (range -48 / +89 ms). Patients were divided into two groups according to deltaQTdc: group A "recoverers" (deltaQTdc > 9.5 ms, n = 59, 50%), group B "non-recoverers" (deltaQTdc < 9.5 ms, n = 59, 50%). CK-MB release was compared in the two groups.

Results: Eighty-three percent of patients were male, with mean age of 62 years (range 41-80 years). Unstable angina was present in 35% of cases, with similar distribution in the two groups. PCI was performed in 1.94 lesions/patient with the implantation of 1.6 stent/patient. Compared to baseline, a reduction in both QTc and QTdc was documented at 6 and 18 hours after PCI (p < 0.05). Periprocedural variations (CK-MB > 2 upper limit of normal) was detected in 4 patients (7%) of group A and 12 patients (20%) in group B (p = 0.06). Peak CK-MB release was significantly lower in group A (13 +/- 14.3 IU/l) compared to group B (23.2 +/- 35 IU/l, p < 0.05).

Conclusions: After successful coronary stenting there is a rapid normalization of QTd and QTdc. The lack of recovery of both QTd and QTdc is related to minor elevations of CK-MB and may therefore be further explored as a useful non-invasive marker of heterogeneous reperfusion after PCI.

Background: Octogenarians are the fastest growing segment of our population and show a high prevalence of coronary disease. Despite these trends they are underrepresented in randomized controlled trials on acute coronary syndromes. Although older patients with acute coronary syndromes are at increased risk of death or reinfarction, they are less likely to be treated with an aggressive strategy.

Methods: In a retrospective analysis, we evaluated 176 consecutive octogenarians admitted to our Division of Cardiology with non-ST-elevation acute coronary syndrome, the causes of their exclusion from cardiac catheterization, and in particular the impact of associated comorbid conditions.

Results: Demographic characteristics, left ventricular ejection fraction and medical therapy were comparable in the groups of patients treated with a conservative or aggressive strategy. Cardiovascular risk factors and the TIMI risk score were similarly distributed between the two groups. The most important cause of exclusion from coronary angiography was the presence of comorbidity (77% of patients of this group). In order to assess the total comorbidity burden, we applied the Charlson comorbidity index to this group and found that 32% of patients excluded from aggressive strategy did not show a so severe associate disorder complexity.

Conclusions: The use of a validated index to measure associated disorders is advisable in our clinical practice to properly assess illness severity, in order to not deny an interventional procedure which could improve the quality of life of the oldest patients.

Orthostatic hypotension is associated with significant morbidity and mortality in elderly patients. In orthostatic hypotension caused by central and peripheral nervous system disorders (neurogenic orthostatic hypotension), the release of catecholamine in the standing posture is insufficient to compensate adequately for decreased venous return to the heart. Primary autonomic failure exhibits, often, supine hypertension, that can be worsened by pressor agents, such as midodrine, used to prevent syncope episodes. Salt-retaining steroid fludrocortisone, also, used to treat orthostatic hypotension, increases blood pressure both in supine and in standing position. We describe 3 patients with neurogenic orthostatic hypotension caused by pure autonomic failure. They complained of several syncope episodes. On examination, orthostatic hypotension and supine hypertension were detected in the absence of pharmacological therapy. All the patients presented hypertensive organ disease. Fludrocortisone acetate was started in one patient, and short-acting vasopressor agents during the day and dihydropyridine-calcium antagonist during the night in the other two. During the follow-up a transient ischemic attack occurred in the patient treated with fludrocortisone. When fludrocortisone was titrated down and short-acting antihypertensive drugs were started, the patient did not complain of any symptoms. Supine hypertension is part of pure autonomic failure, and short-acting antihypertensive agents should be associated with vasopressor agents to prevent hypertensive target organ disease.