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

Background: Complications due to undetectable coronary artery disease are the major causes of morbidity and mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The aim of our study was to evaluate the importance of significant coronary artery disease identification and the impact of coronary revascularization on early and late outcomes after surgical repair of AAA.

Methods: Between January 1994 and July 2004, 210 patients (204 males and 6 females, mean age 68 +/- 12 years) were candidates to elective surgical repair of AAA. Coronary angiography was performed in 122 patients (58%) in presence of angina symptoms, previous myocardial infarction, echocardiographic or scinti-scan evidence of myocardial ischemia. Coronary revascularization was performed in 83 patients (39.5%). The population was divided into two groups: coronary artery bypass graft/coronary angioplasty (CABG/PTCA) + AAA group (83 patients submitted to CABG surgery [n = 61], or PTCA [n = 22], for significant coronary artery disease before surgical repair of AAA), AAA group (127 patients without significant coronary artery disease, operated for AAA). Follow-up (90% complete) had a mean duration of 42 +/- 23 months.

Results: CABG/PTCA + AAA group compared to AAA group presented major symptoms of angina (p = 0.001), higher incidence of previous myocardial infarction (67 vs 10%, p < 0.0001), lower mean value of left ventricular ejection fraction (50 vs 54%, p = 0.01). Operative mortality was 0.95%, and was not related to any cardiac morbidity: operative mortality was observed in the AAA group (2 patients died of anossic cerebral damage and respiratory failure) and was absent in the CABG/PTCA + AAA group (p = 0.8). The overall 8-year survival in the AAA group and in the CABG/PTCA + AAA group was 80 +/- 11 vs 95 +/- 2.8%, respectively (p = 0.7). Freedom from cardiac late death and freedom from cardiac events (recurrence of angina, myocardial infarction, congestive heart failure) were high in both groups (93 +/- 6.4 vs 97 +/- 2.3%, p = 0.6; and 91 +/- 6.6 vs 89 +/- 6.7%, p = 0.5, respectively). In the CABG/PTCA + AAA group symptoms for angina (p = 0.0002) and dyspnea (p < 0.0001) significantly improved during the follow-up.

Conclusions: Significant coronary artery disease was not negligible (39.5%) in patients candidates to surgical repair of AAA. Identification and correction of coronary artery disease prior to AAA surgery is the most important strategy to reduce the risk of vascular procedure. The beneficial impact of coronary revascularization on early and late outcomes is evident, in terms of satisfactory survival and freedom from cardiac adverse events. Therefore, coronary angiography is strongly suggested to optimize early and long-term results.

Background: Psychological disturbances like anxiety, depression, post-traumatic stress disorder are often associated with coronary artery disease and, in some studies, play a prognostic role after a coronary event. Despite some psychological disturbances following coronary artery bypass graft (CABG) have an impact on outcomes of both the surgical intervention and the rehabilitation program, their complexity as well as their clinical and instrumental determinants are still not fully understood. The aim of this study was to determine in male subjects with coronary artery disease the prevalence and complexity of psychological disturbances occurring after CABG as well as their predictors.

Methods: One hundred eighteen males without history of psychological disturbances consecutively admitted to our rehabilitation inpatient service between September 2002 and September 2003 underwent 11 +/- 2 days after CABG extensive psychometric testing including the Minnesota Multiphasic Personality Inventory-2, the Cognitive Behavioral Assessment.2, and the Hamilton test. Cardiac evaluation included coronary risk factors, NYHA class, coronary heart disease history, medical therapy, CABG number, and echocardiography.

Results: Mean age 63.7 +/- 8.1 years; ejection fraction 54.6 +/- 10.3%; NYHA class I 92.4%, NYHA class II and III 7.6%; CABG number 1 (11%), 2 (23.7%), 3 (39.8%), 4 (21.8%), 5 (4.2%); coronary artery disease length 64 +/- 85 months, hospital stay 31.3 +/- 8 days. The score was above clinical cut-off on scale for depression in 16-39.8% of the patients, state anxiety in 27.1%, trauma in 16.1%, type A personality in 16.1%. Subjects above clinical cut-off for depression, anxiety and trauma did not differ from subjects below in terms of clinical and instrumental characteristics. Age, ejection fraction, coronary risk factors, coronary heart disease duration, and CABG number did not predict the development of depression, anxiety and trauma. Psychological disturbances often clustered in the same subjects.

Conclusions: In males following CABG, psychological disturbances are extremely frequent, often clustered, and independent of subjects' characteristics and coronary heart disease severity.

In patients with not very frequent episodes of atrial fibrillation (AF), highly symptomatic for palpitation, hemodynamically well tolerated but long enough to require emergency room (ER) intervention, the best outpatient treatment appears to be the "pill-in-the-pocket" approach. In several studies, in-hospital administration of flecainide or propafenone in a single oral loading dose has been shown to be effective and superior to placebo in terminating recent-onset AF. Recently, a multicenter Italian study has been carried out to evaluate the feasibility and the safety of self-administered oral loading of flecainide or propafenone in terminating AF of recent onset outside the hospital. Either flecainide or propafenone were administered orally to restore sinus rhythm in 268 patients with mild heart disease or none, who came to the ER with AF of recent onset that was hemodynamically well tolerated. Of these patients, 21% were excluded from the study because of treatment failure or side effects. During a mean follow-up of 15 months, 94% of the arrhythmic episodes were interrupted by the oral loading of flecainide or propafenone; the mean time to resolution of symptoms was about 2 hours. Adverse effects were reported during one or more arrhythmic episodes by 7% of the patients, including atrial flutter at a rapid ventricular rate in 1 patient. The numbers of monthly visits to the ER and hospitalizations were 90% lower during follow-up than the year before enrollment. These results show that in a selected, risk-stratified population of patients with recurrent AF, the "pill-in-the-pocket" treatment is feasible and safe, with a high rate of compliance by patients, a low rate of adverse effects, and a marked reduction in ER visits. Some recommendations on the practical use of this type of treatment are given.

Experimental, clinical and epidemiological researches have shown the incontestable causal relationship between low high-density lipoprotein (HDL) plasma concentrations and cardiovascular pathology on an atherosclerotic basis. Low HDL levels characterize about 10% of the general population and they represent the most frequent dyslipidemia in patients with coronary artery disease. Reduced HDL concentrations would be unable to effectively eliminate the cholesterol excess at the vascular wall, contributing to the inflammatory phenomena that characterize the pathogenesis of atherosclerosis since its initial phases. Results of numerous studies reasonably allow to suppose that HDL are able to exert, also directly, anti-inflammatory actions through the modulation of expression of diverse acute phase proteins. Although the today available therapeutic options aiming to increase HDL levels still show a modest effectiveness, in the experimental and pre-clinical field, the results of genetic investigations and pharmacological interventions have given more encouraging results, making nearer the possibility of treating this pathology concrete.

The aim of this statistical note, the fourth in the series, is to describe and critically appraise the randomized controlled clinical trial (RCCT) GUSTO V, which combined in a single RCCT both the superiority and non-inferiority hypotheses. In this note we present the logical path that the authors have presumably followed in planning a RCCT of such a kind. The results are reported and possible critical aspects are highlighted and debated upon. Finally the cardiologist reader is stimulated to give his own opinion on this kind of approach.

Background: One of the most utilized systems for risk stratification in cardiac surgery is the EuroSCORE. It considers some risk factors that should influence the surgical risk. The aim of this study was to evaluate if our results, related to isolated coronary artery bypass surgery, are well predictable by this system and which are the parameters statistically significant for hospital mortality.

Methods: From January 1, 2002 to April 30, 2004, 724 patients underwent isolated myocardial revascularization. All risk factors considered for the EuroSCORE system evaluation and the EuroSCORE value itself were analyzed to assess their significance to predict surgical risk. Univariate statistical analysis was performed with the Student's t-test for quantitative variables and the chi2 in contingency tables for categorical variables. Logistic regression was used for multivariate analysis.

Results: Cumulative operative mortality was 3.7% (27 patients). The EuroSCORE value, age, critical preoperative state, emergency and low ejection fraction were all statistically significant risk factors for hospital mortality. Multivariate analysis excluded only the critical preoperative state. The analysis of contingency tables showed that the surgical risk was statistically significant above the age of 75 years. The same analysis revealed that the mortality rate was statistically different in the three groups and it showed that the system could over-estimate mortality at lower EuroSCOREs and under-estimate mortality at higher EuroSCOREs.

Conclusions: This study confirms the value of the EuroSCORE for risk stratification in this group of patients. The most important parameters considered for its calculation confirmed their predictive value. This model allows a reliable quality control of our surgical practice.

The decision to treat an elderly patient with massive pulmonary embolism with thrombolytic therapy is not easy due to the risk for hemorrhagic complications, increasing for each incremental year of age. We report the case of a 92-year-old male, referred to the emergency department after recurrence of syncopal episodes. Echocardiography proved to be very useful to make diagnosis of massive pulmonary embolism. Thrombolytic therapy with tenecteplase was successful and resulted in early thrombus resolution and hemodynamic stability, with no major complications.

Coronary angioplasty, eventually followed by stent implantation, represents the gold standard of acute myocardial infarction (AMI) treatment. Optimal reperfusion implies both patency of the infarct-related artery and a good myocardial microrevascularization with normal tissue reperfusion. The so called no-reflow phenomenon mainly occurs in the presence of highly thrombotic lesions, especially during primary angioplasty and it represents a negative prognostic factor of the outcome of AMI patients treated with angioplasty. A 77-year-old high-risk male patient, previous coronary artery bypass graft with the saphenous vein graft to the left anterior descending coronary artery for post-AMI angina in 1984, aided by 118 ambulance for anterior AMI was admitted to our cath-lab for primary coronary angioplasty. During the transport he was given aspirin i.v. 300 mg, heparin 5000 IU and abciximab (9.4 ml bolus plus infusion for 12 hours). The time of treatment (from symptom onset to first inflation) was about 90 min. Coronary angiography showed a massive thrombus occlusion of the vein graft with TIMI 0 distal flow. We employed the Export Catheter for mechanical aspiration of the occluding thrombus. The procedure was completed with direct stent implantation with good angiographic outcome. The use of thrombus aspiration and protection devices (filters or occlusive balloons) associated or not with the use of glycoprotein IIb/IIIa receptor blockers, has reduced the risk of distal embolization and of no-reflow phenomenon.

Background: Most of the studies on the identification of cardiovascular risk factors have been conducted either in northern Europe or in the United States. However, genetic as well as dietary factors may vary across different countries and geographical areas and there are few data about the cardiovascular risk profile in our country.

Methods: A sample of 3144 subjects (1463 males, 1681 females aged 35-74 years) were randomly selected among the population qualifying for healthcare assistance, registered with 170 general practitioners. Demographic data, clinical information, lab tests and current pharmacological treatments were collected using an electronic case report form.

Results: The prevalences of cardiovascular risk factors in the population were: smoking habit 22.7%, obesity 12.8%, hypertension 39.2%, hypercholesterolemia 25.5%, hyperglycemia and diabetes 5.5%. Thirty-five point four percent of the subjects presented a low absolute 10-year cardiovascular risk level (< 5%), 31.1% an intermediate risk (5-9%), 24.9% a moderate risk (10-19%), and 8.6% a high risk (> or = 20%) of developing cardiovascular diseases.

Conclusions: In the area of Verona approximately 20,000 out of 231,592 subjects, aged 35-74 years, may present an absolute 10-year cardiovascular risk level > or = 20%. These results represent the epidemiological basis for planning and implementing preventive interventions toward cardiovascular diseases.