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Hospitalization of patients with heart failure is often caused by poor adherence to drug therapy, by suboptimal utilization of ACE inhibitors and beta-blockers, and by the lack of systematic monitoring of patients after discharge. The aim of the study is to verify the impact of an outpatient management program on the hospitalization rate and functional status of patients with chronic heart failure. Over a five-year period, 435 patients entered our outpatient management program, which includes adjustment in medical therapy, patient education and visits timed according to the patient's status. Fifty-six percent of the patients were in New York Heart functional class I-II; 74% were male; mean age was 62 +/- 11 years. Heart failure was due to coronary heart disease in 42%, dilated cardiomyopathy in 35%, hypertensive heart disease in 13%, other etiologies in 10%. The following changes in medical therapy were made compared to the period before referral: ACE inhibitors in 88% of the patients vs 70% (p < 0.05), mean dose of enalapril and captopril respectively 18 +/- 6 mg vs 11 +/- 4 mg (p < 0.05) and 89 +/- 28 mg vs 61 +/- 34 mg (p < 0.05); digoxin in 71 vs 70% (NS); furosemide in 90 vs 87%; beta-blockers in 16 vs 6% (p < 0.05); amiodarone in 24 vs 16% (p < 0.05); oral anticoagulants in 22 vs 12% (p < 0.05); calcium channel blockers in 10 vs 16% (p < 0.05). During the follow-up period (35 +/- 11 months), there were 111 hospital admissions compared to 518 during the year before recruitment (p < 0.05). Seventy-two patients died (65 for cardiac causes) and four patients underwent cardiac transplantation. Functional status improved (301 patients in I-II functional class and 56 in III-IV after referral compared to 225 and 132 before referral, respectively). Our results were obtained through adjustment in pharmacological therapy, intensive patient education and therapeutic continuity made possible by our outpatient heart-failure clinic organization. It is likely that the increase in costs due to therapeutic adjustment and to the increase in the number of visits is counterbalanced by the reduced rate of hospital admissions.

Three patients affected by dilated cardiomyopathy complicated by refractory ventricular tachycardia, with a high risk of sudden cardiac death, underwent transcatheter electric fulguration. The technique was applied transeptally, using the terminals of two catheter electrodes as cathode and anode. These were placed at the right and left ventricular apex, at septal level where the "critical" arrhythmia point had been identified by endocardial mapping. All patients had previously experienced more than one episode of cardiac arrest and had successfully taken several antiarrhythmic drugs. All patients presented variable morphology of ventricular tachycardia (whether spontaneous or induced). In all of them clinical tachycardia was considered as having a left bundle branch block morphology with an earlier activation at low septal level. After treatment, antiarrhythmic therapy (amiodarone 200 mg/day) was continued for all patients, although at a lower dose than before fulguration. One patient has been free from sustained ventricular tachycardia for more than two years after fulguration. In the other patients we observed an early and late arrhythmic recurrence (respectively within 1 and 8 months following fulguration) in spite of antiarrhythmic therapy. The second patient presented no further recurrence after permanent pacemaker implantation. The third patient showed an arrhythmic recurrence, with a different morphology from the previous one, concomitantly with a septic process. This technique does not appear dangerous and may be used, in highly specialized centres, on carefully selected patients as a therapeutic approach after pharmacological therapy and before automatic defibrillator implantation or surgical antiarrhythmic intervention.

Myocardial scintigraphy shows to have diagnostic ability after latest proposal to use Thallium-201. Thus we verified its iconographic effectiveness in 10 normal subjects and 25 patients with myocardial infarction variously localized. In both groups we obtained adequate and expressive results: the former showed omogeneous images and continuous outlines, whereas the latter showed "cold areas" in agreement with the localization provided by electrocardiography. The further utilization of myocardial imaging with Thallium-201 in 2 patients with prior infarction, in whom present ecg is equivocal, provided scintigraphic evidence of prior necrotic lesion. This emphasizes diagnostic sensitivity of myocardial scintigraphy with Thallium-201 encouraging its use in those patients in whom electrocardiography is not able to give its usual diagnostic contribution.