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The implantable cardioverter defibrillator (ICD) is today an indisputable evidence-based treatment for cardiac sudden death both in primary and secondary prevention. However many clinical conditions that would represent an indication to ICD implantation, according to guidelines, may be potentially reversible or may be accompanied by temporary contraindications to the implant. Moreover transvenous cardioverter defibrillator implantation still carries a not negligible risk of complications both acutely and at follow-up. The Wearable Cardioverter Defibrillator and the Subcutaneous Defibrillator are two recently developed technologies that can potentially overcome the aforementioned limitations of traditional transvenous ICDs. This review will discuss the main aspects of these 2 technologies, the data coming from clinical experiences and future perspectives.

Background: Aim of the study was to evaluate the prognostic and decision making value of Holter detected myocardial ischemia after acute myocardial infarction in comparison with clinically detected postinfarction angina and exercise test., Methods: To this aim the patients consecutively admitted to our coronary care unit with acute myocardial infarction during one year were retrospectively evaluated. One hundred and eighty-nine patients (age 70+/-11 years, 137 male and 51 female) had a 24 hour Holter monitoring. One-year follow up of these patients was obtained., Results: Myocardial ischemia was detected by Holter monitoring in 21 patients (11%), 4 with and 17 without angina. Symptom limited exercise test was obtained before discharge in 116 patients (62%): 45% were positive, 42% non-diagnostic and 13 negative for myocardial ischemia. Post infarction angina was present in 15 patients (9%). Patients with Holter detected myocardial ischemia were older (73+/-10 vs 66+/-11 years, p<0.05) and had higher prevalence of both angina and positive exercise test (p<0.01). One-year follow up was obtained in 186 patients. Holter detected myocardial ischemia positive predictive value for death or reinfarction was 15%, negative predictive value was 90%, similar to the absence of angina (90%) and the absence of positive exercise test (93%). Angina and exercise test identified 62% of patients with Holter detected myocardial ischemia. Residual myocardial ischemia was exclusively observed by Holter monitoring in 4% of the population, particularly in 1 patients with and 7 without exercise test., Conclusions: The additive contribution of Holter detected myocardial ischemia in the prognosis and decision making of post infarction patients is rather scanty.

Background: Morphological and functional changes induced by aging can hamper a clear distinction between pathological or paraphysiological phenomena in very old people. The incidence of hyperkinetic ventricular arrhythmias, for example, progressively increases in the elderly, even in the absence of overt cardiac disease., Methods: One-hundred fifty-two clinically stable patients older than 80 years, submitted within 15 days to clinical evaluation, 24-hour continuous ambulatory ECG monitoring and echo Doppler examination, in the absence of antiarrhythmic treatment, were retrospectively selected in order to evaluate the incidence of ventricular arrhythmias, in patients with and without significant heart disease. The further aim of the study was to correlate the number of arrhythmias with left ventricular morphological and functional parameters, echocardiographically assessed. From the initial population, 80 patients (41 males, age 83 +/- 3 years) had significant heart disease (ischemic, hypertensive or valvular): Group I. Seventy-two patients (30 males, age 83 +/- 3 years) had no clinical or instrumental signs of heart disease: Group II., Results: Considering echocardiographic data, Group I patients had a significantly higher left ventricular end-diastolic diameter (52 +/- 6 mm vs 47 +/- 4 mm, p < 0.01), lower ejection fraction (57 +/- 10% vs 64 +/- 6%, p < 0.01) and higher mass (275 +/- 84 g vs 208 +/- 46 g, p < 0.01), when compared with Group II. From ECG monitoring data, significant differences between the two groups were recorded in the incidence of premature ventricular beats per hour (79 +/- 163 vs 15 +/- 34, Group I vs Group II, p < 0.01) and presence of complex phenomena (couplets, triplets and runs: 51% vs 22%, p < 0.01). In old patients with documented cardiac disease a significant correlation was present between premature ventricular beats incidence and left ventricular end diastolic diameter (r = 0.39, p < 0.05) and left ventricular ejection fraction (r = 0.40, p < 0.05), while in patients without heart disease, no significant correlation was found between incidence of premature ventricular beats and echocardiographic morpho-functional parameters., Conclusions: In conclusion, hyperkinetic ventricular arrhythmias are globally frequent in old persons of very advanced age (more than 80 years), but, also in this subset, a significant distinction in terms of incidence and severity of arrhythmias is present between subjects with and without cardiac disease. A significant correlation between incidence of premature beats and non-invasive morpho-functional left ventricular parameters is present only for patients with overt heart disease.

Flecainide and propafenone are antiarrhythmic drugs of the class 1C (Vaughan and Williams) commonly used for ventricular arrhythmias. The purpose of the present study was to evaluate the efficacy of these drugs in 170 consecutive patients with ventricular arrhythmias who referred to our cardiological ambulatory. The study population was divided into two groups according to the absence (group A,82 patients) or presence of organic heart disease (group 1B: 51 patients with left ventricular ejection fraction (LVEF) >35%; group 2B: 37 patients with LVEF<35%). Ventricular arrhythmias were evaluated with a 48 hours Holter monitoring at baseline, and with a control 24 hours Holter monitoring at 15 days (for optimizing the dosage), at 5 months and at 10 months from the beginning of antiarrhythmic therapy. Patients of group A were randomly assigned to antiarrhythmic treatment (flecainide 150-300 mg/die or propafenone 450-900 mg/die). For patients of group B, such choice was leaded by the clinical and strumental data (32 patients were treated with flecainide, 56 patients with propafenone). In the 160 patients who ended the 10 months follow-up, we observed the following results: patients of group A showed a mean percentage reduction in incidence of premature ventricular complexes (PVC) after therapy in comparison to basal conditions of 93% and 89% with flecainide and propafenone, respectively, after a treatment of 5 months (p < 0.001); after 10 months mean percentage reduction of PVC was 91% with each drug (p = n.s.); complex ventricular events (CVE) were reduced of 90% and of 100% after 5 and 10 months, respectively, of treatment with flecainide and of 100% both after 5 and 10 months of treatment with propafenone (p = n.s.) -- patients of group 1B showed a mean percentage reduction of PVC of 87% and 84% after 5 and 10 months, respectiively, of treatment with propafenone (p = n.s.); after 5 months of therapy mean percentage CVE reduction was 66% with flecainide and 86% with propafenone (p < 0.001); after 10 months this mean reduction was 53% with flecainide and 73% with propafenone (p < 0.001). -- patients of group 2B showed a mean reduction of PVC of 59% and 58% after 5 and 10 months of therapy with flecainide, and of 65% and 67% after 5 and 10 months of therapy with propafenone (p = n.s.); CVE were reduced of 28% with flecainide and of 47% with propafenone after 5 months of treatment (p < 0.001) and of 36% with flecainide against 52% with propafenone after 10 months (p < 0.01). In the present study there was no significant difference between the two drugs in terms of tollerance and collateral effects (8% with flecainide vs 7%, with propafenone). Our results confirm the efficacy of the 1C class drugs in the treatment of "essential" ventricular arrhytmias. This efficacy appears reduced in non selected patients with organic heart disease. In these latter patients propafenone has shown more efficacy than flecainide in reducing CVE.