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Polymyalgia rheumatica (PMR) is an inflammatory disorder that affects people over 50 years of age, characterized by pain and stiffness in the neck and shoulder and pelvic girdles. PMR may occur as an isolated condition or concomitantly with giant cell arteritis. Similar to other inflammatory rheumatic disorders, PMR is associated with an increased cardiovascular risk due to inflammatory changes in large arterial vessels, which result in an increased chance of developing aneurysms and dissections. International guidelines do not provide specific indications about the management of PMR patients with aortic wall inflammation. In this review, we propose a diagnostic pathway for the management of PMR patients with aortic involvement based on literature data and personal experience.

Atrial fibrillation is the most common arrhythmia in clinical practice. Although postoperative atrial fibrillation occurs in a small percentage of the total number of cases, it is associated with increased mortality, longer hospital stay and higher hospitalization costs, making this issue of particular relevance. The aim of this literature review is to describe the risk profile of this patient subset and to focus on the current knowledge of available prophylactic and therapeutic strategies.

Acute myocardial infarction is a rare but potential life-threatening complication of pregnancy. Its incidence is increasing because of the enlargement of the reproductive age. Treatment needs to be urgent because of the very high mortality rate. The aim of this literature review is to provide a better understanding of the available diagnostic modalities and interventional and pharmacological treatment options in the management of pregnant patients with acute myocardial infarction in order to improve the overall care provision and ensure both maternal and fetal well-being.

In the last years, both the increase in percutaneous coronary revascularization and the instance of more reliable and individualized treatments have led interventional cardiologists to seek for a valuable adjunct to angiography in order to improve assessment and treatment of atherosclerotic coronary disease. Intravascular ultrasound (IVUS) allows precise tomographic measurement of lumen area, plaque size, and, to some extent, composition, with low risks and affordable costs. It is not yet clear whether routine use of IVUS provides a middle-to-long-term benefit in prevention of recurrent cardiovascular events. This review reports the main studies on IVUS imaging, underlining impact of ultrasound in the development of contemporary percutaneous revascularization techniques.

The occlusion of a patent foramen ovale (PFO) is one of the most promising and controversial issues of interventional cardiology, with an increasing number of procedures, indications and scientific publications. Although this procedure is considered relatively feasible and efficacious, complications may occur, and the balance between risks and benefits is not always favorable. Data on long-term safety and efficacy are also lacking. From cryptogenic stroke in young patients, indications for occlusion have been extended to include patients with drug-refractory migraine. In this setting, the prevalence of PFO is higher than in the general population, suggesting a possible pathogenetic role. Pathophysiology of this condition and evidence to support occlusion of PFO are incomplete, but a trend towards improving has been reported in many retrospective studies. The only randomized study for migraine benefits in PFO occlusion (MIST) has failed to show a reduction in frequency and intensity of attacks. Selection criteria for patients who will most probably benefit from occlusion are needed. The aim of this brief analysis is to focus the pathophysiological and diagnostic issues on migraine, evaluate their relation with PFO, and review studies to outline percutaneous closure indications.

We report a case of left atrial myxoma presenting as acute respiratory failure following surgical intervention for voluntary interruption of pregnancy. After cardiac surgery T-wave changes were observed on the ECG, most likely due to coronary embolism.

Aims: Cardiac resynchronization therapy is currently used in selected patients with end-stage heart failure. However, 30% of patients do not respond to CRT. The aim of our study was to find echocardiographic (TDI), electrocardiographic (QRS interval and electric distance between right and left catheter), clinical (6MW test) or autonomical (HRV) parameters able to predict responsiveness to CRT., Materials and Methods: 47 patients (mean age 74+/-10 years) with end-stage heart failure, symptomatic, with left ventricular (LV) ejection fraction less than 35% and QRS 120 ms, underwent CRT., Results: At thirteen months follow up, all clinical and echocardiographic parameters significantly improves (EF p<0.001; LVED volume p<0.001; 6MWT p<0.001; max delay TDI p<0.001; HRV p<0.05; Right-left distance p<0.05). A positive response was documented in 31/47 (67.4%) patients who presented an increase in LVEF > or = 5 units. There was a significant difference of LVED diameter (p<0.05) and HRV (p<0.05) between responders and non responders. Receiver-operating curve analysis showed that a positive response to CRT may be predicted in patients with LVED diameter <67 mm (with a sensitivity of 77% and a specificity of 88%)., Conclusions: Our results confirm the clinical improvement obtained by CRT in end-stage heart failure patients as well as the limited value of QRS duration and intraventricular dyssynchrony as predictor of clinical recovery after CRT. While a most-advanced clinical stage of disease (HRV) without an advance left ventricular remodeling (LVED diameter) demonstrated to predict response to CRT, with sensitivity of 77% and specificity of 88%.

Outcome in palliative care can be defined as patients' quality of life, quality of death and satisfaction with care. In an Italian multicentre prospectic study ('Staging') the quality of life of 571 palliative care patients with advanced cancer disease was assessed since the beginning of palliative care till the end of the study. We analyzed the tissue of quality of life missing data and the possibility to input the missing quality of life evaluation through the quality of life evaluation made by a proxy (doctor, nurse). The greatest functional impairment and an increasing level of some symptoms (fatigue, general malaise, emotional status) were observed during the last two weeks of life, whereas for other symptoms (gastro-intestinal, pain) some degree of control was possible. The quality of life analysis for palliative care patients should consider the different response of different quality of life components to the palliative care intervention.

Patients with unstable angina fall into a wide prognostic and therapeutic spectrum but, in general, have great access to specialty care and invasive procedures. In the modern era, in which admissions for unstable angina outnumber those for myocardial infarction, and growing economic pressures are placed on health care systems, cardiologists must re-examine clinical strategies for treating unstable angina in the light of health-cost accounting. The aims of the present study were to examine the current management of patients admitted to our cardiology department and to calculate the medical costs. A patient schedule was drawn up to prospectively register the number and type of cardiac processes carried out during hospitalization for all unstable angina patients in the period between March 1st and May 30th, 1995. Time (minutes) actually spent by both physicians and nurses for each cardiac process were carefully recorded in order to calculate the activity budget. The effective economic budget was built for each cardiac process taking into account salaries, consumable supplies, equipment service contracts, depreciation and indirect medical and non medical costs for CCU and ward. Based to the Diagnosis Related Groups (DRG) system, 53 out of 318 patients (16%) were admitted with documented or suspected unstable angina and allocated to discharge into four DRGs: DRG 140-medically treated unstable angina: 18 patients; DRG 124-unstable angina with angiography: 16 patients; DRG 122-unstable angina evolving in myocardial infarction: 6 patients; DRG 112-unstable angina with angioplasty: 13 patients. The mean cost for hospitalized patient with unstable angina was 5,574,958 Italian Liras (DRG 140 = 2,687,719; DRG 124 = 2,800,347; DRG 122 = 6,086,563; DRG 112 = 12,751,454). The difference in costs was essentially related to the procedures involved in medical care, DRGs with expensive cardiac processes having higher costs. Furthermore, these data show a deep discrepancy between "real" costs and current DRG reimbursement. In conclusion, data show the standard management of unstable angina at our center; calculating the true costs of unstable angina is the first step towards maximizing resources and optimizing benefits.

The cost of diagnostic and therapeutic procedures in patients with acute myocardial infarction (AMI) during hospitalization was determined using both the Diagnosis Related Group (DRG) and Process Related Group (PRG) systems. This cost-analysis system was planned and performed to estimate the cost of medical and non-medical staff involved in patient care, as well as commensurate costs. Over a three-month period, 45 patients discharged with a diagnosis of AMI, equivalent to 410 code ICD-9-CM, were enrolled in the study. The collected data were then processed and the cost for each DRG was derived. The mean cost borne for each patient with AMI was 5,864,345 Italian lire with a maximum of 17,138,300 lire for DRG 112 and a minimum of 3,332,329 lire for DRG 123. Our data suggest that in patients with AMI, there is profound discrepancy between the current DRG reimbursements and "real" cost, for example in DRG 112 (a discrepancy equivalent to 166%). The cost difference is essentially related to different procedures involved in medical care and, therefore, it follows that the overall cost of patient with AMI is primarily related to PRG cost and is largely independent of other components. These results prove that therapeutic strategies are very important in determining the cost for each DRG and that the cost for each DRG can change in relation to the PRG performed and to the progression of illness. The utilization of DRG and PRG systems appears to be an essential tool that can be used to build a system in which not only efficiency but also quality of care are evaluated.

A large body of evidence has been accumulating that insulin plays a role in coronary heart disease (CHD). Hyperinsulinemia has been considered a risk factor for CHD according to prospective studies. Cross-sectional studies found an association between hyperinsulinemia and prevalence of CHD, while population studies have shown that populations at increased risk for CHD are hyperinsulinemic. Strong relations between hyperinsulinemia and atherosclerotic coronary lesions have been demonstrated by angiographic studies. It has recently been observed that also patients with microvascular angina are hyperinsulinemic. Several mechanisms have been proposed to explain the role of hyperinsulinemia in the development of atherothrombosis. Hyperinsulinemia is the consequence of insulin resistance, a defect in insulin-mediated glucose uptake. Experimental evidence suggests that insulin has actions that may promote atherosclerosis, which clinical studies suggest the existence of a metabolic syndrome characterized by the presence of major coronary risk factors in which insulin resistance is the common link.

It is clearly settled that the management of overt heart failure offers poor prognostic impact due to the advanced setting of the disease. Relief of symptoms, objective benefits, as testified by short-term hemodynamic improvements, are as a matter of fact not reliable prognostic markers. Myocardial dysfunction starts early in the natural history of many cardiac diseases, and runs through the steps of progressive wall remodeling, witnessed by quantitative and qualitative changes in cells, interstitium and connective tissue. Experimental studies offered keys to interventions modulated to oppose the pathophysiological changes present in early myocardial dysfunction. At present, medical therapy has made great strides in testing early myocardial dysfunction. Angiotensin-converting enzyme inhibitors, which retard ventricular dilatation and thus may lower myocardial oxygen consumption requirements seem to offer a unique prognostic profile. Preliminary pilot studies on them and some of many large-scale multicentre trials still in progress reached evidence that this class of drugs is by this time a cornerstone of medical therapy, useful to lower cardiac events-rate in patients with heart failure.

The decision to treat hypercholesterolemia must take into account both the risk of death and myocardial infarction and the risk/benefit ratio of treatment. Nowadays there is convincing evidence that hypercholesterolemia in patients with previous myocardial infarction is an important prognostic factor: furthermore, the excess of risk due to cholesterol is consistently higher than that in the general population. Prospective studies demonstrated that cholesterol lowering treatment obtained either with diet or drugs can improve survival and quality of life in postinfarction patients. Experimental, clinical and angiographic studies suggested that cholesterol lowering therapy can produce both stabilization and regression of the atherosclerotic plaque. In view of this, the evaluation of cholesterol level must be part of the general work-up of patients with previous myocardial infarction. The satisfactory results obtained with diet suggest to try a dietary treatment in post-infarction patients with high cholesterol level before using drugs. Since there are no clear-cut upper values, the end point of treatment should be to lower cholesterol levels to the values recommended for the general population, although we believe that threshold values to be obtained in these subjects should be lower than those requested in primary prevention.

We tested the safety and the usefulness of intravenous fibrinolysis in 44 patients with refractory unstable angina, defined as persistence of ischemic episodes during 48-hour Holter monitoring (phase 1) despite maximal medical therapy. After fibrinolysis, recurrence of ischemia was recorded during 1 week of observation in CCU including 2 24-hour Holter monitoring at the beginning and at the end of this week (phase 2): 17 patients completed the observation period without either symptomatic or asymptomatic ischemic episodes (Group A); the remaining 27 patients continued to manifest ischemia (Group B). No bleeding complications occurred. Within a 6-month follow-up, 2 patients of Group A had recurrence of unstable angina while in Group B, 10 patients underwent CABG or PTCA for refractory angina, 6 other patients with refractory angina continued medical therapy, 1 patient had a myocardial infarction and 2 patients died (p less than 0.001). Phase 1: the duration of total ischemia (min/24 hours) was a relevant prognostic marker: higher duration correlated with adverse clinical outcome (p less than 0.01). Phase 2: in comparison with phase 1, duration of total ischemia was significantly reduced (p less than 0.001). A percent value expressing this variation was calculated for each patient: (min of ischemia in phase 2 - min of ischemia in phase 1/min of ischemia in phase 1). The variation thus obtained again gave information on the clinical outcome: the greater was the reduction, the lower was the risk of cardiac events (p less than 0.001). Our data suggest that: clinical stabilization may be obtained with the addition of fibrinolysis to conventional treatment; Holter monitoring bears prognostic information helpful in identifying patients who need further intervention.