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Objective We tested the hypothesis that management of patients with syncope admitted urgently to a general hospital may be influenced by the presence of an in-hospital structured syncope unit. Background The management of syncope is not standardized. Methods We compared six hospitals equipped with a syncope unit organized inside the department of cardiology with six matched hospitals without such facilities. The study enroled all consecutive patients referred to the emergency room from 5 November 2001 to 7 December 2001 who were affected by transient loss of consciousness as their principal symptom. Results There were 279 patients in the syncope unit hospitals and 274 in the control hospitals. In the study group, 30 (11%) patients were referred to the syncope unit for evaluation. In the study group, 12% fewer patients were hospitalized (43 vs 49%, not significant) and 8% fewer tests were performed (3.3±2.2 vs 3.6±2.2 per patient, not significant). In particular, the study group patients underwent fewer basic laboratory tests (75 vs 86%, P =0.002), fewer brain-imaging examinations (17 vs 24%, P =0.05), fewer echocardiograms (11 vs 16%, P =0.04), more carotid sinus massage (13 vs 8%, P =0.03) and more tilt testing (8 vs 1%, P =0.000). In the study group, there was a +56% rate of final diagnosis of neurally mediated syncope (56 vs 36%, P =0.000). Conclusion Although only a minority of patients admitted as an emergency are referred to the syncope unit, overall management is substantially affected. It is speculated that the use of a standardized approach, such as that typically adopted in the syncope unit, is able to influence overall practice in the hospital.

The electrocardiographic patterns, observed during 24-h Holter monitoring, of 10 patients (mean age 35 +/- 22 years) with first and second degree A-V block due to dual A-V nodal pathways are reported. Recordings were selected according to the presence of: sudden and persistent prolongation of the PR interval: sudden normalization of the PR interval: 'atypical' Wenckebach sequences showing sudden and pronounced prolongation of any PR interval prior to the blocked P wave. Besides the already recognized pattern, new aspects were identified: (1) Wenckebach sequences in the slow and fast pathways characterized by a progressive increase in the PR interval until a blocked P wave occurred during long and short PR interval periods, respectively; (2) Wenckebach periods first in the slow and then in the fast pathway; (3) 2:1 A-V block with a normal PR interval in the conducted beat after a Wenckebach sequence in the slow pathway; (4) Wenckebach in the fast pathway and, subsequently, in the slow one characterized by a slight prolongation of the PR interval for some beats followed by a sudden and pronounced increase in the PR interval of one beat and a subsequent progressive slight PR prolongation until a blocked P wave occurred; (5) Wenckebach sequence in the fast pathway with subsequent conduction over the slow pathway without a blocked P wave; (6) blocked P waves during both long and short PR interval periods with slight prolongation of the preceding PR interval. The electrophysiological mechanisms involved in these electrocardiographic patterns together with the nature (anatomical or functional) of the intranodal pathways and the clinical significance of this type of block are discussed.

Beneficial effects of cardiac resynchronisation therapy (CRT), including reverse remodelling, improvement in ejection fraction, and decrease in mitral regurgitation as well as clinical improvements in exercise tolerance, quality of life, and hospitalisation rate, have been well documented [1–4], supporting the routine use of CRT as a worthwhile therapeutic option for patients with severe heart failure and left intraventricular conduction delay (QRS duration > 120 ms) who remain symptomatic despite receiving ‘optimal’ medical treatment. However, not all patients have subjective and/or objective responses to CRT [5, 6]. Given the complexity of the procedure and the associated costs, there is a need for parameters other than QRS duration that could prospectively identify the patients who would benefit most [7]. The beneficial effects of CRT are due to the fact that it corrects dyssynchrony resulting from interand intraventricular conduction delay, thus counteracting its negative haemodynamic effects. Left ventricular conduction delay induces a particular pathophysiological condition in which abrupt anterior septal motion, occurring at the time of decreasing right ventricular volume with pulmonary ejection [8], is associated with delayed contraction of the postero-lateral left ventricular wall. This condition increases wall stress during systole and oxygen demand. Moreover, the asynchrony between the septum and the lateral wall impairs the coaptation of mitral leaflets, thus favouring mitral regurgitation. Finally, tricuspid valve opening and right ventricular filling occur much earlier than mitral valve opening and left ventricular filling, thus contributing to early diastolic displacement of the septum into the left ventricle, a reduced septal contribution to ejection fraction

Fluid imbalance and malnutrition have an important role in the clinical setting of chronic heart failure (CHF). Recently, tetrapolar bioelectrical impedance analysis has been suggested as an attractive method which may be used in the clinical assessment of the body composition. The aim of this study was to determine the effects of body side on whole bioelectrical impedance analysis parameters and test-retest reliability, prior to its use in a large cohort of patients.In 114 consecutive patients with CHF (mean age 65 +/- 10 years, left ventricular ejection fraction 31 +/- 9%, NYHA functional class 2.6 +/- 0.9) we measured the total body resistance, the reactance and the derived angle phase using a single-frequency (50 KHz) tetrapolar plethysmograph device. The evaluations were performed on the left and right sides of the body, in a random order, on two different occasions 30 min apart. The effects of body side were analyzed by the Student's t-test and the test-retest reliability was computed by using the coefficient of variation and intraclass correlation coefficient.In both evaluations, the mean resistance value of the right side was significantly lower (almost 10 ohms) than that of the left side, the reactance was not different, and as a consequence the angle phase was significantly higher (almost 0.1 degrees) in the right than in the left side. The test-retest reliability for all the measurements considered was very high (the intraclass correlation coefficient ranged from 0.95 to 0.99 and the coefficient of variation from 1.7 to 4.3%).In CHF, the body side is important for the whole-body assessment of the resistance and the angle phase, but not for reactance. In addition, all these measurements are characterized by an excellent test-retest reliability and, consequently, do not necessitate a substantial increase in the sample size for the detection of small differences in experimental studies.

Dual-chamber atrio-ventricular synchronous pacing (DDD) has been shown in many studies to provide better hemodynamic parameter [1,2] and quality of life [3, 4] than VVI pacing in patients with A-V block. The complexity of implant procedures, the unreliability of some atrial leads, the extra time required for atrial lead fixation, the complexity of follow-up, the cost and the need for some patients to be programmed out of DDD created reluctance to implant dual-chamber pacemakers, and VVI pacing has been recommended as an acceptable treatment in the absence of retrograde conduction [5]. In order to avoid problems related to atrial leads, in patients with normal sinus node function and A-V block, newer single-lead systems with atrial dipoles have been shown to provide reliable atrial sensing and to ensure reliable AV synchrony in VDD mode [6, 7]. In patients implanted with this type of pacemaker it is important to know the real incidence of sinus node dysfunction over time. A low incidence would favor single-lead VDD systems, whereas a high incidence would make DDD or DDDR pacemaker systems more effective.

The electrophysiological properties of decremental atrioventricular and atriofascicular pathways are not completely understood. We report the case of a patient with fast reentrant tachycardia due to a decremental long atrioventricular pathway, who showed a slow automatic tachycardia arising from the same pathway that was successfully eliminated by radiofrequency catheter ablation.

Radiofrequency catheter ablation of accessory pathways may represent the treatment of choice for patients with symptomatic atrio-ventricular reentrant tachycardia or atrial fibrillation and a high ventricular response through the accessory pathways with short antegrade refractory period. Moreover, catheter ablation has contributed towards understanding anatomical and electrophysiological characteristics of accessory pathways. As far as anatomical characteristics accessory pathways may be classified into fibers with proximal insertion in right or left atrium and fibers with proximal insertion in the atrio-ventricular nodal junction. As far as electrophysiological properties are concerned, accessory pathways may be differentiated into non-decremental and decremental. In non-decremental by-pass tracts (the so-called Kent bundles) the impulse can be conducted antegradely, retrogradely and in both directions. Decremental accessory pathways generally show only antegrade conduction properties (the so-called Mahaim fibers) and can be classified in long and short pathways; in particular, catheter ablation has given considerable evidence that the vast majority (but not all) of them has a proximal insertion on the tricuspid anulus (atrio-ventricular pathways) or on the atrio-ventricular node (nodo-ventricular pathways). Decremental accessory pathways with only retrograde conduction properties are involved in the so called "Permanent Junctional Reciprocating Reentrant Tachycardia".

This is a multicenter, randomized, double-blind, placebo-controlled, cross-over and double-dummy study aimed at testing the efficacy and tolerability of two slow-release propafenone (Pr SR) preparations and compare them with the effect of instant release propafenone (Pr IR). The study was performed in 83 patients with frequent (30 premature ventricular contractions/hour) and stable (35% variability in two 24-hour ECG monitoring periods) symptomatic premature ventricular contractions. Patients were preliminarily studied in wash-out from antiarrhythmic drugs. After a period of placebo administration, all patients underwent three consecutive periods during which they received Pr IR at the dosage of 150 mg x 3, Pr SR at the dosage of 225 mg x 2, Pr SR at the dosage of 325 mg x 2. The periods lasted 10-14 days each and the sequence was randomly assigned. Twenty-four-hour ECG monitoring periods were obtained at the end of the placebo as well as at the last day of each treatment period. Treatment efficacy was evaluated by intention to treat analysis in 80 patients and by protocol in 61. Treatment was considered efficacious when premature ventricular contraction reductionor = 75%, couplet reductionor = 90% and non sustained ventricular tachycardias were completely suppressed. Pr IR 150 mg x 3 was efficacious in 42% of patients, Pr SR 325 mg x 2 in 45.9% and Pr SR 225 mg x 2 in 32%. Tolerability was considered good in the majority of patients. These results show that among the different types studied, Pr SR 325 mg x 2 should be considered the treatment of choice for premature ventricular contractions.

Sudden unexpected cardiac death is a common feature in the natural history of hypertrophic cardiomyopathy (HCM) and in some patients is the first clinical manifestation of the disease (1–4).

The aim of this study was to evaluate how heart rate variability changes during acute myocardial infarction (AMI) and whether this change is different in anterior and inferior AMI. For this purpose 10 patients with anterior (mean age 53 +/- 11 years) and 11 patients with inferior (mean age 55 +/- 11 years) AMI underwent 2 consecutive 24-hour Holter recordings (H1, H2) which started, at most, 6 hours after the onset of symptoms and a further two H at the 10th (H3), and 28th day (H4) of AMI. None of the patients suffered from diabetes or was taking beta-blockers. The standard deviation of the RR intervals (SDRR) for a 24-hour period was evaluated for each H in the group of patients with anterior and inferior AMI. In H1, SDRR was statistically lower in anterior compared to inferior AMI (64 +/- 20 versus 106 +/- 27; p0.0001). No statistically significant differences were found in H2 between the anterior and inferior AMI (72 +/- 19 versus 76 +/- 14), due to a reduction in SDRR in inferior AMI: from 106 +/- 27 in H1 to 76 +/- 14 in H2; p0.002. No statistically significant changes were present in anterior AMI patients between H1 and H2 (64 +/- 20 versus 72 +/- 19). SDRR recovers at H3 increasing in both groups (anterior: 101 +/- 28, p0.001; inferior: 108 +/- 29, p0.004). No further significant changes in SDRR were present at H4 for either group (anterior 117 +/- 30; inferior: 118 +/- 31).(ABSTRACT TRUNCATED AT 250 WORDS)

The Authors report an exceptional case of Atrophic Malignant Papulosis (P.A.M.) or Degos disease, presenting as acute abdomen with ileal and multiple colic perforations. The disease is due to an occlusive, progressive, thrombotic vascular pathology affecting different parts of the body and may bring to death. Usually this rare disease presents with typical multiple papulous skin lesions, followed by a systemic involvement of the digestive, nervous, and visive tracts. Peritonitis and cerebral infarction are the most frequent causes of death.

Electrophysiologic non-invasive transesophageal testing is compared to intracardiac study in the management of patients with Wolff-Parkinson-White (WPW) syndrome. Transesophageal study can be reliably used to identify the participation of the accessory pathway in reciprocating supraventricular tachycardia and to determine the anterograde conduction properties of the accessory pathway. Using the shortest pre-excited interval during induced atrial fibrillation, or programmed and continuous atrial transesophageal stimulation can markedly reduce the need of intracardiac evaluation. The greater safety and economy of transesophageal compared to the intracardiac technique justify its wider use in preliminary screening of all WPW patients, unless ablative treatment has been clinically indicated, and in evaluating long-term drug protection against a potential deleterious ventricular response during atrial tachyarrhythmias.

During recent years criteria for localization of bypass tracts in the Wolff-Parkinson-White syndrome from the conventional ECG have been acquired utilizing epicardial and endocardial mapping data. The polarity of delta wave and QRS in the frontal and horizontal plane and the morphology of retrograde P waves during orthodromic reciprocating tachycardia, are the most indicative elements. An accurate analysis of QRS complexes during atrial fibrillation confirms the site of pre-excitation and could suggest the presence of 2 or more accessory pathways with sufficient spatial separation. Some criteria for identifying multiple accessory pathways are discussed.

It has been shown that in patients with essential hypertension and cardiac hypertrophy Tissue Doppler Imaging (TDI) is able to detect impairment of diastolic function more accurately than pulsed transmitralic Doppler (TD). The aim of this study was to assess if, in hypertensive patients without cardiac hypertrophy, there are differences in diastolic function evaluated by using TDI or TD. We studied 17 patients (46±9 years, 11 male) with never treated essential hypertension. Echocardiographic evaluation was used to assess the following parameters: concentric remodelling (CR) pattern, defined as a normal left ventricular mass index with a relative wall thickness >0.45; global diastolic dysfunction (GDD), detected by correcting for age the TD flow early to atrial (E/A) ratio values; regional diastolic dysfunction (RDD) evaluated by TDI, with the sample volume positioned within the basal septum and defined according to the age-corrected tissue E/A ratio values. CR was found in 12 patients (70%); among these, 4 showed both GDD and RDD, while 5 patients showed only RDD. In the absence of CR, no patient showed either GDD or RDD. At Fisher test analysis, RDD was significantly associated with the presence of CR (p=0.019), whereas no significant association was found between CR and GDD. TDI showed a higher sensitivity in detecting diastolic dysfunction than TD (75% vs 33%) and a higher negative predictive value (63% vs 38%); both TDI and TD had a specificity and positive predictive value of 100%. In conclusion, in hypertensive patients with cardiac remodeling an abnormal regional diastolic function can be observed more frequently than a global diastolic dysfunction, thus suggesting that TDI is able to detect early impairment of diastolic function more accurately than pulsed transmitralic Doppler even in the absence of cardiac hypertrophy.

Background: Mitochondria is known to represent the main intracellular source of ROS. However, the role that the mitochondrial KATP (mKATP) channel could play in the oxidative stress during myocardial hypoxiareoxygenation remains unclear. Methods: Spontaneously beating hearts were dissected from 4-day-old chick embryos, mounted in vitro and submitted successively to 45 min normoxia (21% O2), 30 min anoxia (0% O2) and 60 min reoxygenation at 37°C. The time-course of ROS production in the ventricle was determined by measuring changes in fluorescence resulting from oxidation of the intracellular probe DCFH (10 μM) and expressed as arbitrary units per second (a.u./s). In order to determine the contribution of the mitochondria-derived ROS and its dependence on O2 concentration during reoxygenation, hearts were reoxygenated with 21% or 98% O2 in the absence (control) or in the presence of the complex III inhibitor myxothiazol (10μM). The involvement of the mKATP channel in ROS production has been assessed by using an opener (diazoxide, 50μM) or a blocker (5-hydroxydecanoate, 500 μM) of this channel. Results: In control hearts, ROS production was 0.18±0.04 (n=6) a.u./s under steady normoxia (mean±SD), was suppressed by anoxia and peaked after 9±3 min of reoxygenation, reaching 1.02±0.37 (n=6) and 1.63±0.34 (n=3) a.u./s with 21 and 98% O2, respectively (mean±SD). In myxothiazol-treated hearts, the peak of ROS at reoxygenation was reduced to 0.29±0.18 (n=3) and 0.41±0.08 (n=3) a.u./s with 21 and 98% O2, respectively. With respect to control, 5-hydroxydecanoate (n=5) and diazoxide (n=5) had no effect on DCFH signal measured under normoxia. By contrast, the peak of ROS production during the phase of reoxygenation was doubled by diazoxide (p