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Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational–retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82–89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25–87), with 73 patients (70%) reaching the invasive procedure

The service strategy (same-day transfer between the spoke hospital and the hub center with catheterization laboratory facility to perform invasive procedures) has been shown to improve the management of patients with non-ST-elevation acute coronary syndrome admitted to spoke hospitals. However, few data exist about the safety of this strategy and, in particular, the safety of retransferring patients to spoke centers immediately after successful percutaneous coronary intervention.We used data from a prospective registry to retrospectively describe the application, performance and outcome of the service strategy in the daily clinical practice in our province, organized in 5 spoke hospitals and a hub center in Reggio Emilia, Italy.From January 2013 to December 2017, 1183 consecutive patients were admitted to the cath-lab in the hub center from spoke hospitals with a diagnosis of non-ST-elevation acute coronary syndrome. Mean age was 68 ± 12 years, with a mean GRACE risk score of 137 ± 3. Overall, 1063 patients (90%) were managed with a service strategy. The mean time between hospital admission and access to the cath-lab for coronary artery angiography ± percutaneous coronary intervention was 46.6 h (27.5-71.2). No major adverse events (all-cause mortality, arrhythmias, or acute myocardial infarction) were observed during the back transfer from the invasive center to the referring non-invasive center. At 30 days, acute myocardial infarction was observed in 1.3% of patients and all-cause mortality was 0.5%. At 1-year follow-up, acute myocardial infarction was reported in 10% of patients and all-cause mortality was 2.8%.A wide adoption of the service strategy in our provincial network in patients with non-ST-elevation acute coronary syndrome admitted to spoke centers allowed an early access to the cath-lab as recommended by international guidelines. The safety of the service strategy is confirmed in our experience, with no major adverse events occurring during the back transfer.

The purpose of the study described here was to prospectively evaluate the significance of embolization of the spleen in patients with definite left-sided infective endocarditis (IE) using contrast-enhanced ultrasound (CEUS). From March through October 2012, 6 consecutive patients (4 females and 2 males, aged 27 to 83 years) with definite left-sided IE according to the revised Duke criteria were enrolled. All patients gave informed written consent, and the study was performed in conformity with the ethical guidelines of the Declaration of Helsinki. All patients underwent CEUS of the spleen within 1 week of the definite diagnosis of IE. A blood pool second-generation contrast agent and an ultrasound machine with contrast harmonic imaging technology were used for CEUS. Fifteen consecutive patients (7 females and 8 males, aged 39 to 88 years) who underwent CEUS from October through November 2012 for the study of focal liver lesions constituted the control group. The number of patients did not permit statistical analysis. Splenic CEUS revealed infarctions in 5 patients and an infarcted area in the only patient with negative echocardiography. All splenic CEUS procedures in the control group were negative. In this study, CEUS of the spleen, a repeatable and low-cost imaging technique, easily allowed bedside detection of asymptomatic and even tiny infarctions, and revealed a high rate of embolization in patients with definite left-sided IE. Indeed, splenic CEUS, if applied to the workup of patients with suspect IE, has the potential to accelerate or upgrade the diagnosis itself.

Abstract —Eight Na-repleted volunteers underwent 3 separate 90-minute infusions of either N G -nitro- l -arginine methyl ester (L-NAME) 3.0 mg · kg −1 · min −1 or endothelin-A receptor (ET-A) blocker BQ-123 (BQ) 0.125 nmol · kg −1 · min −1 or both. Mean arterial pressure (MAP), glomerular filtration rate (GFR), renal blood flow (RBF), renal vascular resistances (RVR), and sodium excretion rate (UNaV) were measured at baseline (b) and from 0 to 45 minutes (period 1) and 45 to 90 minutes (period 2) of infusion. BQ alone had no effect. GFR declined by 4.9% ( P P P P P =NS between L-NAME and L-NAME plus BQ). UNaV fell equally with L-NAME or L-NAME plus BQ. MAP rose significantly in period 2 with L-NAME (6.9%; P P =NA versus b, P =0.005 versus L-NAME alone). RBF declined by 12.2% ( P P P P P P P P

In order to study the relationship between the long term renal haemodynamic effects of calcium antagonists and hypertensive renal damage, 8 patients with mild to moderate essential hypertension (6 males and 2 females, aged 19 to 60 years) underwent measurement of 24-hour microalbuminuria (urinary albumin excretion), mean blood pressure, effective renal plasma flow (para-aminohippuric acid clearance) and glomerular filtration rate (inulin clearance) before and after 12 to 16 months’ treatment with amlodipine 10mg once daily. Mean blood pressure fell from 125 ± 7mm Hg at baseline to 101 ± 3mm Hg during treatment with amlodipine (p < 0.001). Effective renal plasma flow did not change (633 ± 51 ml/min · 1.73m2 to 626 ± 46 ml/min · 1.73m2), while renal vascular resistance decreased from 8.5 ± 0.6 dyn · sec · cm−5 to 7.0 ± 0.4 dyn · sec · cm−5 (p = 0.01). Glomerular filtration rate rose significantly (109 ± 7 ml/min · 1.73m2 at baseline to 122 ± 4 ml/min · 1.73m2, p < 0.02 after amlodipine treatment) and urinary albumin excretion decreased from 17.4 ± 4.2 mg/24h to 7.2 ± 1.5 mg/24h (p < 0.05). Our findings show that long term treatment with amlodipine is followed by sustained renal vasodilation, an increase in glomerular filtration rate and, consequently, an increase in filtration fraction. However, despite the long term increase in glomerular filtration, urinary albumin excretion falls substantially. We suggest that long term renal protection afforded by amlodipine may occur independently of its effects on glomerular haemodynamics.

background In-hospital administration of flecainide and propafenone in a single oral loading dose has been shown to be effective and superior to placebo in terminating atrial fibrillation. We evaluated the feasibility and the safety of self-administered oral loading of flecainide and propafenone in terminating atrial fibrillation of recent onset outside the hospital. methods We administered either flecainide or propafenone orally to restore sinus rhythm in 268 patients with mild heart disease or none who came to the emergency room with atrial fibrillation of recent onset that was hemodynamically well tolerated. Of these patients, 58 (22 percent) were excluded from the study because of treatment failure or side effects. Out-of-hospital self-administration of flecainide or propafenone — the “pill-in-thepocket” approach — after the onset of heart palpitations was evaluated in the remaining 210 patients (mean age [±SD], 59±11 years). results During a mean follow-up of 15±5 months, 165 patients (79 percent) had a total of 618 episodes of arrhythmia; of those episodes, 569 (92 percent) were treated 36±93 minutes after the onset of symptoms. Treatment was successful in 534 episodes (94 percent); the time to resolution of symptoms was 113±84 minutes. Among the 165 patients with recurrences, the drug was effective during all the arrhythmic episodes in 139 patients (84 percent). Adverse effects were reported during one or more arrhythmic episodes by 12 patients (7 percent), including atrial flutter at a rapid ventricular rate in 1 patient and noncardiac side effects in 11 patients. The numbers of monthly visits to the emergency room and hospitalizations were significantly lower during follow-up than during the year before the target episode (P

Spongy or noncompacted myocardium is a rare congenital cardiomyopathy characterized by parietal myocardial structural alterations secondary to intrauterine arrest of myocardial fiber compaction. It can be associated with other congenital cardiovascular malformations or manifest as an isolated disease. It is characterized by a wide variety of clinical presentations that range from complete absence of symptoms to thromboembolic manifestations, ventricular arrhythmias and congestive heart failure; the short- and mid-term prognosis is quite severe. We here describe a casual finding of an advanced form of noncompacted myocardium associated with patent ductus arteriosus in a young asymptomatic athlete during a routine visit for agonistic sports eligibility. Although the patient had a normal functional capacity, transthoracic echocardiography showed left ventricular dilation with a moderately depressed contractile function and the presence of numerous prominent trabeculae and deep intertrabecular recesses which communicated with the left ventricular cavity. These findings which were confirmed by further echocardiographic examinations, and the absence of other cardiovascular disorders associated with this disease, led us to the diagnosis of noncompacted myocardium. The patient was not allowed to perform sports activities and underwent percutaneous closure of the patient ductus arteriosus. He was asymptomatic and because in the recent literature there are no data regarding pharmacological therapy in these patients, the subject was submitted to routine clinical follow-up evaluation with no medical therapy.

Imbalances in central and peripheral sympathetic nervous system (SNS) activity have been observed in essential and experimental hypertension. This study was carried out in order to evaluate SNS activity in two distinct tissue types of spontaneously hypertensive rats (SHR), compared to Wistar-Kyoto normotensive (WKY) rats, in the pre-hypertensive phase (4-5 weeks of age). Interstitial concentrations of norepinephrine (NE) and other catecholamines were measured by microdialysis in striated muscle, whose tone is controlled by baroreflexes, and in the subcutaneous adipose tissue where sympathetic output mainly controls metabolism. Two groups of SHR and WKY male rats were studied, aged 4-5 weeks, with a mean body weight of 92 and 86 g respectively. Systolic blood pressure (SBP, tail-cuff) values were 113 mm Hg (SD +/- 6.2) in SHR and 108 mm Hg (SD +/- 7.3) in WKY rats (p=0.28,t test). Two microdialysis probes were positioned in the subcutaneous fatty tissue and in the striated muscle of the parascapular region and perfused with Ringers' solution. The dialysate was collected every thirty minutes for 3 hours and analyzed in HPLC-ED to determine the content of NE and other catecholamines. Interstitial levels of NE were higher in SH than in WKY rats in both tissues. Mean NE values from subcutaneous adipose tissue in 4-5 week-old SHR were 1162 +/- 193 pg/ml compared to 496 + 188 pg/ml in WKY rats (p

BACKGROUND A major source of error in the longitudinal assessment of the intima-media thickness (IMT) is the difficulty in retrieving the same echographic view of the vessel. OBJECTIVE To present a method for increasing the reproducibility of IMT measurements by ultrasound in large arteries. METHOD The Fourier descriptor is a well-known means of describing an object's shape. By means of the discrete Fourier transform (DFT), the shape was represented in a frequency domain; the computational advantages of the DFT then permitted a measure of unlikeness between different shapes (the 'distance' measure; DM) to be defined and used as a criterion for reproducing the contour. When the sonographer compared successive images of a complex vascular segment, like the carotid bifurcation, the identity of the echographic cut was deduced from the identity of the vessel's contour. The best match of the baseline image was the view that minimized the contour DM. RESULTS Preliminary studies in the carotid artery bifurcations of eight subjects showed that the DM responds to systematic variations in the ultrasound interrogation angle and reveals minimal changes in transducer position. Duplicate scans of 12 subjects were performed by three sonographers with different strategies for acquisition of the same images: a low DM was associated with a low difference in pairs of IMT measurements. Data were classified into two groups (normal or borderline vessels with a pooled mean IMT of 0.62 mm and overtly thickened segments with a pooled mean IMT of 1.31 mm). When minimization of the DM was the criterion for the acquisition of replicate scans, the mean absolute difference of paired data for the mean IMT of the distal common carotid artery was 0.03 +/- 0.02 mm for the first group and 0.06 +/- 0.03 mm for the second group. This is a significant reduction in comparison with non-quantitative alternative criteria for image reproduction. For the maximum IMT of the same segments the mean absolute differences were 0.07 +/- 0.03 and 0.13 +/- 0.06 mm in the first and second groups, respectively. CONCLUSION This method can be applied to the serial assessment of single atherosclerotic segments. The computational time is negligible. By reducing the scatter in sequential IMT data, longitudinal investigations (e.g. of the results of antihypertensive therapy) with shorter durations and smaller sample groups may be rendered feasible.