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The ability of different dobutamine-induced wall motion patterns to define the anatomic status of the infarct-related artery (IRA) was evaluated in 159 patients who underwent dobutamine stress echocardiography (DSE) and coronary angiography 10 +/- 2 and 18 +/- 3 days, respectively, after hospital admission. The DSE result was classified as: (1) biphasic: improvement with a low dose followed by deterioration with a high dose; (2) worsening: direct deterioration at low or high doses; (3) sustained improvement: improvement with a low dose that was maintained at high dose; and (4) no change: no change during the entire protocol. A diameter narrowing >70% (50% for the left main stem) of major coronary arteries indicated a severe lesion. Angiograms were classified according to the jeopardy score and collateral circulation graded according to Rentrop's classification. DSE was positive in 92 patients (22 had biphasic results and 70 had worsening results) and negative in 67 patients (14 had sustained improvement and 53 had no changes). Biphasic response was associated with more frequent anterior infarction (p <0.05) and higher resting (p <0.001) and peak (p <0.01) wall motion score indexes. The IRA was totally occluded in 4 of the 92 patients (4%) with positive (worsening pattern) and 12 of the 67 patients (18%) with negative (no change pattern) tests. The biphasic pattern was associated with the highest jeopardy score and was significantly (p <0.05) more specific (100%) compared with worsening (78%) in identifying a severe stenosis of the IRA. The combination of ischemic patterns provided a significantly superior sensitivity (p <0.0001). Logistic regression analysis identified the biphasic pattern as the only significant predictor. Conversely, the prediction of total occlusion of the IRA was poor. Sustained improvement was the most specific (100%) predictor of absence of severe stenosis of the IRA, whereas the combination with no change pattern provided a significantly superior sensitivity (p <0.0001). Thus, DSE effectively predicts the residual stenosis of the IRA. In particular, the biphasic response has an excellent specificity and positive predictive value and is the only significant predictor among clinical and echocardiographic variables. [ABSTRACT FROM AUTHOR]

Concomitant presence of atrial fibrillation and coronary artery disease requiring percutaneous coronary intervention is a frequent occurrence. The choice of optimal antithrombotic therapy, in this context, is still challenging. To offer the best protection both in terms of stroke and stent thrombosis, triple therapy with oral anticoagulation and dual antiplatelet therapy would be required. Several drug combinations have been tested in recent years, including direct oral anticoagulants, with the aim of balancing ischemic and bleeding risk. Both pharmacokinetic aspects of the molecules and patient's characteristics should be analyzed in choosing oral anticoagulation. Then, as suggested by guidelines, triple therapy should start with a seven-day duration and the aim to prolong to thirty days in high thrombotic risk patients. Dual therapy should follow to reach twelve months after coronary intervention. Even not fully discussed by the guidelines, in order to balance ischemic and bleeding risk it should also be considered: 1) integrated assessment of coronary artery disease and procedural complexity of coronary intervention; 2) appropriateness to maintain the anticoagulant drug dosage indicated in technical data sheet; the lack of data on the suspension of antiplatelet drugs one year after percutaneous intervention; 3) the possibility of combination therapy with ticagrelor; and 4) the need to treat the occurrence of paroxysmal atrial fibrillation during acute coronary syndrome. With data provided clinician should pursue a therapy as personalized as possible, both in terms of drug choice and treatment duration, in order to balance ischemic and bleeding risk.

Erdheim-Chester disease (ECD) is a rare multisystemic disorder of non-Langerhans histiocytic cells with a pleomorphic clinical presentation. It affects bones, skin, central nervous system, pituitary gland, ocular tissue, kidneys and perirenal tissue and lungs. Cardiac involvement presents usually with pericardial effusion and right atrial masses, but rarely with conduction system infiltration and subsequent arrhythmic events. Following the discovery of mutations of activating signaling kinase proteins (BRAF, MEK, ALK), the therapeutic landscape has changed to a more precise targeted treatment. Currently vemurafenib is approved for patient with end-organ dysfunction and BRAF-V600E mutation and the prognosis has dramatically improved. Here we present a case of ECD with electrical instability as main clinically relevant manifestation of cardiac involvement., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Anterior ST segment elevation myocardial infarction (A-STEMI) has the worst prognosis among all infarct sites due to larger infarct size and the higher cardiac enzyme release. We retrospectively analyzed 584 A-STEMI undergoing urgent coronary angiography from October 2008 to April 2019. The median follow-up time was 1774 days with a minimum of a 1-year follow-up for 498 patients. In-hospital mortality was 8.6%, while long-term, all-cause mortality and 1-year mortality were 18.8% and 6.8%, respectively. The main predictors for in-hospital mortality were ejection fraction (LV-EF), baseline estimated glomerular filtration rate (eGFR), female gender and cardiogenic shock (CS) at admission, while long-term predictors of mortality were age, coronary artery disease (CAD) extension and LV-EF. Patients presenting with CS (6.5%) showed a higher mortality rate (in-hospital 68.4%, long term 41.7%). Among 245 patients (42%) with multivessel disease (MVD), complete revascularization (CR) during the index procedure was performed in 42.8% of patients and more often in patients with CS at admission (19.1% vs. 6.1%, p = 0.008). Short- and long-term mortality were not significantly influenced by the revascularization strategy (CR/culprit only). Our study confirmed the extreme fragility of A-STEMI patients, especially in case of CS at admission. LV-EF is a powerful predictor of a poor outcome. In MVD, CR during p-PCI did not show any advantage for either long- or short-term mortality compared to the culprit-only strategy.

Background: Heavy calcified lesions can decrease effectiveness of drug eluted stents in preventing restenosis. Rotational atherectomy (RA) demonstrated to improve outcomes in patients with severely calcified lesions pretreated with debulking. However, its feasibility and its safety are continuously on stage. Our aim has been to identify predictors of clinical and procedural outcome in RA., Methods: We retrospectively analyzed a population of patients referred to our cath lab for urgent or elective coronary catheterization treated with RA. The associations between clinical variables and clinical or procedural events were evaluated using logistic regression. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) from procedure date to last day of follow-up. MACE have been defined as follows: cardiovascular death, heart failure hospitalization and target lesion revascularization., Results: The registry included 68 of the 1908 (3.6%) patients that underwent percutaneous coronary intervention. Procedural success was as high as 94% and more than 90% of cases were treated without any complication. The most common complication during PCI with RA was vessel dissection (8.8%) and no procedural death occurred. None of the clinical nor procedural characteristics were associated with burr entrapment or vascular access hematoma. We identified as independent predictor of treated vessel dissection the female sex (OR 16.9, 95% CI 1.55-183.77, P<0.05). Logistic regression revealed age (OR 1.17, 95% CI: 1.02-1.33, P<0.02) as the only independent predictor of MACE. We therefore calculated the ROC curve on age in predicting MACE, that showed a C-statistics of 0.75 (95% CI 0.628 to 0.852, P=0.02), with 80 years old as the best threshold in defining high risk population., Conclusions: RA is a feasible and safe procedure. Females and elderly patients must be carefully selected in order to balance the risk/benefit ratio in these high-risk populations.

Background: Compare the discriminative performance of two validated bleeding risk models for in-hospital bleeding events in a non-selected cohort of acute coronary syndrome (ACS) patients., Methods: CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) scores were calculated in 501 consecutive patients (median age 68 years (IQR 57-77), 31% female) admitted for ACS to the coronary care unit (CCU) of San Paolo Hospital in Milan (Italy). In-hospital haemorrhagic events and mortality were recorded and calibration and discrimination of the two risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic, respectively., Results: Overall bleeding events were observed in 32 patients and major bleedings in 11 (with an incidence of 6.4% and 2.2%, respectively). In-hospital mortality was 2.6%. Regarding major bleedings both risk scores demonstrated an adequate calibration (H-L test p>0.20) and a moderate discrimination with no significant difference in predictive accuracy between the two models (C-statistic 0.69 for CRUSADE and 0.73 for ACUITY-HORIZONS). We also tested the performance of the two risk models in predicting in-hospital mortality, showing an adequate calibration and a very good discrimination (C-statistic 0.88 and 0.89 for the CRUSADE and ACUITY-HORIZONS scores, respectively), with no significant difference in predictive accuracy., Conclusions: In our ACS population the CRUSADE and the ACUITY-HORIZONS risk scores showed a fairly good and comparable predictive accuracy regarding in-hospital bleeding events and they appeared to be very good predictors of in-hospital mortality., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Patients with diabetes mellitus (DM) and acute coronary syndromes have a greater level of platelet aggregation and a poor response to oral antiplatelet drugs. Clopidogrel is still widely used in clinical practice, despite the current evidence favoring ticagrelor and prasugrel., Aim: The aim of this study was to investigate the determinants of clopidogrel use in the population of the multicenter prospective 'Acute Coronary Syndrome and Diabetes Registry' carried out during a 9-week period between March and May 2015 at 29 Hospitals., Patients and Methods: A total of 559 consecutive acute coronary syndrome patients [mean age: 68.7±11.3 years, 50% ST-elevation myocardial infarction (STEMI)], with 'known DM' (56%) or 'hyperglycemia' at admission, were included in the registry; 460 (85%) patients received a myocardial revascularization., Results: At hospital discharge, dual antiplatelet therapy was prescribed to 88% of the patients (clopidogrel ticagrelor and prasugrel to 39, 38, and 23%, respectively). Differences in P2Y12 inhibitor administration were recorded on the basis of history of diabetes, age, and clinical presentation (unstable angina/non-STEMI vs. non-STEMI). On univariate analysis, age older than 75 years or more, known DM, peripheral artery disease, previous myocardial infarction, previous revascularization, complete revascularization, previous cerebrovascular event, creatinine clearance, unstable angina/non-STEMI at presentation, Global Registry of Acute Coronary Events Score, EuroSCORE, CRUSADE Bleeding Score, and oral anticoagulant therapy were significantly associated with clopidogrel choice at discharge. On multivariate analysis, only oral anticoagulant therapy and the CRUSADE Bleeding Score remained independent predictors of clopidogrel prescription., Conclusion: In the present registry of a high-risk population, clopidogrel was the most used P2Y12 inhibitor at hospital discharge, confirming the 'paradox' to treat sicker patients with the less effective drug. Diabetic status, a marker of higher thrombotic risk, did not influence this choice; however, bleeding risk was taken into account.

Background: With this study, we sought to identify patient characteristics associated with clopidogrel prescription and its relationship with in-hospital adverse events in an unselected cohort of ACSs patients., Materials and Methods: We studied all consecutive patients admitted at our institution for ACSs from 2012 to 2014. Patients were divided into two groups based on clopidogrel or novel P2Y12 inhibitors (prasugrel or ticagrelor) prescription and the relationship between clopidogrel use and patient clinical characteristics and in-hospital adverse events was evaluated using logistic regression analysis., Results: The population median age was 68 years (57-77 year) and clopidogrel was prescribed in 230 patients (46%). Patients characteristics associated with clopidogrel prescription were older age, female sex, non-ST-elevation ACS diagnosis, the presence of diabetes mellitus and anemia, worse renal and left ventricular functions and a higher Killip class. Patients on clopidogrel demonstrated a significantly higher incidence of in-hospital mortality (4.8%) than prasugrel and ticagrelor-treated patients (0.4%), while a nonstatistically significant trend emerged considering bleeding events. However, on multivariable logistic regression analysis female sex, the presence of anemia and Killip class were the only variables independently associated with in-hospital death., Conclusion: Patients treated with clopidogrel showed a higher in-hospital mortality. However, clinical variables associated with its use identify a population at high risk for adverse events and this seems to play a major role for the higher in-hospital mortality observed in clopidogrel-treated patients.

Objectives: To first explore in Italy appropriateness of indication, adherence to guideline recommendations and mode of selection for coronary revascularisation., Design: Retrospective, pilot study., Setting: 22 percutaneous coronary intervention (PCI)-performing hospitals (20 patients per site), 13 (59%) with on-site cardiac surgery., Participants: 440 patients who received PCI for stable coronary artery disease (CAD) or non-ST elevation acute coronary syndrome were independently selected in a 4:1 ratio with half diabetics., Primary and Secondary Outcome Measures: Proportion of patients who received appropriate PCI using validated appropriate use scores (ie, AUS≥7). Also, in patients with stable CAD, we examined adherence to the following European Society of Cardiology recommendations: (A) per cent of patients with complex coronary anatomy treated after heart team discussion; (B) per cent of fractional flow reserve-guided PCI for borderline stenoses in patients without documented ischaemia; (C) per cent of patients receiving guideline-directed medical therapy at the time of PCI as well as use of provocative test of ischaemia according to pretest probability (PTP) of CAD., Results: Of the 401 mappable PCIs (91%), 38.7% (95% CI 33.9 to 43.6) were classified as appropriate, 47.6% (95% CI 42.7 to 52.6) as uncertain and 13.7% (95% CI 10.5% to 17.5%) as inappropriate. Median PTP in patients with stable CAD without known coronary anatomy was 69% (78% intermediate PTP, 22% high PTP). Ischaemia testing use was similar (p=0.71) in patients with intermediate (n=140, 63%) and with high PTP (n=40, 66%). In patients with stable CAD (n=352) guideline adherence to the three recommendations explored was: (A) 11%; (B) 25%; (C) 23%. AUS was higher in patients evaluated by the heart team as compared with patients who were not (7 (6.8) vs 5 (4.7); p=0.001)., Conclusions: Use of heart team approaches and adherence to guideline recommendations on coronary revascularisation in a real-world setting is limited. This pilot study documents the feasibility of measuring appropriateness and guideline adherence in clinical practice and identifies substantial opportunities for quality improvement., Trial Registration Number: NCT02748603., Competing Interests: Competing interests: ICJME forms are available for all authors. SL reports honoraria for advisory boards from AstraZeneca, Daiichi Sankyo, and The Medicines Company during the conduct of the study outside the submitted work; LDL reports personal fees from Astra Zeneca, personal fees from Bayer, personal fees from Boehringer-Ingelheim, personal fees from Eli Lilly and Daiichi Sankyo, personal fees from Menarini, personal fees from The Medicines Company, outside the submitted work. SDS reports personal fees from Pfizer, personal fees from AstraZeneca, personal fees from Daiichi Sankyo, personal fees from Correvio, outside the submitted work. The other authors report nothing to disclose. All authors have read and understood BMJ policy on declaration of interests and have no other relevant interests to declare in addition to these., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Patients with diabetes mellitus and acute coronary syndrome (ACS) present an increased risk of adverse cardiovascular events. An Italian Consensus Document indicated 'three specific must' to obtain in this subgroup of patients: optimal oral antiplatelet therapy, early invasive approach and a tailored strategy of revascularization for unstable angina/non-ST-elevation-myocardial infarction (UA/NSTEMI); furthermore, glycemia at admission should be managed with dedicated protocols., Aim: To investigate if previous recommendations are followed, the present multicenter prospective observational registry was carried out in Lombardia during a 9-week period between March and May 2015., Methods and Results: A total of 559 consecutive ACS patients (mean age 68.7 ± 11.3 years, 35% ≥75 years, 50% STEMI), with 'known DM' (56%) or 'hyperglycemia', this last defined as blood glucose value ≥ 126 mg/dl at admission, were included in the registry at 29 hospitals with an on-site 24/7 catheterization laboratory. Patients with known diabetes mellitus received clopidogrel in 51% of the cases, whereas most patients with hyperglycemia (72%) received a new P2Y12 inhibitor: according to clinical presentation in case STEMI prasugrel/ticagrelor were more prescribed than clopidogrel (70 vs. 30%, P < 0.001); on the contrary, no significant difference was found in case of UA/NSTEMI (48 vs. 52%, P = 0.57).Overall, 96% of the patients underwent coronary angiography and 85% received a myocardial revascularization (with percutaneous coronary intervention in 92% of cases) that was however performed in fewer patients with known diabetes mellitus compared with hyperglycemia (79 vs. 90%, P = 0.001).Among UA/NSTEMI, 85% of patients received an initial invasive approach, less than 72 h in 80% of the cases (51% <24 h); no difference was reported comparing known diabetes mellitus to hyperglycemia. Despite similar SYNTAX score, patients with known diabetes mellitus had a higher rate of Heart Team discussion (29 vs. 12%, P = 0.03) and received a surgical revascularization in numerically more cases.Most investigators (85%) followed a local protocol for glycemia management at admission, but insulin was used in fewer than half of the cases; diabetes consulting was performed in 25% of the patients and mainly in case of known diabetes mellitus., Conclusion: Based on data of the present real world prospective registry, patients with ACS and known diabetes mellitus are treated with an early invasive approach in case of UA/NSTEMI and with a tailored revascularization strategy, but with clopidogrel in more cases; glycemia management is taken into account at admission.

: Cancer is associated with a prothrombotic or hypercoagulable state. Intracoronary thrombosis is a rare and potentially life-threatening complication in cancer patients. We describe a rare case of large nonocclusive intracoronary thrombosis successfully treated by means of medical therapy.

Background: Contrast-induced acute kidney injury (CI-AKI) is associated with significantly increased mortality after primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). The prognostic value of CI-AKI depends on the definitions used to define it. We compare the predictive accuracy of long-term mortality of two definitions of CI-AKI on consecutive patients undergoing pPCI for STEMI., Methods: Incidence, risk factors and long-term prognosis of CI-AKI were assessed according to two different definitions: the first as an increase in serum creatinine ≥ 25% or ≥ 0.5 mg/dl from baseline within 72 h after pPCI (contrast-induced nephropathy (CIN) criteria), the second one according to Acute Kidney Injury Network (AKIN) classification system., Results: A total of 402 patients were enrolled. The median follow-up period was 12 ± 4 months. Long-term mortality rate was 9.5%. Independent predictors of long-term mortality were: older age, basal renal impairment, left ventricular ejection fraction <40%, in-hospital major bleedings and CI-AKI. A significant correlation was found between mortality and CI-AKI as assessed by both CIN (HR 4.84, 95% CI: 2.56-9.16, p=0.000) and AKIN (HR 9.70, 95% CI: 5.12-18.37, p=0.000) definitions. The area under the receiver operating curve was significantly larger for predicting mortality with AKIN classification than with CIN criteria (0.7984 versus 0.7759; p=0.0331)., Conclusions: In patients with STEMI treated by pPCI, CI-AKI is a frequent complication irrespective of the criteria used for its definition. AKIN, however, seems to provide a better accuracy in predicting long-term mortality than CIN criteria., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

We report the case of a young woman with an acute myocardial infarction secondary to coronary embolization from a left atrial myxoma, as unusual presentation of a cardiac tumor.We also describe the role of transthoracic echocardiograpy in the multidisciplinary approach to diagnosis and treatment of this life-threatening condition.

Background: Patients undergoing primary percutaneous coronary intervention (PCI) are at high risk for contrast-induced nephropathy (CIN), a complication that has been demonstrated to negatively affect outcomes. It has been suggested that, when compared to males, female patients present higher incidence of CIN and higher mortality after primary PCI. However, the specific role of gender in this setting remains ill-defined given its complex interplay with several co-morbidities and clinical characteristics. We investigated the relationship of patients' variables, including gender, with CIN and mortality after primary PCI., Methods: In a single center study in 323 consecutive patients undergoing primary PCI, the development of CIN and mortality during an 18-month median follow-up period was assessed. CIN was defined as an increase in serum creatinine (≥25% or ≥0.5 mg/dl) from baseline occurring at any time during the first 3 post-procedural days., Results: CIN occurred in 23 female and 26 male patients (25.0% vs 11.2%, p=0.003), while cumulative mortality was 10.6%. Women presented unfavorable basal characteristics and underwent myocardial reperfusion less quickly. At multivariable analysis, reduced left ventricular ejection fraction (LVEF) (odds ratio [OR] 7.32 95% confidence interval [CI]: 2.60-21, p<0.001) and female gender (OR 2.49 95%CI 1.22-5.07, p=0.01) predicted CIN, whereas the occurrence of CIN (hazard ratio [HR] 3.65 95%CI 1.55-8.59, p=0.003) and a Mehran risk score (MRS)≥6 (HR 1.76 95%CI 1.13-2.74, p=0.01) independently predicted long-term mortality., Conclusions: After primary PCI, female gender and LVEF are associated with an increased risk of CIN, whereas MRS and development of CIN predict long-term mortality., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Patients with diabetes mellitus (DM) and acute coronary syndromes (ACS) present a significantly higher risk of developing ischemic complications as compared to nondiabetic patients. Multiple mechanisms contribute to DM patients' enhanced prothrombotic status, including impaired fibrinolysis and coagulation, as well as endothelial and platelet dysfunction. Therefore, antithrombotic agents generally, and antiplatelet agents in particular, represent a logical secondary preventive strategy to reduce the risk of recurrent ischemic events in DM patients with ACS. However, DM patients often show attenuated responses to antiplatelet therapies for ACS patients. DM patients benefit from early coronary angiography and revascularization. Although randomized clinical trials have demonstrated that surgical revascularization is associated with an improved prognosis compared to percutaneous coronary intervention, a tailored revascularization strategy should be provided for each patient. The type of revascularization should be decided on the basis of SYNTAX score, surgical risk profile, and feasibility of total arterial revascularization in case of surgery. An accurate diagnosis and prompt treatment of hyperglycemia should also be provided for all patients. The present multidisciplinary document provides practical recommendations regarding diagnosis of DM and the management of hyperglycemia, from the acute phase to discharge. It is aimed at favoring early detection of hyperglycemia and identification of diabetic patients so as to provide adequate glucose control.

Current guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) recommend the administration of dual antiplatelet therapy with aspirin and an ADP receptor blocker "as early as possible" before angiography (upstream), though this suggestion is not based on the results of randomized clinical trials designed to investigate pre-hospital rather than in-hospital drug administration. The present review analyzed randomized clinical trials, registries and observational studies that assessed clopidogrel, prasugrel and ticagrelor administration in STEMI patients undergoing primary PCI to evaluate if their upstream use may be justified in clinical practice. A significant difference favoring early clopidogrel administration has been demonstrated in observational studies. No evidence is available for prasugrel and ticagrelor; however, the initial delay of their antiplatelet effect in STEMI patients could support an upstream strategy to obtain complete platelet inhibition in the first hours after PCI and prevent major adverse events (e.g., stent thrombosis) despite an increased risk of major bleeding, particularly in case of urgent bypass surgery. Data from specifically designed randomized clinical trials are warranted to establish whether early administration of prasugrel and ticagrelor may favor reperfusion and improve clinical outcome with an acceptable risk-benefit ratio.

The aim of this work was to evaluate associations between invalidating health problems and the main demographic and professional determinants among the employees of the Police Headquarter of the Province of Foggia (South Italy). Personal records of the employees on active service between November 2009 and May 2010 (N. 798 files) have been analysed. 241 personal service records reporting at least an acknowledged occupational related cause were examined. Low educational level increases the risk of occupational related causes (OR = 2.03; 95% Cl = 1.03-3.2; p < 0.002). Traumatisms (49.4%) and osteoarticular system diseases (23.6%) were the most frequent reasons for acknowledgement of work-related causes. The risk of causes related to traumatism was lower among employees with lower educational level (OR = 0.59; 95% CI = 0.36-0.97; p = 0.0038) and higher length of service (OR = 0.83; 95% Cl = 0.79-0.87; p < 0.001). Occupational-health physician knowledgeable about police work plays an important role by screening for specific conditions and educating the Police Officers about increased risks.

Background: Contrast-induced nephropathy (CIN) is the third cause of acute deterioration of renal function in hospitalized patients., Hypothesis: The purpose of the study was to compare the efficacy of saline infusion, saline infusion plus N-acetylcysteine (NAC), and sodium bicarbonate (SB) infusion to prevent CIN in patients undergoing coronary angiography and/or percutaneous coronary intervention., Methods: We prospectively studied 156 patients with a baseline creatinine level > or = 1.2 mg/dL. The primary endpoint was the development of CIN, defined as an increase in serum creatinine concentration > or = 25% over the baseline value within 5 days from contrast exposure., Results: Contrast-induced nephropathy developed in 23 patients (14.7%). Incidence of the primary endpoint was similar in the 3 groups of treatment, occurring in 7 patients (14%) in the saline infusion group, in 9 (17%) in the saline infusion plus NAC group, and in 7 (14%) in the SB infusion group., Conclusions: Our findings suggest that neither the addition of NAC nor the administration of SB add further benefit in CIN prevention, compared to standard hydration with isotonic saline infusion., (Copyright (c) 2009 Wiley Periodicals, Inc.)

One hundred twenty-five patients (60 +/- 10 years old, 60 women) with known (35, previous myocardial infarction) or suspected (90) coronary artery disease (CAD) and no more than 50% coronary stenoses underwent pharmacologic (48 dipyridamole and 77 dobutamine) stress echocardiography (SE) and prospective follow-up (36 +/- 22 months) for cardiac death, nonfatal infarction, and unstable angina. The ability of clinical and SE variables to predict the outcome was assessed by the Cox model. A significant increase in the global chi-square of the model indicated an incremental prognostic value. Nine events occurred: 2 fatal and 5 nonfatal infarctions and 2 hospitalizations for unstable angina. Hypertension, positive SE, and peak wall motion score index were multivariate predictors of outcome, but SE provided an 87.5% increase in the global chi-square (P <.001). Patients with positive SE had a significantly lower event-free survival compared with those with negative SE. Therefore, we conclude that SE provides incremental prognostic information in patients with chest pain without critical coronary artery disease.

Study Objective: To assess the diagnostic and prognostic value of cardiac output assessed by cardiopulmonary exercise testing in patients with anterior acute myocardial infarction (AMI) and left ventricular dysfunction., Patients and Setting: Forty-six patients with AMI (7 female patients; mean +/- SD age, 55 +/- 8 years; ejection fraction, 39 +/- 7%) underwent cardiopulmonary exercise testing and coronary angiography following hospital discharge., Measurement and Results: Cardiac output was estimated from oxygen uptake (VO(2)) during exercise according to a method based on the linear regression between arteriovenous oxygen content difference and percent maximum VO(2). Angiograms were scored using Gensini and Duke "jeopardy" scores. Cardiac output at anaerobic threshold (COAT) < or = 7.3 L/min was the best cutoff value for identifying multivessel coronary artery disease (relative risk, 3.1). Angiographic scores were significantly higher in patients with COAT < 7.3 L/min as compared to those with COAT > 7.3 L/min (82 +/- 8 vs 53 +/- 7 and 6 +/- 2 vs 4 +/- 3, respectively; p < 0.05) and were inversely and significantly correlated to COAT. Conversely, no correlation was found with ECG changes. COAT, VO(2) at anaerobic threshold, and peak VO(2) were univariate prognostic indicators. However, using Cox's model, COAT was the only multivariate predictor of outcome (odds ratio, 0.28; 95% confidence interval [CI], 0.09 to 0.9). Moreover, COAT < 7.3 L/min was associated to an increased risk of further cardiac events (odds ratio, 5; 95% CI, 1.4 to 17) and provided a significant discrimination of survival for the combined end point of cardiac death, reinfarction, and clinically driven revascularization., Conclusions: COAT is a safe and feasible tool providing additional diagnostic and prognostic information in patients with AMI.

Background: The presence of tissue viability is of great importance in the prognostic work-up of patients recovering from acute myocardial infarction. However, uncertainty still exists concerning the optimal tool for its assessment. The present study was undertaken in order to compare low-dose dobutamine echocardiography and rest-redistribution thallium SPECT for predicting late improvement of regional left ventricular function after acute myocardial infarction., Methods: Fifteen patients undergoing coronary angiography, low-dose dobutamine echocardiography and rest-redistribution thallium SPECT after thrombolyzed anterior acute myocardial infarction were studied. A 3 month follow-up echocardiogram was performed in all patients and 9 underwent coronary revascularization., Results: A significant (> or = 70%) residual stenosis of the infarct-related artery was present in 14 patients, whilst a total occlusion was observed in 1. At 3 month follow-up, 41% of the dyssynergic segments improved. The sensitivity, specificity and accuracy for late wall motion improvement was 61, 89 and 77% for low-dose dobutamine echocardiography and, respectively, 76, 45 and 58% for rest-redistribution thallium SPECT. Tissue viability was detected in 65 and 31% of dyssynergic segments by rest-redistribution thallium SPECT and low-dose dobutamine echocardiography, respectively (p < 0.001). The agreement between the two techniques was 48%., Conclusions: Low-dose dobutamine echocardiography is more accurate than rest-redistribution thallium SPECT for predicting 3 month wall motion improvement in patients with acute anterior myocardial infarction, mainly due to its significantly better specificity.

Stress-induced asynergies in the infarct area following thrombolytic therapy are considered to reflect incomplete recanalization of the culprit vessel. However, reperfusion is a dynamic process with successive pathophysiological phases, so that the timing of assessment of residual ischemia may have relevant clinical implications. We studied the time-course of dobutamine-induced homozonal asynergies in 61 (group B) survivors of uncomplicated infarction as compared to 54 (group A) control subjects showing normal response to dobutamine stress echocardiography within 10 days of acute myocardial infarction. The 79 (43 of group A and 36 of group B) patients not presenting new cardiac events underwent further dobutamine stress echo within 90 +/- 17 days, which was positive in 20 and negative in 59. Persistence of test positivity was observed in just 17/36 (47%) patients, who showed significantly more extensive dobutamine-induced asynergies as compared to pre-discharge evaluation and less frequent (p < 0.01) evidence of viable myocardium. These results arise question about the decisional impact of stress-induced wall motion abnormalities in the culprit vessel area early after thrombolysis in low-risk patients and emphasize the need to further clarify the time factor role in this setting.

Background: The aim of the study was to evaluate the usefulness of low-dose dobutamine echocardiographic testing performed within 48 hours from anterior AMI in order to identify the extent of viable myocardium and predict its functional outcome. The early echo-dobutamine test was also compared with a predischarge test in order to evaluate the effects of different timing on the accuracy of the test., Methods: Nineteen consecutive patients, aged 54 +/- 11 years, with a first anterior AMI entered the study. All patients underwent a low-dose dobutamine echocardiographic test within 48 hours from hospital admission and at predischarge. In all the patients, a rest follow-up echocardiogram was performed three months after hospital discharge. Eleven patients underwent a revascularization procedure (7 underwent PTCA and 4 CABG)., Results: Of the 159 dyssynergic segments, 26% improved spontaneously at predischarge and 51% improved at the three-month follow-up. Of the 145 predischarge dyssynergic segments, 38% improved at three months. Considering the results on a segmental basis, early low-dose dobutamine echocardiography showed a sensitivity of 52%, a specificity of 87%, a positive predictive value of 81%, a negative predictive value of 64% and a diagnostic accuracy of 69% for wall-motion improvement at three months. The predischarge test showed very similar values. A slight enhancement of the sensitivity of both tests was observed considering the akinetic segments only. Finally, considering the amount of segmental reversible dysfunction inside the infarct area in the single patients, early low-dose dobutamine echocardiography showed a sensitivity of 86% and a specificity of 80%., Conclusions: Our results indicate that: 1) recovery of regional wall motion after AMI is slow and progressive, with substantial improvement ensuing within the first days after infarction; 2) considering results on a segmental basis, low-dose dobutamine echocardiography performed within 48 hours of AMI shows a high specificity but a low sensitivity for late recovery of regional function, although it gave information similar to what was obtained performing the test at predischarge; 3) the efficiency of test can be improved by considering the amount of reversible segmental dysfunction inside the infarct area in the single patients.

Our aim was to verify whether the sensitivity of pharmachological stress echocardiography for multivessel disease after acute myocardial infarction may be improved by a more aggressive protocol, i.e. not considering the appearance of the first wall motion abnormality as the absolute end-point if it occurs in the infarcted area without clinical or instrumental markers of extensive ischemia or left ventricular dysfunction. One-hundred twenty-one consecutive patients (age 32-71 years) prospectively underwent dobutamine-atropine stress echo (dobutamine infusion up to 40 micrograms/kg/min with additional atropine 1 mg) 11.8 +/- 4.8 days after uncomplicated myocardial infarction and coronary angiography within 6 weeks. Criteria for stopping the test were: significant ST depression or elevation, typical chest pain, major arrhythmias and left ventricular dysfunction. The test was considered as positive if a deterioration of basal wall motion pattern was observed: it was defined homozonally positive (the deterioration occurred in the myocardial area fed by the culprit vessel) or heterozonally positive (the deterioration occurred in a different vascular area). A coronary stenosis > 70% of vessel lumen was defined as critical. Thirty-four patients showed a negative test result. Among the 87 patients with positive test, 65 had no further wall motion deterioration from the first-induced wall motion abnormality (WMA) to peak test (Group A), whereas nine patients showed further homozonal (Group B) and 13 further heterozonal (Group C) asynergies. Sensitivity, specificity and accuracy of dobutamine stress echocardiography for multivessel disease were, respectively, 63%, 96% and 82% using the first-induced wall motion abnormality as test end-point, whilst they were 84% (P < 0.01), 93% and 89% according to the aggressive approach previously described. Dobutamine stress time of patients with multivessel disease was higher in Groups B and C (13.1 +/- 3.6 min) than in Group A (9.8 +/- 3.7 min, P < 0.01) and, finally, the mean obstruction of non-culprit vessel was higher in Group A (62.2%) than in Group C (47.4%, P < 0.05). No major complications were found. We conclude that the sensitivity of dobutamine stress echocardiography for multivessel disease following recent myocardial infarction is critically dependent on the test end-point. It may be improved by a more aggressive approach capable to identify less severe heterozonal coronary lesions.

Details of possible complement activation in acute myocardial infarction (AMI) and the in vivo effects of fibrinolytic agents on this activation are not yet known. We measured complement activation in 40 patients with AMI: 20 were treated with streptokinase, and 20 did not receive any fibrinolytic agent. Anaphylatoxin C4a, C3a and membrane attack complexes SC5b-9 increased about 10-fold (p < 0.0001) during streptokinase infusion. There were no increases in complement catabolic products in AMI patients not treated with streptokinase. Significant transient leukopenia (-29.5%, 7.0 SEM, p = 0.001) and a drop in systolic pressure (-29%, 3.4 SEM, p < 0.0001) occurred after 15 min of streptokinase infusion simultaneously with the peak of anaphylatoxins in plasma.

A new protocol is described for non-invasive evaluation of electrophysiological effects of autonomic nervous system on both normal and abnormal atrio-ventricular conduction in patients with Wolff-Parkinson-White (WPW) syndrome. In 64 WPW patients with stable Kent-type ventricular preexcitation transoesophageal atrial pacing has been carried out to quantify changes in both atrioventricular (AV) node and Kent bundle refractoriness and maximal conductive capability induced by posture, physical exercise and psychophysiological activation. A significant shortening of AV nodal and accessory pathway refractory periods was found, induced by manoeuvres enhancing the sympathetic outflow, being the AV node the most sensitive structure. This finding suggests that an exhaustive investigation protocol of WPW patients should include the evaluation of the neurovegetative effects on cardiac electrophysiological parameters, under conditions which can reproduce as close as possible the individual situations a patient has to face in his real life.

This study was designed to examine the relationships between dose of Wellcome two-chain recombinant tissue type-plasminogen activator (BW rt-PA) and coronary patency and fibrinolytic parameters in acute myocardial infarction (AMI). In an open randomized study, patients with AMI (determined by ECG) and symptoms of less than 4 h duration without contraindications for fibrinolytic therapy were treated with rt-PA in nominal doses of 20 (7.7 MU), 50 (14.8-29.6 MU) or 100 mg (29.6-48.2 MU) administered over 90 min followed by intravenous heparin. Coronary patency was determined by coronary arteriography of the infarct-related artery and haematological parameters (fibrinogen, plasminogen, alpha 2-antiplasmin and fibrin(ogen) degradation products) measured at 90 min. Coronary patency increased in a dose-related manner to 53% (95% C.I. 37-69%) in the 100 mg/90 min group. Logistic regression demonstrated a relationship between dose (in MU kg-1) and coronary patency. Fibrinogen at 90 m was reduced to 74 (61.5-86.4%) of the pooled plasma standard in the nominal 100 mg group. Patients with a higher predose fibrinogen had higher reductions of fibrinogen. Serious bleeding occurred in three (3%) patients, and no intracranial bleeds were reported. BW rt-PA produces dose-related patency of the coronary arteries with moderate, dose-related reduction in fibrinogen.

In order to investigate the prevalence of vectorcardiographic bites, expression of small areas of fibrosis, atrophy or degeneration of the myocardium, we studied, using the vectorcardiograms (VCG) of 101 diabetic patients (35 with insulin-dependent and 66 with non-insulin-dependent diabetes mellitus, aged from 25 to 60 years, without hypertension, coronary artery disease, or intraventricular conduction defects) and 228 normal control subjects, matched for age and sex. The prevalence of bites was 38.6% in diabetic patients and 10.0% in the control group (p less than 0.001). Diabetic patients were also subdivided into groups according to age, sex, metabolic control, risk factors for coronary heart disease, type of diabetes, duration of diabetes and diabetic microangiopathy. No correlation was found between any of the variables investigated nor of a combination of these, and the presence of bites. We conclude that VCG is a sensitive test for cardiac involvement in diabetic patients but that it cannot be used to identify any specific factor able to influence the onset and evolution of this involvement.

The effects of acute changes in cardiac volumes determined by hemodialysis on cardiac voltages were assessed in 18 chronically uremic patients by means of a vectorcardiographic and scalar Frank leads recording, immediately before, at the 90th and 180th minute, and immediately after hemodialysis. The following parameters were simultaneously monitored: body weight, systolic and diastolic blood pressure, heart rate, hematocrit and, in eight patients, echocardiographic systolic and diastolic diameters of the left ventricle. During hemodialysis all voltages considered except R wave in X lead increased significantly. They were inversely correlated with body weight, blood pressure, and systolic and diastolic diameters and directly with hematocrit (volemia-dependent parameters). The maximal vector on the left sagittal plane and the R wave amplitude in Z lead, representing left ventricular posterolateral wall activation, showed the greatest increase. When, at the end of hemodialysis, an amount of fluids ranging from 300 to 800 ml was restored, these cardiac voltages decreased paralleling the increase of left ventricular diameters. In conclusion, these results demonstrate that cardiac voltage and volumes are inversely related.

Potassium canrenoate (KCR) is widely used in cardiac patients as an aldosterone antagonist, antiarrhythmic and diuretic drug. According to experimental and clinical studies it can also elicit an inotropic action. It is not clear, however, whether this inotropic activity occurs in the absence of any treatment or after the myocardial contractility has already been improved with digitalis. In order to evaluate a possible interaction of this drug with digitalis we administered KCR intravenously to 41 anaesthetized dogs either untreated or treated with digitalis, in which aortic and left ventricular pressures were recorded and myocardial contractility was evaluated by calculating in real time the first derivative of ventricular pressure (Formula: see text) max and two other contractility indexes (Formula: see text) max and V.max. The results obtained showed that KCR given at doses of 10, 20 and 30 mg/kg i.v. did not elicit any inotropic effect in dogs not previously digitalized. 100 mg/kg i.v. first depressed cardiac contractility and then increased it. After cardiac performance had been improved by digitalis, KCR further increased all contractility indexes significantly. These results could explain previous observations that no inotropic effect was observed in human subjects not treated with digitalis after treatment with KCR.