Authors/Task Force Members: Karl Swedberg, Chairperson,* Göteborg (Sweden) Writing Committee: John Cleland, Hull (UK), Henry Dargie, Glasgow (UK), Helmut Drexler, Hannover (Germany), Ferenc Follath, Zurich (Switzerland), Michel Komajda, Paris (France), Luigi Tavazzi, Pavia (Italy), Otto A. Smiseth, Oslo (Norway). Other Contributors: Antonello Gavazzi, Bergamo (Italy), Axel Haverich, Hannover (Germany), Arno Hoes, Utrecht (The Netherlands), Tiny Jaarsma, Gronigen (The Netherlands), Jerzy Korewicki, Warsaw (Poland), Samuel Lévy, Marseille (France), Cecilia Linde, Stockholm (Sweden), José-Luis Lopez-Sendon, Madrid (Spain), Markku S. Nieminen, Helsinki (Finland), Luc Piérard, Liège (Belgium), Willem J. Remme, Rhoon (The Netherlands)
ESC Committee for Practice Guidelines (CPG): Silvia G. Priori (Chairperson) (Italy), Maria Angeles Alonso Garcia (Spain), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), Martin Cowie (UK), Veronica Dean (France), Jaap Deckers (The Netherlands), Enrique Fernandez Burgos (Spain), John Lekakis (Greece), Bertil Lindahl (Sweden), Gianfranco Mazzotta (Italy), Keith McGregor (France), João Morais (Portugal), Ali Oto (Turkey), Otto A. Smiseth (Norway)
BACKGROUND A new patient consent form has recently been adopted in our Institution, with a uniformly written text to be used for all medical procedures and interventions. It is accompanied by a separate information sheet, explaining both the details and the risk/benefit profile for each specific procedure/intervention. It should be given to the patient as early as possible after the procedure/intervention is planned. Testing the effectiveness of this new information policy has been included into the quality assurance goals by our nursing staff. METHODS From mid April to mid June 2004 a questionnaire was administered to all patients who had undergone an elective cardiac interventional procedure. The timing, manner and perceived completeness of the information received by patients was investigated by 14 yes/no or multiple choice questions. A goal of <5% deviation from a 100% standard was set for all indicators. RESULTS Two hundred and thirty-eight valid questionnaires were obtained out of 308 consecutive procedures. Seven patients (3%) refused the questionnaire. The response rate was >90% for each question. Seventy-eight patients (33%) had a history of cardiac interventional procedures. The information sheet had been received before the procedure in 93% of cases, and this had happened in the ward in 58% of cases; the procedure had been performed at least 1 hour after receipt of the information sheet in 83% of cases. Twenty-seven patients (13%) stated they had not read the information sheet, in most cases (92%) because they felt they already knew enough. Among patients who had read the information sheet, 99% deemed it could be easily understood. Difficulties in asking questions were reported by 6% of patients. When questions had been asked, the nursing staff was addressed in 42% of cases, and the answers were rated as clear in 98% of cases. The consent form was not read at all by 13% of patients, due to alleged lack of time, and was not read completely by another 15%; 98% of those who had read it, however, found it was fairly understandable. CONCLUSIONS The effectiveness of our new patient information policy seems to approach our quality goals, and is liable to further improvement. The nursing staff of the cardiac catheterization unit is involved in the patient information process, and has full competence to study this issue.
BACKGROUND:Since epidemiological studies on congestive heart failure (CHF) have shown somewhat contradictory results, detailed analyses of local trends may be useful in order to plan health strategies.METHODS:All patients discharged from public hospitals between 1996 and 2001 with a DRG 127 were evaluated. For patients living in the city of Turin, 1- and 12-month survival analysis was performed. Multivariate analysis was performed for both the total DRG 127 discharges and patients without acute CHF (ICD9CM 785).RESULTS:During the 6-year period 56292 discharges were classified as DRG 127. Hospital discharges for CHF increased until 1999, and then remained stable. Because of the progressive decrease of total number of hospital discharges, the percentage of DRG 127 increased from 1.3 to 2%. Mean age increased from 72.8 to 75.4 years in men and from 77.9 to 80.0 years in women. The average hospital stay decreased from 10.8 to 9.9 days in men, from 11.5 to 10.7 days in women. Within 12 months 17.4% of patients were re-hospitalized. The in-hospital mortality decreased from 17.3 to 14.3% in men and from 20.1 to 14.6% in women. For urban population both 1-month and 12-month mortality (from 40.5 to 35.5% in men, from 33.5 to 28.7% in women) decreased. The subgroup with acute CHF within DRG 127 decreased from 11.8 to 4.8%. At multivariate analysis in-hospital mortality is logically correlated with the age of patients and an increase of the mortality, both in women and men, is shown for patients not admitted in a cardiology department.CONCLUSIONS:The number of CHF hospital discharges, between 1998 and 2001, remained stable, but increased with respect to total admissions. The reduction of in-hospital, 1-month, and 12-month mortality seems to be more dependent on different patient characteristics than to a real effect.
Isolated left ventricular noncompaction is a genetically heterogeneous congenital disorder characterized by an altered structure of the myocardial wall. This cardiomyopathy is thought to be due to an arrest of intrauterine compaction of the myocardial fibers in the absence of any other structural heart disease. Noncompaction of the left ventricular myocardium is an uncommon finding and remains frequently overlooked even by experienced echocardiographers. However, a correct diagnosis of noncompaction has important implications due to the possible association with other cardiac abnormalities and/or muscle disorders, progressive left ventricular dysfunction, risk of thromboembolism, and life-threatening arrhythmias. Furthermore, because of the familial association described with ventricular noncompaction, screening with echocardiography of first relatives is recommended. Since echocardiography is the diagnostic technique of choice, missed diagnoses may be due to nonoptimal imaging of the lateral and apical myocardium, and/or insufficient disease awareness by echocardiographers. To increase awareness of left ventricular noncompaction, the present paper reviews embryology, genetics, clinical features and pathophysiology, diagnosis, treatment and prognosis of patients affected by isolated left ventricular noncompaction.
ESC Committee for Practice Guidelines (CPG), Silvia G. Priori (Chairperson) (Italy), Maria Angeles Alonso Garcia (Spain), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), Martin R Cowie (UK), Veronica Dean (France), Jaap Deckers (The Netherlands), Enrique Fernandez Burgos (Spain), John Lekakis (Greece), Bertil Lindahl (Sweden), Gianfranco Mazzotta (Italy), João Morais (Portugal), Ali Oto (Turkey), Otto A. Smiseth (Norway)
Experimental, clinical and epidemiological researches have shown the incontestable causal relationship between low high-density lipoprotein (HDL) plasma concentrations and cardiovascular pathology on an atherosclerotic basis. Low HDL levels characterize about 10% of the general population and they represent the most frequent dyslipidemia in patients with coronary artery disease. Reduced HDL concentrations would be unable to effectively eliminate the cholesterol excess at the vascular wall, contributing to the inflammatory phenomena that characterize the pathogenesis of atherosclerosis since its initial phases. Results of numerous studies reasonably allow to suppose that HDL are able to exert, also directly, anti-inflammatory actions through the modulation of expression of diverse acute phase proteins. Although the today available therapeutic options aiming to increase HDL levels still show a modest effectiveness, in the experimental and pre-clinical field, the results of genetic investigations and pharmacological interventions have given more encouraging results, making nearer the possibility of treating this pathology concrete.
The tako-tsubo-like syndrome (also named left ventricular apical ballooning) is an unusual cardiomyopathy with a high incidence in the Japanese female population, following an emotional stress. The clinical features (typical chest pain), electrocardiographic (negative T wave and persistent ST-segment elevation in anterior leads), echocardiographic (transient left ventricular apical dysfunction with hyperkinesis of basal segments) are suggestive of an acute anterior myocardial infarction; nevertheless all reports in the literature show coronary arteries without angiographic lesions. We report the case of a 77-year-old female (without cardiovascular risk factors) with two prior episodes of paroxysmal atrial fibrillation, who arrived to the emergency department with chest pain, electrocardiographic and echocardiographic features, suggestive of an acute anterior myocardial infarction, not preceded by any emotional stress. Coronary angiography showed coronary arteries without atherosclerotic lesions; left ventriculography showed an anteroapical dysfunction. The follow-up performed with transthoracic echocardiography (2 months later) showed complete regression of regional wall motion abnormalities. The pathophysiological determinant seems to be related to the release of catecholamines (such as epinephrine and norepinephrine) able to create a transient board of ischemic cardiomyopathy through a direct cellular damage.
BACKGROUND Most of the studies on the identification of cardiovascular risk factors have been conducted either in northern Europe or in the United States. However, genetic as well as dietary factors may vary across different countries and geographical areas and there are few data about the cardiovascular risk profile in our country. METHODS A sample of 3144 subjects (1463 males, 1681 females aged 35-74 years) were randomly selected among the population qualifying for healthcare assistance, registered with 170 general practitioners. Demographic data, clinical information, lab tests and current pharmacological treatments were collected using an electronic case report form. RESULTS The prevalences of cardiovascular risk factors in the population were: smoking habit 22.7%, obesity 12.8%, hypertension 39.2%, hypercholesterolemia 25.5%, hyperglycemia and diabetes 5.5%. Thirty-five point four percent of the subjects presented a low absolute 10-year cardiovascular risk level (< 5%), 31.1% an intermediate risk (5-9%), 24.9% a moderate risk (10-19%), and 8.6% a high risk (> or = 20%) of developing cardiovascular diseases. CONCLUSIONS In the area of Verona approximately 20,000 out of 231,592 subjects, aged 35-74 years, may present an absolute 10-year cardiovascular risk level > or = 20%. These results represent the epidemiological basis for planning and implementing preventive interventions toward cardiovascular diseases.
BACKGROUND:Antihypertensive therapy aims to reduce long-term morbidity and mortality. Drugs characterized by controlled release show a better pharmacokinetic and pharmacodynamic profile compared to standard formulations.METHODS:The present study evaluated the effects of nifedipine controlled release (0.33, 0.66 and 1.32 mg/kg per os), nifedipine standard (0.08, 0.165 and 0.33 mg/kg per os) and amlodipine (0.08, 0.165 and 0.33 mg/kg per os) on mean arterial blood pressure, heart rate and pressure rate index of spontaneously hypertensive rats (SHR). These were treated by gastric gavage, and analyzed after 30 min, 1, 3, 6, 12, and 24 hours. Moreover, plasma levels of nifedipine and amlodipine were also assayed by high-performance liquid chromatography.RESULTS:Nifedipine controlled release showed a longer antihypertensive effect when compared with standard formulation and with amlodipine. The highest dose of nifedipine controlled release decreased blood pressure soon after 1 hour with a maximum decrease (-20 mmHg) at 3 hours. The effect was still significant 24 hours later (p < 0.05). Amlodipine antihypertensive effect lasted 12 hours with a maximum decrease of 18 mmHg at 6 hours. The treatment of SHR rats with nifedipine controlled release, at each of the tested doses, did not cause any significant alterations in heart rate recorded at the beginning of the experiments. Nifedipine standard (0.165 and 0.33 mg/kg) and amlodipine (0.33 mg/kg) increased heart rate in SHR rats. Interestingly enough, pressure rate index was slightly affected by nifedipine standard release and amlodipine whereas it was remarkably reduced by nifedipine controlled release (p < 0.01 vs vehicle until 9 hours). All the compounds showed maximum plasma concentrations paralleled by maximum antihypertensive effects, as evidenced at high-performance liquid chromatography method.CONCLUSIONS:Nifedipine controlled release showed more pronounced antihypertensive effects and longer pharmacokinetic properties with respect to nifedipine standard release and amlodipine.
BACKGROUND:Complications due to undetectable coronary artery disease are the major causes of morbidity and mortality in the surgical treatment of abdominal aortic aneurysm (AAA). The aim of our study was to evaluate the importance of significant coronary artery disease identification and the impact of coronary revascularization on early and late outcomes after surgical repair of AAA.METHODS:Between January 1994 and July 2004, 210 patients (204 males and 6 females, mean age 68 +/- 12 years) were candidates to elective surgical repair of AAA. Coronary angiography was performed in 122 patients (58%) in presence of angina symptoms, previous myocardial infarction, echocardiographic or scinti-scan evidence of myocardial ischemia. Coronary revascularization was performed in 83 patients (39.5%). The population was divided into two groups: coronary artery bypass graft/coronary angioplasty (CABG/PTCA) + AAA group (83 patients submitted to CABG surgery [n = 61], or PTCA [n = 22], for significant coronary artery disease before surgical repair of AAA), AAA group (127 patients without significant coronary artery disease, operated for AAA). Follow-up (90% complete) had a mean duration of 42 +/- 23 months.RESULTS:CABG/PTCA + AAA group compared to AAA group presented major symptoms of angina (p = 0.001), higher incidence of previous myocardial infarction (67 vs 10%, p < 0.0001), lower mean value of left ventricular ejection fraction (50 vs 54%, p = 0.01). Operative mortality was 0.95%, and was not related to any cardiac morbidity: operative mortality was observed in the AAA group (2 patients died of anossic cerebral damage and respiratory failure) and was absent in the CABG/PTCA + AAA group (p = 0.8). The overall 8-year survival in the AAA group and in the CABG/PTCA + AAA group was 80 +/- 11 vs 95 +/- 2.8%, respectively (p = 0.7). Freedom from cardiac late death and freedom from cardiac events (recurrence of angina, myocardial infarction, congestive heart failure) were high in both groups (93 +/- 6.4 vs 97 +/- 2.3%, p = 0.6; and 91 +/- 6.6 vs 89 +/- 6.7%, p = 0.5, respectively). In the CABG/PTCA + AAA group symptoms for angina (p = 0.0002) and dyspnea (p < 0.0001) significantly improved during the follow-up.CONCLUSIONS:Significant coronary artery disease was not negligible (39.5%) in patients candidates to surgical repair of AAA. Identification and correction of coronary artery disease prior to AAA surgery is the most important strategy to reduce the risk of vascular procedure. The beneficial impact of coronary revascularization on early and late outcomes is evident, in terms of satisfactory survival and freedom from cardiac adverse events. Therefore, coronary angiography is strongly suggested to optimize early and long-term results.
BACKGROUND:No assessment has been made up today concerning clinical features, coronary artery flow and mid-term prognosis between acute non-ST-elevation myocardial infarction (NSTEMI) patients without epicardial coronary disease and those with epicardial coronary artery stenosis > 50% of at least one vessel.METHODS:We evaluated consecutive NSTEMI patients who had undergone coronary angiography within the first 48 hours of infarction. We examined their age, sex, smoking habits, the incidence of diabetes, dyslipidemia, hypertension, and left ventricular ejection fraction. The coronary blood flow was assessed according to the conventional TIMI flow grade and with the TIMI frame count (TFC).RESULTS:From October 1, 2001 to December 31, 2003, 50 patients out of 996 with NSTEMI (20 males, 30 females, mean age 60 +/- 13 years), showed normal coronary arteries (5%). This subset of patients was compared with 50 NSTEMI patients with coronary stenosis. Patients of the first group were younger and more frequently female with respect to NSTEMI patients with coronary stenosis. The differences between the two groups with respect to diabetes, hypertension, dyslipidemia incidence and ejection fraction (52 vs 47%) were not statistically significant. With the corrected TFC (cTFC) method we found a slow flow in at least one coronary vessel in a high percentage of NSTEMI patients with normal coronary arteries. When we compared normal vessels between the two groups, we found a higher cTFC in NSTEMI patients with normal coronary arteries than in NSTEMI patients with coronary stenosis. After a 16 +/- 8 months of follow-up we observed 8 events in the normal vessel group and 10 in the coronary stenosis group (p = NS).CONCLUSIONS:The possible hypothesis of microvessel dysfunction as a pathogenesis of a slow flow in NSTEMI patients with normal coronary arteries is strong. Further studies are warranted to investigate microvessel disease and characteristics and possible causes of abnormalities. A larger perspective study with a longer follow-up is needed as well to evaluate the prognosis in this subset of patients.
It seems reasonable to suppose that there is some relationship between the fanciful descriptions of arterial pulse dating back to ancient times and the more sophisticated data stemming from the technological advances of recent years. The clinical evidence derived from "the flowing blood" has always been associated with diseases of the heart and vessels and indeed of apparently unrelated organs, as well as with emotional states. Centuries before the Christian era, Chinese and Indian doctors seat great store by the study of the pulse which was described in imaginative terms and considered a clue to a person's character and illnesses. This subject was just as important to Greeks and Romans: to mention just one famous name Galeno, who wrote extensively about pulses. Up to the 18th century many European Universities had chairs entitled: "De pulsibus et urines" and from this time onwards sphygmic doctrine gained an ever-growing space in the scientific literature in the attempt to establish diagnostic and prognostic connections (often rather whimsical ones) between different kinds of pulses and so-called "crises of cerebral, thoracic and abdominal organs". Between the mid 18th century and the end of the 19th century the study of pulses was mainly focused on identifying arrhythmias and valvular defects even though we still find descriptions of "alternating" and "paradoxical" pulses accompanied by somewhat ambiguous explanations. From the second half of the 20th century the possibility of measuring the pulse wave velocity and the "augmentation index" has led to remarkable advances in epidemiological studies of cardiovascular diseases. This work would like to draw the readers' attention to the relevance a simple semeiological practice such as the examination of the pulse still has in the clinical approach to a patient even in these modern times.
Coronary artery calcifications seem to be correlated with a high risk of coronary heart disease. Computed tomography has been shown to be capable of providing accurate, non-invasive measurements of coronary artery calcifications. Coronary calcium is a recognized marker of atherosclerosis. Atherosclerotic burden of coronary arteries correlates strongly with the amount of coronary artery calcifications measured by computed tomography. The presence and extent of breast arterial calcifications detected at mammography has been associated with diabetes and hypertension and it seems to be correlated with the extent of coronary atherosclerosis. This review analyzes the relationship between coronary artery calcifications, breast arterial calcifications and the increased risk of subsequent cardiovascular events.
Pulmonary embolism is a common disease process associated with a high mortality rate. In patients with massive pulmonary embolism, systemic thrombolysis is considered to be the treatment of choice, but surgical or catheter thrombectomy may be alternative emergency treatments. A 36-year-old woman with massive pulmonary embolism and contraindications to thrombolytic therapy was treated with catheter thrombectomy using the Angiojet thrombectomy system. The procedure was successfully performed with an excellent immediate angiographic result at the site of the rheolytic thrombectomy. The clinical improvement was maintained while in-hospital and during a 4-month follow-up period, with a decrease to a normal level of the peak systolic pulmonary pressure. Our case report indicates that in patients with contraindications to systemic thrombolysis, catheter thrombectomy for massive pulmonary embolism may constitute a life-saving intervention.
Up to now the apical right ventricle one is the best pacemaker implantation. As a matter of fact this site is easily reachable by catheter and dislocations are few. Nevertheless evidence from the literature demonstrates dyssynchrony in myocardial contraction pattern, diastolic dysfunction and mismatch in perfusion and innervation. For this reason alternative sites of stimulation have been tested. One of these is represented by the right ventricular outflow tract. Some studies have compared this site to the apical one, showing a better cardiac index in the former; moreover QRS was narrower and fewer perfusional defects have been found. On the contrary, other studies did not show any significant differences between these two sites of stimulation. In order to obtain cardiac resynchronization, biventricular pacing, has been introduced, consisting in the contemporary stimulation of the lateral wall of both ventricles from a cardiac vein, originating from the coronary sinus. It has been proposed a bifocal stimulation, in which we introduce one catheter into the apex and another one in the right ventricular outflow tract: in this case QRS complex is narrower but cardiac output is not increased. A newer pacing technique is represented by direct His bundle stimulation. We can obtain a narrow QRS complex, like the physiological one. So we might solve problems related to intraventricular dyssynchrony.
Atrial septal aneurysm (ASA) is a well-recognized cardiac abnormality of uncertain clinical significance. It has early been reported as an unexpected finding during autopsy, but it may also be diagnosed in living patients by echocardiographic techniques. An association between ASA and focal cerebral ischemic events has been suggested. Nevertheless, the role of ASA as a risk factor for cerebral ischemia is poorly defined. Several studies have demonstrated a significantly higher proportion of ASA in the patients referred for transesophageal echocardiography after a cerebral ischemic event of unknown cause. However, ASA is often associated with other cardiac abnormalities such as patent foramen ovale, atrial septal defects, as well as mitral valve prolapse or atrial arrhythmias. Due to the fact that these abnormalities are also possible sources of cardiac emboli it is even more difficult to assess the embolic potential of an ASA, independently. In this review, we have examined most of the papers on this topic to try to define the prevalence of ASA in the stroke patients and how this abnormality could be a risk factor for recurrences of cerebrovascular events.
