The electrical or pharmacological acceleration of heart rate is shown to be an effective therapeutic mean in some types of arrhythmias refractory to common antiarrhythmic drugs. The Authors report two cases of relapsing ventricular arrhythmia, treated successfully through i.v administration of atropine followed by high frequency endocavitary electrostimulation. Besides, three more cases are reported where the treatment of cardiac arrhythmia has been performed successfully by acceleration of heart rate after atropine. The most sensitive arrhythmias to this kind of treatment, are those whose origin can be attributed to a re-entry mechansim, and specifically those which present a particular shape of the ECG labeled by French Authors as "torsades de pointe".

schedule, starting antihypertensive treatment in elderly hypertensive patients (60 to 75 years old) with 25 mg of hydrochlorothiazide once daily and doubling the dose if a satisfactory response was not achieved, was compared with antihypertensive treatment of 100 mg of metoprolol once daily, adding 12.5 mg of hydrochlorothiazide for patients whose response was not satisfactorialy achieved with metoprolol alone. Systolic and diastolic blood pressure was significantly reduced with both regimens. The frequency rates of responders (diastolic blood pressure, \m=le\95mm Hg) in the metoprolol group and the hydrochlorothiazide group were 50% and 47% after four weeks and 65% and 61% after eight weeks, respectively. There were no significant differences in total symptom score or single symptoms between the regimens, but significantly more patients had hypokalemia and hyperuri- cemia with the hydrochlorothiazide regimen. Thus, we conclude that beginning antihypertensive treatment with 100 mg of metoprolol once daily and adding a small dose of hydrochlorothiazide (12.5 mg) in patients whose

Surgical treatment of atrial fibrillation (AF) has a high success rate and nowadays simpler and faster procedures have been proposed. The following is a description of the case of a patient who, after a modified Maze procedure, developed an atypical left atrial flutter and underwent a successful radiofrequency ablation procedure. A 71-year-old male underwent surgical biological valve replacement and a concomitant modified Maze procedure. After surgery the patient developed a persistent atrial arrhythmia with severe symptoms and refractory to any drug. For this reason, an electrophysiological study was planned. We performed a three-dimensional atrial mapping using the real-time position management system (Boston Scientific). Right atrial mapping indicated an early activation area on the septum. After transseptal puncture, left atrial mapping showed a reentry circuit around the mitral annulus with positive entrainment. A linear lesion was made between the mitral annulus and the superior right pulmonary vein and sinus rhythm was restored. After 7 months of follow-up the patient is asymptomatic and still in stable sinus rhythm. In conclusion, the follow-up of surgical AF may be improved by close collaboration between the surgeon and electrophysiologist. The available data suggest that a combined surgical and percutaneous approach could be the strategy of choice.

BACKGROUND:Combination therapy with aspirin plus ticlopidine has become the reference antithrombotic therapy after coronary stenting. However despite its effectiveness, ticlopidine is associated with a significant incidence of severe side effects. Thus, clopidogrel, a ticlopidine analogue with an excellent safety profile, has been introduced in clinical practice. To date only a few, underpowered studies comparing the clinical efficacy of clopidogrel and aspirin versus standard combination therapy after coronary stenting have been performed and the odds ratios (OR) vary substantially among them. The purpose of the present investigation was to update the data regarding this issue by means of a formal meta-analysis.METHODS:Ten studies were considered suitable for analysis. The OR were calculated for 30 days of follow-up in patients who had undergone successful coronary stenting. Primary endpoints were a composite of death and non-fatal myocardial infarction (MI) (efficacy endpoint) as well as a composite of major adverse side effects (safety endpoint) as considered in every single study. Secondary endpoints were a composite of major adverse cardiac events, according to single study definition, and individual cardiac events as well.RESULTS:Overall, 11688 patients were included. At 30 days, the OR for death and non-fatal MI was 0.63 (95% confidence interval-CI 0.47 to 0.85, p = 0.003) in favor of patients treated with clopidogrel and aspirin. There was also a trend toward less major adverse cardiac events (OR 0.83, 95% CI 0.66 to 1.03, p = 0.1), less mortality (OR 0.70, 95% CI 0.40 to 1.25, p = 0.2), and less non-fatal MI (OR 0.76, 95% CI 0.54 to 1.07, p = 0.1). Furthermore, OR for major adverse side effects was 0.53 (95% CI 0.42 to 0.66, p < 0.00001) in favor of clopidogrel. Similarly, drug intolerance was significantly reduced by clopidogrel (OR 0.51, 95% CI 0.36 to 0.72, p < 0.0001). Fewer patients on clopidogrel developed neutropenia or thrombocytopenia (OR 0.58, 95% CI 0.18 to 1.81, p = 0.3), while the incidence of severe bleeding was similar in the two groups (OR 1.19, 95% CI 0.71 to 1.99, p = 0.5).CONCLUSIONS:The present meta-analysis demonstrates that clopidogrel reduces the 30-day combined endpoint of death and non-fatal MI, thereby showing a superior clinical efficacy compared to ticlopidine in patients who had undergone successful coronary stenting. A significantly better safety profile than ticlopidine was also reported, confirming on a larger scale the findings of randomized comparative trials.

To date, only a few studies have compared the clinical efficacy of intracoronary ultrasound (IVUS)‐guided to angiographically guided stenting. Furthermore, it is not yet known whether the lower restenosis rate shown with the former strategy would translate into a substantial clinical advantage. Therefore, the aim of the present investigation was to improve the level of evidence of these studies by means of a formal meta‐analysis. Nine studies were considered suitable for analysis. Odds ratios (ORs) were calculated for 6‐month clinical follow‐up. Primary endpoint was a composite of death and nonfatal myocardial infarction (MI), as considered in every single study. Secondary endpoints were major adverse cardiac events (MACEs), according to single study definition, the individual cardiac events, as well as several pre‐ and postprocedure and follow‐up angiographic parameters. Overall, 2,972 patients were included. At 6 months, the OR for death and nonfatal MI was 1.13 (95% CI = 0.79–1.61; P = 0.5) for patients with IVUS‐guided stenting. However, patients with IVUS‐guided stenting had less target vessel revascularizations (OR = 0.62; 95% CI = 0.49–0.78; P = 0.00003) and MACEs (OR = 0.79; 95% CI = 0.64–0.98; P = 0.03) compared to angiographically guided stenting. In addition, subjects treated with IVUS‐guided stenting had significantly less binary restenosis (OR = 0.75; 95% CI = 0.60–0.94; P = 0.01). The present meta‐analysis demonstrates that IVUS‐guided stenting implantation has a neutral effect on long‐term death and nonfatal MI compared to an angiographic optimization. However, IVUS‐guided stenting significantly lowers 6‐month angiographic restenosis and target vessel revascularizations. Whether these benefits could be very helpful when dealing with lesions at high risk for restenosis is still an issue. Cathet Cardiovasc Intervent 2003;59:314–321. © 2003 Wiley‐Liss, Inc.

Background: Disruption of the atherosclerotic plaque is a common feature of both acute coronary syndromes and balloon dilatation of coronary artery stenoses.Hypothesis: The study was undertaken to evaluate whether the known association of cholesterol levels and acute coronar syndromes also exists for the occurrence of angiographically detectable endothelial disruption (ED) following coronary angioplasty.Methods: For this purpose, we examined 79 consecutive patients (men/women 58/21; mean age: 62+/-11 years), with a noncalcified, de novo, significant stenosis in a single native coronary artery, undergoing elective coronary intervention because of stable effort angina. Coronary angioplasty was performed using regular balloon catheters, aiming for a balloon/artery ratio of 1, with stent implantation allowed only provisionally. Following balloon dilatation, patients were divided into two groups according to the presence or absence of angiographically detectable ED.Results: Endothelial disruption occurred in 28 patients (35%). The two groups with and without ED were comparable with respect to clinical, angiographic, and procedural parameters. A history of hypercholesterolemia was significantly more frequent in patients with ED (93 vs. 2%; p<0.001). Total and low-density lipoprotein (LDL) cholesterol levels were significantly higher in the group with ED (230.1+/-46.5 vs. 204.4+/-30.2 mg/dl, p<0.05; and 150.6+/-39.2 vs. 125.8+/-26 mg/dl, p<0.03, respectively). A cut-off value of LDL cholesterol greater than or equal to135 mg/dl identified patients at higher risk of developing ED.Conclusion: High cholesterol levels appear to favor the occurrence of ED during coronary angioplasty. Aggressive lipid-lowering therapy and a more careful procedural approach may be war-ranted in patients with hypercholesterolemia undergoing coronary interventions in order to decrease the occurrence of ED and the associated clinical (acute ischemia) and procedural (stent implantation) consequences.

A modern cardiology department has very frequent relations with a heart surgery center for the management of stable and unstable patients with coronary artery disease. Therefore, these relations need to be formally defined. This impelling necessity stems from the clinical evidence that a high number of unstable patients need a timely revascularization as well as from the economical pressure to correctly allocate the limited surgical resources available. Thus three main contexts should be clearly defined: 1) surgical support during coronary angioplasty (PTCA), when this activity is performed on-site; 2) timely revascularization of unstable patients admitted to the coronary care unit or the ward; 3) surgical prioritization of stable subjects undergoing diagnostic catheterization. The increased experience in PTCA as well as several technical improvements, namely stents, has dramatically reduced the need for emergency surgical revascularization and has induced an evolution in the stand-by strategy with new concepts such as "surgical back-up" or "next available operating room". Therefore, the role of heart surgery has switched from the emergency treatment of the frequent complications of PTCA to the timely revascularization of subjects not suitable for percutaneous interventions. Thus, PTCA "without on-site" surgical facilities is gaining widespread acceptance. With the aim of defining the requirements to perform PTCA at hospitals without coronary surgery facilities, several aspects are reviewed. Furthermore, the concepts of timely surgical revascularization in unstable patients as well as the management of surgical prioritization for stable subjects submitted to diagnostic catheterization are discussed in detail. Therefore, there is still a tight relation between cardiology and heart surgery in several clinical contexts. However, the main issues of these relations as well as outcomes do not differ significantly whether heart surgery is on-site or off-site.

BACKGROUND:Since an inverse relationship between percutaneous coronary angioplasty (PTCA) case-load and in-hospital major adverse cardiac events (MACE) exists, we intended to evaluate the performance of low-volume PTCA operators, during the first year of our interventional program, by applying the more accurate index represented by the MACE rate within the first month.METHODS:The data relative to both the PTCA procedure and the control visit 3-4 weeks later, were retrospectively reviewed. Death, myocardial infarction and need for revascularization were the end-points evaluated, both globally and with respect to the individual operators.RESULTS:During 1999, 61 consecutive patients (53M, 8F; mean age: 59.9+/-10.4 years) were treated by two full-trained operators. Stable angina was the indication in 75% of cases. Comorbidities as diabetes and prior revascularization, were present in 16 and 5% of cases, respectively. Multivessel procedures were performed in 33% of cases, with a total number of lesions of 84 (77% A/B1 type). Stents were implanted in 70% of cases, as a bail-out in 12%. Procedural success rate was 93%. Overall one-month MACE rate was 3.3%, accounted for by 1 in-hospital emergency coronary surgery occurred to operator 1 (3.6% one-month MACE rate) and 1 elective coronary operation performed in a stable patient previously treated by operator 2 (3% one-month MACE rate).CONCLUSIONS:PTCA performed in a low-volume center by low-volume operators is not necessarily associated with a poor outcome, provided that adequate selection of low-risk cases is accomplished. Although only 52% of the Italian centers met in 1999 the recommended volume standards, reaching optimal case-load should anyway be pursued. Some time should however be conceded, provided that close monitoring of one-month MACE rate shows adequate performance of both the institution and the operators.

BACKGROUND:Due to its pivotal role in the management of patients with ischemic heart disease, the use of coronary angiography has been continuously and progressively increasing over the years. However, an inappropriate rate of its utilization has been reported in 2 to 58% of cases. The aim of our study was therefore to evaluate the appropriateness of the indications for coronary angiography at our Institution.METHODS:All the patients undergoing coronary angiography at the catheterization laboratory of the Maggiore Hospital in Bologna during 1999 were evaluated. By retrospectively reviewing the data forms filled in at the time of insertion of the patient on the waiting list, the indications for coronary angiography were categorized as appropriate (class I/IIa), of uncertain value (class IIb) and inappropriate (class III), according to the guidelines of the American College of Cardiology/American Heart Association. In a blind fashion to this classification, the reports of coronary angiography were also reviewed to determine, both globally and in the different clinical subsets, the prevalence of significant coronary stenoses and of angiographically normal vessels.RESULTS:Class I/IIa indications were found in 72% of patients, as opposed to 28% in class lIb and none in class III. In the clinical subsets of stable angina, previous myocardial infarction and out-of-hospital cardiac arrest, the appropriateness was significantly higher, ranging from 74 to 100%, compared to recent myocardial infarction (63%) and unstable angina (59%) (accounting by itself for about one half of all class IIb indications). The overall prevalence of significant coronary artery disease was 87%, while in only 3% of cases did coronary angiography reveal normal vessels.CONCLUSIONS:In our population, the use of coronary angiography was highly appropriate and only seldom of uncertain value. The accurate noninvasive selection of patients which, in view of the limited access to the catheterization laboratory, we needed to perform before proceeding to coronary angiography probably played a major role in these results.

BACKGROUND:Exercise testing (ET) is the preferred initial strategy for risk stratification after acute myocardial infarction (MI) in patients who are able to exercise and have an interpretable electrocardiogram (ECG). Although the current guidelines do not recommend annual follow-up ET of symptom-free patients years after MI, this is still common practice worldwide. Thus, this study was undertaken to explore the value of ET in the prediction of cardiac events in stable, medically-treated patients with a remote history of Q-wave MI.METHODS:Seven hundred sixty-six consecutive patients (male gender 89%, mean age 57 +/- 8.6 years) with a remote history of Q-wave MI (mean time from MI 2.8 +/- 0.75 years), who underwent Bruce treadmill ET and whose data were prospectively entered into our institutional database, were enrolled. Patients were followed up for an average of 7 +/- 0.6 years. The endpoints were: 1) primary (cardiac death or non-fatal reinfarction), 2) secondary (cardiac death, non-fatal reinfarction or unstable angina), and 3) all-cause mortality.RESULTS:Two hundred and eighty-two recurrent ischemic events occurred [cardiac death (n = 67), non-fatal infarction (n = 54), and unstable angina (n = 161)] and an additional 103 patients underwent revascularization procedures. Multivariate risk predictors for the primary endpoints were: older age relative risk-RR 1.04 (95% confidence interval-CI 1.01-1.06 per year), baseline heart rate > or = 90 b/min RR 2.34 (95% CI 1.37-4.0), and ST segment depression at rest ECG RR 1.91 (95% CI 1.22-2.98). For the secondary endpoints the predictors were: older age RR 1.02 (95% CI 1.01-1.04 per year), baseline heart rate > or = 90 b/min RR 1.61 (95% CI 1.06-2.45), ST segment depression at rest ECG RR 1.8 (95% CI 1.33-2.44), exercise angina RR 1.94 (95% CI 1.4-2.69), and exercise time stage < or = II RR 1.56 (95% CI 1.16-2.1). The addition of exercise variables improved the predictive power of the multivariate model only for secondary and all-cause mortality endpoints. Furthermore, clinical stratification alone had a predictive value comparable to that of ET results.CONCLUSIONS:Although the identification of patients at risk for recurrent cardiac events is still the main goal of re-stratification in stable, asymptomatic patients with previous MI, the value of ET in these cases is negligible. Markers of exercise ischemia or ventricular dysfunction would be weak at best. The poor predictive performance of ET severely limits its usefulness as a screening measure for identifying patients likely to benefit from cardiac catheterization and revascularization. Therefore, cost-ben-efit considerations would suggest that risk stratification by means of ET in stable, asymptomatic patients with a remote history of Q-wave MI is inappropriate.