We briefly describe our experience with transthoracic Doppler echocardiography for the direct evaluation of mid-distal left anterior descending coronary artery (LAD) stenosis. Three patients with previous myocardial infarction, scheduled for coronary flow reserve evaluation, underwent Doppler analysis of the mid-distal LAD. In all 3 cases, the mid-distal LAD stenosis was accurately quantified by the Doppler spectrum as confirmed by quantitative coronary angiography. Our study demonstrated the feasibility of transthoracic Doppler echocardiography in the discrimination of significant and non-significant mid-distal LAD stenosis. Limitations of such a technique could be related to the variable coronary anatomy and to the severity of the atherosclerotic process.

EchocardiographyVolume 21, Issue 8 p. 755-756 IMAGE SECTION Section Editor: Ivan D'Cruz, M.D. Echo-Color Doppler Diagnosis of an Unusual Cause of Neck Mass Giancarlo Scognamiglio M.D., Giancarlo Scognamiglio M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorGabriele Giordano M.D., Gabriele Giordano M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorPaolo Gallo M.D., Paolo Gallo M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorSalvatore Nilo M.D., Salvatore Nilo M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorManlio Cocozza M.D., Manlio Cocozza M.D. Department of Cardiology, Clinica Sanatrix, Naples, ItalySearch for more papers by this authorPasquale Guarini M.D., Pasquale Guarini M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this author Giancarlo Scognamiglio M.D., Giancarlo Scognamiglio M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorGabriele Giordano M.D., Gabriele Giordano M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorPaolo Gallo M.D., Paolo Gallo M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorSalvatore Nilo M.D., Salvatore Nilo M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this authorManlio Cocozza M.D., Manlio Cocozza M.D. Department of Cardiology, Clinica Sanatrix, Naples, ItalySearch for more papers by this authorPasquale Guarini M.D., Pasquale Guarini M.D. Department of Cardiology and ICU, Villa dei Fiori Hospital, Acerra, ItalySearch for more papers by this author First published: 25 September 2009 https://doi.org/10.1111/j.0742-2822.2004.03144.x Address for correspondence and reprint requests: Giancarlo Scognamiglio, M.D., Department of Cardiology and ICU, Villa dei Fiori Hospital, C.so Italia, 157, 80011 Acerra, Italy. Fax: 390-818-819-648; E-mail: gianca.scog@tiscali.it Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume21, Issue8November 2004Pages 755-756 RelatedInformation

BACKGROUND:We evaluated the diuretic output in patients with decompensated chronic heart failure (CHF), previously treated by i.v. infusion with dobutamine and dopamine (dob-dop) or with amrinone (amr). Our target was to identify the possible discrepancies in urinary output perhaps linked to the different type of inotropic stimulation in the two subsets.METHODS:Adjunctive therapy with dob-dop or amr was chosen because the administration of diuretics only, without cardiac support, as tested in previous hospitalizations, had been demonstrated to produce unfavourable results, mainly expressed by finding of a low output syndrome in 50% of cases or more. The administration of i.v. infusion was maintained during 17 hours (1000 min approximatively), and included infusion in separate pumps of the two amines, dobutamine at dose of 5 micrograms/kg/min and dopamine at dose of 2.8 micrograms/kg/min or, alternatively, i.v. infusion of amr, administered at dose of 7 micrograms/kg/min. Infusion volumes were similar in the two subsets. The two subsets were homogeneous relatively to renal impairment, i.e. to the parameters (urinary Na, U/P creatinine, U/P urea, urinary osmolality) we fixed as markers idoneous to demonstrate the occurrence of organic renal damage (acute tubular necrosis).RESULTS:The diuresis was recovered in all 24 patients, and the urine volume resulted more pronounced in the subset attributed to the dob-dop at both the 8th and the 17th hour readings. We found no harmful alterations in HR and AP, whereas renal function parameters have been shown to enhance in both the dob-dop and amr arms. The diuretic effectiveness of the SIEV obtained by catecholamine implementation exercised a synergistic, favourable effect on diuresis, renal flow, glomerular filtration rate, and sodium post-proximal delivery. Amr resulted less effective then dob-dop simultaneous administration relatively to the diuretic effect. No remarkable differences were found in the two subsets as regards the heart rate, whereas a decrease in arterial pressure was found after amr. A persistent shift towards a condition of chronic renal failure, was identified in 4/24 patients, the two groups despite of the prolonged treatment at optimized doses: no remarkable side effects were reported.CONCLUSIONS:Thus, the selective effect upon renal hemodynamics, as exercised by dob-dop infusion low doses of dop, together with the enhanced renal output due to dob, has been shown to be more effective than amr influence: thus, the catecholamine therapeutical approach has been demonstrated to possess the best effectiveness in excitation of diuresis, among the CHF oliguric patients.

In a controlled, randomized, 6-year trial the safety and efficacy of picotamide, a dual-action antithromboxane agent, were assessed in 50 patients with type 2 diabetes mellitus at increased risk of thrombotic vascular events. The patients were randomized to two groups of equal size and received 900 mg picotamide daily or placebo. After phase I (double-blind; years 1–2), patients receiving placebo were treated, if necessary, with antiplatelet drugs (aspirin, ticlopidine) while members of the other group continued to receive 600 mg picotamide daily. In the course of the study 21 vascular events occurred: 16 in the group receiving placebo (fatal myocardial infarction, n = 7; non-fatal stroke, n = 3) and five in the group receiving drug (fatal myocardial infarction, n = 2) ( P < 0.005; Fisher's exact test). One patient (placebo group) died of malignant disease. During the initial double-blind phase a total of nine vascular events was observed (six and three in the groups receiving placebo and drug, respectively). Picotamide treatment was well tolerated and no major side-effects were observed during the study periods.

The ex vivo antiaggregatory activity of picotamide, a dual antithromboxane agent, was assessed to find whether it was maintained in long-term treatment. In a double-blind, placebo-controlled 2-year study, 50 type 2 diabetic patients (35 men and 15 women; mean age 66 ± 5 years) were enrolled and randomly given picotamide, 300 mg t.i.d. or the corresponding placebo. Platelet aggregation studies were performed at baseline and after 1, 3, 6, 12, 18 and 24 months. Compliance to the treatment was assessed by pill count at each visit. Forty-nine patients concluded the study. Starting from month 1, compared with placebo, picotamide-treated patients showed a significant inhibition of agonist-induced (ADP, arachidonic acid and collagen) platelet aggregation (–41%). The antiaggregatory effect was maintained throughout the study. At month 24, in the picotamide group, platelet aggregation was significantly lower compared with placebo (–30%). After 24 months of treatment, 20 out of 23 (86%) picotamide-treated patients showed a significant inhibition of platelet aggregation, whereas the remaining three patients had a normal platelet response. During the study, 12 patients suffered from thrombotic events of death: nine in the placebo group and three in the picotamide group, respectively. It was concluded that picotamide maintains its antiaggregatory effect, in long-term treatment, in more than 85% of patients.

The prevalence of carotid kinking and coiling in patients with hypertension or diabetes was investigated. The authors studied three groups: 130 subjects with hypertension, 105 with diabetes, and 50 normal subjects who were comparable for age, sex distribution, and the presence of other risk factors. Color flow ultrasonography of the extracranial carotid arteries was performed by standard technique. Hard-copy photographs were obtained in three long-axis and three short-axis projections. The prevalence of carotid kinking and coiling was significantly higher in the group of hypertensive patients than in diabetics and normal subjects (14.6% vs 2% and 14.6% vs 4%, respectively; P < 0.01 for both comparisons). The prevalence of carotid kinking was associated with the duration of hypertension, whereas it did not show any association with cigarette smoking and serum cholesterol levels. A long-term observation of these patients is necessary for determining the natural history of carotid kinking and the potential for modification by adequate antihypertensive therapy. The results of this study show that a significantly higher prevalence of carotid kinking is present in hypertensive patients in comparison with normal subjects and diabetics and this is correlated with the time of onset of hypertension.

BACKGROUND AND PURPOSE:We assessed the effects of long-term treatment with picotamide, an antiplatelet agent with dual antithromboxane activity, on the evolution of early asymptomatic carotid atherosclerotic lesions in diabetic patients.METHODS:In a double-blind, placebo-controlled, 2-year study, 50 type II normotensive diabetic patients (35 men; mean age, 66 +/- 5 years) with asymptomatic mild or moderate nonstenotic (< 50%) carotid atherosclerotic lesions and negative history of cerebrovascular ischemic events were enrolled and randomly given picotamide (300 mg TID) or the corresponding placebo. A high-resolution, real-time B-scan echographic assessment of carotid arteries was performed at baseline and after 1, 3, 6, 12, 18, and 24 months of double-blind treatment. Prevalence and evolutionary trends of carotid atherosclerotic lesions (number per patient and mean stenosis expressed as percent) were considered as efficacy primary end points.RESULTS:At baseline, mean +/- SD numbers of carotid atherosclerotic lesions per patient were 2.7 +/- 1.8 and 2.2 +/- 1.2 in the picotamide and placebo groups, respectively. Mean +/- SD percent stenosis was 25.3 +/- 7% in the picotamide group and 27.3 +/- 6% in the placebo group. Forty-nine patients completed the study. At month 24, the placebo group (n = 24) showed a significant progression in number of carotid atherosclerotic lesions (3.04 +/- 1.8; P < .02 versus baseline) and in mean percent stenosis (35 +/- 17%; 95% confidence interval, 33% to 37%; P < .01 versus baseline). In the picotamide group (n = 25), mean number of carotid atherosclerotic lesions (2.7 +/- 1.6) and percent stenosis (26 +/- 9%; 95% confidence interval, 24.8% to 27.2%) remained unchanged. At month 24, compared with randomized placebo, lesion numbers (P < .03) and percent stenosis (P < .01) in the picotamide group were significantly lower. During the study, 12 patients experienced major or minor ischemic vascular events (9 in the placebo group and 3 in the picotamide group; P = .07).CONCLUSIONS:In diabetic patients compared with patients receiving placebo, long-term treatment with picotamide can slow the evolution of early carotid atherosclerotic lesions, inhibiting progression of plaque number and growth.

Several studies have suggested an increased incidence of thromboembolic events in patients with VVI pacemaker (VVI patients); furthermore, other authors have demonstrated that a treatment with anticoagulants or antiplatelet drugs may be effective in reducing thromboembolic events, thus suggesting an increased formation of platelet thrombi in these patients. In this respect, platelet aggregability was investigated in ten VVI patients and ten age– and sex–matched subjects. β–thromboglobulin (β–Tg) and platelet factor 4 (PF4) plasma levels were determined as weJJ as platelet aggregation induced by ADP, collagen, epinephrine, and arachidonic acid. Plasma β–Tg JeveJs were increased in the patient group (86 ± 24 vs 24 ± 13 ng/mL; P < 0.001) in presence of normal PF4 values (14 ± 11 vs 13 ± 6 ng/mL; NS). Aggregation curves showed abnormal values of maximal amplitude, slope, and lag time. In particular, maximal amplitude was significantJy higher in VVI patients as compared with controls (ADP P < 0.01, collagen P < 0.001, adrenaline P < 0.01, arachidonic acid P < 0.05). These findings strongly suggest an increase of platelet activity in VVI patients.

A two years follow up on 105 diabetic patients and 50 normal subjects was carried out by high resolution real time echotomography, aiming to evaluate the prevalence and the evolutionary trends of carotid atherosclerotic plaques. The prevalence of atherosclerotic lesions was higher in diabetic patients than in normal subjects, and the most part of them showed an "intermediate" echographic pattern, minimal stenosis and regular surface. The results of the two years follow up indicate that the "soft" and the "hard" plaque types were those showing a more significant progression toward to the "mixed" type. "Hard" and "mixed" plaques, particularly those showing irregular surface, resulted most associated with higher degree of vessel stenosis. Four diabetic patients experienced three minor and one major ischemic events during the follow up; however all the patients had shown plaques with "intermediate" pattern, regular surface, and no signs of vessel stenosis progression. Further studies, performed for longer period of time with a higher number of patients are needed to evaluate the evolutionary trends of carotid plaques in diabetic patients and their relationship with clinical ischemic events.

The kinetics of idebenone (45 mg twice daily p.o.) in 6 Caucasian chronic hepatopathic patients without portal hypertension were studied. The pharmacokinetic parameters were evaluated both for single (day 1) and multiple (day 10) administrations. These 6 patients showed a first order bi-compartimental kinetic curve for idebenone and for its metabolites, superimposable on the curves obtained from healthy volunteers. The C(max) parameters, tmax and bioavailability confirm the absence of accumulation. On day 12, 48 h after the last administration (performed on day 10), there was no evidence of residual drug. One of these patients was being treated with diuretics (chlorthalidone) and with perfusion fluids, including 5% glucose, and no interference was shown between the two drugs. There is no evidence of any particular side effect or alteration of the haematochemical parameters that could be thought to be drug related. This study confirms that idebenone at the dose of 90 mg/day p.o. administered to hepatopathic patients does not cause accumulation or toxicity.

This study evaluated the efficacy and tolerability of idebenone, a new neuroactive drug, in 33 patients aged from 50 to 80 years. They were affected by chronic cerebrovascular disease (CCVD) and their last cerebrovascular accident had taken place at least 3 months prior to enrollment. All these subjects presented a score within the range of the following psychometric scales: Hamilton Scale for Depression <24; Hachinski Dementia Score >/=18 and < 25; Mini Mental State >/=16 and =22; Hachinski Ischemic Score =7. Even without a cortical degenerative disease, their cerebral computerized tomography (CT) scan had to be positive for CCVD. The study was divided into three different periods: (1) 7 days from the enrollment and wash-out; (2) 3 months of treatment (idebenone 45 mg b.i.d. per os); (3) 1 week for the follow up. During the study, the following evaluation scales were administered: Sandoz Clinical Assessment of Geriatrics (SCAG), Gottfries-Brane-Steen (GBS), Instrumental Activity of Daily Living (IADL), Greene Relatives' Stress Scale (GRSS), Toulouse Piéron, Randt Memory Test. The results show that idebenone is effective both in improving the sense of psycho-physical wellbeing and in improving cognitive, attentive and behavioural efficiency. The tolerability of the treatment was very good.

The clinical efficacy of heparan sulphate* was investigated in a randomised, double-blind controlled study in patients with occlusive arterial disease of the lower limbs at stage II of the Fontaine classification. Two groups of twenty patients with a history of claudication for at least six months were given either 100 mg b.i.d. heparan sulphate or 50 mg b.i.d. mesoglycan for three months. At the end of treatment, pain free walking distance and systolic ankle-arm pressure ratio improved more in the heparan sulphate than in the mesoglycan group. Heparan sulphate also significantly reduced ADP and collagen induced platelet aggregation and these findings strongly suggest that the drug may be effective in reducing platelet activation. The results of this study indicate that heparan sulphate may have a beneficial effect both in the treatment of peripheral arterial vascular disease and in the prevention of associated thrombotic events.

An 18-month follow-up study was performed to compare the safety and efficacy of ketanserin and nifedipine in 35 consecutive hypertensive patients with intermittent claudication. Blood pressure values, painfree walking distance, systolic ankle-arm pressure ratio, and laboratory parameters were measured before and after months 1, 3, 6, 9, 12 and 18 of treatment. Cardiovascular events were recorded throughout the study. The subjects assigned to either group were matched for age, sex, clinical features, and potential risk factors. When compared with baseline values, both drugs were significantly effective in reducing blood pressure levels. The antihypertensive effect of ketanserin was more gradual than that of nifedipine. Main painfree walking distance increased more significantly in the ketanserin group (p < 0.01) than in the nifedipine group (p = 0.05), and was maintained throughout the treatment period. Systolic ankle-arm pressure ratio increased significantly (p = 0.05) with both drugs during the 6 months of therapy. At the end of treatment both painfree walking distance and systolic ankle-arm pressure ratio improved more significantly (p = 0.05) in the ketanserin group than in the nifedipine group. Throughout the entire treatment period, ketanserin did not alter heart rate, while nifedipine increased mean heart rate significantly (p < 0.01). Two ketanserin and two nifedipine patients complained of mild adverse effects. No significant changes were observed in biochemical or hematological parameters during the entire study. One patient from the ketanserin group vs. 3 patients from the nifedipine group experienced significant ischemic cardiovascular events. However, the difference did not reach statistical significance (p = 0.27, Fisher exact test). Results indicate that ketanserin has a more significant effect than nifedipine in the treatment of hypertensive patients with associated obstructive peripheral vascular disease.

A young Italian patient with a multisystem disorder and a solitary osteosclerotic bone lesion is described. His clinicopathological situation involved sensory-motor polyneuropathy, organomegaly, endocrine dysfunction, skin alterations, edema of the lower limbs and generalized lymphadenopathy. These features were consistent with the diagnosis of POEMS syndrome, reported primarily in Japanese patients. M components were not found in this patient's serum or urine. Bone marrow biopsy showed only a slight plasma cell infiltrate; histological study of the sural nerve evidenced a mixture of both axonal degeneration and segmental demyelinization. Lymph node biopsy revealed peculiar pathological changes resembling those of type II Castleman-like disease. A wide bone defect with osteosclerotic margins and trabeculation was evidenced in the right ilium. The relationship of these findings to plasma cell dyscrasias is discussed. After prednisone and local radiotherapy failed, the patient was treated with human recombinant interferon for 18 months. After three months of therapy he has experienced remarkable improvement of his neurological symptoms and almost complete recovery of organomegaly and lymphadenopathy. These improvements have continued to the present.

An investigation on the therapeutic effect of L-carnitine was performed at three different centres and included two hundred patients, 40 to 65 years of age, with exercise-induced stable angina. In one hundred randomly selected patients the drug was administered orally in daily doses of 2 g in addition to the already instituted therapy, and the effect studied over a 6-month period. Compared with the control group, these patients showed a significant reduction in the number of premature ventricular contractions (PVC) at rest, as well as an increased tolerance during ergometric cycle exercise as demonstrated by an increased maximal cardiac frequency, increased maximal systolic arterial blood pressure and therefore also increased double cardiac product and reduced ST-segment depression during maximal effort. This was accompanied by improvement in cardiac function and resultant performance, as shown by an increase in the number of patients belonging to class I of the NYHA classification and a reduction in the consumption of cardioactive drugs. Laboratory analysis showed an improvement in plasma lipid levels. The authors conclude, after having discussed the particular metabolic mechanisms, that L-carnitine undoubtedly represents an interesting therapeutic drug for patients with exercise-induced stable angina.

This paper reports a case of endomyocardial disease due to hypereosinophilic syndrome. Two-dimensional echocardiography showed prevalent right ventricular involvement, with obliteration of the apex due to an echogenic mass progressively filling the whole ventricular cavity. RMN accurately defined the presence and the characteristics of the infiltrative mass in the right ventricular chamber. A different intensity of spin-echo imaging sequence was used to differentiate between thrombotic and infiltrative leukemic images. It is concluded that prevalent right ventricular involvement during eosinophilic endomyocardiopathy is a relatively rare disease which can be detected and evaluated by the use of echocardiography and RMN studies.

The clinical efficacy of picotamide was investigated in a randomized, double- blind, placebo-controlled study in patients with peripheral occlusive arterial disease of the lower limbs at functional stage II of the Fontaine classification. Forty patients with a history of claudication for at least six months were admit ted to the study and were given either 3 x 300 mg tablets of picotamide (20 subjects) or three identical placebo tablets (20 subjects) for six months. The two groups of patients were similar in regard to clinical features and potential risk factors. At the end of treatment painfree walking distance and systolic ankle-arm pressure ratio improved more in the picotamide than in the placebo group (p=0.05). Systolic ankle pressure curves, determined before and after the six- month treatment, showed a positive trend to a higher postexercise ankle pres sure and a faster return to the preexercise levels in the picotamide group; however, the difference was not statistically significant. Laboratory monitoring revealed a slight prolongation of bleeding time, a significant decrease in arachi donic acid-induced platelet aggregation, and an enhanced fibrinolysis with ab sence of interference with hemostasis in the picotamide group. One patient in the placebo group developed a major cardiovascular event (angina pectoris) during the study. These results indicate that picotamide is an effective drug that may modify the natural course of intermittent claudication and associated vascular prob lems.