SummaryObjectiveTo study the effect of a iodine load on thyroid function of patients with ischaemic heart disease (IHD) and the long‐term influence of unknown subclinical hyperthyroidism.ContextSubclinical hyperthyroidism is considered an independent risk factors for cardiovascular morbidity of patients with IHD. They routinely undergo coronary angiography with iodine contrast media (ICM) which may induce or even worsen hyperthyroidism.DesignA cross‐sectional study followed by a longitudinal study on patients with subclinical hyperthyroidism.Patients810 consecutive IHD outpatients without known thyroid diseases or treatment with drugs influencing thyroid activity undergoing elective coronary angiography.MeasurementsWe evaluated thyroid function either before and 1 month after ICM; patients with thyrotoxicosis at baseline or after ICM were then followed up for 1 year.Results58 patients had hyperthyroidism at baseline (HB, 7.2%), independently associated to FT4 levels, thyroid nodules and family history of thyroid diseases. After ICM, the prevalence of hyperthyroidism was 81 (10%). Hyperthyroidism after ICM was positively predicted by baseline fT4 levels, thyroid nodules, age over 60, male gender, family history of thyroid diseases. Three months after ICM, 34 patients (4.2%) still showed hyperthyroidism (22 from HB, 13 treated with methimazole). One year after ICM, hyperthyroidism was still present in 20 patients (2.5%, all from HB, 13 treated).ConclusionsThe prevalence of spontaneous subclinical hyperthyroidism in IHD is surprisingly elevated and is further increased by iodine load, particularly in patients with thyroid nodules and familial history of thyroid diseases, persisting in a not negligible number of them even after one year.

A 29-year-old woman with two mechanical valve prostheses was referred to our institution for sudden and self-resolved diplopia 2 weeks after childbirth. From the beginning of pregnancy, nadroparin was started instead of warfarin. The echocardiogram performed at hospital admission revealed a severe aortic prosthesis regurgitation due to incomplete leaflet apposition with a prosthetic aortic transvalvular gradient increase. Three-dimensional transoesophageal echocardiography revealed a thrombus located between the two prostheses, causing intermittent aortic valve malfunction. Intravenous heparin was started. Three days later, a second transoesophageal echocardiogram revealed a decreased aortic transvalvular gradient, but an oval thrombus adhered to the mitral prosthesis and fluctuating through the prosthetic valve was detected. Tissue plasminogen activator infusion was started. To reduce cerebral embolization, carotid filters used during artery angioplasty were placed in common carotid arteries, left and right. No complication occurred during and after the procedure. With thrombus absence at 30-min transoesophageal echocardiography, filters were removed. The patient continued intravenous heparin until achievement of a therapeutic international normalized ratio range and she was asymptomatic on discharge.

Aspirin resistance occurs most frequently in diabetic patients and is associated with poor prognosis. The purpose of this study was to evaluate the prevalence of aspirin resistance in a cohort of diabetic patients and whether it can be reversed using more bioavailable aspirin formulations.

Sudden cardiac death is the largest cause of natural death in Western countries. 1 Zipes D. Wellens H. Sudden cardiac death. Circulation. 1998; 98: 2334-2351 Crossref PubMed Scopus (1631) Google Scholar , 2 Myerburg R. Kessler K. Castellanos A. Sudden cardiac death: epidemiology, transient risk, and intervention assessment. Ann Intern Med. 1993; 15: 1187-1197 Crossref Scopus (462) Google Scholar Most sudden cardiac deaths are caused by malignant ventricular arrhythmias. The occurrence of sudden cardiac death 3 Barron H. Lesh M. Autonomic nervous system and sudden cardiac death. J Am Coll Cardiol. 1996; 27: 1053-1060 Abstract Full Text PDF PubMed Scopus (229) Google Scholar and ventricular tachyarrhythmia (VT)/ventricular fibrillation (VF) episodes 4 Lombardi F. Makikallio T.H. Myerburg R.J. Huikuri H. Sudden cardiac death: role of heart rate variability to identify patients at risk. Cardiovasc Res. 2001; 50: 210-217 Crossref PubMed Scopus (103) Google Scholar , 5 Shusterman V. Aysin B. Gottipaty V. et al. Autonomic nervous system activity and the spontaneous initiation of ventricular tachycardia ESVEM Investigators. Electrophysiologic Study Versus Electrocardiographic Monitoring Trial. J Am Coll Cardiol. 1998; 32: 1891-1899 Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar is associated with an imbalance between sympathetic and parasympathetic tone. Spinal cord stimulation (SCS) could restore autonomic balance by inhibiting sympathetic stimulation of the heart. Accumulating evidence demonstrates that SCS is a safe antianginal treatment that does not hide myocardial infarction symptoms. 6 DeJongste M.J. Spinal cord stimulation for ischemic heart disease. Neurol Res. 2000; 22: 293-298 PubMed Google Scholar Recently, it was shown that SCS modifies the capacity of intrinsic cardiac neurons to generate activity. 7 Foreman R.D. Linderoth B. Ardell J.L. et al. Modulation of intrinsic cardiac neurons by spinal cord stimulation: implications for its therapeutic use in angina pectoris. Cardiovasc Res. 2000; 47: 367-375 Crossref PubMed Scopus (151) Google Scholar SCS also acts to suppress the excitatory effects that local myocardial ischemia exerts on such neurons. 7 Foreman R.D. Linderoth B. Ardell J.L. et al. Modulation of intrinsic cardiac neurons by spinal cord stimulation: implications for its therapeutic use in angina pectoris. Cardiovasc Res. 2000; 47: 367-375 Crossref PubMed Scopus (151) Google Scholar Issa et al 8 Issa Z.F. Zhou X. Ujhelyi M.R. et al. Thoracic spinal cord stimulation reduces the risk of ischemic ventricular arrhythmias in a postinfarction heart failure canine model. Circulation. 2005; 11: 3217-3220 Crossref Scopus (131) Google Scholar showed in dogs that the occurrence of VT/VF is reduced from 59% to 23% when SCS was applied during transient myocardial ischemia. SCS also appeared to have an antiarrhythmic effect on spontaneous nonsustained VT and sustained VT during ischemia reperfusion in association with a reduction of repolarization alterations in a porcine ischemia-reperfusion model. 9 Odenstedt J. Linderoth B. Bergfeldt L. et al. Spinal cord stimulation effects on myocardial ischemia, infarct size, ventricular arrhythmia, and noninvasive electrophysiology in a porcine ischemia-reperfusion model. Heart Rhythm. 2011; 8: 892-898 Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar In addition, long-term SCS significantly decreased ventricular arrhythmias and improved cardiac contractile function in canine heart failure. 10 Lopshire J. Zhou X. Dusa C. et al. Spinal cord stimulation improves ventricular function and reduces ventricular arrhythmias in a canine postinfarction heart failure model. Circulation. 2009; 28: 286-294 Crossref Scopus (119) Google Scholar

Spinal cord stimulation (SCS) is believed to be effective in treating refractory angina. The need for SCS-related chest paresthesia, however, has hitherto made impossible placebo-controlled trials. Subliminal (non paresthesic) SCS, however, might be also effective on anginal pain. In this trial we compared subliminal SCS with paresthesic SCS and with sham SCS. Twenty-five refractory angina patients, who had never received SCS before, underwent SCS device implantation and were randomized to three groups: paresthesic SCS (group PS; n=10), subliminal SCS (group SS; n=7) or "sham" SCS (group NS; n=8). After 1month group NS patients were randomized to either group PS or SS. After 1month, changes in angina episodes (p=0.016), nitroglycerin use (p=0.015), angina class (p=0.02), quality of life score (p=0.05), and items 2 (p=0.008) and 3 (p=0.009) of Seattle angina questionnaire differed significantly among groups. Group PS showed significant improvement in outcomes compared to group NS, whereas there were no significant differences between groups SS and NS; furthermore, only nitroglycerin use differed significantly between groups PS and SS. At 3months, a significant difference between groups PS and SS was observed in angina attacks (p=0.002), but not in other variables. Thus, in this study, paresthesic, but not subliminal SCS was superior to sham SCS in improving clinical status in refractory angina patients. The lack of significant differences between PS and SS groups in this small study suggests that a possible role for subliminal SCS in individual patients deserves to be assessed in larger trials with appropriate statistical power.

Background: Despite the established benefit of intramuscular (i.m.) influenza vaccination, new adjuvants and delivery methods for comparable or improved immunogenicity are being explored. Intradermal (i.d.) antigen administration is hypothesized to initiate an efficient immune response at reduced antigen doses similar to that observed after i.m. full dose vaccination.Methods: in a randomized, partially blinded phase II study 224, healthy adults aged >= 18 to <= 60 years were randomly assigned to four groups and received trivalent influenza vaccine at single doses of 3.0, 4.5 and 6.0 mu g hemagglutinin (HA) antigen of each influenza virus strain via i.d. injection or 15.0 mu g HA of each influenza strain via i.m. delivery. Serum anti-influenza virus antibodies were determined by hemagglutination inhibition (HI) assay before and 3 weeks after vaccination. Safety assessments were made at baseline and at the follow-up visit by the investigators and for a 4-day period post-vaccination by the subjects themselves.Results: The EMEA requirements for re-licensing of influenza vaccines were fulfilled in all groups 3 weeks after vaccination, irrespective of dose and mode of administration. High seroconversion rates were observed in all study groups and for all strains ranging from 50.9 to 85.5% and 70.4 to 87.0% after i.d. and i.m. vaccination, respectively. Seroprotection rates for the A strains A/Solomon Islands and A/Wisconsin were generally higher compared to the B/Malaysia strain and ranged from 89.1 to 98.2% across the W. groups. Similar rates of 96.3% for the A/Solomon Islands and 94.4% for the A/Wisconsin strain were observed in the i.m. group. Seroprotection rates for the B/Malaysia strain were 65.5, 83.0 and 72.7% after i.d. administration of 3.0, 4.5, and 6.0 mu g HA of each strain, respectively, compared to a seroprotection rate of 85.2% in the i.m. group. In addition, marked increases in geometric mean titer (GMT) were observed across the groups for all influenza virus strains ranging from 6.9 to 70.5 for W. and from 16.9 to 56.5 for i.m. antigen delivery. Both routes of administration were well tolerated. Systemic reactions were broadly similar across the groups. With respect to local reactions the frequency of injection site pain and ecchymosis were significantly lower following i.d. vaccination, while other local reactions such as erythema occurred at higher rates with i.d. than with i.m. vaccine administration, as expected due to the mechanism of action for the W. route.Conclusions: The virosomal adjuvanted influenza vaccine (inflexal (R) V) was shown to be overall highly immunogenic and well tolerated when given i.d. at reduced doses to healthy adults, eliciting an immune response similar to that observed with full dose i.m. administration and thus suggesting a promising antigen-sparing strategy for universal influenza vaccination against endemic influenza. Trial registration: ISRCTN registry number: 33950739. (C) 2009 Elsevier Ltd. All rights reserved.

The modern cardiovascular imaging era has seen the introduction in clinical practice of highly innovative and performing diagnostic features. The negative side of this outstanding evolution risks to be an under-assessment of well-established classical diagnostic techniques. Thereby, to support the actual relevance of a properly executed chest X-ray, this article describes two paradigmatic cases of exceptional cardiac abnormalities, in which X-rays played a key diagnostic role.

Background: Spinal cord stimulation (SCS) has proven antianginal and antiischemic effects in severe coronary artery disease patients, minimizing frequency, intensity, and duration of pain. The mechanism explaining these effects has been detected in a sympathicolytic effect of the SCS. We monitored 30‐minute‐long recordings of the heart rate variability (HRV) and its spectral power parameters to evaluate the influence of SCS on the sympathetic/parasympathetic balance. Methods and Results: Eight patients underwent HRV recordings in controlled environmental conditions. The patients were seated in a relaxed position and isolated from external contacts. During three consecutive 30‐minute periods, the SCS was programmed, in a randomized fashion, to stimulate at a level generating paresthesias (ON), at a subliminal level (SUB, amplitude 80% of ON), or switched off (OFF). The low‐frequency/high‐frequency ratio during stimulation (ON) was significantly lower compared to that found while the SCS was turned OFF (0.54, 0.35–1.04 vs 1.21, 0.80–2.48; P = 0.036). The stimulation resulted in a median 52% (33–65%) reduction of the sympathetic activity compared to basal (ON vs OFF, P = 0.049). Conclusion: No difference emerged instead comparing OFF versus SUB (P = 0.575). The stimulation effect was not influenced by the randomized sequence. Thirty‐minute SCS significantly influenced the sympathetic/parasympathetic balance reducing sympathetic modulation.

AIMSAn antiarrhythmic effect of spinal cord stimulation (SCS) has been recognized in an animal model. The actual mechanism is still mainly unknown. An adrenergic output reduction has been advocated as the main mechanism, although a modulation effect on the arrhythmic substrate has not yet been investigated. We studied T-wave alternans (TWA) modifications to test the hypothesis that SCS affects the arrhythmic substrate.METHODS AND RESULTSWe performed TWA assessment in three high-risk patients who previously had undergone implantation of both implantable cardioverter defibrillator and SCS to treat refractory angina. The test was performed after switching off the SCS and after 2 and 24 h stimulation at the default amplitude. The protocol was executed 2 months apart in order to assess the reproducibility of the results, collecting a total of 18 TWA reports. In all the three patients, we observed a significant reduction of TWA amplitude after 2 h stimulation. All the tests were classified as negative after 24 h stimulation with the nominal parameters.CONCLUSIONSpinal cord stimulation results in a decrease in the TWA magnitude, and thus it seems to positively affect the arrhythmic substrate in a time-dependent manner.

Spinal cord stimulation is currently used to treat refractory angina. Some concerns may arise about the possible interaction concerning the spinal cord stimulator in patients already implanted with a pacemaker or a cardioverter defibrillator. We are going to describe the successful implantation of a spinal cord stimulator in a patient previously implanted with a cardioverter defibrillator.

Background: Epidemiological studies conducted in Sicily and Sardinia, the two major Mediterranean islands, showed elevated incidence and prevalence of multiple sclerosis (MS)and a recent increase in disease frequency. Objective: To confirm the central highlands of Sicily as areas of increasing MS prevalence and elevated incidence, we performed a follow-up study based on the town of Caltanissetta (Sicily), southern Italy. Methods: We made a formal diagnostic reappraisal of all living patients found in the previous study performed in 1981. All possible information sources were used to search for patients affected by MS diagnosed according to the Poser criteria. We calculated prevalence ratios, for patients affected by MS who were living and resident in the study area on December 31, 2002. Crude and age- and sex-specific incidence ratios were computed for the period from January 1, 1993, to December 31, 2002. Results: The prevalence of definite MS rose in 20 years from 69.2 (retrospective prevalence rate) to 165.8/100,000 population. We calculated the incidence of definite MS for the period 1970–2000. These rates calculated for 5-year periods increased from 2.3 to 9.2/100,000/year. Conclusion: This survey shows the highest prevalence and incidence figures of MS in the Mediterranean area and confirms central Sicily as a very-high-risk area for MS.

OBJECTIVE The follow-up patency rates and associated clinical and angiographic variables following stenting of very long (> or =50 mm) and chronic (>6 months) total coronary artery occlusive lesions are not well documented. The aim of the present study was to evaluate the early results and mid-term outcomes following angioplasty of such lesions. METHODS Between January 2000 and June 2002, we treated 278 chronic coronary occlusions. Of these, eighty-nine occlusions (89 patients) were with lesions > or =50 mm long; these patients constituted the study population. RESULTS Mean duration of occlusion was 7 +/- 2 months (range, 6-13 months). Procedural success was obtained in 81 patients. A total of 211 coronary stents (2.6 +/- 1.1 stents/patient) were implanted, and mean stent length was 59 +/- 9 mm. In 3 patients, TIMI flow 1-2 was observed after stent implantation. Thus, the angiographic success was considered to be 78/89 patients (87.6%). Periprocedural major adverse cardiac events occurred in 6 patients (6.7%). Clinical success was obtained in 74 patients (83%). During a 9.6 +/- 2 month follow-up, forty-three patients (55.1%) remained angina free, thirty-two (41%) had recurrence of angina, three patients (3.9%) had a new myocardial infarction and no deaths were reported. Target vessel revascularization was required in 34 patients (43.6%). Angiographic follow-up was obtained in 70 patients (90%) at a mean of 7.4 +/- 2 months. Restenosis was observed in 36 patients (51%), six of whom had reocclusion. A significant correlation was observed between the need for reintervention and stent length (R 0.52), residual stenosis (R 0.73) and diabetes mellitus (0.68). CONCLUSION Although coronary artery stenting for very long (> or =50 mm) chronically occlusive lesions is feasible, safe and associated with a low incidence of periprocedural adverse clinical events, these complex and expensive procedures still have a high 6-month restenosis rate. These results might be significantly improved with the advent of drug-eluting stents.

Infection of devices for percutaneous transcatheter closure of atrial septal defects are exceedingly rare. Two cases of device‐associated endocarditis have been reported, which were both operated on. We describe the successful treatment with antibiotics of a device‐associated endocarditis. Catheter Cardiovasc Interv 2004;63:351–354. © 2004 Wiley‐Liss, Inc.