P383 THIRD–DEGREE ATRIOVENTRICULAR BLOCK AND HYPERCALCEMIA: NOT ALWAYS JUST THE HEART

A 81–year–old lady was admitted to the ER due to anorexia, fever and oliguria. Previous medical history was unknown as she had arrived in Italy one month before and her son was not aware of it. Upon arrival she was soporous and bradicardic. Physical examination consisted of mild pulmonary rales, diffuse abdominal pain and leg edema. ECG showed a third–degree atrioventricular block with narrow QRS and average heart rate of 40 bpm with no signs of ischemia. X–ray showed mild congestion. She was admitted to CCU. Blood tests showed hypoglicemia (53 mg/dL), anemia (Hb 9.9g/dL), low platelet count, renal dysfunction (creatinine 1.43mg/dL), high C–reactive protein, normal potassium but high calcemia (13 mg/dL). To investigate hypercalcemia parathyroid hormone was dosed and was in range, so a CT scan was needed to rule out pancreatitis, cancer or bone lesions. Also a cardiac echo was done: it showed a hypertrophic left ventricle with preserved contractility, no significant valvular dysfunctions, normal right sections with pulmonary hypertension, no pericardial effusion. While performing the subcostal view however multiple formations were seen at the hepatic level. CT scan confirmed multiple pathological conglomerating lymphadenopathies in the abdomen towards the femoral region, reaching 5 cm of diameter; no bone lesions were found. Inguinal lymph node biopsy was performed. Due to persistent complete AV block along with persistent hypercalcemia and hypoglycemia despite medical therapy, considering the electrolyte imbalance not corrigible due to a malignancy a pacemaker was implanted. The result of the lymph node biopsy was consistent with a form of Diffuse Large B–Cell Lymphoma. This case highlights how a 3–rd degree AV block may present with non–specific symptoms. When it is found it may not always represent a pure cardiac problem as sometimes it is the epiphenomenon of a systemic disease. Particularity of this case is that cardiologists are less used to take into consideration calcium balance. Nevertheless, although infrequent, hypercalcemia is a cause of significant conduction disease. After having looked for it, searching for its etiology is mandatory as some could be reversible and thus the AV block as well. For this reason, when a complete AV block is found ruling out hypercalcemia is fundamental, taking into consideration that the conduction disease may represent the first red flag of an unknown malignancy

Atrial longitudinal strain in cardiac aTTR amyloidosis and occurrence of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND In systemic amyloidosis cardiac infiltration by amyloid fibrils leads to increased stiffness of the myocardium and of the atrial walls. There is a reduction in left atrial mechanical function and a high risk of thrombi formation.

Atrial deformation by speckle tracking echocardiography peak atrial longitudinal strain (PALS) can predict the incidence of atrial fibrillation (AF) and ischaemic stroke in the general population and in patients (pts) with cryptogenic stroke. The predictive value of PALS seems to differ in different pts populations according to the prevalence of ventricular versus atrial myopathy (1).

PURPOSE to compare parameters of atrial function in cardiac amyloidosis pts in sinus rhythm (SR) and AF and to observe if they are associated  with the occurrence of new onset AF at follow-up (FUP).

METHODS between 2016-2021 all pts with diagnosis of cardiac aTTR amyloidosis referred to the Clinic underwent an echocardiographic study including 2D-speckle tracking evaluation of left ventricular and left and right atrial strain. All pts received a regular FUP (clinical, echo, ECG and 24 hours Holter monitoring). Atrial function was evaluated by PALS in all pts and by PALS and PACS (peak atrial longitudinal strain during atrial contraction phase) in pts in SR.

RESULTS 47 pts with aTTR cardiac amyloid (39/47 wild-tipe) were studied. Mean age = 82 ± 5 years, LV mass = 190 ± 46 g/m2; LV EF= 53%±9, GLS= -10%±4, EF/GLS ratio=-5,5 ± 2, left atrial (LA) volume = 49 ± 9 ml/m2, LA PALS 9,7%±6,6, right atrial (RA) PALS 15,9 ± 9,6. At the time of diagnosis 29 pts were in SR and 18 pts were in AF. Pts in AF  had lower PALS (5,1%±3,7 in AF pts vs 11,9%±6,9 in SR pts, p = 0,001) and lower (less negative) GLS (-9,1%±3,1 in AF pts vs -11,8%± 4,2 in SR pts, p = 0,02). LA volume was not significantly different in AF pts compare to SR pts (51,4 ml/m2 ± 7,65 vs 47,6 ml/m2 ± 10,9; p = 0,19).

During a median FUP of 21 months 8 pts had a new onset AF. There was no significant difference in atrial size and atrial deformation parameters between pts who had new onset AF at FUP compared to pts who did not (Tab 1). The only parameter associated with new onset AF at FUP was GLS (-8.21%± 2,8 vs -13.01%±4,02, CI -10.8—5.6 vs -14.8—11.18, respectively, in pts who developed new onset AF compared to pts who did not, p = 0.007).

5 pts had a cardioembolic stroke at FUP: at the time of the admission for stroke they were all in AF.

CONCLUSIONS Our data show that in this group of pts with aTTR cardiac amyloidosis all echo parameters of LA size and function were overall impaired. In this setting of advanced disease LA volume was not significantly different in pts in AF compared to pts in SR and was not associated with new-onset AF at FUP. Deformation parameters were significantly more impaired in pts in AF compared to pts in SR, however PALS was not associated with the occurrence of new onset AF at follow-up. The only parameter associated with the occurrence of new onset AF at follow-up was GLS. Abstract Table 1

99mTc-DPD myocardial uptake and regional longitudinal strain in aTTR amyloidosis cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND amyloid cardiomyopathy is characterized by a typical "apical sparing" pattern of systolic longitudinal strain (LS) as visualized by echocardiography. Strain is well preserved at the apex of the left ventricle (LV) with a gradient from apex to base and the greatest impairment in the basal segments. The reason of this distribution is not clear. It could be a function of different amount of amyloid deposition. SPECT images using Technetium 99m bone tracers have shown a distribution mimicking regional LS.

PURPOSE to compare regional myocardial LS and myocardial distribution of 99m Technetium-DPD (99m Tc-DPD) uptake in patients affected by aTTR amyloidosis cardiomyopathy.

METHODS between 2016-2021 70 patients referred to our Cardiology Unit with heart failure/shortness of breath on exertion and showing significant left ventricular hypertrophy at 2-D echocardiography underwent 99m Tc-DPD scintigraphy to test the presence of cardiac amyloid. Grade 2-3 myocardial uptake at 180 minutes in the absence of abnormalities in the analysis of serum free light chains and serum and urine protein electrophoresis with immunofixation was considered sufficient for the diagnosis of aTTR amyloidosis. When scintigraphy was positive a SPECT study was performed to obtain semi quantitative measurements of segmental myocardial uptake (expressed as % of total myocardial uptake).  Regional  mean count was calculated by using a 6 basal, 12 mid and 2 apical segmental model.  All patients underwent standard and 2D speckle tracking echocardiography. Mean systolic LS was calculated for each of 18 segments and mean basal (6 segments), mean mid (6 segments) and mean apical (6 segments) LS was calculated.

RESULTS 46/70 patients had a positive scan and fulfilled criteria for aTTR amyloidosis. 33/46 had SPECT analysis. Male/female ratio was 29/4, age = 80 ± 6 years; 9/33 aortic stenosis; 19/33 carpal tunnel; 25/33 wild-type aTTR (4/33 ongoing genetic test); LV mass-=228 ± 48 g/m2; RWT = 0,73 ± 0,14; EF= 53 ± 9; EF to GLS ratio= 5,6 ±1,8.

ANOVA showed a significant difference between basal, mid and apical strain as well as between basal, mid and apical uptake (-5,5 ± 4,4; -9,6 ± 3,2; -15,9 ± 5,6; p < 0,001; 55 ± 14; 62 ± 10; 51 ± 11; p = 0,0019). Comparison between groups showed that mean LS at the apex was significantly lower compared to basal and mid mean LS (Bonferroni test, p < 0,001) (Fig 1). Apical myocardial uptake was significantly lower compared to mid segment but not to basal (Bonferroni test, p = 0,02, p = 0,6 respectively) (Fig 1).  Spearman’s test showed a correlation between LS and myocardial 99m Tc-DPD uptake (p = 0,01, Rho = 0,24).

CONCLUSIONS Our data show that in this group of patients with cardiac aTTR amyloidosis apical LS is significantly lower compared to basal and mid segments and apical myocardial 99m Tc-DPD uptake is significantly lower compared to mid segments; a correlation between myocardial 99m Tc-DPD uptake distribution and the degree of LS impairment is present. Abstract Figure.

Bleeding risk assessment and management in atrial fibrillation patients

In this executive summary of a Consensus Document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in atrial fibrillation (AF) patients. The main aim of the document was to summarise ‘best practice’ in dealing with bleeding risk in AF patients when approaching antithrombotic therapy, by addressing the epidemiology and size of the problem, and review established bleeding risk factors. We also summarise definitions of bleeding in the published literature. Patient values and preferences balancing the risk of bleeding against thromboembolism as well as the prognostic implications of bleeding are reviewed. We also provide an overview of published bleeding risk stratification and bleeding risk schema. Brief discussion of special situations (e.g. periablation, peri-devices such as implantable cardioverter defibrillators [ICD] or pacemakers, presentation with acute coronary syndromes and/or requiring percutanous coronary interventions/stents and bridging therapy) is made, as well as a discussion of the prevention of bleeds and managing bleeding complications. Finally, this document puts forwards consensus statements that may help to define evidence gaps and assist in everyday clinical practice.

The optimal management of patients on oral anticoagulation undergoing coronary artery stenting. The 10th Anniversary Overview

Even 10 years after the first appearance in the literature of articles reporting on the management of patients on oral anticoagulation (OAC) undergoing percutaneous coronary intervention with stent (PCI-S), this issue is still controversial. Nonetheless, some guidance for the everyday management of this patient subset, accounting for about 5-8 % of all patients referred for PCI-S, has been developed. In general, a period of triple therapy (TT) of OAC, with either vitamin K-antagonists (VKA) or non-vitamin K-antagonist oral anticoagulants (NOAC), aspirin, and clopidogrel is warranted, followed by the combination of OAC, and a single antiplatelet agent for up to 12 months, and then OAC alone. The duration of the initial period of TT is dependent on the individual risk of thromboembolism, and bleeding, as well as the clinical context in which PCI-S is performed (elective vs acute coronary syndrome), and the type of stent implanted (bare-metal vs drug-eluting). In this article, we aim to provide a comprehensive, at-a-glance, overview of the management strategies, which are currently suggested for the peri-procedural, medium-term, and long-term periods following PCI-S in OAC patients. While acknowledging that most of the evidence has been obtained from patients on OAC because of atrial fibrillation, and with warfarin being the most frequently used VKA, we refer in this overview to the whole population of OAC patients undergoing PCI-S. We refer to the whole population of patients on OAC undergoing PCI-S also when OAC is carried out with NOAC rather than VKA, pointing out, when appropriate, the particular management issues.

Percutaneous rheolytic thrombectomy with the AngioJet System for the treatment of intermediate-risk acute pulmonary embolism: a case report and an appraisal of contemporary indications and technique

Percutaneous mechanical thrombectomy (PMT) for treatment of clinically significant pulmonary embolism (PE) has been shown to be technically feasible and effective, aiming at thrombus resolution without increase in major bleeding. Despite its success, use of PMT in clinical practise has not become widespread, because it is challenging. Among several devices proposed, AngioJet rheolytic thrombectomy (ART) appears as the most effective and easy-to-use. We present the case of a 69-year-old woman who developed acute intermediate-risk PE, with right ventricular dysfunction and major myocardial necrosis, who was successfully treated by ART. The peculiarities of the case, toghether with the principles, tecnique and tips and tricks of ART, its effectiveness and potential complications are discussed.

Coronary stenting for ST-elevation myocardial infarction vs. other indications in patients on oral anticoagulation: any difference in in-hospital management and outcome?

AIM

The aim of this paper was to compare the in-hospital management and outcome of patients on oral anticoagulation (OAC) undergoing coronary artery stenting (PCI-S) for ST-elevation myocardial infarction (STEMI) vs. other indications.

METHODS

One hundred and sixteen patients on OAC at the time of PCI-S who were prospectively enrolled in a multi-center, observational registry, were evaluated. Patients were segregated according to whether PCI-S was performed for STEMI (group 1) or other indications, such as non ST-elevation acute coronary syndromes, stable angina, silent ischemia, etc. (group 2), and the pharmacological and procedural management, as well as the in-hospital outcome, were compared.

RESULTS

No significant differences were observed in vascular access site, sheath size and type of stent implanted, nor was significantly different the use of glycoprotein IIb/IIIa inhibitors, and the use and dose of intravenous unfractionated heparin. Although not statistically different, the in-hospital occurrence of death (3.7% vs. 1.1%; OR 3.3; 95% confidence intervals [CI] 0.2-56.0), stent thrombosis (3.7% vs. 1.1%; OR 3.3; 95% CI 0.2-56.0) and major bleeding (7.4% vs. 2.2%; OR 3.4; 95% CI 0.4-25.9) was consistently about 3-fold higher in group 1.

CONCLUSION

The in-hospital pharmacological and procedural management of OAC patients undergoing PCI-S for STEMI vs. other indications appears not different. Although not significantly different however, the in-hospital occurrence of major bleeding, as well as of death and stent thrombosis, appears substantially higher in patients treated for STEMI, warranting therefore further larger, prospective studies.

Triple therapy of warfarin, aspirin and a thienopyridine for patients treated with vitamin K antagonists undergoing coronary stenting. A review of the evidence

Dual antiplatelet treatment of aspirin and a thienopyridine (either ticlopidine or clopidogrel) is the standard of care in patients undergoing coronary artery stenting (PCI-S). Such treatment however, is not generally applicable in patients with concomitant indication for vitamin K antagonists (VKA), in whom therefore the optimal treatment is currently undefined. According to the limited available evidence, the management of these patients is substantially variable, but triple therapy of VKA, aspirin and a thienopyridine is the most frequently adopted. Both VKA and dual antiplatelet treatment in fact are warranted to actually prevent systemic thromboembolism and stent thrombosis, although an increased haemorrhagic risk might be associated with such therapy. A substantial incidence of bleeding has been effectively observed with triple therapy in a few, small, retrospective, observational series. The risk of haemorrhage appears to increase with the duration of treatment, although concomitant factors (i.e., advanced age, presence of gastrointestinal lesions, excessive anticoagulation or traumatic manoeuvres), rather than the administration of numerous antithrombotic agents in itself, may play a role. As expected, no thromboembolic or thrombotic events have been generally reported with such treatment. Because of the limited and poor quality data currently available on the management of patients with an indication for VKA undergoing PCI-S, large-scale registries and clinical trials are warranted to determine the optimal antithrombotic treatment in this patient subset, which is foreseen to progressively increase over the next years.

Contemporary antithrombotic treatment after coronary stenting in patients with indication for long-term anticoagulation

AIM

Dual antiplatelet treatment with aspirin and a thienopyridine is the antithrombotic treatment recommended after percutaneous coronary intervention with stent implantation (PCI-S). Optimal treatment in patients with an indication for long-term oral anticoagulation (OAC) undergoing PCI-S is currently undefined. The aim of this study was to evaluate the contemporary management of these patients, and determine the safety and the efficacy of the various regimens.

METHODS

A systematic review of the literature reporting on this issue was carried out.

RESULTS

The adopted strategies showed substantial variability, and the regimens used included: substitution of OAC for dual antiplatelet therapy in 25-54% of cases, addition to OAC of a single antiplatelet agent in 12-25% and institution of triple therapy with OAC (or low-molecular-weight heparin), aspirin and a thienopyridine in about 60%. OAC was systematically aimed at a lower intensity in 33% of cases, whereas in another 29% this was pursued only when a high hemorrhagic risk was perceived. Both safety and efficacy of the various regimens appeared suboptimal, with a 30-day occurrence of major bleeding and thrombotic complications of 3-7% and 4%, respectively.

CONCLUSIONS

Due to the suboptimal safety and/or efficacy of the various regimens adopted, the optimal antithrombotic treatment in patients with an indication for OAC undergoing PCI-S remains to be defined. Since the number of this patient subgroup is foreseen to progressively increase over the next years, large scale registries and clinical trials are warranted.

Subcutaneous enoxaparin following thrombolysis and intravenous unfractionated heparin in ST-elevation acute myocardial infarction: safety and efficacy of low vs full dose

AIM

In ST-segment elevation myocardial infarction (STEMI) treated with fibrin-specific thrombolytic agents, early intravenous unfractionated heparin (UFH) is warranted. Low molecular weight heparin Enoxaparin currently represents an alternative to UFH, to be used until hospital discharge. Since optimal dosing of subcutaneous Enoxaparin is not standardized, we conducted an observational study to compare safety and efficacy of low (4,000 U once daily) vs full dose (100 U/kg twice daily) regimens.

METHODS

All STEMI patients successfully treated with tenecteplase and intravenous UFH and referred to the Catheterization Laboratory between June 2002-November 2003 for predischarge coronary angiography, were evaluated. The primary end-point was the composite of hemorrhages and residual angina/reinfarction during Enoxaparin administration, whereas secondary end-points were occurrence of venous thromboembolism (VTE) during Enoxaparin administration, and infarct-related artery (IRA) patency rate at predischarge coronary angiography.

RESULTS

Out of 123 patients, 57 (M/F 45/12, mean age 65.8+/-8.1 years) received low dose, and 66 (men/women 45/21, mean age 62.6+/-11.8 years) full dose subcutaneous Enoxaparin. The incidence of the composite primary end-point was comparable in both groups (19% vs 26%; P=NS). Also, null was the occurrence of VTE, whereas the IRA patency rate did not significantly differ in the 2 groups (84% vs 86% TIMI 3 and 11% vs 9% TIMI 2 flow grades; P=NS).

CONCLUSIONS

In patients with STEMI undergoing successful recanalization with tenecteplase and intravenous UFH, low dose subcutaneous Enoxaparin appears preferable to full dose, in the light of comparable safety and clinical efficacy and superior easiness of use.

Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism

BACKGROUND

To investigate the frequency of cardiac troponin I (cTnI) increases in patients with pulmonary embolism (PE) and to assess the correlation between this finding, the clinical presentation, and outcomes.

METHODS

Consecutive patients admitted to the coronary care unit with acute PE were prospectively enrolled between January 2000 and December 2001. cTnI was sequentially determined. Various cut off concentrations were analysed, but patients were categorised prospectively as having increased or no increased cTnI based on a cut off concentration of 0.6 ng/ml. The main outcome measure was in-hospital mortality.

RESULTS

On admission, 14 of the 48 patients (29%) had cTnI concentrations greater than the receiver operating characteristic curve value used to diagnose acute myocardial infarction (> 0.6 ng/ml). Subsequently, six patients developed increases for an overall prevalence of 42% (20 of 42). The prevalence was higher when lower cut off concentrations were used: 73% (35 of 48) at the 99th centile and 60% (29 of 48) at the 10% coefficient of variability. Increased cTnI > 0.6 ng/ml was associated with a slower oxygen saturation (86 (7)% v 93 (4)%, p < 0.0001) and more frequent involvement of the main pulmonary arteries as assessed by spiral computed tomography (100% v 60%, p = 0.022). In-hospital mortality was 36% (5 of 14) of patients with increases > 0.6 ng/ml v 3% (1 of 42) of patients with lower concentrations (p = 0.008). Increased cTnI > 0.6 ng/ml on admission was the most powerful predictor of mortality (p = 0.046).

CONCLUSIONS

In high risk patients with acute PE, cTnI was frequently detected on admission. It was the strongest independent predictor of mortality.

Enoxaparin for the treatment of acute myocardial infarction with persistent ST-segment elevation

Enoxaparin (E) is a low-molecular-weight heparin which has been proven more effective than unfractionated heparin (UFH) for the treatment of non-ST-segment elevation acute coronary syndromes. Limited and inconclusive on the other hand, are the data on the use of E in acute myocardial infarction with persistent ST-segment elevation (STEAMI). Therefore, we performed a review of the literature in order to evaluate the level of evidence relative to the efficacy and safety of E in such a clinical setting. The effect of E in STEAMI has been evaluated in 7 clinical studies, including a total of about 9500 patients. Compared to placebo, E resulted more effective on the incidence of the combined end-point of death, re-infarction and recurrent angina in the study by Glick et al. and on the patency of the infarct-related artery in the AMI-SK study. Compared to UFH, E resulted more effective on the incidence of the combined end-point of death, reinfarction and unstable angina in the study by Baird et al. and of in-hospital re-infarction and refractory ischemia rates in both ASSENT-3 and ASSENT-3 PLUS, while the effect on the patency of the infarct-related artery, which was evaluated in HART-II and ENTIRE-TIMI 23, resulted non univocal. Overall, bleeding complications were more frequent than with placebo and comparable to UFH, with the exception of ASSENT-3 PLUS where pre-hospital administration of E was associated with a doubled incidence of intracranial bleeding (although only in patients older than 75 years). In conclusion, the administration of E, in association with aspirin and thrombolytics, already appears a possible therapeutic option for the treatment of STEAMI, due to its good efficacy and safety profile, along with its easiness of use. However, prior to have its use recommended, the current B level of evidence of a superior efficacy and safety compared to UFH needs to be reinforced. Further-more, some open issues relative to the use of E in particular settings (aged patients, in association with glycoprotein IIb/IIIa inhibitors and during percutaneous coronary revascularization) need to be clarified.

Outcome of percutaneous coronary angioplasty (PTCA) performed in a low-volume institution by low-volume operators, evaluated by means of the one-month major adverse cardiac event rate

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.

Appropriateness of the use of coronary angiography in a population of patients with ischemic heart disease

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.

Ticlopidine versus oral anticoagulation for coronary stenting

BACKGROUND

A 2-4 week course of ticlopidine plus aspirin following coronary stenting is considered effective in preventing thrombotic occlusion of the stented vessel and safe in regards to bleeding and peripheral vascular complications. However, rare, although potentially life-threatening haematological complications have been reported with this drug regimen.

OBJECTIVES

To evaluate the efficacy and safety of ticlopidine plus aspirin versus oral anticoagulants after coronary stenting

SEARCH STRATEGY

Electronic search of the Cochrane Library, Medline, Embase from 1991 to June 1999; references from trials and experts.

SELECTION CRITERIA

Randomised controlled trials comparing ticlopidine plus aspirin versus oral anticoagulants (either with or without aspirin) after elective or bail out coronary stenting.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed trial quality and compiled data on outcomes including: total mortality, non fatal myocardial infarction and revascularization occurring within the first 30 days after hospitalization, stent thrombosis on angiography, major and minor bleeding, neutropenia, thrombocytopenia, thrombotic thrombocytopenic purpura.

MAIN RESULTS

Four trials (n=2436 patients) were included. Ticlopidine plus aspirin compared to oral anticoagulants significantly reduced the risk of non-fatal acute myocardial infarction and revascularization at 30 days, combined negative events (mortality, myocardial infarction, revascularization at 30 days) (RR: 0.41; 95% CI: 0.25-0.69; NNT for 30 days: 22; 95% CI: 14-45), and major bleeding (RR in high quality studies: 0.24; 95% CI: 0.07-0.79). Ticlopidine plus aspirin compared to oral anticoagulants significantly increased the risk of eutropenia, thrombocytopenia and neutropenia (RR 5; 95% CI: 1.08-13.07; NNT for 30 days: 142; 95% CI: 76-1000). Ticlopidine plus aspirin vs oral anticoagulation did not affect all cause mortality. Ticlopidine plus aspirin significantly reduced the risk of stent thrombosis (angiography) which was seen only on studies with blinded outcome assessment (RR: 0.14; 95% CI: 0.03-0.60; NNT for 30 days: 33; 95% CI:16-166). Minor bleeding was reported only in one study and no studies recorded thrombotic thrombocytopenic purpura (TTP).

REVIEWER'S CONCLUSIONS

Ticlopidine plus aspirin after coronary stenting is effective in reducing the risk of the revascularization, non fatal myocardial infarction and bleeding complications when compared with oral anticoagulants. No effect is observed on total mortality. However, the haematological side effects of ticlopidine are still a matter of concern, and strict monitoring of blood-cell counts is recommended. Physicians should also be aware of the possibility of rare although potentially life-threatening complications such as TTP

Current perspectives The diagnosis of acute pulmonary embolism. A review of the literature and current clinical practice

The optimal approach to the diagnosis of acute pulmonary embolism is still controversial. The poor sensitivity and specificity of most of the clinical manifestations, the suboptimal accuracy of the majority of the laboratory and instrumental examinations and the highly variable local availability of the diagnostic resources, makes it in fact difficult for a univocal strategy to be adopted. Recently published practical guidelines, however, support the use of lung scanning (either ventilation/perfusion or only perfusion) as a first-line imaging test, since this approach allows for a correct diagnosis in most patients, after careful history taking, physical examination and electrocardiogram, chest X-ray and arterial blood gas analysis performance. When lung scanning is non-diagnostic, either serial non-invasive (i.e. ultrasonographic) evaluation of the lower limbs or pulmonary angiography should follow. Growing evidence is accumulating on the use of spiral computed tomography scanning either as an alternative or as a complement to lung scanning, while echocardiography should be reserved for the bedside evaluation of critically ill patients, when more validated techniques are not readily available. The role of plasma D-dimer measurement has yet to be defined, especially in hospitalized patients. In current clinical practice, however, these recommendations seem to be only partially followed. Depending in fact on the different characteristics of the populations examined in the seven available studies reporting on this issue, the use of the different diagnostic techniques appears highly variable. Although a standard diagnostic pathway does not seem applicable to all patients with suspected acute pulmonary embolism, further work is nonetheless needed in order to identify in different patient subsets the diagnostic approach capable of minimizing the use of diagnostic resources while obtaining the greatest amount of information.

[Initial experience with the use of abciximab in the salvage treatment of acute coronary thrombosis in the Hemodynamics Laboratory]

The optimal treatment of acute thrombotic complications in the Catheterization Laboratory has not been defined yet, due to the limited efficacy shown by various pharmacological regimens, even when associated to coronary angioplasty (PTCA). The aim of our study was therefore to evaluate the effects of abciximab (ReoPro), a new potent inhibitor of the platelet glycoprotein IIb/IIIa, when administered as a "rescue" treatment for acute thrombotic coronary occlusion during diagnostic or interventional procedures. Sixteen patients (12 males, 4 females, mean age 59.3 +/- 9.2 years, range 43-77 years), with unstable angina and consecutively treated with abciximab due to clinical instability attributable to coronary thrombosis angiographically proven during PTCA (9 cases) or diagnostic angiography (7 cases), were identified. The individual angiographic films and medical records were then reviewed in order to evaluate the effects of treatment on coronary flow, thrombus size and occurrence of in-hospital adverse events: death, non-fatal acute myocardial infarction (AMI), need for urgent myocardial revascularization and hemorrhage. The administration of abciximab, in association with PTCA (associated in turn with stent implantation in 8 cases), induced a significant increase of coronary TIMI flow grade (0.3 +/- 0.6 vs 2.4 +/- 0.9; p < 0.05) and a significant decrease of thrombus "score" (size) 2.4 +/- 0.9 vs 1.3 +/- 0.6; p < 0.01). No deaths nor need for urgent myocardial revascularization were observed; in 31% of cases (5 patients) evolution towards AMI occurred, while however 94% of cases (15 patients) had a coronary occlusion before treatment. No major hemorrhagic complications were observed, while in 12% of cases (2 patients) a groin hematoma associated with moderate hemoglobin drop, developed. In conclusion, the administration of abciximab, associated with the common "rescue" interventional procedures, in patients with acute thrombotic coronary occlusion in the Catheterization Laboratory, appears to be effective in restoring adequate coronary flow and reducing the thrombus size (limiting therefore the evolution towards AMI), and safe, not having been associated with significant hemorrhagic complications.

Diagnostic approach to acute pulmonary embolism in a general hospital. A two-year analysis

BACKGROUND

Several approaches have been proposed for the diagnosis of acute pulmonary embolism (PE), but little is known about the strategies effectively used in daily clinical practice.

METHODS

Retrospective evaluation of the diagnostic strategy used in our institution in the patients (pts) discharged between January 1st 1995 and December 31st 1996 with diagnostic code 415.1, corresponding to acute PE in the International Classification of Disease.

RESULTS

One-hundred-twenty-seven patients (49 M; 78 F; mean age: 71.5 +/- 15 years; range: 25-95) were identified. Electrocardiogram, chest X-ray, blood gas analysis and plasma D-dimer measurement were performed in 122 (96%), 121 (95%), 114 (90%) and 86 (68%) pts, respectively. Out of the 102 pts surviving the initial phase (early mortality: 20%), 83 (81%) underwent lung scintigraphy, 10 (10%) spiral CT scanning and 2 (2%) pulmonary angiography, while 7 (7%) were treated directly. Thirty of the 83 pts undergoing lung scintigraphy had non-diagnostic results, but only 8 of them underwent further investigation (with spiral CT in 6 cases and pulmonary angiography in 2 cases). Transthoracic echocardiography and ultrasonography of the lower limbs were used in 49 (48%) and 74 (73%) pts respectively, for diagnostic confirmation and to search for the embolic source.

CONCLUSIONS

At our institution, where multiple and modern diagnostic facilities are available, ventilation/perfusion lung scanning still represents the most frequently used imaging technique. Spiral CT is employed quite often as an alternative to either lung scintigraphy or pulmonary angiography which, in turn, is used very seldom. Ultrasonography of the lower-limbs is widely utilized (although not in a serial manner and only as a second-line test), while the role of echocardiography appears to be marginal. Spiral CT, pulmonary angiography and lower-limb ultrasonography showed high diagnostic accuracy, while the accuracy of lung scintigraphy and echocardiography was confirmed as being suboptimal. However, due to the retrospective design of our study and the characteristics of our population, these results cannot be extrapolated to pts referred for suspected acute PE, in whom further investigations are thus warranted in order to identify the most cost-effective diagnostic approach.

[Use of verapamil vs. beta blockers in patients with myocardial infarct. Retrospective evaluation of the yearly case load of a coronary care unit]

BACKGROUND, MATERIALS AND METHODS

To compare the relative use of verapamil and beta-blockers, which have shown comparable efficacy in reducing mortality and reinfarction rates in selected patients with myocardial infarction (MI), we retrospectively evaluated the ongoing treatment at the time of the pre-discharge evaluation in 221 consecutive patients (167 males and 54 females; mean age: 62.3 +/- 10.8 years) discharged alive in 1994 from our Hospital with the diagnosis of Q-wave MI.

RESULTS

The examination of the computerized files of our central database, showed that verapamil was administered (as a monotherapy or in association) to 4% of the patients, compared to 34% of beta-blockers. The choice between the two drugs appeared not to be influenced by age (62 +/- 11 vs 57 +/- 8 years), anterior (70% vs 57%) or inferior (30% vs 40%) MI location or echocardiographic left ventricular ejection fraction (50.2 +/- 10% vs 52.3 +/- 11%), which were comparable in both groups. On the other hand, beta-blockers were used significantly more often (52% vs 10%; p < 0.05) in the presence of hypertension, while verapamil was preferred (although statistical significance was not reached) in patients with contraindications to beta-blockers, such as chronic obstructive lung disease or peripheral artery disease (20% vs 9% and 10% vs 4%; p = ns, respectively).

CONCLUSIONS

In conclusion, our study gives, for the first time, an estimate of the real use of verapamil in patients with MI, confirming, in keeping with the indications in the literature, that its administration is limited and essentially reserved to patients with contraindications to beta-blockers. A wider use of verapamil (and even more of beta-blockers) would be however hoped for, due to the relevant number of patients (62% of our population) treated with drugs, such as diltiazem, dihydropyridines or nitrates, for which a conclusive demonstration of efficacy on major clinical end-points are lacking.

[ST segment depression during recovery after treadmill exercise test in stable patients with previous myocardial infarction]

BACKGROUND

The significance of exercise-induced ST segment depression is well known while limited data are available on the clinical/prognostic power of ST depression occurring only during recovery. Aim of the study was to clarify the clinical/prognostic value of "recovery only" ST depression in stable patients late from myocardial infarction (AMI) and to determine whether the addition of recovery data to exercise parameters improves the interpretation of exercise test.

METHODS

From a population of 766 consecutive patients (mean age: 57.2 +/- 8.6 yrs.; male: 89%) who underwent a Bruce Treadmill test at least 1 year after a Q wave AMI and whose exercise data were prospectively entered in the database of our Institution, 4 different Groups were identified: 1) 99 patients with a negative exercise test; 2) 53 patients with "exercise only" ST depression; 3) 140 patients with "exercise and recovery" ST depression; 4) 31 patients with "recovery only" ST depression. The main clinical and exercise data and a cardiac follow-up (average mean length: 1530 +/- 600 day) were evaluated by one-way analysis of variance, Bonferroni T-test, chi-square, relative risk (RR) with 95% confidence intervals (CI), Kaplan-Meler method and log-rank.

RESULTS

Baseline clinical parameters were similar in the 4 Groups except for older age in Group 3 compared to Group 2 (< 0.05) and higher prevalence of anterior AMI in Group 4 compared to others (= 0.004). Patients with exercise and recovery ST depression or with "recovery only" ST depression had significantly less exercise tolerance than patients with negative exercise test or "exercise only" ST depression [exercise duration (< 0.05, Group 1 vs. 3, vs. 4; Group 2 vs. 3), peak rate pressure product (< 0.05), maximal heart rate (< 0.05; Group 1 vs. 2; vs. 3; vs. 4)]. Exercise-induced ST depression was higher and angina was significantly more frequent in patients with exercise and recovery ST depression as well as an high Mark's risk score (< 0.001). Only patients with exercise and recovery ST depression demonstrated significantly higher risk of overall mortality (RR: 1.35, CI: 1.04-1.74), unstable angina (RR: 1.34, CI: 1.09-1.65) or revascularisation procedures (RR: 1.51, CI: 1.25-1.83). Relative risk of patients with "recovery only" ST depression was similar to that of subjects with "exercise only" ST depression.

CONCLUSIONS

In stable patients with old Q wave AMI, "recovery only" ST depression is rate, but does represent a true sign of ischemia. It could be associated with indirect indexes of worse ventricular function. The prognostical power of "recovery only" ST depression is mild, although similar to that of "exercise only" ST depression. Moreover the presence of ST depression not only during exercise but also during the recovery phase identifies patients with more severe prognosis. Therefore the inclusion of findings from the recovery phase in the analysis of the exercise test could increase the predictive power of the test itself.

Effect of acute edema on left ventricular function and coronary vascular resistance in the isolated rat heart

The impact of acute myocardial edema on coronary flow and left ventricular performance was studied in isolated isovolumic rat hearts. After 15 min of aortic perfusion with Krebs-Henseleit buffer, hearts (10/group) were either removed for determination of water content or perfused for another 90 min. Three groups were perfused at a constant pressure of 60, 100, or 140 mmHg, and two groups were perfused at 60 or 140 mmHg with adenosine added. Compared with the 15-min group, there was a significant increase in water content in all groups except the 60-mmHg group (P < 0.005). There was a direct linear relationship between increases in coronary vascular resistance over time and water content (P < 0.0001). A decrease in developed pressure and peak +dP/dt was observed only in those groups that accumulated water. An inverse linear relationship was found between changes in developed pressure and water content (P = 0.0001). Water content had no effect on end-diastolic pressure below 5 ml/g; above 5 ml/g, a direct linear relationship was evident (P = 0.009). The results suggest that myocardial edema increases vascular resistance and decreases systolic performance. End-diastolic pressure is less influenced by edema than either systolic or coronary vascular function.

[Relations between acute myocardial edema, coronary vascular resistance and left ventricular mechanics in isolated rat heart]

To evaluate the effect of acute myocardial edema (ME) on coronary vascular resistance (CVR) and left ventricular (LV) mechanical function, the LV water content (% of total weight) of seven groups (n = 10 each) of isolated rat heart was determined. Group I included non-perfused hearts and served as control. Group II was perfused with Krebs-Henseleit buffer only for the brief equilibration period which preceded every experiment. Group III, IV and V were perfused for 90 min at the constant pressure of 60, 100 and 140 mmHg respectively. Group VI and VII were perfused for 90 min at the constant flow of 10 and 30 ml/min respectively. The hearts were contracting isovolumically against a fluid-filled latex balloon with fixed volume. CVR and LV functional parameters were measured throughout the whole perfusion period. The water content of Group I (78.2 +/- 0.3%) was significantly lower than Group II (80.5 +/- 0.3%). A higher degree of ME was present in groups III, IV and V (80.2 +/- 0.3, 81.4 +/- 0.3 and 83.3 +/- 0.2%, respectively), as well as in groups VI and VII (80.7 +/- 0.1 and 83.4 +/- 0.2%, respectively). CVR significantly increased over time in groups III, IV and V (about +30, +35 and +50%, respectively), as well as in groups VI and VII (about +22 and +20%, respectively). LV developed pressure did not change over time in Group III (which did not show further fluid accumulation after the equilibration period); it decreased on the other hand in groups IV (about -27%) and V (about -40%). In groups VI and VII, LV developed pressure showed as increase (about +28%) and a reduction (about -29%) respectively. In conclusion, in the isolated crystalloid-perfused rat heart, ME is directly dependent on coronary perfusion pressure and/or flow. ME induces an increase in CVR and a rapid and significant depression of LV function.

Efficacy of long-term administration of transdermal nitroglycerin in asymptomatic patients with effort-induced silent myocardial ischemia

The aim of our study was to investigate the effect of transdermal nitroglycerin (NTG) on effort-induced silent myocardial ischemia in asymptomatic patients treated with beta-blockers or calcium antagonists. The acute effect was compared to two different schedules, continuous (24 h/day) or intermittent (16 h/day), of long-term administration. Ten asymptomatic patients with coronary artery disease and a treadmill test positive for ischemia without angina were enrolled. Both acute (2 days) and long-term (24 days) evaluations were conducted in a randomized, double-blind, crossover fashion. The ergometric parameters were collected on the 1st and the 2nd day of the acute phase (placebo and transdermal NTG, respectively) and at the end of each 12-day period of long-term administration (continuous and intermittent, respectively). Transdermal NTG administration acutely increased (p < 0.05) both time to 1-mm ST segment depression (451 +/- 43.2 vs. 374 +/- 24.1 s) and total exercise time (561.3 +/- 43.2 vs. 419.5 +/- 24.5 s). The acute efficacy was maintained over long-term treatment, regardless of the modality of administration. During continuous and intermittent patch application, time to 1-mm ST segment depression was 437.9 +/- 30.4 and 422 +/- 33.4 s (p = NS vs. acute) and total exercise time was 498.8 +/- 30.4 and 495.1 +/- 33 s (p = NS vs. acute), respectively. Transdermal NTG increases, both acutely and chronically, exercise tolerance in asymptomatic patients with effort-induced silent myocardial ischemia. With the NTG dose we used, tolerance does not seem to be a problem over long-term administration.

Exercise-induced ventricular arrhythmias in patients with healed myocardial infarction

BACKGROUND

Controversy exists about the clinical and prognostic significance of exercise-induced ventricular arrhythmias late after myocardial infarction. The aim of the study was to identify the main clinical and prognostic features of exercise-induced ventricular arrhythmias in out-patients with healed Q-wave myocardial infarction.

METHODS

The study population was 777 consecutive patients who underwent a symptom-limited (Bruce protocol) treadmill test from May 1988 to January 1991 after myocardial infarction (at least 1 year). Clinical and exercise data were prospectively entered in a computerized database and retrospectively two different groups were selected: (1) 228 patients with exercise-induced ventricular arrhythmias; (2) 549 patients without. Incidence and morphology of exercise-induced ventricular arrhythmias, various exercise parameters and a follow-up were evaluated.

RESULTS

Patients with exercise-induced ventricular arrhythmias were older (P < 0.001), had higher blood pressure (P < 0.03) and peak exercise rate pressure product (P < 0.00) than the others. No difference was found in the incidence of exercise-ischaemia: either symptomatic or not. When simple (< or = 2 Lown) versus complex (> or = 3 Lown) exercise-induced ventricular arrhythmias were considered, the latter were more frequent in patients with anterior myocardial infarction, shorter exercise duration (P < 0.001) and lower exercise rate pressure product, lower ejection fraction and lower incidence of exercise-induced ischaemia. In the follow-up (mean 24 +/- 13 month) there were 24 deaths: five (2.2%) in patients with exercise-induced ventricular arrhythmias and 19 (3.4%) in patients without. Cardiac event rate was similar in both groups.

CONCLUSIONS

We conclude that in out-patients with healed myocardial infarction exercise-induced ventricular arrhythmias are quite frequent, but they are not associated with exercise-induced ischaemia, either symptomatic or not. Exercise-induced ventricular arrhythmias seem to be related to age or peak workload. Moreover patients with these arrhythmias have no adjunctive negative risk on prognosis.

Reduced cardiovascular responsiveness to exercise-induced sympathoadrenergic stimulation in patients with cirrhosis

Cardiovascular responsiveness to sympathoadrenergic activation obtained by muscle exercise in the supine position was evaluated in 22 patients with cirrhosis (11 alcoholic, 11 postnecrotic/cryptogenic; 14 with ascites) and 10 controls of comparable age. Plasma norepinephrine, heart rate, diastolic arterial pressure and cardiac function, as evaluated by systolic time intervals, were monitored. At rest, cirrhotics had higher norepinephrine (154 +/- 19 S.E.M. ng/l) and heart rate (79 +/- 2 beats per min) than controls (71 +/- 3 ng/l, p less than 0.01; 67 +/- 2 beats per min, p less than 0.001), whereas diastolic arterial pressure was similar. Among systolic time intervals, electromechanical systole, pre-ejection period, electromechanical delay and pre-ejection period to left ventricular ejection time ratios were prolonged (p less than 0.05 or less). Exercise led to significant increases in plasma norepinephrine, heart rate and diastolic arterial pressure in both controls and patients. In the latter, however, whereas the increase in norepinephrine was greater (p less than 0.001), those in heart rate and diastolic arterial pressure were less (p less than 0.005). As expected, most systolic time intervals shortened, but the decrease in pre-ejection period (p less than 0.05), isometric contraction time (p less than 0.02) and pre-ejection period to left ventricular ejection time ratio (p = 0.06) was less in patients than in controls. Direct correlations between exercise-induced changes in norepinephrine and both diastolic arterial pressure (r = 0.81; p less than 0.005) and heart rate (r = 0.85; p less than 0.002) were observed in controls, while inverse correlations (r = -0.67, p less than 0.001 and r = -0.44; p less than 0.05) were found in cirrhotics. These results suggest that cardiovascular reactivity to the sympathetic drive is impaired in cirrhotics. The impairment of cardiac contractility may be due to altered electromechanical coupling.

Felodipine in chronic stable angina: a randomized, double-blind, placebo-controlled, crossover study

To investigate the antianginal efficacy and tolerability of felodipine, a new dihydropyridine calcium antagonist, 20 patients with stable exertional angina, not completely controlled by beta-blocker monotherapy, entered a randomized, double-blind, placebo-controlled, crossover study. Patients on standard beta-blocker therapy, who had at least 3 weekly anginal episodes and a reproducible exercise test (stopped for angina and ECG signs of ischaemia) at the end of 2 weeks placebo treatment, were eligible for the study. They were randomized to one sequence of treatment: felodipine 5 mg twice daily for 2 weeks followed by placebo for a further 2 weeks, or vice versa. Beta-blocker treatment was unchanged throughout the study. A treadmill test was carried out at the end of each crossover period, 2-4 h after drug administration. The number of anginal attacks and nitroglycerin consumption was recorded on a diary card. At rest, felodipine significantly (P less than 0.05) reduced standing systolic but not diastolic blood pressure. Heart rate was not modified by the active treatment. At ischaemic threshold and at peak exercise, heart rate, systolic blood pressure and rate-pressure product remained unchanged. Exercise duration was increased by felodipine (P less than 0.01) and maximal ST change was reduced (P less than 0.01). Time to 1 mm ST depression was prolonged non-significantly by felodipine (basal 5.7 +/- 1.5, felodipine 7.4 +/- 2.0, placebo 6.6 +/- 1.5 min). The number of patients who stopped exercise due to angina and ST change was 20/20 at baseline, 16/20 with placebo and 10/20 with felodipine. Felodipine significantly reduced weekly anginal episodes (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Gallopamil in stable effort angina. Effects of 2 different dosages]

The effects of gallopamil, a calcium channel blocker methoxy derivative of verapamil, recently introduced into clinical use in Germany, were evaluated in 20 patients with stable exertional angina. Two different dosages of the drug were used: 25 mg tid and 50 mg tid. It was observed that both dosages improved exercise tolerance (355 +/- 95 sec after placebo; 462 +/- 78 sec, p less than 0.01 and 511 +/- 97 sec, p less than 0.01 after the two doses) while the time taken to produce ischemia (-1 mm ST depression) was significantly prolonged only by the higher dose of the drug (204 +/- 101 sec after placebo; 324 +/- 135 sec after gallopamil 150 mg, p less than 0.05). Both dosages of gallopamil caused a significant reduction in the double product in the first phases of the exercise (double product 3 degrees min of exercise x 10(2): 173 +/- 140 after placebo; 153 +/- 34, p less than 0.05 and 145 +/- 30, p less than 0.05 after the two doses), while they did not affect this parameter at the end of the exercise. Our data seem to confirm that gallopamil works through a lowered myocardial metabolic demand as a consequence of the reduction of the afterload. Both dosages of the drug decreased the number of episodes of angina, but the higher dose was more effective. The drug is safe and well tolerated. All patients completed the study. Furthermore, no particular haemodynamic problems were observed.