The Impact of Education and Culture on Poverty Reduction: Evidence from Panel Data of European Countries

The 2030 Agenda has among its key objectives the poverty eradication through increasing the level of education. A good level of education and investment in culture of a country is in fact necessary to guarantee a sustainable economy, in which coexists satisfactory levels of quality of life and an equitable distribution of income. There is a lack of studies in particular on the relations between some significant dimensions, such as education, culture and poverty, considering time lags for the measurement of impacts. Therefore, this study aims to fill this gap by focusing on the relationship between education, culture and poverty based on a panel of data from 34 European countries, over a 5-year period, 2015-2019. For this purpose, after applying principal component analysis to avoid multicollinearity problems, the authors applied three different approaches: pooled-ordinary least squares model, fixed effect model and random effect model. Fixed-effects estimator was selected as the optimal and most appropriate model. The results highlight that increasing education and culture levels in these countries reduce poverty. This opens space to new research paths and policy strategies that can start from this connection to implement concrete actions aimed at widening and improving educational and cultural offer.

Influence of contractile reserve and inducible ischaemia on left ventricular remodelling after acute myocardial infarction

OBJECTIVE

To assess the relative influence of contractile reserve and inducible ischaemia on subsequent left ventricular volume changes after myocardial infarction.

DESIGN

Left ventricular end diastolic and end systolic index volumes were calculated prospectively at discharge and at six months in 143 patients referred for early postinfarction dobutamine stress echocardiography. On the basis of their responses to this test, patients were divided into three groups: scar (n = 48; group 1); contractile reserve (n = 36; group 2); inducible ischaemia (n = 59; group 3).

RESULTS

At six months, the left ventricular end diastolic index volume decreased in group 2 (mean (SD), -3.9 (9.4) ml/m2) and increased in both group 1 (+2.8 (10.6) ml/m2, p = 0.009 v group 2) and group 3 (+7.5 (11.4) ml/m2, p < 0.0001 v group 2). The end systolic index volume decreased in group 2 (-4.9 (7.3) ml/m2) and increased in both group 1 (+1.3 (8.3) ml/m2, p = 0.0015 v group 2) and group 3 (+2.8 (8.9) ml/m2, p = 0.0002 v group 2). In multivariate analysis, the contractile reserve (hazard ratio 0.19, 95% confidence interval (CI) 0.14 to 0.47), inducible ischaemia (5.86, 95% CI 1.54 to 29.7), and end systolic index volume at discharge (1.04, 95% CI 0.99 to 1.11) were independent predictors of an increase in end diastolic index volume of > or = 15 ml/m2 at six months.

CONCLUSIONS

Contractile reserve and inducible ischaemia, as detected by early dobutamine stress echocardiography, identify patients with differences in long term left ventricular remodelling after acute myocardial infarction.

Electrogram width parameter analysis in implantable cardioverter defibrillators: Influence of body position and electrode configuration

The "EGM width criterion" is a discrimination algorithm that was available in the last generation ICDs. It improved ventricular tachycardia detection by withholding inappropriate therapy deliveries in the presence of narrow QRS tachycardias. The accuracy of the algorithm depends on the optimal settings of the intracardiac EGM source, the "slew thresholds," and the "width threshold." The possible dependence of these parameters on body position may affect the detection efficacy. Whether these effects can be minimized by a proper choice of the electrode configuration used for signal analysis is still to be investigated. This study aimed to evaluate the stability of the slew threshold and width threshold obtained in the supine and orthostatic positions detected by the tip-to-ventricular coil and can-to-ventricular coil electrode configurations. Their time dependence was also evaluated at the 6-month follow-up. Fifty-eight patients who were recipients of an ICD (model Medtronic 7223cx and 7227cx) were included in the study. Changing from supine to orthostatic position caused a marked variation of slew and width thresholds (21.0 +/- 13.9 V/s and 10.1 +/- 9.6 ms, respectively) in 36% of patients with tip-to-ventricular coil and in 44% of patients with can-to-defibrillating coil (the mean slew threshold variation was in this case 17.6 +/- 15.8 V/s, while the mean width threshold variation was 18.8 +/- 21.0 ms). Width threshold variation was statistically significant (P < 0.02) with the latter electrode configuration. Slew thresholds settings changed between the 1- and 6-month follow-ups in the 75% of patients with can-to-defibrillating coil configuration and in 50% with tip-to-defibrillating coil. These time related variations were significantly larger with the tip-to-defibrillating coil configuration (P < 0.01). In conclusion, EGM width parameters may change between supine and orthostatic position and over time with tip-to-defibrillating coil configuration and can-to-defibrillating coil configuration. The former configuration was less sensitive to body position changes, but more sensitive to time related variations. These findings may be useful for optimal programming of the EGM width criterion, but if parameter programming based on these results can improve the discrimination specificity still needs to be investigated.

Incremental prognostic value of stress echocardiography as an adjunct to exercise electrocardiography after uncomplicated myocardial infarction

OBJECTIVE

To assess the prognostic value of stress echocardiography as an adjunct to exercise electrocardiography in patients with uncomplicated acute myocardial infarction.

DESIGN

496 patients underwent a maximum exercise ECG and pharmacological stress echocardiography (406 dobutamine and 90 dipyridamole) within 15 days of uncomplicated acute myocardial infarction and were followed for a mean of 25 months (range 1-74 months) for reinfarction, unstable angina, and cardiac death. Patients undergoing revascularisation were omitted.

RESULTS

Exercise ECG was positive in 162 patients (32.6%) and low threshold positive (< 100 W) in 91 (18%). Stress echocardiography was positive in 239 patients (48%) (194 with dobutamine and 45 with dipyridamole stress). The agreement between the two tests was 63% (kappa = 0.24, 95% confidence interval 0.15 to 0.33). Sixty nine spontaneous events occurred (14 cardiac deaths, 26 reinfarctions, and 29 with unstable angina requiring hospital admission), and 126 patients underwent revascularisation (39 coronary angioplasty and 87 bypass surgery). By receiver operating characteristic curve analysis, stress echocardiography provided incremental prognostic information compared with clinical data. A low threshold positive exercise ECG was associated with a worse outcome, but there was a fivefold increase in risk in patients with positive stress echocardiography who also had a high threshold (> 100 W) positive exercise ECG. Event-free survival of patients with both tests positive was significantly less than in patients with only one positive test or with both tests negative.

CONCLUSIONS

Stress echocardiography provides additional prognostic information after uncomplicated acute myocardial infarction, but the greatest gain is found in patients with a high threshold positive exercise ECG.

Prognostic interaction between viability and residual myocardial ischemia by dobutamine stress echocardiography in patients with acute myocardial infarction and mildly impaired left ventricular function

Dobutamine stress echocardiography (DSE) accurately detects viable myocardium and residual ischemia in patients with acute myocardial infarction (AMI). The prognostic interaction of viability and ischemia has not been completely clarified in these patients. This study assesses the long-term effect of viability, ischemia, or their combination on survival in patients with AMI and mildly impaired left ventricular (LV) function. Four hundred eleven patients (age 57 +/- 9 years) underwent predischarge DSE (up to 40 microg/kg/min plus atropine if needed) after uncomplicated AMI and were prospectively followed for 23 months (range 1 to 78). According to DSE findings, patients were divided into 4 groups: viability only, ischemia only, combination of viability and ischemia, and scar. Adverse outcome occurred in 64 patients: 34 patients had hard events (9 cardiac deaths, 25 nonfatal AMI) and 30 patients had unstable angina requiring hospitalization. The combination of viability and ischemia, diabetes mellitus, and non-Q-wave AMI were significant predictors of all events at univariate and multivariate analysis. The same variables were also univariate predictors of hard events, but multivariate analysis indicated only the combination of viability and ischemia and diabetes as independent predictors. The event-free survival of patients with combined viability and ischemia was significantly lower (hazard ratio 3 [95% confidence interval 1.8 to 11]) compared with patients with ischemia only. Thus, viability and ischemia show a significant adverse prognostic interaction in patients with AMI and preserved LV function.

Coronary flow reserve of normal left anterior descending artery in patients with ischemic heart disease: A transesophageal Doppler study

The aim of this study was to investigate the flow reserve of a normal left anterior descending coronary artery (LAD) in patients with coronary artery disease (CAD) of other epicardial vessels by Doppler transesophageal echocardiography (TEE). Thirty-one consecutive patients (age 59 +/- 8 years; 23 men) referred for TEE were considered. Eighteen patients had CAD and a 70% or greater LAD stenosis (group 1); 13 patients had right and/or circumflex CAD (>/=70% stenosis) and normal or minimally diseased LAD (group 2). Ten patients (age 54 +/- 11 years) with normal coronary arteries constituted group 3. Baseline and adenosine (0.160 microg/kg per minute intravenously over 60 minutes) flow velocities in the LAD were measured by pulsed Doppler examination during TEE. Peak and mean systolic and diastolic flow velocities were calculated. Adenosine/baseline peak and mean velocity ratios were used for evaluating blood flow reserve in the LAD. Heart rate and arterial pressure values were similar in the 3 groups at baseline and during adenosine infusion. Baseline and adenosine-related flow velocities were comparable in the 3 groups. Peak and mean diastolic velocity ratios were lower in groups 1 and 2 compared with group 3 (peak velocity ratio 1.68 +/- 0.81 and 1.93 +/- 0.35 vs 2.62 +/- 0.32, P <. 05; mean velocity ratio 1.71 +/- 0.86 and 2.01 +/- 0.41 vs 2.84 +/- 0.74, P <.05), whereas no differences were found between groups 1 and 2. No significant differences were found in systolic flow velocity ratios among the 3 groups. Patients with ischemic heart disease have a reduced diastolic flow velocity reserve in the LAD independent from the presence of significant LAD stenosis. Thus the adenosine TEE-Doppler study should be considered a screening test for CAD rather than for LAD disease.

Prognostic value of myocardial viability in medically treated patients with global left ventricular dysfunction early after an acute uncomplicated myocardial infarction: a dobutamine stress echocardiographic study

BACKGROUND

Residual viable myocardium identified by dobutamine stress after myocardial infarction may act as an unstable substrate for further events such as subsequent angina and reinfarction. However, in patients with severe global left ventricular dysfunction, viability might be protective rather than detrimental. The aim of this study was to assess the impact on survival of echocardiographically detected viability in medically treated patients with global left ventricular dysfunction evaluated after acute uncomplicated myocardial infarction.

METHODS AND RESULTS

The data bank of the large-scale, prospective, multicenter, observational Echo Dobutamine International Cooperative (EDIC) study was interrogated to select 314 medically treated patients (271 men; age, 58+/-9 years) who underwent low-dose (</=10 microg x kg-1 x min-1) dobutamine for the detection of myocardial viability and high-dose dobutamine for the detection of myocardial ischemia (</=40 microg x kg-1 x min-1 with atropine </=1 mg) performed 12+/-6 days after an acute uncomplicated myocardial infarction and showing a moderate to severe resting left ventricular dysfunction (wall motion score index [WMSI] >1.6). Patients were followed up for 9+/-7 months. Low-dose dobutamine stress echocardiography identified myocardial viability in 130 patients (52%). Dobutamine-atropine stress echocardiography was positive for ischemia in 148 patients (47%) and negative in 166 patients (53%). During the follow-up, there were 12 cardiac deaths (3.8% of the total population). With the use of Cox proportional hazards model, delta low-dose WMSI (the variation between rest WMSI and low-dose WMSI) was shown to exert a protective effect by reducing cardiac death by 0.8 for each decrease in WMSI at low-dose dobutamine (coefficient, -0.2; hazard ratio, 0.8; P<0.03); WMSI at peak stress was the best predictor of cardiac death in this set of patients (hazard ratio, 14.9; P<0.0018).

CONCLUSIONS

In medically treated patients with severe global left ventricular dysfunction early after acute uncomplicated myocardial infarction, the presence of myocardial viability identified as inotropic reserve after low-dose dobutamine is associated with a higher probability of survival. The higher the number of segments showing improvement of function, the better the impact is of myocardial viability on survival. The presence of inducible ischemia in this set of patients is the best predictor of cardiac death.

Value of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease: a report from the Echo-Persantine and Echo-Dobutamine International Cooperative Studies

OBJECTIVES

This study sought to verify the effectiveness of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease.

BACKGROUND

Noninvasive prognostic assessment of single-vessel disease is an unresolved issue to date.

METHODS

The study evaluated prospectively collected data from 754 patients with angiographic single-vessel disease who underwent either dipyridamole (n = 576) or dobutamine (n = 178) stress echocardiography. Invasive treatment (coronary revascularization within 3 months of stress testing) was performed in 260 patients and medical treatment in 494.

RESULTS

Echocardiographic positivity was observed in 421 patients (56%). Patients treated invasively had a higher incidence of stress test positivity (69% vs. 49%, p < 0.001) and left anterior descending coronary artery involvement (60% vs. 46%, p < 0.001) than patients maintained with medical therapy. During a mean follow-up of 37 months, 54 hard cardiac events occurred (14 deaths, 40 nonfatal infarctions): 37 in medically and 17 in invasively treated patients (7.5% vs. 6.5%, p = NS). On Cox analysis, a positive result on stress testing was the only independent prognostic predictor in medically treated patients (relative risk 2.92, 95% confidence interval 1.29 to 6.59). The 4-year infarction-free survival rate was higher for a negative than a positive stress test result in medically (93.9% vs. 87.3%, p = 0.009) but not invasively treated patients (92.7% vs. 97.1%, p = 0.545). Moreover, a significantly higher 4-year infarction-free survival rate was found in invasively versus medically treated patients with a positive (p = 0.012), but not in those with a negative, stress test result (p = 0.853).

CONCLUSIONS

Pharmacologic stress echocardiography is effective in risk stratification of single-vessel disease and can accurately discriminate patients in whom coronary revascularization can have the maximal beneficial effect. These findings have a potential favorable impact on the cost-effectiveness of invasive procedures.

Multicenter trial on prognostic value of inducible ischemia, assessed by dobutamine stress echocardiography and exercise electrocardiography test, in patients with uncomplicated myocardial infarction, treated with thrombolytic therapy

BACKGROUND

Thrombolysis has reduced early and longterm mortality by about 20%; sometimes, however, there is a re-occlusion of the infarct related artery or an unsuccessful thrombolysis. In these situations, there is a possible increase in detrimental events in the follow-up.

OBJECTIVES

The aim of the study was to compare the prognostic value of dobutamine echocardiography (DET) and ECG exercise test (EET) in pts submitted to thrombolysis.

METHODS

One hundred and fifty-one pts, with acute uncomplicated myocardial infarction, were enrolled. The pts were able to perform EET and had a sufficient echocardiographic window; 58 had anterior myocardial infarction (38%), 79 had inferior (52%), 2 had lateral (1%), 12 had non-Q (8%). EET was performed with an initial load of 25 Watt, and thereafter, 25 W every two minutes. DET was performed with step-wise infusion every three minutes (5, 10, 20, 30 and 40 mcg/kg/min.). If the target heart rate was not reached, a further dose of 40 mcg/kg/min. together with atropine 0.25-1 mg was administered, in the absence of signs and symptoms of ischemia.

RESULTS

During a mean (+/- SD) follow-up period of 8 +/- 4.5 months (range 1-23), 16 spontaneous events happened (4 deaths, 5 non-fatal re-infarctions, 7 unstable angina). One-hundred and three EET (68%) were negative for ongoing ischaemia, while 48 were positive, 79 DET (52%) were negative for ongoing ischaemia and 72 were positive (48%). Statistical results: DET and EET had a sensitivity of 41% and 54%, a specificity of 57% and 74%, a positive predictive value of 7% and 14%, a negative predictive value of 91% and 95%, an accuracy of 56% and 73%. Kaplan-Maier survival curves demonstrated that patients with Peak Wall motion > 1.8 and EET score > 3, had the higher risk of spontaneous events.

CONCLUSION

A few spontaneous events happened in the follow-up. These data demonstrate that patients treated with thrombolysis are not at high risk of spontaneous events. DET and EET, therefore, have had a high negative predictive value. For this reason, we can conclude that pts with negative tests can be considered at low risk and do not need any further investigations.

ECG changes during dobutamine stress test and spontaneous recovery of contractility in patients with myocardial infarction

Recent reports suggest a relationship between ECG changes and myocardial viability during dobutamine stress echocardiography in patients with myocardial infarction. The aim of the study was to analyze the predictive value of T-wave normalization and ST segment elevation during low- (10 mucg/Kg/m') and high-dose (40 mucg/Kg/m') dobutamine stress test for late spontaneous recovery of function in patients with a first uncomplicated Q-wave myocardial infarction.

METHODS

Seventy eight consecutive patients (59 +/- 9 yrs; males = 67; anterior MI = 41, inferoposterior MI = 37 pts) underwent baseline 2D echo and dobutamine stress test at 9 +/- 2 days from onset of symptoms and they were free of cardiac events during the first three months after myocardial infarction. T-wave normalization (negative T-wave becoming > or = 1 mm upright in > or = 2 leads) and ST segment elevation (> or = 0.1 mm in > or = 2 leads) at low- and high-dose dobutamine infusion were compared with an improvement of contractility in the infarct area detected echocardiographically at three months. A wall motion score decrease in infarct area > or = 2 was the criterion for recovery of contractility.

RESULTS

ST segment elevation occurred in 19/78 patients at low dose (24%) and in 45/78 patients at high dose (58%). Late recovery of contractility in the infarct area was observed in 38/78 patients (49%). The positive and negative predictive values of ST segment elevation for late recovery of contractility were, respectively, 63-56% at low dose and 47-48% at high dose. A baseline negative T-wave in > or = 2 leads was present in 56 patients, and 27 (48%) showed recovery of contractility at three months. T-wave normalization occurred in 14 patients at low-dose (25%) and in 29 patients at high-dose dobutamine infusion (52%). The positive and negative predictive values of T-wave normalization were, respectively, 71-59% at low dose and 62-67% at high dose. Both ECG markers were present in 10/56 patients at low dose and in 19 patients at high dose. The positive and negative predictive values, respectively, were 70-57% at low dose and 58-57% at high dose. At univariate analysis, neither the ECG changes alone nor their combination during dobutamine stress testing were shown to be significant predictors of recovery of function.

CONCLUSIONS

Our study demonstrates that in patients with a first uncomplicated Q-wave myocardial infarction, the T-wave normalization and/or the ST segment elevation occurring during early dobutamine stress testing are not reliable predictors of late spontaneous recovery of contractility in the infarct area.

Different clinical and prognostic significance of painful and silent myocardial ischemia detected by exercise electrocardiography and dobutamine stress echocardiography after uncomplicated myocardial infarction

Prevalence and prognostic significance of painful and silent ischemia detected by exercise electrocardiography (ECG) and dobutamine stress echocardiography (DSE) were evaluated in 407 consecutive patients recovering from acute myocardial infarction. Painful ischemia assessed by both tests was not associated with different clinical characteristics of patients; on the other hand, it identified a higher risk subgroup compared with silent ischemia during exercise ECG but not during DSE.

Prognostic value of residual ischaemia assessed by exercise electrocardiography and dobutamine stress echocardiography in low-risk patients following acute myocardial infarction

BACKGROUND

Risk stratification after uncomplicated myocardial infarction is major clinical problem. In particular, the prognostic value of residual inducible ischaemia is still controversial. We compared the relative prognostic value of exercise ECG and dobutamine stress echocardiography performed in the early post-infarction period.

METHODS

Four hundred and six patients (53 female) aged 57 +/- 9 years, undergoing maximal exercise ECG and dobutamine stress echocardiography within 10 days of an uncomplicated myocardial infarction off therapy, were prospectively followed-up for 8.8 months. Age, sex, diabetes, smoking habit, hypertension, dyslipidaemia, infarct location, thrombolysis and resting wall motion score index were taken into account among clinical variables. Prognostic correlations were made vs spontaneous events (cardiac death, non-fatal reinfarction and unstable angina requiring hospitalization) whilst patients undergoing revascularization (by means of percutaneous transluminal coronary angioplasty or coronary artery bypass surgery) at the time of the procedure were censored.

RESULTS

One hundred and twenty-seven events occurred during the follow-up: 41 (10%) were spontaneous (five deaths, 12 reinfarctions and 24 unstable angina) and 86 procedural (27 angioplasty and 59 bypass surgery). Spontaneous events were not predicted by any clinical, exercise ECG or dobutamine stress echocardiography variable, but the negative predictive value of both tests was excellent (91% and 90% respectively). With a multivariate Cox analysis, male gender, positive low-workload (< 100 W) exercise ECG (P < 0.0001), positive low-dose dobutamine stress echocardiography (P < 0.0001) and rest-stress wall motion score index variation (P < 0.001) were found to predict cumulative cardiac events with an independent and additive value. Dobutamine stress echocardiography was significantly more sensitive (P < 0.05) and less specific (P < 0.01) in predicting the outcome of patients with anterior infarction, whilst exercise ECG was significantly more sensitive (P < 0.05) in patients with non-Q wave infarction.

CONCLUSIONS

(1) Spontaneous events are poorly predicted by provocative tests in low-risk patients after uncomplicated myocardial infarction. (2) However, both exercise ECG and dobutamine stress echocardiography can predict a favourable outcome with a very high negative predictive value. (3) Dobutamine stress echocardiography should be considered a secondary option in cases where the exercise ECG is equivocal or when the location of ischaemia is a relevant issue. (4) The possibility that the two tests have a differential utility depending on the infarct location and type (Q wave vs non-Q wave) may be clinically relevant and deserves further evaluation.

Prognostic value of left ventricular volume response during dobutamine stress echocardiography

AIMS

An abnormal left ventricular volume response during dobutamine echocardiography identified patients with severe coronary artery disease. The aim of the study was to assess the prognostic value of left ventricular volume changes during dobutamine stress echocardiography in 136 patients.

METHODS AND RESULTS

Endpoints were defined as spontaneous cardiac events at follow-up. Left ventricular end-diastolic and end-systolic volume changes (abnormal response: < 10% and < 20% decrease, respectively) were compared with other clinical and stress test variables. During 18 +/- 7 months of follow-up, 31 cardiac events occurred: 12 hard events (cardiac death [n = 6], myocardial infarction [n = 6]) and 19 soft events (unstable angina [n = 16], congestive heart failure [n = 3]). End-diastolic volume response (P = 0.006), diabetes (P = 0.008), inducible wall motion abnormalities (P = 0.024), end-systolic volume response (P = 0.039) and inducible angina (P = 0.038) were related to a greater likelihood of cardiac events. The Cox regression analysis revealed end-diastolic volume response (odds ratio: 3.0; CI 1.44-6.32) and diabetes (odds ratio: 2.7; CI 1.28-5.69) to be independent predictors of spontaneous cardiac events. Diabetes (odds ratio: 4.0; CI 1.26-12.80) and < 40% baseline ejection fraction (odds ratio: 2.21; CI1.14-4.29) were independent predictors of hard events.

CONCLUSION

An abnormal end-diastolic volume response during dobutamine stress echocardiography identifies patients with an unfavourable outcome; they should be considered for more accurate prognostic stratification.

Dobutamine-induced ST-segment elevation in patients with acute myocardial infarction and the role of myocardial ischemia, viability, and ventricular dyssynergy

We analyzed the relation between dobutamine-induced Q-wave ST-segment elevation and regional contraction during low (5 to 10 microg/kg/min) and high doses (20 to 40 microg/kg/min) of dobutamine in a series of 391 dobutamine echocardiographic tests performed 10 +/- 2 days after a first uncomplicated acute myocardial infarction (AMI). ST-segment elevation was defined as > or = 1 mm new or additional J-point elevation with a horizontal or upsloping ST segment lasting 80 ms. Wall motion score index at rest was derived using a 16 segment-4 grade score model. Patients with dobutamine-induced ST-segment elevation had a higher wall motion score index at rest (anterior wall AMI: 1.67 +/- 0.27 vs 1.43 +/- 0.30, p = 0.0001; inferior wall AMI: 1.44 +/- 0.27 vs 1.30 +/- 0.18, p = 0.0001) and similar incidence and extent of myocardial viability and homozonal ischemia in comparison with those without ST-segment elevation. The sensitivity, specificity, and accuracy of dobutamine-induced ST-segment elevation for detecting residual homozonal ischemia were 51%, 55%, and 54%, respectively, in patients with anterior wall AMI, and 42%, 68%, and 58%, respectively, in patients with inferior wall AMI. In conclusion, dobutamine-induced ST-segment elevation is not associated with higher incidence and extent of viable or jeopardized myocardium but rather to a greater extent of wall motion abnormalities at rest. Thus, this finding does not represent a clinically reliable discriminator for selecting patients for coronary angiography and possible revascularization procedures.

[Comparison of anti-arrhythmic therapy guided by the transesophageal electropharmacologic test and emperic therapy in the prophylaxis of atrial fibrillation recurrence]

BACKGROUND

There is no written data about the efficacy of transesophageal electropharmacologic test (TEPT) to guide antiarrhythmic therapy in the prophylaxis of paroxysmal atrial fibrillation (PAF) recurrences. Aim of this study was to assess the efficacy of TEPT compared to empiric treatment in the prophylaxis of PAF.

METHODS

One-hundred-sixty patients (pts) with previous episodes of PAF were randomized in two groups: Gr A (90 pts) was submitted to basal transesophageal electrophysiologic study (BTES); Gr B (70 pts) was submitted to randomized empiric antiarrhythmic therapy with flecainide (F), propafenone (P) and sotalol (S). The end-points of stimulation protocol in Gr A were the induction of sustained atrial fibrillation (SAF)- > or = 1 min duration- or the end of protocol. SAF was inducible in 68/90 pts (Gr A1) while it was not in 22/90 pts (Gr A2). Pts in Gr A1 were subsequently submitted to TEPT at steady-state of F, P or S randomized in first choice. Pts responders (R) (SAF non inducible) were submitted to TEPT with other antiarrhythmic drugs randomized in second choice: R were followed-up with the same drug in chronic oral assumption, while non responders (NR) were submitted to TEPT with the last drug and followed-up with the same drug both in R and NR case. The same stimulation protocol was employed in TEPT as in BTES. Pts in Gr A2 withdrew from the study. During follow-up all-pts were submitted to periodic specialist examinations every three months. In case of PAF recurrence pts withdrew from the study.

RESULTS

Mean follow-up duration in the study population was 17.5 +/- 8.5 months. One-hundred-eight TEPT were performed in Gr A1: 36 tests with F, 40 with P and 32 with S. Twenty pts were R with F (55% of tests) and 17 finished the follow-up, 22 pts were R with P (55% of tests) and 16 finished the follow-up, 19 pts were R with S (59% of tests) and 15 finished the follow-up; 3 pts with F, 2 pts with P and 2 pts with S were NR in last choice and finished the follow-up. In Gr A1 61/68 pts (90%) were R and 55/68 (81%) finished the follow-up (13 pts withdrew from the study). In Gr B (70 pts) 23 pts were randomized to F and 20 finished the follow-up, 24 pts were randomized to P and 20 finished the follow-up, 23 pts were randomized to S and 20 finished the follow-up (10 pts withdrew from the study). PAF recurrences during follow-up in Gr A1 were in 15/55 pts (27%): 9/48 pts (19%) R and 6/7 pts (86%) NR, and in Gr B in 41/60 pts (68%). Gr A1 vs Gr B p < 0.001. Univariate and multivariate statistical analysis showed the empiric treatment as the only variable with high predictive value for PAF recurrences (risk ratio 1.53). PPV and NPV of TEPT were respectively 86 and 81%.

CONCLUSIONS

TEPT-guided antiarrhythmic therapy in the prophylaxis of PAF recurrences seems to be an effective method in predicting the efficacy of the chronic antiarrhythmic therapy, when compared to the empiric treatment. The non inducibility of SAF at TEPT would have a high predictive value for event-free follow-up.

Usefulness of dipyridamole transesophageal echocardiography in the evaluation of myocardial ischemia and coronary artery flow

High-dose dipyridamole transesophageal stress echocardiography has recently been proposed as a useful and safe method to assess myocardial ischemia in patients with poor transthoracic acoustic window. It has also been shown that transesophageal echocardiography (TEE) allows the study of coronary blood flow reserve (CBFR) in the left anterior descending artery (LAD). The aim of our study was to assess whether the morphologic information and pathophysiologic data on CBFR and myocardial ischemia can be collected by a single stress TEE without comprimizing its feasibility, safety and accuracy. We studied, 29 patient with known or suspected CAD (previous myocardial infarction or angina) (Group A), and as a control group, we studied 11 patients with mitral disease or mitral prostheses (Group B). All patients underwent the coronary angiography. None of Group B patients showed significant coronary artery stenosis (> 70%). In baseline conditions left ventricular wall motion and LAD coronary blood flow velocity (CBFV) were also evaluated. The following CBFV parameters were measured: maximal diastolic velocity (MaxDV), mean diastolic velocity (MnDV), maximal systolic velocity (MaxSV), mean systolic velocity (MnSV). The ratios of dipyridamole to rest maximal and o mean to diastolic velocities (MaxDV-Dip/Max DV-rest; MnDv-Dip/MnDV-rest) were measured as indexes of CBFR. No side effects were observed and the test could be completed in all patients (feasibility 100%). Wall motion analysis was adequate in all patients (feasibility 100%). Comparison between wall motion analysis was obtained and angiographic findings shown that the overall sensitivity and specificity of TEE were 84% and 93% respectively. Sensitivity for one, two and three vessel disease was 60%, 70% and 100%, respectively. LAD CBFV was adequately recorded in 85% of patients. CBFR parameters showed a significant difference between the two groups (Max DV-Dip/Max DV-rest: 1.67 +/- 0.7 vs. 2.73 +/- 0.6, P < 0.001); comparison between Group B patients and those of Group A with angiographically documented LAD stenosis showed a statistically significant difference in CBFR parameters (MaxDV-Dip/MnDV-rest, 2.73 +/- 0.6 vs. 1.65 +/- 0.7, P < 0.001, MnDV-Dip/MnDV-rest, 2.56 +/- 0.5 vs. 1.69 +/- 0.6 < 0.001). We conclude that transesophageal stress echocardiography is a useful method to study CAD and that it is possible to assess both morphologic and pathophysiologic information during a single examination.

Carcinogenicity, DNA adduct formation and K-ras activation by 7H-dibenzo[c,g]carbazole in strain A/J mouse lung

N-Heterocyclic polynuclear aromatic hydrocarbons (NHA) are environmental pollutants formed during the combustion of organic materials. 7-H-Dibenzo[c,g]carbazole (DBC) is a potent carcinogen in lung, liver and skin. We undertook these studies to determine whether tissue specificity for DBC lung carcinogenicity in the strain A/J mouse is mirrored by formation of DBC-DNA adducts in lung tissue and whether these adducts are consistent with mutation patterns in the K-ras gene. Strain A/J mice were given a single i.p. injection of DBC at doses of 0, 5, 10, 20 or 40 mg/kg and levels of DNA adducts in the lung were monitored by 32P-postlabeling on days 1, 3, 5, 7, 14 and 21. The remaining animals were sacrificed 8 months after DBC treatment and lung tumor multiplicity and K-ras mutation patterns in the tumors were determined. The lung tumor response to DBC was dose related, with an average of 4.7 +/- 1.2 tumors/mouse at 5 mg/kg and 48.1 +/- 5.5 tumors/mouse at 40 mg/kg. As many as seven DBC-DNA adducts were observed in the lung. DNA binding levels in the lung were highest at 40 mg/kg, with maximum binding at 5-7 days. At lower dose levels the maximum binding to DNA decreased and shifted to earlier time points. The DBC-DNA adduct in the lung with the highest level of binding at all dose levels was DBC-DNA adduct 3. The majority of DBC-induced mutations in the K-ras gene in the lung were A-->T (80%) transversions in the third base of codon 61, a mutation that has not been previously observed in chemically induced lung tumors in strain A/J mice.

The atropine factor in pharmacologic stress echocardiography. Echo Persantine (EPIC) and Echo Dobutamine International Cooperative (EDIC) Study Groups

OBJECTIVES

This study sought to compare, head to head, the two most popular pharmacologic stress echocardiographic tests--dipyridamole and dobutamine--with state of the art protocols in a large multicenter prospective study.

BACKGROUND

In the continuing quest for ideal diagnostic accuracy, pharmacologic stress echocardiography has quickly moved over the years from low to high dose regimens and is currently performed with atropine coadministration.

METHODS

Dobutamine (up to 40 microgram/kg body weight per min) plus atropine (up to 1 mg over 4 h) and dipyridamole (up to 0.84 mg/kg per min over 10 h) plus atropine (up to 1 mg over 4 h) stress echocardiography was performed on different days, in random order and within 1 week in 360 patients with chest pain syndrome. Thirteen different echocardiographic laboratories, all fulfilling quality control criteria for stress echocardiographic reading, contributed to the study.

RESULTS

No major complications occurred during either test. The test was interrupted before achievement of predetermined end points for limiting side effects in 37 dobutamine-atropine and 7 dipyridamole-atropine stress echocardiographic studies (feasibility 90% vs. 98%, p < 0.01). Diagnostic accuracy was assessed in a subset of 110 patients with no obvious rest dyssynergy (akinesia or dyskinesia) who underwent coronary angiography independently of test results and within 1 week of testing. Significant coronary artery disease (> or = 50% diameter reduction in at least one major coronary vessel by quantitative coronary angiography) was found in 92 patients. Sensitivity for detection of coronary artery disease was 84% (77 of 92) for dobutamine-atropine and 82% (75 of 92) for dipyridamole-atropine stress echocardiography (p = NS), with a specificity of 89% (16 of 18) for dobutamine-atropine and 94% (17 of 18) for dipyridamole-atropine stress echocardiography (p = NS). A significant correlation was present between peak wall motion score index during dipyridamole-atropine and dobutamine-atropine stress echocardiography (r = 0.83, p < 0.0001).

CONCLUSIONS

Dobutamine-atropine and dipyridamole-atropine stress echocardiography are safe and feasible, although submaximal studies are more frequent with dobutamine. The two stresses have comparable accuracy in the detection of angiographically assessed coronary artery disease, although dobutamine is marginally more sensitive and dipyridamole marginally more specific. Stratification of the ischemic response in the space domain is also comparable with the two stresses.

[Prognostic value of echo-dobutamine test in patients with ischemic heart disease: comparison with exercise test]

BACKGROUNDS

The aim of the study was to assess the relative prognostic accuracy of dobutamine echocardiography (TED) vs maximal bicycle exercise electrocardiography (TE) in patients with proven coronary artery disease.

METHODS

One hundred and thirty consecutive patients (70 patients with uncomplicated recent myocardial infarction, 19 asymptomatic patients with previous myocardial infarction and 41 patients with stable angina pectoris and previous myocardial infarction or previous myocardial revascularization procedure) underwent TED (incremental dobutamine infusion: 5 to 40 ncg/kg/min, continued with atropine 0.25 to 1 mg iv if necessary) and TE on different days and in random order. Criteria for positivity were: new or worsening regional dyssynergy for TED; ST segment shift > or = 1 mm from baseline for TE. End points were defined as spontaneous events (cardiac death, myocardial infarction and unstable angina) and total events (spontaneous events plus myocardial revascularization procedures).

RESULTS

During 15.4 +/- 7.9 (range 1-33) months of follow-up, 33 events occurred: cardiac death (1), myocardial infarction (4) unstable angina (21) myocardial revascularization (7). Sensitivity, specificity, positive and negative predictive value, prognostic accuracy were similar for TED and TE (P = NS). Cumulative event-free survival curves as a function of TED and TE results were both statistically significant. A Cox stepwise regression analysis identified TED positivity obtained without atropine administration as the best predictor of spontaneous and total events (Odds ratio 5.33 and 4.38, respectively). Cumulative survival curves obtained by the combination of TED and TE results were statistically different (P < 0.05 and P < 0.001 for spontaneous and total events, respectively) and showed a poor clinical outcome in patients with both tests or only TED positive. TED correctly predicted clinical outcome in 24/39 patients in whom there was disagreement between the two tests.

CONCLUSIONS

In patients with proven coronary artery disease, TED and TE have a similar accuracy for predicting clinical outcome. Where a discrepancy is seen between the two tests, TED appears to have a slightly higher prognostic value.

[Multiplane transesophageal echocardiography and adenosine in the study of coronary blood reserve]

BACKGROUND

Coronary blood reserve is the capacity of coronary vessels to vasodilate and thereby to increase the blood flow, when the heart needs more energy. However, when a coronary stenosis occurs, the capacity to vasodilate is reduced or completely diminished. It is then necessary to use all the tools useful in evaluating the functional conditions of the coronary vessels. Above all, the intracoronary Doppler technique is used to measure the velocity of blood flow. Our purpose was to evaluate a non-invasive tool "Multiplane Transesophageal Echocardiography" in the study of velocity of the anterior descendent artery before and after adenosine infusion.

METHODS

At first, we studied 28 patients (pts), which we divided in two groups: Group A, 18 pts 59.38 +/- 8.23 mean age, 15 M. and 3 F., with anterior descending disease; Group B 10 pts, 59.20 +/- 8.48 mean age, 7 M. and 3 F, without significant stenosis (> 75%). Echocardiography examinations were performed with a 5 MHz multiplane probe, connected to a 1000 Hewlett Parkard echocardiography. Before the test, Diazepam 1 mg i.v. and Lidocaine spray were administered to the patients. We introduced the transesophageal probe and after choosing the best position of the aortic short axis view, we studied the anterior descending artery and measured the maximum and mean diastolic and sistolic velocities (V.MAX D., V.MN.D., V.MAX S., V.MN.S.).

RESULTS

Transesophageal echocardiography allowed us to study the anterior descending artery in 95% of pts. There were no side effects, except for one pt affected by severe bradicardia. In Group B there was an increase of the diastolic and sistolic velocity after adenosine infusion, resulting twice greater they the rest values. The adenosine/rest velocities ratios were statistically significant (V.MAX D. p < 0.02) (V.MN.D. p < 0.03).

CONCLUSION

Our results demonstrated an higher capacity of the Multiplane Transesophageal Echocardiography in studiing coronary blood reserve. We used adenosine, as a vasodilator drug, because of its short half-life and because it can be replatedly infused. The flow velocity values increased up to more than twice the rest values only in normal subjects.

[Use of high doses of atropine during dipyridamole echocardiography: safety and efficacy of the combined test]

BACKGROUND

Recent reports demonstrated an increased accuracy of dipyridamole echocardiography test with the intravenous infusion of 0.25 to 1 mg of atropine in 1-4 consecutive administrations at the end of the test. The effect of higher doses of atropine during dipyridamole echocardiography, potentially able to further increase heart rate and myocardial oxygen consumption, has not been evaluated. The aim of the study was to evaluate the effect of high doses of atropine during dipyridamole echocardiography and to investigate the possible pharmacological interference between dipyridamole and atropine.

METHODS

One-hundred consecutive patients (M = 81, F = 19; mean age 58 yrs) without inducible wall motion abnormalities at 14th minute of a high-dose (0.84 mg/Kg in 10') dipyridamole echocardiography test were studied. Seventy-five patients referred to the test in pharmacological wash-out were randomly divided in three groups: 25 patients (Group 1) received 10 mcg/Kg of atropine in 60"; 25 patients (Group 2) received 15 mcg/Kg of atropine in 120"; 25 patients (Group 3) received 20 mcg/Kg of atropine in 120"; moreover, 25 patients with a full-dose oral beta-blocker therapy (Group 4) received 20 mcg/Kg of atropine in 120". Atropine was infused during the 15th and 16th minute of the test. Heart rate (HR) changes and new wall motion abnormalities induced by atropine were considered and compared for each Group. In 60 patients (15 randomly selected from each Group) the effect on mean HR and R-R interval (msec) of the same dose of atropine infused during dipyridamole echocardiography was evaluated in resting conditions 24 hours apart.

RESULTS

The dipyridamole-atropine test was well tolerated and accomplished in all patients. HR increased significantly in all Groups of patients in comparison with pre-atropine HR values (Group 1: +14 +/- 8 b/m', p < 0.0001; Group 2: +19 +/- 8 b/m', p < 0.0001; Group 3: +22 +/- 9 b/m', p < 0.0001; Group 4: +19 +/- 8 b/m', p < 0.0001; Groups 2, 4 vs Group 1: p = 0.03, Group 3 vs Group 1: p = 0.002). No patients in Group 1 (0%), 3 patients in Groups 2 and 3 (12%), and 5 patients in Group 4 (20%) showed new wall motion abnormalities after atropine infusion (Group 4 vs Group 1: p = 0.06). Effects of atropine on HR and mean R-R interval were significantly more pronounced in resting conditions than during dipyridamole test (HR: +25 +/- 11 vs +18 +/- 9 b/m', p < 0.001; R-R: -256 +/- 122 vs -127 +/- 68 msec, p < 0.0001).

CONCLUSIONS

High doses of atropine during dipyridamole echocardiography test are safe and more effective for induction of new wall motion abnormalities than usual doses, particularly in patients tacking beta-blockers. The likelihood of an antagonistic mechanism between atropine and endogenous, dipyridamole-induced adenosine on sinus node is supported from our results.

Prognostic value of high dose dipyridamole echocardiography in patients with chronic coronary artery disease and preserved left ventricular function

OBJECTIVES

The prognostic value of dipyridamole echocardiography was assessed in patients with chronic coronary artery disease and preserved left ventricular function.

BACKGROUND

Few data are available on the prognostic value of dipyridamole echocardiography in patients with a low risk of cardiac events.

METHODS

Two hundred sixty-eight consecutive patients with stable, proven or suspected coronary artery disease and ejection fraction > or = 0.40 underwent high dose (up to 0.84 mg/kg body weight) dipyridamole echocardiography. In 204 patients definite exercise electrocardiographic (ECG) results were also available.

RESULTS

During a mean (+/- SD) follow-up period of 16 +/- 8 months (range 6 to 36), 33 spontaneous events occurred: 15 "hard" events (cardiac death [n = 6], myocardial infarction [n = 9]) and 18 "soft" events (unstable angina). Events occurred more frequently in patients with positive findings on dipyridamole echocardiography (59% vs. 3%, p < 0.001; hard events 24% vs. 2%, p < 0.01). A positive response at the low dose (up to 0.56 mg/kg) identified patients with a high incidence of hard events (7 of 16 patients, sensitivity 50%, specificity 96%). In patients with an exercise ECG, a comparable sensitivity for cardiac events was found (89% vs. 93%, p = NS), but dipyridamole echocardiography was more specific (91% vs. 61%, p < 0.01). A positive response on the low work load exercise ECG (< 8 min) and a positive response to low dose dipyridamole echocardiography had similar accuracy (82% vs. 90%, p = NS). Cox analysis identified dipyridamole echocardiography as the best predictor of cardiac events (odds ratio [OR] 20.9, 95% confidence interval [CI] 10.8 to 37.9); the highest risk of hard events was found in patients with a positive response to low dose dipyridamole echocardiography (OR 25.4, 95% CI 12.2 to 54.1).

CONCLUSIONS

In patients with chronic coronary artery disease and a low incidence of cardiac events, dipyridamole echocardiography was effective in prognostic stratification, and positive low work load exercise ECG results were a reliable predictor of subsequent events. Consequently, dipyridamole echocardiography should be considered a complementary tool in the presence of high work load positivity or ambiguous exercise ECG results.

Adenomas induced by polycyclic aromatic hydrocarbons in strain A/J mouse lung correlate with time-integrated DNA adduct levels

The induction of DNA adducts and adenomas in the lungs of strain A/J mice has been investigated following the single i.p. administration of each of the following polycyclic aromatic hydrocarbons (PAH): pyrene, dibenz[a,h]anthracene, benzo[a]pyrene, benzo[b]fluoranthene, 5-methylchrysene, and cyclopenta[c,d]pyrene. DNA adducts were measured by 32P-postlabeling at times between 1 and 21 days following injection, while adenomas were counted at 240 days after treatment. Pyrene did not induce either DNA adducts or lung adenomas at any of the doses examined. Each of the remaining PAH induced both adenomas and DNA adducts in a dose-dependent manner, with dibenz[a,h]anthracene > 5-methylchrysene > cyclopenta[c,d]pyrene > benzo[a]pyrene > benzo[b]fluoranthene. DNA adducts reached maximal levels between 3 and 9 days after injection, followed by a gradual decrease. The time-integrated DNA adduct level (TIDAL) was calculated by numerically integrating the areas under the adduct persistence curves extrapolated to 240 days for each PAH at each dose level. This value represents the effective total molecular dose of PAH that was delivered to the lung DNA over the entire course of tumorigenesis. A strong correlation of lung adenoma induction with the TIDAL values was observed for each PAH. The slopes of the tumors versus TIDAL value relationships were essentially identical for 5-methylchrysene, cyclopenta[cd]pyrene, benzo[a]pyrene, and benzo[b]fluoranthene. The slope of this relationship for dibenz[a,h]anthracene was markedly greater. The essentially identical induction of adenomas as a function of TIDAL values for these PAH suggests that the formation and persistence of DNA adducts determines their carcinogenic potency.

[A comparison between flecainide and sotalol in the prevention of recurrences of paroxysmal atrial fibrillation]

OBJECTIVES

Aim of the present study was to assess the efficacy and safety of flecainide (F) and sotalol (S) for the prevention of recurrences of paroxysmal atrial fibrillation (PAF).

METHODS

Sixty-six patients with PAF (> or = 3 episodes of atrial fibrillation in the last year) in sinus rhythm, were randomized to pharmacological oral treatment with F (20 patients-Group A), with S (20 patients-Group B) and placebo (P) (26 patients-Group C). During the follow-up (one year duration) were evaluated on I, III, VI and XII months the number and tolerance of the atrial fibrillation recurrences, cardiac and/or noncardiac side effects. The patients with more than two recurrences in the same follow-up interval withdrew from the study. In each patient 14 clinical and laboratory variables were evaluated.

RESULTS

After 12 months were arrhythmia-free respectively 70% of Group A patients, 60% of Group B patients, 27% of Group C patients. Univariate analysis showed that treatment with F was related to decrease of atrial fibrillation recurrences (one recurrence 67%, two recurrences 81%, three recurrences 81%), treatment with S was related to decrease of recurrences (two recurrences 59%); the variable most significantly related to the risk of arrhythmia recurrence is the higher value of basal cardiac rate (one recurrence t = 2.15, two t = 2.22, three t = 2.96, four t = 2.06). There was not statistically significant difference in maintenance of sinus rhythm at the end of the follow-up between the groups of patients on F and S (p = 0.163); treatment efficacy was significantly higher than P (p = 0.002). Multivariate analysis showed that treatment with F and S decreases the risk of arrhythmia recurrence respectively of 85% and 76% versus placebo at the end of the follow-up. The incidence of cardiac and/or noncardiac side effects was not clinically significant.

CONCLUSION

F and S are both effective and safe for prevention of PAF, with 70% and 60% respectively of patients arrhythmia-free after 12 months of treatment. Side effects were common, but clinically significant adverse events were uncommon. A higher value of basal cardiac rate was predictive of atrial fibrillation recurrences in the patients during treatment.

[The predictive value for major arrhythmic events of ventricular arrhythmias, particularly nonsustained ventricular tachycardias, in the subacute phase of a fibrinolyzed infarct. An analysis of GISSI-2 data. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico]

BACKGROUND

The relationship between ventricular arrhythmias (VA) in the subacute phase of a myocardial infarction (MI) and subsequent major arrhythmic events, i.e. sustained ventricular tachycardia (SVT) and sudden death (SD), is well known. The importance of left ventricular dysfunction in the same context is also well established. The vast majority of the data in the literature come from the prefibrinolytic era and/or are derived from limited data bases.

MATERIALS, METHODS AND RESULTS

We examined the large, uniform GISSI-2 population of acute fibrinolysed myocardial infarctions in order to evaluate the significance and predictive power of VA detected by Holter monitoring during the subacute phase. Particular attention was paid to the occurrence of nonsustained ventricular tachycardias (NSVT) since their role is still uncertain, so it is hard to assess the utility of invasive measures such as programmed electrical stimulation (PES). Left ventricular function was evaluated by mono-, and two-dimensional echocardiography. Holter monitoring was available in 8,676 patients; a six-month follow-up, as regards mortality was completed in 8,552 patients (98.5%) and, as regards SVT incidence, in 7.713 (88.9%). During the follow-up 256 patients died (3%), 84 out of them suddenly (1%). Twenty-six [corrected] patients out of 7,713 (0.3%) experienced one or more SVT. The relationship between VA, left ventricular dysfunction and major arrhythmic events was evaluated by odds ratios (OR) and their confidence intervals (CI). Odds ratios for the combined end-point (SD and/or SVT) was 4.49 (CI 95% 2.69-7.51) if the Holter showed > 10 VEB/hour; 2.34 (CI 1.48-3.68) if couplets were present; 3.26 (1.52-6.99) if NSVT were present; 3.02 (2.02-4.50) if any complex ventricular arrhythmia was detected. Left ventricular disfunction seemed to exert a more powerful influence: OR 9.80 (CI 5.75-16.69) for SD and/or SVT. Any arrhythmic parameter had very low positive (< or = 3%) and very high (approximately 99%) negative predictive power. Multivariate analysis (Cox Model) including major prognostic factors confirmed the independent prognostic value of frequent VA (RR 2.75; 95% CI 1.58-4.79), couplets (RR 1.91; CI 1.28-2.86); complex VA (RR 2.02; CI 1.36-3.00). NSVT, after adjusting for the selected risk factors, was not independently associated with a worse prognosis.

CONCLUSIONS

Ventricular arrhythmias detected by Holter monitoring during the subacute phase of a MI still have prognostic significance for major arrhythmic events in the fibrinolytic era. The presence of NSVT triples the risk of SD and/or SVT in the six months after an acute MI, but loses any predictive power in a multivariate analysis. Only 6.6% of the patients showed one or more episodes of NSVT in the Holter recording. If the ongoing clinical trials, MUSTT and MADIT, will confirm the usefulness of PES in such patients, the benefit will be confirmed to a very small proportion of the patients at risk of specific diagnostic tests. The positive predictive power of VA is very low and it is therefore mandatory to add other non-invasive variables to the screening to identify the subgroups at greatest risk. On the other hand the very high (99%) negative predictive power of VA and left ventricular dysfunction enables us to identify a large population of infarcts with a negligible risk, who need no further sophisticated investigations. From the point of view of the cost/benefit evaluation this seems to be an outstanding result.

[Effect of the acute administration of molsidomine in refractory congestive heart failure. A double-blind randomized non-invasive study]

The effect of vasodilator Molsidomine (M) vs placebo on left ventricular dimensions and function measured by echocardiography was evaluated in a randomized study on 23 patients (pts) with refractory congestive heart failure (R CF) (NYHA class III-IV). The pts were randomized in two groups: group A (12 pts) received M, group B received an identical appearing placebo. Adequate echocardiograms were obtained before and one hour after 2 tablets of M (4 mg) or P; left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD), mean rate of circumferential shortening and left ventricular fractional shortening were calculated on the echocardiograms obtained. At the same time mean arterial pressure (MAP) and heart rate were measured. In group A, the single-dose test induced a significant reduction in LVEDD (74.1 +/- 7.2 to 72.1 +/- 7.1 mm; p less than 0.01), in LVESD (64.4 +/- 8.4 to 61.6 +/- 7.4 mm; p less than 0.01) and in MAP (96.5 +/- 8.3 to 85.4 +/- 7.2 mmHg; p less than 0.05). No significant changes were noted in the other parameters. Moreover, changes of parameters evaluated in group A between pts with idiopathic cardiomyopathy and pts with ischemic heart disease showed no statistical differences. Thus, acute Molsidomine therapy is effective in reducing left ventricular diameters and MAP in pts with RCF without changes of echocardiographic contractility indexes.