Metabolic abnormalities linked to an increased cardiovascular risk are associated with high-grade prostate cancer: a single biopsy cohort analysis

BACKGROUND

Smoking, hypertension, abdominal obesity and metabolic abnormalities have been considered individual factors involved in prostate cancer (PCa) pathogenesis. All of these factors are used to define the individual cardiovascular risk (CVR). The aim of our study was to evaluate the association between CVR and PCa diagnosis and grade among a consecutive series of men undergoing prostate biopsy.

METHODS

From 2010 onwards, consecutive patients undergoing 12-core prostate biopsy were enrolled. Body mass index was measured before the biopsy. Blood samples were collected and tested for: PSA, fasting glucose, triglycerides and high-density lipoproteins. Blood pressure was also recorded. Metabolic syndrome was defined according to the Adult Treatment Panel III and CVR according to the European Association of Cardiologist Guidelines. We evaluated the association between CVR and PCa biopsy Gleason score using logistic regression analyses.

RESULTS

Five hundred and eighty-four patients were enrolled. Four hundred and six patients (70%) presented a moderate/high CVR. Two hundred and thirty-seven (40.6%) patients had cancer on biopsy; 157 with moderate/high CVR and 80 with low/no CVR (P=0.11). Out of the 237 patients with PCa, 113 had a Gleason score 6 and 124 a Gleason score ⩾7. Out of them, 92/124 (75%) presented a moderate/high CVR (P=0.004). Moderate/high CVR was not associated with an increased risk of PCa (odds ratio (OR): 0.741, confidence interval (CI): 0.474-1.156; P=0.186) but with an increased risk of Gleason score ⩾7 (OR: 2.154, CI: 1.076-4.314; P=0.030).

CONCLUSIONS

In our study, a moderate/high CVR is associated with an increased risk of a high-grade Gleason score when PCa is diagnosed on biopsy. Although these results should be confirmed in multicentre studies, patients with moderate/high CVR should be carefully evaluated for PCa diagnosis.

Structure, Production and Function of Erythropoietin: Implications for Therapeutical Use in Cardiovascular Disease

Erythropoietin (EPO) is a 30,400 daltons glycoprotein, consisting of 165 amino acids produced mainly in the kidney and in the liver and regulating erythrocyitosis. It primarily acts on erythroid precursor cell at colony-forming units-erythroid stage inhibiting the apoptosis. EPO binds on a specific membrane receptor thereby activating at least three specific intracellular signaling pathways, such as phosphatidylinositol 3-kinase/ protein kinase B, Ras-mitogen-activated protein kinase and some members of the signal transducers and activators of transcription family. In addition to kidney and liver, EPO mRNA has been detected in other tissues; accordingly EPO receptor has been identified in several type of cells and recent reports have suggested new roles for EPO in non-haematopoietic tissues with a robust evidence for neuroprotective and cardioprotective activity. In different animal models, in vitro, in isolated perfused heart and in vivo, recombinant human erythropoietin protects heart from ischemia reperfusion injury and reduces myocardial damage. EPO tissue protective activity can be separated from erythropoietic activity. Molecules owing the first property but not the second one have been described. In patients with acute myocardial infarction serum EPO level correlates inversely with infarct size. Acute coronary syndrome, extracorporeal circulation and percutaneous coronary intervention are potential fields of application for tissue protective EPO activity to reduce myocardial damage, increase cardiac function ad improve outcome.

Multivariate analysis of matrix-assisted laser desorption/ionization mass spectrometric data related to glycoxidation products of human globins in nephropathic patients

To clarify the possible pathogenetic role of oxidation products originated from the glycation of proteins, human globins from nephropathic patients have been studied by matrix-assisted laser desorption/ionization mass spectrometry (MALDI), revealing not only unglycated and monoglycated globins, but also a series of different species. For the last ones, structural assignments were tentatively done on the basis of observed masses and expectations for the Maillard reaction pattern. Consequently, they must be considered only propositive, and the discussion which will follow must be considered in this view. In our opinion this approach does not seem to compromise the intended diagnostic use of the data because distinctions are valid even if the assignments are uncertain. We studied nine healthy subjects and 19 nephropathic patients and processed the data obtained from the MALDI spectra using a multivariate analysis. Our results showed that multivariate analytical techniques enable differential aspects of the profile of molecular species to be identified in the blood of end stage nephropathic patients. A correct grouping can be achieved by principal component analysis (PCA) and the results suggest that several products involved in carbonyl stress exist in nephropathic patients. These compounds may have a relevant role as specific markers of the pathological state.

Metabolomic fingerprinting of plant extracts

The standardization and quality control of plant extracts is an important topic, in particular, when such extracts are used for medicinal purposes. Consequently, the development of fast and effective analytical methods for metabolomic fingerprinting of plant extracts is of high interest. In this investigation, electrospray mass spectrometry (ESI-MS) and (1)H NMR techniques were employed with further statistical analyses of the acquired data. The results showed that negative ion mode ESI-MS is particularly effective for characterization of plant extracts. Different samples of the same species appear well-clustered and separated from the other species. To verify the effectiveness of the method, two other batches of extracts from a species, in which the principal components were already identified (Cynara scolymus), were analyzed, and the components that were verified by the principal component analysis (PCA) were found to be within the region identified as characteristic of Cynara Scolymus extracts. The data from extracts of the other species were well separated from those pertaining to the species previously characterized. Only the case of a species that was strictly correlated from a botanical point of view, with extracts that were previously analyzed, showed overlapping.

Advanced Glycation End Products/Peptides: Anin VivoInvestigation

Advanced glycation end products/peptides (AGE/peptides) originate by in vivo enzymatic digestion of nonenzymatically glycated proteins, which are produced by reaction of glucose with primary amino groups present in the protein chain following the Maillard pattern. AGE/peptides are highly reactive species and can interact with tissue and circulating proteins, leading to tissue modification and impaired protein functionality. Serum levels of AGE/peptides are reported to be particularly high in diabetes (in terms of higher production) or in end-stage renal disease (in terms of accumulation). For these reasons, their structural identification is of high interest, giving information on their relationship with the pathological state and allowing the design of possible therapeutic interventions. We report here some preliminary results obtained by liquid chromatography/electrospray ionization/mass spectrometry (LC/ESI/MS) and matrix-assisted laser desorption ionization MS (MALDI-MS) investigations carried out on the low-molecular-weight serum peptide fraction from 10 healthy subjects, 10 patients with poorly controlled diabetes, and 10 patients with end-stage nephropathy.

Evaluation of Glyoxal and Methylglyoxal Levels in Uremic Patients under Peritoneal Dialysis

Advanced glycation end products (AGEs) accumulate in serum and tissues of patients with chronic renal failure, even in the absence of diabetes, and a different clearance of these species has been observed by hemodialysis and peritoneal dialysis (CAPD). Furthermore, it has been shown that not only AGE but also 1,2-dicarbonyl compounds are formed during heat sterilization of glucose-based peritoneal dialysis fluids. Therefore, we investigated the level of some AGEs (pentosidine and free pentosidine) and dicarbonyl compounds (glyoxal and methylglyoxal) in end-stage renal disease patients subjected to peritoneal dialysis. Samples (20 from healthy subjects, 16 from uremic patients before and after 12 h of peritoneal dialysis) were analyzed, and the plasma and dialysate levels of glyoxal, methylglyoxal, pentosidine, and free pentosidine were determined. In plasma of uremic patients, mean values of pentosidine showed a small decrease after dialysis and were always higher than those of healthy control subjects. An analogous trend was observed for free pentosidine. In the case of peritoneal dialysate, no pentosidine and free pentosidine were found at time zero, whereas both compounds were detected after 12 h of dialysis. Glyoxal and methylglyoxal mean levels showed a decrease in plasma after dialysis even if their values were always higher than those of healthy control subjects. Surprisingly, an analogous trend was observed also in dialysate. These results might indicate that glyoxal and methylglyoxal already present in the dialysis fluid react with the peritoneal matrix proteins, accounting for the gradual loss of peritoneal membrane function that is often observed in patients subjected to CAPD for a long time.

A rapid liquid chromatography electrospray ionization mass spectrometry(n) method for evaluation of synephrine in Citrus aurantium L. samples

Immature bitter orange fruit and its extracts have been introduced into the market as an alternative to Ephedra in weight loss products. However, the safety of the immature bitter orange fruit and its extracts is a debated argument due to the presence of synephrine, a constituent known as a sympathomimetic agent. In this paper, we describe the development of a new, rapid, and simple liquid chromatography-electrospray ionization-tandem mass spectrometry method devoted to the quantitative determination of synephrine in bitter orange samples, containing a high quantity of synephrine, and sweet orange samples, known to contain a low level of synephrine but at the same time being one of the main synephrine sources in a normal human diet. Two bitter orange dry extracts containing 5 and 6% sSynephrine and 10 sweet orange samples have been analyzed. Between the sweet orange samples, six were fresh oranges and four were fresh-squeezed juices; in these samples, the synephrine levels ranged from 0.00128 to 0.00349%.

The role of different phenomena in surface-activated chemical ionization (SACI) performance

In previous studies, the production of ions in an APCI source without any corona discharge was observed, and the intensity of the ion signals showed significant increases on placing a metallic surface at 45 degrees inside an orthogonal ion source. This method was named surface-activated chemical ionization (SACI). The present study was performed to investigate the mechanisms of ion production with or without the presence of the metallic surface, by varying instrumental parameters and the geometrical configuration. Approximate calculations show that, in the absence of corona discharge and of any additional surfaces, ions cannot be produced by collisional phenomena, because of their low kinetic energy, in the 10(-2) to 10(-3) eV range. Two alternative possibilities have been considered: the first takes into account that ions may originate by collision of neutral clusters of polar solvent molecules with the APCI source surfaces through clusterelectric effect. The second takes into account that the water dissociation constant k(w) is temperature dependent, passing from 10(-14.1669) at 20 degrees C to 10(-12.4318) at 90 degrees C. It means that the [H(+)] varies from 8.3 x 10(-8) to 6.1 x 10(-7) M going from 20 to 90 degrees C. Hence, at the high temperatures experimented in the APCI vaporizer, H(+) becomes available in solution in molar quantities analogous to those of analyte, and the protonation of the analyte itself can consequently occur. The activation of further ionization processes in the presence of the metallic surface can be reasonably attributed to interactions between gas-phase analyte molecules and solvent molecules adsorbed on the surface. Experiments performed with a thin layer of deuterated glycerol on the surface led to unequivocal results, i.e. the production of [M + D](+) ions of the analyte.

Tissue plasminogen activator antigen is strongly associated with myocardial infarction in young women

Women who develop acute myocardial infarction (AMI) at a young age have fewer classical risk factors and less coronary stenosis than older women. In this rare population, it is plausible that a heightened hemostatic system may play an important mechanistic role in thrombus formation and in the development of AMI. We chose to investigate whether or not there is an association between premature AMI and the plasma concentrations of five hemostatic measurements that had been previously established as risk factors for AMI, and of the inflammation marker C-reactive protein (CRP). Women who had survived AMI at the age of 45 years or less (n = 141) were drawn from those admitted to 125 Italian coronary care units over a 3-year period. In them, and in an equal number of controls, plasma levels of immunoreactive tissue plasminogen activator (tPA), plasminogen activation inhibitor 1 (PAI-1), von Willebrand factor (VWF), fibrinogen, D-dimer and CRP were measured. Higher levels of VWF, fibrinogen, CRP and tPA were associated with AMI. After adjustment for both classical and hemostatic risk factors, only tPA maintained an independent association with AMI: the odds ratios (taken as an index of relative risk) for tPA values in the middle and higher tertiles were 2.86 (CI 1.63-5.02) and 8.18 (CI 2.66-25.20), respectively. In conclusion, there is a strong association between non-fatal AMI and increased plasma levels of tPA antigen. This finding is thought to be the expression of a reduced rather than enhanced fibrinolytic activity.

A matrix-assisted laser desorption/ionization mass spectrometry study of the non-enzymatic glycation products of human globins in diabetes

The molecular species present in globins from healthy and diabetic subjects with and without chronic complications have been analyzed by matrix-assisted laser desorption/ionization mass spectrometry. The technique demonstrated the presence of glycated and glyco-oxidated species of both alpha- and beta-globins. Their abundances show a good linear relationship with respect to HbA1c values and with the mean daily plasma glucose levels over the 6 weeks preceding the investigation. Interestingly, slightly different behaviour is observed in the data from patients with and without chronic complications; the plots of HbA1c vs. the abundance of glycated and glyco-oxidated species show different slopes and different intercepts with the y-axis. To investigate this aspect the mean abundances of glyco-oxidated species from healthy subjects and from diabetic patients with and without complications were calculated. Higher values were found for the two last sets of samples, but no significant difference was found between them. These data could indicate different individual proclivities to oxidation and/or different oxidation kinetics related to behavioural and environmental factors.

Characterisation via electrospray ionisation multistage mass spectrometry of three related series of nitrido technetium complexes containing phosphinothiolate and dithiocarbamate ligands

Nine nitrido technetium compounds comprising bis-substituted Tc(N)(PS)(2) (1-4) (PS = bidentate phosphinothiolate ligands) and Tc(N)(dtc)(2) (5, 6) derivatives (dtc = bidentate dithiocarbamate), and mixed-ligand Tc(N)(PS)(dtc) (7-9) species, were subjected to electrospray ionisation mass spectrometry and MS(n) experiments. Bis-substituted phosphinothiolato complexes 1-4 lead to the straightforward formation of dinuclear species reasonably originating from proton bound dimers. These dinuclear species do not show, under collisionally induced fragmentation processes, the formation of monomeric units but cleavages related to the ligand framework, thereby proving the high stability of the [Tc--H(+)--Tc] bond. Bis-dithiocarbamate compounds 5 and 6 show, instead, abundant [M+H](+), [M+Na](+) and [2M+Na](+) ions, and their collisionally induced fragmentations are highly favoured with cleavages related to the C--N and C--S bonds. During these processes, the coordination of a water molecule to [MH-L](+) product ions is observed, as proved by the collisionally induced H(2)O loss detected for this species. Mixed-ligand compounds 7 and 8 show the protonated molecules and Na(+)-cationised ions with fragmentation processes related to the dithiocarbamate moiety. This behaviour indicates that coordination of ether- and ester-substituted dithiocarbamates to the [Tc [triple chemical bond] N] group is weaker than that of phosphinothiolates. Conversely, diethyldithiocarbamate inserted in mixed complex 9 enhances both C--N and Tc--S bonds, and fragmentation processes suggest that metal-phosphinothiolate and metal-dithiocarbamate show comparable strength.

The complexity of non-enzymatic glycation product sets of human globins

AIMS/HYPOTHESIS

Recently an individual variability in the relationships between mean blood glucose levels and HbA1c has been observed among diabetic patients. The aim of this study was to provide an accurate description and evaluation of glycated and glyco-oxidated globins from diabetic subjects and their relationship with HbA1c and plasma glucose values.

METHODS

We studied 20 type 2 diabetic and 10 healthy subjects. Plasma samples were analysed by matrix-assisted laser desorption ionisation mass spectrometry.

RESULTS

The presence of glycated and glyco-oxidated species of both alpha and beta globin was demonstrated. Values for these showed a good linear relationship with HbA1c values and the mean daily plasma glucose values for the 6 weeks preceding the investigation. Trends differed according to whether patients had chronic complications or not, differences being seen in the slopes of the plots relating HbA1c to the abundance of glycated and glyco-oxidated species.

CONCLUSIONS/INTERPRETATION

The data obtained are consistent with the concept that individuals have a different individual proclivity for oxidation and/or that different oxidation kinetics are related to behavioural and environmental factors. Our data are thus relevant to the analysis of phenotype differences in diabetic patients.

Electron and electrospray ionization mass spectrometry in the characterization of some 1-allyl-3-phenylaziridines

A series of cis- and trans-isomeric aziridines has been studied under electron impact (EI) and electrospray ionization (ESI) conditions. The fragmentation patterns of the examined compounds have been elucidated by means of sequential product ion fragmentation experiments (MS(n)) performed using an ion trap mass spectrometer. Particular attention has been paid to isomer characterization in these precursors of azetidinones, that in turn are precursors of new beta-lactam antibiotics.

Electrospray mass spectrometry of a series of mixed nitrido 99gTc- heterocomplexes conjugated with bioactive molecules

Electrospray ionization mass spectrometry (ESI-MS) was successfully employed for the identification of six nitrido technetium mixed ligand complexes with a general formula of [99gTc(N)(O,S-BID)(PNP)], where PNP represents a heterodiphosphine and O,S-BID represents a simple dianionic bidentate ligand (compounds 1-3) or a more sophisticated N-substituted O,S-cysteine framework conjugated with a bio- active molecule (BAM) (compounds 4-6). In spite of similar coordination spheres exhibited by all the complexes investigated, simple co-ordination compounds 1-3 displayed collisionally-induced fragmentation processes (MSn) different from those observed in biomolecule-containing compounds 4-6. In the latter, more decomposition channels were observed. This behavior is likely to be associated with some additional intramolecular contacts of the biomolecule (or part of the biomolecule) with pendant group(s) incorporated in the PNP-co-ligand. This view is further supported by the observations arising from both in vitro binding affinity experiments and nuclear magnetic resonance investigations. The presence of cationized forms for all compounds 1-6 and the practical lack of the [2M + Na]+ species for biomolecule-containing compounds 4-6 provided further evidence of a subtly different structural conformation.

Electrospray ionization mass spectrometry in the structural characterization of some diphenyllead(IV) thiosemicarbazonates

The behavior in electrospray ionization mass spectrometry (ESI-MS) conditions of some complexes formed by Pb(C6H5)2(OAc)2 with salicylaldehyde, 2-ketobutyric acid, pyridine-2-carbaldehyde, 2-acetylpyridine, and 2-benzoylpyridine thiosemicarbazones, was studied in detail with the aid of collisional experiments performed by ion trap. The homoleptic complexes of tridentate thiosemicarbazonate dianions (TSC2-) lose the phenyl groups first, destabilizing the high oxidation state of the metal and leading to Pb(II) complexes in which the TSC2- ligand or a part of it remains coordinated to the metal. The main difference among the complexes derives from the presence of a carboxylate group on the 2-ketobutyric acid thiosemicarbazonato ligand, which probably interacts with a Na+ cation leading to ESI-generated [M+Na]+ species. In the absence of the carboxylate group, the production of abundant protonated molecules is observed. These different behaviors have been rationalized from the structural point of view. The heteroleptic mononuclear complexes, including thiosemicarbazonate and AcO- monoanions in the coordination sphere, do not yield intact ionized molecular species, and the most abundant ESI-generated ion is due to AcO- loss. The spectrum of the binuclear heteroleptic complex formed by the salicylaldehyde thiosemicarbazonate monoanion is conditioned by the weak bonding interaction displayed by the acetate bridge. MSn experiments yield important information on the relative ligand-Pb bond strengths. This work forms part of the search for chelating agents that can be used for effective chemotherapy of organolead poisoning.

Is the atmospheric pressure chemical ionisation and collisionally induced methanol loss from protonated dehydroamino acids a retrosynthetic process?

Unsaturated 5(4H)-oxazolones lead, by methanolysis, to the corresponding dehydroamino acid derivatives. Interestingly, under atmospheric pressure chemical ionisation (APCI) conditions, the latter give rise, aside from abundant [M+H](+) ions, to [MHbondCH(3)OH](+) species, formally corresponding to the protonated oxazolones employed for their synthesis. Retrosynthetic processes have often been described as energetically favoured decompositions of odd-electron molecular ions but never invoked in APCI-activated fragmentations. To investigate this possible retrosynthetic process, occurring also under collisional conditions, some experiments on the deuterated analogues have been undertaken. The breakdown curves of [M+H](+) of oxazolones and [MHbondCH(3)OH](+) of the dehydroamino acid derivatives are superimposable, proving their structural identity and giving experimental evidence of the occurrence of a real retrosynthetic process from even-electron protonated molecules.

Atmospheric pressure photoionization mechanisms. 2. The case of benzene and toluene

Benzene and toluene have been proposed previously as dopants in atmospheric pressure photoionization (APPI) experiments on compounds exhibiting ionization energies higher than the energy of photons used for irradiation. Their low ionization energies lead to their easy photoionization and the ions so formed lead to the ionization of analytes through charge exchange. However, some measurements have shown that some protonation reactions also take place, and a series of experiments was undertaken to investigate this unexpected behavior. It was shown that, when benzene is irradiated in the APPI source, the odd-electron molecular ions of phenol, diphenyl ether and phenoxyphenol are produced in high yield, together with protonated diphenyl ether and protonated phenoxyphenol. These results have been confirmed by deuterium labelling and MS(n) experiments. A possible mechanism is proposed, based on a radical attack by benzene molecular ions on oxygen molecules present inside the APPI source, analogous to that proposed in the literature for phenyl radicals. Similar results have been obtained with toluene, proving that APPI is able to activate a series of reactions leading to highly reactive species which are highly effective in promoting ionization of molecules with ionization energies higher than the photon energy.

The mass spectrometric behaviour of fluorinated ephedrines under different protonating conditions

The behaviour of di- and tri-fluorinated-ephedrines and -norephedrines has been studied by fast atom bombardment, atmospheric pressure chemical ionisation (APCI) and electrospray ionisation (ESI) experiments and compared with that of the unfluorinated analogues. Under all the employed ionisation conditions [MH](+) and [MH-H(2)O](+) species are mainly produced. Both high- and low-energy collisional experiments were performed on the protonated molecules to put in evidence any possible significant differences due to different ionisation methods. Multiple MS/MS experiments, performed by ion trap, allowed establishment of the decomposition pathways at lower activation energy. The data thus obtained indicate that the presence of fluorinated substituents leads to a higher stability of the molecular species, with strengthening of the C(1)-C(2) bond of the molecule and with a lower proclivity to thermally-induced dehydration.

Electrospray ionization mass spectrometry in studies of aluminium(III)-ligand solution equilibria

Electrospray ionization mass spectrometry (ESI-MS) has been applied to the study of solution equilibria between Al(III) and the two ligands 4-hydroxy-3-pyridinecarboxylic acid (4H3P) and 3-hydroxy-4-pyridinecarboxylic acid (3H4P). The results compare well with the speciation data obtained from potentiometric, UV-visible spectroscopy, and NMR measurements. This agreement suggests the applicability of ES-MS to the study of more complicated aluminium-ligand systems.

Surface-activated no-discharge atmospheric pressure chemical ionization

A new ionization method named surface-activated chemical ionization (SACI) has been realized. In this invention a commercially available atmospheric pressure chemical ionization (APCI) chamber, employed without any corona discharge (no-discharge APCI), has been modified with the insertion of a gold surface, leading to a significant improvement in the ionization efficiency. The ionization of the sample takes place by both gas-phase and surface-activated processes. This new ionization source is able to generate ions with high molecular mass and low charge states, leading to improved sensitivity and reduced noise. The new device has been tested in the analysis of some peptides. A comparison between the performance with and without the presence of the surface, and the optimization of the operating conditions (nebulizing gas flow, sample solution flow, pH of solution, and surface area), are reported and discussed.

Synthesis and physicochemical characteristics of a liver-targeted conjugate of fluorodeoxyuridine monophosphate with lactosaminated human albumin

In previous experiments fluorodeoxyuridine monophosphate (FUdRMP) was conjugated with lactosaminated human albumin (L-HSA). Fluorodeoxyuridine (FUdR) is an anticancer agent and L-HSA is a hepatotropic carrier of drugs obtained by the covalent linkage of lactose residues to the albumin molecule. The conjugate was synthesised via the imidazolide of FUdRMP at alkaline pH. Peripheral venous administration of L-HSA-FUdRMP produced enhanced FUdR levels in hepatic blood and might accomplish a non-invasive loco-regional chemotherapy of liver micrometastases. In the present paper some physicochemical characteristics of L-HSA-FUdRMP are reported. Polyacrylamide gel electrophoresis indicated that the coupling reaction did not cause covalent aggregation of the L-HSA molecules. 31P NMR spectra of the conjugate showed that FUdRMP was linked to L-HSA by phosphoamide bonds to lysine and histidine residues, and the area of the peak due to the lysine bond represented more than 80% of the spectrum of L-HSA-FUdRMP. MALDI analysis revealed a partial degradation of the peptide backbone of the conjugate which could not be detected using other methods of analysis. The degradation was not caused by the coupling of lactose molecules to albumin, but rather a consequence of FUdRMP conjugation with L-HSA. This fragmentation was dependent on the pH of the medium used for the FUdRMP coupling reaction. By decreasing the pH to 7.5, conjugates were obtained with a lower drug load but with a substantially reduced fragmentation, which should be preferred for a clinical use of L-HSA-FUdRMP.

[Reporting echocardiography exams with the G8-Cardio ANMCO software]

BACKGROUND

The availability of a common computerized program for echocardiographic study archiving and reporting at national and/or international level could make it possible to standardize the echo reports of different echocardiographic laboratories, and to use the wealth of data thus obtainable with echocardiography, and to exploit its capillary territorial distribution, with the aim of collecting echocardiographic data in a standard format for epidemiological, scientific and administrative purposes.

METHODS

To develop such a software, an ad hoc joint National Association of Hospital Cardiologists and Italian Society of Echocardiography task force worked in conjunction with the Italian Branch of Agilent Technologies to standardize the phraseology of accepted echocardiographic terms and of the quantitative parameters derived from transthoracic and transesophageal echocardiographic examination at rest as well as during exercise and pharmacological stress, and to develop an ad hoc software. This echocardiographic study archiving and reporting program is part of the whole G8-Cardio ANMCO software developed to computerize the whole cardiological chart. The software has been developed by Agilent Technologies to provide a fast, easy-access and easy to use report generator for the non-computer specialist using DBMS Oracle 7.3 database and Power Builder 5.0 to develop a user-friendly interface.

RESULTS

The number of qualitative and quantitative variables contained in the program is 733 for echocardiography at rest, while it depends on the stressor and on the length of the examination for the stress echo (dipyridamole 214-384, dobutamine 236-406, exercise 198-392). The program was tested and refined in our laboratory between November 1999 and May 2000. During this time period, 291 resting and 56 stress echocardiographic studies were reported and recorded in a database. On average, each resting echocardiographic study lasting 10 +/- 4 (range 5-17) min was recorded using 50 +/- 11 (range 33-67) variables and 41,566 bytes of hard-disk memory space. Stress echocardiographic studies, each lasting 7 +/- 5 (range 5-21) min, were recorded using 143 +/- 74 (range 38-194) variables and 38,531 bytes of hard-disk memory space.

CONCLUSIONS

To our knowledge this software represents the first experience of a common computerized program for echo archiving and reporting carried out at national level.

[The role of biochemical markers of myocardial damage in clinical practice: the diagnosis of infarct and risk stratification. The Intersociety Interdisciplinary Study Group of the ANMCO-SIBioC-SIMeL, Markers of Muocardial Lesions. L'Associazione Nazionale Medici Cardiologi Ospedalieri-Società Italiana di Biochimica Clinica-Società Italiana di Medicina di Laboratorio]

For many years creatine kinase (CK) and CK-MB isoenzymes were used together with the ECG to confirm the presence of myocardial infarction. During the last decade newer cardiac markers have been introduced and immunological test systems developed for their quantification. Among these new markers, a prominent role has emerged for cardiac troponins (T or I). These technological advanced assays have shown greater sensitivity compared to "conventional cardiac enzymes;, thereby identifying patients with small--at times, microscopic--infarcts who would not have met defining criteria for myocardial infarction in an earlier era. Another major advantage shown by both cardiac troponins with respect to "conventional cardiac enzymes" is their ability to predict clinical outcome over a short- or long-term follow-up in patients with acute coronary syndromes, and this appears to be particularly relevant in patients with micronecrosis, who constitute a high-risk subgroup of unstable angina patients. Recently, myoglobin has also been widely applied as a marker. Although lacking in myocardial specificity, it is the earliest marker to show an increase after coronary occlusion. Thus, the combined use of myoglobin and a cardiospecific structural protein such as troponin T or I may prove an attractive strategy for biochemical testing in chest pain patients. With the routine use of these novel cardiac markers, fascinating opportunities are now open in the field of diagnostic classification (making the World Health Organization definition of myocardial infarction obsolete) and risk stratification in chest pain patients; opportunities that were unforeseen in the era of cardiac enzymes. However, the use of these markers has also posed some important questions on: a) the best and most cost-effective diagnostic strategy in chest pain patients; b) the remaining role of cardiac enzymes; c) the therapeutic consequences of a positive test result.

[Atherosclerosis and simvastatin: new questions for the new millennium]

Coronary artery disease is still associated with high morbidity and mortality in Western countries. Lipid blood levels have a tight correlation with the risk of coronary events, and the results of many trials on lipid-lowering therapy (and particularly on simvastatin) demonstrated a significant reduction in total and cardiac mortality, and in the incidence of myocardial infarction and coronary events; even the progression of coronary stenosis has been reduced by treatment with statins. Beyond cholesterol reduction, simvastatin exerts many favorable effects on endothelial function, inflammatory activity, expression of pro-thrombotic factors and oxidative stress, yielding a rational basis for its important clinical positive effects, both in primary and secondary prevention of coronary disease. Future developments, which are the subjects of many planned or ongoing clinical trials, are related to the treatment of high-risk patients, the evaluation of the efficacy of elevated simvastatin dosages and of a deep reduction in cholesterol blood levels, the interaction between simvastatin and other drugs (antioxidant compounds, vitamins, antiplatelet drugs) or interventional procedures (percutaneous transluminal coronary angioplasty). Particularly, the Heart Protection Study, the A to Z trial, and the SEARCH and SMART studies will provide important data on a wider, earlier and greater use of simvastatin, which has been demonstrated effective both in the prevention and treatment of acute coronary syndromes.

The effect of verapamil on left ventricular remodelling and diastolic function after acute myocardial infarction (the Verapamil Infarction Study on Remodelling and Relaxation--VISOR)

The VISOR is a double blind, randomized, placebo-controlled study aimed to assess the effects of early and prolonged administration of verapamil on the left ventricular geometry and diastolic function in patients with anterior acute myocardial infarction treated with thrombolysis. Patients with heart failure or ejection fraction < 45% were excluded. Within 12 hours from starting thrombolysis, 70 patients were given verapamil (5 mg/hour intravenously for the first 24 hours, followed by 120 mg t.i.d. perorally for 6 months) or equivalent placebo. Echocardiograms were performed on admittance, before discharge, after 3 months and 6 months. The following parameters were calculated: left ventricular volumes, ejection fraction, sphericity index, early (E) and late (A) transmitral peak flow velocities and time-velocity integrals with their ratios, deceleration time and half-time of E, isovolumic relaxation time (IVRT), and non-invasive time constant of ventricular relaxation (tau). The basal and the last available parameters were considered for statistical analysis. The effects of the treatment on the left ventricular volumes, ejection fraction, and sphericity index were not statistically relevant. Conversely, a reduction of E/A ratio (P < .05) and increases of A integral (P < .01), deceleration time and half-time of E, IVRT and tau (P < .05) were found in the placebo group and not in the verapamil group. No significant changes in the blood pressure, heart rate, PQ interval, and biochemical parameters were observed in the two groups. In conclusion, in patients with a thrombolysed anterior acute myocardial infarction and preserved systolic function, verapamil can prevent alterations of the diastolic function in absence of effect on ventricular remodelling, and has a good safety profile.

Prothrombotic genetic risk factors in young survivors of myocardial infarction

It has long been thought that an individual thrombotic tendency increases the risk of myocardial infarction, especially in young adults. Several "prothrombotic" genetic factors that may influence the individual thrombotic risk have been identified. To investigate the association between the risk of myocardial infarction at a young age and genetic factors thought to be associated with an increased tendency to thrombosis (the polymorphisms 4G/5G of the PAI-1 gene, PIA1/PIA2 of the platelet glycoprotein IIIa, C3550T of the platelet glycoprotein Ib gene, G10976A of the factor VII gene, C677T of the methylenetetrahydrofolate reductase gene, G1691A of the factor V gene, and G20210A of the prothrombin gene), we performed a case-control study evaluating 200 survivors (185 men, 15 women) of myocardial infarction who had experienced the event before the age of 45 years and 200 healthy subjects with a negative exercise test, individually matched for sex, age, and geographic origin with the cases. The presence of the PIA2 polymorphic allele was the only prothrombotic genetic factor associated with the risk of myocardial infarction at a young age. The odds ratio for carriers of the PIA2 allele compared with those of the PIA1 allele was 1.84 (95% confidence intervals (CI) 1.12 to 3.03). There was a significant interaction between the presence of the PIA2 allele and smoking: with their simultaneous presence, 46% (95% confidence intervals 11% to 81%) of premature myocardial infarctions were attributable to the interaction between the two factors. In conclusion, carrying the PIA2 polymorphic allele of platelet glycoprotein IIIa was the only genetic prothrombotic factor associated with the risk of developing myocardial infarction at a young age. The clinical expression of this genetic predisposition seems to be enhanced by smoking.

Gallopamil activity on asynergic viable myocardium in acute myocardial infarction: insights on stunned and hibernating myocardium

The influence of the calcium antagonist gallopamil on the contractility of asynergic viable myocardium after acute myocardial infarction treated with thrombolysis was investigated by two-dimensional echocardiography. Sixteen patients with > or = 1 viable segment(s), identified during the low-dose phase (up to 10 micrograms/kg/min) of a dobutamine echocardiographic test (up to 40 micrograms/kg/min) performed 4-5 days after a first acute myocardial infarction, were given a gallopamil intravenous bolus (50 micrograms/kg) 12-24 hours later. Two-dimensional echocardiography was done before and 15 minutes after the bolus. A score index of 1 (normokinesis) to 4 (dyskinesis) and a 16-segment model were used. A segment was considered viable when a resting asynergy (score > or = 2) improvement of > or = 1 grade was seen during low-dose dobutamine. Follow-up echocardiograms were done 3-5 months later. A total of 30 viable segments were found; of these, 10 showed sustained improvement in contractility (group A) during high-dose dobutamine, while 20 exhibited a biphasic response returning to their basal contractile state (group B). After the gallopamil bolus, 9 of 10 group A segments improved their contractility, in comparison with 0 of 20 group B segments (P < .001). Infarct-related vessel significant (> or = 75%) coronary stenosis was present in the tributary vessel of 0 of 10 group A and of 20 of 20 group B segments (P < .001). At follow-up, 9 of 10 group A segments showed a spontaneous contractile improvement; of the 20 group B segments, 8 of 10 that underwent revascularization (7 angioplasty, 3 bypass graft) showed contractile improvement, in comparison with 0 of 10 segments not revascularized (P = .001). We conclude that gallopamil may reverse the contractile dysfunction of postischemic stunned myocardium in patients with acute myocardial infarction, whereas no effects are apparent on ischemic/hibernating myocardium.

Identification of viable myocardium early after acute myocardial infarction under beta-blockade by enoximone echocardiography

The influence of the beta-blocker metoprolol on the capacity either of low-dose dobutamine echocardiography or the recently introduced enoximone echocardiography to detect viable dysfunctioning myocardium after myocardial infarction was investigated. Initial clinical experience would suggest that the phosphodiesterase III inhibitor enoximona could be an alternative pharmacological stimulation, inducing an increase in contractility in the presence or absence of beta-receptor stimulation. Ten patients with a baseline low-dose dobutamine-echocardiographic test (up to 10 micrograms/kg/min) positive for myocardial viability in > or = 1 segment(s), performed 4-5 days after a first acute myocardial infarction treated with rtPA, were randomized after the administration of intravenous metoprolol (15 mg in three 5-mg boluses) either to dobutamine (up to 15 micrograms/kg/min) or to an enoximone intravenous bolus (1 mg/kg over 5 min) under echocardiographic monitoring, in a crossover sequence, with a 24-h interval. The infarct related artery was patent (TIMI grade 2 o 3) in all the patients. Follow-up echocardiograms were performed 5-7 weeks later. Resting asynergy was found in 40 segments; of these, 17 were viable. All the viable segments remained unresponsive during the post-metoprolol dobutamine infusion, while improved their contractility during enoximone echocardiography. Two patients suffering from early post-infarction angina underwent coronary angioplasty successfully. Eight out of ten patients (2 revascularized and 6 not) showed contractile recovery in a total of 14 segments at the follow-up echocardiogram. Sensitivity, specificity and overall accuracy in predicting reversible dysfunction after acute myocardial infarction for enoximone echocardiography were 93, 85, and 88%, respectively. Our results support the value of enoximone echocardiography in the identification of myocardial viability after myocardial infarction, in patients treated with beta-blockers, which interfere heavily with the results of dobutamine echocardiography.

[Early echocardiographic identification of viable myocardium after acute myocardial infarct using inotropic agents: comparison of dobutamine and enoximone]

BACKGROUND

The reversibility of regional dysfunction early after acute myocardial infarction may be obtained with inotropic adrenergic stimulation, in particular during low dose dobutamine infusion, suggesting the presence of viable myocardium. The aim of this study was to determine whether viable myocardium can be identified by two-dimensional echocardiography after an i.v. bolus of enoximone-positive inotropic non-adrenergic drug, phosphodiesterase III inhibitor as well as during dobutamine infusion, in patients with acute myocardial infarction.

METHODS

Twelve male patients, aged 57 +/- 10 years and treated with rtPA (100 mg i.v. in 180 minutes) within the first 6 hours of a first anterior myocardial infarction were studied. All patients underwent a dobutamine infusion (5 and 10 mcg/kg/min, 5 minutes per dose) 4 +/- 1 days after entrance, followed by an enoximone bolus (1 mg/kg over 5 minutes) 1 hour later. Echocardiography was performed before dobutamine and enoximone, during dobutamine, 10 minutes after enoximone and at 6 +/- 2 months follow-up. A Wall Motion Score Index (WMSI) was calculated as recommended by the American Society of Echocardiography. All patients underwent coronarography on days 9-11 post-infarction.

RESULTS

Improvement in regional function of basally asynergic segments occurred in 8 patients during dobutamine infusion, as well as after enoximone i.v. bolus, and in 1 patient only during dobutamine infusion. Both dobutamine and enoximone tests were found to be negative in the other 3 patients. A decrease of WMSI was observed with both dobutamine and enoximone tests (from 1.84 +/- 0.32 to 1.73 +/- 0.31; p = .002 with dobutamine; from 1.84 +/- 0.32 to 1.70 +/- 0.27; p = .0132 with enoximone) with concordant wall motion changes between two tests in 73/84 (87%; K = 0.61) basally asynergic segments. There were no complications occurred during the study. Of 8 patients with positive response for viable myocardium to both tests, 6 had a patent and 2 an occluded infarct-related artery. However, in the latter a collateral circulation toward necrotic area was present. At follow-up improvement in regional function of basally asynergic segments, with a decrease of WMSI (from 1.74 +/- 0.23 to 1.59 +/- 0.24; p < .05), was observed in 4 of 8 patients with viable myocardium detected by either dobutamine or enoximone.

CONCLUSIONS

1) Viable asynergic myocardium may be identified early after acute myocardial infarction by enoximone bolus, as carefully and safely as by dobutamine infusion; 2) transient recovery of post-ischemic myocardial dysfunction may be obtained independently of beta-receptor stimulation.

[The usefulness of the echo-dipyridamole test in the early period after an uncomplicated acute myocardial infarct]

OBJECTIVES

The aim of this study was to examine the ability of Dipyridamole Echocardiography Test (DET)--performed early after an acute myocardial infarction (AMI)--to assess: a) the presence of induced ischemia and its relation with coronary artery stenoses; b) the presence of myocardial viability and the comparison with late wall motion; c) the appearance of cardiac events during hospitalization and in the following period.

METHODS

Ninety-five patients with AMI, subjected to thrombolytic therapy and without complications, underwent a DET on the 4th-5th day. All had a coronary angiography on the 8th-10th day; stenoses were deemed significative when > or = 70%. DET was carried out after drug discontinuance and following standard protocol; parietal kinesis was analyzed according to a 14 segment model. The myocardium was deemed viable when an improvement of a basal dyskinesis was noted; ischemia was considered when a new asynergy appeared or a basal dyskinesis worsened or enlarged; a wall motion score index (WMSI) was calculated. All 95 pts. had a clinical follow-up at 12 +/- 6 months (3-18); 62 pts. had a late echocardiographic examination at 6 +/- 3 months (3-15).

RESULTS

Induced ischemia appeared in 59/95 pts. (62%): in 6/14 pts. (42%) without significative stenoses, in 29/49 pts. (59%) with a single vessel disease, and in 24/32 pts. (75%) with multivessel disease. In identifying multivessel disease, DET sensibility (SE) was 75% and specificity (SP) was 95-97%. In single or no vessel disease WMSI changed from 1.42 to 1.49 (p < 0.0001); in multivessel disease WMSI changed from 1.52 to 1.69 (p < 0.0001). As regards the assessment of diseased vessel(s), DET showed little accuracy when dyskinesis appeared in the basal segments of the inferior and lateral wall or in the mid-apical segments of the anterior and lateral wall; DET properly identified the culprit vessel when dyskinesis appeared in the remaining segments. Myocardial viability was noted in 26% of dyskinetic segments. In single or no vessel disease WMSI changed from 1.41 (basal--> B) to 1.35 (viability phase--> V) and was found 1.31 at the late echocardiography (L): p < 0.0001 between B and V, and between B and L. In multivessel disease WMSI changed from 1.5 (B) to 1.47 (V) and to 1.5 (L): p < 0.05 between B and V, NS between B and L. In comparison with late echocardiography, DET SE was 70%, SP 99%, positive predictive value (PPV) 97%, negative predictive value (NPV) 86%. As regards the prognostic value about cardiac events, DET SE was 80% and NPV was 78%; about only major cardiac events, the respective values are 91% and 97%.

CONCLUSIONS

DET performed early after an AMI allows a better prognostic assessment, as it provides information about: a) the place and the severity of coronary artery stenoses; b) the presence and the extension of induced ischemia and of myocardial viability; c) the risk of subsequent cardiac events.