[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to evaluate the usefulness of brain natriuretic peptide (BNP) in diagnosing congestive heart failure (CHF), in an unselected population.
Eighty-three patients (47 men, 36 women, mean age 70 +/- 10 years) were referred to our hospital ambulatory from their general practitioners, with a diagnosis of CHF.
Clinical-instrumental evaluation confirmed diagnosis in 45 patients (54%) (group A), and excluded it in the remaining 38 (46%) (group B). There were no differences between groups regarding age, weight, height, heart rate, blood pressure. Statistically significant differences between groups were found regarding ejection fraction (44 +/- 10% group A vs 60 +/- 7% group B, p < 0.01), and BNP blood concentration (162 +/- 226 pg/ml group A vs 73 +/- 23 pg/ml group B, p < 0.01). Forty-two patients in group A (93%) and 25 in group B (65%) had a BNP value > 20 pg/ml (p < 0.05). Using this cut-off value, sensitivity was 93%, specificity 34%, negative predictive value 81% and positive predictive value 62%. Forty-two patients in group A (93%) and 14 in group B (36%) had an "abnormal" electrocardiogram (p < 0.01). The presence of electrocardiographic abnormalities showed a sensitivity for the diagnosis of CHF of 93%, specificity of 63%, negative predictive value of 89% and positive predictive value of 77%.
In our population BNP dosage confirms the high negative predictive value reported in the literature and may be useful to exclude diagnosis of CHF in patients with suspect signs and symptoms.
No preview · Article · Sep 2002 · Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Massive pulmonary embolism associated with cardiac arrest has an extremely high mortality in spite of cardiopulmonary resuscitation maneuvers. An early diagnosis of pulmonary embolism as cause of cardiac arrest and a rapid specific therapy able to obtain a restoration of pulmonary flow can improve the prognosis. The authors report a case of cardiac arrest for massive pulmonary embolism promptly diagnosed by echocardiography and treated by thrombolytic therapy with an initial favourable outcome.
No preview · Article · Jan 2002 · Minerva cardioangiologica
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to investigate the diagnostic utility of clinical probability, rapid plasma D-dimer assay, compression ultrasonography (CUS) and transthoracic echocardiography (TTE) in patients with suspected pulmonary embolism.
One hundred forty consecutive outpatients with suspected pulmonary embolism were enrolled in a prospective trial. We evaluated sensitivity, specificity, positive and negative predictive value of a combination of clinical probability, D-dimer, CUS and TTE using perfusion lung scan and pulmonary angiography as a combined gold standard for determining the presence or absence of pulmonary embolism. Clinical probability was assessed in accordance with the PIOPED criteria. The D-dimer (Nycocard) level was considered as abnormal > 0.3 mg/l, the CUS if incompressibility of the leg veins was showed, and the TTE if right ventricular dilation was present, in the absence of chronic pulmonary disease. The combination of these tests was considered consistent with the presence of pulmonary embolism if D-dimer plus CUS and/or TTE showed abnormal results. A pulmonary embolism was excluded if D-dimer and CUS showed normal findings or a low clinical probability was associated with normal findings of CUS and TTE.
One hundred eleven patients were evaluated. Pulmonary embolism was present in 45/111 (40%) patients. The combination of tests showed positive findings in 39/39 patients with pulmonary embolism, negative findings in 47/50 without pulmonary embolism and non-diagnostic results in 22/111 (20%) patients (95% confidence interval--CI 12-28%). There were three false positive and no false negative results. Sensitivity and specificity were 100 and 94% respectively (95% CI 92-100% and 87-100%); positive and negative predictive values were 93 and 100% (95% CI 85-100% and 93-100%). None of these tests, separately, showed enough sensitivity and specificity.
The combination of clinical probability, D-dimer, CUS and TTE was highly accurate to confirm or rule out pulmonary embolism.
No preview · Article · Feb 2000 · Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Background. The aim of this study was to investigate the diagnostic utility of clinical probability, rapid plasma D-dimer assay, compression ultrasonography (CUS) and transthoracic echocardiography (TTE) in patients with suspected pulmonary embolism. Methods: One hundred forty consecutive outpatients with suspected pulmonary embolism were enrolled in a prospective trial. We evaluated sensitivity, specificity, positive and negative predictive value of a combination of clinical probability, D-dimer, CUS and TTE using perfusion lung scan and pulmonary angiography as a combined gold standard for determining the presence or absence of pulmonary embolism. Clinical probability was assessed in accordance with the PIOPED criteria. The D-dimer (Nycocard) level was considered as abnormal > 0.3 mg/l, the CUS if incompressibility of the leg veins was showed, and the TTE if right ventricular dilation was present, in the absence of chronic pulmonary disease. The combination of these tests was considered consistent with the presence of pulmonary embolism if D-dimer plus CUS and/or TTE showed abnormal results. A pulmonary embolism was excluded if D-dimer and CUS showed normal findings or a low clinical probability was associated with normal findings of CUS and TTE. Results. One hundred eleven patients were evaluated. Pulmonary embolism was present in 45/111 (40%) patients. The combination of tests showed positive findings in 39/39 patients with pulmonary embolism, negative findings in 47/50 without pulmonary embolism and non-diagnostic results in 22/111 (20%) patients (95% confidence interval-CI 12-28%). There were three false positive and no false negative results. Sensitivity and specificity were 100 and 94% respectively (95% CI 92-100% and 87-160%); positive and negative predictive values were 93 and 100% (95% CI 85-100% and 93-100%). None of these tests, separately, showed enough sensitivity and specificity. Conclusions. The combination of clinical probability, D-dimer, CUS and TTE was highly accurate to confirm or rule out pulmonary embolism.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the behaviour and knowledge of students on cardiovascular risk factors and to programme a campaign for the prevention of cardiovascular diseases.
All students attending the last year of the secondary school of this province answered a questionnaire. An educational campaign followed the analysis of the questionnaire.
The analysis of 3675 questionnaires shows that almost all students were between 18 and 20; 16% of males (m) and 7.4% of females (f) were overweight; 1.5% and 0.4% respectively were obese; 88.8% of m and 44% of were doing physical activity; 32.4% of m and 26.8% of f were cigarette smokers. Knowledge about cardiovascular risk factors were poor. Development of the prevention campaign. In the school districts four seminars were organized to discuss about cardiovascular prevention with science teachers of the province, using audiovisual materials. The same teachers devote 4-6 hours to the same matters during school lessons. In the next months conferences destined to the population of the province will be organized.
This program allows to promote health education in the whole population, through the students, with a low cost.
[Show abstract][Hide abstract] ABSTRACT: Echocardiographic detection of right heart thromboemboli (RHTE) during pulmonary embolism (PE) shows an uncommon but life-threatening event. The treatment of this condition is not well established. The aim of our study is to evaluate the efficacy and safety of recombinant tissue-type plasminogen activator (rt-PA) in treating RHTE.
We performed a transthoracic echocardiogram within (mean +/- SD) 120+/-45 min from onset of symptoms on 30 consecutive patients with proven massive PE. Seven patients (23%) showed RHTE, four patients (57%) had cardiogenic shock; and all patients showed echocardiographic features of acute cor pulmonale. The seven patients with RHTE received an IV infusion of 100 mg rt-PA over a period of 2 h with continuous echocardiographic monitoring.
We observed complete RHTE lysis at 45 to 60 min from the onset of rt-PA infusion and significant reductions at 2 h in the following: 14% in right ventricle (RV) end-diastolic diameter (reduction, 40.8 to 35 mm; p < 0.01); 12% in RV/left ventricular ratio (reduction, 0.83 to 0.73; p < 0.01); and 17% in tricuspid regurgitant flow velocity (reduction, 3.5 to 2.9 m/s; p < 0.01). The interventricular septal and RV wall motions improved. An excellent clinical outcome was achieved rapidly in all patients. No adverse events were recorded.
We demonstrated the rapid, effective, and safe action of rt-PA in RHTE resolution and an improvement in pulmonary perfusion. Our data confirm the important role of an early, systematic echocardiographic approach in order to detect RHTE quickly in patients with suspected massive PE.
[Show abstract][Hide abstract] ABSTRACT: Two-hundred and fourteen patients with congestive heart failure were identified over a six-month period in the general practice of 29 GPs covering an adult population of 29,959 subjects residing in the region of Calabria, in southern Italy, with an overall prevalence of 7 per 1000. Males represented 52% of the cases and females 48%, with a median age of 75 years. On average, the condition was first diagnosed 41 months before the present examination. Patients generally had a high body mass index (28 kg/m2). Patients were classified as follows in the NYHA classification: 9.4% in class I, 45.3% in class II, 39.2% in class III, 6.1% in class IV. Hypertension, either alone or associated with ischemic heart disease (totally about 75% of cases), was the most common etiology, while COPD was the most commonly associated chronic condition. Clinical symptoms and signs were used to classify patients in a simplified version of the Boston score which was reported in 48% of cases as definite, 12% as possible, 6% as improbable and 34% as absent. A specific treatment was already ongoing in 97% of patients. The most commonly administered drugs were diuretics (83%), ACE-inhibitors (77%), and digitalis (67%). This three-drug combination (alone or with other drugs) covered 46% of patients. A comparison of four predefined typologies of treatment against the Boston score suggested that at least part of the outcome in classifying patients using this procedure was due to pathomorphosis of the syndrome induced by early pharmacological treatment.
No preview · Article · Jan 1999 · Giornale italiano di cardiologia
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to analyse the attitudes towards and knowledge of primary prevention of venous thromboembolism (VTE) among hospital doctors in Calabria.
The survey was based on theoretical knowledge and practical management of hortopedics, surgeons, gynecologists and internists working in 14 hospitals.
Out of a total of 340 physicians contacted, 154 (45%) agreed to take part in the survey. 82% of those who responded used VTE prophylaxis on a routine basis. Unfractioned heparin (71%) was the most frequently used methods; early deambulation (55%), low molecular weight heparin (49%) and elastic stocking (49%) were less frequently employed. Surprisingly, one third used aspirin. 75% of those contacted had modified their approach to prevention during the last few years, in particular owing to improvements in pharmacological therapy and increased awareness of the problem. In the survey of clinical practice, 80% of those who took part correctly identified the VTE risk, 86% suggested the best treatment, but only 27% assessed the exact frequency rate of deep venous thrombosis (DVT) and pulmonary embolism (PE) in the absence of prophylaxis.
Most of the doctors contacted showed scant interest in the primary prevention of VTE. The 45% who agreed to be interviewed revealed a good practical approach but were not sufficiently aware of the real incidence of DVT and PE in a clinical risk context without prophylaxis. Although they must be interpreted with caution, these findings allow the real behaviour of hospital physicians in this region to be assessed with regard to the primary prevention of VTE and suggest the need for more correct information about this aspect of venous thromboembolic disease which is not yet sufficiently well known.
[Show abstract][Hide abstract] ABSTRACT: This study was designed to assess the feasibility of percutaneous incannulation of cephalic vein for the implantation of pacemaker and defibrillator leads.
The development of the subclavian vein puncture technique for pacemaker lead implantation has many advantages compared to surgical isolation of cephalic vein. However, initial enthusiasm has been dampened by reports of serious complications because of the anatomical relationships of the subclavian vein.
Percutaneous incannulation of the right cephalic vein was attempted in 75 patients who were candidates for permanent pacemaker or ICD implantation. The technique was effective in 46 patients. It was shown to be ineffective in 18, despite the presence of a normal vein. In seven patients, the cephalic vein was found to be unusable for passing the electrocatheter and in four patients, the vein was absent. In the patients in whom the vein was present, the success rate was 46/71 (64%). The average implantation time was 7.2 minutes (range 5-10), while the average time for conventional surgical technique was 15.2 minutes (range 14-20) (p < 0.001). All patients remained free from complications during a mean follow-up period of 8.2 months (range 1 to 18).
In our opinion, percutaneous incannulation of cephalic vein could be adopted as the first step in pacemaker or defibrillator implantation procedures, as it shows satisfactory success rates, simplicity of execution and absence of complications. Most importantly, in the event of failure, it does not compromise the use of a conventional technique.
No preview · Article · Nov 1998 · Giornale italiano di cardiologia
[Show abstract][Hide abstract] ABSTRACT: Prosthetic valve thrombosis can determine different degrees of valvular insufficiency or obstruction, with a potentially fatal course. The current literature has not established whether the best treatment is thrombolysis or surgery (thrombectomy or valvular replacement). However, both treatments expose the patient to the risk of serious sequelae or death. Here we describe a case of acute thrombosis in a prosthetic mitral valve. At presentation, the patient was in pulmonary edema and had a low cardiac output. She was treated with recombinant tissue-type plasminogen activator infusion (rt-PA 100 mg in 2 hours). Both clinically as well as echocardiographically, we observed a quick regression of the obstruction, but after the treatment, the patient developed an ischemic stroke with aphasia and hemiplegia. The authors conclude that thrombolysis is a highly effective treatment in resolving prosthetic thrombosis. However, because it carries a significant risk of embolization, it should be limited to patients with hemodynamic deterioration in whom surgery could also entail a significant risk of death.
No preview · Article · May 1998 · Giornale italiano di cardiologia
[Show abstract][Hide abstract] ABSTRACT: Clinical history of patients with severe chronic aortic regurgitation is characterized by a long period without any symptom, although the left ventricle enlarges progressively. The administration of oral vasodilators could reduce ventricular enlargement or its progression, delaying the development of myocardial dysfunction and/or the need for valvular surgery.
To verify the efficacy of long-term captopril therapy to reduce left ventricular mass and dimensions in patients with severe chronic aortic regurgitation.
This is a prospective echocardiographic study in which each individual patient is considered his own control case. Eleven asymptomatic patients with severe chronic aortic regurgitation in sinus rhythm, who had an ejection fraction greater than 50% and were not taking cardiovascular drugs, were orally administered captopril at the maximum tolerated dosage (127 +/- 13 mg/day). Follow-up lasted for 24 +/- 3 months.
Left ventricular telediastolic diameter decreased from 69 +/- 5 to 61 +/- 3 mm (p < 0.01), telesystolic diameter decreased from 48 +/- 5 to 41 +/- 4 mm (p < 0.01); ejection fraction increased from 56 +/- 4 to 61 +/- 3% (p < 0.001); myocardial mass decreased from 208 +/- 32 to 174 +/- 27 g/m2 (p < 0.01), and mean wall stress from 264 +/- 35 to 203 +/- 25 mmHg (p < 0.001). All variations were still significant at 6 months.
These results suggest that captopril has a favourable effect on left ventricular mass, dimensions and load conditions, and could favourably influence the natural history of chronic aortic regurgitation. The efficacy of medical treatment can be verified through serial echocardiographic study.
No preview · Article · Sep 1997 · Giornale italiano di cardiologia
[Show abstract][Hide abstract] ABSTRACT: Early diagnosis is important for the prognosis of patients affected with pulmonary embolisms. The mortality rate ranges from 30% in untreated cases to 10% in cases getting early treatment. In this context, it is essential to obtain a correct diagnosis in order to start the best treatment for each patient. The aim of our study is to evaluated the contribution of mono- bidimensional echocardiography and color-doppler for the early diagnosis of acute massive pulmonary embolism. We examined 23 patients (14 women with a mean age of 67 +/- 13 years; 9 men with a mean age of 58 +/- 16 years) who were referred to us for observation over a 30-month period. These patients had been admitted to the intensive care unit for suspected acute massive pulmonary embolism and the diagnosis was subsequently confirmed by a pulmonary scintigraphy. None of the 23 patients showed a positive case history of previous heart disease and/or pulmonary disease. The patients were checked using 2D-doppler echocardiography, 120 +/- 45 minutes from the onset of the symptoms. They were then divided into two groups (A and B) based on the presence or absence of thromboembolus in the right cavity of the heart. Seven patients (30%) revealed thromboemboli and were treated effectively with rt-PA (100 mg/2 hours). An increase in the size of the right ventricle with an affected rate RV/LV > 0.6 and the abnormal kinetics of the ventricular septum proved to be the most sensitive parameters for right ventricular overload, as signs of acute massive pulmonary ambolisms were observed in all 23 patients. Tricuspid regurgitation speed (from 2.9 to 3.6 m/sec) and peak systolic pulmonary pressure (67 mmHg) were recorded in all patients. Our observations suggest that the hemodynamic effects of an acute massive pulmonary embolism can be enumerated and monitored by analyzing ventricle size and septum kinetics. To summarize, echocardiography proved to be a simple and realistic test. It enabled correct diagnosis and made it possible not only to start thrombolytic therapy without requiring other exams, but also to monitor and evaluate the effects of this therapy.
No preview · Article · May 1997 · Giornale italiano di cardiologia
[Show abstract][Hide abstract] ABSTRACT: Background:
The delay between onset of symptoms and coronary care unit admission is decisive in the outcome of patients with acute myocardial infarction.Objective:
To evaluate the influence of the factors that affect the delay in acute myocardial infarction treatment.Methods:
Multicenter case-control study conducted by 118 coronary care units in Italy. The median and mean times in cases and controls were compared for decision time, home-to-hospital time, and in-hospital time, and the influence of several potential risk factors on the delay was evaluated by comparison of patients admitted more than 6 hours after onset with those admitted within 6 hours after onset.Results:
Among 5301 patients with acute myocardial infarction, 590 who came to a coronary care unit after 12 hours were considered cases. Controls included 600 patients treated within 2 hours, 603 between 2 and 6 hours, and 466 between 6 and 12 hours. The median decision time among cases was 50-fold higher than that of controls who presented within 2 hours. Home-to-hospital time and in-hospital time appeared to play a less important role. Among the patient-related variables, advanced age, living alone, low intensity of initial symptoms, history of diabetes, strong pain at onset of the infarction, occurrence of symptoms at night, and involvement of a general practitioner seemed to affect delay significantly.Conclusion:
Interventions aimed at reducing the delay in acute myocardial infarction treatment should primarily focus on the help-seeking behavior of patients.(Arch Intern Med. 1995;155:1481-1488)
No preview · Article · Jul 1995 · Archives of Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: GISSI-3 is a multicentre randomised clinical trial to assess the efficacy of lisinopril, transdermal glyceryl trinitrate (GTN), and their combination in improving survival and ventricular function after acute myocardial infarction (AMI). Between June, 1991, and July, 1993, 19 394 patients were randomised from 200 coronary care units in Italy. Eligible patients presented within 24 h of symptom onset and had no clear indications for or against the study treatments. In a factorial design patients were randomly assigned 6 weeks of oral lisinopril (5 mg initial dose and then 10 mg daily) or open control as well as nitrates (intravenous for the first 24 h followed by transdermal GTN 10 mg daily) or open control. Complete clinical data and 6-week follow-up were available for 18 895 (97.4%) patients randomised. Two-dimensional echocardiographic data were available for 14 209 patients. Overall 6-week mortality was 6.7%. Lisinopril, started within 24 h from AMI symptoms, produced significant reductions in overall mortality (odds ratio 0.88 [95% CI 0.79-0.99]) and in the combined outcome measure of mortality and severe ventricular dysfunction (0.90 [0.84-0.98]). In the same trial the systematic administration of transdermal GTN did not show any independent effect on the same outcome measures (0.94 [0.84-1.05] and 0.94 [0.87-1.02]). Systematic combined administration of lisinopril and GTN also produced significant reductions in overall mortality (0.83 [0.70-0.97]) and in the combined endpoint (0.85 [0.76-0.94]). The favourable effect of lisinopril alone or with GTN was clear also in the predefined high-risk populations (elderly patients and women) for the combined endpoint. These findings were obtained in a population intensively exposed to recommended treatments (thrombolysis 72%, beta-blockade 31%, and aspirin 84%); non-protocol treatment with angiotensin-converting-enzyme inhibitors and nitrates was allowed for specific clinical indications. No excess of unfavourable clinically relevant events in the treated groups was reported.
[Show abstract][Hide abstract] ABSTRACT: The effects of diltiazem hydrochloride (0.3 mg/kg i.v. over 2 min.) was studied by continuous electrocardiographic monitoring in 60 patients. Conversion to sinus rhythm was achieved in 55 patients (91%). Electrocardiographic findings were: undisturbed sinus rhythm in 20 patients; A-V junctional rhythm in 4 patients; complex ventricular arrhythmias (ventricular tachycardia or complex VPCs) in 19 patients. Patients with complex ventricular arrhythmias were matched against patients with normal sinus rhythm, with respect to the following parameters: age, sex, heart disease, tachycardia duration, tachycardia cycle length, sinus cycle length, pre- and post-infusion blood pressure. No differences between the two groups of patients were found. Ventricular arrhythmias occurring at the termination of supraventricular tachycardia are difficult to explain. Nevertheless, these arrhythmias are not associated with organic heart disease. They could be the expression of triggered activity.
No preview · Article · Nov 1992 · Giornale italiano di cardiologia
[Show abstract][Hide abstract] ABSTRACT: A total of 90 AMI patients (80 male, 10 female; mean age: 62 years, range: 36-70 yrs) who were admitted to the coronary care unit within six hours of the onset of symptoms were evaluated for the following: the incidence and variability of complex ventricular ectopic beats (classes Lown III-V) in the acute, subacute and chronic phases of myocardial infarction. The diagnostic utility of Holter monitoring and treadmill exercise testing was compared so as to reveal complex ventricular ectopic beats. The relation between complex ventricular ectopic beats and left ventricular dysfunction was determined using the echocardiographic technique (ejection fraction, fractional shortening). The hospital mortality rate was 6.6% (6/9 patients) while the post-hospital mortality rate was 3.5% (3/84 patients). The prevalence rate of complex ventricular ectopic beats detected by Holter monitoring was respectively: 85.5% (77/90 patients) in the acute phase, 8.5% (7/80) at the 72nd hour, 18.5% (15/80) in the pre-discharge phase. At 1, 3, 6 and 12 months the prevalence rate was respectively 35% (27/77 patients), 28.8% (22/77), 24.6 (19/77), 24.6% (19/77). A high variability in arrhythmic groups was found. Each group was composed of new arrhythmic patients and stable arrhythmic patients, in addition to a small number of patients who were arrhythmic in the preceding control but no arrhythmic in the following control. This specific analysis of various groups revealed that the pre-discharge phase is the period with the highest number of "stable arrhythmic" patients (4 Holter positive out of 5) compared to the 1st month (3 Holter positive out of 4) and the 3rd month (2 Holter positive out of 3).(ABSTRACT TRUNCATED AT 250 WORDS)
No preview · Article · Aug 1990 · Giornale italiano di cardiologia
[Show abstract][Hide abstract] ABSTRACT: Diltiazem (0.3 mg/kg body weight intravenous in 2 minutes) was administered to 40 patients (24 males, 16 females, mean age 51.55 years) with paroxysmal supraventricular tachyarrhythmias: 7 patients with atrial fibrillation, 6 patients with atrial flutter, 25 patients with paroxysmal supraventricular tachycardia, 2 patients with uncommon atrioventricular reciprocating tachycardia. In patients with atrial fibrillation intravenous diltiazem produced a significant decrease of ventricular response (from 160 +/- 11 to 113.57 +/- 10.34--p less than 0.01). In patients with atrial flutter intravenous diltiazem produced variable effects: an increase in atrio-ventricular block (from 2:1 to 3:1 atrio-ventricular conduction (2 patients); conversion to sinus rhythm (1 patient); change to atrial fibrillation (1 patient); no appreciable change of the basic rhythm (2 patients). In paroxysmal supraventricular tachycardia patients conversion to sinus rhythm occurred in 20/22 patients (91%) treated with intravenous diltiazem (mean conversion time 4.69 minutes). In the 2 patients with uncommon atrioventricular nodal reciprocating tachycardia diltiazem increased P'-R and R-P' intervals without appreciable change of the basic rhythm. No serious side effects from drug administration were noted. Intravenous diltiazem appears to be as a highly effective medication in conversion or control of paroxysmal supraventricular tachyarrhythmias.
No preview · Article · Oct 1986 · Giornale italiano di cardiologia